I 
116TH CONGRESS 
1ST SESSION H. R. 2452 
To amend the Social Security Act to establish a Medicare for America health 
program to provide for comprehensive health coverage for all Americans. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 1, 2019 
Ms. DELAURO (for herself, Ms. SCHAKOWSKY, Mr. KENNEDY, Mr. CLAY, Ms. 
NORTON, Mr. GRIJALVA, Mr. CARBAJAL, Mrs. TRAHAN, Mr. RYAN, Ms. 
JACKSON LEE, Mr. THOMPSON of Mississippi, Ms. ROYBAL-ALLARD, Ms. 
MCCOLLUM, Ms. MOORE, Mr. RUSH, and Mr. HIGGINS of New York) in-
troduced the following bill; which was referred to the Committee on Ways 
and Means, and in addition to the Committees on Energy and Commerce, 
Education and Labor, the Judiciary, Natural Resources, and House Ad-
ministration, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To amend the Social Security Act to establish a Medicare 
for America health program to provide for comprehensive 
health coverage for all Americans. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Medicare for America Act of 2019’’. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—TRANSITIONING TO AND ESTABLISHING MEDICARE FOR 
AMERICA 
Subtitle A—Transitional Public Health Option 
Sec. 101. Establishment. 
Sec. 102. Eligibility. 
Sec. 103. Benefits. 
Sec. 104. Premiums. 
Sec. 105. Providers and reimbursement rates. 
Sec. 106. Account; funding. 
Subtitle B—Medicare for America 
Sec. 111. Establishment and administration of Medicare for America. 
Sec. 112. Modifications to and coordination with existing Federal health pro-
grams. 
Subtitle C—Targeted Reforms 
Sec. 121. No surprise billing. 
Sec. 122. Limitation on removal of Medicare Advantage providers by MA orga-
nizations. 
Sec. 123. Network adequacy. 
Sec. 124. Eliminating the 24-month waiting period for Medicare coverage for 
individuals with disabilities. 
Sec. 125. Eliminating the waiting period for individuals on State Medicaid 
waiting lists. 
Sec. 126. Employer health plan options. 
Sec. 127. Prohibition on step therapy and prior authorization under group 
health plans. 
Sec. 128. Medicare outpatient observation services. 
Sec. 129. Abortion coverage. 
Sec. 130. Applicability of mental health parity. 
Sec. 131. Student loan forgiveness for health care providers participating in 
Medicare for America. 
Sec. 132. Clarification of the definition of pediatric medical necessity in quali-
fying group coverage. 
Sec. 133. Safe staffing requirements. 
Sec. 134. Enhancements for reduced cost-sharing. 
Sec. 135. Repeal of bonus payments for Medicare Advantage plans. 
TITLE II—TAX PROVISIONS 
Sec. 201. Sunset of Public Law 115–97. 
Sec. 202. Surtax. 
Sec. 203. Basis of property acquired from a decedent. 
Sec. 204. Medicare payroll tax. 
Sec. 205. Net investment income tax. 
Sec. 206. Termination of deduction for contributions to health savings ac-
counts. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6211
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
Sec. 207. Increase in excise tax on small cigars and cigarettes and other to-
bacco products. 
Sec. 208. Excise tax on alcohol. 
Sec. 209. Tax on sugared drinks. 
Sec. 210. Repeal of excise tax on high-cost employer-sponsored health coverage. 
TITLE III—DRUG-RELATED PROVISIONS 
Sec. 301. Establishment of the Prescription Drug and Medical Device Review 
Board. 
Sec. 302. Membership; staff. 
Sec. 303. Prohibition against excessive price. 
Sec. 304. Enforcement provisions. 
Sec. 305. Authority. 
Sec. 306. Regulations. 
Sec. 307. Report to Federal agencies. 
Sec. 308. Definitions. 
Sec. 309. Moratorium on direct-to-consumer drug advertising. 
Sec. 310. Reporting on justification for drug price increases. 
TITLE IV—OUTCOMES AND REPORTING 
Sec. 401. Sense of Congress. 
Sec. 402. Evaluation of bill’s outcome. 
TITLE 
I—TRANSITIONING 
TO 
AND 
ESTABLISHING 
MEDI-
CARE FOR AMERICA 
Subtitle A—Transitional Public 
Health Option 
SEC. 101. ESTABLISHMENT. 
The Secretary of Health and Human Services (in this 
subtitle referred to as the ‘‘Secretary’’) shall establish a 
public health plan option that is offered in the individual 
market through the Federal and State Exchanges under 
title I of the Patient Protection and Affordable Care Act 
to eligible individuals for plan years 2021 and 2022 in 
accordance with this subtitle. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
SEC. 102. ELIGIBILITY. 
Subject to subsection (b), an individual is eligible to 
enroll in such public health plan option if the individual 
is otherwise eligible to purchase individual health insur-
ance coverage through an Exchange and the individual re-
sides in a rating area in which the Secretary makes the 
public health plan option available. 
SEC. 103. BENEFITS. 
(a) IN GENERAL.—The public health plan option 
shall be a qualified health plan within the meaning of sec-
tion 1301(a) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18021(a)) that— 
(1) meets all requirements applicable to quali-
fied health plans under subtitle D of title I of the 
Patient Protection and Affordable Care Act (other 
than 
the 
requirement 
under 
section 
1301(a)(1)(C)(ii) 
of 
such 
Act 
(42 
U.S.C. 
18021(a)(1)(C)(ii))) and title XXVII of the Public 
Health Service Act; 
(2) provides coverage of the essential health 
benefits described in section 1302(b) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 
18022(b)); 
(3) provides silver and gold-level coverage de-
scribed in section 1302(d)(1)(C) of the Patient Pro-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
tection and Affordable Care Act (42 U.S.C. 
18022(d)(1)(C)); and 
(4) provides coverage of comprehensive repro-
ductive health services, including abortion. 
(b) 
PREEMPTION.—Notwithstanding 
section 
1303(a)(1) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18023(a)(1))— 
(1) a State may not prohibit the public health 
plan option from offering the coverage described in 
subsection (a)(4); and 
(2) no State law that would prohibit such a 
plan from offering such coverage shall apply to such 
plan. 
SEC. 104. PREMIUMS. 
(a) IN GENERAL.—The Secretary shall establish pre-
mium rates for the public health plan option that— 
(1) are adjusted based on the applicable rating 
area; 
(2) are at a level sufficient to fully finance— 
(A) the costs of health benefits provided by 
such plans; and 
(B) administrative costs related to oper-
ating the plans; 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(3) comply with the requirements under section 
2701 of the Public Health Service Act (42 U.S.C. 
300gg); and 
(4) ensure that no individual or household will 
pay more than 8 percent of adjusted gross monthly 
income toward the monthly premium. 
(b) FEDERAL SUBSIDIES.—Federal subsidies shall be 
provided to ensure that the premium shall be— 
(1) zero in the case of an individual whose an-
nual household income is below 200 percent of the 
poverty line; 
(2) determined by a linear sliding scale, in the 
case of an individual whose household income is at 
least 200 percent of the poverty line, but not more 
than 600 percent of the poverty line; and 
(3) no individual or household above 600 per-
cent of poverty level will pay more than 8 percent 
of adjusted gross monthly income toward such 
monthly premium. 
SEC. 105. PROVIDERS AND REIMBURSEMENT RATES. 
(a) IN GENERAL.—The Secretary shall establish a 
rate schedule for reimbursing types of health care pro-
viders furnishing items and services under the public 
health insurance plan option at rates based on rates ap-
plied for such items and services under title XVIII of the 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
Social Security Act, as of the date of the enactment of 
this Act, that are necessary to maintain network ade-
quacy. The Secretary shall establish a rate schedule for 
items and services not currently covered under title XVIII 
of the Social Security Act, such as dental, vision, and 
hearing benefits, well child visits, and reproductive health 
services, at a level to ensure adequate access to providers. 
(b) PARTICIPATING PROVIDERS.— 
(1) IN GENERAL.—A health care provider that 
is a participating provider of services or supplier 
under the Medicare program under title XVIII of 
the Social Security Act or under the Medicaid pro-
gram under title XIX of such Act on the date of en-
actment of this title shall be a participating provider 
for the public health insurance plan option. 
(2) ADDITIONAL
PROVIDERS.—The Secretary 
shall establish a process to allow health care pro-
viders not described in paragraph (1) to become par-
ticipating providers for the public health insurance 
plan option. 
(3) 
CLARIFICATION.—Notwithstanding 
any 
other provision of law, health care providers may not 
be prohibited from participating in the public health 
insurance option for reasons other than their ability 
to provide covered services. Health care providers 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
and institutions are prohibited from denying covered 
individuals access to any covered benefits and serv-
ices because of their religious objections. 
(c) PRESCRIPTION
DRUGS.—The Secretary shall 
apply the provisions of section 1860D–11(i) of the Social 
Security Act (42 U.S.C. 1395w–111(i)) to prescription 
drugs under the public health plan option in the same 
manner as such provisions apply with respect to applicable 
covered part D drugs under such section. 
SEC. 106. ACCOUNT; FUNDING. 
(a) ESTABLISHMENT.—There is established in the 
Treasury of the United States an account for the receipts 
and disbursements attributable to the operation of the 
public health plan option. 
(b) APPROPRIATION.—There is appropriated to the 
account established under subsection (a), out of any funds 
in the Treasury not otherwise obligated, such sums as may 
be necessary to be used by the Secretary for purposes of 
carrying out this part. 
(c) 
PROHIBITION
OF
STATE
IMPOSITION
OF 
TAXES.—Section 1854(g) of the Social Security Act (42 
U.S.C. 1395w–24(g)) shall apply to receipts and disburse-
ments described in subsection (a) in the same manner as 
such section applies to payments or premiums described 
in such section. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(d) CLARIFICATION.—Any provision of law restricting 
the use of Federal funds with respect to any reproductive 
health service shall not apply to funds appropriated under 
subsection (b) or with respect to the account under sub-
section (a). 
Subtitle B—Medicare for America 
SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDI-
CARE FOR AMERICA. 
The Social Security Act is amended by adding at the 
end the following new title: 
‘‘TITLE XXII—MEDICARE FOR 
AMERICA 
‘‘PART A—COMPREHENSIVE HEALTH COVERAGE 
‘‘SEC. 2201. ESTABLISHMENT. 
‘‘The Secretary shall establish a public health insur-
ance program, to be known as ‘Medicare for America’, 
which shall for calendar year 2023 and each subsequent 
calendar year provide comprehensive health benefits in ac-
cordance with this part to individuals enrolled for coverage 
under this title. 
