worker rights, and the impact of national labor poli-
cies. 
‘‘(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 
services 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 
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home- and community-based long-term services and sup-
port benefits under any State plan or waiver under title 
XIX as 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 
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individual is eligible under any other federally fund-
ed program that provides benefits or assistance. 
‘‘(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 2029, a health insurance issuer may offer health 
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insurance coverage in the individual market only if such 
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 
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sponsor, MA for America plan, individuals eligible for cov-
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. 
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‘‘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 2029, 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) 
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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. 
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(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, 2031, 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. 
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(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. 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 2026, 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-
work of such plan if the organization has cause 
to remove such provider or supplier. 
‘‘(B) CAUSE TO REMOVE PROVIDERS.— 
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‘‘(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-
tion of a provider of services or supplier in 
a network of such plan does not constitute 
cause for the MA organization to remove 
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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 
2026, 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 
provider or supplier and to the Secretary 
an explanation of the reason or reasons for 
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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 
422.202(a) of title 42, Code of Fed-
eral Regulations, shall apply. 
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‘‘(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; 
‘‘(II) information regarding the 
options available to an individual en-
rolled in such plan to request the con-
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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 
plan receiving items or services from the 
provider or supplier during the plan year 
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in effect on the date of removal or during 
the previous plan year. 
‘‘(F) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as affect-
ing the ability of a provider of services or sup-
plier to decline to participate in a network of an 
MA plan. 
‘‘(8) TRANSPARENCY IN MEASURES USED BY 
MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO-
VIDER NETWORKS.— 
‘‘(A) IN GENERAL.—Beginning with plan 
year 2026, an MA organization offering an MA 
plan shall publish and make accessible the in-
formation described in subparagraph (B)— 
‘‘(i) in the annual bid information 
submitted by the MA organization with re-
spect to the MA plan under section 1854; 
and 
‘‘(ii) on the Internet Web Site for the 
MA plan. 
‘‘(B) INFORMATION DESCRIBED.—The in-
formation described in this subparagraph is the 
following: 
‘‘(i) Information regarding the meas-
ures used by the MA organization to estab-
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lish or modify the provider network of the 
MA plan, including measures of the quality 
and efficiency of providers. Such informa-
tion shall include the specifications, meth-
odology, and sample size of such measures. 
‘‘(ii) Other information related to the 
establishment or modification of such pro-
vider network that the Secretary deter-
mines appropriate. 
‘‘(C) LIMITATION.—The information de-
scribed in subparagraph (B) shall not include 
any individually identifiable information of any 
provider or supplier of services.’’. 
(b) ENFORCEMENT.— 
(1) SANCTIONS FOR NONCOMPLIANCE.—Section 
1857(g)(1) of the Social Security Act (42 U.S.C. 
1395w–27(g)(1)) is amended— 
(A) in subparagraph (J), by striking ‘‘or’’; 
(B) by redesignating subparagraph (K) as 
subparagraph (L); 
(C) by inserting after subparagraph (J) 
the following new subparagraph: 
‘‘(K) 
fails 
to 
comply 
with 
section 
1852(d)(7) or 1852(d)(8); or’’; and 
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(D) in subparagraph (L) (as so redesig-
nated), by striking ‘‘through (J)’’ and inserting 
‘‘through (K)’’. 
(2) SANCTIONS NOT APPLICABLE TO PART D.— 
Title XVIII of the Social Security Act is amended— 
(A) in section 1860D–12(b)(3)(E) (42 
U.S.C. 1395w— 
(B) in section 1894(e)(6)(B) (42 U.S.C. 
1395eee(e)(6)(B)), by inserting ‘‘(other than 
paragraph (1)(K) of such section)’’ after 
‘‘1857(g)(1)’’. 
(c) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 
Not later than one year after the date of enactment of 
this Act, the Secretary of Health and Human Services 
shall take such measures as are necessary to ensure that 
the Medicare Advantage Compare Tool takes into account 
the preferences and utilization needs of such individuals. 
SEC. 122. NETWORK ADEQUACY. 
(a) IN GENERAL.—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: 
‘‘(9) NETWORK
ADEQUACY
REQUIREMENTS.— 
Beginning in plan year 2024, notwithstanding any 
other provision of law, the following shall apply: 
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‘‘(A) PROVIDER AVAILABILITY.—When es-
tablishing a plan network, a Medicare Advan-
tage organization offering an MA plan shall, 
among other factors determined by the Sec-
retary, consider the following: 
‘‘(i) The anticipated enrollment in the 
plan. 
‘‘(ii) The expected types of services 
provided and utilization of services by en-
rollees under the plan. 
‘‘(iii) The number and types of pro-
viders needed to provide such services. 
‘‘(iv) The number of network pro-
viders who are not accepting new patients. 
‘‘(v) The location of providers and en-
rollees, taking into account geographic dis-
bursement. 
‘‘(vi) The full-time equivalent avail-
ability of a provider to provide such serv-
ices. 
‘‘(B) PROVISION
OF
CARE
IN
A
TIMELY 
MANNER.—A Medicare Advantage organization 
offering an MA plan shall ensure that providers 
are able to provide services in a timely manner, 
as defined by the Secretary, under the plan. 
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‘‘(C) APPLICATION OF NETWORK ACCESS 
ADEQUACY STANDARDS.—In applying the net-
work access adequacy standards pursuant to 
paragraph (1), the Secretary shall seek input 
from patient advocacy groups, providers of serv-
ices and suppliers, and MA plans under this 
part. 
‘‘(D) CERTIFICATION.—Each plan year, a 
Medicare Advantage organization shall certify 
to the Secretary, with respect to each MA plan 
offered by the organization, that the providers, 
including specialists and subspecialists, in the 
plan network are able to provide the services re-
quired under the organization’s contract with 
the Secretary under section 1857 with respect 
to the offering of such plan and to meet the 
needs of the enrollees within the plan service 
area during the year. 
‘‘(E) ANNUAL
REPORTING.—Each plan 
year, a Medicare Advantage organization shall 
report to the Secretary, and make public the 
following with respect to each MA plan offered 
by the organization: 
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‘‘(i) AVERAGE WAIT TIME.—The aver-
age wait time for primary and specialty 
care for enrollees under the plan. 
‘‘(ii) UTILIZATION
OF
OUT-OF-NET-
WORK PROVIDERS.—The utilization of out- 
of-network providers under the plan. 
‘‘(iii) AVERAGE COST PER PATIENT.— 
The average annual spending per patient 
for primary and specialty care for enrollees 
under the plan. 
‘‘(F) CERTIFICATION.—In advance of the 
annual, coordinated election period under sec-
tion 1851(e)(3), a Medicare Advantage organi-
zation shall certify to the Secretary the accu-
racy of provider directories for each plan of-
fered by the organization. 
‘‘(G) NETWORK
REVIEW.—The Secretary 
shall ensure that the network of each MA plan 
offered by a Medicare Advantage organization 
meets the network adequacy guidelines estab-
lished under this paragraph and under section 
422.112(a)(4) of title 42, Code of Federal Reg-
ulations (or any successor regulation to such 
section) at least once every 3 years or when a 
material change in network occurs. 
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‘‘(H) AUTHORITY.—The Secretary shall 
have the authority to stop any further enroll-
ment in a Medicare Advantage plan if there is 
a pattern of excessive violations of this para-
graph.’’. 
(b) ENFORCEMENT.—Section 1857(g)(1)(K) of the 
Social Security Act (42 U.S.C. 1395w–27(g)(1)(K)), as 
added by section 2(b), is amended by striking ‘‘or 
1852(d)(8)’’ and inserting ‘‘, 1852(d)(8), or 1852(d)(9)’’. 
SEC. 123. ELIMINATING THE 24-MONTH WAITING PERIOD 
FOR MEDICARE COVERAGE FOR INDIVID-
UALS WITH DISABILITIES. 
(a) IN GENERAL.—Section 226(b) of the Social Secu-
rity Act (42 U.S.C. 426(b)) is amended— 
(1) in paragraph (2)(A), by striking ‘‘, and has 
for 24 calendar months been entitled to,’’; 
(2) in paragraph (2)(B), by striking ‘‘, and has 
been for not less than 24 months,’’; 
(3) in paragraph (2)(C)(ii), by striking ‘‘, in-
cluding the requirement that he has been entitled to 
the specified benefits for 24 months,’’; 
(4) in the first sentence, by striking ‘‘for each 
month beginning with the later of (I) July 1973 or 
(II) the twenty-fifth month of his entitlement or sta-
tus as a qualified railroad retirement beneficiary de-
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scribed in paragraph (2), and’’ and inserting ‘‘for 
each month for which the individual meets the re-
quirements of paragraph (2), beginning with the 
month following the month in which the individual 
meets the requirements of such paragraph, and’’; 
and 
(5) in the second sentence, by striking ‘‘the’’ 
twenty-fifth month of his entitlement‘‘’’ and all that 
follows through ‘‘paragraph (2)(C) and’’. 
(b) CONFORMING AMENDMENTS.— 
(1) SECTION 226.—Section 226 of the Social 
Security Act (42 U.S.C. 426) is amended by— 
(A) striking subsections (e)(1)(B), (f), and 
(h); and 
(B) redesignating subsections (g) and (i) 
as subsections (f) and (g), respectively. 
(2) MEDICARE DESCRIPTION.—Section 1811(2) 
of the Social Security Act (42 U.S.C. 1395c(2)) is 
amended by striking ‘‘have been entitled for not less 
than 24 months’’ and inserting ‘‘are entitled’’. 
(3) MEDICARE COVERAGE.—Section 1837(g)(1) 
of the Social Security Act (42 U.S.C. 1395p(g)(1)) 
is amended by striking ‘‘25th month of’’ and insert-
ing ‘‘month following the first month of’’. 
