I 
119TH CONGRESS 
1ST SESSION H. R. 3069 
To establish an improved Medicare-for-All national health insurance program. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 29, 2025 
Ms. JAYAPAL (for herself, Mrs. DINGELL, Ms. ADAMS, Ms. ANSARI, Ms. 
BALINT, Ms. BARRAGA´N, Mr. BELL, Mr. BEYER, Ms. BONAMICI, Mr. 
BOYLE of Pennsylvania, Ms. BROWN, Mr. CARBAJAL, Mr. CARSON, Mr. 
CARTER of Louisiana, Mr. CASAR, Mrs. CHERFILUS-MCCORMICK, Ms. 
CHU, Ms. CLARKE of New York, Mr. CLEAVER, Mr. COHEN, Ms. CROCK-
ETT, Mr. DAVIS
of Illinois, Ms. DEGETTE, Mr. DELUZIO, Mr. 
DESAULNIER, Ms. DEXTER, Mr. DOGGETT, Ms. ESCOBAR, Mr. 
ESPAILLAT, Mrs. FOUSHEE, Ms. LOIS FRANKEL of Florida, Ms. FRIED-
MAN, Mr. FROST, Mr. GARAMENDI, Mr. GARCIA of California, Mr. 
GARCI´A of Illinois, Mr. GOLDMAN of New York, Mr. GOMEZ, Mr. GREEN 
of Texas, Mrs. HAYES, Ms. HOYLE of Oregon, Mr. HUFFMAN, Mr. JACK-
SON of Illinois, Ms. JACOBS, Mr. JOHNSON of Georgia, Ms. KAMLAGER- 
DOVE, Mr. KEATING, Ms. KELLY of Illinois, Mr. KENNEDY of New York, 
Mr. KHANNA, Ms. LEE of Pennsylvania, Ms. LEGER FERNANDEZ, Mr. 
LEVIN, Mr. LIEU, Ms. LOFGREN, Ms. MCCOLLUM, Mr. MCGARVEY, Mr. 
MCGOVERN, Mrs. MCIVER, Mr. MEEKS, Ms. MENG, Mr. MFUME, Mr. 
MIN, Mr. MULLIN, Mr. NADLER, Mr. NEGUSE, Ms. NORTON, Ms. 
OCASIO-CORTEZ, Ms. OMAR, Mr. PALLONE, Mr. PANETTA, Ms. PINGREE, 
Mr. POCAN, Ms. PRESSLEY, Mr. QUIGLEY, Mrs. RAMIREZ, Ms. RANDALL, 
Mr. RASKIN, Ms. RIVAS, Ms. SALINAS, Ms. SA´NCHEZ, Ms. SCHAKOWSKY, 
Mr. SCOTT of Virginia, Mr. SHERMAN, Ms. SIMON, Mr. SMITH of Wash-
ington, Ms. STANSBURY, Mr. SWALWELL, Mr. TAKANO, Mr. THANEDAR, 
Mr. THOMPSON of Mississippi, Mr. THOMPSON of California, Ms. TITUS, 
Ms. TLAIB, Ms. TOKUDA, Mr. TONKO, Mrs. TRAHAN, Mr. VARGAS, Ms. 
VELA´ZQUEZ, Ms. WATERS, Mrs. WATSON COLEMAN, Ms. WILLIAMS of 
Georgia, Ms. WILSON of Florida, Mr. HARDER of California, Mr. IVEY, 
and Mr. TORRES of New York) introduced the following bill; which was 
referred to the Committee on Energy and Commerce, and in addition to 
the Committees on Ways and Means, Education and Workforce, Rules, 
Oversight and Government Reform, Armed Services, and the Judiciary, 
for a period to be subsequently determined by the Speaker, in each case 
for consideration of such provisions as fall within the jurisdiction of the 
committee concerned 
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A BILL 
To establish an improved Medicare-for-All national health 
insurance program. 
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 All Act’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—ESTABLISHMENT OF THE MEDICARE FOR ALL 
PROGRAM; UNIVERSAL COVERAGE; ENROLLMENT 
Sec. 101. Establishment of the Medicare for All Program. 
Sec. 102. Universal coverage. 
Sec. 103. Freedom of choice. 
Sec. 104. Non-discrimination. 
Sec. 105. Enrollment. 
Sec. 106. Effective date of benefits. 
Sec. 107. Prohibition against duplicating coverage. 
TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE 
BENEFITS AND BENEFITS FOR LONG-TERM CARE 
Sec. 201. Comprehensive benefits. 
Sec. 202. No cost-sharing; other limitations. 
Sec. 203. Exclusions and limitations. 
Sec. 204. Coverage of long-term care services. 
TITLE III—PROVIDER PARTICIPATION 
Sec. 301. Provider participation and standards; whistleblower protections. 
Sec. 302. Qualifications for providers. 
Sec. 303. Use of private contracts. 
TITLE IV—ADMINISTRATION 
Subtitle A—General Administration Provisions 
Sec. 401. Administration. 
Sec. 402. Consultation. 
Sec. 403. Regional administration. 
Sec. 404. Beneficiary ombudsman. 
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Sec. 405. Conduct of related health programs. 
Subtitle B—Control Over Fraud and Abuse 
Sec. 411. Application of Federal sanctions to all fraud and abuse under the 
Medicare for All Program. 
TITLE V—QUALITY ASSESSMENT 
Sec. 501. Quality standards. 
Sec. 502. Addressing health care disparities. 
TITLE VI—HEALTH BUDGET; PAYMENTS; COST CONTAINMENT 
MEASURES 
Subtitle A—Budgeting 
Sec. 601. National health budget. 
Subtitle B—Payments to Providers 
Sec. 611. Payments to institutional providers based on global budgets. 
Sec. 612. Payment to individual providers through fee-for-service. 
Sec. 613. Ensuring accurate valuation of services under the Medicare physician 
fee schedule. 
Sec. 614. Payment prohibitions; capital expenditures; special projects. 
Sec. 615. Office of Health Equity. 
Sec. 616. Office of Primary Care. 
Sec. 617. Payments for prescription drugs and approved devices and equip-
ment. 
TITLE VII—UNIVERSAL MEDICARE TRUST FUND 
Sec. 701. Universal Medicare Trust Fund. 
TITLE VIII—CONFORMING AMENDMENTS TO THE EMPLOYEE 
RETIREMENT INCOME SECURITY ACT OF 1974 
Sec. 801. Prohibition of employee benefits duplicative of benefits under the 
Medicare for All Program; coordination in case of workers’ 
compensation. 
Sec. 802. Application of continuation coverage requirements under ERISA and 
certain other requirements relating to group health plans. 
Sec. 803. Effective date of title. 
TITLE IX—ADDITIONAL CONFORMING AMENDMENTS 
Sec. 901. Relationship to existing Federal health programs. 
Sec. 902. Sunset of provisions related to the State Exchanges. 
Sec. 903. Sunset of provisions related to pay for performance programs. 
TITLE X—TRANSITION 
Subtitle A—Medicare for All Transition Over 2 Years and Transitional Buy- 
In Option 
Sec. 1001. Medicare for all transition over two years. 
Sec. 1002. Establishment of the Medicare transition buy-in. 
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Subtitle B—Transitional Medicare Reforms 
Sec. 1011. Eliminating the 24-month waiting period for Medicare coverage for 
individuals with disabilities. 
Sec. 1012. Ensuring continuity of care. 
TITLE XI—MISCELLANEOUS 
Sec. 1101. Definitions. 
Sec. 1102. Rules of construction. 
Sec. 1103. No use of resources for law enforcement of certain registration re-
quirements. 
TITLE 
I—ESTABLISHMENT 
OF 
THE MEDICARE FOR ALL PRO-
GRAM; 
UNIVERSAL 
COV-
ERAGE; ENROLLMENT 
SEC. 101. ESTABLISHMENT OF THE MEDICARE FOR ALL 
PROGRAM. 
There is hereby established a national health insur-
ance program to provide comprehensive protection against 
the costs of health care and health-related services, in ac-
cordance with the standards specified in, or established 
under, this Act. 
SEC. 102. UNIVERSAL COVERAGE. 
