Medicare for All Act of 2021
Bill: H.R.1976 | Sponsor: Rep. Jayapal, Pramila (D-WA)
Policy area: Health

Summary:
Medicare for All Act of 2021
This bill establishes a national health insurance program that is administered by the Department of Health and Human Services (HHS).
Among other requirements, the program must (1) cover all U.S. residents; (2) provide for automatic enrollment of individuals upon birth or residency in the United States; and (3) cover items and services that are medically necessary or appropriate to maintain health or to diagnose, treat, or rehabilitate a health condition, including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, and long-term care.
The bill prohibits cost-sharing (e.g., deductibles, coinsurance, and copayments) and other charges for covered services. Additionally, private health insurers and employers may only offer coverage that is supplemental to, and not duplicative of, benefits provided under the program.
Health insurance exchanges and specified federal health programs terminate upon program implementation. However, the program does not affect coverage provided through the Department of Veterans Affairs or the Indian Health Service.
The bill also establishes a series of implementing provisions relating to (1) health care provider participation; (2) HHS administration; and (3) payments and costs, including the requirement that HHS negotiate prices for prescription drugs.
Individuals who are age 18 or younger, age 55 or older, or already enrolled in Medicare may enroll in the program starting one year after enactment of this bill; other individuals may buy into the program at this time. The program must be fully implemented two years after enactment.

To establish an improved Medicare for All national health insurance 
                                program.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Medicare for All 
Act of 2021''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
   TITLE I--ESTABLISHMENT OF THE MEDICARE FOR ALL PROGRAM; UNIVERSAL 
                          COVERAGE; ENROLLMENT

Sec. 101. Establishment of the Medicare for All Program.
Sec. 102. Universal coverage.
Sec. 103. Freedom of choice.
Sec. 104. Non-discrimination.
Sec. 105. Enrollment.
Sec. 106. Effective date of benefits.
Sec. 107. Prohibition against duplicating coverage.
  TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND 
                      BENEFITS FOR LONG-TERM CARE

Sec. 201. Comprehensive benefits.
Sec. 202. No cost-sharing; other limitations.
Sec. 203. Exclusions and limitations.
Sec. 204. Coverage of long-term care services.
                   TITLE III--PROVIDER PARTICIPATION

Sec. 301. Provider participation and standards; whistleblower 
                            protections.
Sec. 302. Qualifications for providers.
Sec. 303. Use of private contracts.
                        TITLE IV--ADMINISTRATION

             Subtitle A--General Administration Provisions

Sec. 401. Administration.
Sec. 402. Consultation.
Sec. 403. Regional administration.
Sec. 404. Beneficiary ombudsman.
Sec. 405. Conduct of related health programs.
                Subtitle B--Control Over Fraud and Abuse

Sec. 411. Application of Federal sanctions to all fraud and abuse under 
                            the Medicare for All Program.
                      TITLE V--QUALITY ASSESSMENT

Sec. 501. Quality standards.
Sec. 502. Addressing health care disparities.
      TITLE VI--HEALTH BUDGET; PAYMENTS; COST CONTAINMENT MEASURES

                         Subtitle A--Budgeting

Sec. 601. National health budget.
                   Subtitle B--Payments to Providers

Sec. 611. Payments to institutional providers based on global budgets.
Sec. 612. Payment to individual providers through fee-for-service.
Sec. 613. Ensuring accurate valuation of services under the Medicare 
                            physician fee schedule.
Sec. 614. Payment prohibitions; capital expenditures; special projects.
Sec. 615. Office of Health Equity.
Sec. 616. Office of Primary Care.
Sec. 617. Payments for prescription drugs and approved devices and 
                            equipment.
                TITLE VII--UNIVERSAL MEDICARE TRUST FUND

Sec. 701. Universal Medicare Trust Fund.
  TITLE VIII--CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME 
                          SECURITY ACT OF 1974

Sec. 801. Prohibition of employee benefits duplicative of benefits 
                            under the Medicare for All Program; 
                            coordination in case of workers' 
                            compensation.
Sec. 802. Application of continuation coverage requirements under ERISA 
                            and certain other requirements relating to 
                            group health plans.
Sec. 803. Effective date of title.
               TITLE IX--ADDITIONAL CONFORMING AMENDMENTS

Sec. 901. Relationship to existing Federal health programs.
Sec. 902. Sunset of provisions related to the State Exchanges.
Sec. 903. Sunset of provisions related to pay for performance programs.
                          TITLE X--TRANSITION

 Subtitle A--Medicare for All Transition Over 2 Years and Transitional 
                             Buy-In Option

Sec. 1001. Medicare for all transition over two years.
Sec. 1002. Establishment of the Medicare transition buy-in.
               Subtitle B--Transitional Medicare Reforms

Sec. 1011. Eliminating the 24-month waiting period for Medicare 
                            coverage for individuals with disabilities.
Sec. 1012. Ensuring continuity of care.
                        TITLE XI--MISCELLANEOUS

Sec. 1101. Definitions.
Sec. 1102. Rules of construction.
Sec. 1103. No use of resources for law enforcement of certain 
                            registration requirements.

   TITLE I--ESTABLISHMENT OF THE MEDICARE FOR ALL PROGRAM; UNIVERSAL 
                          COVERAGE; ENROLLMENT

SEC. 101. ESTABLISHMENT OF THE MEDICARE FOR ALL PROGRAM.

    There is hereby established a national health insurance program to 
provide comprehensive protection against the costs of health care and 
health-related services, in accordance with the standards specified in, 
or established under, this Act.

SEC. 102. UNIVERSAL COVERAGE.

    (a) In General.--Every individual who is a resident of the United 
States is entitled to benefits for health care services under this Act. 
The Secretary shall promulgate a rule that provides criteria for 
determining residency for eligibility purposes under this Act.
    (b) Treatment of Other Individuals.--The Secretary may make 
eligible for benefits for health care services under this Act other 
individuals not described in subsection (a), and regulate the 
eligibility of such individuals, to ensure that every person in the 
United States has access to health care. In regulating such 
eligibility, the Secretary shall ensure that individuals are not 
allowed to travel to the United States for the sole purpose of 
obtaining health care items and services provided under the program 
established under this Act.

SEC. 103. FREEDOM OF CHOICE.

    Any individual entitled to benefits under this Act may obtain 
health services from any institution, agency, or individual qualified 
to participate under this Act.

SEC. 104. NON-DISCRIMINATION.

    (a) In General.--No person shall, on the basis of race, color, 
national origin, age, disability, marital status, citizenship status, 
primary language use, genetic conditions, previous or existing medical 
conditions, religion, or sex, including sex stereotyping, gender 
identity, sexual orientation, and pregnancy and related medical 
conditions (including termination of pregnancy), be excluded from 
participation in or be denied the benefits of the program established 
under this Act (except as expressly authorized by this Act for purposes 
of enforcing eligibility standards described in section 102), or be 
subject to any reduction of benefits or other discrimination by any 
participating provider (as defined in section 301), or any entity 
conducting, administering, or funding a health program or activity, 
including contracts of insurance, pursuant to this Act.
    (b) Claims of Discrimination.--
            (1) In general.--The Secretary shall establish a procedure 
        for adjudication of administrative complaints alleging a 
        violation of subsection (a).
            (2) Jurisdiction.--Any person aggrieved by a violation of 
        subsection (a) by a covered entity may file suit in any 
        district court of the United States having jurisdiction of the 
        parties. A person may bring an action under this paragraph 
        concurrently as such administrative remedies as established in 
        paragraph (1).
            (3) Damages.--If the court finds a violation of subsection 
        (a), the court may grant compensatory and punitive damages, 
        declaratory relief, injunctive relief, attorneys' fees and 
        costs, or other relief as appropriate.
    (c) Continued Application of Laws.--Nothing in this title (or an 
amendment made by this title) shall be construed to invalidate or 
otherwise limit any of the rights, remedies, procedures, or legal 
standards available to individuals aggrieved under section 1557 of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18116), 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.), section 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.). Nothing in this 
title (or an amendment to this title) shall be construed to supersede 
State laws that provide additional protections against discrimination 
on any basis described in subsection (a).

SEC. 105. ENROLLMENT.

    (a) In General.--The Secretary shall provide a mechanism for the 
enrollment of individuals eligible for benefits under this Act. The 
mechanism shall--
            (1) include a process for the automatic enrollment of 
        individuals at the time of birth in the United States (or upon 
        establishment of residency in the United States);
            (2) provide for the enrollment, as of the dates described 
        in section 106, of all individuals who are eligible to be 
        enrolled as of such dates, as applicable; and
            (3) include a process for the enrollment of individuals 
        made eligible for health care services under section 102(b).
    (b) Issuance of Universal Medicare Cards.--In conjunction with an 
individual's enrollment for benefits under this Act, the Secretary 
shall provide for the issuance of a Universal Medicare card that shall 
be used for purposes of identification and processing of claims for 
benefits under this program. The card shall not include an individual's 
Social Security number.

SEC. 106. EFFECTIVE DATE OF BENEFITS.

    (a) In General.--Except as provided in subsection (b), benefits 
shall first be available under this Act for items and services 
furnished 2 years after the date of the enactment of this Act.
    (b) Coverage for Certain Individuals.--
            (1) In general.--For any eligible individual who--
                    (A) has not yet attained the age of 19 as of the 
                date that is 1 year after the date of the enactment of 
                this Act; or
                    (B) has attained the age of 55 as of the date that 
                is 1 year after the date of the enactment of this Act,
        benefits shall first be available under this Act for items and 
        services furnished as of such date.
            (2) Option to continue in other coverage during transition 
        period.--Any person who is eligible to receive benefits as 
        described in paragraph (1) may opt to maintain any coverage 
        described in section 901, private health insurance coverage, or 
        coverage offered pursuant to subtitle A of title X (including 
        the amendments made by such subtitle) until the date described 
        in subsection (a).

SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE.

    (a) In General.--Beginning on the effective date described in 
section 106(a), it shall be unlawful for--
            (1) a private health insurer to sell health insurance 
        coverage that duplicates the benefits provided under this Act; 
        or
            (2) an employer to provide benefits for an employee, former 
        employee, or the dependents of an employee or former employee 
        that duplicate the benefits provided under this Act.
    (b) Construction.--Nothing in this Act shall be construed as 
prohibiting the sale of health insurance coverage for any additional 
benefits not covered by this Act, including additional benefits that an 
employer may provide to employees or their dependents, or to former 
employees or their dependents.

  TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND 
                      BENEFITS FOR LONG-TERM CARE

SEC. 201. COMPREHENSIVE BENEFITS.

    (a) In General.--Subject to the other provisions of this title and 
titles IV through IX, individuals enrolled for benefits under this Act 
are entitled to have payment made by the Secretary to an eligible 
provider for the following items and services if medically necessary or 
appropriate for the maintenance of health or for the diagnosis, 
treatment, or rehabilitation of a health condition:
            (1) Hospital services, including inpatient and outpatient 
        hospital care, including 24-hour-a-day emergency services and 
        inpatient prescription drugs.
            (2) Ambulatory patient services.
            (3) Primary and preventive services, including chronic 
        disease management.
            (4) Prescription drugs and medical devices, including 
        outpatient prescription drugs, medical devices, and biological 
        products.
            (5) Mental health and substance use treatment services, 
        including inpatient care.
            (6) Laboratory and diagnostic services.
            (7) Comprehensive reproductive, maternity, and newborn 
        care.
            (8) Oral health, audiology, and vision services.
            (9) Rehabilitative and habilitative services and devices.
            (10) Emergency services and transportation.
            (11) Early and periodic screening, diagnostic, and 
        treatment services, as described in sections 1902(a)(10)(A), 
        1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security 
        Act (42 U.S.C. 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B); 
        1396d(r)).
            (12) Necessary transportation to receive health care 
        services for persons with disabilities, older individuals with 
        functional limitations, or low-income individuals (as 
        determined by the Secretary).
            (13) Long-term care services and support (as described in 
        section 204).
            (14) Hospice care.
            (15) Services provided by a licensed marriage and family 
        therapist or a licensed mental health counselor.
    (b) Revision.--The Secretary shall, at least annually, and on a 
regular basis, evaluate whether the benefits package should be improved 
to promote the health of beneficiaries, account for changes in medical 
practice or new information from medical research, or respond to other 
relevant developments in health science, and shall make recommendations 
to Congress regarding any such improvements. Such recommendations may 
not include a recommendation to eliminate any benefit.
    (c) Hearings.--
            (1) In general.--The Committee on Energy and Commerce and 
        the Committee on Ways and Means of the House of Representatives 
        shall, not less frequently than annually, hold a hearing on the 
        recommendations submitted by the Secretary under subsection 
        (b).
            (2) Exercise of rulemaking authority.--Paragraph (1) is 
        enacted--
                    (A) as an exercise of rulemaking power of the House 
                of Representatives, and, as such, shall be considered 
                as part of the rules of the House, and such rules shall 
                supersede any other rule of the House only to the 
                extent that rule is inconsistent therewith; and
                    (B) with full recognition of the constitutional 
                right of either House to change such rules (so far as 
                relating to the procedure in such House) at any time, 
                in the same manner, and to the same extent as in the 
                case of any other rule of the House.
    (d) Complementary and Integrative Medicine.--
            (1) In general.--In carrying out subsection (b), the 
        Secretary shall consult with the persons described in paragraph 
        (2) with respect to--
                    (A) identifying specific complementary and 
                integrative medicine practices that are appropriate to 
                include in the benefits package; and
                    (B) identifying barriers to the effective provision 
                and integration of such practices into the delivery of 
                health care, and identifying mechanisms for overcoming 
                such barriers.
            (2) Consultation.--In accordance with paragraph (1), the 
        Secretary shall consult with--
                    (A) the Director of the National Center for 
                Complementary and Integrative Health;
                    (B) the Commissioner of Food and Drugs;
                    (C) institutions of higher education, private 
                research institutes, and individual researchers with 
                extensive experience in complementary and alternative 
                medicine and the integration of such practices into the 
                delivery of health care;
                    (D) nationally recognized providers of 
                complementary and integrative medicine; and
                    (E) such other officials, entities, and individuals 
                with expertise on complementary and integrative 
                medicine as the Secretary determines appropriate.
    (e) States May Provide Additional Benefits.--Individual States may 
provide additional benefits for the residents of such States, as 
determined by such State, and may provide benefits to individuals not 
eligible for benefits under this Act, at the expense of the State, 
subject to the requirements specified in section 1102.

SEC. 202. NO COST-SHARING; OTHER LIMITATIONS.

    (a) In General.--The Secretary shall ensure that no cost-sharing, 
including deductibles, coinsurance, copayments, or similar charges, is 
imposed on an individual for any benefits provided under this Act.
    (b) No Balance Billing.--No provider may impose a charge to an 
enrolled individual for covered services for which benefits are 
provided under this Act.
    (c) No Prior Authorization.--Benefits provided under this Act shall 
be covered without any need for any prior authorization determination 
and without any limitation applied through the use of step therapy 
protocols.

SEC. 203. EXCLUSIONS AND LIMITATIONS.