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(4) RAILROAD RETIREMENT SYSTEM.—Section 
7(d)(2)(ii) of the Railroad Retirement Act of 1974 
(45 U.S.C. 231f(d)(2)(ii)) is amended— 
(A) by striking ‘‘has been entitled to an 
annuity’’ and inserting ‘‘is entitled to an annu-
ity’’; 
(B) by striking ‘‘, for not less than 24 
months’’; and 
(C) by striking ‘‘could have been entitled 
for 24 calendar months, and’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to insurance benefits under title 
XVIII of the Social Security Act with respect to items and 
services furnished in months beginning after the date of 
enactment of this Act. 
SEC. 124. ELIMINATING THE WAITING PERIOD FOR INDI-
VIDUALS 
ON 
STATE 
MEDICAID 
WAITING 
LISTS. 
The Secretary of Health and Human Services is ap-
propriated such sums as are necessary to facilitate enroll-
ment, not later than 90 days after the date of the enact-
ment of this Act, all eligible individuals who, as of the 
date of the enactment of this Act, are on State Medicaid 
waiting lists or State Medicaid waiver waiting lists. 
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SEC. 125. EMPLOYER HEALTH PLAN OPTIONS. 
(a) DEFINITION.—A qualifying employer-sponsored 
plan is— 
(1) a governmental plan (within the meaning of 
section 2791(d)(8) of the Public Health Service 
Act); or 
(2) any other plan or coverage that meets the 
criteria under subsection (b), includes vision, dental, 
and hearing benefits, and provides health coverage 
that is equivalent to an actuarial value of at least 80 
percent of the coverage provided under title XXII of 
the Social Security Act and makes a premium con-
tribution of at least 70 percent. 
Such plan shall require a premium contribution from the 
employer of at least 70 percent regardless of whether cov-
erage is for single, spousal, or dependent care. 
(b) OBLIGATION.—Large employers shall, with re-
spect to any full-time employee of such employer— 
(1) offer a qualifying employer-sponsored plan 
to such employee, in accordance with subsection (a); 
or 
(2) make a contribution of 8 percent of their 
annual payroll to the Medicare Trust Fund under 
title XXII of the Social Security Act. 
(c) EMPLOYEE CHOICE.—An employee may opt-out 
of a qualifying employer-sponsored plan as satisfied by 
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subsection (b)(1) in order to enroll in Medicare for Amer-
ica. The employer shall make a contribution equal to the 
contribution it shall make in order to meet the require-
ments established by subsection (a)(1) or (a)(2). The Sec-
retary of Health and Human Services shall have authority 
to set standards for determining whether employers or in-
surers are undertaking any actions to affect the risk pool 
within Medicare for America by inducing individuals to de-
cline coverage under a qualifying employer-sponsored plan 
and instead to enroll in Medicare for America. An em-
ployer violating such standards shall be treated as not 
meeting the requirements of subsection (a). 
(d) EMPLOYEE EDUCATION ON HEALTH COVERAGE 
OPTIONS.—Large employers shall disseminate to employ-
ees such publicly available information on coverage options 
under Medicare for America as the Secretary deems ap-
propriate, including contact information for assistance. 
(e) SPECIAL RULES.— 
(1) ANNUAL PAYROLL.—For purposes of this 
paragraph, the term ‘‘annual payroll’’ means, with 
respect to any employer for any calendar year, the 
aggregate wages paid by the employer during such 
calendar year. 
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(2) AGGREGATION RULES.—Related employers 
and predecessors shall be treated as a single em-
ployer for purposes of this subsection. 
(3) REDUCTION FOR PART-TIME EMPLOYEES.— 
In the case of a part-time employee, the employer 
contribution requirements of paragraph (1) shall be 
treated as satisfied if the employer contribution with 
respect to such employee is not less than the part- 
time employment ratio of the contribution required 
under paragraph (1). 
(4) RULES RELATED TO PART-TIME EMPLOY-
MENT.—For purposes of this subsection— 
(A) PART-TIME
EMPLOYEE.—The term 
‘‘part-time employee’’ means, with respect to 
any month, an employee who works on average 
fewer than 30 hours per week. 
(B) PART-TIME
EMPLOYMENT
RATIO.— 
The term ‘‘part-time employment ratio’’ means, 
with respect to a part-time employee of an em-
ployer in a month, a fraction— 
(i) the numerator of which is the 
number of hours in the employee’s normal 
work week; and 
(ii) the denominator of which is 30 
hours. 
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(C) SPECIAL
RULES.—Under rules pre-
scribed by the Secretary of Health and Human 
Services, in consultation with the Secretary of 
the Treasury, in the case of an employee for an 
employer whose defined work week for full-time 
employees is less than 30 hours, any reference 
in this subsection to 30 hours is deemed a ref-
erence to the number of hours in the work week 
so defined. 
(D) CONVERSION TO HOURS OF EMPLOY-
MENT.—The Secretary of Health and Human 
Services, in consultation with the Secretary of 
the Treasury, shall establish rules for the con-
version of compensation to hours of employ-
ment, for purposes of this subsection in the 
case of employees that receive compensation on 
a salaried basis, or on the basis of a commis-
sion, or other contingent or bonus basis, rather 
than based on an hourly wage. 
(f) TIMING
AND MANNER.—Each employer that 
makes a financial contribution under subsection (b)(2) 
and (c) under this section (other than with respect to cov-
erage under a group health plan) shall pay such contribu-
tion in a form and manner, specified by the Secretary of 
the Treasury, based upon the form and manner in which 
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employer excise taxes are required to be paid under section 
3111 of the Internal Revenue Code of 1986. 
(g) NON-DISCRIMINATION.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided for in this title (or an amendment made by 
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 Edu-
cation Amendments of 1972 (20 U.S.C. 1681 et 
seq.), the Age Discrimination Act of 1975 (42 
U.S.C. 6101 et seq.), or section 504 of the Rehabili-
tation Act of 1973 (29 U.S.C. 794), be excluded 
from participation in, be denied the benefits of, or 
be subjected to discrimination under, any health pro-
gram or activity, any part of which is receiving Fed-
eral financial assistance, including credits, 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 amend-
ments) or any employer-sponsored insurance. 
(2) CONTINUED APPLICATION OF LAWS.—Noth-
ing 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 
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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), or the Age Discrimination Act of 1975 
(42 U.S.C. 611 et seq.), or to supersede State laws 
that provide additional protections against discrimi-
nation on any basis described in paragraph (1). 
(3) LIMITATION.—A group health plan may not 
establish rules relating to the health insurance cov-
erage eligibility (including continued eligibility) or 
contribution requirements of any full-time employee 
under the terms of the plan that have the effect of 
discriminating in favor of higher-wage employees. 
(4) REGULATIONS.—The Secretary of Health 
and Human Services, in conjunction with the Sec-
retary of Labor, may promulgate regulations to im-
plement this subsection. 
SEC. 126. PROHIBITION ON STEP THERAPY AND PRIOR AU-
THORIZATION 
UNDER 
GROUP 
HEALTH 
PLANS. 
Section 2719A of the Public Health Service Act (42 
U.S.C. 300gg–19a) is amended by adding at the end the 
following new subsection: 
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‘‘(e) PROHIBITION AGAINST STEP THERAPY
AND 
PRIOR AUTHORIZATION.—Beginning with the first plan 
year following the date of the enactment of this subsection, 
a group health plan may not require a prior authorization 
determination for coverage of any benefit under such plan 
and may not apply treatment limitations through the use 
of step therapy protocols.’’. 
SEC. 127. MEDICARE OUTPATIENT OBSERVATION SERV-
ICES. 
Section 1861(i) of the Social Security Act (42 U.S.C. 
1395x(i)) is amended by adding at the end the following: 
‘‘For purposes of this subsection, an individual receiving 
outpatient observation services shall be deemed to be an 
inpatient during such period, and the date such individual 
ceases receiving such services shall be deemed the hospital 
discharge date (unless such individual is admitted as a 
hospital inpatient at the end of such period)’’. 
SEC. 128. ABORTION COVERAGE. 
Notwithstanding any other provision of law, Federal 
funds may be used to provide for abortion services under 
any health program or activity. 
SEC. 129. APPLICABILITY OF MENTAL HEALTH PARITY. 
Section 2726 of the Public Health Service Act shall 
apply to all health coverage in the same manner and to 
the same extent as such section applies to health insurance 
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issuers and group health plans under title XXVII of such 
Act. 
SEC. 130. STUDENT LOAN FORGIVENESS FOR HEALTH CARE 
PROVIDERS PARTICIPATING IN MEDICARE 
FOR AMERICA. 
(a) IN GENERAL.—Beginning on the date after the 
date of the enactment of this Act, after the conclusion of 
each plan year, the Secretary of Health and Human Serv-
ices, in conjunction with the Secretary of Education, shall 
cancel the applicable percent specified in subsection (b) 
of the total amount due on any eligible Federal loan made 
20 years prior to date of enactment and any date after 
the date of enactment of this Act for a borrower who is 
a Medicare for America participating provider and sub-
mits an employment certification form described in sub-
section (d). 
(b) APPLICABLE PERCENT.—For purposes of sub-
section (a), the applicable percent is 10 percent of any 
eligible Federal loan for each year the health care provider 
participates in Medicare for America. 
(c) DEFINITIONS.—In this section: 
(1) ELIGIBLE FEDERAL LOAN.—The term ‘‘eli-
gible Federal loan’’ means any loan made under part 
D of title IV of the Higher Education Act of 1965 
(20 U.S.C. 1087a). 
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(2) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ means a physician, physician 
assistant, registered nurse, nurse practitioner, ad-
vanced practice nurse, licensed practical nurse, psy-
chologist, mental health counselor, marriage and 
family therapist, direct care worker, health social 
worker, dentist, dental hygienist, pharmacist, phys-
ical therapist, occupational therapist, or any other 
health care provider specified by the Secretary of 
Health and Human Services if the Secretary deter-
mines such specification for purposes of this section 
is necessary to ensure workforce adequacy. 
(3) MEDICARE
FOR
AMERICA
PARTICIPATING 
PROVIDER.—The term ‘‘Medicare for America par-
ticipating provider’’ means a health care provider 
that meets the definition of such term under section 
105 or works at a participating provider or entity as 
defined under section 105. 