‘‘SEC. 2202. ELIGIBILITY; AUTOMATIC ENROLLMENT. 
‘‘(a) ELIGIBLE INDIVIDUALS.—For purposes of this 
title, every individual who is— 
‘‘(1) a resident of the United States or a terri-
tory of the United States; 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(2) an individual who is lawfully present, as 
defined in section 152.2 of title 45 of the Code of 
Federal Regulations; or 
‘‘(3) an individual who would be eligible for cov-
erage under a State Medicaid plan pursuant to sec-
tion 1903(v) (as such section was in effect as of the 
date of the enactment of this title), 
is entitled to benefits for health care services under this 
title. The Secretary shall promulgate a rule that provides 
criteria for applying this subsection, including determining 
residency for eligibility purposes under this title. Nothing 
in this title shall preclude a State from using State funds 
to provide for an individual’s health coverage who is not 
eligible under this subsection. 
‘‘(b) ENROLLMENTS.—Subject to subsection (c): 
‘‘(1) IN
GENERAL.—Beginning in 2023, the 
Secretary shall provide a mechanism for the enroll-
ment of individuals entitled to benefits under this 
title and, in conjunction with such enrollment, the 
issuance of a Medicare for America card which may 
be used for purposes of identification and processing 
of claims for benefits under this title. The card shall 
not use the individual’s social security number as an 
identifier. As a condition of participation in the pro-
gram, participating providers shall facilitate enroll-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
ment as specified by the Secretary. The State enti-
ties responsible for enrolling individuals in the Med-
icaid program under title XIX and the Children’s 
Health Insurance Program under title XXI shall 
serve as the enrolling entity for Medicare for Amer-
ica within each State. 
‘‘(2) AUTOMATIC ENROLLMENTS.—The mecha-
nism provided under paragraph (1) shall, subject to 
paragraph (4), provide, for plan years, for the fol-
lowing automatic enrollments under Medicare for 
America: 
‘‘(A) ENROLLMENT AT BIRTH.—For plan 
years (beginning with plan year 2023), a proc-
ess, established by the Secretary in consultation 
with the Commissioner of Social Security, for 
the automatic enrollment of eligible individuals 
born during such plan year. 
‘‘(B) 
CURRENT
MEDICARE
BENE-
FICIARIES.— 
‘‘(i) 
CURRENT
MEDICARE
BENE-
FICIARIES.—For plan years (beginning 
with plan year 2023), a process established 
by the Secretary for the automatic enroll-
ment of all individuals who are enrolled for 
benefits under part A or B of title XVIII 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(other than individuals who are enrolled 
for such benefits and receiving benefits 
under title XIX). 
‘‘(ii) CONTINUING POPULATION.—For 
plan years (beginning with plan year 
2023), a process established by the Sec-
retary for the automatic enrollment of eli-
gible individuals who attain the age of 65 
during such plan year. 
‘‘(iii) DUALS.—For plan years (begin-
ning with plan year 2025), a process estab-
lished by the Secretary for the automatic 
enrollment of eligible individuals who are 
enrolled for benefits under part A or B of 
title XVIII and receiving benefits under 
title XIX. 
‘‘(C) 
OTHER
INDIVIDUALS
WITHOUT 
QUALIFIED
HEALTH
COVERAGE.—For 
plan 
years (beginning with plan year 2023), a proc-
ess established by the Secretary for the auto-
matic enrollment of eligible individuals who are 
not enrolled in other qualified health coverage 
(as defined in paragraph (4)(B)) for such plan 
year. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(3) OTHER ENROLLMENTS.—The mechanism 
provided under paragraph (1) shall provide for the 
following: 
‘‘(A) IN
GENERAL.—Enrollment periods 
and processes for each plan year (beginning 
with plan year 2023) for enrollment under 
Medicare for America of any eligible individual 
not otherwise described in paragraph (2). 
‘‘(B) SMALL EMPLOYERS.— 
‘‘(i) IN
GENERAL.—For plan years 
(beginning with plan year 2023), a process 
and methodology under which a small em-
ployer, as defined in section 126(d)(3) of 
the Medicare for America Act, may provide 
for the enrollment of the employees of such 
employer under Medicare for America. For 
purposes of this subparagraph, the term 
‘small employer’ means any employer for 
any calendar year if the annual payroll of 
such employer for the preceding calendar 
year does not exceed $2,000,000 or has 
fewer than 100 employees. 
‘‘(ii) REQUIREMENT.—Small employ-
ers shall either provide coverage as defined 
within the meaning of section 2791(d)(8) 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
of the Public Health Service Act or facili-
tate the enrollment of their employees into 
Medicare for America. Small employers fa-
cilitating enrollment into Medicare for 
America will not be subject to a mandatory 
employer contribution. 
‘‘(iii) 
AUTHORITY.—The 
Secretary 
may set standards for determining whether 
employers are undertaking any actions to 
affect the risk pool within Medicare for 
America by inducing individuals to decline 
coverage under a qualifying employer-spon-
sored plan and instead to enroll in Medi-
care for America. An employer violating 
such standards shall be treated as not 
meeting the requirements of qualified 
health coverage. 
‘‘(C) LARGE EMPLOYERS.—For plan years 
(beginning with plan year 2027), the Secretary 
shall provide for a process and methodology 
under which a large employer may provide for 
the enrollment of the employees of such em-
ployer under Medicare for America. For pur-
poses of the preceding sentence, the term ‘large 
employer’ means an employer with at least 100 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
employees or whose annual payroll exceeds 
$2,000,000. 
‘‘(D) MEMBERS OF CONGRESS AND THEIR 
STAFF.—Beginning for plan year 2023, Mem-
bers of Congress and their staff, subject to 
paragraph (4), shall be enrolled in Medicare for 
America. 
‘‘(4) OPT
OUT
FOR
INDIVIDUALS
ENROLLED 
UNDER QUALIFIED HEALTH COVERAGE.— 
‘‘(A) IN GENERAL.—The mechanism pro-
vided under paragraph (1) shall provide, with 
respect to a plan year, for a process that en-
ables individuals who are enrolled in qualified 
health coverage for such plan year to opt out of 
coverage under Medicare for America for such 
year. 
‘‘(B) QUALIFIED HEALTH COVERAGE DE-
FINED.—For purposes of this section, the term 
‘qualified health coverage’ means coverage 
under any of the following: 
‘‘(i) For plan years 2023 and 2024: 
‘‘(I) Qualified employer coverage, 
as defined in section 126 of the Medi-
care for America Act. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(II) Medical coverage under 
chapter 55 of title 10, United States 
Code, including coverage under the 
TRICARE program. 
‘‘(III) A health care program 
under chapter 17 or 18 of title 38, 
United States Code, as determined by 
the Secretary of Veterans Affairs, in 
coordination with the Secretary of 
Health and Human Services and the 
Secretary. 
‘‘(IV) The health benefit program 
under chapter 89 of title 5, United 
States Code. 
‘‘(V) Medical benefits and serv-
ices provided by or through the Indian 
Health Service. 
‘‘(VI) The Medicaid program 
under title XIX of the Social Security 
Act. 
‘‘(VII) The CHIP program under 
title XXI of the Social Security Act. 
‘‘(ii) For plan years 2025 and 2026: 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(I) Coverage described in sub-
clause (I), (II), (III), (IV), or (V) of 
clause (i). 
‘‘(II) Coverage described in sub-
clause (VI) of clause (i), but only with 
respect to coverage that is not for in-
dividuals described in subclause (VIII) 
of section 1902(a)(10)(A)(i) or who 
are also enrolled for benefits under 
title XVIII. 
‘‘(iii) For each subsequent plan year, 
coverage described in subclause (I), (II), 
(III), (IV), or (V) of clause (i). 
‘‘(c) WAIVER.—The Secretary shall establish a proc-
ess under which the Secretary may grant waivers to States 
for additional time before populations described in a pre-
vious subsection of this section of such State are automati-
cally enrolled under Medicare for America so long as the 
State can demonstrate substantial progress has been made 
in transitioning these populations. 
‘‘SEC. 2203. BENEFITS. 
‘‘(a) IN GENERAL.—Medicare for America shall, in 
accordance with this section, provide coverage for all the 
benefits, as determined to be medically necessary, as cov-
ered and defined under parts A and B of title XVIII and 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
title XIX as of the date of the enactment of this title, 
including the following: 
‘‘(1) Ambulatory patient services. 
‘‘(2) Emergency care and urgent care services. 
‘‘(3) Hospitalization. 
‘‘(4) Maternity and newborn care. 
‘‘(5) Behavioral health services, including men-
tal health, substance use disorder services, and in-
tensive home and community based services. 
‘‘(6) Prescription drugs approved by the Food 
and Drug Administration. 
‘‘(7) Rehabilitative and habilitative services and 
devices, including the following: 
‘‘(A) Physical therapy. 
‘‘(B) Speech therapy. 
‘‘(C) Occupational therapy. 
‘‘(8) Laboratory services. 
‘‘(9) Preventive and wellness services and 
chronic disease management. 
‘‘(10) Pediatric services, all services that would 
otherwise be coverable under early and periodic 
screening, diagnostic, and treatment under the Med-
icaid program under title XIX and services otherwise 
included under the maternal, infant, and early child-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
hood home visiting program under section 511, as of 
the date of the enactment of this title. 
‘‘(11) Dental care, at a minimum the services 
necessary to prevent disease and promote oral 
health, restore oral structures to health and func-
tion, and treat emergency conditions, nightguards, 
mouthguards, and dentures. 
‘‘(12) Hearing health services including aids 
and exams. 
‘‘(13) Vision services. 
‘‘(14) Home and community based long-term 
services and supports. 
‘‘(15) Chiropractic services. 
‘‘(16) Durable medical equipment (as defined 
for purposes of title XIX), including the following: 
‘‘(A) Wheelchairs and accessories. 
‘‘(B) Walking aides such as walkers, canes, 
and crutches. 
‘‘(C) Bathroom equipment such as com-
modes and safety equipment. 
‘‘(D) Inhalation therapy equipment such as 
nebulizers. 
‘‘(E) Hospital beds and accessories. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(F) Other devices such as Continuous 
Positive Airway Pressure (CPAP) machines, 
apnea monitors, and ventilators. 
‘‘(G) Insulin pumps and glucometers. 
‘‘(H) Breast pumps. 
‘‘(I) Lymphedema compression treatment 
items. 
‘‘(J) Wigs for medical conditions. 
‘‘(K) Augmentative and alternative com-
munication devices, including dual-use devices. 
‘‘(L) Oxygen. 
‘‘(M) Orthotic and prosthetic devices. 
‘‘(N) Disposable medical supplies. 