    (a) In General.--Benefits for items and services are not available 
under this Act unless the items and services meet the standards 
developed by the Secretary pursuant to section 201(a).
    (b) Treatment of Experimental Items and Services and Drugs.--
            (1) In general.--In applying subsection (a), the Secretary 
        shall make national coverage determinations with respect to 
        items and services that are experimental in nature. Such 
        determinations shall be consistent with the national coverage 
        determination process as defined in section 1869(f)(1)(B) of 
        the Social Security Act (42 U.S.C. 1395ff(f)(1)(B)).
            (2) Appeals process.--The Secretary shall establish a 
        process by which individuals can appeal coverage decisions. The 
        process shall, as much as is feasible, follow the process for 
        appeals under the Medicare program described in section 1869 of 
        the Social Security Act (42 U.S.C. 1395ff).
    (c) Application of Practice Guidelines.--
            (1) In general.--In the case of items and services for 
        which the Department of Health and Human Services has 
        recognized a national practice guideline, such items and 
        services shall be deemed to meet the standards specified in 
        section 201(a) if they have been provided in accordance with 
        such guideline. For purposes of this subsection, an item or 
        service not provided in accordance with a practice guideline 
        shall be deemed to have been provided in accordance with the 
        guideline if the health care provider providing the item or 
        service--
                    (A) exercised appropriate professional judgment in 
                accordance with the laws and requirements of the State 
                in which such item or service is furnished in deviating 
                from the guideline;
                    (B) acted in the best interest of the individual 
                receiving the item or service; and
                    (C) acted in a manner consistent with the 
                individual's wishes.
            (2) Override of standards.--
                    (A) In general.--An individual's treating physician 
                or other health care professional authorized to 
                exercise independent professional judgment in 
                implementing a patient's medical or nursing care plan 
                in accordance with the scope of practice, licensure, 
                and other law of the State where items and services are 
                to be furnished may override practice standards 
                established pursuant to section 201(a) or practice 
                guidelines described in paragraph (1), including such 
                standards and guidelines that are implemented by a 
                provider through the use of health information 
                technology, such as electronic health record 
                technology, clinical decision support technology, and 
                computerized order entry programs.
                    (B) Limitation.--An override described in 
                subparagraph (A) shall, in the professional judgment of 
                such physician, nurse, or health care professional, 
                be--
                            (i) consistent with such physician's, 
                        nurse's, or health care professional's 
                        determination of medical necessity and 
                        appropriateness or nursing assessment;
                            (ii) in the best interests of the 
                        individual; and
                            (iii) consistent with the individual's 
                        wishes.

SEC. 204. COVERAGE OF LONG-TERM CARE SERVICES.

    (a) In General.--Subject to the other provisions of this Act, 
individuals enrolled for benefits under this Act are entitled to the 
following long-term services and supports and to have payment made by 
the Secretary to an eligible provider for such services and supports if 
medically necessary and appropriate and in accordance with the 
standards established in this Act, for maintenance of health or for 
care, services, diagnosis, treatment, or rehabilitation that is related 
to a medically determinable condition, whether physical or mental, of 
health, injury, or age that--
            (1) causes a functional limitation in performing one or 
        more activities of daily living; or
            (2) requires a similar need of assistance in performing 
        instrumental activities of daily living.
    (b) Eligibility.--An individual shall be eligible for services and 
supports described in this section if such individual has one or more 
medically determinable conditions described in subsection (a).
    (c) Services and Supports.--Long-term services and supports under 
this section shall be tailored to an individual's needs, as determined 
through assessment, and shall be defined by the Secretary to--
            (1) include any long-term nursing services for the 
        enrollee, whether provided in an institution or in a home and 
        community-based setting;
            (2) provide coverage for a broad spectrum of long-term 
        services and supports, including for home and community-based 
        services and other care provided through non-institutional 
        settings;
            (3) provide coverage that meets the physical, mental, and 
        social needs of recipients while allowing recipients their 
        maximum possible autonomy and their maximum possible civic, 
        social, and economic participation;
            (4) prioritize delivery of long-term services and supports 
        through home and community-based services over 
        institutionalization;
            (5) unless an individual elects otherwise, ensure that 
        recipients will receive home and community based long-term 
        services and supports (as defined in subsection (f)(4)), 
        regardless of the individuals's type or level of disability, 
        service need, or age;
            (6) be provided with the goal of enabling persons with 
        disabilities to receive services in the least restrictive and 
        most integrated setting appropriate to the individual's needs;
            (7) be provided in such a manner that allows persons with 
        disabilities to maintain their independence, self-
        determination, and dignity;
            (8) provide long-term services and supports that are of 
        equal quality and equally accessible across geographic regions; 
        and
            (9) ensure that long-term services and supports provide 
        recipient's the option of self-direction of services from 
        either the recipient or care coordinators of the recipient's 
        choosing.
    (d) Public Consultation.--In developing regulations to implement 
this section, the Secretary shall consult with an advisory commission 
on long-term services and supports that includes--
            (1) people with disabilities who use long-term services and 
        supports and older adults who use long-term services and 
        supports;
            (2) representatives of people with disabilities and 
        representatives of older adults;
            (3) groups that represent the diversity of the population 
        of people living with disabilities, including racial, ethnic, 
        national origin, primary language use, age, sex, including 
        gender identity and sexual orientation, geographical, and 
        socioeconomic diversity;
            (4) providers of long-term services and supports, including 
        family attendants and family caregivers, and members of 
        organized labor;
            (5) disability rights organizations; and
            (6) relevant academic institutions and researchers.
    (e) Budgeting and Payments.--Budgeting and payments for long-term 
services and supports provided under this section shall be made in 
accordance with the provisions under title VI.
    (f) Definitions.--In this section:
            (1) The term ``long-term services and supports'' means 
        long-term care, treatment, maintenance, or services needed to 
        support the activities of daily living and instrumental 
        activities of daily living, including home and community-based 
        services and any additional services and supports identified by 
        the Secretary to support people with disabilities to live, 
        work, and participate in their communities.
            (2) The term ``activities of daily living'' means basic 
        personal everyday activities, including tasks such as eating, 
        toileting, grooming, dressing, bathing, and transferring.
            (3) The term ``instrumental activities of daily living'' 
        means activities related to living independently in the 
        community, including but not limited to, meal planning and 
        preparation, managing finances, shopping for food, clothing, 
        and other essential items, performing essential household 
        chores, communicating by phone or other media, and traveling 
        around and participating in the community.
            (4) The term ``home and community-based services'' means 
        the home and community-based services that are coverable under 
        subsections (c), (d), (i), and (k) of section 1915 of the 
        Social Security Act (42 U.S.C. 1396n), and as defined by the 
        Secretary, including as defined in the home and community-based 
        services settings rule in sections 441.530 and 441.710 of title 
        42, Code of Federal Regulations (or a successor regulation).

                   TITLE III--PROVIDER PARTICIPATION

SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; WHISTLEBLOWER 
              PROTECTIONS.

    (a) In General.--An individual or other entity furnishing any 
covered item or service under this Act is not a qualified provider 
unless the individual or entity--
            (1) is a qualified provider of the items or services under 
        section 302;
            (2) has filed with the Secretary a participation agreement 
        described in subsection (b); and
            (3) meets, as applicable, such other qualifications and 
        conditions with respect to a provider of services under title 
        XVIII of the Social Security Act as described in section 1866 
        of the Social Security Act (42 U.S.C. 1395cc).
    (b) Requirements in Participation Agreement.--
            (1) In general.--A participation agreement described in 
        this subsection between the Secretary and a provider shall 
        provide at least for the following:
                    (A) Items and services to eligible persons shall be 
                furnished by the provider without discrimination, in 
                accordance with section 104(a). Nothing in this 
                subparagraph shall be construed as requiring the 
                provision of a type or class of items or services that 
                are outside the scope of the provider's normal 
                practice.
                    (B) No charge will be made to any enrolled 
                individual for any covered items or services other than 
                for payment authorized by this Act.
                    (C) The provider agrees to furnish such information 
                as may be reasonably required by the Secretary, in 
                accordance with uniform reporting standards established 
                under section 401(b)(1), for--
                            (i) quality review by designated entities;
                            (ii) making payments under this Act, 
                        including the examination of records as may be 
                        necessary for the verification of information 
                        on which such payments are based;
                            (iii) statistical or other studies required 
                        for the implementation of this Act; and
                            (iv) such other purposes as the Secretary 
                        may specify.
                    (D) In the case of a provider that is not an 
                individual, the provider agrees not to employ or use 
                for the provision of health services any individual or 
                other provider that has had a participation agreement 
                under this subsection terminated for cause. The 
                Secretary may authorize such employment or use on a 
                case-by-case basis.
                    (E) In the case of a provider paid under a fee-for-
                service basis for items and services furnished under 
                this Act, the provider agrees to submit bills and any 
                required supporting documentation relating to the 
                provision of covered items and services within 30 days 
                after the date of providing such items and services.
                    (F) In the case of an institutional provider paid 
                pursuant to section 611, the provider agrees to submit 
                information and any other required supporting 
                documentation as may be reasonably required by the 
                Secretary within 30 days after the date of providing 
                such items and services and in accordance with the 
                uniform reporting standards established under section 
                401(b)(1), including information on a quarterly basis 
                that--
                            (i) relates to the provision of covered 
                        items and services; and
                            (ii) describes items and services furnished 
                        with respect to specific individuals.
                    (G) In the case of a provider that receives payment 
                for items and services furnished under this Act based 
                on diagnosis-related coding, procedure coding, or other 
                coding system or data, the provider agrees--
                            (i) to disclose to the Secretary any system 
                        or index of coding or classifying patient 
                        symptoms, diagnoses, clinical interventions, 
                        episodes, or procedures that such provider 
                        utilizes for global budget negotiations under 
                        title VI or for meeting any other payment, 
                        documentation, or data collection requirements 
                        under this Act; and
                            (ii) not to use any such system or index to 
                        establish financial incentives or disincentives 
                        for health care professionals, or that is 
                        proprietary, interferes with the medical or 
                        nursing process, or is designed to increase the 
                        amount or number of payments.
                    (H) The provider complies with the duty of provider 
                ethics and reporting requirements described in 
                paragraph (2).
                    (I) In the case of a provider that is not an 
                individual, the provider agrees that no board member, 
                executive, or administrator of such provider receives 
                compensation from, owns stock or has other financial 
                investments in, or serves as a board member of any 
                entity that contracts with or provides items or 
                services, including pharmaceutical products and medical 
                devices or equipment, to such provider.
            (2) Provider duty of ethics.--Each health care provider, 
        including institutional providers, has a duty to advocate for 
        and to act in the exclusive interest of each individual under 
        the care of such provider according to the applicable legal 
        standard of care, such that no financial interest or 
        relationship impairs any health care provider's ability to 
        furnish necessary and appropriate care to such individual. To 
        implement the duty established in this paragraph, the Secretary 
        shall--
                    (A) promulgate reasonable reporting rules to 
                evaluate participating provider compliance with this 
                paragraph;
                    (B) prohibit participating providers, spouses, and 
                immediate family members of participating providers, 
                from accepting or entering into any arrangement for any 
                bonus, incentive payment, profit-sharing, or 
                compensation based on patient utilization or based on 
                financial outcomes of any other provider or entity; and
                    (C) prohibit participating providers or any board 
                member or representative of such provider from serving 
                as board members for or receiving any compensation, 
                stock, or other financial investment in an entity that 
                contracts with or provides items or services (including 
                pharmaceutical products and medical devices or 
                equipment) to such provider.
            (3) Termination of participation agreement.--
                    (A) In general.--Participation agreements may be 
                terminated, with appropriate notice--
                            (i) by the Secretary for failure to meet 
                        the requirements of this Act;
                            (ii) in accordance with the provisions 
                        described in section 411; or
                            (iii) by a provider.
                    (B) Termination process.--Providers shall be 
                provided notice and a reasonable opportunity to correct 
                deficiencies before the Secretary terminates an 
                agreement unless a more immediate termination is 
                required for public safety or similar reasons.
                    (C) Provider protections.--
                            (i) Prohibition.--The Secretary may not 
                        terminate a participation agreement or in any 
                        other way discriminate against, or cause to be 
                        discriminated against, any covered provider or 
                        authorized representative of the provider, on 
                        account of such provider or representative--
                                    (I) providing, causing to be 
                                provided, or being about to provide or 
                                cause to be provided to the provider, 
                                the Federal Government, or the attorney 
                                general of a State information relating 
                                to any violation of, or any act or 
                                omission the provider or representative 
                                reasonably believes to be a violation 
                                of, any provision of this title (or an 
                                amendment made by this title);
                                    (II) testifying or being about to 
                                testify in a proceeding concerning such 
                                violation;
                                    (III) assisting or participating, 
                                or being about to assist or 
                                participate, in such a proceeding; or
                                    (IV) objecting to, or refusing to 
                                participate in, any activity, policy, 
                                practice, or assigned task that the 
                                provider or representative reasonably 
                                believes to be in violation of any 
                                provision of this Act (including any 
                                amendment made by this Act), or any 
                                order, rule, regulation, standard, or 
                                ban under this Act (including any 
                                amendment made by this Act).
                            (ii) Complaint procedure.--A provider or 
                        representative who believes that he or she has 
                        been discriminated against in violation of this 
                        section may seek relief in accordance with the 
                        procedures, notifications, burdens of proof, 
                        remedies, and statutes of limitation set forth 
                        in section 2087(b) of title 15, United States 
                        Code.
    (c) Whistleblower Protections.--
            (1) Retaliation prohibited.--No person may discharge or 
        otherwise discriminate against any employee because the 
        employee or any person acting pursuant to a request of the 
        employee--
                    (A) notified the Secretary or the employee's 
                employer of any alleged violation of this title, 
                including communications related to carrying out the 
                employee's job duties;
                    (B) refused to engage in any practice made unlawful 
                by this title, if the employee has identified the 
                alleged illegality to the employer;
                    (C) testified before or otherwise provided 
                information relevant for Congress or for any Federal or 
                State proceeding regarding any provision (or proposed 
                provision) of this title;
                    (D) commenced, caused to be commenced, or is about 
                to commence or cause to be commenced a proceeding under 
                this title;
                    (E) testified or is about to testify in any such 
                proceeding; or
                    (F) assisted or participated or is about to assist 
                or participate in any manner in such a proceeding or in 
                any other manner in such a proceeding or in any other 
                action to carry out the purposes of this title.
            (2) Enforcement action.--Any employee covered by this 
        section who alleges discrimination by an employer in violation 
        of paragraph (1) may bring an action, subject to the statute of 
        limitations in the anti-retaliation provisions of the False 
        Claims Act and the rules and procedures, legal burdens of 
        proof, and remedies applicable under the employee protections 
        provisions of the Surface Transportation Assistance Act.
            (3) Application.--
                    (A) Nothing in this subsection shall be construed 
                to diminish the rights, privileges, or remedies of any 
                employee under any Federal or State law or regulation, 
                including the rights and remedies against retaliatory 
                action under the False Claims Act (31 U.S.C. 3730(h)), 
                or under any collective bargaining agreement. The 
                rights and remedies in this section may not be waived 
                by any agreement, policy, form, or condition of 
                employment.
                    (B) Nothing in this subsection shall be construed 
                to preempt or diminish any other Federal or State law 
                or regulation against discrimination, demotion, 
                discharge, suspension, threats, harassment, reprimand, 
                retaliation, or any other manner of discrimination, 
                including the rights and remedies against retaliatory 
                action under the False Claims Act (31 U.S.C. 3730(h)).
            (4) Definitions.--In this subsection:
                    (A) Employer.--The term ``employer'' means any 
                person engaged in profit or nonprofit business or 
                industry, including one or more individuals, 
                partnerships, associations, corporations, trusts, 
                professional membership organization including a 
                certification, disciplinary, or other professional 
                body, unincorporated organizations, nongovernmental 
                organizations, or trustees, and subject to liability 
                for violating the provisions of this Act.
                    (B) Employee.--The term ``employee'' means any 
                individual performing activities under this Act on 
                behalf of an employer.

