II 116th CONGRESS 1st Session S. 470 IN THE SENATE OF THE UNITED STATES February 13, 2019 Ms. Stabenow (for herself, Mr. Brown , Ms. Baldwin , Mr. Blumenthal , Mr. Booker , Mr. Cardin , Ms. Duckworth , Mr. Durbin , Ms. Harris , Ms. Klobuchar , Mr. Leahy , Mr. Markey , Mr. Merkley , Mr. Peters , Mr. Reed , Mrs. Shaheen , Ms. Smith , Mr. Whitehouse , Mrs. Gillibrand , and Mr. Heinrich ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to provide for an option for any citizen or permanent resident of the United States age 50 to 64 to buy into Medicare.

1. Short title This Act may be cited as the Medicare at 50 Act . 2. Medicare buy-in option for individuals 50 to 64 years of age (a) In general 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: 1899C. Medicare buy-in option for individuals 50 to 64 years of age (a) Option (1) In general Every individual who meets the requirements described in paragraph (3) shall be eligible to enroll under this section. (2) Part A, B, and D benefits and protections An individual enrolled under this section is entitled to the same benefits (and shall receive the same protections) under this title as an individual who is entitled to benefits under part A and enrolled under parts B and D, including the ability to enroll in a Medicare Advantage plan that provides qualified prescription drug coverage (an MA–PD plan) and including access to the Medicare Beneficiary Ombudsman under section 1808(c). (3) Requirements for eligibility The requirements described in this paragraph are the following: (A) Age The individual has attained 50 years of age, but has not attained 65 years of age. (B) Medicare eligibility (but for age) The individual is not otherwise entitled to benefits under part A or eligible to enroll under part A or part B but would be eligible for benefits under part A or part B if the individual were 65 years of age. (b) Enrollment and coverage periods (1) In general The Secretary shall establish enrollment and coverage periods for individuals who enroll under this section. (2) Coordination Such periods shall be established in coordination with the enrollment and coverage periods for plans offered under an Exchange established under title I of the Patient Protection and Affordable Care Act and plans under parts C and D. If the Secretary determines appropriate, the Secretary may expand such enrollment periods beyond the enrollment periods under such an Exchange or under parts C and D. (3) Beginning of coverage and special enrollment periods The Secretary shall establish such periods so that coverage under this section shall first begin on January 1 of the first year beginning at least one year after the date of the enactment of this section and shall include special enrollment periods, in accordance with section 155.420 of title 45 of the Code of Federal Regulations, that are applicable to qualified health plans offered through an Exchange. (c) Premium (1) Amount of monthly premiums The Secretary shall (beginning for the first year that begins more than 1 year after the date of the enactment of this section), during September of the preceding year, determine a monthly premium for all individuals enrolled under this section. Such monthly premium shall be equal to 1/12 of the annual premium computed under paragraph (2)(B), which shall apply with respect to coverage provided under this section for any month in the succeeding year. (2) Annual premium (A) Combined per capita average for all Medicare benefits The Secretary shall estimate the average, annual per capita amount for benefits and administrative expenses that will be payable under parts A, B, and D (including, as applicable, under part C) in the year for all individuals enrolled under this section. (B) Annual premium The annual premium under this subsection for months in a year is equal to the average, annual per capita amount estimated under subparagraph (A) for the year. (3) Increased premium for certain part C and D plans Nothing in this section shall preclude an individual from choosing a Medicare Advantage plan or a prescription drug plan that requires the individual to pay an additional amount (because of supplemental benefits or because it is a more expensive plan). In such case the individual would be responsible for the increased monthly premium. (d) Payment of premiums (1) In general Premiums for enrollment under this section shall be paid to the Secretary at such times, and in such manner, as the Secretary determines appropriate. (2) Deposit into Medicare Buy-In trust Fund Amounts collected by the Secretary under this section shall be deposited in the Medicare Buy-In Trust Fund established under paragraph (3). (3) Medicare Buy-In 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 Medicare Buy-In Trust Fund (in this paragraph referred to as the Trust Fund ). The Trust Fund shall consist of such gifts and bequests as may be made as provided in section 201(i)(1) and such amounts as may be deposited in, or appropriated to, such fund as provided in this title. (B) Incorporation of Provisions Subsections (b) through (i) of section 1841 shall apply with respect to the Trust Fund and this title in the same manner as they apply with respect to the Federal Supplementary Medical Insurance Trust Fund and part