(a) IN GENERAL.—Every individual who is a resident 
of the United States is entitled to benefits for health care 
services under this Act. The Secretary shall promulgate 
a rule that provides criteria for determining residency for 
eligibility purposes under this Act. 
(b) TREATMENT OF OTHER INDIVIDUALS.—The Sec-
retary may make eligible for benefits for health care serv-
ices under this Act other individuals not described in sub-
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section (a), and regulate the eligibility of such individuals, 
to ensure that every person in the United States has ac-
cess to health care. In regulating such eligibility, the Sec-
retary shall ensure that individuals are not allowed to 
travel to the United States for the sole purpose of obtain-
ing health care items and services provided under the pro-
gram established under this Act. 
SEC. 103. FREEDOM OF CHOICE. 
Any individual entitled to benefits under this Act may 
obtain health services from any institution, agency, or in-
dividual qualified to participate under this Act. 
SEC. 104. NON-DISCRIMINATION. 
(a) IN GENERAL.—No person shall, on the basis of 
race, color, national origin, age, disability, marital status, 
citizenship status, primary language use, genetic condi-
tions, previous or existing medical conditions, religion, or 
sex, including sex stereotyping, gender identity, sexual ori-
entation, and pregnancy and related medical conditions 
(including termination of pregnancy), be excluded from 
participation in or be denied the benefits of the program 
established under this Act (except as expressly authorized 
by this Act for purposes of enforcing eligibility standards 
described in section 102), or be subject to any reduction 
of benefits or other discrimination by any participating 
provider (as defined in section 301), or any entity con-
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ducting, administering, or funding a health program or 
activity, including contracts of insurance, pursuant to this 
Act. 
(b) CLAIMS OF DISCRIMINATION.— 
(1) IN GENERAL.—The Secretary shall establish 
a procedure for adjudication of administrative com-
plaints alleging a violation of subsection (a). 
(2) JURISDICTION.—Any person aggrieved by a 
violation of subsection (a) by a covered entity may 
file suit in any district court of the United States 
having jurisdiction of the parties. A person may 
bring an action under this paragraph concurrently 
as such administrative remedies as established in 
paragraph (1). 
(3) DAMAGES.—If the court finds a violation of 
subsection (a), the court may grant compensatory 
and punitive damages, declaratory relief, injunctive 
relief, attorneys’ fees and costs, or other relief as ap-
propriate. 
(c) CONTINUED APPLICATION OF LAWS.—Nothing in 
this title (or an amendment made by this title) shall be 
construed to invalidate or otherwise limit any of the rights, 
remedies, procedures, or legal standards available to indi-
viduals aggrieved under section 1557 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18116), title 
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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.), section 504 of the Reha-
bilitation Act of 1973 (29 U.S.C. 794), or the Age Dis-
crimination Act of 1975 (42 U.S.C. 611 et seq.). Nothing 
in this title (or an amendment to this title) shall be con-
strued to supersede State laws that provide additional pro-
tections against discrimination on any basis described in 
subsection (a). 
SEC. 105. ENROLLMENT. 
(a) IN GENERAL.—The Secretary shall provide a 
mechanism for the enrollment of individuals eligible for 
benefits under this Act. The mechanism shall— 
(1) include a process for the automatic enroll-
ment of individuals at the time of birth in the 
United States (or upon establishment of residency in 
the United States); 
(2) provide for the enrollment, as of the dates 
described in section 106, of all individuals who are 
eligible to be enrolled as of such dates, as applicable; 
and 
(3) include a process for the enrollment of indi-
viduals made eligible for health care services under 
section 102(b). 
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TITLE II—COMPREHENSIVE BEN-
EFITS, INCLUDING PREVEN-
TIVE BENEFITS AND BENE-
FITS FOR LONG-TERM CARE 
SEC. 201. COMPREHENSIVE BENEFITS. 
(a) IN GENERAL.—Subject to the other provisions of 
this title and titles IV through IX, individuals enrolled for 
benefits under this Act are entitled to have payment made 
by the Secretary to an eligible provider for the following 
items and services if medically necessary or appropriate 
for the maintenance of health or for the diagnosis, treat-
ment, or rehabilitation of a health condition: 
(1) Hospital services, including inpatient and 
outpatient hospital care, including 24-hour-a-day 
emergency services and inpatient prescription drugs. 
(2) Ambulatory patient services. 
(3) Primary and preventive services, including 
chronic disease management. 
(4) Prescription drugs and medical devices, in-
cluding outpatient prescription drugs, medical de-
vices, and biological products, and all contraceptive 
items approved by the Food and Drug Administra-
tion. 
(5) Mental health and substance use treatment 
services, including inpatient care. 
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(6) Laboratory and diagnostic services. 
(7) Comprehensive reproductive care, including 
abortion, contraception, and assistive reproductive 
technology. 
(8) Maternity and newborn care. 
(9) Comprehensive gender affirming health 
care. 
(10) Oral health, audiology, and vision services. 
(11) Rehabilitative and habilitative services and 
devices. 
(12) Emergency services and transportation. 
(13) Early and periodic screening, diagnostic, 
and treatment services, as described in sections 
1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 
1905(r) of the Social Security Act (42 U.S.C. 
1396a(a)(10)(A); 
1396a(a)(43); 
1396d(a)(4)(B); 
1396d(r)). 
(14) Necessary transportation to receive health 
care services for persons with disabilities, older indi-
viduals with functional limitations, or low-income in-
dividuals (as determined by the Secretary). 
(15) Long-term care services and support (as 
described in section 204). 
(16) Hospice care. 
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(17) Services provided by a licensed marriage 
and family therapist or a licensed mental health 
counselor. 
(18) Any service described in a preceding para-
graph that is furnished via telehealth, to the extent 
practical. 
(b) REVISION.—The Secretary shall, at least annu-
ally, and on a regular basis, evaluate whether the benefits 
package should be improved to promote the health of bene-
ficiaries, account for changes in medical practice or new 
information from medical research, or respond to other 
relevant developments in health science, and shall make 
recommendations to Congress regarding any such im-
provements. Such recommendations may not include a rec-
ommendation to eliminate any benefit. 
(c) HEARINGS.— 
(1) IN GENERAL.—The Committee on Energy 
and Commerce and the Committee on Ways and 
Means of the House of Representatives shall, not 
less frequently than annually, hold a hearing on the 
recommendations submitted by the Secretary under 
subsection (b). 
(2) EXERCISE OF RULEMAKING AUTHORITY.— 
Paragraph (1) is enacted— 
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(A) as an exercise of rulemaking power of 
the House of Representatives, and, as such, 
shall be considered as part of the rules of the 
House, and such rules shall supersede any other 
rule of the House only to the extent that rule 
is inconsistent therewith; and 
(B) with full recognition of the constitu-
tional right of either House to change such 
rules (so far as relating to the procedure in 
such House) at any time, in the same manner, 
and to the same extent as in the case of any 
other rule of the House. 
(d) COMPLEMENTARY
AND
INTEGRATIVE
MEDI-
CINE.— 
(1) IN GENERAL.—In carrying out subsection 
(b), the Secretary shall consult with the persons de-
scribed in paragraph (2) with respect to— 
(A) identifying specific complementary and 
integrative medicine practices that are appro-
priate to include in the benefits package; and 
(B) identifying barriers to the effective 
provision and integration of such practices into 
the delivery of health care, and identifying 
mechanisms for overcoming such barriers. 
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(2) CONSULTATION.—In accordance with para-
graph (1), the Secretary shall consult with— 
(A) the Director of the National Center for 
Complementary and Integrative Health; 
(B) the Commissioner of Food and Drugs; 
(C) institutions of higher education, pri-
vate research institutes, and individual re-
searchers with extensive experience in com-
plementary and alternative medicine and the in-
tegration of such practices into the delivery of 
health care; 
(D) nationally recognized providers of com-
plementary and integrative medicine; and 
(E) such other officials, entities, and indi-
viduals with expertise on complementary and 
integrative medicine as the Secretary deter-
mines appropriate. 
(e) STATES
MAY
PROVIDE
ADDITIONAL
BENE-
FITS.—Individual States may provide additional benefits 
for the residents of such States, as determined by such 
State, and may provide benefits to individuals not eligible 
for benefits under this Act, at the expense of the State, 
subject to the requirements specified in section 1102. 
