I 118th CONGRESS 1st Session H. R. 5299 IN THE HOUSE OF REPRESENTATIVES August 29, 2023 Mr. Espaillat introduced the following bill; which was referred to the Committee on Ways and Means , and in addition to the Committee on Energy and Commerce , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to establish a demonstration program for international coverage under the Medicare program.

1. Short title This Act may be cited as the Earned Benefits Equality and Family Reunification Act . 2. Establishing a demonstration program for international coverage under the Medicare program Title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) is amended by inserting after section 1866F the following new section: 1866G. Demonstration program for international coverage (a) Implementation of 10-Year demonstration program Not later than 1 year after the date of the enactment of this section, the Secretary shall implement a 10-year demonstration program under this title (in this section referred to as the Program) to allow Applicable Beneficiaries to apply Medicare benefits to coverage of items and services, premiums, and other cost-sharing under the health insurance systems of other countries. Through the Program, the Secretary shall make payments under subsection (e) to or on behalf of Applicable Beneficiaries participating in the Program. (b) Program design (1) In general The Secretary shall design the Program in such a manner to allow for the evaluation of the extent to which the Program accomplishes the following purposes: (A) Increases the quality of care for Applicable Beneficiaries participating in the Program. (B) Decreases the cost of care to the government for the Applicable Beneficiaries. (C) Enables Applicable Beneficiaries to reunify with family members. (D) Reduced strain on the medical infrastructure of the United States. (2) Consultation In designing the Program, the Secretary shall use open door forums and other mechanisms to seek input from a consortium of stakeholders that may include but are not limited to— (A) the United States Department of State; (B) clinical and analytical experts with relevant expertise; (C) beneficiaries; and (D) foreign health insurance system experts. (3) Program considerations In consultation with stakeholders as identified in subsection (b)(2), the Secretary shall issue guidance on— (A) the guidelines to ensure the usage of medications and equipment that are of acceptable quality relative to American quality standards; (B) ways to ensuring quality of care; and (C) ways to target low-income Americans as participants in the program. (c) Selected countries initial selection In choosing Selected Countries for the Program, the Secretary shall initially select at least 11 distinct nations or political subdivisions thereof, which shall include Canada, the Federal Republic of Germany, the Republic of India, the State of Israel, the Republic of Korea, the Republic of the Philippines, the Republic of Panama, the United Mexican States, Dominican Republic, and at least one nation or political subdivision thereof in Africa. (d) Applicable beneficiary (1) Voluntary beneficiary participation An Applicable Beneficiary may participate in the Program on a voluntary basis and may terminate participation in the Program at any time. The election to participate in the Program or to terminate participation shall constitute a Special Election Period under section 1852(e)(4) of this title. (2) Services In order to participate in the Program, an Applicable Beneficiary shall agree to receive coverage of health care items and services in a Selected Country during such time as the Applicable Beneficiary is a resident of that country. (3) Beneficiary access to services Nothing in this section shall be construed as limiting an Applicable Beneficiary’s access to items and services covered under this title when furnished in the United States, and Applicable Beneficiaries shall not be required to relinquish access to such benefits as a condition of receiving services from a participant in the Program. (4) Number of applicable beneficiaries The Secretary may cap the number of Applicable Beneficiaries accepted into the Program, but at a number no smaller than 150,000. (e) Physician certification Participating physicians must be in good standing with accreditation institutions or licensing authorities in the Selected Countries. (f) Payments (1) In general The Secretary shall make payments to or on behalf of Applicable Beneficiaries for the costs of health care items and services paid by Applicable Beneficiaries in Selected Countries. Such payments may include payments for individual items or services paid by Applicable Beneficiaries, payments for cost sharing incurred by Applicable Beneficiaries, and premiums and equivalent charges for health insurance coverage paid by Applicable Beneficiaries. Payments shall not include reimbursement for taxes levied on income for the purpose of funding health care. (2) Payment amounts The Secretary shall limit the amounts of payment to ensure such payments and funds expended to design, implement, and evaluate the Program do not exceed in the aggregate the amount the Secretary would pay under this title for equivalent services delivered in the United States. (3) No duplicate payment The Secretary shall make or permit payments under this paragraph only for a calendar month in which the Applicable Beneficiary resides in the Selected Country and does not incur any costs under this title other than the payment hereunder. (g) Role of medicare advantage (1) In carrying out the Program, the Secretary may administer the Program, either in part or exclusively, through Medicare Advantage Organizations. (2) To the extent Medicare Advantage Organizations carry out functions under the Program, payments made by such organizations under subsection (e) shall be considered as if they were benefits under the original Medicare fee-for-service program option for purposes of sections 1852 and 1854 of this title, and a component of standard prescription drug coverage and not supplemental prescription drug coverage, under section 1860D2(a) of this title. (3) The Secretary may limit the number of Medicare Advantage Organizations participating in the Program, in accordance with criteria established by the Secretary. (h) Reporting The Secretary shall conduct annual intermediate and a final evaluation of the Program. Each such evaluation shall determine the extent to which each of the purposes described in subsection (b) have been accomplished under the Program. The evaluation shall contain recommendations to Congress with regards to the expansion of the Program. (i) Addressing waste, fraud, and abuse (1) Participating physicians are required to go through Fraud, Waste, and Abuse training within 90 days of implementation of the demonstration project and at least annually thereafter. (2) The Secretary must create a system to allow patients and physicians to report instances or concerns of waste, fraud, and abuse. (j) Definitions In this section: (1) Applicable beneficiary The term Applicable Beneficiary means an individual who— (A) is entitled to or enrolled for benefits under part A, and enrolled for benefits under part B; (B) may be enrolled in a Medicare Advantage plan under part C; (C) is either— (i) a resident of the United States at the time of application to the Program who intends to relocate to a Selected Country on or after the date of such application, or is a former resident of the United States who has relocated to a Selected Country within 180 days of application to the Program; or (ii) a resident of a Selected Country for whom the Medicare program is at the time of application the primary payor of their health care costs; and (D) meets such other criteria as the Secretary determines appropriate. (2) Selected country The term Selected Country means a nation or political subdivision thereof identified by the Secretary as having a health care system that provides for— (A) health care coverage in scope and quality of coverage appropriate for Medicare beneficiaries in accordance with criteria established by the Secretary; and (B) cost of coverage, coinsurance, and items and services that is equivalent to or less than expected costs for such coverage, coinsurance, and items and services in the United States under this title. (k) Funding (1) Administrative funding The Secretary shall allocate funds made available under section 1115A(f)(1) to design, implement, and evaluate the Program. (2) Benefit funding Payments for items and services under the Program shall be made in appropriate part from the Federal Hospital Insurance Trust Fund established by section 1817 of this title and the Federal Supplementary Medical Insurance Trust Fund established by section 1841 of this title. (l) Waivers The Secretary may waive any provision of this title as may be necessary to carry out the Program under this section. (m) Limitations on review There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of— (1) the selection of organizations, sites, or participants to test the Program; and (2) the elements, parameters, scope, and duration of the Program. The preceding sentence shall not prevent an Applicable Beneficiary, having been selected as a participant, from exercising a right to appeal under sections 1869, 1155, 1852(g), 1860D–4, or otherwise. (n) Administration (1) Chapter 35 of title 44, United States Code, shall not apply to the activities under this section. (2) The Secretary may enter into contracts for the administration of the Program without regard to any requirement for the use of competitive procedures. .