(d) EMPLOYMENT CERTIFICATION FORM.— 
(1) IN GENERAL.—In order to receive loan can-
cellation under this paragraph, a borrower shall sub-
mit to the Secretary of Education an employment 
certification form that is developed by the Secretary 
of Education and includes self-certification of em-
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ployment and a separate part for employer certifi-
cation that indicates the dates of employment. 
(2) DEFERMENT.—If a borrower submits to the 
Secretary of Education the employment certification 
form described in paragraph (1), during the period 
in which the borrower is employed as a Medicare for 
America participating provider for which loan can-
cellation is eligible under this section, the borrower’s 
eligible Federal Direct Loan shall be placed in 
deferment. 
(e) INTEREST CANCELED.—If a portion of a loan is 
canceled under this section for any year, the entire amount 
of interest on such loan that accrues for such year shall 
be canceled. 
(f) REGULATIONS.—The Secretary of Health and 
Human Services and the Secretary of Education may pro-
mulgate regulations to implement this section. 
SEC. 131. CLARIFICATION OF THE DEFINITION OF PEDI-
ATRIC MEDICAL NECESSITY IN QUALIFYING 
GROUP COVERAGE. 
(a) DEFINITION.—The following definition of pedi-
atric medical necessity shall be incorporated into benefit 
standards of all plans subject to the requirements of sec-
tion 1302 of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18022) and all group plans by 2026. 
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(b) DEVELOPMENT OF DEFINITION.—Pediatric med-
ical necessity, or pediatric medically necessary care, shall 
be defined as health care interventions that are evidence 
based, evidence informed, or based on consensus advisory 
opinion and that are recommended by recognized health 
care professionals, to promote optimal growth and devel-
opment in a child and to prevent, detect, diagnose, treat, 
ameliorate, or palliate the effects of physical, genetic, con-
genital, developmental, behavioral, or mental conditions, 
injuries, or disabilities. 
(c) UPDATES
TO DEFINITION.—The Secretary of 
Health and Human Services, in consultation with experts 
in the field of pediatric care and key stakeholders, includ-
ing patient and family groups, shall review and update this 
definition on a biennial basis, consistent with up-to-date 
standards of pediatric healthcare practice that are based 
on— 
(1) the views of pediatric healthcare providers 
and experts practicing in relevant clinical areas; 
(2) recommendations of medical-specialty soci-
eties, other pediatric healthcare provider organiza-
tions, and family and patient groups; and 
(3) credible scientific evidence published in 
peer-reviewed literature that is generally recognized 
by the relevant health care provider community. 
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SEC. 132. SAFE STAFFING REQUIREMENTS. 
(a) MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENTS.—The Public Health Service 
Act (42 U.S.C. 201 et seq.) is amended by adding at the 
end the following new title: 
‘‘TITLE 
XXXIV—MINIMUM 
DI-
RECT 
CARE 
REGISTERED 
NURSE STAFFING REQUIRE-
MENT 
‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 
‘‘(a) STAFFING PLAN.— 
‘‘(1) IN GENERAL.—A hospital shall implement 
a staffing plan that— 
‘‘(A) provides adequate, appropriate, and 
quality delivery of health care services and pro-
tects patient safety; and 
‘‘(B) is consistent with the requirements of 
this title. 
‘‘(2) EFFECTIVE DATES.— 
‘‘(A) 
IMPLEMENTATION
OF
STAFFING 
PLAN.—Subject to subparagraph (B), the re-
quirements under paragraph (1) shall take ef-
fect on a date to be determined by the Sec-
retary, but not later than 1 year after the date 
of the enactment of this title. 
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‘‘(B) APPLICATION
OF
MINIMUM
DIRECT 
CARE
REGISTERED
NURSE-TO-PATIENT
RA-
TIOS.—The requirements under subsection (b) 
shall take effect as soon as practicable, as de-
termined by the Secretary, but not later than— 
‘‘(i) 2028; and 
‘‘(ii) in the case of a hospital in a 
rural 
area 
(as 
defined 
in 
section 
1886(d)(2)(D) of the Social Security Act), 
2030. 
‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE- 
TO-PATIENT RATIOS.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (4) and other provisions of this section, a hos-
pital’s staffing plan shall provide that, at all times 
during each shift within a unit of the hospital, and 
with a full complement of ancillary and support 
staff, a direct care registered nurse may be assigned 
to not more than the following number of patients 
in that unit: 
‘‘(A) One patient in trauma emergency 
units. 
‘‘(B) One patient in operating room units, 
provided that a minimum of 1 additional person 
serves as a scrub assistant in such unit. 
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‘‘(C) Two patients in critical care units, in-
cluding neonatal intensive care units, emer-
gency critical care and intensive care units, 
labor and delivery units, coronary care units, 
acute respiratory care units, postanesthesia 
units, and burn units. 
‘‘(D) Three patients in emergency room 
units, pediatrics units, stepdown units, telem-
etry units, antepartum units, and combined 
labor, delivery, and postpartum units. 
‘‘(E) Four patients in medical-surgical 
units, intermediate care nursery units, acute 
care psychiatric units, and other specialty care 
units. 
‘‘(F) Five patients in rehabilitation units 
and skilled nursing units. 
‘‘(G) Six patients in postpartum (3 cou-
plets) units and well-baby nursery units. 
‘‘(2) 
SIMILAR
UNITS
WITH
DIFFERENT 
NAMES.—The Secretary may apply minimum direct 
care registered nurse-to-patient ratios established in 
paragraph (1) for a hospital unit referred to in such 
paragraph to a type of hospital unit not referred to 
in such paragraph if such type of hospital unit pro-
vides a level of care to patients whose needs are 
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similar to the needs of patients cared for in the hos-
pital unit referred to in such paragraph. 
‘‘(3) APPLICATION
OF
RATIOS
TO
HOSPITAL 
NURSING PRACTICE STANDARDS.— 
‘‘(A) IN GENERAL.—A patient assignment 
may be included in the calculation of the direct 
care registered nurse-to-patient ratios required 
in this subsection only if care is provided by a 
direct care registered nurse and the provision of 
care to the particular patient is within that di-
rect care registered nurse’s competence. 
‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC 
COMPETENCE.—A hospital shall not assign a di-
rect care registered nurse to a hospital unit un-
less that hospital determines that the direct 
care registered nurse has demonstrated current 
competence in providing care in that unit, and 
has also received orientation to that hospital’s 
unit sufficient to provide competent care to pa-
tients in that unit. 
‘‘(C) DUTIES OF THE ASSIGNED DIRECT 
CARE REGISTERED NURSE.—Each patient shall 
be assigned to a direct care registered nurse 
who shall directly provide the assessment, plan-
ning, supervision, implementation, and evalua-
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100 
tion of the nursing care provided to the patient 
at least every shift and has the responsibility 
for the provision of care to a particular patient 
within his or her scope of practice. 
‘‘(D) NURSE
ADMINISTRATORS
AND
SU-
PERVISORS.—A registered nurse who is a nurse 
administrator, nurse supervisor, nurse manager, 
charge nurse, case manager, or any other hos-
pital administrator or supervisor, shall not be 
included in the calculation of the direct care 
registered nurse-to-patient ratio unless that 
nurse has a current and active direct patient 
care assignment and provides direct patient 
care in compliance with the requirements of this 
section, including competency requirements. 
The exemption in this subsection shall apply 
only during the hours in which the individual 
registered nurse has the principal responsibility 
of providing direct patient care and has no ad-
ditional job duties as would a direct care reg-
istered nurse. 
‘‘(E) OTHER
PERSONNEL.—Other per-
sonnel may perform patient care tasks based on 
their training and demonstrated skill but may 
not perform or assist in direct care registered 
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101 
nurse functions unless authorized to do in ac-
cordance with State scope of practice laws and 
regulations. 
‘‘(F) TEMPORARY NURSING PERSONNEL.— 
A hospital shall not assign any nursing per-
sonnel from temporary nursing agencies patient 
care to any hospital unit without such personnel 
having demonstrated competence on the as-
signed unit and received orientation to that hos-
pital’s unit sufficient to provide competent care 
to patients in that unit. 
‘‘(G) ANCILLARY AND ADDITIONAL STAFF-
ING.—The need for additional staffing of direct 
care registered nurses, licensed vocational or 
practical nurses, licensed psychiatric techni-
cians, certified nursing or patient care assist-
ants, or other licensed or unlicensed ancillary 
staff above the minimum registered nurse-to-pa-
tient ratios shall be based on the assessment of 
the individual patient’s nursing care require-
ment, the individual patient’s nursing care plan, 
and acuity level. 
‘‘(4) RESTRICTIONS.— 
‘‘(A) PROHIBITION AGAINST AVERAGING.— 
A hospital shall not average the number of pa-
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102 
tients and the total number of direct care reg-
istered nurses assigned to patients in a hospital 
unit during any 1 shift or over any period of 
time for purposes of meeting the requirements 
under this subsection. 
‘‘(B) PROHIBITION
AGAINST
IMPOSITION 
OF MANDATORY OVERTIME REQUIREMENTS.—A 
hospital shall not impose mandatory overtime 
requirements to meet the hospital unit direct 
care registered nurse-to-patient ratios required 
under this subsection. 
‘‘(C) 
RELIEF
DURING
ROUTINE
AB-
SENCES.—A hospital shall ensure that only a 
direct care registered nurse who has dem-
onstrated current competence to the hospital in 
providing care on a particular unit and has also 
received orientation to that hospital’s unit suffi-
cient to provide competent care to patients in 
that unit may relieve another direct care reg-
istered nurse during breaks, meals, and other 
routine, expected absences from a hospital unit. 
‘‘(D) APPLICATION OF DIRECT CARE REG-
ISTERED
NURSE-TO-PATIENT
RATIOS
IN
PA-
TIENT-ACUITY
ADJUSTABLE
UNITS.—Patients 
shall be cared for only on units or patient care 
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103 
areas where the direct care registered nurse-to- 
patient ratios meet the level of intensity, type 
of care, and the individual requirements and 
needs of each patient. Notwithstanding para-
graph (2), hospitals that provide patient care in 
units or patient care areas that are acuity 
adaptable or acuity adjustable shall apply the 
direct care registered nurse-to-patient ratio re-
quired in this section for the highest patient 
acuity level or level of care in that unit or pa-
tient care area, and shall comply with all other 
requirements of this section. 