‘‘(17) Family planning, including the following: 
‘‘(A) Reproductive health exams. 
‘‘(B) Patient counseling and education re-
lated to family planning. 
‘‘(C) Abortion. 
‘‘(D) Screening, testing, treatment, and 
pre- and post-test counseling for sexually trans-
mitted diseases and HIV. 
‘‘(E) Contraceptives including pill, patch, 
medication, condom, implant, or other devices 
used to prevent pregnancy. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00020
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(F) Voluntary sterilization for bene-
ficiaries over the age of 21. 
‘‘(G) Infertility treatment. 
‘‘(18) Gender-confirming medical procedures 
and treatment. 
‘‘(19) Screening, testing, treatment, and pre- 
and post-test counseling for sexually transmitted dis-
eases and HIV. 
‘‘(20) Dietary and nutrition counseling. 
‘‘(21) Medically necessary food and vitamins for 
digestive and inherited metabolic disorders. 
‘‘(22) Nursing facilities. 
‘‘(23) Acupuncture. 
‘‘(24) Digital health therapeutics, as approved 
by the Center for Healthcare and the Center for 
Medicare and Medicaid Innovation. 
‘‘(25) Telehealth. 
‘‘(26) Non-emergency medical transportation. 
‘‘(27) Care coordination, including services de-
fined in section 440.169 of title 42, Code of Federal 
Regulations. 
‘‘(28) Palliative care. 
‘‘(29) Any additional benefit or service not in-
cluded in this section that is coverable by any State 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00021
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
plan (or waiver of such State plan) under title XIX 
on the date of the enactment of this title. 
‘‘(b) UPDATES.—Benefits coverable under Medicare 
for America shall be updated in accordance with the Na-
tional Coverage Determination process that had, as of the 
date before the date of the enactment of this title, applied 
with respect to benefits covered under title XVIII. 
‘‘(c) IMPLEMENTING POLICIES.—The Secretary shall 
establish payment models, quality measures, and other im-
plementing policies that provide further access to the cov-
erage under this title. For purposes of the previous sen-
tence, the Secretary shall consult with stakeholders, in-
cluding those covering pediatrics, disabilities, and seniors. 
‘‘(d) PROHIBITION
AGAINST
DUPLICATING
COV-
ERAGE.— 
‘‘(1) IN GENERAL.—It is unlawful for a private 
health insurer (other than an insurer with respect to 
a Medicare Advantage for America plan under part 
C of this title or qualified employer-based coverage) 
to sell health insurance coverage that duplicates the 
benefits provided under Medicare for America under 
this part. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed as prohibiting the sale of 
health insurance coverage for any additional benefits 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00022
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
not covered by this part, insofar as the coverage sat-
isfies the conditions of paragraphs (3) and (4). 
Nothing shall preclude employers meeting the re-
quirements under section 126 of the Medicare for 
America Act from providing supplemental coverage 
under this section to their employees. 
‘‘(3) APPLICATION OF PROTECTIONS.—For pur-
poses of paragraph (2), health insurance coverage 
for any additional benefits must satisfy the following 
conditions: 
‘‘(A) The provisions of section 2718 of the 
Public Health Service Act, relating to a medical 
loss ratio. 
‘‘(B) The provisions of section 2702 of the 
Public Health Service Act, relating to guaran-
teed issue. 
‘‘(C) The provisions of section 2701 of the 
Public Health Service Act, relating to commu-
nity rating. 
‘‘(D) The provisions of section 2704 of the 
Public Health Service Act, relating to the ban 
on pre-existing conditions exclusions. 
‘‘(4) NO FEES TO BROKERS.—For purposes of 
paragraph (2), the condition described in this para-
graph is that health insurance coverage described in 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00023
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
such paragraph does not pay fees to insurance bro-
kers. 
‘‘(e) STATES MAY PROVIDE ADDITIONAL BENE-
FITS.—Individual States may provide additional benefits 
for the residents of such States at the expense of the 
State. 
‘‘(f) PROHIBITION AGAINST STEP THERAPY
AND 
PRIOR
AUTHORIZATION.—Items and services covered 
under Medicare for America shall be covered without any 
need for any prior authorization determination and with-
out any limitation applied through the use of step therapy 
protocols. 
‘‘SEC. 2204. PREMIUMS. 
‘‘(a) IN GENERAL.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
each individual enrolled for benefits under this title 
for a year shall pay monthly community-rated pre-
miums for such year in an amount determined by 
the Secretary in accordance with subsection (b). 
‘‘(2) 
GRANDFATHERED
MEDICARE
BENE-
FICIARIES.—In the case of an individual enrolled 
under part B of title XVIII as of the date of the en-
actment of this part, the premium applied under this 
section for such individual for benefits under this 
title shall be the lesser of— 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00024
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(A) the premium otherwise applicable to 
such individual under such title XVIII if this 
title had not been enacted; or 
‘‘(B) the premium that would be applied to 
such individual under this title without the ap-
plication of this paragraph. 
‘‘(b) PREMIUM CONTRIBUTION BASED ON INCOME.— 
The amount of a monthly premium, with respect to a plan 
year (beginning with 2023), under this section shall be 
established by the Secretary in accordance with the fol-
lowing: 
‘‘(1) Such premium shall be determined such 
that the collective premiums for the plan year are 
with respect to the costs of health benefits provided 
under this title for such year and related administra-
tive costs. 
‘‘(2) Premiums shall vary by family composition 
only. 
‘‘(3) Federal subsidies shall be provided to en-
sure that the premium shall be— 
‘‘(A) zero in the case of an individual 
whose annual household income is below 200 
percent of the poverty line; 
‘‘(B) determined by a linear sliding scale, 
in the case of an individual whose household in-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00025
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
come is at least 200 percent of the poverty line, 
but not more than 600 percent of the poverty 
line; and 
‘‘(C) no individual or household will pay 
more than 8 percent of adjusted gross monthly 
income toward such premium. 
‘‘(4) For an individual whose employer will be 
making a firm-wide contribution under this title in 
lieu of offering employer-sponsored insurance (as 
specified in section 126(b)(1)(B) of the Medicare for 
America Act), such individual shall pay a premium 
in accordance with this subsection. 
‘‘(5) For an individual who has opted out of 
their employer-sponsored insurance in order to enroll 
in Medicare for America as specified in section 
126(c) of such Act, the individual shall pay the less-
er of— 
‘‘(A) the premium described in this sub-
section; or 
‘‘(B) the amount owed after the amount of 
employer contribution (as specified in section 
126(b)(1)(B) of the Medicare for America Act) 
is subtracted from the premium established by 
the Secretary of Health and Human Services as 
described in paragraph (1), whichever is less. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00026
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(c) DEPOSITS.—Amounts paid under this section for 
coverage under this title shall be deposited in the Treasury 
to the credit of the Trust Fund established under section 
2206. 
‘‘(d) APPEALS
FOR CERTAIN MEDICARE GRAND-
FATHERED POPULATION.—In calculating premiums for 
purposes of subsection (a)(2): 
‘‘(1) Any individual that was subject to a late 
enrollment penalty under part B of title XVIII shall 
have the right to appeal the assessment of the pen-
alty for good faith enrollment mistakes. 
‘‘(2) The Secretary, in consultation with the 
Commissioner of Social Security, shall develop and 
publish a formal application for requesting an action 
of the Secretary under paragraph (1) to correct or 
eliminate the effects of an error, misrepresentation, 
or inaction described in such paragraph and deter-
mine and publish specific timelines for timely resolu-
tion of such a request. 
‘‘(3) The Secretary shall also require that all 
such determinations with respect to such requests 
shall be reached within 15 business days of the sub-
mission of such application. All determinations shall 
be in writing through a standard decision notice 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00027
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
which shall include an explanation of the reasons for 
the determination. 
‘‘(4) The Commissioner of Social Security shall 
enter into contracts with independent review organi-
zations in accordance with this subsection for the 
purpose of reviewing and determining individual ap-
peals of determinations under paragraph (3) with re-
spect to an application relating to enrollment under 
part A or part B. 
‘‘(5) An individual who receives an adverse de-
termination under paragraph (3) may appeal to an 
independent review organization designated by the 
Commission. Any such appeal must be sent to the 
independent review organization within 90 days of 
the date the individual received the determination to 
be eligible for review. The independent review orga-
nization shall review and reach a determination of 
the review in writing within 45 days of the receipt 
of any such appeal. 
‘‘(6) The Secretary of the Treasury may not 
enter into a contract under paragraph (4) with an 
independent review organization— 
‘‘(A) unless the organization has staff that 
has the appropriate knowledge of, and experi-
ence with, the eligibility and coordination of 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00028
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
benefits rules and regulations under this title; 
and 
‘‘(B) to the extent the organization is a fis-
cal intermediary under section 1816, a carrier 
under section 1842, or a Medicare administra-
tive contractor under section 1874A. 
‘‘(7) The Secretary shall provide for access by 
independent review organizations conducting appeal 
determinations under this subsection, to the data-
base of the Coordination of Benefits Contractor of 
the Centers for Medicare & Medicaid Services as 
necessary in order to conduct the duties of such or-
ganizations to determine appeals pursuant to this 
subsection. 
‘‘SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT- 
OF-POCKET LIMITS. 
‘‘(a) PAYMENT
OF BENEFITS; COST-SHARING.— 
There shall be paid, in the case of each individual who 
is enrolled under Medicare for America and incurs ex-
penses for items and services with respect to which bene-
fits are payable under this part, subject to subsection (c), 
80 percent of the reimbursement rates established pursu-
ant to section 2206 for such items and services, except 
that for the following services, the amounts paid under 
this section shall be equal to 100 percent of the reimburse-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00029
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
ment rates established pursuant to section 2206 for such 
items and services: 
‘‘(1) USPTF recommended preventive and 
chronic disease services. 
‘‘(2) Long-term services and supports. 
‘‘(3) Generic drugs, and prescription drugs if 
medically necessary. 
‘‘(4) All services for individuals who are medi-
cally frail or otherwise have special medical needs, 
(including children with serious emotional disturb-
ance and adults with serious mental illness), individ-
uals with chronic substance use disorders, or individ-
uals with serious and complex medical conditions 
(such as epilepsy and HIV), individuals with a phys-
ical, intellectual or developmental disability that sig-
nificantly impairs their ability to perform one or 
more activities of daily living. 
‘‘(5) Pregnancy related services. 
‘‘(6) Emergency services. 
‘‘(7) Services for children under age 21. 
The Secretary shall establish a default monthly payment 
plan under the Medicare for America benefits package to 
ensure the payment owed by the individual enrolled under 
Medicare for America is spread-out evenly throughout the 
year. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00030
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(b) DEDUCTIBLE.—There shall be no deductible 
under Medicare for America. 
