I 
119TH CONGRESS 
1ST SESSION H. R. 4406 
To amend title I of the Patient Protection and Affordable Care Act to 
authorize the establishment of, and provide support for, State-based 
universal health care systems that provide comprehensive health benefits 
to State residents, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 15, 2025 
Mr. KHANNA (for himself, Mrs. CHERFILUS-MCCORMICK, Mr. COHEN, Mr. 
MCGOVERN, Ms. NORTON, Mr. NEGUSE, Ms. OMAR, Ms. PINGREE, Ms. 
SALINAS, Mr. SMITH of Washington, Mr. THANEDAR, Mr. HUFFMAN, 
Ms. TLAIB, Mrs. WATSON COLEMAN, Ms. JAYAPAL, Ms. LEE of Pennsyl-
vania, Mr. THOMPSON of Mississippi, Ms. ANSARI, Ms. BONAMICI, Mr. 
NADLER, Mrs. RAMIREZ, Ms. DEXTER, and Ms. VELA´ZQUEZ) introduced 
the following bill; which was referred to the Committee on Energy and 
Commerce, and in addition to the Committees on Armed Services, Ways 
and Means, Oversight and Government Reform, and Education and 
Workforce, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To amend title I of the Patient Protection and Affordable 
Care Act to authorize the establishment of, and provide 
support for, State-based universal health care systems 
that provide comprehensive health benefits to State resi-
dents, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
SECTION 1. SHORT TITLE; PURPOSE. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘State-Based Universal Health Care Act of 2025’’. 
(b) PURPOSE.—The purpose of this Act is to estab-
lish a flexible framework under which States can provide 
comprehensive universal health coverage to their residents. 
SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 
(a) IN GENERAL.—Subtitle D of title I of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18021 et 
seq.) is amended by inserting after section 1334 the fol-
lowing new section: 
‘‘SEC. 1335. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 
‘‘(a) APPLICATION.— 
‘‘(1) IN GENERAL.—Subject to paragraph (6), a 
State may apply to the Secretary (as defined in sub-
section (i)(3)) for the waiver of so much of the re-
quirements described in paragraph (2) with respect 
to health benefits coverage within the State for plan 
years beginning on or after January 1, 2026, as is 
necessary to implement a comprehensive State uni-
versal health care plan in the State under this sec-
tion. Such application shall— 
‘‘(A) be filed at such time and in such 
manner as the Secretary may require; 
‘‘(B) contain such information as the Sec-
retary may require, including— 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(i) a comprehensive description of 
the State legislation, or other State legal 
authority as applicable, and program to 
implement a plan meeting the require-
ments for a waiver under this section; 
‘‘(ii) a plan for how the State will 
achieve in 5 years health coverage for at 
least 95 percent of residents of the State; 
and 
‘‘(iii) a 10-fiscal-year budget plan for 
such plan that is budget neutral for the 
Federal Government; and 
‘‘(C) provide an assurance that the State 
has legal authority to implement such plan or 
has enacted the law described in subsection 
(b)(2). 
‘‘(2) REQUIREMENTS.—The requirements de-
scribed in this paragraph with respect to health ben-
efits coverage within the State for plan years begin-
ning on or after January 1, 2026, are as follows: 
‘‘(A) Sections 1301 through 1324. 
‘‘(B) Section 1402. 
‘‘(C) Sections 36B and 4980H of the In-
ternal Revenue Code of 1986. 
‘‘(D) Title XI of the Social Security Act. 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(E) Title XVIII of the Social Security 
Act. 
‘‘(F) Title XIX of the Social Security Act. 
‘‘(G) Title XXI of the Social Security Act. 
‘‘(H) Chapter 89 of title 5, United States 
Code. 
‘‘(I) Chapter 55 of title 10, United States 
Code, including coverage under the TRICARE 
program. 
‘‘(J) Section 514 of the Employee Retire-
ment Income Security Act of 1974. 