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SEC. 202. NO COST-SHARING; OTHER LIMITATIONS. 
(a) IN GENERAL.—The Secretary shall ensure that 
no cost-sharing, including deductibles, coinsurance, copay-
ments, or similar charges, is imposed on an individual for 
any benefits provided under this Act. 
(b) NO BALANCE BILLING.—No provider may impose 
a charge to an enrolled individual for covered services for 
which benefits are provided under this Act. 
(c) NO PRIOR AUTHORIZATION.—Benefits provided 
under this Act shall be covered without any need for any 
prior authorization determination and without any limita-
tion applied through the use of step therapy protocols. 
SEC. 203. EXCLUSIONS AND LIMITATIONS. 
(a) IN GENERAL.—Benefits for items and services 
are not available under this Act unless the items and serv-
ices meet the standards developed by the Secretary pursu-
ant to section 201(a). 
(b) TREATMENT
OF EXPERIMENTAL ITEMS
AND 
SERVICES AND DRUGS.— 
(1) IN GENERAL.—In applying subsection (a), 
the Secretary shall make national coverage deter-
minations with respect to items and services that are 
experimental in nature. Such determinations shall be 
consistent with the national coverage determination 
process as defined in section 1869(f)(1)(B) of the 
Social Security Act (42 U.S.C. 1395ff(f)(1)(B)). 
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(2) APPEALS
PROCESS.—The Secretary shall 
establish a process by which individuals can appeal 
coverage decisions. The process shall, as much as is 
feasible, follow the process for appeals under the 
Medicare program described in section 1869 of the 
Social Security Act (42 U.S.C. 1395ff). 
(c) APPLICATION OF PRACTICE GUIDELINES.— 
(1) IN GENERAL.—In the case of items and 
services for which the Department of Health and 
Human Services has recognized a national practice 
guideline, such items and services shall be deemed to 
meet the standards specified in section 201(a) if 
they have been provided in accordance with such 
guideline. For purposes of this subsection, an item 
or service not provided in accordance with a practice 
guideline shall be deemed to have been provided in 
accordance with the guideline if the health care pro-
vider providing the item or service— 
(A) 
exercised 
appropriate 
professional 
judgment in accordance with the laws and re-
quirements of the State in which such item or 
service is furnished in deviating from the guide-
line; 
(B) acted in the best interest of the indi-
vidual receiving the item or service; and 
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(C) acted in a manner consistent with the 
individual’s wishes. 
(2) OVERRIDE OF STANDARDS.— 
(A) IN GENERAL.—An individual’s treating 
physician or other health care professional au-
thorized to exercise independent professional 
judgment in implementing a patient’s medical 
or nursing care plan in accordance with the 
scope of practice, licensure, and other law of 
the State where items and services are to be 
furnished may override practice standards es-
tablished pursuant to section 201(a) or practice 
guidelines described in paragraph (1), including 
such standards and guidelines that are imple-
mented by a provider through the use of health 
information technology, such as electronic 
health record technology, clinical decision sup-
port technology, and computerized order entry 
programs. 
(B) LIMITATION.—An override described 
in subparagraph (A) shall, in the professional 
judgment of such physician, nurse, or health 
care professional, be— 
(i) consistent with such physician’s, 
nurse’s, or health care professional’s deter-
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mination of medical necessity and appro-
priateness or nursing assessment; 
(ii) in the best interests of the indi-
vidual; and 
(iii) consistent with the individual’s 
wishes. 
SEC. 204. COVERAGE OF LONG-TERM CARE SERVICES. 
(a) IN GENERAL.—Subject to the other provisions of 
this Act, individuals enrolled for benefits under this Act 
are entitled to the following long-term services and sup-
ports and to have payment made by the Secretary to an 
eligible provider for such services and supports if medically 
necessary and appropriate and in accordance with the 
standards established in this Act, for maintenance of 
health or for care, services, diagnosis, treatment, or reha-
bilitation that is related to a medically determinable condi-
tion, whether physical or mental, of health, injury, or age 
that— 
(1) causes a functional limitation in performing 
one or more activities of daily living; or 
(2) requires a similar need of assistance in per-
forming instrumental activities of daily living. 
(b) ELIGIBILITY.—An individual shall be eligible for 
services and supports described in this section if such indi-
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vidual has one or more medically determinable conditions 
described in subsection (a). 
(c) SERVICES AND SUPPORTS.—Long-term services 
and supports under this section shall be tailored to an in-
dividual’s needs, as determined through assessment, and 
shall be defined by the Secretary to— 
(1) include any long-term nursing services for 
the enrollee, whether provided in an institution or in 
a home- and community-based setting; 
(2) provide coverage for a broad spectrum of 
long-term services and supports, including for home- 
and community-based services and other care pro-
vided through non-institutional settings; 
(3) provide coverage that meets the physical, 
mental, and social needs of recipients while allowing 
recipients their maximum possible autonomy and 
their maximum possible civic, social, and economic 
participation; 
(4) prioritize delivery of long-term services and 
supports through home- and community-based serv-
ices over institutionalization; 
(5) unless an individual elects otherwise, ensure 
that recipients will receive home- and community 
-based long-term services and supports (as defined 
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in subsection (f)(4)), regardless of the individuals’s 
type or level of disability, service need, or age; 
(6) be provided with the goal of enabling per-
sons with disabilities to receive services in the least 
restrictive and most integrated setting appropriate 
to the individual’s needs; 
(7) be provided in such a manner that allows 
persons with disabilities to maintain their independ-
ence, self-determination, and dignity; 
(8) provide long-term services and supports 
that are of equal quality and equally accessible 
across geographic regions; and 
(9) ensure that long-term services and supports 
provide recipients the option of self-direction of serv-
ices from either the recipient or care coordinators of 
the recipient’s choosing. 
(d) PUBLIC CONSULTATION.—In developing regula-
tions to implement this section, the Secretary shall consult 
with an advisory commission on long-term services and 
supports that includes— 
(1) people with disabilities who use long-term 
services and supports and older adults who use long- 
term services and supports; 
(2) representatives of people with disabilities 
and representatives of older adults; 
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(3) groups that represent the diversity of the 
population of people living with disabilities, including 
racial, ethnic, national origin, primary language use, 
age, sex, including gender identity and sexual ori-
entation, geographical, and socioeconomic diversity; 
(4) providers of long-term services and sup-
ports, including family attendants and family care-
givers, and members of organized labor; 
(5) disability rights organizations; and 
(6) relevant academic institutions and research-
ers. 
(e) BUDGETING
AND PAYMENTS.—Budgeting and 
payments for long-term services and supports provided 
under this section shall be made in accordance with the 
provisions under title VI. 
(f) DEFINITIONS.—In this section: 
(1) The term ‘‘long-term services and supports’’ 
means long-term care, treatment, maintenance, or 
services needed to support the activities of daily liv-
ing and instrumental activities of daily living, includ-
ing home- and community-based services and any 
additional services and supports identified by the 
Secretary to support people with disabilities to live, 
work, and participate in their communities. 
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(2) The term ‘‘activities of daily living’’ means 
basic personal everyday activities, including tasks 
such as eating, toileting, grooming, dressing, bath-
ing, and transferring. 
(3) The term ‘‘instrumental activities of daily 
living’’ means activities related to living independ-
ently in the community, including meal planning and 
preparation, managing finances, shopping for food, 
clothing, and other essential items, performing es-
sential household chores, communicating by phone 
or other media, and traveling around and partici-
pating in the community. 
(4) The term ‘‘home and community-based 
services’’ means the home and community-based 
services that are coverable under subsections (c), 
(d), (i), and (k) of section 1915 of the Social Secu-
rity Act (42 U.S.C. 1396n), and as defined by the 
Secretary, including as defined in the home and 
community-based services settings rule in sections 
441.530 and 441.710 of title 42, Code of Federal 
Regulations (or a successor regulation). 
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TITLE III—PROVIDER 
PARTICIPATION 
SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; 
WHISTLEBLOWER PROTECTIONS. 