‘‘(c) MAXIMUM OUT-OF-POCKET LIMIT.— 
‘‘(1) IN GENERAL.—The coverage under Medi-
care shall provide benefits, after the eligible indi-
vidual has incurred out-of-pocket expenses for items 
and services with respect to which benefits are pay-
able under this part in a year equal to the annual 
out-of-pocket threshold specified in paragraph (2), 
with cost-sharing that is equal to $0. 
‘‘(2) ANNUAL OUT-OF-POCKET THRESHOLD.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), subject to subparagraphs (B) and 
(C), the annual out-of-pocket threshold speci-
fied in this paragraph is a threshold that shall 
be determined on a linear sliding scale for 
household income that is at least 200 percent of 
the poverty line, but not more than 600 percent 
of the poverty line, and that shall not exceed— 
‘‘(i) with respect to an individual, 
$3,500; or 
‘‘(ii) with respect to a household, 
$5,000. 
Individuals or households with income above 
600 percent of the Federal poverty line shall 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00031
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
have 
their 
annual 
out-of-pocket 
threshold 
capped at $3,500 and $5,000 respectively. 
‘‘(B) INDEXING.—In the case of plan years 
beginning after 2021, the threshold described in 
subparagraph (A) (as in effect for the preceding 
plan year after application of this subpara-
graph) shall be increased by the percentage in-
crease over the previous year in the medical 
care expenditure category of the Consumer 
Price Index for All Urban Consumers (United 
States city average), published by the Bureau 
of Labor Statistics. 
‘‘(C) EXCEPTION.—For purposes of para-
graph (1), the annual out-of-pocket threshold 
for individuals and households with annual in-
come below 200 percent of the Federal poverty 
line is $0. 
‘‘(d) NO LIFETIME OR ANNUAL LIMITS.—There shall 
be no lifetime or annual limits for any services or benefits 
coverable under Medicare for America. 
‘‘(e) NO BALANCE BILLING.—No provider may im-
pose a charge to an enrolled individual for coverable serv-
ices for which benefits are provided under this part in an 
amount higher than the reimbursement rate for such serv-
ices under section 2206 and may not impose a charge to 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00032
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
such individual for such service other than with respect 
to the other cost-sharing described in this section. 
‘‘(f) NO PRIVATE CONTRACTING.—A health care pro-
vider or health care institution are prohibited from enter-
ing into a private contract with an individual enrolled 
under Medicare for America for any item or service 
coverable under Medicare for America. 
‘‘(g) LIMITATIONS ON THE USE OF FLEXIBLE SAV-
INGS ACCOUNTS.—Flexible Savings Accounts shall only be 
used for benefits and services not covered by Medicare for 
America. 
‘‘SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT 
RATES. 
‘‘(a) IN GENERAL.—The Secretary shall establish a 
rate schedule for reimbursing types of health care pro-
viders furnishing items and services under Medicare for 
America at rates that are consistent with subsection (b) 
and are necessary to maintain network adequacy. 
‘‘(b) RATES.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graphs (2) and (3), the Secretary shall establish 
rates for benefits and services to be provided to 
health care providers and suppliers furnishing under 
Medicare for America based on rates that would be 
applied (including as computed, updated, and ad-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00033
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
justed) under title XVIII or title XIX, whichever is 
higher, for such type of health care providers and 
suppliers and item and service if such title remained 
in effect and, in the case of a type of provider and 
supplier or item or service coverable under Medicare 
for America but not otherwise coverable under title 
XVIII or title XIX, shall provide for rates that en-
sure adequate access to care. 
‘‘(2) EXCEPTIONS.—For purposes of this sec-
tion, in applying paragraph (1) the Secretary shall 
ensure that rates to hospitals for inpatient services 
or outpatient services furnished under Medicare for 
America are at least 110 percent of such rates on 
average or in the aggregate for furnishing such inpa-
tient or outpatient services otherwise applied under 
title XVIII or title XIX, whichever is higher, except 
that for hospitals serving underserved areas as speci-
fied by the Secretary, such rates are increased as 
necessary to ensure adequate access to care. 
‘‘(3) APPLICATION.—In applying rates under 
title XVIII and title XIX, as applicable, for purposes 
of this part, the following shall apply: 
‘‘(A) The Secretary shall provide for site- 
neutral payments for items and services fur-
nished in an outpatient hospital and physician 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00034
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
office, the rate of payment for such service shall 
be the same. 
‘‘(B) The Secretary shall provide for a 
mechanism to provide payments for direct and 
indirect costs of graduate medical education 
programs without any cap on the number of 
residency positions for which payment may be 
made, including payments to hospitals for such 
programs and to eligible facilities for programs 
for population health-based residencies and for 
nurse practitioner post-licensure clinical train-
ing, residency, and fellowship programs. 
‘‘(C) The Secretary shall increase the aver-
age relative value of primary care and other 
mental and behavioral health and cognitive 
services by not less than 30 percent in order to 
ensure adequate access to inpatient and out-
patient care. 
‘‘(D) As a condition of participation in the 
program, participating providers shall accept 
Medicare for America rates paid by employer- 
sponsored insurance plans and Medicare Advan-
tage for America plans. 
‘‘(E) The Secretary shall semiannually re-
view if the rates paid by Medicare for America 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00035
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
are creating barriers to care. The Secretary 
shall have the authority to raise rates as nec-
essary to ensure adequate access to care. 
‘‘(4) INCREASED FEDERAL MATCH FOR MED-
ICAID
AND
THE
CHILDREN’S
HEALTH
INSURANCE 
PROGRAM
FOR
YEARS
2023
THROUGH
2027.—The 
Secretary of Health and Human Services shall pay 
the difference between the Medicare for America 
rates and the Medicaid and CHIP rates during the 
period beginning on January 1, 2023, and ending on 
December 31, 2027. 
‘‘(c) PARTICIPATING PROVIDERS.— 
‘‘(1) IN GENERAL.—A health care provider that 
is a participating provider of services or supplier 
under the Medicare program under title XVIII or 
the Medicaid program under title XIX on the date 
of enactment of this title shall remain a partici-
pating provider for Medicare for America. 
‘‘(2) ADDITIONAL PROVIDERS.—The Secretary 
shall establish a process to allow health care pro-
viders not described in paragraph (1) to become par-
ticipating providers for Medicare for America. 
‘‘(d) PRESCRIPTION DRUGS.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, the Secretary shall, for plan years 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00036
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
beginning on or after the date of the enactment of 
this title, negotiate with pharmaceutical manufactur-
ers the prices (including discounts, rebates, and 
other price concessions) that may be charged to 
Medicare for America and MA for America organiza-
tions during a negotiated price period (as specified 
by the Secretary) for covered drugs for Medicare for 
America enrollees. In negotiating such prices under 
this section, the Secretary shall take into account 
the following factors: 
‘‘(A) The comparative clinical effectiveness 
and cost effectiveness, when available from an 
impartial source, of such drug. 
‘‘(B) The budgetary impact of providing 
coverage of such drug. 
‘‘(C) The number of similarly effective 
drugs or alternative treatment regimens for 
each approved use of such drug. 
‘‘(D) The associated financial burden on 
patients that utilize such drug. 
‘‘(E) The associated unmet patient need 
for such drug. 
‘‘(F) The total revenues from global sales 
obtained by the manufacturer for such drug 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00037
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
and the associated investment in research and 
development of such drug by the manufacturer. 
‘‘(2) FINALIZATION OF NEGOTIATED PRICE.— 
The negotiated price of each covered drug for a ne-
gotiated price period shall be finalized not later than 
30 days before the first plan year in such negotiated 
price period. 
‘‘(3) COMPETITIVE LICENSING AUTHORITY.— 
‘‘(A) IN GENERAL.—Notwithstanding any 
exclusivity under clause (iii) or (iv) of section 
505(j)(5)(F) of the Federal Food, Drug, and 
Cosmetic Act, clause (iii) or (iv) of section 
505(c)(3)(E) of such Act, section 351(k)(7)(A) 
of the Public Health Service Act, or section 
527(a) of the Federal Food, Drug, and Cos-
metic Act, or by an extension of such exclusivity 
under section 505A of such Act or section 505E 
of such Act, and any other provision of law that 
provides for market exclusivity (or extension of 
market exclusivity) with respect to a drug, in 
the case that the Secretary is unable to success-
fully negotiate an appropriate price for a cov-
ered drug for a negotiated price period, the Sec-
retary shall authorize the use of any patent, 
clinical trial data, or other exclusivity granted 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00038
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
by the Federal Government with respect to such 
drug as the Secretary determines appropriate 
for purposes of manufacturing such drug for 
sale under Medicare for America. Any entity 
making use of a competitive license to use pat-
ent, clinical trial data, or other exclusivity 
under this section shall provide to the manufac-
turer holding such exclusivity reasonable com-
pensation, as determined by the Secretary 
based on the following factors: 
‘‘(i) The risk-adjusted value of any 
Federal Government subsidies and invest-
ments in research and development used to 
support the development of such drug. 
‘‘(ii) The risk-adjusted value of any 
investment made by such manufacturer in 
the research and development of such 
drug. 
‘‘(iii) The impact of the price, includ-
ing license compensation payments, on 
meeting the medical need of all patients. 
‘‘(iv) The relationship between the 
price of such drug, including compensation 
payments, and the health benefits of such 
drug. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00039
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(v) Other relevant factors determined 
appropriate by the Secretary to provide 
reasonable compensation. 
‘‘(B) REASONABLE
COMPENSATION.—The 
manufacturer described in subparagraph (A) 
may seek recovery against the United States in 
the United States Court of Federal Claims. 
‘‘(C) INTERIM PERIOD.— 
‘‘(i) IN GENERAL.—Until 1 year after 
a drug described in subparagraph (A) is 
approved under section 505(j) of the Fed-
eral Food, Drug, and Cosmetic Act or sec-
tion 351(k) of the Public Health Service 
Act and is provided under license issued by 
the Secretary under such subparagraph, 
Medicare for America shall not pay more 
for such drug than the average of the 
prices available, during the most recent 12- 
month period for which data is available 
prior to the beginning of such negotiated 
price period, from the manufacturer to any 
wholesaler, retailer, provider, health main-
tenance organization, nonprofit entity, or 
governmental entity in the ten OECD (Or-
ganization for Economic Cooperation and 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00040
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
Development) countries that have the larg-
est gross domestic product with a per cap-
ita income that is not less than half the 
per capita income of the United States or 
the price established by the Prescription 
Drug and Medical Device Review Board 
established under title III of the Medicare 
for America Act of 2019. 