‘‘(3) PASSTHROUGH
OF
FUNDING.—With re-
spect to a State waiver under paragraph (1), under 
which the State assumes responsibility for health 
coverage under one or more of the specified Federal 
health programs, including under each of the Fed-
eral health care or subsidy programs specified in 
subparagraphs (A), (B), (C), (E), (F), (G), (H), and 
(I) of paragraph (2), the Secretary shall not spend 
Federal health or related administrative funds that 
would otherwise have been spent for such a pro-
gram, as applicable, for the time periods covered 
under the waiver and shall provide for an alternative 
means by which the aggregate amount of such funds 
(determined by the Secretary in coordination with 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
the State), including caseload growth, adjusted for 
inflation in health care costs within the State, shall 
be paid to the State for purposes of implementing 
the State plan under the waiver. Any savings in 
health care spending, including administrative sav-
ings, shall be available to the State for reinvestment 
in health care services under the State plan. Such 
amount shall be determined annually by the Sec-
retary, taking into account the amount that would 
otherwise have been spent under each such Federal 
health program, including for administrative activi-
ties and caseload growth, with respect to residents 
of such State, for those time periods covered under 
the waiver, adjusted for inflation in health care 
costs, if such waiver did not apply. Such amount 
shall include funds equal to the aggregate amount of 
premium tax credits, cost-sharing reductions, or 
small-business credits, to the extent applicable to an 
approved waiver, under sections 36B and 45R of the 
Internal Revenue Code of 1986 or under section 
1402 that would have been available to individuals 
and businesses in the State for those time periods 
covered under the waiver, including caseload growth, 
adjusted for inflation in health care costs, if such 
waiver did not apply. 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(4) WAIVER
CONSIDERATION
AND
TRANS-
PARENCY.— 
‘‘(A) IN GENERAL.—An application for a 
waiver under this section shall be considered by 
the Secretary, after taking into account rec-
ommendations of the Panel under subsection 
(g), in accordance with the regulations de-
scribed in subparagraph (B). 
‘‘(B) REGULATIONS.—Not later than 180 
days after the date of the enactment of the 
State-Based Universal Health Care Act of 
2025, the Secretary shall promulgate regula-
tions relating to waivers under this section that 
provide— 
‘‘(i) a process for public notice and 
comment in accordance with the public no-
tice and comment requirements applicable 
under regulations used for Medicaid waiv-
ers pursuant to section 1115 of the Social 
Security Act; 
‘‘(ii) a process for the submission of 
an application that ensures the disclosure 
of— 
‘‘(I) the provisions of law that 
the State involved seeks to waive; and 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(II) the specific plans of the 
State to ensure that the waiver will be 
in compliance with subsection (b); 
‘‘(iii) a process for providing public 
notice and comment after the application is 
received by the Secretary that is sufficient 
to ensure a meaningful level of public 
input and that does not impose require-
ments that are in addition to, or duplica-
tive of, requirements imposed under chap-
ter 5 of title 5, United States Code (com-
monly referred to as the Administrative 
Procedure Act), or requirements that are 
unreasonable or unnecessarily burdensome 
with respect to State compliance; 
‘‘(iv) a process for the submission to 
the Secretary of periodic reports by the 
State concerning the implementation of the 
program under the waiver; 
‘‘(v) a process for the periodic evalua-
tion by the Secretary with respect to waiv-
ers granted under this section; and 
‘‘(vi) a process for providing technical 
assistance on— 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(6) COORDINATION
WITH
1332
WAIVERS.—A 
State may not apply for a waiver under this section 
with respect to a plan year if such State has in ef-
fect, with respect to such plan year, a waiver under 
section 1332. 
‘‘(7) AUTHORIZATION
OF
APPROPRIATIONS.— 
There is authorized to be appropriated such sums as 
may be necessary for providing funds to States with 
a waiver under this section for purposes of carrying 
out activities described in subsection (b)(1)(E). 
‘‘(b) GRANTING OF WAIVERS.— 
‘‘(1) IN GENERAL.—The Secretary shall grant a 
request for a waiver under subsection (a)(1) if the 
Secretary determines that the State plan— 
‘‘(A) will provide, in accordance with sub-
paragraph (B), health benefits coverage to ap-
plicable State residents that is at least as com-
prehensive as the health benefits coverage that 
such residents would have received under one or 
more of the specified Federal health programs 
(as defined in subsection (i)(4)), as applicable, 
for which such residents would have been eligi-
ble, absent such waiver; 
‘‘(B) will provide, in the case of such a 
waiver under subsection (a)(1) for the State to 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
waive any of the requirements described in sub-
section (a)(2)(F), as applicable, health benefits 
coverage to applicable State residents who 
would have otherwise received health benefits 
coverage in the form of medical assistance 
under the State Federal health program de-
scribed in subsection (i)(4)(B) (regardless of 
whether the State provides for such assistance 
through a State Medicaid plan under title XIX 
of the Social Security Act or a waiver of such 
State Medicaid plan) that includes at least the 
mandatory benefits under title XIX of the So-
cial Security Act that are required of a State 
without a waiver of a State Medicaid plan 
under such title, including benefits for early 
and periodic screening, diagnostic, and treat-
ment, benefits for non-emergency transpor-
tation, and retroactive coverage; 
‘‘(C) will provide coverage and cost-sharing 
protections 
against 
excessive 
out-of-pocket 
spending to State residents that are at least as 
affordable as the coverage and cost-sharing pro-
tections under the specified Federal health pro-
gram (as defined in subsection (i)(4)) for which 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
such residents would have been eligible, absent 
such waiver; 
‘‘(D) will provide coverage to all residents 
of the State, including those otherwise covered 
under one or more of the Federal health care 
or subsidy programs specified in subparagraphs 
(B), (C), (E), (F), (G), and (H) of subsection 
(a)(2), except individuals who are eligible for 
benefits through the Indian Health Service or 
for benefits and services under title 38, United 
States Code; 
‘‘(E) will provide for public education ac-
tivities to raise awareness of the availability of 
such coverage and the facilitation of enrollment 
in such coverage, and to raise awareness re-
garding restrictions on the sale of duplicative or 
supplemental private insurance (and, if the 
State chooses to continue to offer qualified 
health plans through an Exchange, public edu-
cation activities will raise awareness of the 
availability of and the facilitation of enrollment 
in such plans in a manner similar to an entity 
that serves as a navigator under a grant under 
section 1311(i)); 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(F) will be publicly administered by an 
agency or multiple agencies of the State, or an 
independent public entity within the govern-
ment of the State; 
‘‘(G) will not preclude the purchase of in-
surance that offers coverage for benefits that 
are not offered under the State plan; 
‘‘(H) will provide systems for complaints, 
appeals, independent review, and other proce-
dures for accessing and maintaining benefits 
that are at least as accessible to applicable 
State residents as those of one or more of the 
specified Federal health programs (as defined 
in subsection (i)(4)) for which such residents 
would have otherwise been eligible without ap-
plication of such waiver under subsection 
(a)(1); and 
‘‘(I) will provide coverage for reproductive 
health care services, including abortion, contra-
ception, and gender-affirming care. 
Subparagraph (D) shall not be construed as limiting 
a State from contracting with one or more private 
entities to administer the State plan. 
‘‘(2) REQUIREMENT TO ENACT A LAW.— 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(A) IN
GENERAL.—A law described in 
this paragraph is a State law (including an ex-
ecutive order by a State governor) that provides 
for State actions under a waiver under this sec-
tion, including the implementation of the State 
plan under subsection (a)(1)(B). 
‘‘(B) TERMINATION OF OPT OUT.—A State 
may repeal a law described in subparagraph (A) 
and terminate the authority provided under the 
waiver with respect to the State. 
‘‘(c) SCOPE OF WAIVER.— 
‘‘(1) IN GENERAL.—The Secretary shall deter-
mine the scope of a waiver of a requirement de-
scribed in subsection (a)(2) granted to a State under 
subsection (a)(1). 
‘‘(2) LIMITATION.—Under this section, the Sec-
retary may not waive any Federal law or require-
ment that is not listed in subsection (a)(2). 
‘‘(d) DETERMINATIONS BY SECRETARY.— 
‘‘(1) TIME
FOR
DETERMINATION.—The Sec-
retary shall, with respect to an application from a 
State under this section and after taking into ac-
count recommendations of the Panel under sub-
section (g) for such application, make a determina-
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
tion under subsection (a)(1) not later than 90 days 
after the receipt of such recommendations. 
‘‘(2) EFFECT OF DETERMINATION.— 
‘‘(A) GRANTING OF WAIVERS.—If the Sec-
retary determines to grant a waiver under sub-
section (a)(1), the Secretary shall notify the 
State involved of such determination and the 
terms and effectiveness of such waiver. 
‘‘(B) DENIAL
OF
WAIVER.—If the Sec-
retary determines a waiver should not be grant-
ed under subsection (a)(1), the Secretary shall 
notify the State involved and the appropriate 
committees of Congress of such determination 
and the reasons therefor. 
‘‘(e) REQUIRED REPORTS; 5-YEAR REVIEW.— 
‘‘(1) IN GENERAL.—As a condition of receipt of 
a waiver under this section, after each 5-year period 
of such waiver, a State shall submit to the Secretary 
a report that is carried out by an independent, non- 
partisan entity, with respect to such 5-year period 
and after a process for public notice and comment 
at the State level, including public hearings, suffi-
cient to ensure a meaningful level of public input, on 
the following: 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
Labor, and the Director of the Office of Personnel 
Management, shall, through the execution of an 
interagency memorandum of understanding among 
such Secretaries and Director— 
‘‘(A) develop a process for coordinating 
and consolidating the State waiver processes 
applicable under the provisions of this section, 
and the existing waiver processes applicable 
under— 
‘‘(i) titles XI, XVIII, XIX, and XXI 
of the Social Security Act; and 
‘‘(ii) any other Federal law relating to 
the provision of health care items or serv-
ices; and 
‘‘(B) ensure that— 
‘‘(i) regulations (including regulations 
required under subsection (a)(4)(B)), rul-
ings, and interpretations issued by such 
Secretaries and Director relating to the 
same matter over which two or more such 
Secretaries or Director have responsibility 
under this section are administered so as 
to have the same effect at all times; and 
‘‘(ii) coordination of policies relating 
to the granting, implementation, and con-
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
tinuation of waivers through such Secre-
taries and Director in order to have a co-
ordinated strategy that avoids duplication 
of effort by the States or Secretaries and 
Director and ensures clarity about waiver 
application status and approval. 
‘‘(2) SINGLE APPLICATION.—The process under 
paragraph (1)(A) shall permit a State to submit a 
single application for a waiver under all of the provi-
sions of this section and the provisions of law listed 
under clauses (i) and (ii) of such paragraph. 
‘‘(3) SUBMISSION
OF
CONFORMING
AMEND-
MENTS.—The Secretary of Health and Human Serv-
ices, in coordination with the other Secretaries listed 
in paragraph (1) (including the Director of the Of-
fice of Personnel Management), shall submit to Con-
gress such recommendations for such technical and 
conforming amendments to law as may be appro-
priate to assist in the implementation of this section. 
‘‘(g) INDEPENDENT ASSESSMENT PANEL FOR COM-
PREHENSIVE HEALTH CARE.— 
‘‘(1) ESTABLISHMENT.—There is established a 
committee to be known as the ‘Independent Assess-
ment Panel for Comprehensive Health Care’ (in this 
section referred to as the ‘Panel’). 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(2) CONSIDERATION
OF
SUBMISSIONS.—The 
Secretary shall forward a copy of each waiver appli-
cation submitted under this section to the Panel for 
consideration under this subsection. 
‘‘(3) DUTIES.—The Panel shall— 
‘‘(A) review any waiver application by a 
State forwarded under paragraph (2) and any 
report submitted under paragraph (1) of sub-
section (e) for purposes of the review under 
paragraph (2) of such subsection; 
‘‘(B) not later than 90 days after submis-
sion of such application (or report) by the 
State, provide to the State and to the Secretary 
the recommendations of the Panel regarding 
the approval or disapproval of such waiver ap-
plication (or regarding the status of the waiver 
for continuation pursuant to subsection (e)(2)) 
and, if applicable, possible improvements to 
such application (or for purposes of subsection 
(e)(2)); and 
‘‘(C) submit to Congress an annual report 
on waiver applications (and waiver reports 
under subsection (e)) reviewed by the Panel 
during the applicable year, including the num-
ber of applications (and reports) received and 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
the number of applications recommended for 
approval (and of reports with respect to which 
recommendations for continuation were pro-
vided). 
‘‘(4) MEMBERSHIP.— 
‘‘(A) NUMBER
AND
APPOINTMENT.—The 
Panel shall consist of 11 members appointed by 
the Secretary of Health and Human Services, 
of whom— 
‘‘(i) one shall be appointed on the rec-
ommendation of the Speaker of the House 
of Representatives; 
‘‘(ii) one shall be appointed on the 
recommendation of the minority leader of 
the House of Representatives; 
‘‘(iii) one shall be appointed on the 
recommendation of the majority leader of 
the Senate; 
‘‘(iv) one shall be appointed on the 
recommendation of the minority leader of 
the Senate; 
‘‘(v) one shall be appointed on the rec-
ommendation of the Republican Governors 
Association; 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00020
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(vi) one shall be appointed on the 
recommendation of the Democratic Gov-
ernors Association; 
‘‘(vii) one shall be a representative 
from the patient advocacy community; 
‘‘(viii) two shall be representatives of 
a labor organization representing health 
care professionals who provide direct pa-
tient care, including at least one labor or-
ganization that primarily represents reg-
istered nurses; 
‘‘(ix) one shall be a representative of 
primary care physicians; and 
‘‘(x) one shall be a representative of 
health care professionals practicing in 
rural or underserved areas. 
‘‘(B) TERM OF SERVICE.— 
‘‘(i) IN GENERAL.—Each member of 
the Panel shall serve a three-year term. A 
member may serve after the expiration of 
that member’s term until a successor has 
been appointed pursuant to subparagraph 
(A). 
‘‘(ii) VACANCY.—Any member ap-
pointed to fill a vacancy occurring before 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00021
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
the expiration of the term for which the 
member’s predecessor was appointed shall 
be appointed only for the remainder of that 
term. A vacancy in the Commission shall 
be filled in the manner in which the origi-
nal appointment was made. 
‘‘(C) PAY.—Members of the Panel shall 
serve without pay. 
‘‘(D) 
CHAIRPERSON; 
VICE
CHAIR-
PERSON.— 
‘‘(i) CHAIRPERSON.—The Secretary of 
Health and Human Services, or a designee 
of the Secretary, shall serve on the Panel 
as the Chairperson of the Panel. 
‘‘(ii) VICE
CHAIRPERSON.—The Ad-
ministrator of the Federal Emergency 
Management Agency, or a designee of the 
Administrator, shall serve on the Panel as 
the Vice Chairperson of the Panel. 
‘‘(5) STAFF, EXPERTS, AND CONSULTANTS.— 
The Panel may— 
‘‘(A) appoint such staff as the Panel con-
siders to be appropriate, without regard to the 
provisions of title 5, United States Code, gov-
erning appointments in the competitive service; 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00022
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(B) fix the pay of such staff, without re-
gard to the provisions of chapter 51 and sub-
chapter III of chapter 53 of such title relating 
to classification and General Schedule pay 
rates; and 
‘‘(C) procure the services of experts and 
consultants in accordance with the provisions of 
section 3109(b) of such title. 
‘‘(6) DETAIL OF FEDERAL PERSONNEL.—Upon 
request of the Panel, the head of any Federal agency 
may detail, on a reimbursable basis, any of the per-
sonnel of the agency to the Panel to assist it in car-
rying out the duties under paragraph (3). 
‘‘(7) FEDERAL
ADVISORY
COMMITTEE
ACT.— 
The Federal Advisory Committee Act (5 U.S.C. 
App.) shall apply to the Panel. 
‘‘(8) AUTHORIZATION
OF
APPROPRIATIONS.— 
There is authorized to be appropriated such sums as 
may be necessary to the Panel for carrying out the 
duties of the panel for each of fiscal years 2026 
through 2031. 
‘‘(h) GUIDANCE RELATING TO AMERICAN INDIANS 
AND ALASKA NATIVES.— 
‘‘(1) IN GENERAL.—The Secretary shall issue 
guidance with respect to applying the provisions of 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00023
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
this section in a manner consistent with the fol-
lowing: 
‘‘(A) To further the goal that Federal 
health services to maintain and improve the 
health of Indians are consonant with and re-
quired by the Federal Government’s historical 
and unique legal relationship with, and result-
ing responsibility to, Indians. 
‘‘(B) No enrollment fee, premium, or simi-
lar charge, and no deduction, copayment, cost 
sharing, or similar charge, is to be imposed 
against an Indian who is furnished an item or 
service through a waiver under this section. All 
costs incurred in waiving such charges shall be 
borne by the Federal Government in fulfillment 
of the trust responsibility. 
‘‘(C) A State may not require the enroll-
ment of an individual who is an Indian in 
health insurance offered through a waiver under 
this section. 
‘‘(D) Health insurance issuers offering cov-
erage pursuant to a waiver under this section 
must make good faith efforts to contract with 
Indian health care providers operating within 
the area served by the issuers. 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00024
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(E) Health insurance issuers offering cov-
erage pursuant to a waiver under this section 
shall pay Indian health care providers, whether 
such providers are participating or nonpartici-
pating providers with respect to the coverage, 
for covered services provided to those Indian 
enrollees who are eligible to receive services 
from such providers at a rate equal to the rate 
negotiated between such entity and the provider 
involved or, if such a rate has not been nego-
tiated, at a rate that is not less than the level 
and amount of payment which the entity would 
make for the services if the services were fur-
nished by a participating provider which is not 
an Indian health care provider. 
‘‘(F) Health insurance issuers offering cov-
erage pursuant to a waiver under this section 
will include a standard contract addendum 
when contracting with Indian health care pro-
viders. The contract addendum will be devel-
oped in consultation with Tribes and in con-
ference with urban Indian health programs op-
erating within the service area of the State. 
‘‘(G) The treatment of Indians under this 
section does not constitute invidious racial dis-
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00025
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
crimination in violation of the due process 
clause of the Fifth or Fourteenth Amendments, 
but is reasonable and rationally designed to fur-
ther the health of Indians. 
‘‘(H) In the case of any State in which 1 
or more Indian health care programs furnishes 
health care services, the State will provide for 
a process under which the State seeks advice on 
a regular, ongoing basis from designees of such 
Indian health care programs and urban Indian 
organizations on matters relating to the appli-
cation of a waiver under this section that are 
likely to have a direct effect on such Indian 
health programs and that— 
‘‘(i) shall include solicitation of advice 
prior to submission of any plan amend-
ments, waiver requests, and proposals for 
demonstration projects likely to have a di-
rect effect on Indians or Indian health care 
programs; and 
‘‘(ii) may include appointment of an 
advisory committee and of a designee of 
such Indian health care programs to the 
medical care advisory committee advising 
the State on its waiver under this section. 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00026
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
‘‘(2) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) The term ‘Indian’ has the meaning 
given such term in section 447.50 of title 42, 
Code of Federal Regulations (as in effect on 
July 1, 2010). 
‘‘(B) The term ‘Indian health care pro-
vider’ has the meaning given such term in sec-
tion 438.14(a) of title 42, Code of Federal Reg-
ulations. 
‘‘(i) DEFINITIONS.—In this section: 
‘‘(1) HEALTH BENEFITS COVERAGE.—The term 
‘health benefits coverage’— 
‘‘(A) means— 
‘‘(i) health insurance coverage, as 
such term is defined in section 2791(b) of 
the Public Health Service Act (42 U.S.C. 
300gg–(b)); and 
‘‘(ii) coverage under a group health 
plan, as such term is defined in section 
2791(a) of the Public Health Service Act 
(42 U.S.C. 300gg–(a)); and 
‘‘(B) includes any medical coverage or 
health benefits provided under one or more of 
the specified Federal health program described 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00027
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB
in subparagraphs (A) through (E) of paragraph 
(4), as applicable to a waiver under subsection 
(a)(1). 
‘‘(2) RESIDENT.—With respect to a State, the 
term ‘resident’ means an individual— 
‘‘(A) who is— 
‘‘(i) a citizen or national of the United 
States; or 
‘‘(ii) an alien lawfully residing in the 
State (including an alien who is granted 
deferred action or who is otherwise author-
ized to remain in the United States); and 
‘‘(B) whose primary residence (as defined 
by the State) is located in the State. 
‘‘(3) 
SECRETARY.—The 
term 
‘Secretary’ 
means— 
‘‘(A) the Secretary of Health and Human 
Services with respect to waivers relating to the 
provisions described in subparagraphs (A), (B), 
and (D) through (G) of paragraph (2) of sub-
section (a); 
‘‘(B) the Secretary of the Treasury with 
respect to waivers relating to the provisions de-
scribed in subparagraph (C) of such paragraph; 
VerDate Sep 11 2014 
00:13 Jul 19, 2025
Jkt 059200
PO 00000
Frm 00028
Fmt 6652
Sfmt 6201
E:\BILLS\H4406.IH
H4406
kjohnson on DSK7ZCZBW3PROD with $$_JOB