(a) IN GENERAL.—An individual or other entity fur-
nishing any covered item or service under this Act is not 
a qualified provider unless the individual or entity— 
(1) is a qualified provider of the items or serv-
ices under section 302; 
(2) has filed with the Secretary a participation 
agreement described in subsection (b); and 
(3) meets, as applicable, such other qualifica-
tions and conditions with respect to a provider of 
services under title XVIII of the Social Security Act 
as described in section 1866 of the Social Security 
Act (42 U.S.C. 1395cc). 
(b) REQUIREMENTS
IN
PARTICIPATION
AGREE-
MENT.— 
(1) IN
GENERAL.—A participation agreement 
described in this subsection between the Secretary 
and a provider shall provide at least for the fol-
lowing: 
(A) Items and services to eligible persons 
shall be furnished by the provider without dis-
crimination, in accordance with section 104(a). 
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Nothing in this subparagraph shall be con-
strued as requiring the provision of a type or 
class of items or services that are outside the 
scope of the provider’s normal practice. 
(B) No charge will be made to any enrolled 
individual for any covered items or services 
other than for payment authorized by this Act. 
(C) The provider agrees to furnish such in-
formation as may be reasonably required by the 
Secretary, in accordance with uniform reporting 
standards established under section 401(b)(1), 
for— 
(i) quality review by designated enti-
ties; 
(ii) making payments under this Act, 
including the examination of records as 
may be necessary for the verification of in-
formation on which such payments are 
based; 
(iii) statistical or other studies re-
quired for the implementation of this Act; 
and 
(iv) such other purposes as the Sec-
retary may specify. 
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(D) In the case of a provider that is not 
an individual, the provider agrees not to employ 
or use for the provision of health services any 
individual or other provider that has had a par-
ticipation agreement under this subsection ter-
minated for cause. The Secretary may authorize 
such employment or use on a case-by-case 
basis. 
(E) In the case of a provider paid under 
a fee-for-service basis for items and services 
furnished under this Act, the provider agrees to 
submit bills and any required supporting docu-
mentation relating to the provision of covered 
items and services within 30 days after the date 
of providing such items and services. 
(F) In the case of an institutional provider 
paid pursuant to section 611, the provider 
agrees to submit information and any other re-
quired supporting documentation as may be 
reasonably required by the Secretary within 30 
days after the date of providing such items and 
services and in accordance with the uniform re-
porting standards established under section 
401(b)(1), including information on a quarterly 
basis that— 
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(i) relates to the provision of covered 
items and services; and 
(ii) describes items and services fur-
nished with respect to specific individuals. 
(G) In the case of a provider that receives 
payment for items and services furnished under 
this Act based on diagnosis-related coding, pro-
cedure coding, or other coding system or data, 
the provider agrees— 
(i) to disclose to the Secretary any 
system or index of coding or classifying pa-
tient symptoms, diagnoses, clinical inter-
ventions, episodes, or procedures that such 
provider utilizes for global budget negotia-
tions under title VI or for meeting any 
other payment, documentation, or data col-
lection requirements under this Act; and 
(ii) not to use any such system or 
index to establish financial incentives or 
disincentives for health care professionals, 
or that is proprietary, interferes with the 
medical or nursing process, or is designed 
to increase the amount or number of pay-
ments. 
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(H) The provider complies with the duty of 
provider ethics and reporting requirements de-
scribed in paragraph (2). 
(I) In the case of a provider that is not an 
individual, the provider agrees that no board 
member, executive, or administrator of such 
provider receives compensation from, owns 
stock or has other financial investments in, or 
serves as a board member of any entity that 
contracts with or provides items or services, in-
cluding pharmaceutical products and medical 
devices or equipment, to such provider. 
(2) PROVIDER DUTY OF ETHICS.—Each health 
care provider, including institutional providers, has a 
duty to advocate for and to act in the exclusive in-
terest of each individual under the care of such pro-
vider according to the applicable legal standard of 
care, such that no financial interest or relationship 
impairs any health care provider’s ability to furnish 
necessary and appropriate care to such individual. 
To implement the duty established in this para-
graph, the Secretary shall— 
(A) promulgate reasonable reporting rules 
to evaluate participating provider compliance 
with this paragraph; 
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(B) 
prohibit 
participating 
providers, 
spouses, and immediate family members of par-
ticipating providers, from accepting or entering 
into any arrangement for any bonus, incentive 
payment, profit-sharing, or compensation based 
on patient utilization or based on financial out-
comes of any other provider or entity; and 
(C) prohibit participating providers or any 
board member or representative of such pro-
vider from serving as board members for or re-
ceiving any compensation, stock, or other finan-
cial investment in an entity that contracts with 
or provides items or services (including pharma-
ceutical products and medical devices or equip-
ment) to such provider. 
(3) TERMINATION OF PARTICIPATION AGREE-
MENT.— 
(A) IN
GENERAL.—Participation agree-
ments may be terminated, with appropriate no-
tice— 
(i) by the Secretary for failure to meet 
the requirements of this Act; 
(ii) in accordance with the provisions 
described in section 411; or 
(iii) by a provider. 
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(B) TERMINATION
PROCESS.—Providers 
shall be provided notice and a reasonable oppor-
tunity to correct deficiencies before the Sec-
retary terminates an agreement unless a more 
immediate termination is required for public 
safety or similar reasons. 
(C) PROVIDER PROTECTIONS.— 
(i) PROHIBITION.—The Secretary may 
not terminate a participation agreement or 
in any other way discriminate against, or 
cause to be discriminated against, any cov-
ered provider or authorized representative 
of the provider, on account of such pro-
vider or representative— 
(I) providing, causing to be pro-
vided, or being about to provide or 
cause to be provided to the provider, 
the Federal Government, or the attor-
ney general of a State information re-
lating to any violation of, or any act 
or omission the provider or represent-
ative reasonably believes to be a viola-
tion of, any provision of this title (or 
an amendment made by this title); 
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(II) testifying or being about to 
testify in a proceeding concerning 
such violation; 
(III) assisting or participating, or 
being about to assist or participate, in 
such a proceeding; or 
(IV) objecting to, or refusing to 
participate in, any activity, policy, 
practice, or assigned task that the 
provider or representative reasonably 
believes to be in violation of any provi-
sion of this Act (including any amend-
ment made by this Act), or any order, 
rule, regulation, standard, or ban 
under this Act (including any amend-
ment made by this Act). 
(ii) COMPLAINT PROCEDURE.—A pro-
vider or representative who believes that he 
or she has been discriminated against in 
violation of this section may seek relief in 
accordance with the procedures, notifica-
tions, burdens of proof, remedies, and stat-
utes of limitation set forth in section 
2087(b) of title 15, United States Code. 
(c) WHISTLEBLOWER PROTECTIONS.— 
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(1) RETALIATION
PROHIBITED.—No person 
may discharge or otherwise discriminate against any 
employee because the employee or any person acting 
pursuant to a request of the employee— 
(A) notified the Secretary or the employ-
ee’s employer of any alleged violation of this 
title, including communications related to car-
rying out the employee’s job duties; 
(B) refused to engage in any practice made 
unlawful by this title, if the employee has iden-
tified the alleged illegality to the employer; 
(C) testified before or otherwise provided 
information relevant for Congress or for any 
Federal or State proceeding regarding any pro-
vision (or proposed provision) of this title; 
(D) commenced, caused to be commenced, 
or is about to commence or cause to be com-
menced a proceeding under this title; 
(E) testified or is about to testify in any 
such proceeding; or 
(F) assisted or participated or is about to 
assist or participate in any manner in such a 
proceeding or in any other manner in such a 
proceeding or in any other action to carry out 
the purposes of this title. 
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(2) ENFORCEMENT
ACTION.—Any employee 
covered by this section who alleges discrimination by 
an employer in violation of paragraph (1) may bring 
an action, subject to the statute of limitations in the 
anti-retaliation provisions of the False Claims Act 
and the rules and procedures, legal burdens of proof, 
and remedies applicable under the employee protec-
tions provisions of the Surface Transportation As-
sistance Act. 
(3) APPLICATION.— 
(A) Nothing in this subsection shall be 
construed to diminish the rights, privileges, or 
remedies of any employee under any Federal or 
State law or regulation, including the rights 
and remedies against retaliatory action under 
the False Claims Act (31 U.S.C. 3730(h)), or 
under any collective bargaining agreement. The 
rights and remedies in this section may not be 
waived by any agreement, policy, form, or con-
dition of employment. 