SEC. 302. QUALIFICATIONS FOR PROVIDERS.

    (a) In General.--A health care provider is considered to be 
qualified to furnish covered items and services under this Act if the 
provider is licensed or certified to furnish such items and services in 
the State in which the individual receiving such items or services is 
located and meets--
            (1) the requirements of such State's law to furnish such 
        items and services; and
            (2) applicable requirements of Federal law to furnish such 
        items and services.
    (b) Limitation.--An entity or provider shall not be qualified to 
furnish covered items and services under this Act if the entity or 
provider provides no items and services directly to individuals, 
including--
            (1) entities or providers that contract with other entities 
        or providers to provide such items and services; and
            (2) entities that are currently approved to coordinate care 
        plans under the Medicare Advantage program established in part 
        C of title XVIII of the Social Security Act (42 U.S.C. 1851 et 
        seq.) but do not directly provide items and services of such 
        care plans.
    (c) Minimum Provider Standards.--
            (1) In general.--The Secretary shall establish, evaluate, 
        and update national minimum standards to ensure the quality of 
        items and services provided under this Act and to monitor 
        efforts by States to ensure the quality of such items and 
        services. A State may establish additional minimum standards 
        which providers shall meet with respect to items and services 
        provided in such State.
            (2) National minimum standards.--The Secretary shall 
        establish national minimum standards under paragraph (1) for 
        institutional providers of services and individual health care 
        practitioners. Except as the Secretary may specify in order to 
        carry out this Act, a hospital, skilled nursing facility, or 
        other institutional provider of services shall meet standards 
        applicable to such a provider under the Medicare program under 
        title XVIII of the Social Security Act (42 U.S.C. 1395 et 
        seq.). Such standards also may include, where appropriate, 
        elements relating to--
                    (A) adequacy and quality of facilities;
                    (B) mandatory minimum safe registered nurse-to-
                patient staffing ratios and optimal staffing levels for 
                physicians and other health care practitioners;
                    (C) training and competence of personnel (including 
                requirements related to the number of or type of 
                required continuing education hours);
                    (D) comprehensiveness of service;
                    (E) continuity of service;
                    (F) patient waiting time, access to services, and 
                preferences; and
                    (G) performance standards, including organization, 
                facilities, structure of services, efficiency of 
                operation, and outcome in palliation, improvement of 
                health, stabilization, cure, or rehabilitation.
            (3) Transition in application.--If the Secretary provides 
        for additional requirements for providers under this 
        subsection, any such additional requirement shall be 
        implemented in a manner that provides for a reasonable period 
        during which a previously qualified provider is permitted to 
        meet such an additional requirement.
            (4) Ability to provide services.--With respect to any 
        entity or provider certified to provide items and services 
        described in section 201(a)(7), the Secretary may not prohibit 
        such entity or provider from participating for reasons other 
        than such entity's or provider's ability to provide such items 
        and services.
    (d) Federal Providers.--Any provider qualified to provide health 
care items and services through the Department of Veterans Affairs, the 
Indian Health Service, or the uniformed services (with respect to the 
direct care component of the TRICARE Program) is a qualifying provider 
under this section with respect to any individual who qualifies for 
such items and services under applicable Federal law.

SEC. 303. USE OF PRIVATE CONTRACTS.

    (a) In General.--This section shall apply beginning 2 years after 
the date of the enactment of this Act.
    (b) Participating Providers.--
            (1) Private contracts for covered items and services for 
        eligible individuals.--An institutional or individual provider 
        with an agreement in effect under section 301 may not bill or 
        enter into any private contract with any individual eligible 
        for benefits under the Act for any item or service that is a 
        benefit under this Act.
            (2) Private contracts for noncovered items and services for 
        eligible individuals.--An institutional or individual provider 
        with an agreement in effect under section 301 may bill or enter 
        into a private contract with an individual eligible for 
        benefits under the Act for any item or service that is not a 
        benefit under this Act only if--
                    (A) the contract and provider meet the requirements 
                specified in paragraphs (3) and (4), respectively;
                    (B) such item or service is not payable or 
                available under this Act; and
                    (C) the provider receives--
                            (i) no reimbursement under this Act 
                        directly or indirectly for such item or 
                        service, and
                            (ii) receives no amount for such item or 
                        service from an organization which receives 
                        reimbursement for such items or service under 
                        this Act directly or indirectly.
            (3) Contract requirements.--Any contract to provide items 
        and services described in paragraph (2) shall--
                    (A) be in writing and signed by the individual (or 
                authorized representative of the individual) receiving 
                the item or service before the item or service is 
                furnished pursuant to the contract;
                    (B) not be entered into at a time when the 
                individual is facing an emergency health care 
                situation; and
                    (C) clearly indicate to the individual receiving 
                such items and services that by signing such a contract 
                the individual--
                            (i) agrees not to submit a claim (or to 
                        request that the provider submit a claim) under 
                        this Act for such items or services;
                            (ii) agrees to be responsible for payment 
                        of such items or services and understands that 
                        no reimbursement will be provided under this 
                        Act for such items or services;
                            (iii) acknowledges that no limits under 
                        this Act apply to amounts that may be charged 
                        for such items or services; and
                            (iv) acknowledges that the provider is 
                        providing services outside the scope of the 
                        program under this Act.
            (4) Affidavit.--A participating provider who enters into a 
        contract described in paragraph (2) shall have in effect during 
        the period any item or service is to be provided pursuant to 
        the contract an affidavit that shall--
                    (A) identify the provider who is to furnish such 
                noncovered item or service, and be signed by such 
                provider;
                    (B) state that the provider will not submit any 
                claim under this Act for any noncovered item or service 
                provided to any individual enrolled under this Act; and
                    (C) be filed with the Secretary no later than 10 
                days after the first contract to which such affidavit 
                applies is entered into.
            (5) Enforcement.--If a provider signing an affidavit 
        described in paragraph (4) knowingly and willfully submits a 
        claim under this title for any item or service provided or 
        receives any reimbursement or amount for any such item or 
        service provided pursuant to a private contract described in 
        paragraph (2) with respect to such affidavit--
                    (A) any contract described in paragraph (2) shall 
                be null and void;
                    (B) no payment shall be made under this title for 
                any item or service furnished by the provider during 
                the 2-year period beginning on the date the affidavit 
                was signed; and
                    (C) any payment received under this title for any 
                item or service furnished during such period shall be 
                remitted.
            (6) Private contracts for ineligible individuals.--An 
        institutional or individual provider with an agreement in 
        effect under section 301 may bill or enter into a private 
        contract with any individual ineligible for benefits under the 
        Act for any item or service.
    (c) Nonparticipating Providers.--
            (1) Private contracts for covered items and services for 
        eligible individuals.--An institutional or individual provider 
        with no agreement in effect under section 301 may bill or enter 
        into any private contract with any individual eligible for 
        benefits under the Act for any item or service that is a 
        benefit under this Act described in title II only if the 
        contract and provider meet the requirements specified in 
        paragraphs (2) and (3), respectively.
            (2) Items required to be included in contract.--Any 
        contract to provide items and services described in paragraph 
        (1) shall--
                    (A) be in writing and signed by the individual (or 
                authorized representative of the individual) receiving 
                the item or service before the item or service is 
                furnished pursuant to the contract;
                    (B) not be entered into at a time when the 
                individual is facing an emergency health care 
                situation; and
                    (C) clearly indicate to the individual receiving 
                such items and services that by signing such a contract 
                the individual--
                            (i) acknowledges that the individual has 
                        the right to have such items or services 
                        provided by other providers for whom payment 
                        would be made under this Act;
                            (ii) agrees not to submit a claim (or to 
                        request that the provider submit a claim) under 
                        this Act for such items or services even if 
                        such items or services are otherwise covered by 
                        this Act;
                            (iii) agrees to be responsible for payment 
                        of such items or services and understands that 
                        no reimbursement will be provided under this 
                        Act for such items or services;
                            (iv) acknowledges that no limits under this 
                        Act apply to amounts that may be charged for 
                        such items or services; and
                            (v) acknowledges that the provider is 
                        providing services outside the scope of the 
                        program under this Act.
            (3) Affidavit.--A provider who enters into a contract 
        described in paragraph (1) shall have in effect during the 
        period any item or service is to be provided pursuant to the 
        contract an affidavit that shall--
                    (A) identify the provider who is to furnish such 
                covered item or service, and be signed by such 
                provider;
                    (B) state that the provider will not submit any 
                claim under this Act for any covered item or service 
                provided to any individual enrolled under this Act 
                during the 2-year period beginning on the date the 
                affidavit is signed; and
                    (C) be filed with the Secretary no later than 10 
                days after the first contract to which such affidavit 
                applies is entered into.
            (4) Enforcement.--If a provider signing an affidavit 
        described in paragraph (3) knowingly and willfully submits a 
        claim under this title for any item or service provided or 
        receives any reimbursement or amount for any such item or 
        service provided pursuant to a private contract described in 
        paragraph (1) with respect to such affidavit--
                    (A) any contract described in paragraph (1) shall 
                be null and void; and
                    (B) no payment shall be made under this title for 
                any item or service furnished by the provider during 
                the 2-year period beginning on the date the affidavit 
                was signed.
            (5) Private contracts for noncovered items and services for 
        any individual.--An institutional or individual provider with 
        no agreement in effect under section 301 may bill or enter into 
        a private contract with any individual for a item or service 
        that is not a benefit under this Act.

                        TITLE IV--ADMINISTRATION

             Subtitle A--General Administration Provisions

SEC. 401. ADMINISTRATION.

    (a) General Duties of the Secretary.--
            (1) In general.--The Secretary shall develop policies, 
        procedures, guidelines, and requirements to carry out this Act, 
        including related to--
                    (A) eligibility for benefits;
                    (B) enrollment;
                    (C) benefits provided;
                    (D) provider participation standards and 
                qualifications, as described in title III;
                    (E) levels of funding;
                    (F) methods for determining amounts of payments to 
                providers of covered items and services, consistent 
                with subtitle B;
                    (G) a process for appealing or petitioning for a 
                determination of coverage or noncoverage of items and 
                services under this Act;
                    (H) planning for capital expenditures and service 
                delivery;
                    (I) planning for health professional education 
                funding;
                    (J) encouraging States to develop regional planning 
                mechanisms; and
                    (K) any other regulations necessary to carry out 
                the purposes of this Act.
            (2) Regulations.--Regulations authorized by this Act shall 
        be issued by the Secretary in accordance with section 553 of 
        title 5, United States Code.
            (3) Accessibility.--The Secretary shall have the obligation 
        to ensure the timely and accessible provision of items and 
        services that all eligible individuals are entitled to under 
        this Act.
    (b) Uniform Reporting Standards; Annual Report; Studies.--
            (1) Uniform reporting standards.--
                    (A) In general.--The Secretary shall establish 
                uniform State reporting requirements and national 
                standards to ensure an adequate national database 
                containing information pertaining to health services 
                practitioners, approved providers, the costs of 
                facilities and practitioners providing items and 
                services, the quality of such items and services, the 
                outcomes of such items and services, and the equity of 
                health among population groups. Such database shall 
                include, to the maximum extent feasible without 
                compromising patient privacy, health outcome measures 
                used under this Act, and to the maximum extent feasible 
                without excessively burdening providers, a description 
                of the standards and qualifications, levels of finding, 
                and methods described in subparagraphs (D) through (F) 
                of subsection (a)(1).
                    (B) Required data disclosures.--In establishing 
                reporting requirements and standards under subparagraph 
                (A), the Secretary shall require a provider with an 
                agreement in effect under section 301 to disclose to 
                the Secretary, in a time and manner specified by the 
                Secretary, the following (as applicable to the type of 
                provider):
                            (i) Any data the provider is required to 
                        report or does report to any State or local 
                        agency, or, as of January 1, 2019, to the 
                        Secretary or any entity that is part of the 
                        Department of Health and Human Services, except 
                        data that are required under the programs 
                        terminated in section 903.
                            (ii) Annual financial data that includes 
                        information on employees (including the number 
                        of employees, hours worked, and wage 
                        information) by job title and by each patient 
                        care unit or department within each facility 
                        (including outpatient units or departments); 
                        the number of registered nurses per staffed bed 
                        by each such unit or department; information on 
                        the dollar value and annual spending (including 
                        purchases, upgrades, and maintenance) for 
                        health information technology; and risk-
                        adjusted and raw patient outcome data 
                        (including data on medical, surgical, 
                        obstetric, and other procedures).
                    (C) Reports.--The Secretary shall regularly analyze 
                information reported to the Secretary and shall define 
                rules and procedures to allow researchers, scholars, 
                health care providers, and others to access and analyze 
                data for purposes consistent with quality and outcomes 
                research, without compromising patient privacy.
            (2) Annual report.--Beginning 2 years after the date of the 
        enactment of this Act, the Secretary shall annually report to 
        Congress on the following:
                    (A) The status of implementation of the Act.
                    (B) Enrollment under this Act.
                    (C) Benefits under this Act.
                    (D) Expenditures and financing under this Act.
                    (E) Cost-containment measures and achievements 
                under this Act.
                    (F) Quality assurance.
                    (G) Health care utilization patterns, including any 
                changes attributable to the program.
                    (H) Changes in the per-capita costs of health care.
                    (I) Differences in the health status of the 
                populations of the different States, including by 
                racial, ethnic, national origin, primary language use, 
                age, disability, sex, including gender identity and 
                sexual orientation, geographical, and income 
                characteristics;
                    (J) Progress on quality and outcome measures, and 
                long-range plans and goals for achievements in such 
                areas.
                    (K) Plans for improving service to medically 
                underserved populations.
                    (L) Transition problems as a result of 
                implementation of this Act.
                    (M) Opportunities for improvements under this Act.
            (3) Statistical analyses and other studies.--The Secretary 
        may, either directly or by contract--
                    (A) make statistical and other studies, on a 
                nationwide, regional, State, or local basis, of any 
                aspect of the operation of this Act;
                    (B) develop and test methods of delivery of items 
                and services as the Secretary may consider necessary or 
                promising for the evaluation, or for the improvement, 
                of the operation of this Act; and
                    (C) develop methodological standards for 
                policymaking.
    (c) Audits.--
            (1) In general.--The Comptroller General of the United 
        States shall conduct an audit of the Department of Health and 
        Human Services every fifth fiscal year following the effective 
        date of this Act to determine the effectiveness of the program 
        in carrying out the duties under subsection (a).
            (2) Reports.--The Comptroller General of the United States 
        shall submit a report to Congress concerning the results of 
        each audit conducted under this subsection.

SEC. 402. CONSULTATION.