B, respectively, except that in applying such section 1841, any reference in such section to this part shall be construed to be a reference to this section and any reference in section 1841(h) to section 1840(d) and in section 1841(i) to sections 1840(b)(1) and 1842(g) are deemed to be references to comparable authority exercised under this section. (e) Not eligible for Medicare cost-Sharing assistance An individual enrolled under this section shall not be treated as enrolled under any part of this title for purposes of obtaining medical assistance for Medicare cost-sharing or otherwise under title XIX. (f) Eligibility for financial assistance (1) In general Individuals enrolled in coverage under this section shall, from amounts transferred under paragraph (2), receive financial assistance for such coverage that is substantially similar to the assistance the individual would have received if the individual were enrolled in a qualified health plan through an Exchange. (2) Transfer of funds to medicare buy-in trust fund (A) In general The Secretary shall transfer to the Medicare Buy-In Trust Fund under subsection (d)(3) for each plan year the amount determined under paragraph (C) for such year. (B) Use of funds The amounts transferred to the Medicare Buy-In Trust Fund under subparagraph (A) shall only be used to reduce the premiums and cost-sharing for coverage under this section of individuals enrolled under such coverage who would be eligible for cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act and premium assistance under section 36B of the Internal Revenue Code of 1986 if such individual were enrolled in a qualified health plan. (C) Amount of transfer (i) In general The amount determined under this subparagraph for any plan year is the aggregate amount the Secretary determines is equal to 100 percent of the premium tax credits under section 36B of the Internal Revenue Code of 1986, and 100 percent of the cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act, that would have been provided for the plan year to eligible individuals who meet specified income criteria and are enrolled for such plan year in coverage provided through enrollment under this section if such individuals were enrolled for such year in a qualified health plan through an Exchange. (ii) Specific requirements The Secretary shall make the determination under clause (i) on a per enrollee basis and shall take into account all relevant factors necessary to determine the value of the premium tax credits and cost-sharing reductions that would have been provided to eligible individuals described in section 1331 of the Patient Protection and Affordable Care Act, including the age and income of the enrollee, geographic differences in average spending for health care across rating areas, the health status of the enrollee for purposes of determining risk adjustment payments and reinsurance payments that would have been made if the enrollee had enrolled in a qualified health plan through an Exchange, and whether any reconciliation of the credit or cost-sharing reductions would have occurred if the enrollee had been so enrolled. This determination shall take into consideration the experience of other States with respect to participation in an Exchange and such credits and reductions provided to residents of the other States, with a special focus on enrollees with income below 200 percent of poverty. (D) Certification (i) In general The Chief Actuary of the Centers for Medicare & Medicaid Services, in consultation with the Office of Tax Analysis of the Department of the Treasury, shall certify whether the methodology used to make determinations under subparagraph (C), and such determinations, meet the requirements of this paragraph. (ii) Corrections The Secretary shall adjust the payment to the Trust Fund for any plan year to reflect any error in the determinations under subparagraph (C) for any preceding plan year. (iii) Application Coverage provided through enrollment under this part and parts B and D pursuant to this section shall be treated as coverage under a qualified health plan in the silver level of coverage in the individual market offered through an Exchange and the Secretary shall be treated as the issuer of such plan. (g) Treatment in relation to the Affordable Care Act (1) 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. (2) Eligibility for premium assistance Coverage provided under this section— (A) shall be treated as coverage under a qualified health plan in the individual market enrolled in through the Exchange where the individual resides for all purposes of section 36B of the Internal Revenue Code of 1986 other than subsection (c)(2)(B) thereof; and (B) shall not be treated as eligibility for other minimum essential coverage for purposes of subsection (c)(2)(B) of such section 36B. The Secretary shall determine the applicable second lowest cost silver plan which shall apply to coverage under this section for purposes of determining the premium assistance amount under section 36B(b)(2) of such Code. Notwithstanding the preceding sentences, in determining the applicable second lowest cost silver plan with respect to any taxpayer under section 36B(b)(3)(B) of such Code, coverage provided under this section shall not be taken