(B) Nothing in this subsection shall be 
construed to preempt or diminish any other 
Federal or State law or regulation against dis-
crimination, demotion, discharge, suspension, 
threats, harassment, reprimand, retaliation, or 
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any other manner of discrimination, including 
the rights and remedies against retaliatory ac-
tion under the False Claims Act (31 U.S.C. 
3730(h)). 
(4) DEFINITIONS.—In this subsection: 
(A) EMPLOYER.—The term ‘‘employer’’ 
means any person engaged in profit or non-
profit business or industry, including one or 
more individuals, partnerships, associations, 
corporations, trusts, professional membership 
organization including a certification, discipli-
nary, or other professional body, unincorporated 
organizations, nongovernmental organizations, 
or trustees, and subject to liability for violating 
the provisions of this Act. 
(B) EMPLOYEE.—The term ‘‘employee’’ 
means any individual performing activities 
under this Act on behalf of an employer. 
SEC. 302. QUALIFICATIONS FOR PROVIDERS. 
(a) IN GENERAL.—A health care provider is consid-
ered to be qualified to furnish covered items and services 
under this Act if the provider is licensed or certified to 
furnish such items and services in the State in which the 
individual receiving such items or services is located and 
meets— 
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(1) the requirements of such State’s law to fur-
nish such items and services; and 
(2) applicable requirements of Federal law to 
furnish such items and services. 
(b) LIMITATION.—An entity or provider shall not be 
qualified to furnish covered items and services under this 
Act if the entity or provider provides no items and services 
directly to individuals, including— 
(1) entities or providers that contract with 
other entities or providers to provide such items and 
services; and 
(2) entities that are currently approved to co-
ordinate care plans under the Medicare Advantage 
program established in part C of title XVIII of the 
Social Security Act (42 U.S.C. 1851 et seq.) but do 
not directly provide items and services of such care 
plans. 
(c) MINIMUM PROVIDER STANDARDS.— 
(1) IN GENERAL.—The Secretary shall estab-
lish, evaluate, and update national minimum stand-
ards to ensure the quality of items and services pro-
vided under this Act and to monitor efforts by 
States to ensure the quality of such items and serv-
ices. A State may establish additional minimum 
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standards which providers shall meet with respect to 
items and services provided in such State. 
(2) NATIONAL
MINIMUM
STANDARDS.—The 
Secretary shall establish national minimum stand-
ards under paragraph (1) for institutional providers 
of services and individual health care practitioners. 
Except as the Secretary may specify in order to 
carry out this Act, a hospital, skilled nursing facility, 
or other institutional provider of services shall meet 
standards applicable to such a provider under the 
Medicare program under title XVIII of the Social 
Security Act (42 U.S.C. 1395 et seq.). Such stand-
ards also may include, where appropriate, elements 
relating to— 
(A) adequacy and quality of facilities; 
(B) mandatory minimum safe registered 
nurse-to-patient staffing ratios and optimal 
staffing levels for physicians and other health 
care practitioners; 
(C) training and competence of personnel 
(including requirements related to the number 
of or type of required continuing education 
hours); 
(D) comprehensiveness of service; 
(E) continuity of service; 
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(F) patient waiting time, access to serv-
ices, and preferences; and 
(G) performance standards, including orga-
nization, facilities, structure of services, effi-
ciency of operation, and outcome in palliation, 
improvement of health, stabilization, cure, or 
rehabilitation. 
(3) TRANSITION IN APPLICATION.—If the Sec-
retary provides for additional requirements for pro-
viders under this subsection, any such additional re-
quirement shall be implemented in a manner that 
provides for a reasonable period during which a pre-
viously qualified provider is permitted to meet such 
an additional requirement. 
(4) ABILITY TO PROVIDE SERVICES.—With re-
spect to any entity or provider certified to provide 
items and services described in section 201(a)(7), 
the Secretary may not prohibit such entity or pro-
vider from participating for reasons other than such 
entity’s or provider’s ability to provide such items 
and services. 
(d) FEDERAL PROVIDERS.—Any provider qualified to 
provide health care items and services through the Depart-
ment of Veterans Affairs, the Indian Health Service, or 
the uniformed services (with respect to the direct care 
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component of the TRICARE Program) is a qualifying pro-
vider under this section with respect to any individual who 
qualifies for such items and services under applicable Fed-
eral law. 
SEC. 303. USE OF PRIVATE CONTRACTS. 
(a) IN GENERAL.—This section shall apply beginning 
2 years after the date of the enactment of this Act. 
(b) PARTICIPATING PROVIDERS.— 
(1) PRIVATE CONTRACTS FOR COVERED ITEMS 
AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in-
stitutional or individual provider with an agreement 
in effect under section 301 may not bill or enter into 
any private contract with any individual eligible for 
benefits under the Act for any item or service that 
is a benefit under this Act. 
(2) PRIVATE
CONTRACTS
FOR
NONCOVERED 
ITEMS AND SERVICES FOR ELIGIBLE INDIVIDUALS.— 
An institutional or individual provider with an agree-
ment in effect under section 301 may bill or enter 
into a private contract with an individual eligible for 
benefits under the Act for any item or service that 
is not a benefit under this Act only if— 
(A) the contract and provider meet the re-
quirements specified in paragraphs (3) and (4), 
respectively; 
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(B) such item or service is not payable or 
available under this Act; and 
(C) the provider receives— 
(i) no reimbursement under this Act 
directly or indirectly for such item or serv-
ice, and 
(ii) receives no amount for such item 
or service from an organization which re-
ceives reimbursement for such items or 
service under this Act directly or indirectly. 
(3) CONTRACT REQUIREMENTS.—Any contract 
to provide items and services described in paragraph 
(2) shall— 
(A) be in writing and signed by the indi-
vidual (or authorized representative of the indi-
vidual) receiving the item or service before the 
item or service is furnished pursuant to the 
contract; 
(B) not be entered into at a time when the 
individual is facing an emergency health care 
situation; and 
(C) clearly indicate to the individual receiv-
ing such items and services that by signing 
such a contract the individual— 
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(i) agrees not to submit a claim (or to 
request that the provider submit a claim) 
under this Act for such items or services; 
(ii) agrees to be responsible for pay-
ment of such items or services and under-
stands that no reimbursement will be pro-
vided under this Act for such items or 
services; 
(iii) acknowledges that no limits under 
this Act apply to amounts that may be 
charged for such items or services; and 
(iv) acknowledges that the provider is 
providing services outside the scope of the 
program under this Act. 
(4) AFFIDAVIT.—A participating provider who 
enters into a contract described in paragraph (2) 
shall have in effect during the period any item or 
service is to be provided pursuant to the contract an 
affidavit that shall— 
(A) identify the provider who is to furnish 
such noncovered item or service, and be signed 
by such provider; 
(B) state that the provider will not submit 
any claim under this Act for any noncovered 
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item or service provided to any individual en-
rolled under this Act; and 
(C) be filed with the Secretary no later 
than 10 days after the first contract to which 
such affidavit applies is entered into. 
(5) ENFORCEMENT.—If a provider signing an 
affidavit described in paragraph (4) knowingly and 
willfully submits a claim under this title for any item 
or service provided or receives any reimbursement or 
amount for any such item or service provided pursu-
ant to a private contract described in paragraph (2) 
with respect to such affidavit— 
(A) any contract described in paragraph 
(2) shall be null and void; 
(B) no payment shall be made under this 
title for any item or service furnished by the 
provider during the 2-year period beginning on 
the date the affidavit was signed; and 
(C) any payment received under this title 
for any item or service furnished during such 
period shall be remitted. 
(6) PRIVATE CONTRACTS FOR INELIGIBLE INDI-
VIDUALS.—An institutional or individual provider 
with an agreement in effect under section 301 may 
bill or enter into a private contract with any indi-
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vidual ineligible for benefits under the Act for any 
item or service. 