‘‘(ii) FEDERAL
PROGRAM
LICENS-
ING.—If such drug is not made available 
at the price determined, the Secretary shall 
authorize such entities to use any patent, 
clinical trial data, or other exclusivity 
granted by the Federal Government with 
respect to such drug as the Secretary de-
termines appropriate for purposes of man-
ufacturing such drug for sale under any 
Federal program, including those provided 
by Medicare for America, Veterans Affairs, 
the Department of Defense, and the Coast 
Guard. 
‘‘(D) AUTHORIZATION FOR SECRETARY TO 
PROCURE DRUGS DIRECTLY.— 
‘‘(i) IN
GENERAL.—The Secretary 
may procure a drug manufactured pursu-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00041
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
ant to a competitive license under subpara-
graph (A) for purposes of this part or pur-
suant to a Federal program license under 
subparagraph (C)(ii) for purposes of a 
Federal program directly from the entity 
manufacturing the drug pursuant to such 
a license. 
‘‘(ii) CLARIFICATION REGARDING AP-
PLICATION
OF
BUY
AMERICAN
ACT.—In 
the case where the Secretary procures a 
drug under this subparagraph, the provi-
sions of chapter 83 of title 41, United 
States Code (commonly referred to as the 
‘Buy American Act’), shall apply. 
‘‘(E) PRIORITY FOR U.S. MANUFACTURERS 
IN AUTHORIZING COMPETITIVE LICENSES.—In 
authorizing a competitive license under this 
paragraph, the Secretary— 
‘‘(i) shall give preference to entities 
that the Secretary determines have the 
highest safety and security standards; and 
‘‘(ii) may give priority to entities that 
will manufacture such drug in the United 
States. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00042
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(4) FDA REVIEW OF LICENSED DRUG APPLI-
CATIONS.—The Secretary shall prioritize review of 
applications under section 505(j) of the Federal 
Food, Drug, and Cosmetic Act for drugs licensed 
under paragraph (3)(A). 
‘‘(5) PROHIBITION
OF
ANTICOMPETITIVE
BE-
HAVIOR.—No drug manufacturer may engage in 
anticompetitive behavior with another manufacturer 
that may interfere with the issuance and implemen-
tation of a competitive license or run contrary to 
public policy. 
‘‘(6) REQUIRED
REPORTING.—The Secretary 
may require pharmaceutical manufacturers to dis-
close to the Secretary such information that the Sec-
retary determines necessary for purposes of carrying 
out this subsection. 
‘‘(7) CLARIFICATION.—Nothing in this sub-
section shall be construed as preventing Medicare for 
America obtaining a discount or reduction of the 
price for a covered drug below the price negotiated 
by the Secretary. 
‘‘(8) VALUE OR COST-EFFECTIVENESS ASSESS-
MENTS.—The use of Quality-Adjusted Life Years, 
Disability-Adjusted Life Years, or other similar 
mechanisms is prohibited for use in value or cost-ef-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00043
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
fectiveness assessments for purposes of this sub-
section. 
‘‘(9) CLARIFICATION.—There shall be no for-
mulary under Medicare for America. 
‘‘SEC. 2207. TRUST FUND; FUNDING. 
‘‘(a) TRUST FUND.—There shall be established a uni-
fied Medicare Trust Fund in which funds provided under 
this title are deposited and from which expenditures under 
this title are made. The Trust Fund shall consist of such 
gifts and bequests as may be made and such amounts as 
may be deposited in, or appropriated to, such Trust Fund 
as provided in this Act. 
‘‘(b) FUNDING.— 
‘‘(1) TAXES.—There are hereby appropriated to 
the Trust Fund for each fiscal year beginning with 
fiscal year 2023, out of any moneys in the Treasury 
not otherwise appropriated, amounts equivalent to 
100 percent of the net increase in revenues to the 
Treasury which is attributable to the amendments 
made by title II of the Medicare for America Act 
and premiums collected under this title. The 
amounts appropriated by the preceding sentence 
shall be transferred from time to time (but not less 
frequently than monthly) from the general fund in 
the Treasury to the Trust Fund, such amounts to be 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00044
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
determined on the basis of estimates by the Sec-
retary of the Treasury of the taxes paid to or depos-
ited into the Treasury; and proper adjustments shall 
be made in amounts subsequently transferred to the 
extent prior estimates were in excess of or were less 
than the amounts that should have been so trans-
ferred. 
‘‘(2) CURRENT PROGRAM RECEIPTS.—Notwith-
standing any other provision of law, there are hereby 
appropriated to the Trust Fund for each fiscal year, 
beginning with fiscal year 2023, the amounts that 
would otherwise have been appropriated to carry out 
the following programs: 
‘‘(A) The Medicare program under title 
XVIII. 
‘‘(B) The Medicaid program under title 
XIX, beginning as of 2027. 
‘‘(3) 
ADDITIONAL
APPROPRIATIONS.—Addi-
tional sums are authorized to be appropriated annu-
ally as needed to maintain maximum quality, effi-
ciency, and access under this part. 
‘‘(4) MEDICAID MAINTENANCE OF EFFORT PAY-
MENTS.—There shall be transferred to the Trust 
Fund the maintenance of effort payments made 
under section 2209. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00045
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(c) RESTRICTIONS SHALL NOT APPLY.—Any other 
provision of law in effect on the date of enactment of this 
title restricting the use of Federal funds for any reproduc-
tive health service, including abortion, shall not apply to 
monies in the Trust Fund. 
‘‘(d) INCORPORATION OF PROVISIONS.—The provi-
sions of subsections (b) through (i) of section 1817 shall 
apply to the Trust Fund under this section in the same 
manner as such provisions applied to the Federal Hospital 
Insurance Trust Fund under such section 1817, except 
that, for purposes of applying such subsections to this sec-
tion, the ‘Board of Trustees of the Trust Fund’ shall mean 
the ‘Secretary’. 
‘‘(e) TRANSFER OF FUNDS.—Any amounts remain-
ing in the Federal Hospital Insurance Trust Fund under 
section 1817 or the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841 after the payment 
of claims for items and services furnished under title 
XVIII have been completed, shall be transferred into the 
Trust Fund under this section. 
‘‘SEC. 2208. ADMINISTRATIVE PROVISIONS. 
‘‘(a) CENTER FOR HEALTH CARE.—Beginning 2023, 
the Centers for Medicare & Medicaid Services shall be re-
named the Center for Health Care and all references in 
law and regulation to such Centers shall be deemed a ref-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00046
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
erence to such Center. All powers, duties, and responsibil-
ities of the Centers for Medicare & Medicaid Services shall 
be transferred to the Center for Health Care. 
‘‘(b) AUTHORITY.—The Secretary shall have the au-
thority to issue interim final rules with respect to any pro-
vision in this part. 
‘‘(c) ADMINISTRATIVE LAW JUDGES.— 
‘‘(1) IN
GENERAL.—The Center for Health 
Care is not authorized to appoint administrative law 
judges, in accordance with pages 11420 through 
11499 of title 70 of the Federal Register (March 8, 
2005). 
‘‘(2) TIMING.—Under this title, administrative 
law judges must issue a decision within 90 days of 
receipt of a hearing request, as specified in sub-
sections (a) and (c) of section 405.1016 of title 2, 
Code of Federal Regulations. 
‘‘(d) COVERAGE DETERMINATIONS APPEALS.— 
‘‘(1) Individuals may appeal a coverage deter-
mination under this title before the individual ob-
tains the service or item that is the subject of the 
appeal. Individuals shall continue to receive the serv-
ice or item if an appeal is filed before the provision 
of the service or item is terminated. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00047
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(2) The Secretary shall eliminate the redeter-
mination by a Medicare administrative contractor 
from the appeals process under the Medicare pro-
gram for beneficiaries. 
‘‘(e) PRIVATE RIGHT OF ACTION.— 
‘‘(1) IN GENERAL.—An applicant or recipient 
denied a right conferred by this title may bring a 
civil action seeking any remedy available in law or 
equity to remedy that violation. State courts and 
district courts of the United States shall have con-
current jurisdiction of such actions. 
‘‘(2) RIGHT DEFINED.—Rights are created by 
any provision of this title that— 
‘‘(A) prescribes, establishes, or confers a 
benefit or protection in favor of the individual 
or individuals seeking to enforce the provision; 
or 
‘‘(B) prescribes, establishes, or imposes a 
duty or obligation on a person or entity to act 
or conduct operations in a manner that benefits 
the individual or individuals seeking to enforce 
the provision. 
‘‘(3) REASONABLE
ATTORNEY
FEES.—In any 
action or proceeding to enforce this title, the court 
may award reasonable attorneys’ fees and litigation 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00048
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
costs (including expert fees) reasonably incurred 
against the defendant or defendants. 
‘‘(4) APPEAL.—Any civil action brought under 
this section shall be subject to appeal as provided in 
sections 1291 and 1292 of title 28 of the United 
States Code. 
‘‘(5) CONTINUED
APPLICATION
OF
OTHER 
LAWS.—Nothing in this title (or an amendment 
made by this title) shall be construed to invalidate 
or limit the rights, remedies, procedures, or legal 
standards available to individuals aggrieved under 
section 1979 of the Revised Statutes (42 U.S.C. 
1983), or to supersede State laws causes of action. 
‘‘(f) NON-DISCRIMINATION.— 
‘‘(1) IN GENERAL.—Except as otherwise pro-
vided for in this title, an individual shall not, on the 
ground prohibited under title VI of the Civil Rights 
Act of 1964 (42 U.S.C. 2000d et seq.), title IX of 
the Education Amendments of 1972 (20 U.S.C. 
1681 et seq.), the Age Discrimination Act of 1975 
(42 U.S.C. 6101 et seq.), section 504 of the Reha-
bilitation Act of 1973 (29 U.S.C. 794), or section 
1557 of the Affordable Care Act (42 U.S.C. 18116), 
be excluded from participation in, be denied the ben-
efits of, or be subjected to discrimination under, any 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00049
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
health program or activity, any part of which is re-
ceiving Federal financial assistance, including cred-
its, subsidies, or contracts of insurance, or under 
any program or activity that is administered by an 
Executive Agency or any entity established under 
this title (or amendments) or any employer-spon-
sored insurance. The enforcement mechanisms pro-
vided for and available under such title VI, title IX, 
section 794, Age Discrimination Act, or such section 
1557 shall apply for purposes of violations of this 
subsection. 