‘‘(E) USE OF VIDEO MONITORS.—A hos-
pital shall not employ video monitors or any 
form of electronic visualization of a patient as 
a substitute for the direct observation required 
for patient assessment by the direct care reg-
istered nurse or required for patient protection. 
Video monitors or any form of electronic visual-
ization of a patient shall not be included in the 
calculation of the direct care registered nurse- 
to-patient ratio required in this subsection and 
shall not replace the requirement of paragraph 
(3)(D) that each patient shall be assigned to a 
direct care registered nurse who shall directly 
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provide the assessment, planning, supervision, 
implementation, and evaluation of the nursing 
care provided to the patient at least every shift 
and have the responsibility for the provision of 
care to a particular patient within his or her 
scope of practice. 
‘‘(F) USE
OF
OTHER
TECHNOLOGY.—A 
hospital shall not employ technology that sub-
stitutes for the assigned registered nurse’s pro-
fessional judgment in assessment, planning, im-
plementation, and evaluation of care. 
‘‘(5) ADJUSTMENT OF RATIOS.— 
‘‘(A) IN GENERAL.—If necessary to protect 
patient safety, the Secretary may prescribe reg-
ulations that— 
‘‘(i) increase minimum direct care reg-
istered nurse-to-patient ratios under this 
subsection to reduce the number of pa-
tients that may be assigned to each direct 
care nurse; or 
‘‘(ii) add minimum direct care reg-
istered nurse-to-patient ratios for units not 
referred to in paragraphs (1) and (2). 
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‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals and registered nurses. 
‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 
‘‘(A) IN
GENERAL.—The Secretary may 
prescribe regulations requiring additional staff-
ing of direct care registered nurses, licensed vo-
cational or practice nurses, licensed psychiatric 
technicians, certified nursing or patient care as-
sistants, or other licensed or unlicensed ancil-
lary staff above the minimum registered nurse- 
to-patient ratios that is based on the assess-
ment of the individual patient’s nursing care 
needs, the individual patient’s nursing care 
plan, and acuity level. 
‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals, registered nurses, and ancillary 
staff. 
‘‘(7) RELATIONSHIP
TO
STATE-IMPOSED
RA-
TIOS.—Nothing in this title shall preempt State 
standards that the Secretary determines to be as 
stringent as Federal requirements for a staffing plan 
established under this title. Minimum direct care 
registered nurse-to-patient ratios established under 
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this subsection shall not preempt State requirements 
that the Secretary determines are as stringent as to 
Federal requirements for direct care registered 
nurse-to-patient ratios established under this title. 
‘‘(8) EXEMPTION IN EMERGENCIES.—The re-
quirements established under this subsection shall 
not apply during a state of emergency if a hospital 
is requested or expected to provide an exceptional 
level of emergency or other medical services. If a 
hospital seeks to apply the exemption under this 
paragraph in response to a complaint filed against 
the hospital for a violation of the provisions of this 
title, the hospital must demonstrate that prompt and 
diligent efforts were made to maintain required 
staffing levels. The Secretary shall issue guidance to 
hospitals that describes situations that constitute a 
state of emergency for purposes of the exemption 
under this paragraph and shall establish necessary 
penalties for violations of this paragraph consistent 
with section 3406. 
‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF-
ING PLAN.— 
‘‘(1) CONSIDERATIONS
IN
DEVELOPMENT
OF 
PLAN.—In developing the staffing plan, a hospital 
shall provide for direct care registered nurse-to-pa-
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tient ratios above the minimum direct care reg-
istered nurse-to-patient ratios required under sub-
section (b) if appropriate based upon consideration 
of, at a minimum, the following factors: 
‘‘(A) The number of patients on a par-
ticular unit on a shift-by-shift basis. 
‘‘(B) The acuity level and nursing care 
plan of patients on a particular unit on a shift- 
by-shift basis. 
‘‘(C) The anticipated admissions, dis-
charges, and transfers of patients during each 
shift that impacts direct patient care. 
‘‘(D) Specialized experience required of di-
rect care registered nurses on a particular unit. 
‘‘(E) Staffing levels and services provided 
by licensed vocational or practical nurses, li-
censed psychiatric technicians, certified nurse 
assistants, or other ancillary staff in meeting 
direct patient care needs not required by a di-
rect care registered nurse. 
‘‘(F) The level of familiarity with hospital 
practices, policies, and procedures by temporary 
agency direct care registered nurses used dur-
ing a shift. 
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‘‘(G) Obstacles to efficiency in the delivery 
of patient care presented by physical layout. 
‘‘(2) DOCUMENTATION OF STAFFING.—A hos-
pital shall specify the system used to document ac-
tual staffing in each unit for each shift. 
‘‘(3) ANNUAL REEVALUATION OF PLAN.— 
‘‘(A) IN GENERAL.—A hospital shall annu-
ally evaluate its staffing plan in each unit in re-
lation to actual patient care requirements. 
‘‘(B) UPDATE.—A hospital shall update its 
staffing plan to the extent appropriate based on 
such evaluation. 
‘‘(4) TRANSPARENCY.— 
‘‘(A) IN GENERAL.—Any staffing plan or 
method used to create and evaluate acuity-level 
and adopted by a hospital under this section 
shall be transparent in all respects, including 
disclosure of detailed documentation of the 
methodology used to determine nursing staff-
ing, identifying each factor, assumption, and 
value used in applying such methodology. 
‘‘(B) PUBLIC
AVAILABILITY.—The Sec-
retary shall establish procedures to provide that 
the documentation submitted under subsection 
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(d) is available for public inspection in its en-
tirety. 
‘‘(5) REGISTERED
NURSE
PARTICIPATION.—A 
staffing plan of a hospital— 
‘‘(A) shall be developed and subsequent re-
evaluations shall be conducted under this sub-
section on the basis of input from direct care 
registered nurses at the hospital from each unit 
or patient care area; and 
‘‘(B) where such nurses are represented 
through collective bargaining, shall require bar-
gaining with the applicable recognized or cer-
tified collective bargaining representative of 
such nurses. Nothing in this title shall be con-
strued to permit conduct prohibited under the 
National Labor Relations Act or chapter 71 of 
title 5, United States Code. 
‘‘(6) STAFFING
COMMITTEES.—If a hospital 
maintains a staffing committee, then the committee 
shall include at least one registered nurse from each 
hospital unit and shall be composed of at least 50 
percent direct care registered nurses. The staffing 
committee shall include meaningful representation of 
other direct care nonmanagement staff. Direct care 
registered nurses who serve on the committee shall 
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be selected by other direct care registered nurses 
from their unit. Other direct care nonmanagement 
staff shall be selected by other direct care non-
management staff. Participation on staffing commit-
tees shall be considered a part of the employee’s reg-
ularly scheduled work week. 
‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos-
pital shall submit to the Secretary its staffing plan and 
any annual updates under subsection (c)(3)(B). A feder-
ally operated hospital may submit its staffing plan 
through the department or agency operating the hospital. 
‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 
‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos-
pital shall post a uniform notice in a form specified by 
the Secretary in regulation that— 
‘‘(1) explains requirements imposed under sec-
tion 3401; 
‘‘(2) includes actual direct care registered 
nurse-to-patient ratios during each shift; 
‘‘(3) includes the actual number and titles of di-
rect care registered nurses assigned during each 
shift; and 
‘‘(4) is visible, conspicuous, and accessible to 
staff, patients, and the public. 
‘‘(b) RECORDS.— 
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‘‘(1) MAINTENANCE OF RECORDS.—Each hos-
pital shall maintain accurate records of actual direct 
care registered nurse-to-patient ratios in each unit 
for each shift for no less than 3 years. Such records 
shall include— 
‘‘(A) the number of patients in each unit; 
‘‘(B) the identity and duty hours of— 
‘‘(i) each direct care registered nurse 
assigned to each patient in each unit in 
each shift; and 
‘‘(ii) ancillary staff who are under the 
coordination of the direct care registered 
nurse; 
‘‘(C) certification that each nurse received 
rest and meal breaks and the identity and duty 
hours of each direct care registered nurse who 
provided such relief; and 
‘‘(D) a copy of each notice posted under 
subsection (a). 
‘‘(2) AVAILABILITY
OF
RECORDS.—Each hos-
pital shall make its records maintained under para-
graph (1) available to— 
‘‘(A) the Secretary; 
‘‘(B) registered nurses and their collective 
bargaining representatives (if any); and 
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112 
‘‘(C) the public under regulations estab-
lished by the Secretary, or in the case of a fed-
erally operated hospital, under section 552 of 
title 5, United States Code (commonly known 
as the Freedom of Information Act). 
‘‘(c) AUDITS.—The Secretary shall conduct periodic 
audits to ensure— 
‘‘(1) implementation of the staffing plan in ac-
cordance with this title; and 
‘‘(2) accuracy in records maintained under this 
section. 
‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 
NURSE STAFFING REQUIREMENTS. 
‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 
shall comply with minimum direct care licensed practical 
nurse staffing requirements that the Secretary establishes 
for units in hospitals. Such staffing requirements shall be 
established not later than 18 months after the date of the 
enactment of this title, and shall be based on the study 
conducted under subsection (b). 
‘‘(b) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
search and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in 
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113 
hospitals. The Director may contract with a qualified enti-
ty or organization to carry out such study under this para-
graph. The Director shall consult with licensed practical 
nurses and organizations representing licensed practical 
nurses regarding the design and conduct of the study. 
‘‘(c) APPLICATION OF REGISTERED NURSE PROVI-
SIONS TO LICENSED PRACTICAL NURSE STAFFING RE-
QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 
and (6) of section 3401(b), paragraphs (1), (2), (3), and 
(4) of section 3401(c), and section 3402 shall apply to 
the establishment and application of direct care licensed 
practical nurse staffing requirements under this section 
pursuant to the additional staffing requirements under 
subsection (b)(3)(G) of section 3401 and in the same man-
ner that they apply to the establishment and application 
of direct care registered nurse-to-patient ratios under sec-
tions 3401 and 3402. 