(c) NONPARTICIPATING PROVIDERS.— 
(1) PRIVATE CONTRACTS FOR COVERED ITEMS 
AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in-
stitutional or individual provider with no agreement 
in effect under section 301 may bill or enter into 
any private contract with any individual eligible for 
benefits under the Act for any item or service that 
is a benefit under this Act described in title II only 
if the contract and provider meet the requirements 
specified in paragraphs (2) and (3), respectively. 
(2) ITEMS REQUIRED TO BE INCLUDED IN CON-
TRACT.—Any contract to provide items and services 
described in paragraph (1) shall— 
(A) be in writing and signed by the indi-
vidual (or authorized representative of the indi-
vidual) receiving the item or service before the 
item or service is furnished pursuant to the 
contract; 
(B) not be entered into at a time when the 
individual is facing an emergency health care 
situation; and 
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(C) clearly indicate to the individual receiv-
ing such items and services that by signing 
such a contract the individual— 
(i) acknowledges that the individual 
has the right to have such items or services 
provided by other providers for whom pay-
ment would be made under this Act; 
(ii) agrees not to submit a claim (or 
to request that the provider submit a 
claim) under this Act for such items or 
services even if such items or services are 
otherwise covered by this Act; 
(iii) agrees to be responsible for pay-
ment of such items or services and under-
stands that no reimbursement will be pro-
vided under this Act for such items or 
services; 
(iv) acknowledges that no limits under 
this Act apply to amounts that may be 
charged for such items or services; and 
(v) acknowledges that the provider is 
providing services outside the scope of the 
program under this Act. 
(3) AFFIDAVIT.—A provider who enters into a 
contract described in paragraph (1) shall have in ef-
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fect during the period any item or service is to be 
provided pursuant to the contract an affidavit that 
shall— 
(A) identify the provider who is to furnish 
such covered item or service, and be signed by 
such provider; 
(B) state that the provider will not submit 
any claim under this Act for any covered item 
or service provided to any individual enrolled 
under this Act during the 2-year period begin-
ning on the date the affidavit is signed; and 
(C) be filed with the Secretary no later 
than 10 days after the first contract to which 
such affidavit applies is entered into. 
(4) ENFORCEMENT.—If a provider signing an 
affidavit described in paragraph (3) knowingly and 
willfully submits a claim under this title for any item 
or service provided or receives any reimbursement or 
amount for any such item or service provided pursu-
ant to a private contract described in paragraph (1) 
with respect to such affidavit— 
(A) any contract described in paragraph 
(1) shall be null and void; and 
(B) no payment shall be made under this 
title for any item or service furnished by the 
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provider during the 2-year period beginning on 
the date the affidavit was signed. 
(5) PRIVATE
CONTRACTS
FOR
NONCOVERED 
ITEMS AND SERVICES FOR ANY INDIVIDUAL.—An in-
stitutional or individual provider with no agreement 
in effect under section 301 may bill or enter into a 
private contract with any individual for a item or 
service that is not a benefit under this Act. 
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TITLE IV—ADMINISTRATION 
Subtitle A—General 
Administration Provisions 
SEC. 401. ADMINISTRATION. 
(a) GENERAL DUTIES OF THE SECRETARY.— 
(1) IN GENERAL.—The Secretary shall develop 
policies, procedures, guidelines, and requirements to 
carry out this Act, including related to— 
(A) eligibility for benefits; 
(B) enrollment; 
(C) benefits provided; 
(D) provider participation standards and 
qualifications, as described in title III; 
(E) levels of funding; 
(F) methods for determining amounts of 
payments to providers of covered items and 
services, consistent with subtitle B; 
(G) a process for appealing or petitioning 
for a determination of coverage or noncoverage 
of items and services under this Act; 
(H) planning for capital expenditures and 
service delivery; 
(I) planning for health professional edu-
cation funding; 
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(J) encouraging States to develop regional 
planning mechanisms; and 
(K) any other regulations necessary to 
carry out the purposes of this Act. 
(2) REGULATIONS.—Regulations authorized by 
this Act shall be issued by the Secretary in accord-
ance with section 553 of title 5, United States Code. 
(3) ACCESSIBILITY.—The Secretary shall have 
the obligation to ensure the timely and accessible 
provision of items and services that all eligible indi-
viduals are entitled to under this Act. 
(b) UNIFORM REPORTING STANDARDS; ANNUAL RE-
PORT; STUDIES.— 
(1) UNIFORM REPORTING STANDARDS.— 
(A) IN GENERAL.—The Secretary shall es-
tablish uniform State reporting requirements 
and national standards to ensure an adequate 
national database containing information per-
taining to health services practitioners, ap-
proved providers, the costs of facilities and 
practitioners providing items and services, the 
quality of such items and services, the outcomes 
of such items and services, and the equity of 
health among population groups. Such database 
shall include, to the maximum extent feasible 
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without compromising patient privacy, health 
outcome measures used under this Act, and to 
the maximum extent feasible without excessively 
burdening providers, a description of the stand-
ards and qualifications, levels of finding, and 
methods 
described 
in 
subparagraphs 
(D) 
through (F) of subsection (a)(1). 
(B) REQUIRED
DATA
DISCLOSURES.—In 
establishing reporting requirements and stand-
ards under subparagraph (A), the Secretary 
shall require a provider with an agreement in 
effect under section 301 to disclose to the Sec-
retary, in a time and manner specified by the 
Secretary, the following (as applicable to the 
type of provider): 
(i) Any data the provider is required 
to report or does report to any State or 
local agency, or, as of January 1, 2019, to 
the Secretary or any entity that is part of 
the Department of Health and Human 
Services, except data that are required 
under the programs terminated in section 
903. 
(ii) Annual financial data that in-
cludes information on employees (including 
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the number of employees, hours worked, 
and wage information) by job title and by 
each patient care unit or department with-
in each facility (including outpatient units 
or departments); the number of registered 
nurses per staffed bed by each such unit or 
department; information on the dollar 
value and annual spending (including pur-
chases, upgrades, and maintenance) for 
health information technology; and risk-ad-
justed and raw patient outcome data (in-
cluding data on medical, surgical, obstet-
ric, and other procedures). 
(C) REPORTS.—The Secretary shall regu-
larly analyze information reported to the Sec-
retary and shall define rules and procedures to 
allow researchers, scholars, health care pro-
viders, and others to access and analyze data 
for purposes consistent with quality and out-
comes research, without compromising patient 
privacy. 
(2) ANNUAL REPORT.—Beginning 2 years after 
the date of the enactment of this Act, the Secretary 
shall annually report to Congress on the following: 
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(A) The status of implementation of the 
Act. 
(B) Enrollment under this Act. 
(C) Benefits under this Act. 
(D) Expenditures and financing under this 
Act. 
(E) 
Cost-containment 
measures 
and 
achievements under this Act. 
(F) Quality assurance. 
(G) Health care utilization patterns, in-
cluding any changes attributable to the pro-
gram. 
(H) Changes in the per-capita costs of 
health care. 
(I) Differences in the health status of the 
populations of the different States, including by 
racial, ethnic, national origin, primary language 
use, age, disability, sex, including gender iden-
tity and sexual orientation, geographical, and 
income characteristics. 
(J) Progress on quality and outcome meas-
ures, and long-range plans and goals for 
achievements in such areas. 
(K) Plans for improving service to medi-
cally underserved populations. 
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(L) Transition problems as a result of im-
plementation of this Act. 
(M) Opportunities for improvements under 
this Act. 
(3) STATISTICAL ANALYSES AND OTHER STUD-
IES.—The Secretary may, either directly or by con-
tract— 
(A) make statistical and other studies, on 
a nationwide, regional, State, or local basis, of 
any aspect of the operation of this Act; 
(B) develop and test methods of delivery of 
items and services as the Secretary may con-
sider necessary or promising for the evaluation, 
or for the improvement, of the operation of this 
Act; and 
(C) develop methodological standards for 
policymaking. 
(c) AUDITS.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct an audit of the De-
partment of Health and Human Services every fifth 
fiscal year following the effective date of this Act to 
determine the effectiveness of the program in car-
rying out the duties under subsection (a). 
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(2) REPORTS.—The Comptroller General of the 
United States shall submit a report to Congress con-
cerning the results of each audit conducted under 
this subsection. 
SEC. 402. CONSULTATION. 