    The Secretary shall consult with Federal agencies, Indian tribes 
and urban Indian health organizations, and private entities, such as 
labor organizations representing health care workers, professional 
societies, national associations, nationally recognized associations of 
health care experts, medical schools and academic health centers, 
consumer groups, and business organizations in the formulation of 
guidelines, regulations, policy initiatives, and information gathering 
to ensure the broadest and most informed input in the administration of 
this Act. Nothing in this Act shall prevent the Secretary from adopting 
guidelines, consistent with the provisions of section 203(c), developed 
by such a private entity if, in the Secretary's judgment, such 
guidelines are generally accepted as reasonable and prudent and 
consistent with this Act.

SEC. 403. REGIONAL ADMINISTRATION.

    (a) Coordination With Regional Offices.--The Secretary shall 
establish and maintain regional offices for purposes of carrying out 
the duties specified in subsection (c) and promoting adequate access 
to, and efficient use of, tertiary care facilities, equipment, and 
services by individuals enrolled under this Act. Wherever possible, the 
Secretary shall incorporate regional offices of the Centers for 
Medicare & Medicaid Services for this purpose.
    (b) Appointment of Regional Directors.--In each such regional 
office there shall be--
            (1) one regional director appointed by the Secretary;
            (2) one deputy director appointed by the regional director 
        to represent the Indian and Alaska Native tribes in the region, 
        if any; and
            (3) one deputy direction appointed by the regional director 
        to oversee long-term services and supports.
    (c) Regional Office Duties.--Each regional director shall--
            (1) provide an annual health care needs assessment with 
        respect to the region under the director's jurisdiction to the 
        Secretary after a thorough examination of health needs and in 
        consultation with public health officials, clinicians, 
        patients, and patient advocates;
            (2) recommend any changes in provider reimbursement or 
        payment for delivery of health services determined appropriate 
        by the regional director, subject to the provisions of title 
        VI; and
            (3) establish a quality assurance mechanism in each such 
        region in order to minimize both underutilization and 
        overutilization of health care items and services and to ensure 
        that all providers meet quality standards established pursuant 
        to this Act.

SEC. 404. BENEFICIARY OMBUDSMAN.

    (a) In General.--The Secretary shall appoint a Beneficiary 
Ombudsman who shall have expertise and experience in the fields of 
health care and education of, and assistance to, individuals enrolled 
under this Act.
    (b) Duties.--The Beneficiary Ombudsman shall--
            (1) receive complaints, grievances, and requests for 
        information submitted by individuals enrolled under this Act or 
        eligible to enroll under this Act with respect to any aspect of 
        the Medicare for All Program;
            (2) provide assistance with respect to complaints, 
        grievances, and requests referred to in paragraph (1), 
        including assistance in collecting relevant information for 
        such individuals, to seek an appeal of a decision or 
        determination made by a regional office or the Secretary; and
            (3) submit annual reports to Congress and the Secretary 
        that describe the activities of the Ombudsman and that include 
        such recommendations for improvement in the administration of 
        this Act as the Ombudsman determines appropriate. The Ombudsman 
        shall not serve as an advocate for any increases in payments or 
        new coverage of services, but may identify issues and problems 
        in payment or coverage policies.

SEC. 405. CONDUCT OF RELATED HEALTH PROGRAMS.

    In performing functions with respect to health personnel education 
and training, health research, environmental health, disability 
insurance, vocational rehabilitation, the regulation of food and drugs, 
and all other matters pertaining to health, the Secretary shall direct 
the activities of the Department of Health and Human Services toward 
contributions to the health of the people complementary to this Act.

                Subtitle B--Control Over Fraud and Abuse

SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL FRAUD AND ABUSE UNDER 
              THE MEDICARE FOR ALL PROGRAM.

    The following sections of the Social Security Act shall apply to 
this Act in the same manner as they apply to title XVIII or State plans 
under title XIX of the Social Security Act:
            (1) Section 1128 (relating to exclusion of individuals and 
        entities).
            (2) Section 1128A (civil monetary penalties).
            (3) Section 1128B (criminal penalties).
            (4) Section 1124 (relating to disclosure of ownership and 
        related information).
            (5) Section 1126 (relating to disclosure of certain 
        owners).
            (6) Section 1877 (relating to physician referrals).

                      TITLE V--QUALITY ASSESSMENT

SEC. 501. QUALITY STANDARDS.

    (a) In General.--All standards and quality measures under this Act 
shall be implemented and evaluated by the Center for Clinical Standards 
and Quality of the Centers for Medicare & Medicaid Services (referred 
to in this title as the ``Center'') or such other agency determined 
appropriate by the Secretary, in coordination with the Agency for 
Healthcare Research and Quality and other offices of the Department of 
Health and Human Services.
    (b) Duties of the Center.--The Center shall perform the following 
duties:
            (1) Review and evaluate each practice guideline developed 
        under part B of title IX of the Public Health Service Act. In 
        so reviewing and evaluating, the Center shall determine whether 
        the guideline should be recognized as a national practice 
        guideline in accordance with and subject to the provisions of 
        section 203(c).
            (2) Review and evaluate each standard of quality, 
        performance measure, and medical review criterion developed 
        under part B of title IX of the Public Health Service Act (42 
        U.S.C. 299 et seq.). In so reviewing and evaluating, the Center 
        shall determine whether the standard, measure, or criterion is 
        appropriate for use in assessing or reviewing the quality of 
        items and services provided by health care institutions or 
        health care professionals. The use of mechanisms that 
        discriminate against people with disabilities is prohibited for 
        use in any value or cost-effectiveness assessments. The Center 
        shall consider the evidentiary basis for the standard, and the 
        validity, reliability, and feasibility of measuring the 
        standard.
            (3) Adoption of methodologies for profiling the patterns of 
        practice of health care professionals and for identifying and 
        notifying outliers.
            (4) Development of minimum criteria for competence for 
        entities that can qualify to conduct ongoing and continuous 
        external quality reviews in the administrative regions. Such 
        criteria shall require such an entity to be administratively 
        independent of the individual or board that administers the 
        region and shall ensure that such entities do not provide 
        financial incentives to reviewers to favor one pattern of 
        practice over another. The Center shall ensure coordination and 
        reporting by such entities to ensure national consistency in 
        quality standards.
            (5) Submission of a report to the Secretary annually 
        specifically on findings from outcomes research and development 
        of practice guidelines that may affect the Secretary's 
        determination of coverage of services under section 
        401(a)(1)(G).

SEC. 502. ADDRESSING HEALTH CARE DISPARITIES.

    (a) Evaluating Data Collection Approaches.--The Center shall 
evaluate approaches for the collection of data under this Act, to be 
performed in conjunction with existing quality reporting requirements 
and programs under this Act, that allow for the ongoing, accurate, and 
timely collection of data on disparities in health care services and 
performance on the basis of race, ethnicity, national origin, primary 
language use, age, disability, sex (including gender identity and 
sexual orientation), geography, or socioeconomic status. In conducting 
such evaluation, the Center shall consider the following objectives:
            (1) Protecting patient privacy.
            (2) Minimizing the administrative burdens of data 
        collection and reporting on providers under this Act.
            (3) Improving data on race, ethnicity, national origin, 
        primary language use, age, disability, sex (including gender 
        identity and sexual orientation), geography, and socioeconomic 
        status.
    (b) Reports to Congress.--
            (1) Report on evaluation.--Not later than 18 months after 
        the date on which benefits first become available as described 
        in section 106(a), the Center shall submit to Congress and the 
        Secretary a report on the evaluation conducted under subsection 
        (a). Such report shall, taking into consideration the results 
        of such evaluation--
                    (A) identify approaches (including defining 
                methodologies) for identifying and collecting and 
                evaluating data on health care disparities on the basis 
                of race, ethnicity, national origin, primary language 
                use, age, disability, sex (including gender identity 
                and sexual orientation), geography, or socioeconomic 
                status under the Medicare for All Program; and
                    (B) include recommendations on the most effective 
                strategies and approaches to reporting quality 
                measures, as appropriate, on the basis of race, 
                ethnicity, national origin, primary language use, age, 
                disability, sex (including gender identity and sexual 
                orientation), geography, or socioeconomic status.
            (2) Report on data analyses.--Not later than 4 years after 
        the submission of the report under subsection (b)(1), and every 
        4 years thereafter, the Center shall submit to Congress and the 
        Secretary a report that includes recommendations for improving 
        the identification of health care disparities based on the 
        analyses of data collected under subsection (c).
    (c) Implementing Effective Approaches.--Not later than 2 years 
after the date on which benefits first become available as described in 
section 106(a), the Secretary shall implement the approaches identified 
in the report submitted under subsection (b)(1) for the ongoing, 
accurate, and timely collection and evaluation of data on health care 
disparities on the basis of race, ethnicity, national origin, primary 
language use, age, disability, sex (including gender identity and 
sexual orientation), geography, or socioeconomic status.

      TITLE VI--HEALTH BUDGET; PAYMENTS; COST CONTAINMENT MEASURES

                         Subtitle A--Budgeting

SEC. 601. NATIONAL HEALTH BUDGET.

    (a) National Health Budget.--
            (1) In general.--By not later than September 1 of each 
        year, beginning with the year prior to the date on which 
        benefits first become available as described in section 106(a), 
        the Secretary shall establish a national health budget, which 
        specifies a budget for the total expenditures to be made for 
        covered health care items and services under this Act.
            (2) Division of budget into components.--The national 
        health budget shall consist of the following components:
                    (A) An operating budget.
                    (B) A capital expenditures budget.
                    (C) A special projects budget.
                    (D) Quality assessment activities under title V.
                    (E) Health professional education expenditures.
                    (F) Administrative costs, including costs related 
                to the operation of regional offices.
                    (G) A reserve fund.
                    (H) Prevention and public health activities.
            (3) Allocation among components.--The Secretary shall 
        allocate the funds received for purposes of carrying out this 
        Act among the components described in paragraph (2) in a manner 
        that ensures--
                    (A) that the operating budget allows for every 
                participating provider in the Medicare for All Program 
                to meet the needs of their respective patient 
                populations;
                    (B) that the special projects budget is sufficient 
                to meet the health care needs within areas described in 
                paragraph (2)(C) through the construction, renovation, 
                and staffing of health care facilities in a reasonable 
                timeframe;
                    (C) a fair allocation for quality assessment 
                activities; and
                    (D) that the health professional education 
                expenditure component is sufficient to provide for the 
                amount of health professional education expenditures 
                sufficient to meet the need for covered health care 
                services.
            (4) Regional allocation.--The Secretary shall annually 
        provide each regional office with an allotment the Secretary 
        determines appropriate for purposes of carrying out this Act in 
        such region, including payments to providers in such region, 
        capital expenditures in such region, special projects in such 
        region, health professional education in such region, 
        administrative expenses in such region, and prevention and 
        public health activities in such region.
            (5) Operating budget.--The operating budget described in 
        paragraph (2)(A) shall be used for--
                    (A) payments to institutional providers pursuant to 
                section 611; and
                    (B) payments to individual providers pursuant to 
                section 612.
            (6) Capital expenditures budget.--The capital expenditures 
        budget described in paragraph (2)(B) shall be used for--
                    (A) the construction or renovation of health care 
                facilities, excluding congregate or segregated 
                facilities for individuals with disabilities who 
                receive long-term care services and support; and
                    (B) major equipment purchases.
            (7) Special projects budget.--The special projects budget 
        described in paragraph (2)(C) shall be used for the purposes of 
        allocating funds for the construction of new facilities, major 
        equipment purchases, and staffing in rural or medically 
        underserved areas (as defined in section 330(b)(3) of the 
        Public Health Service Act (42 U.S.C. 254b(b)(3))), including 
        areas designated as health professional shortage areas (as 
        defined in section 332(a) of the Public Health Service Act (42 
        U.S.C. 254e(a))), and to address health disparities, including 
        racial, ethnic, national origin, primary language use, age, 
        disability, sex (including gender identity and sexual 
        orientation), geography, or socioeconomic health disparities.
            (8) Temporary worker assistance.--
                    (A) In general.--For up to 5 years following the 
                date on which benefits first become available as 
                described in section 106(a), at least 1 percent of the 
                budget shall be allocated to programs providing 
                assistance to workers who perform functions in the 
                administration of the health insurance system, or 
                related functions within health care institutions or 
                organizations who may be affected by the implementation 
                of this Act and who may experience economic dislocation 
                as a result of the implementation of this Act.
                    (B) Clarification.--Assistance described in 
                subparagraph (A) shall include wage replacement, 
                retirement benefits, job training and placement, 
                preferential hiring, and education benefits.
            (9) Reserve fund.--The reserve fund described in paragraph 
        (2)(G) shall be used to respond to the costs of an epidemic, 
        pandemic, natural disaster, or other such health emergency, or 
        market-shift adjustments related to patient volume.
            (10) Supplemental indian health service allocation.--The 
        Secretary shall annually determine the need to provide an 
        allotment of supplemental funds to Indian Health Services, 
        including payments to providers, capital expenditures, special 
        projects, health professional education, administrative 
        expenses, and prevention and public health activities.
    (b) Definitions.--In this section:
            (1) Capital expenditures.--The term ``capital 
        expenditures'' means expenses for the purchase, lease, 
        construction, or renovation of capital facilities and for major 
        equipment.
            (2) Health professional education expenditures.--The term 
        ``health professional education expenditures'' means 
        expenditures in hospitals and other health care facilities to 
        cover costs associated with teaching and related research 
        activities, including the impact of workforce diversity on 
        patient outcomes.

                   Subtitle B--Payments to Providers

SEC. 611. PAYMENTS TO INSTITUTIONAL PROVIDERS BASED ON GLOBAL BUDGETS.