‘‘(2) CONTINUED
APPLICATION
OF
LAWS.— 
Nothing in this title (or an amendment made by this 
title) shall be construed to invalidate or limit the 
rights, remedies, procedures, or legal standards 
available to individuals aggrieved under title VI of 
the Civil Rights Act of 1964 (42 U.S.C. 2000d et 
seq.), title VII of the Civil Rights Act of 1964 (42 
U.S.C. 2000e et seq.), title IX of the Education 
Amendments of 1972 (20 U.S.C. 1681 et seq.), sec-
tion 504 of the Rehabilitation Act of 1973 (29 
U.S.C. 794), the Age Discrimination Act of 1975 
(42 U.S.C. 611 et seq.), or section 1557 of the Af-
fordable Care Act (42 U.S.C. 18116) or to super-
sede State laws that provide additional protections 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00050
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
against discrimination on any basis described in 
paragraph (1). 
‘‘(3) HEALTH CARE PROVIDERS.—Health care 
providers may not be prohibited from participating 
in the Medicare for America for reasons other than 
their ability to provide covered services. Health care 
providers and institutions are prohibited from deny-
ing covered individuals access to covered benefits 
and services because of their religious objections. 
This subsection supercedes any provision of law that 
allows for conscience protection. 
‘‘(4) REGULATIONS.—The Secretary may pro-
mulgate regulations to implement this subsection. 
‘‘SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT. 
‘‘(a) IN GENERAL.—A State is not eligible for pay-
ment under any program specified in subsection (c) for 
a calendar quarter in a plan year beginning after 2027 
unless the State makes to the Secretary for transfer to 
the unified Medicare Trust Fund under section 2207 the 
maintenance of effort payment applicable to such State 
and plan year under subsection (b). The Secretary shall 
extend such a waiver (including the availability of Federal 
financial participation under such waiver) for such period 
as may be required for a State to meet the requirement 
of the previous sentence. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00051
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(b) MAINTENANCE OF EFFORT PAYMENTS.—For 
purposes of this section, a maintenance of effort payment 
with respect to a State and plan year is— 
‘‘(1) for plan year 2028 and a State, a payment 
in an amount equal to the total amount of expendi-
tures of the State for medical assistance under title 
XIX and child health assistance under title XXI in-
cluding administrative costs for the plan year before 
the date of the enactment of this title; 
‘‘(2) for plan year 2029 and each subsequent 
plan year before plan year 2033— 
‘‘(A) in the case of a State that is a 
PPACA expansion State, the payment amount 
applied under this subsection for the previous 
plan year, increased by growth in GDP per cap-
ita plus 0.4 percent; and 
‘‘(B) in the case of a State that is not a 
PPACA expansion State, the payment amount 
applied under this subsection for the previous 
plan year, increased by growth in GDP per cap-
ita plus 0.7 percent; and 
‘‘(3) beginning in 2033, for each subsequent 
plan year, with respect to any State, the payment 
amount applied under this subsection for the pre-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00052
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
vious year, increased by growth in GDP per capita 
plus 0.7 percent. 
‘‘(c) PROGRAMS SPECIFIED.—For purposes of this 
section, the programs specified in this subsection are each 
of the following: 
‘‘(1) Block grants for community mental health 
services under subpart I of part B of title XIX of 
the Public Health Service Act. 
‘‘(2) Block grants and programs for social serv-
ices and elder justice under title XX. 
‘‘(3) Maternal and child health services block 
grants under title V. 
‘‘(4) Block grants for prevention and treatment 
of substance abuse under subpart II of part B of 
title XIX of the Public Health Service Act. 
‘‘(5) State Targeted Response to Opioid Crisis 
Grant Community Services Block Grant. 
‘‘(6) Grants under section 330 of the Public 
Health Service Act. 
‘‘(7) Ryan White HIV/AIDS Program grants 
under title XXVI of the Public Health Service Act. 
‘‘SEC. 2210. APPLICATION OF TITLE XVIII PROVISIONS. 
‘‘Except as specified otherwise in this title, in imple-
menting Medicare for America, the Secretary shall to the 
greatest extent practicable apply the following provisions 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00053
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
of title XVIII to the program under this title, benefits cov-
ered under this title, individuals entitled to benefits under 
this title, and providers of services and suppliers partici-
pating under the program under this title in a similar 
manner as such provisions applied to the program under 
title XVIII, benefits covered under such title, individuals 
entitled to benefits or enrolled under such title, and pro-
viders of services and suppliers participating under the 
program under such title: 
‘‘(1) Section 1801. 
‘‘(2) Section 1805. 
‘‘(3) Section 1806. 
‘‘(4) Section 1807. 
‘‘(5) Section 1809. 
‘‘(6) Section 1814. 
‘‘(7) Section 1815. 
‘‘(8) Section 1816. 
‘‘(9) Section 1818. 
‘‘(10) Section 1818A. 
‘‘(11) Section 1819. 
‘‘(12) Section 1820. 
‘‘(13) Section 1834. 
‘‘(14) Section 1834A. 
‘‘(15) Section 1843. 
‘‘(16) Section 1846. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00054
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(17) Section 1847. 
‘‘(18) Section 1851. 
‘‘(19) Section 1852. 
‘‘(20) Section 1855. 
‘‘(21) Section 1856. 
‘‘(22) Section 1857. 
‘‘(23) Section 1858. 
‘‘(24) Section 1861. 
‘‘(25) Section 1863. 
‘‘(26) Section 1864. 
‘‘(27) Section 1866B. 
‘‘(28) Section 1866C. 
‘‘(29) Section 1866E. 
‘‘(30) Section 1867. 
‘‘(31) Section 1868. 
‘‘(32) Section 1869. 
‘‘(33) Section 1871. 
‘‘(34) Section 1874A. 
‘‘(35) Section 1880. 
‘‘(36) Section 1881. 
‘‘(37) Section 1881A. 
‘‘(38) Section 1891. 
‘‘(39) Section 1894. 
‘‘(40) Section 1895. 
‘‘(41) Section 1896. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00055
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘PART B—HOME AND COMMUNITY BASED LONG- 
TERM SERVICES AND SUPPORTS 
‘‘SEC. 2231. HOME AND COMMUNITY BASED LONG-TERM 
SERVICES AND SUPPORTS BENEFIT. 
‘‘All individuals enrolled under Medicare for America 
under this title shall have coverage for home and commu-
nity based long-term services and supports benefits. Noth-
ing in this part shall be construed to limit an enrollee’s 
entitlement to any other benefit that is covered pursuant 
to section 2203, including nursing facility benefits. 
‘‘SEC. 2232. ELIGIBILITY. 
‘‘(a) ELIGIBLE INDIVIDUALS.—An individual who is 
eligible for home and community based long-term services 
and supports benefits under this part is an individual who 
satisfies each of the following: 
‘‘(1) The individual is eligible for Medicare for 
America. 
‘‘(2) The individual is determined by a licensed 
health care practitioner to be unable to perform, 
without substantial assistance, at least one Activity 
of 
Daily 
Living 
as 
described 
in 
section 
7702B(c)(2)(B) of the Internal Revenue Code of 
1986, or to require substantial assistance with one 
or more of the following areas: 
‘‘(A) Communication. 
‘‘(B) Social interaction. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00056
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(C) Learning. 
‘‘(D) Self-care. 
‘‘(E) Self-management. 
‘‘(F) Impairments that affect the person’s 
capacity for social or economic participation. 
‘‘(b) CLARIFICATION.—Under this part, in the case 
of an individual described in subsection (a) who experi-
ences periods in which their functional capacity changes 
or improves, such individual shall continue to have access 
to benefits under this part as needed. If such an individ-
ual’s functional capacity improves to a point in which the 
individual no longer requires home and community based 
long-term services and supports, or requires fewer serv-
ices, the individual shall be able to immediately and 
seamlessly resume receiving all needed services if and 
when their functional needs recur. Eligibility for services 
shall be maintained if, without the services, the individual 
would have reduced functional capacity. When assessing 
functional impairment, the individual will be assessed 
without regard to any current services or the ameliorative 
effects of other mitigating measures described in section 
3(4)(E)(i)(I) of the Americans With Disabilities Act of 
1990. 
‘‘(c) BENEFITS.— 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00057
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(1) DEFINITION.—For purposes of this title, 
the term ‘home and community based long-term 
services and supports benefit’ means the daily living 
supports needed by eligible individuals in order to 
live, work, and participate in their communities, and 
includes all home and community based services and 
supports coverable as of the date of the enactment 
of this title, under any State plan or waiver under 
title XIX, including— 
‘‘(A) home health aides and homemakers; 
‘‘(B) direct support professionals and per-
sonal attendant care services; 
‘‘(C) hospice; 
‘‘(D) nursing care; 
‘‘(E) medical social services; 
‘‘(F) care coordination, including case 
management, fiscal intermediary, and support 
brokerage services; 
‘‘(G) short-term inpatient care, including 
respite care and care for pain control; 
‘‘(H) behavioral health home and commu-
nity based long-term services and supports, in-
cluding assertive community treatment; peer 
support services; intensive care coordination, in-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00058
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
cluding case management; supported employ-
ment; and supported housing wraparound; 
‘‘(I) private-duty nursing; 
‘‘(J) respite services provided in the indi-
vidual’s home or broader community; and 
‘‘(K) transitional services to support an in-
dividual’s transition from an institutional set-
ting to the community. 
‘‘(2) NON-APPLICATION.—The provisions of sec-
tions 424.22(a)(1)(i) and 424.22(a)(1)(ii) of title 42 
of the Code of Federal Regulations does not apply 
in the case of the benefit described in paragraph 
(1)(A). 
‘‘(d) HOME AND COMMUNITY BASED LONG-TERM 
SERVICES
AND
SUPPORTS
WORKFORCE
DEVELOP-
MENT.— 
‘‘(1) IN GENERAL.—The Secretary shall ensure 
that the number of individuals in the home and com-
munity based long-term services and supports work-
force is adequate to ensure community integration 
for all beneficiaries under Medicare for America. In 
so doing, the Secretary may consider a wide range 
of factors, including payment rates for direct care 
workers, career pipelines and credentialing, worker 
rights, and the impact of national labor policies. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00059
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(2) SELF-DIRECTED MODEL.—All eligible indi-
viduals shall be defaulted into a self-directed care 
option (as defined by the Secretary). The Secretary 
must consult with eligible individuals, caregivers, 
workers and their representatives, including unions, 
and state entities responsible for administering the 
LTSS benefit to establish this model. 
‘‘(3) COMMUNITY
FIRST.—The benefit under 
this part shall be arranged for and provided with a 
community first presumption and eligible individuals 
shall be provided home and community based long- 
term services and support available under this sec-
tion, regardless of type or level of disability or serv-
ice need. No eligible individual may be referred to an 
institution without first being offered and, if chosen, 
provided home and community based long-term serv-
ices and supports. Individuals in an institution on 
the effective date of the bill, and at least annually 
or upon any change in condition thereafter, shall be 
informed of, and if chosen, provided with home and 
community based long-term services and supports. 
