plan receiving items or services from the 
provider or supplier during the plan year 
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 2020, 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: 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00081
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(i) Information regarding the meas-
ures used by the MA organization to estab-
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: 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00082
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(K) 
fails 
to 
comply 
with 
section 
1852(d)(7) or 1852(d)(8); or’’; and 
(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–112(b)(3)(E)), 
by 
striking 
‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 
(1)(F) and (1)(K)’’; and 
(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. 123. 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: 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00083
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
‘‘(9) NETWORK
ADEQUACY
REQUIREMENTS.— 
Beginning in plan year 2019, notwithstanding any 
other provision of law, the following shall apply: 
‘‘(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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00084
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
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. 
‘‘(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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00085
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
following with respect to each MA plan offered 
by the organization: 
‘‘(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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00086
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
section) at least once every 3 years or when a 
material change in network occurs. 
‘‘(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. 124. 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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00087
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(II) the twenty-fifth month of his entitlement or sta-
tus as a qualified railroad retirement beneficiary de-
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)) 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00088
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
is amended by striking ‘‘25th month of’’ and insert-
ing ‘‘month following the first month of’’. 
(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. 125. 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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00089
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
date of the enactment of this Act, are on State Medicaid 
waiting lists or State Medicaid waiver waiting lists. 
SEC. 126. 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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00090
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(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 
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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00091
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
respect to any employer for any calendar year, the 
aggregate wages paid by the employer during such 
calendar year. 
(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— 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00092
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(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 
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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00094
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
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 
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-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00095
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
retary of Labor, may promulgate regulations to im-
plement this subsection. 
SEC. 127. 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: 
‘‘(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. 128. 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)’’. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00096
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
SEC. 129. 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. 130. 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 
issuers and group health plans under title XXVII of such 
Act. 
SEC. 131. 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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00097
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
eligible Federal Loan for each year the health care pro-
vider 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). 
(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. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00098
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
(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-
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 Secretary of Education may promul-
gate regulations to implement this section. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00099
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
100 
SEC. 132. 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 2023. 
(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— 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00100
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
101 
(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. 
SEC. 133. 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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00101
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
102 
‘‘(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. 
‘‘(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) 2023; 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), 
2025. 
‘‘(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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00102
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
103 
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. 
‘‘(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, deliver, 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. 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00103
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
104 
‘‘(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 
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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00104
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
105 
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-
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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00105
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
106 
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 
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-
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00106
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
107 
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-
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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00107
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
108 
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 
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 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00108
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS
109 
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 
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— 
VerDate Sep 11 2014 
20:58 May 08, 2019
Jkt 089200
PO 00000
Frm 00109
Fmt 6652
Sfmt 6201
E:\BILLS\H2452.IH
H2452
pamtmann on DSKBFK8HB2PROD with BILLS