‘‘(d) EFFECTIVE DATE.—The requirements of this 
section shall take effect as soon as practicable, as deter-
mined by the Secretary, but not later than— 
‘‘(1) 2 years after the date of the enactment of 
this title; and 
‘‘(2) in the case of a hospital in a rural area 
(as defined in section 1886(d)(2)(D) of the Social 
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114 
Security Act), 4 years after the date of the enact-
ment of this title. 
‘‘(e) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
search and Quality, shall complete a study of registered 
and practical nurse staffing requirements in clinics and 
other outpatient settings, and its effects on patient care 
in outpatient settings. The Director may contract with a 
qualified entity or organization to carry out such study 
under this subsection. The Director shall consult with reg-
istered nurses and licensed practice nurses working in out-
patient settings, including professional nursing associa-
tions and labor organizations representing both registered 
and practice nurses working in outpatient settings regard-
ing the design and conduct of the study. 
‘‘SEC. 3404. WHISTLEBLOWER AND PATIENT PROTECTIONS. 
‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 
nurses have a duty and right to act based on their profes-
sional judgment in accordance with State nursing laws 
and regulations of the State in which the direct nursing 
care is being performed and to provide care in the exclu-
sive interests of the patients and to act as the patient’s 
advocate. 
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‘‘(b) ACCEPTANCE
OF
PATIENT
CARE
ASSIGN-
MENTS.—The nurse is responsible for providing com-
petent, safe, therapeutic, and effective nursing care to as-
signed patients. Before accepting a patient assignment, a 
nurse shall— 
‘‘(1) have the necessary professional knowledge, 
judgment, skills, and ability to provide the required 
care; 
‘‘(2) determine using professional judgment in 
accordance with State nursing laws and regulations 
of the State in which the direct nursing care is being 
performed whether the nurse is competent to per-
form the nursing care required; and 
‘‘(3) determine whether acceptance of a patient 
assignment would expose the patient or nurse to risk 
of harm. 
‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 
A nurse may object to, or refuse to participate in, any 
activity, policy, practice, assignment, or task if in good 
faith— 
‘‘(1) the nurse reasonably believes it to be in 
violation of section 3401 or 3403; or 
‘‘(2) the nurse is not prepared by education, 
training, or experience to fulfill the assignment with-
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116 
out compromising the safety of any patient or jeop-
ardizing the license of the nurse. 
‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL 
OF ASSIGNMENT BARRED.— 
‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE-
TALIATION.—No hospital shall discharge, retaliate, 
discriminate, or otherwise take adverse action in any 
manner with respect to any aspect of a nurse’s em-
ployment (as defined in section 3407), including dis-
charge, promotion, compensation, or terms, condi-
tions, or privileges of employment, based on the 
nurse’s refusal of a work assignment under sub-
section (c). 
‘‘(2) NO FILING OF COMPLAINT.—No hospital 
shall file a complaint or a report against a nurse 
with a State professional disciplinary agency because 
of the nurse’s refusal of a work assignment under 
subsection (c). 
‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar-
gaining representative, or legal representative of any nurse 
who has been discharged, discriminated against, or retali-
ated against in violation of subsection (d)(1) or against 
whom a complaint or report has been filed in violation of 
subsection (d)(2) may (without regard to whether a com-
plaint has been filed under subsection (f) of this section 
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or subsection (b) of section 3406) bring a cause of action 
in a United States district court. A nurse who prevails 
on the cause of action shall be entitled to one or more 
of the following: 
‘‘(1) Reinstatement. 
‘‘(2) Reimbursement of lost wages, compensa-
tion, and benefits. 
‘‘(3) Attorneys’ fees. 
‘‘(4) Court costs. 
‘‘(5) Other damages. 
‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 
collective bargaining representative, or other individual 
may file a complaint with the Secretary against a hospital 
that violates the provisions of this title. For any complaint 
filed, the Secretary shall— 
‘‘(1) receive and investigate the complaint; 
‘‘(2) determine whether a violation of this title 
as alleged in the complaint has occurred; and 
‘‘(3) if such a violation has occurred, issue an 
order that the complaining nurse or individual shall 
not suffer any discharge, retaliation, discrimination, 
or other adverse action prohibited by subsection (d) 
or subsection (h). 
‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 
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‘‘(1) IN GENERAL.—The Secretary shall provide 
for the establishment of a toll-free telephone hotline 
to provide information regarding the requirements 
under sections 3401 through 3403 and to receive re-
ports of violations of such section. 
‘‘(2) NOTICE TO PATIENTS.—A hospital shall 
provide each patient admitted to the hospital for in-
patient care with the hotline described in paragraph 
(1), and shall give notice to each patient that such 
hotline may be used to report inadequate staffing or 
care. 
‘‘(h) PROTECTION FOR REPORTING.— 
‘‘(1) PROHIBITION
ON
RETALIATION
OR
DIS-
CRIMINATION.—A hospital shall not discriminate or 
retaliate in any manner against any patient, em-
ployee, or contract employee of the hospital, or any 
other individual, on the basis that such individual, in 
good faith, individually or in conjunction with an-
other person or persons, has presented a grievance 
or complaint, or has initiated or cooperated in any 
investigation or proceeding of any governmental en-
tity, regulatory agency, or private accreditation 
body, made a civil claim or demand, or filed an ac-
tion relating to the care, services, or conditions of 
the hospital or of any affiliated or related facilities. 
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‘‘(2) GOOD FAITH DEFINED.—For purposes of 
this subsection, an individual shall be deemed to be 
acting in good faith if the individual reasonably be-
lieves— 
‘‘(A) the information reported or disclosed 
is true; and 
‘‘(B) a violation of this title has occurred 
or may occur. 
‘‘(i) PROHIBITION ON INTERFERENCE 
WITH RIGHTS.— 
‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw-
ful for any hospital to— 
‘‘(A) interfere with, restrain, or deny the 
exercise, or attempt to exercise, by any person 
of any right provided or protected under this 
title; or 
‘‘(B) coerce or intimidate any person re-
garding the exercise or attempt to exercise such 
right. 
‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR 
PRACTICES.—It shall be unlawful for any hospital to 
discriminate or retaliate against any person for op-
posing any hospital policy, practice, or actions which 
are alleged to violate, breach, or fail to comply with 
any provision of this title. 
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‘‘(3) PROHIBITION
ON
INTERFERENCE
WITH 
PROTECTED COMMUNICATIONS.—A hospital (or an 
individual representing a hospital) shall not make, 
adopt, or enforce any rule, regulation, policy, or 
practice which in any manner directly or indirectly 
prohibits, impedes, or discourages a direct care 
nurse from, or intimidates, coerces, or induces a di-
rect care nurse regarding, engaging in free speech 
activities or disclosing information as provided under 
this title. 
‘‘(4) PROHIBITION
ON
INTERFERENCE
WITH 
COLLECTIVE ACTION.—A hospital (or an individual 
representing a hospital) shall not in any way inter-
fere with the rights of nurses to organize, bargain 
collectively, and engage in concerted activity under 
section 7 of the National Labor Relations Act (29 
U.S.C. 157). 
‘‘(j) NOTICE.—A hospital shall post in an appropriate 
location in each unit a conspicuous notice in a form speci-
fied by the Secretary that— 
‘‘(1) explains the rights of nurses, patients, and 
other individuals under this section; 
‘‘(2) includes a statement that a nurse, patient, 
or other individual may file a complaint with the 
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121 
Secretary against a hospital that violates the provi-
sions of this title; and 
‘‘(3) provides instructions on how to file such a 
complaint. 
‘‘(k) EFFECTIVE DATE.— 
‘‘(1) REFUSAL; RETALIATION; CAUSE
OF
AC-
TION.— 
‘‘(A) 
IN
GENERAL.—Subsections 
(c) 
through (e) shall apply to objections and refus-
als occurring on or after the effective date of 
the provision of this title to which the objection 
or refusal relates. 
‘‘(B) EXCEPTION.—Subsection (c)(2) shall 
not apply to objections or refusals in any hos-
pital before the requirements of section 3401(a) 
or 3403(a), as applicable, apply to that hos-
pital. 
‘‘(2) PROTECTIONS
FOR
REPORTING.—Sub-
section (h)(1) shall apply to actions occurring on or 
after the effective date of the provision to which the 
violation relates, except that such subsection shall 
apply to initiation, cooperation, or participation in 
an investigation or proceeding on or after the date 
of enactment of this title. 
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122 
‘‘(3) NOTICE.—Subsection (j) shall take effect 
18 months after the date of enactment of this title. 
‘‘SEC. 3405. ENFORCEMENT. 
‘‘(a) IN GENERAL.—The Secretary shall enforce the 
requirements and prohibitions of this title in accordance 
with this section. 
‘‘(b) PROCEDURES
FOR RECEIVING
AND INVES-
TIGATING COMPLAINTS.—The Secretary shall establish 
procedures under which— 
‘‘(1) any person may file a complaint alleging 
that a hospital has violated a requirement or a pro-
hibition of this title; and 
‘‘(2) such complaints shall be investigated by 
the Secretary. 
‘‘(c) REMEDIES.—If the Secretary determines that a 
hospital has violated a requirement of this title, the Sec-
retary— 
‘‘(1) shall require the facility to establish a cor-
rective action plan to prevent the recurrence of such 
violation; and 
‘‘(2) may impose civil money penalties, as de-
scribed in subsection (d). 
‘‘(d) CIVIL PENALTIES.— 
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‘‘(1) IN GENERAL.—In addition to any other 
penalties prescribed by law, the Secretary may im-
pose civil penalties as follows: 
‘‘(A) HOSPITAL LIABILITY.—The Secretary 
may impose on a hospital found to be in viola-
tion of this title a civil money penalty of— 
‘‘(i) not more than $25,000 for the 
first knowing violation of this title by such 
hospital; and 
‘‘(ii) not more than $50,000 for any 
subsequent knowing violation of this title 
by such hospital. 