The Secretary shall consult with Federal agencies, 
Indian tribes and urban Indian health organizations, and 
private entities, such as labor organizations representing 
health care workers, professional societies, national asso-
ciations, nationally recognized associations of health care 
experts, medical schools and academic health centers, con-
sumer groups, and business organizations in the formula-
tion of guidelines, regulations, policy initiatives, and infor-
mation gathering to ensure the broadest and most in-
formed input in the administration of this Act. Nothing 
in this Act shall prevent the Secretary from adopting 
guidelines, consistent with the provisions of section 203(c), 
developed by such a private entity if, in the Secretary’s 
judgment, such guidelines are generally accepted as rea-
sonable and prudent and consistent with this Act. 
SEC. 403. REGIONAL ADMINISTRATION. 
(a) COORDINATION WITH REGIONAL OFFICES.—The 
Secretary shall establish and maintain regional offices for 
purposes of carrying out the duties specified in subsection 
(c) and promoting adequate access to, and efficient use 
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of, tertiary care facilities, equipment, and services by indi-
viduals enrolled under this Act. Wherever possible, the 
Secretary shall incorporate regional offices of the Centers 
for Medicare & Medicaid Services for this purpose. 
(b) APPOINTMENT OF REGIONAL DIRECTORS.—In 
each such regional office there shall be— 
(1) one regional director appointed by the Sec-
retary; 
(2) one deputy director appointed by the re-
gional director to represent the Indian and Alaska 
Native tribes in the region, if any; and 
(3) one deputy direction appointed by the re-
gional director to oversee long-term services and 
supports. 
(c) REGIONAL OFFICE DUTIES.—Each regional di-
rector shall— 
(1) provide an annual health care needs assess-
ment with respect to the region under the director’s 
jurisdiction to the Secretary after a thorough exam-
ination of health needs and in consultation with pub-
lic health officials, clinicians, patients, and patient 
advocates; 
(2) recommend any changes in provider reim-
bursement or payment for delivery of health services 
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determined appropriate by the regional director, sub-
ject to the provisions of title VI; and 
(3) establish a quality assurance mechanism in 
each such region in order to minimize both under-
utilization and overutilization of health care items 
and services and to ensure that all providers meet 
quality standards established pursuant to this Act. 
SEC. 404. BENEFICIARY OMBUDSMAN. 
(a) IN GENERAL.—The Secretary shall appoint a 
Beneficiary Ombudsman who shall have expertise and ex-
perience in the fields of health care and education of, and 
assistance to, individuals enrolled under this Act. 
(b) DUTIES.—The Beneficiary Ombudsman shall— 
(1) receive complaints, grievances, and requests 
for information submitted by individuals enrolled 
under this Act or eligible to enroll under this Act 
with respect to any aspect of the Medicare for All 
Program; 
(2) provide assistance with respect to com-
plaints, grievances, and requests referred to in para-
graph (1), including assistance in collecting relevant 
information for such individuals, to seek an appeal 
of a decision or determination made by a regional of-
fice or the Secretary; and 
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(3) submit annual reports to Congress and the 
Secretary that describe the activities of the Ombuds-
man and that include such recommendations for im-
provement in the administration of this Act as the 
Ombudsman determines appropriate. The Ombuds-
man shall not serve as an advocate for any increases 
in payments or new coverage of services, but may 
identify issues and problems in payment or coverage 
policies. 
SEC. 405. CONDUCT OF RELATED HEALTH PROGRAMS. 
In performing functions with respect to health per-
sonnel education and training, health research, environ-
mental health, disability insurance, vocational rehabilita-
tion, the regulation of food and drugs, and all other mat-
ters pertaining to health, the Secretary shall direct the ac-
tivities of the Department of Health and Human Services 
toward contributions to the health of the people com-
plementary to this Act. 
Subtitle B—Control Over Fraud 
and Abuse 
SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL 
FRAUD AND ABUSE UNDER THE MEDICARE 
FOR ALL PROGRAM. 
The following sections of the Social Security Act shall 
apply to this Act in the same manner as they apply to 
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title XVIII or State plans under title XIX of the Social 
Security Act: 
(1) Section 1128 (relating to exclusion of indi-
viduals and entities). 
(2) Section 1128A (civil monetary penalties). 
(3) Section 1128B (criminal penalties). 
(4) Section 1124 (relating to disclosure of own-
ership and related information). 
(5) Section 1126 (relating to disclosure of cer-
tain owners). 
(6) Section 1877 (relating to physician refer-
rals). 
TITLE V—QUALITY ASSESSMENT 
SEC. 501. QUALITY STANDARDS. 
(a) IN GENERAL.—All standards and quality meas-
ures under this Act shall be implemented and evaluated 
by the Center for Clinical Standards and Quality of the 
Centers for Medicare & Medicaid Services (referred to in 
this title as the ‘‘Center’’) or such other agency deter-
mined appropriate by the Secretary, in coordination with 
the Agency for Healthcare Research and Quality and other 
offices of the Department of Health and Human Services. 
(b) DUTIES OF THE CENTER.—The Center shall per-
form the following duties: 
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(1) Review and evaluate each practice guideline 
developed under part B of title IX of the Public 
Health Service Act. In so reviewing and evaluating, 
the Center shall determine whether the guideline 
should be recognized as a national practice guideline 
in accordance with and subject to the provisions of 
section 203(c). 
(2) Review and evaluate each standard of qual-
ity, performance measure, and medical review cri-
terion developed under part B of title IX of the Pub-
lic Health Service Act (42 U.S.C. 299 et seq.). In 
so reviewing and evaluating, the Center shall deter-
mine whether the standard, measure, or criterion is 
appropriate for use in assessing or reviewing the 
quality of items and services provided by health care 
institutions or health care professionals. The use of 
mechanisms that discriminate against people with 
disabilities is prohibited for use in any value or cost- 
effectiveness assessments. The Center shall consider 
the evidentiary basis for the standard, and the valid-
ity, reliability, and feasibility of measuring the 
standard. 
(3) Adoption of methodologies for profiling the 
patterns of practice of health care professionals and 
for identifying and notifying outliers. 
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(4) Development of minimum criteria for com-
petence for entities that can qualify to conduct ongo-
ing and continuous external quality reviews in the 
administrative regions. Such criteria shall require 
such an entity to be administratively independent of 
the individual or board that administers the region 
and shall ensure that such entities do not provide fi-
nancial incentives to reviewers to favor one pattern 
of practice over another. The Center shall ensure co-
ordination and reporting by such entities to ensure 
national consistency in quality standards. 
(5) Submission of a report to the Secretary an-
nually specifically on findings from outcomes re-
search and development of practice guidelines that 
may affect the Secretary’s determination of coverage 
of services under section 401(a)(1)(G). 
SEC. 502. ADDRESSING HEALTH CARE DISPARITIES. 
(a) 
EVALUATING
DATA
COLLECTION
AP-
PROACHES.—The Center shall evaluate approaches for the 
collection of data under this Act, to be performed in con-
junction with existing quality reporting requirements and 
programs under this Act, that allow for the ongoing, accu-
rate, and timely collection of data on disparities in health 
care services and performance on the basis of race, eth-
nicity, national origin, primary language use, age, dis-
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ability, sex (including gender identity and sexual orienta-
tion), geography, or socioeconomic status. In conducting 
such evaluation, the Center shall consider the following ob-
jectives: 
(1) Protecting patient privacy. 
(2) Minimizing the administrative burdens of 
data collection and reporting on providers under this 
Act. 
(3) Improving data on race, ethnicity, national 
origin, primary language use, age, disability, sex (in-
cluding gender identity and sexual orientation), ge-
ography, and socioeconomic status. 
(b) REPORTS TO CONGRESS.— 
(1) REPORT ON EVALUATION.—Not later than 
18 months after the date on which benefits first be-
come available as described in section 106(a), the 
Center shall submit to Congress and the Secretary 
a report on the evaluation conducted under sub-
section (a). Such report shall, taking into consider-
ation the results of such evaluation— 
(A) identify approaches (including defining 
methodologies) for identifying and collecting 
and evaluating data on health care disparities 
on the basis of race, ethnicity, national origin, 
primary language use, age, disability, sex (in-
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cluding gender identity and sexual orientation), 
geography, or socioeconomic status under the 
Medicare for All Program; and 
(B) include recommendations on the most 
effective strategies and approaches to reporting 
quality measures, as appropriate, on the basis 
of race, ethnicity, national origin, primary lan-
guage use, age, disability, sex (including gender 
identity and sexual orientation), geography, or 
socioeconomic status. 