    (a) In General.--Not later than the beginning of each fiscal 
quarter during which an institutional provider of care (including 
hospitals, skilled nursing facilities, Federally qualified health 
centers, and independent dialysis facilities) is to furnish items and 
services under this Act, the Secretary shall pay to such institutional 
provider a lump sum in accordance with the succeeding provisions of 
this subsection and consistent with the following:
            (1) Payment in full.--Such payment shall be considered as 
        payment in full for all operating expenses for items and 
        services furnished under this Act, whether inpatient or 
        outpatient, by such provider for such quarter, including 
        outpatient or any other care provided by the institutional 
        provider or provided by any health care provider who provided 
        items and services pursuant to an agreement paid through the 
        global budget as described in paragraph (3).
            (2) Quarterly review.--The regional director, on a 
        quarterly basis, shall review whether requirements of the 
        institutional provider's participation agreement and negotiated 
        global budget have been performed and shall determine whether 
        adjustments to such institutional provider's payment are 
        warranted. This review shall include consideration for 
        additional funding necessary for unanticipated items and 
        services for individuals with complex medical needs or market-
        shift adjustments related to patient volume. The review shall 
        also include an assessment of any adjustments made to ensure 
        that accuracy and need for adjustment was appropriate.
            (3) Agreements for salaried payments for certain 
        providers.--Certain group practices and other health care 
        providers, as determined by the Secretary, with agreements to 
        provide items and services at a specified institutional 
        provider paid a global budget under this subsection may elect 
        to be paid through such institutional provider's global budget 
        in lieu of payment under section 612 of this title. Any--
                    (A) individual health care professional of such 
                group practice or other provider receiving payment 
                through an institutional provider's global budget shall 
                be paid on a salaried basis that is equivalent to 
                salaries or other compensation rates negotiated for 
                individual health care professionals of such 
                institutional provider; and
                    (B) any group practice or other health care 
                provider that receives payment through an institutional 
                provider global budget under this paragraph shall be 
                subject to the same reporting and disclosure 
                requirements of the institutional provider.
            (4) Interim adjustments.--The regional director shall 
        consider a petition for adjustment of any payment under this 
        section filed by an institutional provider at any time based on 
        the following:
                    (A) Factors that led to increased costs for the 
                institutional provider that can reasonably be 
                considered to be unanticipated and out of the control 
                of the institutional provider, such as--
                            (i) natural disasters;
                            (ii) outbreaks of epidemics or infectious 
                        diseases;
                            (iii) unexpected facility or equipment 
                        repairs or purchases;
                            (iv) significant and unexpected increases 
                        in pharmaceutical or medical device prices; and
                            (v) unanticipated increases in complex or 
                        high-cost patients or care needs.
                    (B) Changes in Federal or State law that result in 
                a change in costs.
                    (C) Reasonable increases in labor costs, including 
                salaries and benefits, and changes in collective 
                bargaining agreements, prevailing wage, or local law.
    (b) Payment Amount.--
            (1) In general.--The amount of each payment to a provider 
        described in subsection (a) shall be determined before the 
        start of each fiscal year through negotiations between the 
        provider and the regional director with jurisdiction over such 
        provider. Such amount shall be based on factors specified in 
        paragraph (2).
            (2) Payment factors.--Payments negotiated pursuant to 
        paragraph (1) shall take into account, with respect to a 
        provider--
                    (A) the historical volume of services provided for 
                each item and services in the previous 3-year period;
                    (B) the actual expenditures of such provider in 
                such provider's most recent cost report under title 
                XVIII of the Social Security Act for each item and 
                service compared to--
                            (i) such expenditures for other 
                        institutional providers in the director's 
                        jurisdiction; and
                            (ii) normative payment rates established 
                        under comparative payment rate systems, 
                        including any adjustments, for such items and 
                        services;
                    (C) projected changes in the volume and type of 
                items and services to be furnished;
                    (D) wages for employees, including any necessary 
                increases mandatory minimum safe registered nurse-to-
                patient ratios and optimal staffing levels for 
                physicians and other health care workers;
                    (E) the provider's maximum capacity to provide 
                items and services;
                    (F) education and prevention programs;
                    (G) permissible adjustment to the provider's 
                operating budget due to factors such as--
                            (i) an increase in primary or specialty 
                        care access;
                            (ii) efforts to decrease health care 
                        disparities in rural or medically underserved 
                        areas;
                            (iii) a response to emergent epidemic 
                        conditions;
                            (iv) an increase in complex or high-cost 
                        patients or care needs; or
                            (v) proposed new and innovative patient 
                        care programs at the institutional level;
                    (H) whether the provider is located in a high 
                social vulnerability index community, zip code, or 
                census track, or is a minority-serving provider; and
                    (I) any other factor determined appropriate by the 
                Secretary.
            (3) Limitation.--Payment amounts negotiated pursuant to 
        paragraph (1) may not--
                    (A) take into account capital expenditures of the 
                provider or any other expenditure not directly 
                associated with the provision of items and services by 
                the provider to an individual;
                    (B) be used by a provider for capital expenditures 
                or such other expenditures;
                    (C) exceed the provider's capacity to provide care 
                under this Act; or
                    (D) be used to pay or otherwise compensate any 
                board member, executive, or administrator of the 
                institutional provider who has any interest or 
                relationship prohibited under section 301(b)(2) of this 
                Act or disclosed under section 301 of this Act.
            (4) Limitation on compensation.--Compensation costs for any 
        employee or any contractor or any subcontractor employee of an 
        institutional provider receiving global budgets under this 
        section shall meet the compensation cap established in section 
        702 of the Bipartisan Budget Act of 2013 (41 U.S.C. 
        4304(a)(16)) and implementing regulations.
            (5) Regional negotiations permitted.--Subject to section 
        614, a regional director may negotiate changes to an 
        institutional provider's global budget, including any 
        adjustments to address unforeseen market-shifts related to 
        patient volume.
    (c) Baseline Rates and Adjustments.--
            (1) In general.--The Secretary shall use existing 
        prospective payment systems under title XVIII of the Social 
        Security Act to serve as the comparative payment rate system in 
        global budget negotiations described in subsection (b). The 
        Secretary shall update such comparative payment rate systems 
        annually.
            (2) Specifications.--In developing the comparative payment 
        rate system, the Secretary shall use only the operating base 
        payment rates under each such prospective payment systems with 
        applicable adjustments.
            (3) Limitation.--The comparative rate system established 
        under this subsection shall not include the value-based payment 
        adjustments and the capital expenses base payment rates that 
        may be included in such a prospective payment system.
            (4) Initial year.--In the first year that global budget 
        payments under this Act are available to institutional 
        providers and for purposes of selecting a comparative payment 
        rate system used during initial global budget negotiations for 
        each institutional provider, the Secretary shall take into 
        account the appropriate prospective payment system from the 
        most recent year under title XVIII of the Social Security Act 
        to determine what operating base payment the institutional 
        provider would have been paid for covered items and services 
        furnished the preceding year with applicable adjustments, 
        excluding value-based payment adjustments, based on such 
        prospective payment system.
    (d) Operating Expenses.--For purposes of this title, ``operating 
expenses'' of a provider include the following:
            (1) The cost of all items and services associated with the 
        provision of inpatient care and outpatient care, including the 
        following:
                    (A) Wages and salary costs for physicians, nurses, 
                and other health care practitioners employed by an 
                institutional provider, including mandatory minimum 
                safe registered nurse-to-patient staffing ratios and 
                optimal staffing levels for physicians and other 
                healthcare workers.
                    (B) Wages and salary costs for all ancillary staff 
                and services.
                    (C) Costs of all pharmaceutical products 
                administered by health care clinicians at the 
                institutional provider's facilities or through services 
                provided in accordance with State licensing laws or 
                regulations under which the institutional provider 
                operates.
                    (D) Costs for infectious disease response 
                preparedness, including maintenance of a 1-year or 365-
                day stockpile of personal protective equipment, 
                occupational testing and surveillance, medical services 
                for occupational infectious disease exposure, and 
                contact tracing.
                    (E) Purchasing and maintenance of medical devices, 
                supplies, and other health care technologies, including 
                diagnostic testing equipment.
                    (F) Costs of all incidental services necessary for 
                safe patient care and handling.
                    (G) Costs of patient care, education, and 
                prevention programs, including occupational health and 
                safety programs, public health programs, and necessary 
                staff to implement such programs, for the continued 
                education and health and safety of clinicians and other 
                individuals employed by the institutional provider.
            (2) Administrative costs for the institutional provider.

SEC. 612. PAYMENT TO INDIVIDUAL PROVIDERS THROUGH FEE-FOR-SERVICE.

    (a) In General.--In the case of a provider not described in section 
611(a) (including those in group practices who are not receiving 
payment on a salaried basis described in section 611(a)(3) and 
providers of home and community-based services), payment for items and 
services furnished under this Act for which payment is not otherwise 
made under section 611 shall be made by the Secretary in amounts 
determined under the fee schedule established pursuant to subsection 
(b). Such payment shall be considered to be payment in full for such 
items and services, and a provider receiving such payment may not 
charge the individual receiving such item or service in any amount.
    (b) Fee Schedule.--
            (1) Establishment.--Not later than 1 year after the date of 
        the enactment of this Act, and in consultation with providers 
        and regional office directors, the Secretary shall establish a 
        national fee schedule for items and services payable under this 
        Act. The Secretary shall evaluate the effectiveness of the fee-
        for-service structure and update such fee schedule annually.
            (2) Amounts.--In establishing payment amounts for items and 
        services under the fee schedule established under paragraph 
        (1), the Secretary shall take into account--
                    (A) the amounts payable for such items and services 
                under title XVIII of the Social Security Act; and
                    (B) the expertise of providers and value of items 
                and services furnished by such providers.
    (c) Electronic Billing.--The Secretary shall establish a uniform 
national system for electronic billing for purposes of making payments 
under this subsection.
    (d) Physician Practice Review Board.--Each director of a regional 
office, in consultation with representatives of physicians practicing 
in that region, shall establish and appoint a physician practice review 
board to assure quality, cost effectiveness, and fair reimbursements 
for physician-delivered items and services. The use of mechanisms that 
discriminate against people with disabilities is prohibited for use in 
any value or cost-effectiveness assessments.

SEC. 613. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE MEDICARE 
              PHYSICIAN FEE SCHEDULE.

    (a) Standardized and Documented Review Process.--Section 1848(c)(2) 
of the Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by 
adding at the end the following new subparagraph:
                    ``(P) Standardized and documented review process.--
                            ``(i) In general.--Not later than one year 
                        after the date of enactment of this 
                        subparagraph, the Secretary shall establish, 
                        document, and make publicly available, in 
                        consultation with the Office of Primary Health 
                        Care, a standardized process for reviewing the 
                        relative values of physicians' services under 
                        this paragraph.
                            ``(ii) Minimum requirements.--The 
                        standardized process shall include, at a 
                        minimum, methods and criteria for identifying 
                        services for review, prioritizing the review of 
                        services, reviewing stakeholder 
                        recommendations, and identifying additional 
                        resources to be considered during the review 
                        process.''.
    (b) Planned and Documented Use of Funds.--Section 1848(c)(2)(M) of 
the Social Security Act (42 U.S.C. 1395w-4(c)(2)(M)) is amended by 
adding at the end the following new clause:
                            ``(x) Planned and documented use of 
                        funds.--For each fiscal year (beginning with 
                        the first fiscal year beginning on or after the 
                        date of enactment of this clause), the 
                        Secretary shall provide to Congress a written 
                        plan for using the funds provided under clause 
                        (ix) to collect and use information on 
                        physicians' services in the determination of 
                        relative values under this subparagraph.''.
    (c) Internal Tracking of Reviews.--
            (1) In general.--Not later than 1 year after the date of 
        enactment of this Act, the Secretary shall submit to Congress a 
        proposed plan for systematically and internally tracking the 
        Secretary's review of the relative values of physicians' 
        services, such as by establishing an internal database, under 
        section 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w-
        4(c)(2)), as amended by this section.
            (2) Minimum requirements.--The proposal shall include, at a 
        minimum, plans and a timeline for achieving the ability to 
        systematically and internally track the following:
                    (A) When, how, and by whom services are identified 
                for review.
                    (B) When services are reviewed or reviewed or when 
                new services are added.
                    (C) The resources, evidence, data, and 
                recommendations used in reviews.
                    (D) When relative values are adjusted.
                    (E) The rationale for final relative value 
                decisions.
    (d) Frequency of Review.--Section 1848(c)(2) of the Social Security 
Act (42 U.S.C. 1395w-4(c)(2)) is amended--
            (1) in subparagraph (B)(i), by striking ``5'' and inserting 
        ``4''; and
            (2) in subparagraph (K)(i)(I), by striking ``periodically'' 
        and inserting ``annually''.
    (e) Consultation With Medicare Payment Advisory Commission.--
            (1) In general.--Section 1848(c)(2) of the Social Security 
        Act (42 U.S.C. 1395w-4(c)(2)) is amended--
                    (A) in subparagraph (B)(i), by inserting ``in 
                consultation with the Medicare Payment Advisory 
                Commission,'' after ``The Secretary,''; and
                    (B) in subparagraph (K)(i)(I), as amended by 
                subsection (d)(2), by inserting ``, in coordination 
                with the Medicare Payment Advisory Commission,'' after 
                ``annually''.
            (2) Conforming amendments.--Section 1805 of the Social 
        Security Act (42 U.S.C. 1395b-6) is amended--
                    (A) in subsection (b)(1)(A), by inserting the 
                following before the semicolon at the end: ``and 
                including coordinating with the Secretary in accordance 
                with section 1848(c)(2) to systematically review the 
                relative values established for physicians' services, 
                identify potentially misvalued services, and propose 
                adjustments to the relative values for physicians' 
                services''; and
                    (B) in subsection (e)(1), in the second sentence, 
                by inserting ``or the Ranking Minority Member'' after 
                ``the Chairman''.
    (f) Periodic Audit by the Comptroller General.--Section 1848(c)(2) 
of the Social Security Act (42 U.S.C. 1395w-4(c)(2)), as amended by 
subsection (a), is amended by adding at the end the following new 
subparagraph:
                    ``(Q) Periodic audit by the comptroller general.--
                            ``(i) In general.--The Comptroller General 
                        of the United States (in this subsection 
                        referred to as the `Comptroller General') shall 
                        periodically audit the review by the Secretary 
                        of relative values established under this 
                        paragraph for physicians' services.
                            ``(ii) Access to information.--The 
                        Comptroller General shall have unrestricted 
                        access to all deliberations, records, and data 
                        related to the activities carried out under 
                        this paragraph, in a timely manner, upon 
                        request.''.

SEC. 614. PAYMENT PROHIBITIONS; CAPITAL EXPENDITURES; SPECIAL PROJECTS.

    (a) Sense of Congress.--It is the sense of Congress that tens of 
millions of people in the United States do not receive healthcare 
services while billions of dollars that could be spent on providing 
health care are diverted to profit. There is a moral imperative to 
correct the massive deficiencies in our current health system and to 
eliminate profit from the provision of health care.
    (b) Prohibitions.--Payments to providers under this Act may not 
take into account, include any process for the provision of funding 
for, or be used by a provider for--
            (1) marketing of the provider;
            (2) the profit or net revenue of the provider, or 
        increasing the profit or net revenue of the provider;
            (3) incentive payments, bonuses, or other compensation 
        based on patient utilization of items and services or any 
        financial measure applied with respect to the provider (or any 
        group practice, integrated health care delivery system, or 
        other provider with which the provider contracts or has a 
        pecuniary interest), including any value-based payment or 
        employment-based compensation;
            (4) any agreement or arrangement described in section 
        203(a)(4) of the Labor-Management Reporting and Disclosure Act 
        of 1959 (29 U.S.C. 433(a)(4)); or
            (5) political or contributions prohibited under section 317 
        of the Federal Elections Campaign Act of 1971 (52 U.S.C. 
        30119(a)(1)).
    (c) Payments for Capital Expenditures.--
            (1) In general.--The Secretary shall pay, from amounts made 
        available for capital expenditures pursuant to section 
        601(a)(2)(B), such sums determined appropriate by the Secretary 
        to providers who have submitted an application to the regional 
        director of the region or regions in which the provider 
        operates or seeks to operate in a time and manner specified by 
        the Secretary for purposes of funding capital expenditures of 
        such providers.
            (2) Priority.--The Secretary shall prioritize allocation of 
        funding under paragraph (1) to projects that propose to use 
        such funds to improve service in a medically underserved area 
        (as defined in section 330(b)(3) of the Public Health Service 
        Act (42 U.S.C. 254b(b)(3))) or to address health disparities, 
        including racial, ethnic, national origin, primary language 
        use, age, disability, sex (including gender identity and sexual 
        orientation), geography, or socioeconomic health disparities.
            (3) Limitation.--The Secretary shall not grant funding for 
        capital expenditures under this subsection for capital projects 
        that are financed directly or indirectly through the diversion 
        of private or other non-Medicare for All Program funding that 
        results in reductions in care to patients, including reductions 
        in registered nursing staffing patterns and changes in 
        emergency room or primary care services or availability.
            (4) Capital assets not funded by the medicare for all 
        program.--Operating expenses and funds shall not be used by an 
        institutional provider receiving payment for capital 
        expenditures under this subsection for a capital asset that was 
        not funded by the Medicare for All program without the approval 
        of the regional director or directors of the region or regions 
        where the capital asset is located.
    (d) Prohibition Against Co-Mingling Operating and Capital Funds.--
Providers that receive payment under this title shall be prohibited 
from using, with respect to funds made available under this Act--
            (1) funds designated for operating expenditures for capital 
        expenditures or for profit; or
            (2) funds designated for capital expenditures for operating 
        expenditures.
    (e) Payments for Special Projects.--
            (1) In general.--The Secretary shall allocate to each 
        regional director, from amounts made available for special 
        projects pursuant to section 601(a)(2)(C), such sums determined 
        appropriate by the Secretary for purposes of funding projects 
        described in such section, including the construction, 
        renovation, or staffing of health care facilities, in rural, 
        underserved, or health professional or medical shortage areas 
        within such region and to address health disparities, including 
        racial, ethnic, national origin, primary language use, age, 
        disability, sex, including gender identity and sexual 
        orientation, geography, or socioeconomic health disparities. 
        Each regional director shall, prior to distributing such funds 
        in accordance with paragraph (2), present a budget describing 
        how such funds will be distributed to the Secretary.
            (2) Distribution.--A regional director shall distribute 
        funds to providers operating in the region of such director's 
        jurisdiction in a manner determined appropriate by the 
        director.
    (f) Prohibition on Financial Incentive Metrics in Payment 
Determinations.--The Secretary may not utilize any quality metrics or 
standards for the purposes of establishing provider payment 
methodologies, programs, modifiers, or adjustments for provider 
payments under this title.