‘‘(B) INDIVIDUAL
LIABILITY.—The Sec-
retary may impose on an individual who— 
‘‘(i) is employed by a hospital found 
by the Secretary to have violated this title; 
and 
‘‘(ii) knowingly violates this title, a 
civil money penalty of not more than 
$20,000 for each such violation by the in-
dividual. 
‘‘(2) PROCEDURES.—The provisions of section 
1128A of the Social Security Act (other than sub-
sections (a) and (b)) shall apply with respect to a 
civil money penalty or proceeding under this sub-
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124 
section in the same manner as such provisions apply 
with respect to a civil money penalty or proceeding 
under such section 1128A. 
‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(1) INTERNET WEBSITE.—The Secretary shall 
publish on the internet website of the Department of 
Health and Human Services the names of hospitals 
on which a civil money penalty has been imposed 
under this section, the violation for which such pen-
alty was imposed, and such additional information 
as the Secretary determines appropriate. 
‘‘(2) CHANGE OF OWNERSHIP.—With respect to 
a hospital that had a change of ownership, as deter-
mined by the Secretary, penalties imposed on the 
hospital while under previous ownership shall no 
longer be published by the Secretary pursuant to 
paragraph (1) after the 1-year period beginning on 
the date of change of ownership. 
‘‘(f) USE OF FUNDS.—Funds collected by the Sec-
retary pursuant to this section are authorized to be appro-
priated to carry out this title. 
‘‘SEC. 3406. DEFINITIONS. 
‘‘For purposes of this title: 
‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 
means the determination, using a hospital acuity 
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measurement tool that has been developed and es-
tablished in coordination with direct care registered 
nurses and made transparent pursuant to section 
3401(c)(4), of nursing care requirements, based on 
the assigned direct care registered nurse’s profes-
sional judgment of— 
‘‘(A) the severity and complexity of an in-
dividual patient’s illness or injury; 
‘‘(B) the need for specialized equipment; 
and 
‘‘(C) the intensity of nursing interventions 
required. 
‘‘(2) COMPETENCE.—The term ‘competence’ or 
‘competent’ means the satisfactory application of the 
duties and responsibilities of a registered nurse in 
providing nursing care to specific patient popu-
lations and for acuity levels for each patient care 
unit or area pursuant to the State nursing laws and 
regulations of the State in which the direct nursing 
care is being performed. 
‘‘(3) 
DIRECT
CARE
LICENSED
PRACTICAL 
NURSE.—The term ‘direct care licensed practical 
nurse’ means an individual who has been granted a 
license by at least one State to practice as a licensed 
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126 
practical nurse or a licensed vocational nurse and 
who provides bedside care for one or more patients. 
‘‘(4) DIRECT CARE REGISTERED NURSE.—The 
term ‘direct care registered nurse’ means an indi-
vidual who has been granted a license by at least 
one State to practice as a registered nurse and who 
provides bedside care for one or more patients. 
‘‘(5) EMPLOYMENT.—The term ‘employment’ 
includes the provision of services under a contract or 
other arrangement. 
‘‘(6) HOSPITAL.—The term ‘hospital’ has the 
meaning given that term in section 1861(e) of the 
Social Security Act. 
‘‘(7) NURSE.—The term ‘nurse’ means any di-
rect care registered nurse or direct care licensed 
practice nurse (as the case may be), regardless of 
whether or not the nurse is an employee. 
‘‘(8) NURSING CARE PLAN.—The term ‘nursing 
care plan’ means a plan developed by the assigned 
direct care registered nurse (in accordance with 
nursing law in the State in which the nursing care 
is performed) that indicates the nursing care to be 
given to individual patients that— 
‘‘(A) considers the acuity level of the pa-
tient; 
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‘‘(B) is developed in coordination with the 
patient, the patient’s family, or other represent-
atives when appropriate, and staff of other dis-
ciplines involved in the care of the patient; 
‘‘(C) reflects all elements of the nursing 
process; and 
‘‘(D) recommends the number and skill 
mix of additional licensed and unlicensed direct 
care staff needed to fully implement the nursing 
care plan. 
‘‘(9) PROFESSIONAL
JUDGMENT.—The term 
‘professional judgment’ means, in accordance with 
State nursing laws and regulations of the State in 
which the direct nursing care is being performed, the 
direct care registered nurse’s application of knowl-
edge, expertise, and experience in conducting a com-
prehensive nursing assessment of each patient and 
in making independent decisions about patient care 
including the need for additional staff. 
‘‘(10) STAFFING
PLAN.—The term ‘staffing 
plan’ means a staffing plan required under section 
3401. 
‘‘(11) STATE OF EMERGENCY.—The term ‘state 
of emergency’— 
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128 
‘‘(A) means a state of emergency that is 
an unpredictable or unavoidable occurrence at 
an unscheduled or unpredictable interval, relat-
ing to health care delivery and requiring imme-
diate medical interventions and care; and 
‘‘(B) does not include a state of emergency 
that results from a labor dispute in the health 
care industry or consistent understaffing. 
‘‘SEC. 3407. RULE OF CONSTRUCTION. 
‘‘Nothing in this title shall be construed to authorize 
disclosure of private and confidential patient information, 
if such disclosure is not authorized or required by other 
applicable law.’’. 
(b) RECOMMENDATIONS TO CONGRESS.—Not later 
than 1 year after the date of enactment of this Act, the 
Secretary of Health and Human Services shall submit to 
Congress a report containing recommendations for ensur-
ing that sufficient numbers of nurses are available to meet 
the requirements imposed by title XXXIV of the Public 
Health Service Act, as added by subsection (a). 
(c) REPORT BY HRSA.— 
(1) IN GENERAL.—Not later than 2 years after 
the date of enactment of this Act, the Administrator 
of the Health Resources and Services Administra-
tion, in consultation with the National Health Care 
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129 
Workforce Commission, shall submit to Congress a 
report regarding the relationship between nurse 
staffing levels and nurse retention in hospitals. 
(2) UPDATED REPORT.—Not later than 5 years 
after the date of enactment of this Act, the Adminis-
trator of the Health Resources and Services Admin-
istration, in consultation with the National Health 
Care Workforce Commission, shall submit to Con-
gress an update of the report submitted under para-
graph (1). 
(d) ENFORCEMENT
OF REQUIREMENTS THROUGH 
FEDERAL PROGRAMS.— 
(1) MEDICARE PROGRAM.—Section 1866(a)(1) 
of the Social Security Act (42 U.S.C. 1395cc(a)(1)) 
is amended— 
(A) in subparagraph (X), by striking ‘‘, 
and’’ and inserting a comma; 
(B) in subparagraph (Y), by striking the 
period at the end and inserting ‘‘, and’’; and 
(C) by inserting after subparagraph (Y) 
the following new subparagraph: 
‘‘(Z) in the case of a hospital, to comply 
with the provisions of title XXXIV of the Public 
Health Service Act.’’. 
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130 
(2) MEDICAID PROGRAM.—Section 1902(a) of 
the Social Security Act (42 U.S.C. 1396a(a)) is 
amended— 
(A) by striking ‘‘and’’ at the end of para-
graph (82); 
(B) by striking the period at the end of 
paragraph (83) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (83) the 
following new paragraph: 
‘‘(84) provide that any hospital that receives a 
payment under such plan comply with the provisions 
of title XXXIV of the Public Health Service Act (re-
lating to minimum direct care registered nurse staff-
ing requirements).’’. 
(e) NURSING HOMES.—No later than one year after 
enactment of this Act, the Secretary of Health and 
Human Services shall promulgate a rule for minimum 
staffing standards for skilled nursing facilities under the 
Medicare program and for nursing facilities under the 
Medicaid program that align with the standards set in this 
section. 
SEC. 133. ENHANCEMENTS FOR REDUCED COST-SHARING. 
(a) IN GENERAL.—Section 1402 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18071) is 
amended— 
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131 
(1) in subsection (b)(1), by striking ‘‘silver’’ 
and inserting ‘‘gold’’; 
(2) by amending subsection (c)(1)(B) to read as 
follows: 
‘‘(B) COORDINATION
WITH
ACTUARIAL 
LIMITS.—The Secretary shall ensure the reduc-
tion under this paragraph shall not result in the 
plan’s share of the total allowed costs of bene-
fits provided under the plan becoming less 
than— 
‘‘(i) 95 percent in the case of an eligi-
ble insured described in paragraph (2)(A); 
‘‘(ii) 90 percent in the case of an eli-
gible 
insured 
described 
in 
paragraph 
(2)(B); and 
‘‘(iii) 85 percent in the case of an eli-
gible 
insured 
described 
in 
paragraph 
(2)(C).’’; and 
(3) by amending subsection (c)(2) to read as 
follows: 
‘‘(2) ADDITIONAL REDUCTION.—The Secretary 
shall establish procedures under which the issuer of 
a qualified health plan to which this section applies 
shall further reduce cost-sharing under the plan in 
a manner sufficient to— 
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‘‘(A) in the case of an eligible insured 
whose household income is not less than 100 
percent but not more than 200 percent of the 
poverty line for a family of the size involved, in-
crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 95 
percent of such costs; 
‘‘(B) in the case of an eligible insured 
whose household income is more than 200 per-
cent but not more than 300 percent of the pov-
erty line for a family of the size involved, in-
crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 90 
percent of such costs; and 
‘‘(C) in the case of an eligible insured 
whose household income is more than 300 per-
cent but not more than 400 percent of the pov-
erty line for a family of the size involved, in-
crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 85 
percent of such costs.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this subsection shall apply to plan years beginning after 
December 31, 2025. 
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133 
(c) FUNDING.—Section 1402 of the Patient Protec-
tion and Affordable Care Act (42 U.S.C. 18071) is amend-
ed by adding at the end the following new subsection: 
‘‘(g) FUNDING.—Out of any funds in the Treasury 
not otherwise appropriated, there are appropriated to the 
Secretary such sums as may be necessary for payments 
under this section.’’. 