(2) REPORT
ON
DATA
ANALYSES.—Not later 
than 4 years after the submission of the report 
under subsection (b)(1), and every 4 years there-
after, the Center shall submit to Congress and the 
Secretary a report that includes recommendations 
for improving the identification of health care dis-
parities based on the analyses of data collected 
under subsection (c). 
(c) IMPLEMENTING EFFECTIVE APPROACHES.—Not 
later than 2 years after the date on which benefits first 
become available as described in section 106(a), the Sec-
retary shall implement the approaches identified in the re-
port submitted under subsection (b)(1) for the ongoing, 
accurate, and timely collection and evaluation of data on 
health care disparities on the basis of race, ethnicity, na-
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tional origin, primary language use, age, disability, sex 
(including gender identity and sexual orientation), geog-
raphy, or socioeconomic status. 
TITLE 
VI—HEALTH 
BUDGET; 
PAYMENTS; COST CONTAIN-
MENT MEASURES 
Subtitle A—Budgeting 
SEC. 601. NATIONAL HEALTH BUDGET. 
(a) NATIONAL HEALTH BUDGET.— 
(1) IN GENERAL.—By not later than September 
1 of each year, beginning with the year prior to the 
date on which benefits first become available as de-
scribed in section 106(a), the Secretary shall estab-
lish a national health budget, which specifies a budg-
et for the total expenditures to be made for covered 
health care items and services under this Act. 
(2) DIVISION OF BUDGET INTO COMPONENTS.— 
The national health budget shall consist of the fol-
lowing components: 
(A) An operating budget. 
(B) A capital expenditures budget. 
(C) A special projects budget. 
(D) Quality assessment activities under 
title V. 
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(E) Health professional education expendi-
tures. 
(F) Administrative costs, including costs 
related to the operation of regional offices. 
(G) A reserve fund. 
(H) Prevention and public health activities. 
(3) ALLOCATION
AMONG
COMPONENTS.—The 
Secretary shall allocate the funds received for pur-
poses of carrying out this Act among the compo-
nents described in paragraph (2) in a manner that 
ensures— 
(A) that the operating budget allows for 
every participating provider in the Medicare for 
All Program to meet the needs of their respec-
tive patient populations; 
(B) that the special projects budget is suf-
ficient to meet the health care needs within 
areas described in paragraph (2)(C) through 
the construction, renovation, and staffing of 
health care facilities in a reasonable timeframe; 
(C) a fair allocation for quality assessment 
activities; and 
(D) that the health professional education 
expenditure component is sufficient to provide 
for the amount of health professional education 
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expenditures sufficient to meet the need for cov-
ered health care services. 
(4) REGIONAL
ALLOCATION.—The Secretary 
shall annually provide each regional office with an 
allotment the Secretary determines appropriate for 
purposes of carrying out this Act in such region, in-
cluding payments to providers in such region, capital 
expenditures in such region, special projects in such 
region, health professional education in such region, 
administrative expenses in such region, and preven-
tion and public health activities in such region. 
(5) OPERATING BUDGET.—The operating budg-
et described in paragraph (2)(A) shall be used for— 
(A) payments to institutional providers 
pursuant to section 611; and 
(B) payments to individual providers pur-
suant to section 612. 
(6) CAPITAL
EXPENDITURES
BUDGET.—The 
capital expenditures budget described in paragraph 
(2)(B) shall be used for— 
(A) the construction or renovation of 
health care facilities, excluding congregate or 
segregated facilities for individuals with disabil-
ities who receive long-term care services and 
support; and 
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(B) major equipment purchases. 
(7) SPECIAL PROJECTS BUDGET.—The special 
projects budget described in paragraph (2)(C) shall 
be used for the purposes of allocating funds for the 
construction of new facilities, major equipment pur-
chases, and staffing in rural or medically under-
served areas (as defined in section 330(b)(3) of the 
Public Health Service Act (42 U.S.C. 254b(b)(3))), 
including areas designated as health professional 
shortage areas (as defined in section 332(a) of the 
Public Health Service Act (42 U.S.C. 254e(a))), and 
to address health disparities, including racial, ethnic, 
national origin, primary language use, age, dis-
ability, sex (including gender identity and sexual ori-
entation), geography, or socioeconomic health dis-
parities. 
(8) TEMPORARY WORKER ASSISTANCE.— 
(A) IN GENERAL.—For up to 5 years fol-
lowing the date on which benefits first become 
available as described in section 106(a), at least 
1 percent of the budget shall be allocated to 
programs providing assistance to workers who 
perform functions in the administration of the 
health insurance system, or related functions 
within health care institutions or organizations 
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who may be affected by the implementation of 
this Act and who may experience economic dis-
location as a result of the implementation of 
this Act. 
(B) CLARIFICATION.—Assistance described 
in subparagraph (A) shall include wage replace-
ment, retirement benefits, job training and 
placement, preferential hiring, and education 
benefits. 
(9) RESERVE
FUND.—The reserve fund de-
scribed in paragraph (2)(G) shall be used to respond 
to the costs of an epidemic, pandemic, natural dis-
aster, or other such health emergency, or market- 
shift adjustments related to patient volume. 
(10) SUPPLEMENTAL INDIAN HEALTH SERVICE 
ALLOCATION.—The Secretary shall annually deter-
mine the need to provide an allotment of supple-
mental funds to Indian Health Services, including 
payments to providers, capital expenditures, special 
projects, health professional education, administra-
tive expenses, and prevention and public health ac-
tivities. 
(b) DEFINITIONS.—In this section: 
(1) CAPITAL EXPENDITURES.—The term ‘‘cap-
ital expenditures’’ means expenses for the purchase, 
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lease, construction, or renovation of capital facilities 
and for major equipment. 
(2) HEALTH
PROFESSIONAL
EDUCATION
EX-
PENDITURES.—The term ‘‘health professional edu-
cation expenditures’’ means expenditures in hospitals 
and other health care facilities to cover costs associ-
ated with teaching and related research activities, in-
cluding the impact of workforce diversity on patient 
outcomes. 
Subtitle B—Payments to Providers 
SEC. 
611. 
PAYMENTS 
TO 
INSTITUTIONAL 
PROVIDERS 
BASED ON GLOBAL BUDGETS. 
(a) IN GENERAL.—Not later than the beginning of 
each fiscal quarter during which an institutional provider 
of care (including hospitals, skilled nursing facilities, Fed-
erally qualified health centers, and independent dialysis fa-
cilities) is to furnish items and services under this Act, 
the Secretary shall pay to such institutional provider a 
lump sum in accordance with the succeeding provisions of 
this subsection and consistent with the following: 
(1) PAYMENT IN FULL.—Such payment shall be 
considered as payment in full for all operating ex-
penses for items and services furnished under this 
Act, whether inpatient or outpatient, by such pro-
vider for such quarter, including outpatient or any 
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other care provided by the institutional provider or 
provided by any health care provider who provided 
items and services pursuant to an agreement paid 
through the global budget as described in paragraph 
(3). 
(2) QUARTERLY REVIEW.—The regional direc-
tor, on a quarterly basis, shall review whether re-
quirements of the institutional provider’s participa-
tion agreement and negotiated global budget have 
been performed and shall determine whether adjust-
ments to such institutional provider’s payment are 
warranted. This review shall include consideration 
for additional funding necessary for unanticipated 
items and services for individuals with complex med-
ical needs or market-shift adjustments related to pa-
tient volume. The review shall also include an as-
sessment of any adjustments made to ensure that 
accuracy and need for adjustment was appropriate. 
(3) AGREEMENTS
FOR
SALARIED
PAYMENTS 
FOR CERTAIN PROVIDERS.—Certain group practices 
and other health care providers, as determined by 
the Secretary, with agreements to provide items and 
services at a specified institutional provider paid a 
global budget under this subsection may elect to be 
paid through such institutional provider’s global 
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