into account as a silver plan of the individual market. (3) Eligibility for cost-sharing reductions For purposes of applying section 1402 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18071 )— (A) coverage provided under this section shall be treated as coverage under a qualified health plan in the silver level of coverage in the individual market offered through an Exchange; and (B) the Secretary shall be treated as the issuer of such plan. (4) Medicaid managed care States are prohibited from buying their Medicaid beneficiaries ages 50 to 64 into Medicare under this section, and individuals otherwise eligible for enrollment under a State plan under title XIX are prohibited from coverage under this title pursuant to enrollment under this section. The preceding sentence shall not apply to Medicaid beneficiaries whose Medicaid coverage or eligibility does not meet the definition of minimum essential coverage under a government-sponsored program under section 1.5000A–2 of title 26, Code of Federal Regulations (or any successor regulation). (h) Guaranteed issue of Medigap policies upon first enrollment and each subsequent enrollment In the case of an individual who enrolls under this section (including an individual who was previously enrolled under this section), paragraphs (2)(A), (2)(D), (3)(B)(ii), and (3)(B)(vi) of section 1882(s)— (1) shall be applied by substituting 50 for 65 ; (2) if the individual was enrolled under this section and subsequently disenrolls, shall apply each time the individual subsequently reenrolls under this section as if the individual had attained 50 years of age on the date of such reenrollment (and as if the individual had never previously enrolled in a Medicare supplemental policy); and (3) shall be applied as if this section had not been enacted (and as if the individual had never previously enrolled in a Medicare supplemental policy) when the individual attains 65 years of age. (i) Oversight There is established an advisory committee to be known as the Medicare Buy In Oversight Board to monitor and oversee the implementation of this section, including the experience of the individuals enrolling under this section. The Medicare Buy In Oversight Board shall make periodic recommendations for the continual improvement of the implementation of this section as well as the relationship of enrollment under this section to other health care programs. (j) Outreach and enrollment (1) In general During the period that begins on January 1, 2019, and ends on December 31, 2021, the Secretary shall award grants to eligible entities for the following purposes: (A) Outreach and enrollment To carry out outreach, public education activities, and enrollment activities to raise awareness of the availability of, and encourage, enrollment under this section. (B) Assisting individuals' transition under this section To provide assistance to individuals to enroll under this section. (C) Raising awareness of premium assistance and cost-sharing reductions To distribute fair and impartial information concerning enrollment under this section and the availability of premium assistance tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act, and to assist eligible individuals in applying for such tax credits and cost-sharing reductions. (2) Eligible entities (A) In general In this subsection, the term eligible entity means— (i) a State; or (ii) a nonprofit community-based organization. (B) Enrollment agents Such term includes a licensed independent insurance agent or broker that has an arrangement with a State or nonprofit community-based organization to enroll eligible individuals under this section. (C) Exclusions Such term does not include an entity that— (i) is a health insurance issuer; or (ii) receives any consideration, either directly or indirectly, from any health insurance issuer in connection with the enrollment of any individuals under this section. (3) Priority In awarding grants under this subsection, the Secretary shall give priority to awarding grants to States or eligible entities in States that have geographic rating areas at risk of having no qualified health plans in the individual market. (4) Funding For purposes of carrying out this subsection, there is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $500,000,000 for calendar year 2019 and for each subsequent calendar year. (k) No effect on benefits for individuals otherwise eligible or on Trust funds The Secretary shall implement the provisions of this section in such a manner to ensure that such provisions— (1) have no effect on the benefits under this title for individuals who are entitled to, or enrolled for, such benefits other than through this section; and (2) have no negative impact on the Federal Hospital Insurance Trust Fund or the Federal Supplementary Medical Insurance Trust Fund (including the Medicare Prescription Drug Account within such Trust Fund). (l) 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. . 3. Authority to negotiate fair prices for Medicare prescription drugs (a) In general Section 1860D–11 of the Social Security Act ( 42 U.S.C. 1395w–111 ) is amended by striking subsection (i). (b) Effective date The amendment made by this section shall take effect on the date of the enactment of this Act.