SEC. 134. REPEAL OF BONUS PAYMENTS FOR MEDICARE 
ADVANTAGE PLANS. 
Section 1853(o) of the Social Security Act (42 U.S.C. 
1395w–23(o)) is repealed. 
TITLE II—TAX PROVISIONS 
SEC. 201. SUNSET OF PUBLIC LAW 115–97. 
(a) IN GENERAL.—All provisions of, and amend-
ments made by, Public Law 115–97 shall not apply to cal-
endar, taxable, plan, or limitation years beginning after 
December 31, 2026. 
(b) APPLICATION OF CERTAIN LAWS.—The Internal 
Revenue Code of 1986 shall be applied and administered 
to years described in subsection (a) as if the provisions 
and amendments described in subsection (a) had never 
been enacted. 
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134 
SEC. 202. SURTAX. 
There is hereby imposed a tax of 5 percent on the 
adjusted gross income of each taxpayer to the extent such 
income exceeds $500,000. 
SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECE-
DENT. 
(a) IN GENERAL.—Section 1014 of the Internal Rev-
enue Code of 1986 is amended by striking ‘‘person, be’’ 
and all that follows through the period at the end and 
inserting the following: ‘‘person, be the basis in the hands 
of the decedent.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section to property acquired or passed after the date 
of enactment of this Act. 
SEC. 204. MEDICARE PAYROLL TAX. 
(a) IN GENERAL.—Section 3101(b)(2) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘0.9 per-
cent’’ and inserting ‘‘4 percent’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
SEC. 205. NET INVESTMENT INCOME TAX. 
(a) IN GENERAL.—Section 1411(a) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘3.8 per-
cent’’ each place such term appears and inserting ‘‘6.9 
percent’’. 
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135 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
SEC. 206. TERMINATION OF DEDUCTION FOR CONTRIBU-
TIONS TO HEALTH SAVINGS ACCOUNTS. 
Section 223(b) of the Internal Revenue Code of 1986 
is amended by adding at the end the following new para-
graph: 
‘‘(9) TERMINATION OF DEDUCTION.—Notwith-
standing any other provision of this subsection, the 
monthly limitation for any month beginning after 
December 31, 2023, is zero.’’. 
SEC. 207. INCREASE IN EXCISE TAX ON SMALL CIGARS AND 
CIGARETTES AND OTHER TOBACCO PROD-
UCTS. 
(a) SMALL CIGARS.—Section 5701(a)(1) of the Inter-
nal Revenue Code of 1986 is amended by striking 
‘‘$50.33’’ and inserting ‘‘$100.66’’. 
(b) CIGARETTES.—Section 5701(b) of such Code is 
amended— 
(1) by striking ‘‘$50.33’’ in paragraph (1) and 
inserting ‘‘$100.66’’; and 
(2) by striking ‘‘$105.69’’ in paragraph (2) and 
inserting ‘‘$211.38’’. 
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136 
(c) PIPE TOBACCO.—Section 5701(f) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘$2.8311 
cents’’ and inserting ‘‘$50.00’’. 
(d) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 
such Code is amended by striking ‘‘$24.78’’ and inserting 
‘‘$49.56’’. 
(e) LARGE
CIGARS.—Paragraph (2) of section 
5701(a) of the Internal Revenue Code of 1986 is amended 
by striking ‘‘52.75 percent’’ and all that follows through 
the period and inserting ‘‘$24.78 per pound (and a propor-
tionate tax at the like rate on all fractional parts of a 
pound) but not less than 5.033 cents per cigar.’’. 
(f) SMOKELESS TOBACCO.— 
(1) IN GENERAL.—Section 5701(e) of the Inter-
nal Revenue Code of 1986 is amended— 
(A) in paragraph (1), by striking ‘‘$1.51’’ 
and inserting ‘‘$28.04’’; 
(B) in paragraph (2), by striking ‘‘50.33 
cents’’ and inserting ‘‘$12.42’’; and 
(C) by adding at the end the following: 
‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE 
SINGLE-USE
UNITS.—On discrete single-use units, 
$107.65 per each 1,000 single-use units.’’. 
(2) 
DISCRETE
SINGLE-USE
UNIT.—Section 
5702(m) of such Code is amended— 
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(A) in paragraph (1), by striking ‘‘or chew-
ing tobacco’’ and inserting ‘‘chewing tobacco, 
discrete single-use unit’’; 
(B) in paragraphs (2) and (3), by inserting 
‘‘that is not a discrete single-use unit’’ before 
the period in each such paragraph; and 
(C) by adding at the end the following: 
‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 
‘discrete single-use unit’ means any product con-
taining tobacco that— 
‘‘(A) is not intended to be smoked; and 
‘‘(B) is in the form of a lozenge, tablet, 
pill, pouch, dissolvable strip, or other discrete 
single-use or single-dose unit’’. 
SEC. 208. EXCISE TAX ON ALCOHOL. 
(a) DISTILLED SPIRITS.—Section 5001(a)(1) of the 
Internal Revenue Code of 1986 is amended by striking 
‘‘$13.50’’ and inserting ‘‘$16.00’’. 
(b) WINE.—(1) Section 5041(b)(1) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘$1.07 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gallon’’. 
(2) Section 5041(b)(2) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$1.57 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gal-
lon’’. 
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(3) Section 5041(b)(3) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$3.15 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gal-
lon’’. 
(4) Section 5041(b)(4) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$3.40 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gal-
lon’’. 
(5) Section 5041(b)(5) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$3.30 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gal-
lon’’. 
(6) Section 5041(b)(3) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$22.6 cents 
per wine gallon’’ and inserting ‘‘$16.00 per proof 
gallon’’. 
(c) BEER.—Section 5051(B) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$18 for per barrel’’ 
and inserting ‘‘$16 per proof gallon’’. 
SEC. 209. TAX ON SUGARED DRINKS. 
(a) IN GENERAL.—Subchapter D of chapter 32 of the 
Internal Revenue Code of 1986 is amended by inserting 
after part I the following new part: 
‘‘PART II—SUGAR-SWEETENED BEVERAGES 
‘‘Sec. 4171. Imposition of tax. 
‘‘Sec. 4172. Definitions. 
‘‘Sec. 4173. Special rules. 
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‘‘SEC. 4171. IMPOSITION OF TAX. 
‘‘(a) IN GENERAL.—There is hereby imposed a tax 
on the sale or transfer of any specified sugar-sweetened 
beverage product by the manufacturer, producer, or im-
porter thereof. 
‘‘(b) RATE OF TAX.—The rate of tax imposed under 
subsection (a) shall be equal to one cent per 4.2 grams 
of caloric sweetener contained in such specified sugar- 
sweetened beverage product. 
‘‘(c) PERSONS LIABLE
FOR TAX.—The manufac-
turer, producer, or importer referred to in subsection (a) 
shall be liable for the tax imposed by such subsection. 
‘‘SEC. 4172. DEFINITIONS. 
‘‘(a) SPECIFIED
SUGAR-SWEETENED
BEVERAGE 
PRODUCT.—For purposes of this part— 
‘‘(1) IN GENERAL.—For purposes of this part, 
the term ‘specified sugar-sweetened beverage prod-
uct’ means— 
‘‘(A) any liquid intended for human con-
sumption which contains a caloric sweetener, 
and 
‘‘(B) any liquid, or solid mixture of ingre-
dients, which— 
‘‘(i) contains a caloric sweetener, and 
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140 
‘‘(ii) is intended for use as an ingre-
dient in a liquid described in subparagraph 
(A). 
‘‘(2) EXCEPTIONS.—The following shall not be 
treated as liquids described in paragraph (1)(A): 
‘‘(A) Any liquid the primary ingredients of 
which are milk or soy, rice, or similar plant- 
based milk substitute. 
‘‘(B) Any liquid composed entirely of one 
or more of the following: 
‘‘(i) The original liquid resulting from 
the pressing of fruit or vegetables. 
‘‘(ii) The liquid resulting from the re-
constitution of fruit or vegetable juice con-
centrate. 
‘‘(iii) The liquid resulting from the 
restoration of water to dehydrated fruit or 
vegetable juice. 
‘‘(C) Infant formula. 
‘‘(D) Any liquid products manufactured for 
use as— 
‘‘(i) an oral nutritional therapy for 
persons who cannot absorb or metabolize 
dietary nutrients from food or beverages, 
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141 
‘‘(ii) a source of necessary nutrition 
used due to a medical condition, or 
‘‘(iii) an oral electrolyte solution for 
infants and children formulated to prevent 
dehydration due to illness. 
‘‘(E) Any liquid with respect to which tax 
is imposed under chapter 51 (relating to dis-
tilled spirits, wines, and beer) or under section 
7652 by reason of the tax imposed under chap-
ter 51 being imposed on like articles of domes-
tic manufacture. 
‘‘(b) CALORIC SWEETENER.—For purposes of this 
part, the term ‘caloric sweetener’ means monosaccharides, 
disaccharides, and high-fructose corn syrup. 
‘‘SEC. 4173. SPECIAL RULES. 
‘‘(a) SWEETENER TAXED ONLY ONCE.—In the case 
of any specified sugar-sweetened beverage product which 
is manufactured or produced by including one or more 
other specified sugar-sweetened beverage products, no tax 
shall be imposed under this section on any caloric sweet-
ener contained in the resulting specified sugar-sweetened 
beverage product if tax was previously imposed under this 
section on such caloric sweetener when contained in the 
specified sugar-sweetened beverage product so included. 
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‘‘(b) INFLATION ADJUSTMENT.—In the case of any 
sale after December 31, 2015, the one cent amount in sec-
tion 4171(b) shall be increased by an amount equal to— 
‘‘(1) such amount, multiplied by 
‘‘(2) the cost-of-living adjustment determined 
under section 1(f)(3) for the calendar year in which 
such sale occurs, determined by substituting ‘cal-
endar year 2014’ for ‘calendar year 1992’ in sub-
paragraph (B) thereof. 