‘‘(e) ADMINISTRATION
OF
SERVICES
AND
SUP-
PORTS.—State entities responsible for administering home 
and community based long-term services and support ben-
efits under any State plan or waiver under title XIX as 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00060
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
of the date of the enactment of this title shall continue 
to administer the benefits and services coverable under 
this section. 
‘‘(f) COORDINATION WITH OTHER FEDERAL BENE-
FITS.— 
‘‘(1) RULE
OF
CONSTRUCTION.—Nothing in 
this part shall be construed as prohibiting benefits 
paid under this part from being used to compensate 
a caregiver who provides community living assistance 
services and supports to a dependent relative for 
providing community living assistance services and 
supports to an eligible individual under this part. 
‘‘(2) DEPENDENT
RELATIVE
DEFINED.—The 
term ‘dependent relative’ means a child, grandchild, 
niece, nephew, parent, grandparent, sibling, aunt, or 
uncle (of such caregiver or his or her spouse or do-
mestic partner); such caregiver’s spouse or domestic 
partner, if such child, grandchild, niece, nephew, 
parent, grandparent, sibling, aunt, uncle, spouse, or 
domestic partner is an eligible individual. 
‘‘(3) SUPPLEMENT
NOT
SUPPLANT.—Benefits 
received under this part by a caregiver shall supple-
ment, but not supplant, other benefits for which the 
individual is eligible under any other federally fund-
ed program that provides benefits or assistance. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00061
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(4) DISREGARD.—The benefit paid under this 
part shall be disregarded for purposes of deter-
mining or continuing the eligibility of the individual 
or the spouse of the individual for receipt of benefits 
under any other Federal, State, or locally funded as-
sistance program, including benefits paid under title 
II or XVI, under the laws administered by the Sec-
retary of Veterans Affairs, under low-income hous-
ing assistance programs, under the supplemental nu-
trition assistance program established under the 
Food and Nutrition Act of 2008, or under programs 
administered by State vocational rehabilitation agen-
cies. 
‘‘(5) REGULATIONS.—Not later than one year 
after the date of the enactment of this section, the 
Secretary shall promulgate such regulations as are 
necessary to carry out this part and to prevent fraud 
and abuse with respect to the benefits under this 
part. 
‘‘PART C—MEDICARE ADVANTAGE FOR AMERICA 
‘‘SEC. 2221. ALL PRIVATE PLANS. 
‘‘(a) IN GENERAL.—For plan years beginning with 
plan year 2023, a health insurance issuer may offer health 
insurance coverage in the individual market only if such 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00062
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
issuer has entered into a contract with the Secretary 
under subsection (b) to offer such coverage. 
‘‘(b) AGREEMENTS.—The Secretary shall enter into 
an agreement with an MA for America sponsor to offer 
MA for America plans under this part for the coverage 
of individuals enrolled under Medicare for America who 
elect to receive benefits under part A through such a plan. 
‘‘(c) MA FOR AMERICA PLAN; MA FOR AMERICA 
SPONSOR.—For purposes of this part: 
‘‘(1) MA FOR
AMERICA
PLAN.—An MA for 
America plan is a Medicare Advantage plan under 
part C of title XVIII, except such plan shall provide 
coverage for individuals enrolled under Medicare for 
America under part A of this title, with respect to 
at least the benefits covered under such part A. 
‘‘(2) MA FOR AMERICA SPONSOR.—An MA for 
America sponsor is a sponsor of an MA for America 
plan. 
‘‘SEC. 2222. APPLICATION OF MEDICARE ADVANTAGE PRO-
VISIONS. 
‘‘For purposes of applying this part, except as other-
wise specified under this part, the provisions of part C 
of title XVIII, as in effect as of the date of the enactment 
of this title shall apply with respect to an MA for America 
sponsor, MA for America plan, individuals eligible for cov-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00063
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
erage under this part, individuals enrolled under such 
plan, and benefits covered under part A in a similar man-
ner and to a similar extent as such provisions applied to 
an MA organization, MA plan, individuals eligible for 
under part C of such title, individuals enrolled under an 
MA plan, and benefits covered under fee-for-service Medi-
care as of such date. 
‘‘SEC. 2223. MEDICARE ADVANTAGE FOR AMERICA PAY-
MENT RATES. 
‘‘The rates for Medicare Advantage for America 
plans shall be equal to the rates paid by Medicare for 
America. The Administrator of the Center for Healthcare 
shall pay Medicare Advantage for America plans 95 per-
cent of average Medicare for America costs in each county. 
‘‘SEC. 2224. SEPARATE PREMIUM FOR MEDICARE ADVAN-
TAGE FOR AMERICA PLANS FURNISHING 
SUPPLEMENTAL BENEFITS. 
‘‘Nothing in this part shall preclude an individual 
from choosing a Medicare Advantage for America plan 
which requires the individual to pay an additional, sepa-
rate amount because of supplemental benefits or because 
it is a more expensive plan. In such case the individual 
enrolled under such plan would be responsible for a sepa-
rate monthly premium. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00064
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘SEC. 2225. PRESCRIPTION DRUG PRICING UNDER MEDI-
CARE ADVANTAGE FOR AMERICA PLANS. 
‘‘Medicare Advantage for America plans, for prescrip-
tion drugs, shall pay no more than the price negotiated 
under Medicare for America. 
‘‘SEC. 2226. BAN ON PAYING BROKERS’ FEES. 
‘‘Medicare Advantage for America plans may not pay 
fees to insurance brokers. 
‘‘SEC. 2227. CLARIFICATION ON MEDICARE ADVANTAGE EM-
PLOYER GROUP WAIVER PLANS AND THE 
MEDICARE 
SECONDARY 
PAYER 
REQUIRE-
MENT. 
‘‘Such plans shall be exempt from the MSP Require-
ment, and nothing in this section shall be construed as 
prohibiting such plans from contributing to the payment 
of premiums and cost-sharing. 
‘‘SEC. 2228. REFERENCES. 
‘‘Beginning in 2023, all references in law and regula-
tion to Medicare Advantage shall be deemed a reference 
to Medicare Advantage for America.’’. 
SEC. 112. MODIFICATIONS TO AND COORDINATION WITH 
EXISTING FEDERAL HEALTH PROGRAMS. 
(a) MEDICARE, MEDICAID, AND STATE CHILDREN’S 
HEALTH INSURANCE PROGRAM (SCHIP).— 
(1) IN GENERAL.—Notwithstanding any other 
provision of law, subject to paragraphs (2) and (3) 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00065
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
and section 2202(c) of the Social Security Act, as 
added by section 111— 
(A) no benefits shall be available under 
title XVIII of the Social Security Act for any 
item or service furnished— 
(i) beginning on or after January 1, 
2023 (except in the case of an individual 
enrolled under such title and title XIX of 
such Act); and 
(ii) beginning on or after January 1, 
2025, with respect to all individuals, in-
cluding individuals enrolled under such 
title and title XIX of such Act; 
(B) no individual is entitled to medical as-
sistance under a State plan approved under 
title XIX of such Act— 
(i) for any item or service furnished 
on or after January 1, 2025, in the case 
of an individual enrolled under such title 
and title XVIII of the Social Security Act 
or an individual described in subclause 
(VIII) of section 1902(a)(10)(A)(i); and 
(ii) for any item or service furnished 
on or after January 1, 2027; 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00066
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(C) no individual is entitled to medical as-
sistance under a State child health plan under 
title XXI of such Act for any item or service 
furnished on or after January 1, 2025; and 
(D) no payment shall be made to a State 
under section 1903(a) or 2105(a) of such Act 
with respect to medical assistance or child 
health assistance— 
(i) for any item or service furnished 
on or after January 1, 2025, in the case 
of an individual enrolled under such title 
and title XVIII of the Social Security Act 
or an individual described in subclause 
(VIII) of section 1902(a)(10)(A)(i); and 
(ii) for any item or service furnished 
on or after January 1, 2027. 
(2) TRANSITION.—In the case of inpatient hos-
pital services and extended care services during a 
continuous period of stay which began before Janu-
ary 1, 2025, for Medicare and 2027 for Medicaid or 
CHIP, and which had not ended as of such date, for 
which benefits are provided under title XVIII of the 
Social Security Act, under a State plan under title 
XIX of such Act, or under a State child health plan 
under title XXI such Act, the Secretary of Health 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00067
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
and Human Services shall provide for continuation 
of benefits under such title or plan until the end of 
the period of stay. 
(b) OTHER FEDERAL HEALTH PROGRAMS.— 
(1) FEDERAL EMPLOYEES HEALTH BENEFITS 
PROGRAM.—Nothing in this Act, or the amendments 
made by this Act, shall affect benefits made avail-
able under chapter 89 of title 5, United States Code. 
(2) TRICARE.—Nothing in this Act, or the 
amendments made by this Act, shall affect benefits 
made available under sections 1079 and 1086 of 
title 10, United States Code. 
(3) TREATMENT OF BENEFITS FOR VETERANS 
AND NATIVE AMERICANS.— 
(A) IN GENERAL.—Nothing in this Act, or 
the amendments made by this Act, shall affect 
the eligibility of veterans for the medical bene-
fits and services provided under title 38, United 
States Code, or of Indians for the medical bene-
fits and services provided by or through the In-
dian Health Service. 
(B) REEVALUATION.—No reevaluation of 
the Indian Health Service shall be undertaken 
without consultation with tribal leaders and 
stakeholders. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00068
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(C) 
SUPPLEMENTAL
INDIAN
HEALTH 
SERVICES
ALLOCATION.—The Secretary shall 
annually determine the need to provide an allot-
ment of supplemental funds to Indian Health 
Services, including payments to providers, 
health professional education, administrative ex-
penses, and prevention and public health activi-
ties. 
(4) ENROLLEE CHOICE.—Nothing in this Act 
shall preclude individuals enrolled in the Federal 
Employees Health Benefits Program or TRICARE 
or individuals receiving benefits provided under title, 
38, United States Code or the Indian Health Service 
from enrolling in Medicare for America. Enrollees 
shall be entitled to the employer contribution as es-
tablished under section 126(c) of such Act. 