SEC. 615. OFFICE OF HEALTH EQUITY.

    Title XVII of the Public Health Service Act (42 U.S.C. 300u et 
seq.) is amended by adding at the end the following:

``SEC. 1712. OFFICE OF HEALTH EQUITY.

    ``(a) In General.--There is established, in the Office of the 
Secretary of Health and Human Services, an Office of Health Equity, to 
be headed by a Director, to ensure coordination and collaboration 
across the programs and activities of the Department of Health and 
Human Services with respect to ensuring health equity.
    ``(b) Monitoring, Tracking, and Availability of Data.--
            ``(1) In general.--In carrying out subsection (a), the 
        Director of the Office of Health Equity shall monitor, track, 
        and make publicly available data on--
                    ``(A) the disproportionate burden of disease and 
                death among people of color, disaggregated by race, 
                major ethnic group, Tribal affiliation, national 
                origin, primary language use, English proficiency 
                status, immigration status, length of stay in the 
                United States age, disability, sex (including gender 
                identity and sexual orientation), incarceration, 
                homelessness, geography, and socioeconomic status;
                    ``(B) barriers to health, including such barriers 
                relating to income, education, housing, food insecurity 
                (including availability, access, utilization, and 
                stability), employment status, working conditions, and 
                conditions related to the physical environment 
                (including pollutants and population density);
                    ``(C) barriers to health care access, including--
                            ``(i) lack of trust and awareness;
                            ``(ii) lack of transportation;
                            ``(iii) geography;
                            ``(iv) hospital and service closures;
                            ``(v) lack of health care infrastructure 
                        and facilities; and
                            ``(vi) lack of health care professional 
                        staffing and recruitment;
                    ``(D) disparities in quality of care received, 
                including discrimination in health care settings and 
                the use of racially-biased practice guidelines and 
                algorithms; and
                    ``(E) disparities in utilization of care.
            ``(2) Analysis of cross-sectional information.--The 
        Director of the Office of Health Equity shall ensure that the 
        data collection and reporting process under paragraph (1) 
        allows for the analysis of cross-sectional information on 
        people's identities.
    ``(c) Policies.--In carrying out subsection (a), the Director of 
the Office of Health Equity shall develop, coordinate, and promote 
policies that enhance health equity, including by--
            ``(1) providing recommendations on--
                    ``(A) cultural competence, implicit bias, and 
                ethics training with respect to health care workers;
                    ``(B) increasing diversity in the health care 
                workforce; and
                    ``(C) ensuring sufficient health care professionals 
                and facilities; and
            ``(2) ensuring adequate public health funding at the local 
        and State levels to address health disparities.
    ``(d) Consultation.--In carrying out subsection (a), the Director 
of the Office of Health Equity, in coordination with the Director of 
the Indian Health Service, shall consult with Indian Tribes and with 
Urban Indian organizations on data collection, reporting, and 
implementation of policies.
    ``(e) Annual Report.--In carrying out subsection (a), the Director 
of the Office of Health Equity shall develop and publish an annual 
report on--
            ``(1) statistics collected by the Office;
            ``(2) proposed evidence-based solutions to mitigate health 
        inequities; and
            ``(3) health care professional staffing levels and access 
        to facilities.
    ``(f) Centralized Electronic Repository.--In carrying out 
subsection (a), the Director of the Office of Health Equity shall--
            ``(1) establish and maintain a centralized electronic 
        repository to incorporate data collected across Federal 
        departments and agencies on race, ethnicity, Tribal 
        affiliation, national origin, primary language use, English 
        proficiency status, immigration status, length of stay in the 
        United States age, disability, sex (including gender identity 
        and sexual orientation), incarceration, homelessness, 
        geography, and socioeconomic status; and
            ``(2) make such data available for public use and analysis.
    ``(g) Privacy.--Notwithstanding any other Federal or State law, no 
Federal or State official or employee or other entity shall disclose, 
or use, for any law enforcement or immigration purpose, any personally 
identifiable information (including with respect to an individual's 
religious beliefs, practices, or affiliation, national origin, 
ethnicity, or immigration status) that is collected or maintained 
pursuant to this section.''.

SEC. 616. OFFICE OF PRIMARY CARE.

    Title XVII of the Public Health Service Act (42 U.S.C. 300u et 
seq.) is amended by adding at the end the following:

``SEC. 1713. OFFICE OF PRIMARY CARE.

    ``(a) In General.--There is established, in the Office of Health 
Equity established under section 1712, an Office of Primary Health 
Care, to be headed by a Director, to ensure coordination and 
collaboration across the programs and activities of the Department of 
Health and Human Services with respect to increasing access to high-
quality primary health care, particularly in underserved areas and for 
underserved populations.
    ``(b) National Goals.--Not later than 1 year after the date of 
enactment of this section, the Director of the Office of Primary Health 
Care shall publish national goals--
            ``(1) to increase access to high-quality primary health 
        care, particularly in underserved areas and for underserved 
        populations; and
            ``(2) to address health disparities, including with respect 
        to race, ethnicity, national origin (disaggregated by major 
        ethnic group and Tribal affiliation), primary language use, 
        English proficiency status, immigration status, length of stay 
        in the United States, age, disability, sex (including gender 
        identity and sexual orientation), incarceration, homelessness, 
        geography, and socioeconomic status.
    ``(c) Other Responsibilities.--In carrying out subsections (a) and 
(b), the Director of the Office of Primary Health Care shall--
            ``(1) coordinate, in consultation with the Secretary, 
        health professional education policies and goals to achieve the 
        national goals published pursuant to subsection (b);
            ``(2) develop and maintain a system to monitor the number 
        and specialties of individuals pursuing careers in, or 
        practicing, primary health care through their health 
        professional education, any postgraduate training, and 
        professional practice;
            ``(3) develop, coordinate, and promote policies that expand 
        the number of primary health care practitioners, registered 
        nurses, mid-level practitioners, and dentists;
            ``(4) recommend appropriate training, technical assistance, 
        and patient protection enhancements for primary care health 
        professionals, including registered nurses, to achieve uniform 
        high quality and patient safety;
            ``(5) provide recommendations on targeted programs and 
        resources for Federally qualified health centers, rural health 
        centers, community health centers, and other community-based 
        organizations;
            ``(6) provide recommendations for broader patient referral 
        to additional resources, not limited to health care, and 
        collaboration with other organizations and sectors that 
        influence health outcomes; and
            ``(7) consult with the Secretary on the allocation of the 
        special projects budget under section 601(a)(2)(C) of the 
        Medicare for All Act of 2021.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed--
            ``(1) to preempt any provision of State law establishing 
        practice standards or guidelines for health care professionals, 
        including professional licensing or practice laws or 
        regulations; or
            ``(2) to require that any State impose additional 
        educational standards or guidelines for health care 
        professionals.''.

SEC. 617. PAYMENTS FOR PRESCRIPTION DRUGS AND APPROVED DEVICES AND 
              EQUIPMENT.

    The prices to be paid for covered pharmaceuticals, medical 
supplies, medical technologies, and medically necessary equipment 
covered under this Act shall be negotiated annually by the Secretary.
            (1) In general.--Notwithstanding any other provision of 
        law, the Secretary shall, for fiscal years beginning on or 
        after the date of the enactment of this subsection, negotiate 
        with pharmaceutical manufacturers the prices (including 
        discounts, rebates, and other price concessions) that may be 
        charged to the Medicare for All Program during a negotiated 
        price period (as specified by the Secretary) for covered drugs 
        for eligible individuals under the Medicare for All Program. In 
        negotiating such prices under this section, the Secretary shall 
        take into account the following factors:
                    (A) The comparative clinical effectiveness and cost 
                effectiveness, when available from an impartial source, 
                of such drug.
                    (B) The budgetary impact of providing coverage of 
                such drug.
                    (C) The number of similarly effective drugs or 
                alternative treatment regimens for each approved use of 
                such drug.
                    (D) The total revenues from global sales obtained 
                by the manufacturer for such drug and the associated 
                investment in research and development of such drug by 
                the manufacturer.
            (2) Finalization of negotiated price.--The negotiated price 
        of each covered drug for a negotiated price period shall be 
        finalized not later than 30 days before the first fiscal year 
        in such negotiated price period.
            (3) Competitive licensing authority.--
                    (A) In general.--Notwithstanding any exclusivity 
                under clause (iii) or (iv) of section 505(j)(5)(F) of 
                the Federal Food, Drug, and Cosmetic Act, clause (iii) 
                or (iv) of section 505(c)(3)(E) of such Act, section 
                351(k)(7)(A) of the Public Health Service Act, or 
                section 527(a) of the Federal Food, Drug, and Cosmetic 
                Act, or by an extension of such exclusivity under 
                section 505A of such Act or section 505E of such Act, 
                and any other provision of law that provides for market 
                exclusivity (or extension of market exclusivity) with 
                respect to a drug, in the case that the Secretary is 
                unable to success fully negotiate an appropriate price 
                for a covered drug for a negotiated price period, the 
                Secretary shall authorize the use of any patent, 
                clinical trial data, or other exclusivity granted by 
                the Federal Government with respect to such drug as the 
                Secretary determines appropriate for purposes of 
                manufacturing such drug for sale under Medicare for All 
                Program. Any entity making use of a competitive license 
                to use patent, clinical trial data, or other 
                exclusivity under this section shall provide to the 
                manufacturer holding such exclusivity reasonable 
                compensation, as determined by the Secretary based on 
                the following factors:
                            (i) The risk-adjusted value of any Federal 
                        Government subsidies and investments in 
                        research and development used to support the 
                        development of such drug.
                            (ii) The risk-adjusted value of any 
                        investment made by such manufacturer in the 
                        research and development of such drug.
                            (iii) The impact of the price, including 
                        license compensation payments, on meeting the 
                        medical need of all patients at a reasonable 
                        cost.
                            (iv) The relationship between the price of 
                        such drug, including compensation payments, and 
                        the health benefits of such drug.
                            (v) Other relevant factors determined 
                        appropriate by the Secretary to provide 
                        reasonable compensation.
                    (B) Reasonable compensation.--The manufacturer 
                described in subparagraph (A) may seek recovery against 
                the United States in the United States Court of Federal 
                Claims.
                    (C) Interim period.--Until 1 year after a drug 
                described in subparagraph (A) is approved under section 
                505(j) of the Federal Food, Drug, and Cosmetic Act or 
                section 351(k) of the Public Health Service Act and is 
                provided under license issued by the Secretary under 
                such subparagraph, the Medicare for All Program shall 
                not pay more for such drug than the average of the 
                prices available, during the most recent 12-month 
                period for which data is available prior to the 
                beginning of such negotiated price period, from the 
                manufacturer to any wholesaler, retailer, provider, 
                health maintenance organization, nonprofit entity, or 
                governmental entity in the ten OECD (Organization for 
                Economic Cooperation and Development) countries that 
                have the largest gross domestic product with a per 
                capita income that is not less than half the per capita 
                income of the United States.
                    (D) Authorization for secretary to procure drugs 
                directly.--The Secretary may procure a drug 
                manufactured pursuant to a competitive license under 
                subparagraph (A) for purposes of this Act.
            (4) FDA review of licensed drug applications.--The 
        Secretary shall prioritize review of applications under section 
        505(j) of the Federal Food, Drug, and Cosmetic Act for drugs 
        licensed under paragraph (3)(A).
            (5) Prohibition of anticompetitive behavior.--No drug 
        manufacturer may engage in anticompetitive behavior with 
        another manufacturer that may interfere with the issuance and 
        implementation of a competitive license or run contrary to 
        public policy.
            (6) Required reporting.--The Secretary may require 
        pharmaceutical manufacturers to disclose to the Secretary such 
        information that the Secretary determines necessary for 
        purposes of carrying out this subsection.

                TITLE VII--UNIVERSAL MEDICARE TRUST FUND

SEC. 701. UNIVERSAL MEDICARE TRUST FUND.

    (a) In General.--There is hereby created on the books of the 
Treasury of the United States a trust fund to be known as the Universal 
Medicare Trust Fund (in this section referred to as the ``Trust 
Fund''). The Trust Fund shall consist of such gifts and bequests as may 
be made and such amounts as may be deposited in, or appropriated to, 
such Trust Fund as provided in this Act.
    (b) Appropriations Into Trust Fund.--
            (1) Taxes.--There are appropriated to the Trust Fund for 
        each fiscal year beginning with the fiscal year which includes 
        the date on which benefits first become available as described 
        in section 106, out of any moneys in the Treasury not otherwise 
        appropriated, amounts equivalent to 100 percent of the net 
        increase in revenues to the Treasury which is attributable to 
        the amendments made by sections 801 and 902. The amounts 
        appropriated by the preceding sentence shall be transferred 
        from time to time (but not less frequently than monthly) from 
        the general fund in the Treasury to the Trust Fund, such 
        amounts to be determined on the basis of estimates by the 
        Secretary of the Treasury of the taxes paid to or deposited 
        into the Treasury, and proper adjustments shall be made in 
        amounts subsequently transferred to the extent prior estimates 
        were in excess of or were less than the amounts that should 
        have been so transferred.
            (2) Current program receipts.--
                    (A) Initial year.--Notwithstanding any other 
                provision of law, there is appropriated to the Trust 
                Fund for the fiscal year containing January 1 of the 
                first year following the date of the enactment of this 
                Act, an amount equal to the aggregate amount 
                appropriated for the preceding fiscal year for the 
                following (increased by the consumer price index for 
                all urban consumers for the fiscal year involved):
                            (i) The Medicare program under title XVIII 
                        of the Social Security Act (other than amounts 
                        attributable to any premiums under such title).
                            (ii) The Medicaid program under State plans 
                        approved under title XIX of such Act.
                            (iii) The Federal Employees Health Benefits 
                        program, under chapter 89 of title 5, United 
                        States Code.
                            (iv) The purchased care component of the 
                        TRICARE program, under chapter 55 of title 10, 
                        United States Code (other than amounts 
                        appropriated for the purchased care component 
                        of the TRICARE Overseas Program).
                            (v) The maternal and child health program 
                        (under title V of the Social Security Act), 
                        vocational rehabilitation programs, programs 
                        for drug abuse and mental health services under 
                        the Public Health Service Act, programs 
                        providing general hospital or medical 
                        assistance, and any other Federal program 
                        identified by the Secretary, in consultation 
                        with the Secretary of the Treasury, to the 
                        extent the programs provide for payment for 
                        health services the payment of which may be 
                        made under this Act.
                    (B) Subsequent years.--Notwithstanding any other 
                provision of law, there is appropriated to the trust 
                fund for the fiscal year containing January 1 of the 
                second year following the date of the enactment of this 
                Act, and for each fiscal year thereafter, an amount 
                equal to the amount appropriated to the Trust Fund for 
                the previous year, adjusted for reductions in costs 
                resulting from the implementation of this Act, changes 
                in the consumer price index for all urban consumers for 
                the fiscal year involved, and other factors determined 
                appropriate by the Secretary.
            (3) Restrictions shall not apply.--Any other provision of 
        law in effect on the date of enactment of this Act restricting 
        the use of Federal funds for any reproductive health service 
        shall not apply to monies in the Trust Fund.
    (c) Incorporation of Provisions.--The provisions of subsections (b) 
through (i) of section 1817 of the Social Security Act (42 U.S.C. 
1395i) shall apply to the Trust Fund under this section in the same 
manner as such provisions applied to the Federal Hospital Insurance 
Trust Fund under such section 1817, except that, for purposes of 
applying such subsections to this section, the ``Board of Trustees of 
the Trust Fund'' shall mean the ``Secretary''.
    (d) Transfer of Funds.--Any amounts remaining in the Federal 
Hospital Insurance Trust Fund under section 1817 of the Social Security 
Act (42 U.S.C. 1395i) or the Federal Supplementary Medical Insurance 
Trust Fund under section 1841 of such Act (42 U.S.C. 1395t) after the 
payment of claims for items and services furnished under title XVIII of 
such Act have been completed, shall be transferred into the Universal 
Medicare Trust Fund under this section.

  TITLE VIII--CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME 
                          SECURITY ACT OF 1974

SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF BENEFITS 
              UNDER THE MEDICARE FOR ALL PROGRAM; COORDINATION IN CASE 
              OF WORKERS' COMPENSATION.

    (a) In General.--Part 5 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is 
amended by adding at the end the following new section:

``SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF UNIVERSAL 
              MEDICARE PROGRAM BENEFITS; COORDINATION IN CASE OF 
              WORKERS' COMPENSATION.

    ``(a) In General.--Subject to subsection (b), no employee benefit 
plan may provide benefits that duplicate payment for any items or 
services for which payment may be made under the Medicare for All Act 
of 2021.
    ``(b) Reimbursement.--Each workers compensation carrier that is 
liable for payment for workers compensation services furnished in a 
State shall reimburse the Medicare for All Program for the cost of such 
services.
    ``(c) Definitions.--In this subsection--
            ``(1) the term `workers compensation carrier' means an 
        insurance company that underwrite workers compensation medical 
        benefits with respect to one or more employers and includes an 
        employer or fund that is financially at risk for the provision 
        of workers compensation medical benefits;
            ``(2) the term `workers compensation medical benefits' 
        means, with respect to an enrollee who is an employee subject 
        to the workers compensation laws of a State, the comprehensive 
        medical benefits for work-related injuries and illnesses 
        provided for under such laws with respect to such an employee; 
        and
            ``(3) the term `workers compensation services' means items 
        and services included in workers compensation medical benefits 
        and includes items and services (including rehabilitation 
        services and long-term care services) commonly used for 
        treatment of work-related injuries and illnesses.''.
    (b) Conforming Amendment.--Section 4(b) of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1003(b)) is amended by adding at 
the end the following: ``Paragraph (3) shall apply subject to section 
522(b) (relating to reimbursement of the Medicare for All Program by 
workers compensation carriers).''.
    (c) Clerical Amendment.--The table of contents in section 1 of such 
Act is amended by inserting after the item relating to section 521 the 
following new item:

``Sec. 522. Prohibition of employee benefits duplicative of Universal 
                            Medicare Program benefits; coordination in 
                            case of workers' compensation.''.

SEC. 802. APPLICATION OF CONTINUATION COVERAGE REQUIREMENTS UNDER ERISA 
              AND CERTAIN OTHER REQUIREMENTS RELATING TO GROUP HEALTH 
              PLANS.

    (a) In General.--Part 6 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) shall 
apply only with respect to any employee health benefit plan that does 
not duplicate payments for any items or services for which payment may 
be made under the this Act.
    (b) Conforming Amendment.--Section 601 of part 6 of subtitle B of 
title I of the Employee Retirement Income Security Act of 1974 (19 
U.S.C. 1161) is amended by adding the following subsection at the end:
    ``(c) Subsection (a) shall apply to any group health plan that does 
not duplicate payments for any items or services for which payment may 
be made under the Medicare for All Act of 2021.''.

SEC. 803. EFFECTIVE DATE OF TITLE.

    The provisions of and amendments made by this title shall take 
effect on the date described in section 106(a).

               TITLE IX--ADDITIONAL CONFORMING AMENDMENTS

SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS.

    (a) Medicare, Medicaid, and State Children's Health Insurance 
Program (SCHIP).--
            (1) In general.--Notwithstanding any other provision of law 
        and with respect to an individual eligible to enroll under this 
        Act, subject to paragraphs (2) and (3)--
                    (A) no benefits shall be available under title 
                XVIII of the Social Security Act for any item or 
                service furnished beginning on the date that is 2 years 
                after the date of the enactment of this Act;
                    (B) no individual is entitled to medical assistance 
                under a State plan approved under title XIX of such Act 
                for any item or service furnished on or after such 
                date;
                    (C) no individual is entitled to medical assistance 
                under a State child health plan under title XXI of such 
                Act for any item or service furnished on or after such 
                date; and
                    (D) no payment shall be made to a State under 
                section 1903(a) or 2105(a) of such Act with respect to 
                medical assistance or child health assistance for any 
                item or service furnished on or after such date.
            (2) Transition.--In the case of inpatient hospital services 
        and extended care services during a continuous period of stay 
        which began before the effective date of benefits under section 
        106, and which had not ended as of such date, for which 
        benefits are provided under title XVIII of the Social Security 
        Act, under a State plan under title XIX of such Act, or under a 
        State child health plan under title XXI of such Act, the 
        Secretary shall provide for continuation of benefits under such 
        title or plan until the end of the period of stay.
            (3) School programs.--All school related health programs, 
        centers, initiatives, services, or other activities or work 
        provided under title XIX or title XXI of the Social Security 
        Act as of January 1, 2019, shall be continued and covered by 
        the Medicare for All Program.
    (b) Federal Employees Health Benefits Program.--No benefits shall 
be made available under chapter 89 of title 5, United States Code, with 
respect to items and services furnished to any individual eligible to 
enroll under this Act.
    (c) TRICARE Program.--
            (1) Direct care component.--Nothing in this Act shall 
        affect the eligibility of beneficiaries under chapter 55 of 
        title 10, United States Code, who are entitled to receive care 
        furnished at facilities of the uniformed services under the 
        TRICARE program for such care.
            (2) Purchased care component.--
                    (A) In general.--Except as provided in subparagraph 
                (B), no benefits shall be made available under the 
                purchased care component of the TRICARE program for 
                items or services furnished to any individual eligible 
                to enroll under this Act.
                    (B) TRICARE overseas.--During any period in which 
                an individual is eligible for benefits under the 
                TRICARE Overseas Program and is located in a TRICARE 
                overseas region, the individual may receive benefits 
                for items or services furnished to the individual under 
                the purchased care component of such program during 
                such period.
    (d) Treatment of Benefits for Veterans and Native Americans.--
            (1) In general.--Nothing in this Act shall affect the 
        eligibility of veterans for the medical benefits and services 
        provided under title 38, United States Code, or of Indians for 
        the medical benefits and services provided by or through the 
        Indian Health Service.
            (2) Reevaluation.--No reevaluation of the Indian Health 
        Service shall be undertaken without consultation with tribal 
        leaders and stakeholders.

SEC. 902. SUNSET OF PROVISIONS RELATED TO THE STATE EXCHANGES.

    Effective on the date that is 2 years after the date of the 
enactment of this Act, 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 Internal Revenue Code of 
1986, shall cease to have force or effect.

SEC. 903. SUNSET OF PROVISIONS RELATED TO PAY FOR PERFORMANCE PROGRAMS.

    (a) Effective on the date described in section 106(a), the Federal 
programs related to pay for performance programs and value-based 
purchasing shall terminate, and any other provision of law that relies 
upon participation in or enrollment in such program shall cease to have 
force or effect. Programs that shall terminate include--
            (1) the Merit-based Incentive Payment System established 
        pursuant to subsection (q) of section 1848 of the Social 
        Security Act (42 U.S.C. 1395w-4(q));
            (2) the incentives for meaningful use of certified EHR 
        technology established pursuant to subsection (a)(7) of section 
        1848 of the Social Security Act (42 U.S.C. 1395w-4(a)(7));
            (3) the incentives for adoption and meaningful use of 
        certified EHR technology established pursuant to subsection (o) 
        of section 1848 of the Social Security Act (42 U.S.C. 1395w-
        4(o));
            (4) alternative payment models established under section 
        1833(z) of the Social Security Act (42 U.S.C. 1395(z)); and
            (5) the following programs as established pursuant to the 
        following sections of the Patient Protection and Affordable 
        Care Act:
                    (A) Section 2701 (adult health quality measures).
                    (B) Section 2702 (payment adjustments for health 
                care acquired conditions).
                    (C) Section 2706 (Pediatric Accountable Care 
                Organization Demonstration Projects for the purposes of 
                receiving incentive payments).
                    (D) Section 3002(b) (42 U.S.C. 1395w-4(a)(8)) 
                (incentive payments for quality reporting).
                    (E) Section 3001(a) (42 U.S.C. 1395ww(o)) (Hospital 
                Value-Based Purchasing).
                    (F) Section 3006 (value-based purchasing program 
                for skilled nursing facilities and home health 
                agencies).
                    (G) Section 3007 (42 U.S.C. 1395w-4(p)) (value 
                based payment modifier under physician fee schedule).
                    (H) Section 3008 (42 U.S.C. 1395ww(p)) (payment 
                adjustments for health care-acquired condition).
                    (I) Section 3022 (42 U.S.C. 1395jjj) (Medicare 
                shared savings programs).
                    (J) Section 3023 (42 U.S.C. 1395cc-4) (National 
                Pilot Program on Payment Bundling).
                    (K) Section 3024 (42 U.S.C. 1395cc-5) (Independence 
                at home demonstration program).
                    (L) Section 3025 (42 U.S.C. 1395ww(q)) (hospital 
                readmissions reduction program).
                    (M) Section 10301 (plans for value-based purchasing 
                program for ambulatory surgical centers).

                          TITLE X--TRANSITION

 Subtitle A--Medicare for All Transition Over 2 Years and Transitional 
                             Buy-In Option

SEC. 1001. MEDICARE FOR ALL TRANSITION OVER TWO YEARS.

    Title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.) is 
amended by adding at the end the following new section:

``SEC. 1899C. MEDICARE FOR ALL TRANSITION OVER 2 YEARS.

    ``(a) Transition.--
            ``(1) In general.--Every individual who meets the 
        requirements described in paragraph (3) shall be eligible to 
        enroll in the Medicare for All Program under this section 
        during the transition period starting one year after the date 
        of enactment of the Medicare for All Act of 2021.
            ``(2) Benefits.--An individual enrolled under this section 
        is entitled to the benefits established under title II of the 
        Medicare for All Act of 2021.
            ``(3) Requirements for eligibility.--The requirements 
        described in this paragraph are the following:
                    ``(A) The individual meets the eligibility 
                requirements established by the Secretary under title I 
                of the Medicare for All Act of 2021.
                    ``(B) The individual has attained the applicable 
                year of age, or is currently enrolled in Medicare at 
                the time of the transition to Medicare for All.
            ``(4) Applicable year of age defined.--For purposes of this 
        section, the term `applicable year of age' means one year after 
        the date of enactment of the Medicare for All Act of 2021, the 
        age of 55 or older, the age 18 or younger.
    ``(b) Enrollment; Coverage.--The Secretary shall establish 
enrollment periods and coverage under this section consistent with the 
principles for establishment of enrollment periods and coverage for 
individuals under other provisions of this title. The Secretary shall 
establish such periods so that coverage under this section shall first 
begin on January 1 of the year on which an individual first becomes 
eligible to enroll under this section.
    ``(c) Satisfaction of Individual Mandate.--For purposes of applying 
section 5000A of the Internal Revenue Code of 1986, the coverage 
provided under this section constitutes minimum essential coverage 
under subsection (f)(1)(A)(i) of such section 5000A.
    ``(d) Consultation.--In promulgating regulations to implement this 
section, the Secretary shall consult with interested parties, including 
groups representing beneficiaries, health care providers, employers, 
and insurance companies.''.

SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSITION BUY-IN.

    (a) In General.--To carry out the purpose of this section, for the 
year beginning one year after the date of enactment of this Act and 
ending with the effective date described in section 106(a), the 
Secretary, acting through the Administrator of the Centers for Medicare 
& Medicaid (referred to in this section as the ``Administrator''), 
shall establish, and provide for the offering through the Exchanges, an 
option to buy in to the Medicare for All Program (in this Act referred 
to as the ``Medicare Transition buy-in'').
    (b) Administering the Medicare Transition Buy-In.--
            (1) Administrator.--The Administrator shall administer the 
        Medicare Transition buy-in in accordance with this section.
            (2) Application of aca requirements.--Consistent with this 
        section, the Medicare Transition buy-in shall comply with 
        requirements under title I of the Patient Protection and 
        Affordable Care Act (and the amendments made by that title) and 
        title XXVII of the Public Health Service Act (42 U.S.C. 300gg 
        et seq.) that are applicable to qualified health plans offered 
        through the Exchanges, subject to the limitation under 
        subsection (e)(2).
            (3) Offering through exchanges.--The Medicare Transition 
        buy-in shall be made available only through the Exchanges, and 
        shall be available to individuals wishing to enroll and to 
        qualified employers (as defined in section 1312(f)(2) of the 
        Patient Protection and Affordable Care Act (42 U.S.C. 18032)) 
        who wish to make such plan available to their employees.
            (4) Eligibility to purchase.--Any United States resident 
        may enroll in the Medicare Transition buy-in.
    (c) Benefits; Actuarial Value.--In carrying out this section, the 
Administrator shall ensure that the Medicare Transition buy-in 
provides--
            (1) coverage for the benefits required to be covered under 
        title II of this Act; and
            (2) coverage of benefits that are actuarially equivalent to 
        90 percent of the full actuarial value of the benefits provided 
        under the plan.
    (d) Providers and Reimbursement Rates.--
            (1) In general.--With respect to the reimbursement provided 
        to health care providers for covered benefits, as described in 
        section 201, provided under the Medicare Transition buy-in, the 
        Administrator shall reimburse such providers at rates 
        determined for equivalent items and services under the Medicare 
        for All fee-for-service schedule established in section 612(b) 
        of this Act.
            (2) Prescription drugs.--Any payment rate under this 
        subsection for a prescription drug shall be at the prices 
        negotiated under section 616 of this Act.
            (3) Participating providers.--
                    (A) In general.--A health care provider that is a 
                participating provider of services or supplier under 
                the Medicare program under title XVIII of the Social 
                Security Act (42 U.S.C. 1395 et seq.) or under a State 
                Medicaid plan under title XIX of such Act (42 U.S.C. 
                1396 et seq.) on the date of enactment of this Act 
                shall be a participating provider in the Medicare 
                Transition buy-in.
                    (B) Additional providers.--The Administrator shall 
                establish a process to allow health care providers not 
                described in subparagraph (A) to become participating 
                providers in the Medicare Transition buy-in. Such 
                process shall be similar to the process applied to new 
                providers under the Medicare program.
    (e) Premiums.--
            (1) Determination.--The Administrator shall determine the 
        premium amount for enrolling in the Medicare Transition buy-in, 
        which--
                    (A) may vary according to family or individual 
                coverage, age, and tobacco status (consistent with 
                clauses (i), (iii), and (iv) of section 2701(a)(1)(A) 
                of the Public Health Service Act (42 U.S.C. 
                300gg(a)(1)(A))); and
                    (B) shall take into account the cost-sharing 
                reductions and premium tax credits which will be 
                available with respect to the plan under section 1402 
                of the Patient Protection and Affordable Care Act (42 
                U.S.C. 18071) and section 36B of the Internal Revenue 
                Code of 1986, as amended by subsection (g).
            (2) Limitation.--Variation in premium rates of the Medicare 
        Transition buy-in by rating area, as described in clause (ii) 
        of section 2701(a)(1)(A)(iii) of the Public Health Service Act 
        (42 U.S.C. 300gg(a)(1)(A)) is not permitted.
    (f) Termination.--This section shall cease to have force or effect 
on the effective date described in section 106(a).
    (g) Tax Credits and Cost-Sharing Subsidies.--
            (1) Premium assistance tax credits.--
                    (A) Credits allowed to medicare transition buy-in 
                enrollees in non-expansion states.--Paragraph (1) of 
                section 36B(c) of the Internal Revenue Code of 1986 is 
                amended by redesignating subparagraphs (C) and (D) as 
                subparagraphs (D) and (E), respectively, and by 
                inserting after subparagraph (B) the following new 
                subparagraph:
                    ``(C) Special rules for medicare transition buy-in 
                enrollees.--
                            ``(i) In general.--In the case of a 
                        taxpayer who is covered, or whose spouse or 
                        dependent (as defined in section 152) is 
                        covered, by the Medicare Transition buy-in 
                        established under section 1002(a) of the 
                        Medicare for All Act of 2021 for all months in 
                        the taxable year, subparagraph (A) shall be 
                        applied without regard to `but does not exceed 
                        400 percent'.
                            ``(ii) Enrollees in medicaid nonexpansion 
                        states.--In the case of a taxpayer residing in 
                        a State which (as of the date of the enactment 
                        of the Medicare for All Act of 2021) does not 
                        provide for eligibility under clause (i)(VIII) 
                        or (ii)(XX) of section 1902(a)(10)(A) of the 
                        Social Security Act for medical assistance 
                        under title XIX of such Act (or a waiver of the 
                        State plan approved under section 1115) who is 
                        covered, or whose spouse or dependent (as 
                        defined in section 152) is covered, by the 
                        Medicare Transition buy-in established under 
                        section 1002(a) of the Medicare for All Act of 
                        2021 for all months in the taxable year, 
                        subparagraphs (A) and (B) shall be applied by 
                        substituting `0 percent' for `100 percent' each 
                        place it appears.''.
                    (B) Premium assistance amounts for taxpayers 
                enrolled in medicare transition buy-in.--
                            (i) In general.--Subparagraph (A) of 
                        section 36B(b)(3) of such Code is amended--(I) 
                        by redesignating clause (ii) as clause (iii), 
                        (II) by striking ``clause (ii)'' in clause (i) 
                        and inserting ``clauses (ii) and (iii)'', and 
                        (III) by inserting after clause (i) the 
                        following new clause:
                            ``(ii) Special rules for taxpayers enrolled 
                        in medicare transition buy-in.--In the case of 
                        a taxpayer who is covered, or whose spouse or 
                        dependent (as defined in section 152) is 
                        covered, by the Medicare Transition buy-in 
                        established under section 1002(a) of the 
                        Medicare for All Act of 2021 for all months in 
                        the taxable year, the applicable percentage for 
                        any taxable year shall be determined in the 
                        same manner as under clause (i), except that 
                        the following table shall apply in lieu of the 
                        table contained in such clause:


------------------------------------------------------------------------
 ``In the case of household income
    (expressed as a percent of         The initial         The final
     poverty line) within the            premium            premium
      following income tier:         percentage is--    percentage is--
------------------------------------------------------------------------
Up to 100 percent.................               2.00               2.00
100 percent up to 138 percent.....               2.04               2.04
138 percent up to 150 percent.....               3.06               4.08
150 percent and above.............               4.08           5.00.''.
------------------------------------------------------------------------

                            (ii) Conforming amendment.--Subclause (I) 
                        of clause (iii) of section 36B(b)(3) of such 
                        Code, as redesignated by subparagraph (A)(i), 
                        is amended by inserting ``, and determined 
                        after the application of clause (ii)'' after 
                        ``after application of this clause''.
            (2) Cost-sharing subsidies.--Subsection (b) of section 1402 
        of the Patient Protection and Affordable Care Act (42 U.S.C. 
        18071(b)) is amended--
                    (A) by inserting ``, or in the Medicare Transition 
                buy-in established under section 1002(a) of the 
                Medicare for All Act of 2021,'' after ``coverage'' in 
                paragraph (1);
                    (B) by redesignating paragraphs (1) (as so amended) 
                and (2) as subparagraphs (A) and (B), respectively, and 
                by moving such subparagraphs 2 ems to the right;
                    (C) by striking ``Insured.--In this section'' and 
                inserting ``Insured.--
            ``(1) In general.--In this section'';
                    (D) by striking the flush language; and
                    (E) by adding at the end the following new 
                paragraph:
            ``(2) Special rules.--
                    ``(A) Individuals lawfully present.--In the case of 
                an individual described in section 36B(c)(1)(B) of the 
                Internal Revenue Code of 1986, the individual shall be 
                treated as having household income equal to 100 percent 
                of the poverty line for a family of the size involved 
                for purposes of applying this section.
                    ``(B) Medicare transition buy-in enrollees in 
                medicaid non-expansion states.--In the case of an 
                individual residing in a State which (as of the date of 
                the enactment of the Medicare for All Act of 2021) does 
                not provide for eligibility under clause (i)(VIII) or 
                (ii)(XX) of section 1902(a)(10)(A) of the Social 
                Security Act for medical assistance under title XIX of 
                such Act (or a waiver of the State plan approved under 
                section 1115) who enrolls in such Medicare Transition 
                buy-in, the preceding sentence, paragraph (1)(B), and 
                paragraphs (1)(A)(i) and (2)(A) of subsection (c) shall 
                each be applied by substituting `0 percent' for `100 
                percent' each place it appears.''.
    (h) Conforming Amendments.--
            (1) Treatment as a qualified health plan.--Section 
        1301(a)(2) of the Patient Protection and Affordable Care Act 
        (42 U.S.C. 18021(a)(2)) is amended--
                    (A) in the paragraph heading, by inserting ``The 
                medicare transition buy-in,'' before ``and''; and
                    (B) by inserting ``The Medicare Transition buy-
                in,'' before ``and a multi-State plan''.
            (2) Level playing field.--Section 1324(a) of the Patient 
        Protection and Affordable Care Act (42 U.S.C. 18044(a)) is 
        amended by inserting ``the Medicare Transition buy-in,'' before 
        ``or a multi-State qualified health plan''.

               Subtitle B--Transitional Medicare Reforms

SEC. 1011. ELIMINATING THE 24-MONTH WAITING PERIOD FOR MEDICARE 
              COVERAGE FOR INDIVIDUALS WITH DISABILITIES.

    (a) In General.--Section 226(b) of the Social Security 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 ``, including 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 status as a qualified 
        railroad retirement beneficiary described in paragraph (2), 
        and'' and inserting ``for each month for which the individual 
        meets the requirements 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 inserting ``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 annuity'';
                    (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 December 1 following the date of enactment of this Act, and 
before the date that is 2 years after the date of the enactment of such 
Act.

SEC. 1012. ENSURING CONTINUITY OF CARE.

    (a) In General.--The Secretary shall ensure that all persons 
enrolled or who seeks to enroll in a health plan during the transition 
period of the Medicare for All Program are protected from disruptions 
in their care during the transition period, including continuity of 
care with such persons current health care provider teams.
    (b) Continuity of Coverage and Care in General.--During the 
transition period of the Medicare for All Act, group health plans and 
health insurance issuers offering group or individual health insurance 
coverage shall not end coverage for an enrollee during the transition 
period described in the Act until all ages are eligible to enroll in 
the Medicare for All Program except as expressly agreed upon under the 
terms of the plan.
    (c) Continuity of Coverage and Care for Persons With Complex 
Medical Needs.--
            (1) The Secretary shall ensure that persons with 
        disabilities, complex medical needs, or chronic conditions are 
        protected from disruptions in their care during the transition 
        period, including continuity of care with such persons current 
        health care provider teams.
            (2) During the transition period of the Medicare for All 
        Act group health plans and health insurance issuers offering 
        group or individual health insurance coverage shall not--
                    (A) end coverage for an enrollee who has a 
                disability, complex medical need, or chronic condition 
                during the transition period described in the Act until 
                all ages are eligible to enroll in the Medicare for All 
                Program; or
                    (B) impose any exclusion with respect to such plan 
                or coverage on the basis of a person's disability, 
                complex medical need, or chronic condition during the 
                transition period described under this Act until all 
                ages are eligible to enroll in the Medicare for All 
                Program.
    (d) Public Consultation During Transition.--The Secretary shall 
consult with communities and advocacy organizations of persons living 
with disabilities as well as other patient advocacy organizations to 
ensure that the transition buy-in takes into account the continuity of 
care for persons with disabilities, complex medical needs, or chronic 
conditions.

                        TITLE XI--MISCELLANEOUS

SEC. 1101. DEFINITIONS.

    In this Act--
            (1) the term ``global budget'' means the payment negotiated 
        between an institutional provider and as described in section 
        611(b);
            (2) the term ``group practice'' has the meaning given such 
        term in section 1877(h)(4) of the Social Security Act (42 
        U.S.C. 1395nn(h)(4));
            (3) the term ``individual provider'' means a supplier (as 
        defined in section 1861(d) of such Act (42 U.S.C. 1395x(d)));
            (4) the term ``institutional provider'' means--
                    (A) providers of services described in section 
                1861(u) of such Act (42 U.S.C. 1395x(u));
                    (B) hospitals as defined in section 1861(e) of the 
                Social Security Act (42 U.S.C. 1395x(e)), and any 
                outpatient settings or clinics operating within a 
                hospital license or any setting or clinic that provides 
                outpatient hospital services;
                    (C) psychiatric hospitals (as defined in section 
                1861(e) of the Social Security Act (42 U.S.C. 
                1395x(f)));
                    (D) rehabilitation hospitals (as defined by the 
                Secretary of Health and Human Services under section 
                1886(d)(1)(B)(ii) of the Social Security Act (42 U.S.C. 
                1395ww(d)(1)(B)(ii)));
                    (E) long-term care hospitals as defined in section 
                1861 of the Social Security Act (42 U.S.C. 1395x(ccc)); 
                and
                    (F) independent dialysis facilities and independent 
                end-stage renal disease facilities as described in 42 
                CFR 413.174(b);
            (5) the term ``medically necessary or appropriate'' means 
        the health care items and services or supplies that are needed 
        or appropriate to prevent, diagnose, or treat an illness, 
        injury, condition, disease, or its symptoms for an individual 
        and are determined to be necessary or appropriate for such 
        individual by the physician or other health care professional 
        treating such individual, after such professional performs an 
        assessment of such individual's condition, in a manner that 
        meets--
                    (A) the scope of practice, licensing, and other law 
                of the State in which the individual receiving such 
                items and services is located; and
                    (B) appropriate standards established by the 
                Secretary for purposes of carrying out this Act;
            (6) the term ``provider'' means an institutional provider 
        or a supplier (as defined in section 1861(d) of such Act (42 
        U.S.C. 1395x(d)) if the reference to ``this title'' were a 
        reference to the Medicare for All Program);
            (7) the term ``Secretary'' means the Secretary of Health 
        and Human Services;
            (8) the term ``State'' means a State, the District of 
        Columbia, or a territory of the United States;
            (9) the term ``TRICARE Overseas Program'' means the element 
        of the TRICARE program administered by International SOS (or 
        such successor administrator) under which care and health 
        benefits are furnished to TRICARE beneficiaries located in a 
        TRICARE overseas region;
            (10) the term ``TRICARE program'' has the meaning given 
        such term in section 1072 of title 10, United States Code;
            (11) the term ``uniformed services'' has the meaning given 
        such term in section 101 of title 10, United States Code; and
            (12) the term ``United States'' shall include the States, 
        the District of Columbia, and the territories of the United 
        States.

SEC. 1102. RULES OF CONSTRUCTION.

    (a) In General.--A State or local government may set additional 
standards or apply other State or local laws with respect to 
eligibility, benefits, and minimum provider standards, only if such 
State or local standards--
            (1) provide equal or greater eligibility than is available 
        under this Act;
            (2) provide equal or greater in-person access to benefits 
        under this Act;
            (3) do not reduce access to benefits under this Act;
            (4) allow for the effective exercise of the professional 
        judgment of physicians or other health care professionals; and
            (5) are otherwise consistent with this Act.
    (b) Relation to State Licensing Law.--Nothing in this Act shall be 
construed to preempt State licensing, practice, or educational laws or 
regulations with respect to health care professionals and health care 
providers, for such professionals and providers who practice in that 
State.
    (c) Application to State and Federal Law on Workplace Rights.--
Nothing in this Act shall be construed to diminish or alter the rights, 
privileges, remedies, or obligations of any employee or employer under 
any Federal or State law or regulation or under any collective 
bargaining agreement.
    (d) Restrictions on Providers.--With respect to any individuals or 
entities certified to provide items and services covered under section 
201(a)(7), a State may not prohibit an individual or entity from 
participating in the program under this Act for reasons other than the 
ability of the individual or entity to provide such services.

SEC. 1103. NO USE OF RESOURCES FOR LAW ENFORCEMENT OF CERTAIN 
              REGISTRATION REQUIREMENTS.

    Notwithstanding any provision of Federal or State law, no Federal 
or State law enforcement official or employee shall use any funds, 
facilities, property, equipment, or personnel made available pursuant 
to this Act (or any amendment made thereby) to investigate, enforce, or 
assist in the investigation or enforcement of any criminal, civil, or 
administrative violation or warrant for a violation of any requirement 
that individuals register with the Federal Government based on 
religion, national origin, ethnicity, immigration status, or other 
protected category.
                                 <all>