Any increase determined under this subsection shall 
be rounded to the nearest multiple of one-tenth of 
a cent.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 4221(a) is amended by adding at 
the end the following: ‘‘Paragraphs (1), (4), (5), and 
(6) shall not apply to the tax imposed under section 
4171.’’. 
(2) The table of parts for subchapter D of 
chapter 32 of such Code is amended by inserting 
after the item relating to part I the following new 
item: 
‘‘Part II—Sugar-Sweetened Beverages’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
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143 
shall take effect on the date of the enactment of this 
Act. 
(2) EXCISE TAX.—The amendments made by 
subsections (a) and (b) shall apply to sales after the 
date of the enactment of this Act. 
SEC. 210. REPEAL OF EXCISE TAX ON HIGH-COST EM-
PLOYER-SPONSORED HEALTH COVERAGE. 
(a) IN GENERAL.—Chapter 43 of the Internal Rev-
enue Code of 1986 is amended by striking section 4980I. 
(b) CONFORMING AMENDMENT.—Section 6051 of 
such Code is amended— 
(1) in paragraph (14) of subsection (a), by 
striking ‘‘section 4980I(d)(1)’’ and inserting ‘‘sub-
section (g)’’, and 
(2) by adding at the end the following: 
‘‘(g) APPLICABLE
EMPLOYER-SPONSORED
COV-
ERAGE.—For purposes of subsection (a)(14)— 
‘‘(1) IN GENERAL.—The term ‘applicable em-
ployer-sponsored coverage’ means, with respect to 
any employee, coverage under any group health plan 
made available to the employee by an employer 
which is excludable from the employee’s gross in-
come under section 106, or would be so excludable 
if it were employer-provided coverage (within the 
meaning of such section 106). 
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‘‘(2) EXCEPTIONS.—The term ‘applicable em-
ployer-sponsored coverage’ shall not include— 
‘‘(A) any coverage (whether through insur-
ance 
or 
otherwise) 
described 
in 
section 
9832(c)(1) (other than subparagraph (G) there-
of) or for long-term care; 
‘‘(B) any coverage under a separate policy, 
certificate, or contract of insurance which pro-
vides benefits substantially all of which are for 
treatment of the mouth (including any organ or 
structure within the mouth) or for treatment of 
the eye; or 
‘‘(C) any coverage described in section 
9832(c)(3) the payment for which is not exclud-
able from gross income and for which a deduc-
tion under section 162(l) is not allowable. 
‘‘(3) COVERAGE
INCLUDES
EMPLOYEE
PAID 
PORTION.—Coverage shall be treated as applicable 
employer-sponsored coverage without regard to 
whether the employer or employee pays for the cov-
erage. 
‘‘(4) GOVERNMENTAL PLANS INCLUDED.—Ap-
plicable employer-sponsored coverage shall include 
coverage under any group health plan established 
and maintained primarily for its civilian employees 
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by the Government of the United States, by the gov-
ernment of any State or political subdivision thereof, 
or by any agency or instrumentality of any such gov-
ernment. 
‘‘(5) COST OF COVERAGE.— 
‘‘(A) HEALTH FSAS.—In the case of appli-
cable employer-sponsored coverage consisting of 
coverage under a flexible spending arrangement 
(as defined in section 2205(g)), the cost of the 
coverage shall be equal to the amount deter-
mined under rules similar to the rules of section 
4980B(f)(4) with respect to any reimbursement 
under the arrangement reduced by the contribu-
tions described in subsection (a)(14)(B). 
‘‘(B) ARCHER
MSAS
AND
HSAS.—In the 
case of applicable employer-sponsored coverage 
consisting of coverage under an arrangement 
under which the employer makes contributions 
described in subsection (b) or (d) of section 
106, the cost of the coverage shall be equal to 
the amount of employer contributions under the 
arrangement until the termination of HSAs as 
described under section 206 of such Act. 
‘‘(C) 
ALLOCATION
ON
A
MONTHLY 
BASIS.—If cost is determined on other than a 
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monthly basis, the cost shall be allocated to 
months in a taxable period on such basis as the 
Secretary may prescribe.’’. 
(c) CLERICAL AMENDMENT.—The table of sections 
for chapter 43 of such Code is amended by striking the 
item relating to section 4980I. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2026. 
TITLE III—DRUG-RELATED 
PROVISIONS 
SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG 
AND MEDICAL DEVICE REVIEW BOARD. 
There is established in the Department of Health and 
Human Services a board to be known as the Prescription 
Drug and Medical Device Price Review Board (in this Act 
referred to as the ‘‘Board’’). 
SEC. 302. MEMBERSHIP; STAFF. 
(a) MEMBERS.—The Board shall be composed of the 
members as follows: 
(1) The Assistant Secretary for Planning and 
Evaluation of the Department of Health and Human 
Services (or the Assistant Secretary’s designee). 
(2) The Administrator of the Centers for Medi-
care & Medicaid Services or, beginning with 2025, 
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the Administrator of the Center for Health Care (or 
the Administrator’s designee). 
(3) The Assistant Director for the Health Serv-
ices Division of the Federal Bureau of Prisons (or 
the Assistant Director’s designee). 
(4) The Secretary of Defense (or the Sec-
retary’s designee). 
(5) The Secretary of Veterans Affairs (or the 
Secretary’s designee). 
(6) The Commissioner of Food and Drugs (or 
the Commissioner’s designee). 
(7) The Director of the National Institutes of 
Health (or the Director’s designee). 
(b) CHAIRPERSON.—The Board shall designate 1 
member of the Board to serve as the chairperson. 
(c) DIRECTOR AND STAFF.— 
(1) DIRECTOR.—The Board shall have a direc-
tor who shall be appointed by the chairperson of the 
Board, subject to rules prescribed by the Board. 
(2) STAFF.—The director may appoint and fix 
the pay of such additional personnel as the chair-
person considers appropriate, subject to rules pre-
scribed by the Board. 
(3) APPLICABILITY OF CERTAIN CIVIL SERVICE 
LAWS.—The director and staff of the Board shall be 
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appointed subject to the provisions of title 5, United 
States Code, governing appointments in the competi-
tive service, and shall be paid in accordance with the 
requirements of chapter 51 and subchapter III of 
chapter 53 of such title relating to classification and 
General Schedule pay rates; except that an indi-
vidual so appointed may not receive pay in excess of 
the maximum annual rate of basic pay payable for 
grade GS–15 of the General Schedule. 
(d) ASSISTANCE FOR THE BOARD.—Subject to sec-
tion 306(g), in carrying out this title, the Board— 
(1) may seek assistance from outside experts in 
the fields of consumer advocacy, medicine, pharma-
cology, pharmacy, and prescription drug reimburse-
ment; and 
(2) shall establish and maintain an advisory 
group and a stakeholder group for purposes of seek-
ing such assistance. 
(e) INITIAL MEETING.—The Board shall hold its ini-
tial meeting not later than 90 days after the date of the 
enactment of this Act. 
(f) BANNED INDIVIDUALS.— 
(1) DRUG
COMPANY
LOBBYISTS.—No former 
registered drug manufacturer lobbyist— 
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(A) may be appointed to the position of 
Director of the Office; or 
(B) may be employed by the Office during 
the 6-year period beginning on the date on 
which the registered lobbyist terminates its reg-
istration in accordance with section 4(d) of the 
Lobbying Disclosure Act of 1995 (2 U.S.C. 
1603(d)) or the agent terminates its status, as 
applicable. 
(2) SENIOR
EXECUTIVES
OF
LAW-BREAKING 
COMPANIES.—No former senior executive of a cov-
ered entity— 
(A) may be appointed to the position of 
Director of the Office; or 
(B) may be employed by the Office during 
the 6-year period beginning on the later of— 
(i) the date of the settlement; and 
(ii) the date on which the enforcement 
action has concluded. 
(3) COVERED ENTITY.—The term ‘‘covered en-
tity’’ means any entity that is— 
(A) a drug manufacturer; and 
(B)(i) operating under Federal settlement, 
including a Federal consent decree; or 
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(ii) the subject of an enforcement ac-
tion in a court of the United States or by 
an agency. 
SEC. 303. PROHIBITION AGAINST EXCESSIVE PRICE. 
(a) PROHIBITION.—Beginning on the effective date 
of the regulation required by subsection (b), the manufac-
turer of a prescription drug or medical device shall not 
charge an excessive price, as determined pursuant to such 
regulation, for such drug or device. 
(b) FORMULA.—The Board shall by regulation pre-
scribe a formula for determining whether the average 
manufacturer price of such drug or device over an annual 
quarter is an excessive price. 
(c) DETERMINATION OF EXCESSIVE PRICE.—If the 
Board determines, on its own initiative or in response to 
a petition submitted under subsection (d), that the manu-
facturer of a prescription drug or medical device charges 
an excessive price for such drug or device in violation of 
subsection (a)— 
(1) the Board shall give the manufacturer— 
(A) notice of such violation; and 
(B) subject to subsection (d), a period to 
correct such violation; and 
(2) if the manufacturer fails to correct the vio-
lation by the end of such period, the manufacturer 
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shall 
be 
subject 
to 
section 
304, 
section 
1927(c)(2)(E) of the Social Security Act (as added 
by subsection (c) of section 304), and section 4192 
of the Internal Revenue Code of 1986, as added by 
subsection (d) of section 304. 
(d) PETITIONS.—Any person may petition the Board 
to make a determination under subsection (c) regarding 
the pricing of a prescription drug or medical device. Not 
later than 90 days after the date of receipt of such a peti-
tion, the Board shall— 
(1) make a determination under subsection (c) 
regarding such pricing; or 
(2) decline to make such a determination. 
(e) CONTINUING VIOLATION.—The Board shall not 
be required to give a manufacturer an opportunity to cor-
rect a violation, as described in subsection (c)(1)(B), be-
fore the manufacturer becomes subject to the provisions 
described in subsection (c)(2) for such violation, if— 
(1) the Board has already provided such an op-
portunity to correct to the manufacturer; and 
(2) the Board finds that the violation of sub-
section (a) is a continuation of an earlier violation 
with respect to which such an opportunity was pro-
vided. 
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