(c) SUNSET OF PROVISIONS RELATED TO THE STATE 
EXCHANGES.—Effective January 1, 2022, the Federal 
and State Exchanges established pursuant to title I of the 
Patient Protection and Affordable Care Act (Public Law 
111–148) shall terminate, and any other provision of law 
that relies upon participation in or enrollment through 
such an Exchange, including such provisions of the Inter-
nal Revenue Code of 1986, shall cease to have force or 
effect. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00069
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(d) SEVERABILITY.—Every provision in this Act and 
every application of the provisions in this Act are severable 
from each other as a matter of Federal law. If any applica-
tion of any provision in this Act to any person or group 
of persons or circumstances is found by a court to be in-
valid, the remainder of this Act and the application of the 
Act’s provisions to all other persons and circumstances 
may not be affected. 
Subtitle C—Targeted Reforms 
SEC. 121. NO SURPRISE BILLING. 
(a) SURPRISE BILL DEFINED.—For purposes of this 
section the term ‘‘surprise bill’’— 
(1) means a bill for health care services, other 
than emergency services, received by an insured for 
services rendered by an out-of-network health care 
provider, where such services were rendered by such 
out-of-network provider at an in-network facility, 
during a service or procedure performed by an in- 
network provider or during a service or procedure 
previously approved or authorized by the health car-
rier and the insured did not knowingly elect to ob-
tain such services from such out-of-network provider; 
and 
(2) does not include a bill for health care serv-
ices received by an insured when an in-network 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00070
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
health care provider was available to render such 
services and the insured knowingly elected to obtain 
such services from another health care provider who 
was out-of-network. 
(b) No non-participating health care provider shall 
require prior authorization for rendering emergency serv-
ices to an insured. 
(c) No health carrier shall impose, for emergency 
services rendered to an insured by an out-of-network 
health care provider, a coinsurance, copayment, deductible 
or other out-of-pocket expense that is greater than the co-
insurance, copayment, deductible or other out-of-pocket 
expense that would be imposed if such emergency services 
were rendered by an in-network health care provider. 
(d) PAYMENT AMOUNT.—If emergency services were 
rendered to an insured by an out-of-network health care 
provider, such health care provider may bill the health car-
rier directly and the health carrier shall reimburse such 
health care provider the greatest of the following amounts: 
(1) The amount payable under Medicare for 
America for such services if rendered by a health 
care provider participating in Medicare for America. 
(2) The arbitrated amount between the quali-
fying health plan and the non-participating provider. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00071
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(e) Nothing in this section shall be construed to pro-
hibit the qualifying health plan and the non-participating 
health care provider from agreeing to a greater reimburse-
ment amount. 
(f) NON-EMERGENCY SERVICES.—With respect to a 
surprise bill, the following applies: 
(1) An individual enrolled in the qualifying 
health plan shall only be required to pay the applica-
ble coinsurance that would be imposed for such 
health care services if such services were rendered by 
a participating health care provider. 
(2) The qualifying health plan shall reimburse 
the non-participating health care provider or indi-
vidual enrolled in such health plan, as applicable, for 
health care services rendered at the qualifying health 
plane rate as payment in full, unless the health plan 
and the non-participating health care provider agree 
otherwise. 
(g) If health care services were rendered to an indi-
vidual enrolled in qualifying health coverage by a non-par-
ticipating health care provider and the qualifying health 
plan failed to inform such enrollee, if such enrollee was 
required to be informed, of the network status of such 
non-participating health care provider, the qualifying 
health plan shall not impose coinsurance expense that is 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00072
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
greater than the maximum out-of-pocket expense that 
would be imposed if such services were rendered by a 
qualifying health care provider. 
(h) EMERGENCY SERVICES.— 
(1) NO PRIOR AUTHORIZATION.—A health care 
provider not participating in Medicare for America 
may not require prior authorization for rendering 
emergency services to an individual enrolled under 
Medicare for America. 
(2) OUT-OF-POCKET EXPENSES.—A health care 
provider not participating in Medicare for America 
may not impose, for emergency services rendered to 
an individual enrolled in Medicare for America, a co-
insurance, copayment, or other out-of-pocket expense 
that is greater than the coinsurance or maximum 
out-of-pocket expense that would be imposed if such 
emergency services were rendered by a Medicare for 
America participating provider. 
(3) PAYMENT AMOUNT.—If emergency services 
are rendered to an individual enrolled in Medicare 
for America by a health care provider not partici-
pating in Medicare for America, such health care 
provider may bill Medicare for America directly and 
Medicare for America shall reimburse such health 
care provider the greatest of the following amounts: 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00073
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(3) If health care services were rendered to an 
individual enrolled in Medicare for America by a 
health care provider not participating in Medicare 
for America and the Secretary of Health and 
Human Services failed to inform such enrollee, if 
such enrollee was required to be informed, of the 
network status of such non-participating health care 
provider, the Secretary shall not impose a coinsur-
ance expense that is greater than the maximum out- 
of-pocket expense that would be imposed if such 
services were rendered by a provider participating in 
Medicare for America. 
SEC. 122. LIMITATION ON REMOVAL OF MEDICARE ADVAN-
TAGE PROVIDERS BY MA ORGANIZATIONS. 
(a) LIMITATION.—Section 1852(d) of the Social Se-
curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 
at the end the following: 
‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS 
FROM MA PLANS BY MA ORGANIZATIONS.— 
‘‘(A) REMOVAL
OF
PROVIDERS
WITH 
CAUSE.—Beginning with plan year 2020, except 
as provided in subparagraph (C), an MA orga-
nization offering an MA plan may only remove 
a provider of services or a supplier from a net-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00075
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
work of such plan if the organization has cause 
to remove such provider or supplier. 
‘‘(B) CAUSE TO REMOVE PROVIDERS.— 
‘‘(i) IN GENERAL.—An MA organiza-
tion offering an MA plan has cause to re-
move a provider of services or a supplier 
from a network of such plan if the Sec-
retary determines that the provider or sup-
plier is— 
‘‘(I) medically negligent; 
‘‘(II) in violation of any legal or 
contractual requirement applicable to 
the provider or supplier acting within 
the lawful scope of practice, including 
any participation or other requirement 
applicable to such provider or supplier 
under this title or under any contrac-
tual term for such plan; or 
‘‘(III) otherwise unfit to furnish 
items and services in accordance with 
requirements of this title. 
‘‘(ii) CONSIDERATION OF COST TO MA 
ORGANIZATIONS.—For purposes of sub-
paragraph (A), cost to an MA organization 
offering an MA plan due to the participa-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00076
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
tion of a provider of services or supplier in 
a network of such plan does not constitute 
cause for the MA organization to remove 
such provider or supplier from the network 
mid-year, and such cost may not be consid-
ered as a factor in favor of a determination 
that such organization has cause to remove 
the provider. 
‘‘(C) EXCEPTION.—With respect to each 
upcoming plan year, beginning with plan year 
2020 an MA organization offering an MA plan 
may only remove a provider of services or sup-
plier from a network of such plan for reasons 
not specified in subparagraph (B)(i) before the 
date that is 60 days before the first day of the 
annual coordinated election period for such plan 
year under section 1851(e)(3). 
‘‘(D) NOTICE AND APPEAL PROCESS.— 
‘‘(i) IN GENERAL.—Any removal of a 
provider of services or supplier from a net-
work of an MA plan may occur only after 
the completion of a fair notice and appeal 
process that the Secretary shall establish 
by regulation. Such process shall require 
the MA organization to provide to such 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00077
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
provider or supplier and to the Secretary 
an explanation of the reason or reasons for 
the removal. The Secretary shall make this 
information publicly available. 
‘‘(ii) APPLICATION.— 
‘‘(I) APPLICATION OF NEW PROC-
ESS.—In the case of a removal of a 
provider of services or supplier from a 
network of an MA plan occurring on 
or after the effective date published in 
a final rule for such fair notice and 
appeal process, such process shall 
apply in lieu of the process for the 
termination or suspension of a pro-
vider 
contract 
under 
section 
422.202(a) of title 42, Code of Fed-
eral Regulations. 
‘‘(II) CONTINUATION
OF
OLD 
PROCESS.—In the case of a removal of 
a provider of services or supplier from 
a network of an MA plan occurring 
before such effective date, the process 
for the termination or suspension of a 
provider 
contract 
under 
section 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00078
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
422.202(a) of title 42, Code of Fed-
eral Regulations, shall apply. 
‘‘(E) PARTICIPANT NOTICE AND PROTEC-
TION.— 
‘‘(i) NOTICE
TO
PARTICIPANTS
OF 
PROVIDER
REMOVAL.—Not less than 60 
days before the date on which a provider 
of services or supplier is removed from a 
network of an MA plan, the MA organiza-
tion offering such plan shall provide writ-
ten notification of the removal to each in-
dividual enrolled in such plan receiving 
items or services from the provider or sup-
plier during the plan year in effect on the 
date of removal or during the previous 
plan year. Such notification shall include 
at the minimum— 
‘‘(I) the names and telephone 
numbers of available in-network pro-
viders of services and suppliers offer-
ing items and services that are the 
same or similar to the items and serv-
ices offered by the removed provider 
or supplier; 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00079
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(II) information regarding the 
options available to an individual en-
rolled in such plan to request the con-
tinuation of medical treatment or 
therapy with the removed provider or 
supplier; and 
‘‘(III) one or more customer serv-
ice telephone numbers that an indi-
vidual enrolled in such plan may ac-
cess to obtain information regarding 
changes to the network of the plan. 
‘‘(ii) ANNUAL NOTICE OF CHANGE.— 
In addition to providing the notification of 
removal as required under clause (i), the 
MA organization offering such MA plan 
shall include such notification in the an-
nual notice of change for the MA plan for 
the upcoming plan year. 
‘‘(iii) CONTINUITY OF CARE.—In any 
case in which a provider of services or sup-
plier is removed from a network of an MA 
plan, such plan shall ensure that the re-
moval satisfies the continuity of care re-
quirements under paragraph (1)(A) with 
respect to each individual enrolled in such 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00080
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
172 
‘‘(H) the total expenditures of the manu-
facturer on research and development for such 
drug that is used for— 
‘‘(i) basic and preclinical research; 
‘‘(ii) clinical research; 
‘‘(iii) new drug development; 
‘‘(iv) pursuing new or expanded indi-
cations for such drug through supple-
mental applications under section 505 of 
the Federal Food, Drug, and Cosmetic Act 
or section 351 of the Public Health Service 
Act; and 
‘‘(v) carrying out postmarket require-
ments related to such drug, including those 
under section 505(o)(3) of the Federal 
Food, Drug, and Cosmetic Act; 
‘‘(I) the total revenue and the net profit 
generated from the qualifying drug for each cal-
endar year since the approval of the application 
for the drug under section 505 of the Federal 
Food, Drug, and Cosmetic Act or the issuance 
of the license for the drug under section 351, 
or since the manufacturer acquired such ap-
proved application or license; and 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00172
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS