TAM17H14 S.L.C. 115TH CONGRESS 1ST SESSION S. ll To establish a Medicare-for-all national health insurance program. IN THE SENATE OF THE UNITED STATES llllllllll Mr. SANDERS (for himself, Ms. BALDWIN, Mr. BLUMENTHAL, Mr. BOOKER, Mr. FRANKEN, Mrs. GILLIBRAND, Ms. HARRIS, Mr. HEINRICH, Ms. HIRONO, Mr. LEAHY, Mr. MARKEY, Mr. MERKLEY, Mr. SCHATZ, Mr. UDALL, Ms. WARREN, and Mr. WHITEHOUSE) introduced the following bill; which was read twice and referred to the Committee on llllllllll A BILL To establish a Medicare-for-all national health insurance program. 1 Be it enacted by the Senate and House of Representa- 2 tives of the United States of America in Congress assembled, 3 4 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. (a) SHORT TITLE.—This Act may be cited as the 5 ‘‘Medicare for All Act of 2017’’. 6 (b) TABLE OF CONTENT.—The table of contents for 7 this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM; UNIVERSAL ENTITLEMENT; ENROLLMENT TAM17H14 S.L.C. 2 Sec. Sec. Sec. Sec. Sec. Sec. Sec. 101. 102. 103. 104. 105. 106. 107. Establishment of the Universal Medicare Program. Universal entitlement. Freedom of choice. Non-discrimination. Enrollment. Effective date of benefits. Prohibition against duplicating coverage. TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND BENEFITS FOR LONG-TERM CARE Sec. Sec. Sec. Sec. Sec. 201. 202. 203. 204. 205. Comprehensive benefits. No cost-sharing. Exclusions and limitations. Coverage of long-term care services under Medicaid. State standards. TITLE III—PROVIDER PARTICIPATION Sec. 301. Provider participation and standards. Sec. 302. Qualifications for providers. Sec. 303. Use of private contracts. TITLE IV—ADMINISTRATION Subtitle A—General Administration Provisions Sec. Sec. Sec. Sec. Sec. 401. 402. 403. 404. 405. Administration. Consultation. Regional administration. Beneficiary ombudsman. Complementary conduct of related health programs. Subtitle B—Control Over Fraud and Abuse Sec. 411. Application of Federal sanctions to all fraud and abuse under Universal Medicare 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 and individual providers. Sec. 612. Ensuring accurate valuation of services under the Medicare physician fee schedule. Sec. 613. Office of primary health care. Sec. 614. Payments for prescription drugs and approved devices and equipment. TAM17H14 S.L.C. 3 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 Universal Medicare Program; coordination in case of workers’ compensation. Sec. 802. Repeal 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. TITLE X—TRANSITION Subtitle A—Transitional Medicare Buy-in Option and Transitional Public Option Sec. 1001. Lowering the Medicare age. Sec. 1002. Establishment of the Medicare transition plan. Subtitle B—Transitional Medicare Reforms Sec. 1011. Medicare protection against high out-of-pocket expenditures for feefor-service benefits and elimination of parts A and B deductibles. Sec. 1012. Reduction in Medicare part D annual out-of-pocket threshold and elimination of cost-sharing above that threshold. Sec. 1013. Coverage of dental and vision services and hearing aids and examinations under Medicare part B. Sec. 1014. Eliminating the 24-month waiting period for Medicare coverage for individuals with disabilities. TITLE XI—MISCELLANEOUS Sec. 1101. Definitions. TAM17H14 S.L.C. 4 4 TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM; UNIVERSAL ENTITLEMENT; ENROLLMENT 5 SEC. 101. ESTABLISHMENT OF THE UNIVERSAL MEDICARE 1 2 3 6 7 PROGRAM. There is hereby established a national health insur- 8 ance program to provide comprehensive protection against 9 the costs of health care and health-related services, in ac10 cordance with the standards specified in, or established 11 under, this Act. 12 13 SEC. 102. UNIVERSAL ENTITLEMENT. (a) IN GENERAL.—Every individual who is a resident 14 of the United States is entitled to benefits for health care 15 services under this Act. The Secretary shall promulgate 16 a rule that provides criteria for determining residency for 17 eligibility purposes under this Act. 18 (b) TREATMENT OF OTHER INDIVIDUALS.—The Sec- 19 retary may make eligible for benefits for health care serv20 ices under this Act other individuals not described in sub21 section (a), and regulate the nature of eligibility of such 22 individuals, while inhibiting travel and immigration to the 23 United States for the sole purpose of obtaining health care 24 services. TAM17H14 S.L.C. 5 1 2 SEC. 103. FREEDOM OF CHOICE. Any individual entitled to benefits under this Act may 3 obtain health services from any institution, agency, or in4 dividual qualified to participate under this Act. 5 6 SEC. 104. NON-DISCRIMINATION. (a) IN GENERAL.—No person shall, on the basis of 7 race, color, national origin, age, disability, or sex, includ8 ing sex stereotyping, gender identity, sexual orientation, 9 and pregnancy and related medical conditions (including 10 termination of pregnancy), be excluded from participation 11 in, be denied the benefits of, or be subjected to discrimina12 tion by any participating provider as defined in section 13 301, or any entity conducting, administering, or funding 14 a health program or activity, including contracts of insur15 ance, pursuant to this Act. 16 17 (b) CLAIMS OF DISCRIMINATION.— (1) IN GENERAL.—The Secretary shall establish 18 a procedure for adjudication of administrative com- 19 plaints alleging a violation of subsection (a). 20 (2) JURISDICTION.—Any person aggrieved by a 21 violation of subsection (a) by a covered entity may 22 file suit in any district court of the United States 23 having jurisdiction of the parties. 24 (3) DAMAGES.—If the court finds a violation of 25 subsection (a), the court may grant compensatory 26 and punitive damages, declaratory relief, injunctive TAM17H14 S.L.C. 6 1 relief, attorneys’ fees and costs, or other relief as ap- 2 propriate. 3 4 SEC. 105. ENROLLMENT. (a) IN GENERAL.—The Secretary shall provide a 5 mechanism for the enrollment of individuals eligible for 6 benefits under this Act. The mechanism shall— 7 (1) include a process for the automatic enroll- 8 ment of individuals at the time of birth in the 9 United States and at the time of immigration into 10 the United States or other acquisition of qualified 11 resident status in the United States; 12 (2) provide for the enrollment, as of the date 13 described in section 106, of all individuals who are 14 eligible to be enrolled as of such date; and 15 (3) include a process for the enrollment of indi- 16 viduals made eligible for health care services under 17 section 102(b). 18 (b) ISSUANCE OF UNIVERSAL MEDICARE CARDS.— 19 In conjunction with an individual’s enrollment for benefits 20 under this Act, the Secretary shall provide for the issuance 21 of a Universal Medicare card that shall be used for pur22 poses of identification and processing of claims for bene23 fits under this program. The card shall not include an in24 dividual’s Social Security number. TAM17H14 S.L.C. 7 1 2 SEC. 106. EFFECTIVE DATE OF BENEFITS. (a) IN GENERAL.—Except as provided in subsection 3 (b), benefits shall first be available under this Act for 4 items and services furnished on January 1 of the fourth 5 calendar year that begins after the date of enactment of 6 this Act. 7 (b) COVERAGE FOR CHILDREN.— 8 (1) IN GENERAL.—For any eligible individual 9 who has not yet attained the age of 19, benefits 10 shall first be available under this Act for items and 11 services furnished on January 1 of the first calendar 12 year that begins after the date of enactment of this 13 Act. 14 (2) OPTION TO CONTINUE IN OTHER COVERAGE 15 DURING TRANSITION PERIOD.—Any 16 eligible to receive benefits as described in paragraph 17 (1) may opt to maintain any coverage described in 18 section 901, private health insurance coverage, or 19 coverage offered pursuant to subtitle A of title X 20 (including the amendments made by such subtitle) 21 until the effective date described in subsection (a). 22 SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. 23 (a) IN GENERAL.—Beginning on the effective date person who is 24 described in section 106(a), it shall be unlawful for— TAM17H14 S.L.C. 8 1 (1) a private health insurer to sell health insur- 2 ance coverage that duplicates the benefits provided 3 under this Act; or 4 (2) an employer to provide benefits for an em- 5 ployee, former employee, or the dependents of an 6 employee or former employee that duplicate the ben- 7 efits provided under this Act. 8 (b) CONSTRUCTION.—Nothing in this Act shall be 9 construed as prohibiting the sale of health insurance cov10 erage for any additional benefits not covered by this Act, 11 including additional benefits that an employer may provide 12 to employees or their dependents, or to former employees 13 or their dependents. 17 TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND BENEFITS FOR LONG-TERM CARE 18 SEC. 201. COMPREHENSIVE BENEFITS. 14 15 16 19 (a) IN GENERAL.—Subject to the other provisions of 20 this title and titles IV through IX, individuals enrolled for 21 benefits under this Act are entitled to have payment made 22 by the Secretary to an eligible provider for the following 23 items and services if medically necessary or appropriate 24 for the maintenance of health or for the diagnosis, treat25 ment, or rehabilitation of a health condition: TAM17H14 S.L.C. 9 1 (1) Hospital services, including inpatient and 2 outpatient hospital care, including 24-hour-a-day 3 emergency services and inpatient prescription drugs. 4 (2) Ambulatory patient services. 5 (3) Primary and preventive services, including 6 chronic disease management. 7 (4) Prescription drugs, medical devices, biologi- 8 cal products, including outpatient prescription drugs, 9 medical devices, and biological products. 10 11 (5) Mental health and substance abuse treatment services, including inpatient care. 12 (6) Laboratory and diagnostic services. 13 (7) Comprehensive reproductive, maternity, and 14 newborn care. 15 (8) Pediatrics. 16 (9) Oral health, audiology, and vision services. 17 (10) Short-term rehabilitative and habilitative 18 services and devices. 19 (b) REVISION AND ADJUSTMENT.—The Secretary 20 shall, on a regular basis, evaluate whether the benefits 21 package should be improved or adjusted to promote the 22 health of beneficiaries, account for changes in medical 23 practice or new information from medical research, or re24 spond to other relevant developments in health science, TAM17H14 S.L.C. 10 1 and shall make recommendations to Congress regarding 2 any such improvements or adjustments. 3 4 5 (c) COMPLEMENTARY AND INTEGRATIVE MEDI- CINE.— (1) IN GENERAL.—In carrying out subsection 6 (b), the Secretary shall consult with the persons de- 7 scribed in paragraph (1) with respect to— 8 (A) identifying specific complementary and 9 integrative medicine practices that, on the basis 10 of research findings or promising clinical inter- 11 ventions, are appropriate to include in the bene- 12 fits package 13 (B) identifying barriers to the effective 14 provision and integration of such practices into 15 the delivery of health care, and identifying 16 mechanisms for overcoming such barriers. 17 (2) CONSULTATION.—In accordance with para- 18 19 20 graph (1), the Secretary shall consult with— (A) the Director of the National Center for Complementary and Integrative Health; 21 (B) the Commissioner of Food and Drugs. 22 (C) institutions of higher education, pri- 23 vate research institutes, and individual re- 24 searchers with extensive experience in com- 25 plementary and alternative medicine and the in- TAM17H14 S.L.C. 11 1 tegration of such practices into the delivery of 2 health care; 3 (D) nationally recognized providers of com- 4 plementary and integrative medicine; and 5 (E) such other officials, entities, and indi- 6 viduals with expertise on complementary and 7 integrative medicine as the Secretary deter- 8 mines appropriate. 9 10 (d) STATES MAY PROVIDE ADDITIONAL BENEFITS.—Individual States may provide additional benefits 11 for the residents of such States at the expense of the 12 State. 13 14 SEC. 202. NO COST-SHARING. (a) IN GENERAL.—The Secretary shall ensure that 15 no cost-sharing, including deductibles, coinsurance, copay16 ments, or similar charges, be imposed on an individual for 17 any benefits provided under this Act, except as described 18 in subsection (b). 19 (b) EXCEPTIONS.—The Secretary may— 20 (1) impose cost-sharing with respect to services 21 provided under section 1946 of the Social Security 22 Act, as added by section 204; and 23 24 25 (2) set a cost-sharing schedule for prescription drugs and biological products— (A) provided that— TAM17H14 S.L.C. 12 1 (i) such schedule is evidence-based 2 and encourages the use of generic drugs; 3 (ii) such cost-sharing does not apply 4 to preventive drugs; and 5 (iii) such cost-sharing does not exceed 6 $200 annually per individual, adjusted an- 7 nually for inflation; and 8 (B) under which the Secretary may exempt 9 brand-name drugs from consideration in deter- 10 mining whether an individual has reached any 11 out-of-pocket limit if a generic version of such 12 drug is available. 13 (c) NO BALANCE BILLING.—Notwithstanding con- 14 tracts in accordance with section 303, no provider may 15 impose a charge to an enrolled individual for covered serv16 ices for which benefits are provided under this Act. 17 18 SEC. 203. EXCLUSIONS AND LIMITATIONS. (a) IN GENERAL.—Benefits for services are not avail- 19 able under this Act unless the services meet the standards 20 specified in section 201(a), as defined by the Secretary. 21 (b) TREATMENT OF EXPERIMENTAL SERVICES AND 22 DRUGS.— 23 (1) IN GENERAL.—In applying subsection (a), 24 the Secretary shall make national coverage deter- 25 minations with respect to services that are experi- TAM17H14 S.L.C. 13 1 mental in nature. Such determinations shall be con- 2 sistent with the national coverage determination 3 process as defined in section 1869(f)(1)(B) of the 4 Social Security Act (42 U.S.C. 1395ff(f)(1)(B)). 5 (2) APPEALS PROCESS.—The Secretary shall 6 establish a process by which individuals can appeal 7 coverage decisions. The process shall, as much as is 8 feasible, follow process for appeals under the Medi- 9 care program described in section 1869 of the Social 10 Security Act (42 U.S.C. 1395ff). 11 (c) APPLICATION OF PRACTICE GUIDELINES.—In the 12 case of services for which the Department of Health and 13 Human Services has recognized a national practice guide14 line, the services are considered to meet the standards 15 specified in section 201(a) if they have been provided in 16 accordance with such guideline. For purposes of this sub17 section, a service shall be considered to have been provided 18 in accordance with a practice guideline if the health care 19 provider providing the service exercised appropriate pro20 fessional discretion to deviate from the guideline in a man21 ner authorized or anticipated by the guideline. TAM17H14 S.L.C. 14 1 SEC. 204. COVERAGE OF LONG-TERM CARE SERVICES 2 3 UNDER MEDICAID. Title XIX of the Social Security Act (42 U.S.C. 1396 4 et seq.) is amended by inserting the following section after 5 section 1946: 6 ‘‘STATE PLAN FOR PROVIDING LONG-TERM CARE 7 8 SERVICES ‘‘SEC. 1947. (a) IN GENERAL.—For quarters begin- 9 ning on or after the effective date of benefits under section 10 106(a) of the Medicare for All Act of 2017, notwith11 standing any other provision of this title— 12 ‘‘(1) a State plan for medical assistance shall 13 provide for making medical assistance available for 14 services that are long-term care services (as defined 15 in subsection (b)) in a manner consistent with this 16 section; and 17 ‘‘(2) no payment to a State shall be made 18 under this title with respect to expenditures incurred 19 by the State in providing medical assistance after 20 such date for services that are not long-term care 21 services. 22 ‘‘(b) LONG-TERM CARE SERVICES DEFINED.—In this 23 section, the term ‘long-term care services’ means the fol24 lowing: TAM17H14 S.L.C. 15 1 ‘‘(1) Nursing facility services for individuals 21 2 years of age or over described in subparagraph (A) 3 of section 1905(a)(4). 4 5 6 7 8 9 ‘‘(2) Home health services described in section 1905(a)(7). ‘‘(3) Nursing services described in section 1905(a)(8). ‘‘(4) Rehabilitative services described in section 1905(a)(13). 10 ‘‘(5) Inpatient services for individuals 65 years 11 of age or over provided in an institution for mental 12 disease described in section 1905(a)(14). 13 14 ‘‘(6) Intermediate care facility services described in section 1905(a)(15). 15 ‘‘(7) Inpatient psychiatric hospital services for 16 individuals under age 21 described in section 17 1905(a)(16). 18 19 20 21 22 23 ‘‘(8) Case management services described in section 1905(a)(19). ‘‘(9) Personal care services described in section 1905(a)(24). ‘‘(10) Nursing facility services described in section 1905(a)(29). TAM17H14 S.L.C. 16 1 ‘‘(11) Home and community-based services pro- 2 vided under a State plan amendment under section 3 1915(i). 4 5 ‘‘(12) Payment for self-directed personal assistance services provided under section 1915(j). 6 ‘‘(13) Home and community-based attendant 7 services and supports provided under a State plan 8 amendment under section 1915(k). 9 ‘‘(c) MAINTENANCE OF EFFORT.— 10 ‘‘(1) ELIGIBILITY 11 ‘‘(A) IN STANDARDS.— GENERAL.—Beginning on the date 12 described in subsection (a), no payment may be 13 made under section 1903 with respect to med- 14 ical assistance provided under a State plan for 15 medical assistance if the State adopts income 16 and resource standards and methodologies for 17 purposes of determining an individual’s eligi- 18 bility for medical assistance under the State 19 plan that are more restrictive than those ap- 20 plied as of May 5, 2017. 21 ‘‘(B) INDEXING OF AMOUNTS OF INCOME 22 AND RESOURCE STANDARDS.—In 23 whether a State has adopted income or resource 24 standards that are more restrictive than the 25 standards which applied as of May 5, 2017, the determining TAM17H14 S.L.C. 17 1 Secretary shall deem the amount of any such 2 standard that was applied as of such date to be 3 increased by the percentage increase in the 4 medical care component of the consumer price 5 index for all urban consumers (U.S. city aver- 6 age) from September of 2017 to September of 7 the fiscal year for which the Secretary is mak- 8 ing such determination. 9 ‘‘(2) EXPENDITURES.— 10 ‘‘(A) IN GENERAL.—For each fiscal year 11 or portion of a fiscal year that occurs during 12 the period that begins on the first day of the 13 first fiscal quarter that begins on or after the 14 effective date of benefits under section 106(a) 15 of the Medicare for All Act of 2017, as a condi- 16 tion of receiving payments under section 17 1903(a), a State shall make expenditures for 18 medical assistance for services that are long- 19 term care services in an amount that is not less 20 than the expenditure floor determined for the 21 State and fiscal year (or portion of a fiscal 22 year) under subparagraph (B). 23 ‘‘(B) EXPENDITURE 24 25 ‘‘(i) IN FLOOR.— GENERAL.—For each fiscal year or portion of a fiscal year described in TAM17H14 S.L.C. 18 1 subparagraph (A), the Secretary shall de- 2 termine for each State an expenditure floor 3 that shall be equal to— 4 ‘‘(I) the amount of the State’s 5 expenditures for fiscal year 2017 on 6 medical assistance for long-term care 7 services; increased by 8 9 10 ‘‘(II) the growth factor determined under subclause (ii). ‘‘(ii) GROWTH FACTOR.—For each fis- 11 cal year or portion of a fiscal year de- 12 scribed in subparagraph (A), the Secretary 13 shall, not later than September 1 of the 14 fiscal year preceding such fiscal year or 15 portion of a fiscal year, determine a 16 growth factor for each State that takes 17 into account— 18 19 ‘‘(I) the percentage increase in health care costs in the State; 20 ‘‘(II) the total amount expended 21 by the State for the previous fiscal 22 year on medical assistance for long- 23 term care services; 24 ‘‘(III) the increase, if any, in the 25 total population of the State from TAM17H14 S.L.C. 19 1 July of 2017 to July of the fiscal year 2 preceding the fiscal year involved; and 3 ‘‘(IV) the increase, if any, in the 4 population of individuals aged 65 and 5 older of the State from July of 2017 6 to July of the fiscal year preceding 7 the fiscal year involved. 8 ‘‘(iii) PRORATION RULE.—Any 9 amount determined under this subpara- 10 graph for a portion of a fiscal year shall be 11 prorated based on the length of such por- 12 tion of a fiscal year relative to a complete 13 fiscal year. 14 15 ‘‘(d) NONAPPLICATION MENTS.—Beginning OF CERTAIN REQUIRE- on the date described in subsection 16 (a), any provision of this title requiring a State plan for 17 medical assistance to make available medical assistance 18 for services that are not long-term care services or services 19 described in section 901(a)(3)(A)(ii) of the Medicare for 20 All Act of 2017 shall have no effect.’’. 21 22 SEC. 205. STATE STANDARDS. (a) IN GENERAL.—Nothing in this Act shall prohibit 23 individual States from setting additional standards, with 24 respect to eligibility, benefits, and minimum provider 25 standards, consistent with the purposes of this Act, pro- TAM17H14 S.L.C. 20 1 vided that such standards do not restrict eligibility or re2 duce access to benefits or services. 3 (b) RESTRICTIONS ON PROVIDERS.—With respect to 4 any individuals or entities certified to provide services cov5 ered under section 201(a)(7), a State may not prohibit 6 an individual or entity from participating in the program 7 under this Act, for reasons other than the ability of the 8 individual or entity to provide such services. TITLE III—PROVIDER PARTICIPATION 9 10 11 12 SEC. 301. PROVIDER PARTICIPATION AND STANDARDS. (a) IN GENERAL.—An individual or other entity fur- 13 nishing any covered service under this Act is not a quali14 fied provider unless the individual or entity— 15 16 (1) is a qualified provider of the services under section 302; 17 18 (2) has filed with the Secretary a participation agreement described in subsection (b); and 19 (3) meets, as applicable, such other qualifica- 20 tions and conditions with respect to a provider of 21 services under title XVIII of the Social Security Act 22 as described in section 1866 of the Social Security 23 Act (42 U.S.C. 1395cc). 24 (b) REQUIREMENTS 25 MENT.— IN PARTICIPATION AGREE- TAM17H14 S.L.C. 21 1 (1) IN GENERAL.—A participation agreement 2 described in this subsection between the Secretary 3 and a provider shall provide at least for the fol- 4 lowing: 5 (A) Services to eligible persons will be fur- 6 nished by the provider without discrimination, 7 in accordance with section 104(a). Nothing in 8 this subparagraph shall be construed as requir- 9 ing the provision of a type or class of services 10 that are outside the scope of the provider’s nor- 11 mal practice. 12 (B) No charge will be made to any enrolled 13 individual for any covered services other than 14 for payment authorized by this Act. 15 (C) The provider agrees to furnish such in- 16 formation as may be reasonably required by the 17 Secretary, in accordance with uniform reporting 18 standards established under section 401(b)(1), 19 for— 20 21 (i) quality review by designated entities; 22 (ii) making payments under this Act, 23 including the examination of records as 24 may be necessary for the verification of in- TAM17H14 S.L.C. 22 1 formation on which such payments are 2 based; 3 (iii) statistical or other studies re- 4 quired for the implementation of this Act; 5 and 6 (iv) such other purposes as the Sec- 7 retary may specify. 8 (D) In the case of a provider that is not 9 an individual, the provider agrees not to employ 10 or use for the provision of health services any 11 individual or other provider that has had a par- 12 ticipation agreement under this subsection ter- 13 minated for cause. 14 (E) In the case of a provider paid under 15 a fee-for-service basis, the provider agrees to 16 submit bills and any required supporting docu- 17 mentation relating to the provision of covered 18 services within 30 days after the date of pro- 19 viding such services. 20 (2) TERMINATION 21 22 OF PARTICIPATION AGREE- MENT.— (A) IN GENERAL.—Participation agree- 23 ments may be terminated, with appropriate no- 24 tice— TAM17H14 S.L.C. 23 1 2 3 4 (i) by the Secretary for failure to meet the requirements of this Act; or (ii) by a provider. (B) TERMINATION PROCESS.—Providers 5 shall be provided notice and a reasonable oppor- 6 tunity to correct deficiencies before the Sec- 7 retary terminates an agreement unless a more 8 immediate termination is required for public 9 safety or similar reasons. 10 (C) PROVIDER PROTECTIONS.— 11 (i) PROHIBITION.—The Secretary may 12 not terminate a participation agreement or 13 in any other way discriminate against, or 14 cause to be discriminated against, any cov- 15 ered provider or authorized representative 16 of the provider, on account of such pro- 17 vider or representative— 18 (I) providing, causing to be pro- 19 vided, or being about to provide or 20 cause to be provided to the provider, 21 the Federal Government, or the attor- 22 ney general of a State information re- 23 lating to any violation of, or any act 24 or omission the provider or represent- 25 ative reasonably believes to be a viola- TAM17H14 S.L.C. 24 1 tion of, any provision of this title (or 2 an amendment made by this title); 3 (II) testifying or being about to 4 testify in a proceeding concerning 5 such violation; 6 (III) assisting or participating, or 7 being about to assist or participate, in 8 such a proceeding; or 9 (IV) objecting to, or refusing to 10 participate in, any activity, policy, 11 practice, or assigned task that the 12 provider or representative reasonably 13 believes to be in violation of any provi- 14 sion of this Act (including any amend- 15 ment made by this Act), or any order, 16 rule, regulation, standard, or ban 17 under this Act (including any amend- 18 ment made by this Act). 19 (ii) COMPLAINT PROCEDURE.—A pro- 20 vider or representative who believes that he 21 or she has been discriminated against in 22 violation of this section may seek relief in 23 accordance with the procedures, notifica- 24 tions, burdens of proof, remedies, and stat- TAM17H14 S.L.C. 25 1 utes of limitation set forth in section 2 2087(b) of title 15, United States Code. 3 4 SEC. 302. QUALIFICATIONS FOR PROVIDERS. (a) IN GENERAL.—A health care provider is consid- 5 ered to be qualified to provide covered services if the pro6 vider is licensed or certified and meets— 7 8 9 (1) all the requirements of State law to provide such services; and (2) applicable requirements of Federal law to 10 provide such services. 11 (b) MINIMUM PROVIDER STANDARDS.— 12 (1) IN GENERAL.—The Secretary shall estab- 13 lish, evaluate, and update national minimum stand- 14 ards to ensure the quality of services provided under 15 this Act and to monitor efforts by States to ensure 16 the quality of such services. A State may also estab- 17 lish additional minimum standards which providers 18 shall meet with respect to services provided in such 19 State. 20 (2) NATIONAL MINIMUM STANDARDS.—The na- 21 tional minimum standards under paragraph (1) shall 22 be established for institutional providers of services 23 and individual health care practitioners. Except as 24 the Secretary may specify in order to carry out this 25 Act, a hospital, skilled nursing facility, or other in- TAM17H14 S.L.C. 26 1 stitutional provider of services shall meet standards 2 for such a provider under the Medicare program 3 under title XVIII of the Social Security Act (42 4 U.S.C. 1395 et seq.). Such standards also may in- 5 clude, where appropriate, elements relating to— 6 (A) adequacy and quality of facilities; 7 (B) training and competence of personnel 8 9 (including continuing education requirements); (C) comprehensiveness of service; 10 (D) continuity of service; 11 (E) patient satisfaction, including waiting 12 time and access to services; and 13 (F) performance standards, including orga- 14 nization, facilities, structure of services, effi- 15 ciency of operation, and outcome in palliation, 16 improvement of health, stabilization, cure, or 17 rehabilitation. 18 (3) TRANSITION IN APPLICATION.—If the Sec- 19 retary provides for additional requirements for pro- 20 viders under this subsection, any such additional re- 21 quirement shall be implemented in a manner that 22 provides for a reasonable period during which a pre- 23 viously qualified provider is permitted to meet such 24 an additional requirement. TAM17H14 S.L.C. 27 1 (4) ABILITY TO PROVIDE SERVICES.—With re- 2 spect to any entity or provider certified to provide 3 services described in section 201(a)(7), the Secretary 4 may not prohibit such entity or provider from par- 5 ticipating for reasons other than its ability to pro- 6 vide such services. 7 (c) FEDERAL PROVIDERS.—Any provider qualified to 8 provide health care services through the Department of 9 Veterans Affairs or Indian Health Service is a qualifying 10 provider under this section with respect to any individual 11 who qualifies for such services under applicable Federal 12 law. 13 14 SEC. 303. USE OF PRIVATE CONTRACTS. (a) IN GENERAL.—Subject to the provisions of this 15 subsection, nothing in this Act shall prohibit an institu16 tional or individual provider from entering into a private 17 contract with an enrolled individual for any item or serv18 ice— 19 20 21 22 23 (1) for which no claim for payment is to be submitted under this Act, and (2) for which the provider receives— (A) no reimbursement under this Act directly or on a capitated basis, and 24 (B) receives no amount for such item or 25 service from an organization which receives re- TAM17H14 S.L.C. 28 1 imbursement for such items or service under 2 this Act directly or on a capitated basis. 3 4 5 (b) BENEFICIARY PROTECTIONS.— (1) IN GENERAL.—Subsection (a) shall not apply to any contract unless— 6 (A) the contract is in writing and is signed 7 by the beneficiary before any item or service is 8 provided pursuant to the contract; 9 10 (B) the contract contains the items described in paragraph (2); and 11 (C) the contract is not entered into at a 12 time when the beneficiary is facing an emer- 13 gency health care situation. 14 (2) ITEMS REQUIRED TO BE INCLUDED IN CON- 15 TRACT.—Any 16 to which subsection (a) applies shall clearly indicate 17 to the beneficiary that by signing such contract the 18 beneficiary— contract to provide items and services 19 (A) agrees not to submit a claim (or to re- 20 quest that the provider submit a claim) under 21 this Act for such items or services even if such 22 items or services are otherwise covered by this 23 Act; 24 (B) agrees to be responsible, whether 25 through insurance offered under section 107(b) TAM17H14 S.L.C. 29 1 or otherwise, for payment of such items or serv- 2 ices and understands that no reimbursement 3 will be provided under this Act for such items 4 or services; 5 (C) acknowledges that no limits under this 6 Act apply to amounts that may be charged for 7 such items or services; 8 (D) if the provider is a non-participating 9 provider, acknowledges that the beneficiary has 10 the right to have such items or services pro- 11 vided by other providers for whom payment 12 would be made under this Act; and 13 (E) acknowledges that the provider is pro- 14 viding services outside the scope of the program 15 under this Act. 16 17 (c) PROVIDER REQUIREMENTS.— (1) IN GENERAL.—Subsection (a) shall not 18 apply to any contract unless an affidavit described 19 in paragraph (2) is in effect during the period any 20 item or service is to be provided pursuant to the 21 contract. 22 23 24 25 (2) AFFIDAVIT.—An affidavit is described in this subparagraph shall— (A) identify the practitioner, and be signed by such practitioner; TAM17H14 S.L.C. 30 1 (B) provide that the practitioner will not 2 submit any claim under this title for any item 3 or service provided to any beneficiary (and will 4 not receive any reimbursement or amount de- 5 scribed in paragraph (1)(B) for any such item 6 or service) during the 1–year period beginning 7 on the date the affidavit is signed; and 8 (C) be filed with the Secretary no later 9 than 10 days after the first contract to which 10 such affidavit applies is entered into. 11 (3) ENFORCEMENT.—If a physician or practi- 12 tioner signing an affidavit described in paragraph 13 (2) knowingly and willfully submits a claim under 14 this title for any item or service provided during the 15 1-year period described in paragraph (2)(B) (or re- 16 ceives any reimbursement or amount described in 17 subsection (a)(2) for any such item or service) with 18 respect to such affidavit— 19 (A) this subsection shall not apply with re- 20 spect to any items and services provided by the 21 physician or practitioner pursuant to any con- 22 tract on and after the date of such submission 23 and before the end of such period; and 24 (B) no payment shall be made under this 25 title for any item or service furnished by the TAM17H14 S.L.C. 31 1 physician or practitioner during the period de- 2 scribed in clause (i) (and no reimbursement or 3 payment of any amount described in subsection 4 (a)(2) shall be made for any such item or serv- 5 ice). 6 7 8 9 10 11 TITLE IV—ADMINISTRATION Subtitle A—General Administration Provisions SEC. 401. ADMINISTRATION. (a) GENERAL DUTIES OF THE SECRETARY.— (1) IN GENERAL.—The Secretary shall develop 12 policies, procedures, guidelines, and requirements to 13 carry out this Act, including related to— 14 (A) eligibility for benefits; 15 (B) enrollment; 16 (C) benefits provided; 17 (D) provider participation standards and 18 qualifications, as described in title III; 19 (E) levels of funding; 20 (F) methods for determining amounts of 21 payments to providers of covered services, con- 22 sistent with subtitle B; 23 (G) the determination of medical necessity 24 and appropriateness with respect to coverage of 25 certain services; TAM17H14 S.L.C. 32 1 (H) planning for capital expenditures and 2 service delivery; 3 (I) planning for health professional edu- 4 cation funding; 5 (J) encouraging States to develop regional 6 planning mechanisms; and 7 (K) any other regulations necessary to 8 carry out the purpose of this Act. 9 (2) REGULATIONS.—Regulations authorized by 10 this Act shall be issued by the Secretary in accord- 11 ance with section 553 of title 5, United States Code. 12 (b) UNIFORM REPORTING STANDARDS; ANNUAL RE- 13 14 15 PORT; STUDIES.— (1) UNIFORM (A) IN REPORTING STANDARDS.— GENERAL.—The Secretary shall es- 16 tablish uniform State reporting requirements 17 and national standards to ensure an adequate 18 national database containing information per- 19 taining to health services practitioners, ap- 20 proved providers, the costs of facilities and 21 practitioners providing such services, the qual- 22 ity of such services, the outcomes of such serv- 23 ices, and the equity of health among population 24 groups. Such standards shall include, to the 25 maximum extent feasible without compromising TAM17H14 S.L.C. 33 1 patient privacy, health outcome measures, and 2 to the maximum extent feasible without exces- 3 sively burdening providers, the measures de- 4 scribed in subparagraphs (D) through (F) of 5 subsection (a)(1). 6 (B) REPORTS.—The Secretary shall regu- 7 larly analyze information reported to it and 8 shall define rules and procedures to allow re- 9 searchers, scholars, health care providers, and 10 others to access and analyze data for purposes 11 consistent with quality and outcomes research, 12 without compromising patient privacy. 13 (2) ANNUAL REPORT.—Beginning January 1 of 14 the second year beginning after the effective date of 15 this Act, the Secretary shall annually report to Con- 16 gress on the following: 17 18 (A) The status of implementation of the Act. 19 (B) Enrollment under this Act. 20 (C) Benefits under this Act. 21 (D) Expenditures and financing under this 22 23 24 25 Act. (E) Cost-containment achievements under this Act. (F) Quality assurance. measures and TAM17H14 S.L.C. 34 1 (G) Health care utilization patterns, in- 2 cluding any changes attributable to the pro- 3 gram. 4 5 (H) Changes in the per-capita costs of health care. 6 (I) Differences in the health status of the 7 populations of the different States, including in- 8 come and racial characteristics, and other popu- 9 lation health inequities. 10 (J) Progress on quality and outcome meas- 11 ures, and long-range plans and goals for 12 achievements in such areas. 13 14 (K) Necessary changes in the education of health personnel. 15 16 (L) Plans for improving service to medically underserved populations. 17 18 (M) Transition problems as a result of implementation of this Act. 19 (N) Opportunities for improvements under 20 this Act. 21 (3) STATISTICAL 22 IES.—The 23 tract— ANALYSES AND OTHER STUD- Secretary may, either directly or by con- TAM17H14 S.L.C. 35 1 (A) make statistical and other studies, on 2 a nationwide, regional, State, or local basis, of 3 any aspect of the operation of this Act; 4 (B) develop and test methods of payment 5 or delivery as it may consider necessary or 6 promising for the evaluation, or for the im- 7 provement, of the operation of this Act; and 8 (C) develop methodological standards for 9 10 evidence-based policymaking. (c) AUDITS.— 11 (1) IN GENERAL.—The Comptroller General of 12 the United States shall conduct an audit of the 13 Board every fifth fiscal year following the effective 14 date of this Act to determine the effectiveness of the 15 program in carrying out the duties under subsection 16 (a). 17 (2) REPORTS.—The Comptroller General of the 18 United States shall submit a report to Congress con- 19 cerning the results of each audit conducted under 20 this subsection. 21 SEC. 402. CONSULTATION. 22 The Secretary shall consult with Federal agencies, 23 Indian tribes and urban Indian health organizations, and 24 private entities, such as professional societies, national as25 sociations, nationally recognized associations of experts, TAM17H14 S.L.C. 36 1 medical schools and academic health centers, consumer 2 groups, and labor and business organizations in the for3 mulation of guidelines, regulations, policy initiatives, and 4 information gathering to ensure the broadest and most in5 formed input in the administration of this Act. Nothing 6 in this Act shall prevent the Secretary from adopting 7 guidelines developed by such a private entity if, in the Sec8 retary’s judgment, such guidelines are generally accepted 9 as reasonable and prudent and consistent with this Act. 10 11 SEC. 403. REGIONAL ADMINISTRATION. (a) COORDINATION WITH REGIONAL OFFICES.—The 12 Secretary shall establish and maintain regional offices to 13 promote adequate access to, and efficient use of, tertiary 14 care facilities, equipment, and services. Wherever possible, 15 the Secretary shall incorporate regional offices of the Cen16 ters for Medicare & Medicaid Services for this purpose. 17 18 19 20 21 22 23 24 (b) APPOINTMENT TORS.—In OF REGIONAL AND STATE DIREC- each such regional office there shall be— (1) one regional director appointed by the Secretary; (2) for each State in the region, a deputy director; and (3) one deputy director to represent the Native American and Alaska Native tribes in the region. TAM17H14 S.L.C. 37 1 (c) REGIONAL OFFICE DUTIES.—Regional offices 2 shall be responsible for— 3 (1) providing an annual State health care needs 4 assessment report to the Secretary, after a thorough 5 examination of health needs, in consultation with 6 public health officials, clinicians, patients, and pa- 7 tient advocates; 8 (2) recommending changes in provider reim- 9 bursement or payment for delivery of health services 10 in the States within the region; and 11 (3) establishing a quality assurance mechanism 12 in the State in order to minimize both under-utiliza- 13 tion and over-utilization and to ensure that all pro- 14 viders meet high quality standards. 15 SEC. 404. BENEFICIARY OMBUDSMAN. 16 (a) IN GENERAL.—The Secretary shall appoint a 17 Beneficiary Ombudsman who shall have expertise and ex18 perience in the fields of health care and education of, and 19 assistance to, individuals entitled to benefits under this 20 Act. 21 (b) DUTIES.—The Beneficiary Ombudsman shall— 22 (1) receive complaints, grievances, and requests 23 for information submitted by individuals entitled to 24 benefits under this Act with respect to any aspect of 25 the Universal Medicare Program; TAM17H14 S.L.C. 38 1 (2) provide assistance with respect to com- 2 plaints, grievances, and requests referred to in sub- 3 paragraph (a), including— 4 (A) assistance in collecting relevant infor- 5 mation for such individuals, to seek an appeal 6 of a decision or determination made by a re- 7 gional office or the Secretary; and 8 (B) assistance to such individuals in pre- 9 senting information under relating to cost-shar- 10 ing; and 11 (3) submit annual reports to Congress and the 12 Secretary that describe the activities of the Office 13 and that include such recommendations for improve- 14 ment in the administration of this Act as the Om- 15 budsman determines appropriate. The Ombudsman 16 shall not serve as an advocate for any increases in 17 payments or new coverage of services, but may iden- 18 tify issues and problems in payment or coverage 19 policies. 20 21 22 SEC. 405. COMPLEMENTARY CONDUCT OF RELATED HEALTH PROGRAMS. In performing functions with respect to health per- 23 sonnel education and training, health research, environ24 mental health, disability insurance, vocational rehabilita25 tion, the regulation of food and drugs, and all other mat- TAM17H14 S.L.C. 39 1 ters pertaining to health, the Secretary shall direct the ac2 tivities of the Department of Health and Human Services 3 toward contributions to the health of the people com4 plementary to this Act. 6 Subtitle B—Control Over Fraud and Abuse 7 SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL 8 FRAUD AND ABUSE UNDER UNIVERSAL MEDI- 9 CARE PROGRAM. 5 10 The following sections of the Social Security Act shall 11 apply to this Act in the same manner as they apply to 12 State medical assistance plans under title XIX of such 13 Act: 14 15 (1) Section 1128 (relating to exclusion of individuals and entities). 16 (2) Section 1128A (civil monetary penalties). 17 (3) Section 1128B (criminal penalties). 18 (4) Section 1124 (relating to disclosure of own- 19 20 21 22 23 24 ership and related information). (5) Section 1126 (relating to disclosure of certain owners). TITLE V—QUALITY ASSESSMENT SEC. 501. QUALITY STANDARDS. (a) IN GENERAL.—All standards and quality meas- 25 ures under this Act shall be performed by the Center for TAM17H14 S.L.C. 40 1 Clinical Standards and Quality of the Centers for Medi2 care & Medicaid Services (referred to in this title as the 3 ‘‘Center’’), in coordination with the Agency for Healthcare 4 Research and Quality and other offices of the Department 5 of Health and Human Services. 6 (b) DUTIES CENTER.—The Center shall per- OF THE 7 form the following duties: 8 (1) PRACTICE GUIDELINES.—The Center shall 9 review and evaluate each practice guideline devel- 10 oped under part B of title IX of the Public Health 11 Service Act. The Center shall determine whether the 12 guideline should be recognized as a national practice 13 guideline. 14 (2) STANDARDS OF QUALITY, PERFORMANCE 15 MEASURES, AND MEDICAL REVIEW CRITERIA.—The 16 Center shall review and evaluate each standard of 17 quality, performance measure, and medical review 18 criterion developed under part B of title IX of the 19 Public Health Service Act (42 U.S.C. 299 et seq.). 20 The Center shall determine whether the standard, 21 measure, or criterion is appropriate for use in as- 22 sessing or reviewing the quality of services provided 23 by health care institutions or health care profes- 24 sionals. In evaluating such standards, the Center 25 shall consider the evidentiary basis for the standard, TAM17H14 S.L.C. 41 1 and the validity, reliability, and feasibility of meas- 2 uring the standard. 3 (3) PROFILING OF PATTERNS OF PRACTICE; 4 IDENTIFICATION OF OUTLIERS.—The 5 adopt methodologies for profiling the patterns of 6 practice of health care professionals and for identi- 7 fying and notifying outliers. 8 (4) CRITERIA 9 QUALITY REVIEWS.—The FOR ENTITIES Center shall CONDUCTING Center shall develop min- 10 imum criteria for competence for entities that can 11 qualify to conduct ongoing and continuous external 12 quality reviews in the administrative regions. Such 13 criteria shall require such an entity to be adminis- 14 tratively independent of the individual or board that 15 administers the region and shall ensure that such 16 entities do not provide financial incentives to review- 17 ers to favor one pattern of practice over another. 18 The Center shall ensure coordination and reporting 19 by such entities to ensure national consistency in 20 quality standards. 21 (5) REPORTING.—The Center shall report to 22 the Secretary annually specifically on findings from 23 outcomes research and development of practice 24 guidelines that may affect the Secretary’s deter- TAM17H14 S.L.C. 42 1 mination of coverage of services under section 2 401(a)(1)(G). 3 4 5 SEC. 502. ADDRESSING HEALTH CARE DISPARITIES. (a) EVALUATING PROACHES.—The DATA COLLECTION AP - Center shall evaluate approaches for the 6 collection of data under this Act, to be performed in con7 junction with existing quality reporting requirements and 8 programs under this Act, that allow for the ongoing, accu9 rate, and timely collection of data on disparities in health 10 care services and performance on the basis of race, eth11 nicity, gender, geography, or socioeconomic status. In con12 ducting such evaluation, the Secretary shall consider the 13 following objectives: 14 (1) Protecting patient privacy. 15 (2) Minimizing the administrative burdens of 16 data collection and reporting on providers under this 17 Act. 18 (3) Improving Universal Medicare Program 19 data on race, ethnicity, gender, geography, and so- 20 cioeconomic status. 21 (b) REPORTS TO CONGRESS.— 22 (1) REPORT ON EVALUATION.—Not later than 23 18 months after the date on which benefits first be- 24 come available as described in section 106(a), the 25 Center shall submit to Congress and the Secretary TAM17H14 S.L.C. 43 1 a report on the evaluation conducted under sub- 2 section (a). Such report shall, taking into consider- 3 ation the results of such evaluation— 4 (A) identify approaches (including defining 5 methodologies) for identifying and collecting 6 and evaluating data on health care disparities 7 on the basis of race, ethnicity, gender, geog- 8 raphy, or socioeconomic status under the Uni- 9 versal Medicare Program; and 10 (B) include recommendations on the most 11 effective strategies and approaches to reporting 12 quality measures, as appropriate, on the basis 13 of race, ethnicity, gender, geography, or socio- 14 economic status. 15 (2) REPORT ON DATA ANALYSES.—Not later 16 than 4 years after the submission of the report 17 under subsection (b)(1), and 4 years thereafter, the 18 Center shall submit to Congress and the Secretary 19 a report that includes recommendations for improv- 20 ing the identification of health care disparities based 21 on the analyses of data collected under subsection 22 (c). 23 (c) IMPLEMENTING EFFECTIVE APPROACHES.—Not 24 later than 2 years after the date on which benefits first 25 become available as described in section 106(a), the Sec- TAM17H14 S.L.C. 44 1 retary shall implement the approaches identified in the re2 port submitted under subsection (b)(1) for the ongoing, 3 accurate, and timely collection and evaluation of data on 4 health care disparities on the basis of race, ethnicity, gen5 der, geography, or socioeconomic status. 6 7 8 9 10 11 12 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 13 1 of each year, beginning with the year prior to the 14 date on which benefits first become available as de- 15 scribed in section 106(a), the Secretary shall estab- 16 lish a national health budget, which specifies the 17 total expenditures to be made for covered health 18 care services under this Act. 19 (2) DIVISION OF BUDGET INTO COMPONENTS.— 20 In addition to the cost of covered health services, the 21 national health budget shall consist of at least the 22 following components: 23 24 (A) Quality assessment activities under title V. TAM17H14 S.L.C. 45 1 2 (B) Health professional education expenditures. 3 (C) Administrative costs. 4 (D) Innovation, including in accordance 5 with section 1115A of the Social Security Act 6 (42 U.S.C. 1315a). 7 (E) Operating and other expenditures not 8 described in subparagraphs (A) through (D) 9 (referred to in this Act as the ‘‘operating com- 10 ponent’’), consisting of amounts not included in 11 the other components. 12 (F) Capital expenditures. 13 (G) Prevention and public health activities. 14 (3) ALLOCATION AMONG COMPONENTS.—The 15 Secretary shall allocate the budget among the com- 16 ponents in a manner that— 17 18 (A) ensures a fair allocation for quality assessment activities; and 19 (B) ensures that the health professional 20 education expenditure component is sufficient 21 to provide for the amount of health professional 22 education expenditures sufficient to meet the 23 need for covered health care services. 24 (4) TEMPORARY 25 WORKER ASSISTANCE.—For up to 5 years following the date on which benefits first TAM17H14 S.L.C. 46 1 become available as described in section 106(a), up 2 to 1 percent of the budget may be allocated to pro- 3 grams providing assistance to workers who perform 4 functions in the administration of the health insur- 5 ance system and who may experience economic dis- 6 location as a result of the implementation of this 7 Act. 8 (5) RESERVE FUND.—The Secretary shall es- 9 tablish and maintain a reserve fund to respond to 10 the costs of treating an epidemic, pandemic, natural 11 disaster, or other such health emergency. 12 (b) DEFINITIONS.—In this section: 13 (1) CAPITAL EXPENDITURES.—The term ‘‘cap- 14 ital expenditures’’ means expenses for the purchase, 15 lease, construction, or renovation of capital facilities 16 and for equipment and includes return on equity 17 capital. 18 (2) HEALTH PROFESSIONAL EDUCATION EX- 19 PENDITURES.—The 20 cation expenditures’’ means expenditures in hospitals 21 and other health care facilities to cover costs associ- 22 ated with teaching and related research activities. term ‘‘health professional edu- TAM17H14 S.L.C. 47 1 Subtitle B—Payments to Providers 2 SEC. 611. PAYMENTS TO INSTITUTIONAL AND INDIVIDUAL 3 4 PROVIDERS. (a) APPLICATION OF PAYMENT PROCESSES UNDER 5 TITLE XVIII.—Except as otherwise provided in this sec6 tion, the Secretary shall establish, by regulation, fee 7 schedules that establish payment amounts for benefits 8 under this Act in a manner that is consistent with proc9 esses for determining payments for items and services 10 under title XVIII of the Social Security Act (42 U.S.C. 11 1395 et seq.), including the application of the provisions 12 of, and amendments made by, section 612. 13 14 (b) APPLICATION MENT OF CURRENT AND PLANNED PAY- REFORMS.—Any payment reform activities or dem- 15 onstrations planned or implemented with respect to such 16 title XVIII as of the date of the enactment of this Act 17 shall apply to benefits under this Act, including any re18 form activities or demonstrations planned or implemented 19 under the provisions of, or amendments made by, the 20 Medicare Access and CHIP Reauthorization Act of 2015 21 (Public Law 114–10) and the Patient Protection and Af22 fordable Care Act (Public Law 111–148). TAM17H14 S.L.C. 48 1 SEC. 612. ENSURING ACCURATE VALUATION OF SERVICES 2 UNDER 3 SCHEDULE. 4 THE (a) STANDARDIZED MEDICARE AND PHYSICIAN FEE DOCUMENTED REVIEW 5 PROCESS.—Section 1848(c)(2) of the Social Security Act 6 (42 U.S.C. 1395w–4(c)(2)) is amended by adding at the 7 end the following new subparagraph: 8 9 ‘‘(P) STANDARDIZED AND DOCUMENTED REVIEW PROCESS.— 10 ‘‘(i) IN GENERAL.—Not later than one 11 year after the date of enactment of this 12 subparagraph, the Secretary shall estab- 13 lish, document, and make publicly available 14 a standardized process for reviewing the 15 relative values of physicians’ services under 16 this paragraph. 17 ‘‘(ii) MINIMUM REQUIREMENTS.—The 18 standardized process shall include, at a 19 minimum, methods and criteria for identi- 20 fying services for review, prioritizing the 21 review of services, reviewing stakeholder 22 recommendations, and identifying addi- 23 tional resources to be considered during 24 the review process.’’. 25 (b) PLANNED AND DOCUMENTED USE OF FUNDS.— 26 Section 1848(c)(2)(M) of the Social Security Act (42 TAM17H14 S.L.C. 49 1 U.S.C. 1305w–4(c)(2)(M)) is amended by adding at the 2 end the following new clause: 3 ‘‘(x) PLANNED AND DOCUMENTED 4 USE OF FUNDS.—For 5 ginning with the first fiscal year beginning 6 on or after the date of enactment of this 7 clause), the Secretary shall provide to Con- 8 gress a written plan for using the funds 9 provided under clause (ix) to collect and 10 use information on physicians’ services in 11 the determination of relative values under 12 this subparagraph.’’. 13 (c) INTERNAL TRACKING OF REVIEWS.— 14 (1) IN GENERAL.—Not each fiscal year (be- later than one year 15 after the date of enactment of this Act, the Sec- 16 retary shall submit to Congress a proposed plan for 17 systematically and internally tracking its review of 18 the relative values of physicians’ services, such as by 19 establishing an internal database, under section 20 1848(c)(2) of the Social Security Act (42 U.S.C. 21 1395w–4(c)(2)), as amended by this section. 22 (2) MINIMUM REQUIREMENTS.—The proposal 23 shall include, at a minimum, plans and a timeline 24 for achieving the ability to systematically and inter- 25 nally track the following: TAM17H14 S.L.C. 50 1 (A) When, how, and by whom services are 2 identified for review. 3 (B) When services are reviewed or re- 4 viewed or when new services are added. 5 (C) The resources, evidence, data, and rec- 6 ommendations used in reviews. 7 (D) When relative values are adjusted. 8 (E) The rationale for final relative value 9 10 decisions. (d) FREQUENCY OF REVIEW.—Section 1848(c)(2) of 11 the Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 12 amended— 13 14 (1) in subparagraph (B)(i), by striking ‘‘5’’ and inserting ‘‘4’’; and 15 (2) in subparagraph (K)(i)(I), by striking ‘‘peri- 16 odically’’ and inserting ‘‘annually’’. 17 (e) CONSULTATION WITH MEDICARE PAYMENT AD- 18 19 VISORY COMMISSION.— (1) IN GENERAL.—Section 1848(c)(2) of the 20 Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 21 amended— 22 (A) in subparagraph (B)(i), by inserting 23 ‘‘in consultation with the Medicare Payment 24 Advisory Commission,’’ after ‘‘The Secretary,’’; 25 and TAM17H14 S.L.C. 51 1 (B) in subparagraph (K)(i)(I), as amended 2 by subsection (d)(2), by inserting ‘‘in coordina- 3 tion with the Medicare Payment Advisory Com- 4 mission,’’ after ‘‘years,’’. 5 (2) CONFORMING AMENDMENTS.—Section 1805 6 of the Social Security Act (42 U.S.C. 1395b–6) is 7 amended— 8 (A) in subsection (b)(1)(A), by inserting 9 the following before the semicolon at the end: 10 ‘‘and including coordinating with the Secretary 11 in accordance with section 1848(c)(2) to sys- 12 tematically review the relative values established 13 for physicians’ services, identify potentially 14 misvalued services, and propose adjustments to 15 the relative values for physicians’ services’’; and 16 (B) in subsection (e)(1), in the second sen- 17 tence, by inserting ‘‘or the Ranking Minority 18 Member’’ after ‘‘the Chairman’’. 19 20 (f) PERIODIC AUDIT ERAL.—Section BY THE COMPTROLLER GEN- 1848(c)(2) of the Social Security Act (42 21 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 22 amended by adding at the end the following new subpara23 graph: 24 25 ‘‘(Q) PERIODIC TROLLER GENERAL.— AUDIT BY THE COMP- TAM17H14 S.L.C. 52 1 ‘‘(i) IN GENERAL.—The Comptroller 2 General of the United States (in this sub- 3 section referred to as the ‘Comptroller 4 General’) shall periodically audit the review 5 by the Secretary of relative values estab- 6 lished under this paragraph for physicians’ 7 services. 8 ‘‘(ii) ACCESS 9 Comptroller TO INFORMATION.—The General shall have unre- 10 stricted access to all deliberations, records, 11 and nonproprietary data related to the ac- 12 tivities carried out under this paragraph, 13 in a timely manner, upon request.’’. 14 15 SEC. 613. OFFICE OF PRIMARY HEALTH CARE. (a) IN GENERAL.—There is established within the 16 Agency for Healthcare Research and Quality an Office of 17 Primary Health Care, responsible for coordinating with 18 the Secretary, the Health Resources and Services Admin19 istration, and other offices in the Department as nec20 essary, in order to— 21 (1) coordinate health professional education 22 policies and goals, in consultation with the Secretary 23 to achieve the national goals specified in subsection 24 (b); TAM17H14 S.L.C. 53 1 (2) develop and maintain a system to monitor 2 the number and specialties of individuals through 3 their health professional education, any postgraduate 4 training, and professional practice; 5 (3) develop, coordinate, and promote policies 6 that expand the number of primary care practi- 7 tioners, registered nurses, midlevel practitioners, and 8 dentists; and 9 (4) recommend the appropriate training, edu- 10 cation, technical assistance, and patient advocacy en- 11 hancements of primary care health professionals, in- 12 cluding registered nurses, to achieve uniform high 13 quality and patient safety. 14 (b) NATIONAL GOALS.—Not later than 1 year after 15 the date of enactment of this Act, the Office of Primary 16 Health Care shall set forth national goals to increase ac17 cess to high quality primary health care, particularly in 18 underserved areas and for underserved populations. 19 20 21 SEC. 614. PAYMENTS FOR PRESCRIPTION DRUGS AND APPROVED DEVICES AND EQUIPMENT. (a) NEGOTIATED PRICES.—The prices to be paid for 22 covered pharmaceuticals, medical supplies, and medically 23 necessary assistive equipment shall be negotiated annually 24 by the Secretary. 25 (b) PRESCRIPTION DRUG FORMULARY.— TAM17H14 S.L.C. 54 1 (1) IN GENERAL.—The Secretary shall establish 2 a prescription drug formulary system, which shall 3 encourage best-practices in prescribing and discour- 4 age the use of ineffective, dangerous, or excessively 5 costly medications when better alternatives are avail- 6 able. 7 (2) PROMOTION OF USE OF GENERICS.—The 8 formulary under this subsection shall promote the 9 use of generic medications to the greatest extent 10 possible. 11 (3) FORMULARY UPDATES AND PETITION 12 RIGHTS.—The 13 be updated frequently and clinicians and patients 14 may petition the Secretary to add new pharma- 15 ceuticals or to remove ineffective or dangerous medi- 16 cations from the formulary. 17 (4) USE formulary under this subsection shall OF OFF-FORMULARY MEDICATIONS.— 18 The Secretary shall promulgate rules regarding the 19 use of off-formulary medications which allow for pa- 20 tient access but do not compromise the formulary. 21 22 23 24 TITLE VII—UNIVERSAL MEDICARE TRUST FUND SEC. 701. UNIVERSAL MEDICARE TRUST FUND. (a) IN GENERAL.—There is hereby created on the 25 books of the Treasury of the United States a trust fund TAM17H14 S.L.C. 55 1 to be known as the Universal Medicare Trust Fund (in 2 this section referred to as the ‘‘Trust Fund’’). The Trust 3 Fund shall consist of such gifts and bequests as may be 4 made and such amounts as may be deposited in, or appro5 priated to, such Trust Fund as provided in this Act. 6 (b) APPROPRIATIONS INTO TRUST FUND.— 7 (1) TAXES.—There are hereby appropriated to 8 the Trust Fund for each fiscal year beginning with 9 the fiscal year which includes the date on which ben- 10 efits first become available as described in section 11 106, out of any moneys in the Treasury not other- 12 wise appropriated, amounts equivalent to 100 per- 13 cent of the net increase in revenues to the Treasury 14 which is attributable to the amendments made by 15 sections 801 and 902. The amounts appropriated by 16 the preceding sentence shall be transferred from 17 time to time (but not less frequently than monthly) 18 from the general fund in the Treasury to the Trust 19 Fund, such amounts to be determined on the basis 20 of estimates by the Secretary of the Treasury of the 21 taxes paid to or deposited into the Treasury; and 22 proper adjustments shall be made in amounts subse- 23 quently transferred to the extent prior estimates 24 were in excess of or were less than the amounts that 25 should have been so transferred. TAM17H14 S.L.C. 56 1 (2) CURRENT PROGRAM RECEIPTS.—Notwith- 2 standing any other provision of law, there are hereby 3 appropriated to the Trust Fund for each fiscal year, 4 beginning with the first fiscal year beginning on or 5 after the effective date of benefits under section 106, 6 the amounts that would otherwise have been appro- 7 priated to carry out the following programs: 8 (A) The Medicare program under title 9 XVIII of the Social Security Act (other than 10 amounts attributable to any premiums under 11 such title). 12 13 (B) The Medicaid program, under State plans approved under title XIX of such Act. 14 (C) The Federal employees health benefit 15 program, under chapter 89 of title 5, United 16 States Code. 17 18 (D) The TRICARE program, under chapter 55 of title 10, United States Code. 19 (E) The maternal and child health pro- 20 gram (under title V of the Social Security Act), 21 vocational rehabilitation programs, programs 22 for drug abuse and mental health services 23 under the Public Health Service Act, programs 24 providing general hospital or medical assistance, 25 and any other Federal program identified by TAM17H14 S.L.C. 57 1 the Secretary, in consultation with the Sec- 2 retary of the Treasury, to the extent the pro- 3 grams provide for payment for health services 4 the payment of which may be made under this 5 Act. 6 (3) RESTRICTIONS SHALL NOT APPLY.—Any 7 other provision of law in effect on the date of enact- 8 ment of this Act restricting the use of Federal funds 9 for any reproductive health service shall not apply to 10 monies in the Trust Fund. 11 (c) INCORPORATION OF PROVISIONS.—The provisions 12 of subsections (b) through (i) of section 1817 of the Social 13 Security Act (42 U.S.C. 1395i) shall apply to the Trust 14 Fund under this section in the same manner as such pro15 visions applied to the Federal Hospital Insurance Trust 16 Fund under such section 1817, except that, for purposes 17 of applying such subsections to this section, the ‘‘Board 18 of Trustees of the Trust Fund’’ shall mean the ‘‘Sec19 retary’’. 20 (d) TRANSFER OF FUNDS.—Any amounts remaining 21 in the Federal Hospital Insurance Trust Fund under sec22 tion 1817 of the Social Security Act (42 U.S.C. 1395i) 23 or the Federal Supplementary Medical Insurance Trust 24 Fund under section 1841 of such Act (42 U.S.C. 1395t) 25 after the payment of claims for items and services fur- TAM17H14 S.L.C. 58 1 nished under title XVIII of such Act have been completed, 2 shall be transferred into the Universal Medicare Trust 3 Fund under this section. 7 TITLE VIII—CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 8 SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICA- 9 TIVE OF BENEFITS UNDER THE UNIVERSAL 4 5 6 10 MEDICARE 11 CASE OF WORKERS’ COMPENSATION. 12 (a) IN GENERAL.—Part 5 of subtitle B of title I of PROGRAM; COORDINATION IN 13 the Employee Retirement Income Security Act of 1974 14 (29 U.S.C. 1131 et seq.) is amended by adding at the end 15 the following new section: 16 ‘‘SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLI- 17 CATIVE OF UNIVERSAL MEDICARE PROGRAM 18 BENEFITS; 19 WORKERS’ COMPENSATION. 20 COORDINATION IN CASE OF ‘‘(a) IN GENERAL.—Subject to subsection (b), no em- 21 ployee benefit plan may provide benefits that duplicate 22 payment for any items or services for which payment may 23 be made under the Medicare for All Act of 2017. 24 ‘‘(b) REIMBURSEMENT.—Each workers compensation 25 carrier that is liable for payment for workers compensa- TAM17H14 S.L.C. 59 1 tion services furnished in a State shall reimburse the Uni2 versal Medicare Program for the cost of such services. 3 ‘‘(c) DEFINITIONS.—In this subsection— 4 ‘‘(1) the term ‘workers compensation carrier’ 5 means an insurance company that underwrite work- 6 ers compensation medical benefits with respect to 1 7 or more employers and includes an employer or fund 8 that is financially at risk for the provision of work- 9 ers compensation medical benefits; 10 ‘‘(2) the term ‘workers compensation medical 11 benefits’ means, with respect to an enrollee who is 12 an employee subject to the workers compensation 13 laws of a State, the comprehensive medical benefits 14 for work-related injuries and illnesses provided for 15 under such laws with respect to such an employee; 16 and 17 ‘‘(3) the term ‘workers compensation services’ 18 means items and services included in workers com- 19 pensation medical benefits and includes items and 20 services (including rehabilitation services and long- 21 term-care services) commonly used for treatment of 22 work-related injuries and illnesses.’’. 23 (b) CONFORMING AMENDMENT.—Section 4(b) of the 24 Employee Retirement Income Security Act of 1974 (29 25 U.S.C. 1003(b)) is amended by adding at the end the fol- TAM17H14 S.L.C. 60 1 lowing: ‘‘Paragraph (3) shall apply subject to section 2 522(b) (relating to reimbursement of the Universal Medi3 care Program by workers compensation carriers).’’. 4 (c) CLERICAL AMENDMENT.—The table of contents 5 in section 1 of such Act is amended by inserting after the 6 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.’’. 7 SEC. 802. REPEAL OF CONTINUATION COVERAGE REQUIRE- 8 MENTS UNDER ERISA AND CERTAIN OTHER 9 REQUIREMENTS 10 HEALTH PLANS. 11 RELATING TO GROUP (a) IN GENERAL.—Part 6 of subtitle B of title I of 12 the Employee Retirement Income Security Act of 1974 13 (29 U.S.C. 1161 et seq.) is repealed. 14 15 16 (b) CONFORMING AMENDMENTS.— (1) Section 502(a) of such Act (29 U.S.C. 1132(a)) is amended— 17 (A) by striking paragraph (7); and 18 (B) by redesignating paragraphs (8), (9), 19 and (10) as paragraphs (7), (8), and (9), re- 20 spectively. 21 (2) Section 502(c)(1) of such Act (29 U.S.C. 22 1132(c)(1)) is amended by striking ‘‘paragraph (1) 23 or (4) of section 606,’’. TAM17H14 S.L.C. 61 1 2 (3) Section 514(b) of such Act (29 U.S.C. 1144(b)) is amended— 3 4 (A) in paragraph (7), by striking ‘‘section 206(d)(3)(B)(i)).’’; and 5 (B) by striking paragraph (8). 6 (4) The table of contents in section 1 of the 7 Employee Retirement Income Security Act of 1974 8 is amended by striking the items relating to part 6 9 of subtitle B of title I of such Act. 10 11 SEC. 803. EFFECTIVE DATE OF TITLE. The amendments made by this title shall take effect 12 on effective date of benefits under section 106(a). 14 TITLE IX—ADDITIONAL CONFORMING AMENDMENTS 15 SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH 13 16 17 PROGRAMS. (a) MEDICARE, MEDICAID, AND STATE CHILDREN’S 18 HEALTH INSURANCE PROGRAM (SCHIP).— 19 (1) IN GENERAL.—Notwithstanding any other 20 provision of law, subject to paragraphs (2) and 21 (3)— 22 (A) no benefits shall be available under 23 title XVIII of the Social Security Act for any 24 item or service furnished beginning on or after TAM17H14 S.L.C. 62 1 the effective date of benefits under section 2 106(a); 3 (B) no individual is entitled to medical as- 4 sistance under a State plan approved under 5 title XIX of such Act for any item or service 6 furnished on or after such date; 7 (C) no individual is entitled to medical as- 8 sistance under a State child health plan under 9 title XXI of such Act for any item or service 10 furnished on or after such date; and 11 (D) no payment shall be made to a State 12 under section 1903(a) or 2105(a) of such Act 13 with respect to medical assistance or child 14 health assistance for any item or service fur- 15 nished on or after such date. 16 (2) TRANSITION.—In the case of inpatient hos- 17 pital services and extended care services during a 18 continuous period of stay which began before the ef- 19 fective date of benefits under section 106, and which 20 had not ended as of such date, for which benefits 21 are provided under title XVIII of the Social Security 22 Act, under a State plan under title XIX of such Act, 23 or under a State child health plan under title XXI 24 such Act, the Secretary of Health and Human Serv- TAM17H14 S.L.C. 63 1 ices shall provide for continuation of benefits under 2 such title or plan until the end of the period of stay. 3 4 (3) SERVICES (A) IN UNDER MEDICAID.— GENERAL.—This subsection shall 5 not apply to entitlement to medical assistance 6 provided under title XIX of the Social Security 7 Act for— 8 9 (i) long-term care services (as defined in section 1947(b) of such Act); or 10 (ii) any other service for which bene- 11 fits are not available under this Act and 12 which is furnished under a State plan 13 under title XIX of the Social Security Act 14 which provided for medical assistance for 15 such service on September 1, 2017. 16 (B) COORDINATION BETWEEN SECRETARY 17 AND STATES.—The 18 with the directors of State agencies responsible 19 for administering State plans under title XIX 20 of the Social Security Act to— Secretary shall coordinate 21 (i) identify services described in sub- 22 paragraph (A)(ii) with respect to each 23 State plan; and 24 25 (ii) ensure that such services continue to be made available under such plan. TAM17H14 S.L.C. 64 1 (C) MAINTENANCE OF EFFORT REQUIRE- 2 MENT.—With 3 in subparagraph (A)(ii) that is made available 4 under a State plan under title XIX of the So- 5 cial Security Act, the maintenance of effort re- 6 quirements described in section 1947(c) of such 7 Act (related to eligibility standards and re- 8 quired expenditures) shall apply to such service 9 in the same manner that such requirements 10 apply to long-term care services (as defined in 11 section 1947(b) of such Act). 12 13 respect to any service described (b) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM.—No benefits shall be made available under chapter 14 89 of title 5, United States Code, for any part of a cov15 erage period occurring on or after the effective date. 16 (c) TRICARE.—No benefits shall be made available 17 under sections 1079 and 1086 of title 10, United States 18 Code, for items or services furnished on or after the effec19 tive date. 20 (d) TREATMENT OF BENEFITS FOR VETERANS AND 21 NATIVE AMERICANS.— 22 (1) IN GENERAL.—Nothing in this Act shall af- 23 fect the eligibility of veterans for the medical bene- 24 fits and services provided under title 38, United 25 States Code, or of Indians for the medical benefits TAM17H14 S.L.C. 65 1 and services provided by or through the Indian 2 Health Service. 3 (2) REEVALUATION.—No reevaluation of the 4 Indian Health Service shall be undertaken without 5 consultation with tribal leaders and stakeholders. 6 SEC. 902. SUNSET OF PROVISIONS RELATED TO THE STATE 7 8 EXCHANGES. Effective on the date described in section 106, the 9 Federal and State Exchanges established pursuant to title 10 I of the Patient Protection and Affordable Care Act (Pub11 lic Law 111–148) shall terminate, and any other provision 12 of law that relies upon participation in or enrollment 13 through such an Exchange, including such provisions of 14 the Internal Revenue Code of 1986, shall cease to have 15 force or effect. 19 TITLE X—TRANSITION Subtitle A—Transitional Medicare Buy-in Option and Transitional Public Option 20 SEC. 1001. LOWERING THE MEDICARE AGE. 16 17 18 21 (a) IN GENERAL.—Title XVIII of the Social Security 22 Act (42 U.S.C. 1395c et seq.) is amended by adding at 23 the end the following new section: 24 ‘‘TRANSITIONAL 25 26 MEDICARE BUY-IN OPTION FOR CERTAIN INDIVIDUALS ‘‘SEC. 1899C. (a) OPTION.— TAM17H14 S.L.C. 66 1 ‘‘(1) IN GENERAL.—Every individual who meets 2 the requirements described in paragraph (3) shall be 3 eligible to enroll under this section. 4 ‘‘(2) PART A, B, AND D BENEFITS.—An indi- 5 vidual enrolled under this section is entitled to the 6 same benefits (and shall receive the same protec- 7 tions) under this title as an individual who is enti- 8 tled to benefits under part A and enrolled under 9 parts B and D, including the ability to enroll in a 10 Medicare Advantage plan that provides qualified pre- 11 scription drug coverage (an MA–PD plan). 12 ‘‘(3) REQUIREMENTS FOR ELIGIBILITY.—The 13 requirements described in this paragraph are the fol- 14 lowing: 15 16 17 18 19 20 ‘‘(A) The individual is a resident of the United States. ‘‘(B) The individual is— ‘‘(i) a citizen or national of the United States; or ‘‘(ii) an alien lawfully admitted for 21 permanent residence. 22 ‘‘(C) The individual is not otherwise enti- 23 tled to benefits under part A or eligible to en- 24 roll under part A or part B. TAM17H14 S.L.C. 67 1 ‘‘(D) The individual has attained the appli- 2 cable years of age but has not attained 65 years 3 of age. 4 ‘‘(4) APPLICABLE YEARS OF AGE DEFINED.— 5 For purposes of this section, the term ‘applicable 6 years of age’ means— 7 ‘‘(A) effective January 1 of the first year 8 following the date of enactment of the Medicare 9 for All Act of 2017, the age of 55; 10 ‘‘(B) effective January 1 of the second 11 year following such date of enactment, the age 12 of 45; and 13 ‘‘(C) effective January 1 of the third year 14 following such date of enactment, the age of 35. 15 ‘‘(b) ENROLLMENT; COVERAGE.—The Secretary shall 16 establish enrollment periods and coverage under this sec17 tion consistent with the principles for establishment of en18 rollment periods and coverage for individuals under other 19 provisions of this title. The Secretary shall establish such 20 periods so that coverage under this section shall first begin 21 on January 1 of the year on which an individual first be22 comes eligible to enroll under this section. 23 24 25 ‘‘(c) PREMIUM.— ‘‘(1) AMOUNT OF MONTHLY PREMIUMS.—The Secretary shall, during September of each year (be- TAM17H14 S.L.C. 68 1 ginning with the first September following the date 2 of enactment of the Medicare for All Act of 2017), 3 determine a monthly premium for all individuals en- 4 rolled under this section. Such monthly premium 5 shall be equal to 1⁄12 of the annual premium com- 6 puted under paragraph (2)(B), which shall apply 7 with respect to coverage provided under this section 8 for any month in the succeeding year. 9 10 ‘‘(2) ANNUAL PREMIUM.— ‘‘(A) COMBINED PER CAPITA AVERAGE FOR 11 ALL MEDICARE BENEFITS.—The 12 estimate the average, annual per capita amount 13 for benefits and administrative expenses that 14 will be payable under parts A, B, and D (in- 15 cluding, as applicable, under part C) in the year 16 for all individuals enrolled under this section. 17 ‘‘(B) ANNUAL Secretary shall PREMIUM.—The annual pre- 18 mium under this subsection for months in a 19 year is equal to the average, annual per capita 20 amount estimated under subparagraph (A) for 21 the year. 22 ‘‘(3) INCREASED 23 C AND D PLANS.—Nothing 24 clude an individual from choosing a Medicare Advan- 25 tage plan or a prescription drug plan which requires PREMIUM FOR CERTAIN PART in this section shall pre- TAM17H14 S.L.C. 69 1 the individual to pay an additional amount (because 2 of supplemental benefits or because it is a more ex- 3 pensive plan). In such case the individual would be 4 responsible for the increased monthly premium. 5 ‘‘(d) PAYMENT OF PREMIUMS.— 6 ‘‘(1) IN GENERAL.—Premiums for enrollment 7 under this section shall be paid to the Secretary at 8 such times, and in such manner, as the Secretary 9 determines appropriate. 10 ‘‘(2) DEPOSIT.—Amounts collected by the Sec- 11 retary under this section shall be deposited in the 12 Federal Hospital Insurance Trust Fund and the 13 Federal Supplementary Medical Insurance Trust 14 Fund (including the Medicare Prescription Drug Ac- 15 count within such Trust Fund) in such proportion 16 as the Secretary determines appropriate. 17 ‘‘(e) NOT ELIGIBLE FOR MEDICARE COST-SHARING 18 ASSISTANCE.—An individual enrolled under this section 19 shall not be treated as enrolled under any part of this title 20 for purposes of obtaining medical assistance for Medicare 21 cost-sharing or otherwise under title XIX. 22 ‘‘(f) TREATMENT IN RELATION TO THE AFFORDABLE 23 CARE ACT.— 24 25 ‘‘(1) SATISFACTION DATE.—For OF INDIVIDUAL MAN- purposes of applying section 5000A of TAM17H14 S.L.C. 70 1 the Internal Revenue Code of 1986, the coverage 2 provided under this section constitutes minimum es- 3 sential coverage under subsection (f)(1)(A)(i) of 4 such section 5000A. 5 6 ‘‘(2) ELIGIBILITY FOR PREMIUM ASSISTANCE.— Coverage provided under this section— 7 ‘‘(A) shall be treated as coverage under a 8 qualified health plan in the individual market 9 enrolled in through the Exchange where the in- 10 dividual resides for all purposes of section 36B 11 of the Internal Revenue Code of 1986 other 12 than subsection (c)(2)(B) thereof; and 13 ‘‘(B) shall not be treated as eligibility for 14 other minimum essential coverage for purposes 15 of subsection (c)(2)(B) of such section 36B. 16 The Secretary shall determine the applicable second 17 lowest cost silver plan which shall apply to coverage 18 under this section for purposes of section 36B of 19 such Code. 20 ‘‘(3) ELIGIBILITY FOR COST-SHARING SUB- 21 SIDIES.—For 22 the Patient Protection and Affordable Care Act (42 23 U.S.C. 18071)— purposes of applying section 1402 of 24 ‘‘(A) coverage provided under this section 25 shall be treated as coverage under a qualified TAM17H14 S.L.C. 71 1 health plan in the silver level of coverage in the 2 individual market offered through an Exchange; 3 and 4 5 6 ‘‘(B) the Secretary shall be treated as the issuer of such plan. ‘‘(g) GUARANTEED ISSUE 7 UPON FIRST ENROLLMENT 8 ROLLMENT.—In AND OF MEDIGAP POLICIES EACH SUBSEQUENT EN- the case of an individual who enrolls 9 under this section (including an individual who was pre10 viously enrolled under this section), paragraphs (2)(A), 11 (2)(D), (3)(B)(ii), and (3)(B)(vi) of section 1882(s)— 12 ‘‘(1) shall be applied by substituting ‘the appli- 13 cable 14 1899C(a)(4))’ for ‘65 years of age’; year of age (as defined in section 15 ‘‘(2) if the individual was enrolled under this 16 section and subsequently disenrolls, shall apply each 17 time the individual subsequently reenrolls under this 18 section as if the individual had attained the applica- 19 ble year of age (as defined in subsection (a)(4)) on 20 the date of such reenrollment (and as if the indi- 21 vidual had never previously enrolled in a Medicare 22 supplemental policy); and 23 ‘‘(3) shall be applied as if this section had not 24 been enacted (and as if the individual had never pre- TAM17H14 S.L.C. 72 1 viously enrolled in a Medicare supplemental policy) 2 when the individual attains 65 years of age. 3 ‘‘(h) NO EFFECT 4 OTHERWISE ELIGIBLE ON BENEFITS OR ON FOR INDIVIDUALS TRUST FUNDS.—The Sec- 5 retary shall implement the provisions of this section in 6 such a manner to ensure that such provisions— 7 ‘‘(1) have no effect on the benefits under this 8 title for individuals who are entitled to, or enrolled 9 for, such benefits other than through this section; 10 and 11 ‘‘(2) have no negative impact on the Federal 12 Hospital Insurance Trust Fund or the Federal Sup- 13 plementary Medical Insurance Trust Fund (includ- 14 ing the Medicare Prescription Drug Account within 15 such Trust Fund). 16 ‘‘(i) CONSULTATION.—In promulgating regulations 17 to implement this section, the Secretary shall consult with 18 interested parties, including groups representing bene19 ficiaries, health care providers, employers, and insurance 20 companies.’’. 21 22 23 SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSITION PLAN. (a) IN GENERAL.—To carry out the purpose of this 24 section, for plan years beginning with the first plan year 25 that begins after the date of enactment of this Act and TAM17H14 S.L.C. 73 1 ending with the effective date described in section 106, 2 the Secretary, acting through the Administrator of the 3 Centers for Medicare & Medicaid (referred to in this sec4 tion as the ‘‘Administrator’’), shall establish, and provide 5 for the offering through the Exchanges, of a public health 6 plan (in this Act referred to as the ‘‘Medicare Transition 7 plan’’) that provides affordable, high-quality health bene8 fits coverage throughout the United States. 9 (b) 10 TION.— ADMINISTRATING THE MEDICARE TRANSI- 11 (1) ADMINISTRATOR.—The Administrator shall 12 administer the Medicare Transition plan in accord- 13 ance with this section. 14 (2) APPLICATION OF ACA REQUIREMENTS.— 15 Consistent with this section, the Medicare Transition 16 plan shall comply with requirements under title I of 17 the Patient Protection and Affordable Care Act (and 18 the amendments made by that title) and title XXVII 19 of the Public Health Service Act (42 U.S.C. 300gg 20 et seq.) that are applicable to qualified health plans 21 offered through the Exchanges, subject to the limita- 22 tion under subsection (e)(2). 23 (3) OFFERING THROUGH EXCHANGES.—The 24 Medicare Transition plan shall be made available 25 only through the Exchanges, and shall be available TAM17H14 S.L.C. 74 1 to individuals wishing to enroll and to qualified em- 2 ployers (as defined in section 1312(f)(2) of the Pa- 3 tient Protection and Affordable Care Act (42 U.S.C. 4 18032)) who wish to make such plan available to 5 their employees. 6 (4) ELIGIBILITY TO PURCHASE.—Any United 7 States resident may enroll in the Medicare Transi- 8 tion plan. 9 (c) BENEFITS; ACTUARIAL VALUE.—In carrying out 10 this section, the Administrator shall ensure that the Medi11 care Transition plan provides— 12 13 (1) coverage for the benefits required to be covered under title II; and 14 (2) coverage of benefits that are actuarially 15 equivalent to 90 percent of the full actuarial value 16 of the benefits provided under the plan. 17 (d) PROVIDERS AND REIMBURSEMENT RATES.— 18 (1) IN GENERAL.—With respect to the reim- 19 bursement provided to health care providers for cov- 20 ered benefits, as described in section 201, provided 21 under the Medicare Transition plan, the Adminis- 22 trator shall reimburse such providers at rates deter- 23 mined for equivalent items and services under the 24 original Medicare fee-for-service program under 25 parts A and B of title XVIII of the Social Security TAM17H14 S.L.C. 75 1 Act (42 U.S.C. 1395c et seq.). For items and serv- 2 ices covered under the Medicare Transition plan but 3 not covered under such parts A and B, the Adminis- 4 trator shall reimburse providers at rates set by the 5 Administrator in a manner consistent with the man- 6 ner in which rates for other items and services were 7 set under the original Medicare fee-for-service pro- 8 gram. 9 (2) PRESCRIPTION DRUGS.—Any payment rate 10 under this subsection for a prescription drug shall be 11 at a rate negotiated by the Administrator with the 12 manufacturer of the drug. If the Administrator is 13 unable to reach a negotiated agreement on such a 14 reimbursement rate, the Administrator shall estab- 15 lish the rate at an amount equal to the lesser of— 16 (A) the price paid by the Secretary of Vet- 17 erans Affairs to procure the drug under the 18 laws administered by the Secretary of Veterans 19 Affairs; 20 (B) the price paid to procure the drug 21 under section 8126 of title 38, United States 22 Code; or 23 (C) the best price determined under sec- 24 tion 1927(c)(1)(C) of the Social Security Act 25 (42 U.S.C. 1396r–8(c)(1)(C)) for the drug. TAM17H14 S.L.C. 76 1 2 (3) PARTICIPATING (A) IN PROVIDERS.— GENERAL.—A health care provider 3 that is a participating provider of services or 4 supplier under the Medicare program under 5 title XVIII of the Social Security Act (42 6 U.S.C. 1395 et seq.) or under a State Medicaid 7 plan under title XIX of such Act (42 U.S.C. 8 1396 et seq.) on the date of enactment of this 9 Act shall be a participating provider in the 10 11 Medicare Transition plan. (B) ADDITIONAL PROVIDERS.—The Ad- 12 ministrator shall establish a process to allow 13 health care providers not described in subpara- 14 graph (A) to become participating providers in 15 the Medicare Transition plan. Such process 16 shall be similar to the process applied to new 17 providers under the Medicare program. 18 (e) PREMIUMS.— 19 (1) DETERMINATION.—The Administrator shall 20 determine the premium amount for enrolling in the 21 Medicare Transition plan, which— 22 (A) may vary according to family or indi- 23 vidual coverage, age, and tobacco status (con- 24 sistent with clauses (i), (iii), and (iv) of section TAM17H14 S.L.C. 77 1 2701(a)(1)(A) of the Public Health Service Act 2 (42 U.S.C. 300gg(a)(1)(A))); and 3 (B) shall take into account the cost-shar- 4 ing reductions and premium tax credits which 5 will be available with respect to the plan under 6 section 1402 of the Patient Protection and Af- 7 fordable Care Act (42 U.S.C. 18071) and sec- 8 tion 36B of the Internal Revenue Code of 1986, 9 as amended by subsection (g). 10 (2) LIMITATION.—Variation in premium rates 11 of the Medicare Transition plan by rating area, as 12 described in clause (ii) of section 2701(a)(1)(A)(iii) 13 of the Public Health Service Act (42 U.S.C. 14 300gg(a)(1)(A)) is not permitted. 15 (f) TERMINATION.—This section shall cease to have 16 force or effect on the effective date described in section 17 106. 18 (g) TAX CREDITS 19 (1) PREMIUM 20 AND COST-SHARING SUBSIDIES.— ASSISTANCE TAX CREDITS.— (A) CREDITS ALLOWED TO MEDICARE 21 TRANSITION PLAN ENROLLEES AT OR ABOVE 44 22 PERCENT 23 STATES.—Paragraph 24 the Internal Revenue Code of 1986 is amended 25 by redesignating subparagraphs (C) and (D) as OF POVERTY IN NON-EXPANSION (1) of section 36B(c) of TAM17H14 S.L.C. 78 1 subparagraphs (D) and (E), respectively, and 2 by inserting after subparagraph (B) the fol- 3 lowing new subparagraph: 4 ‘‘(C) SPECIAL 5 6 RULES FOR MEDICARE TRANSITION PLAN ENROLLEES.— ‘‘(i) IN GENERAL.—In the case of a 7 taxpayer who is covered, or whose spouse 8 or dependent (as defined in section 152) is 9 covered, by the Medicare Transition plan 10 established under section 1002(a) of the 11 Medicare for All Act of 2017 for all 12 months in the taxable year, subparagraph 13 (A) shall be applied without regard to ‘but 14 does not exceed 400 percent’. 15 ‘‘(ii) ENROLLEES IN MEDICAID NON- 16 EXPANSION STATES.—In 17 payer residing in a State which (as of the 18 date of the enactment of the Medicare for 19 All Act of 2017) does not provide for eligi- 20 bility under clause (i)(VIII) or (ii)(XX) of 21 section 1902(a)(10)(A) of the Social Secu- 22 rity Act for medical assistance under title 23 XIX of such Act (or a waiver of the State 24 plan approved under section 1115) who is 25 covered, or whose spouse or dependent (as the case of a tax- TAM17H14 S.L.C. 79 1 defined in section 152) is covered, by the 2 Medicare Transition plan established under 3 section 1002(a) of the Medicare for All Act 4 of 2017 for all months in the taxable year, 5 subparagraphs (A) and (B) shall be ap- 6 plied by substituting ‘0 percent’ for ‘100 7 percent’ each place it appears.’’. 8 (B) PREMIUM 9 10 11 ASSISTANCE AMOUNTS FOR TAXPAYERS ENROLLED IN MEDICARE TRANSITION PLAN.— (i) IN GENERAL.—Subparagraph (A) 12 of section 36B(b)(3) of such Code is 13 amended— 14 15 (I) by redesignating clause (ii) as clause (iii), 16 (II) by striking ‘‘clause (ii)’’ in 17 clause (i) and inserting ‘‘clauses (ii) 18 and (iii)’’, and 19 (III) by inserting after clause (i) 20 the following new clause: 21 ‘‘(ii) SPECIAL RULES FOR TAXPAYERS 22 ENROLLED 23 PLAN.—In 24 covered, or whose spouse or dependent (as 25 defined in section 152) is covered, by the IN MEDICARE TRANSITION the case of a taxpayer who is TAM17H14 S.L.C. 80 1 Medicare Transition plan established under 2 section 1002(a) of the Medicare for All Act 3 of 2017 for all months in the taxable year, 4 the applicable percentage for any taxable 5 year shall be determined in the same man- 6 ner as under clause (i), except that the fol- 7 lowing table shall apply in lieu of the table 8 contained in such clause: ‘‘In the case of household income (expressed as a percent of poverty line) within the following income tier: The initial premium percentage is— Up to 100% 100% up to 138% 138% up to 150% 150% and above 2% 2.04% 3.06% 4.08% 9 (ii) CONFORMING The final premium percentage is— 2% 2.04% 4.08% 5%.’’. AMENDMENT.—Sub- 10 clause 11 36B(b)(3) of such Code, as redesignated 12 by subparagraph (A)(i), is amended by in- 13 serting ‘‘, and determined after the appli- 14 cation of clause (ii)’’ after ‘‘after applica- 15 tion of this clause’’. 16 (I) of (2) COST-SHARING clause (iii) of section SUBSIDIES.—Subsection (b) 17 of section 1402 of the Patient Protection and Af- 18 fordable Care Act (42 U.S.C. 18071(b)) is amend- 19 ed— TAM17H14 S.L.C. 81 1 (A) by inserting ‘‘, or in the Medicare 2 Transition 3 1002(a) of the Medicare for All Act of 2017,’’ 4 after ‘‘coverage’’ in paragraph (1); plan established under section 5 (B) by redesignating paragraphs (1) (as so 6 amended) and (2) as subparagraphs (A) and 7 (B), respectively, and by moving such subpara- 8 graphs 2 ems to the right; 9 (C) by striking ‘‘INSURED.—In this sec- 10 tion’’ and inserting ‘‘INSURED.— 11 ‘‘(1) IN GENERAL.—In this section’’; 12 (D) by striking the flush language; and 13 (E) by adding at the end the following new 14 paragraph: 15 ‘‘(2) SPECIAL 16 RULES.— ‘‘(A) INDIVIDUALS LAWFULLY PRESENT.— 17 In the case of an individual described in section 18 36B(c)(1)(B) of the Internal Revenue Code of 19 1986, the individual shall be treated as having 20 household income equal to 100 percent of the 21 poverty line for a family of the size involved for 22 purposes of applying this section. 23 ‘‘(B) MEDICARE 24 ROLLEES 25 STATES.—In IN TRANSITION MEDICAID PLAN EN- NON-EXPANSION the case of an individual residing TAM17H14 S.L.C. 82 1 in a State which (as of the date of the enact- 2 ment of the Medicare for All Act of 2017) does 3 not provide for eligibility under clause (i)(VIII) 4 or (ii)(XX) of section 1902(a)(10)(A) of the So- 5 cial Security Act for medical assistance under 6 title XIX of such Act (or a waiver of the State 7 plan approved under section 1115) who enrolls 8 in such Medicare Transition plan, the preceding 9 sentence, paragraph (1)(B), and paragraphs 10 (1)(A)(i) and (2)(A) of subsection (c) shall each 11 be applied by substituting ‘0 percent’ for ‘100 12 percent’ each place it appears. 13 ‘‘(C) ADJUSTED COST-SHARING FOR MEDI- 14 CARE TRANSITION PLAN ENROLLEES.—In 15 case of any individual who enrolls in such Medi- 16 care Transition plan, in lieu of the percentages 17 under subsection (c)(1)(B)(i) and (c)(2), the 18 Secretary shall prescribe a method of deter- 19 mining the cost-sharing reduction for any such 20 individual such that the total of the cost-shar- 21 ing and the premiums paid by the individual 22 under such Medicare Transition plan does not 23 exceed the percentage of the total allowed costs 24 of benefits provided under the plan equal to the 25 final premium percentage applicable to such in- the TAM17H14 S.L.C. 83 1 dividual under section 36B(b)(3)(A)(ii) of the 2 Internal Revenue Code of 1986.’’. 3 4 (h) CONFORMING AMENDMENTS.— (1) TREATMENT AS A QUALIFIED HEALTH 5 PLAN.—Section 6 and Affordable Care Act (42 U.S.C. 18021(a)(2)) is 7 amended— 8 9 10 11 1301(a)(2) of the Patient Protection (A) in the paragraph heading, by inserting ‘‘, THE MEDICARE TRANSITION PLAN,’’ before ‘‘AND’’; and (B) by inserting ‘‘The Medicare Transition 12 plan,’’ before ‘‘and a multi-State plan’’. 13 (2) LEVEL PLAYING FIELD.—Section 1324(a) 14 of the Patient Protection and Affordable Care Act 15 (42 U.S.C. 18044(a)) is amended by inserting ‘‘the 16 Medicare Transition plan,’’ before ‘‘or a multi-State 17 qualified health plan’’. 19 Subtitle B—Transitional Medicare Reforms 20 SEC. 1011. MEDICARE PROTECTION AGAINST HIGH OUT-OF- 21 POCKET EXPENDITURES FOR FEE-FOR-SERV- 22 ICE BENEFITS AND ELIMINATION OF PARTS A 23 AND B DEDUCTIBLES. 18 24 (a) PROTECTION AGAINST HIGH OUT-OF-POCKET 25 EXPENDITURES.—Title XVIII of the Social Security Act TAM17H14 S.L.C. 84 1 (42 U.S.C. 1395 et seq.), as amended by section 1001, 2 is amended by adding at the end the following new section: 3 ‘‘PROTECTION 4 5 AGAINST HIGH OUT-OF-POCKET EXPENDITURES ‘‘SEC. 1899D. (a) IN GENERAL.—Notwithstanding 6 any other provision of this title, in the case of an indi7 vidual entitled to, or enrolled for, benefits under part A 8 or enrolled in part B, if the amount of the out-of-pocket 9 cost-sharing of such individual for a year (effective the 10 year beginning January 1 of the year following the date 11 of enactment of the Medicare for All Act of 2017) equals 12 or exceeds $1,500, the individual shall not be responsible 13 for additional out-of-pocket cost-sharing occurred during 14 that year. 15 16 ‘‘(b) OUT-OF-POCKET COST-SHARING DEFINED.— ‘‘(1) IN GENERAL.—Subject to paragraphs (2) 17 and (3), in this section, the term ‘out-of-pocket cost- 18 sharing’ means, with respect to an individual, the 19 amount of the expenses incurred by the individual 20 that are attributable to— 21 22 ‘‘(A) coinsurance and copayments applicable under part A or B; or 23 ‘‘(B) for items and services that would 24 have otherwise been covered under part A or B 25 but for the exhaustion of those benefits. 26 ‘‘(2) CERTAIN COSTS NOT INCLUDED.— TAM17H14 S.L.C. 85 1 ‘‘(A) NON-COVERED ITEMS AND SERV- 2 ICES.—Expenses 3 ices which are not included (or treated as being 4 included) under part A or B shall not be con- 5 sidered incurred expenses for purposes of deter- 6 mining out-of-pocket cost-sharing under para- 7 graph (1). 8 ‘‘(B) ITEMS incurred for items and serv- AND SERVICES NOT FUR- 9 NISHED ON AN ASSIGNMENT-RELATED BASIS.— 10 If an item or service is furnished to an indi- 11 vidual under this title and is not furnished on 12 an assignment-related basis, any additional ex- 13 penses the individual incurs above the amount 14 the individual would have incurred if the item 15 or service was furnished on an assignment-re- 16 lated basis shall not be considered incurred ex- 17 penses for purposes of determining out-of-pock- 18 et cost-sharing under paragraph (1). 19 ‘‘(3) SOURCE OF PAYMENT.—For purposes of 20 paragraph (1), the Secretary shall consider expenses 21 to be incurred by the individual without regard to 22 whether the individual or another person, including 23 a State program or other third-party coverage, has 24 paid for such expenses.’’. TAM17H14 S.L.C. 86 1 (b) ELIMINATION OF PARTS A AND B 2 DEDUCTIBLES.— 3 (1) PART A.—Section 1813(b) of the Social Se- 4 curity Act (42 U.S.C. 1395e(b)) is amended by add- 5 ing at the end the following new paragraph: 6 ‘‘(4) For each year (beginning January 1 of the year 7 following the date of enactment of the Medicare for All 8 Act of 2017), the inpatient hospital deductible for the year 9 shall be $0.’’. 10 (2) PART B.—Section 1833(b) of the Social Se- 11 curity Act (42 U.S.C. 1395l(b)) is amended, in the 12 first sentence— 13 (A) by striking ‘‘and for a subsequent 14 year’’ and inserting ‘‘for each of 2006 through 15 the year that includes the date of enactment of 16 the Medicare for All Act of 2017’’; and 17 18 (B) by inserting ‘‘, and $0 for each year subsequent year’’ after ‘‘$1)’’. 19 SEC. 1012. REDUCTION IN MEDICARE PART D ANNUAL OUT- 20 OF-POCKET THRESHOLD AND ELIMINATION 21 OF COST-SHARING ABOVE THAT THRESHOLD. 22 (a) REDUCTION.—Section 1860D–2(b)(4)(B) of the 23 Social Security Act (42 U.S.C. 1395w–102(b)(4)(B)) is 24 amended— TAM17H14 S.L.C. 87 1 (1) in clause (i), by striking ‘‘For purposes’’ 2 and inserting ‘‘Subject to clause (iii), for purposes’’; 3 and 4 5 6 7 8 (2) by adding at the end the following new clause: ‘‘(iii) REDUCTION IN THRESHOLD DURING TRANSITION PERIOD.— ‘‘(I) IN GENERAL.—Subject to 9 subclause (II), for plan years begin- 10 ning on or after January 1 following 11 the date of enactment of the Medicare 12 for All Act of 2017 and before Janu- 13 ary 1 of the year that is 4 years fol- 14 lowing such date of enactment, not- 15 withstanding clauses (i) and (ii), the 16 ‘annual out-of-pocket threshold’ speci- 17 fied in this subparagraph is equal to 18 $305. 19 ‘‘(II) AUTHORITY TO EXEMPT 20 BRAND-NAME 21 AVAILABLE.—In 22 (I), the Secretary may exempt costs 23 incurred for a covered part D drug 24 that is an applicable drug under sec- 25 tion 1860D–14A(g)(2) if the Sec- DRUGS IF GENERIC applying subclause TAM17H14 S.L.C. 88 1 retary determines that a generic 2 version of that drug is available.’’. 3 (b) ELIMINATION OF COST-SHARING.—Section 4 1860D–2(b)(4)(A) of the Social Security Act (42 U.S.C. 5 1395w–102(b)(4)(A)) is amended— 6 7 8 (1) in clause (i)— (A) by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively; 9 (B) by striking ‘‘subparagraph (B), with 10 cost-sharing’’ and inserting the following: ‘‘sub- 11 paragraph (B)— 12 ‘‘(I) for plan years 2006 through 13 the plan year ending December 31 fol- 14 lowing the date of enactment of the 15 Medicare for All Act of 2017, with 16 cost-sharing’’; 17 (C) in item (bb), as redesignated by sub- 18 paragraph (A), by striking the period at the 19 end and inserting ‘‘; and’’; and 20 21 (D) by adding at the end the following new subclause: 22 ‘‘(II) for the plan year beginning 23 January 1 following the date of enact- 24 ment of the Medicare for All Act of TAM17H14 S.L.C. 89 1 2017 and the two subsequent plan 2 years, without any cost-sharing.’’; and 3 4 5 (2) in clause (ii)— (A) by striking ‘‘clause (i)(I)’’ and inserting ‘‘clause (i)(I)(aa)’’; and 6 (B) by adding at the end the following new 7 sentence: ‘‘The Secretary shall continue to cal- 8 culate the dollar amounts specified in clause 9 (i)(I)(aa), including with the adjustment under 10 this clause, after plan year 2018 for purposes 11 of 1860D–14(a)(1)(D)(iii).’’. 12 (c) CONFORMING AMENDMENTS LOW-INCOME TO 13 SUBSIDY.—Section 1860D–14(a) of the Social Security 14 Act (42 U.S.C. 1395w–114(a)) is amended— 15 16 (1) in paragraph (1)— (A) in subparagraph (D)(iii), by striking 17 ‘‘1860D–2(b)(4)(A)(i)(I)’’ 18 ‘‘1860D–2(b)(4)(A)(i)(I)(aa)’’; and 19 20 and inserting (B) in subparagraph (E)— (i) in the heading, by inserting 21 ‘‘PRIOR 22 COST-SHARING 23 after ‘‘THRESHOLD’’; and TO THE ELIMINATION OF SUCH FOR ALL INDIVIDUALS’’ 24 (ii) by striking ‘‘The elimination’’ and 25 inserting ‘‘For plan years 2006 through TAM17H14 S.L.C. 90 1 the plan year ending December 31 fol- 2 lowing the date of enactment of the Medi- 3 care for All Act of 2017, the elimination’’; 4 and 5 6 (2) in paragraph (2)(E)— (A) in the heading, by inserting ‘‘PRIOR TO 7 THE ELIMINATION OF SUCH COST-SHARING FOR 8 ALL INDIVIDUALS’’ after ‘‘THRESHOLD’’; 9 (B) by striking ‘‘Subject to’’ and inserting 10 ‘‘For plan years 2006 through the plan year 11 ending December 31 following the date of en- 12 actment of the Medicare for All Act of 2017, 13 subject to’’; and 14 15 16 (C) by striking ‘‘1860D–2(b)(4)(A)(i)(I)’’ and inserting ‘‘1860D–2(b)(4)(A)(i)(I)(aa)’’. SEC. 1013. COVERAGE OF DENTAL AND VISION SERVICES 17 AND 18 UNDER MEDICARE PART B. HEARING AIDS 19 (a) DENTAL SERVICES.— 20 (1) REMOVAL OF AND EXAMINATIONS EXCLUSION FROM COV- 21 ERAGE.—Section 22 (42 U.S.C. 1395y(a)) is amended by striking para- 23 graph (12). 24 1862(a) of the Social Security Act (2) COVERAGE.— TAM17H14 S.L.C. 91 1 (A) IN GENERAL.—Section 1861(s)(2) of 2 the Social Security Act (42 U.S.C. 1395x(s)(2)) 3 is amended— 4 5 (i) in subparagraph (FF), by striking ‘‘and’’ at the end; 6 7 (ii) in subparagraph (GG), by inserting ‘‘and’’ at the end; and 8 9 10 (iii) by adding at the end the following new subparagraph: ‘‘(HH) dental services;’’. 11 (B) PAYMENT.—Section 1833(a)(1) of the 12 Social Security Act (42 U.S.C. 1395l(a)(1)) is 13 amended— 14 15 (i) by striking ‘‘and’’ before ‘‘(BB)’’; and 16 (ii) by inserting before the semicolon 17 at the end the following: ‘‘, and (CC) with 18 respect to dental services described in sec- 19 tion 1861(s)(2)(HH), the amount paid 20 shall be an amount equal to 80 percent of 21 the lesser of the actual charge for the serv- 22 ices or the amount determined under the 23 fee schedule established under section 24 1848(b).’’. TAM17H14 S.L.C. 92 1 (C) EFFECTIVE DATE.—The amendments 2 made by this subsection shall apply to items 3 and services furnished on or after January 1 4 following the date of the enactment of this Act. 5 6 (b) VISION SERVICES.— (1) IN GENERAL.—Section 1861(s)(2) of the 7 Social Security Act (42 U.S.C. 1395x(s)(2)), as 8 amended by subsection (a), is amended— 9 10 (A) in subparagraph (GG), by striking ‘‘and’’ at the end; 11 12 (B) in subparagraph (HH), by inserting ‘‘and’’ at the end; and 13 (C) by adding at the end the following new 14 subparagraph: 15 ‘‘(II) vision services;’’. 16 (2) PAYMENT.—Section 1833(a)(1) of the So- 17 cial Security Act (42 U.S.C. 1395l(a)(1)), as amend- 18 ed by subsection (a), is amended— 19 (A) by striking ‘‘and’’ before ‘‘(CC)’’; and 20 (B) by inserting before the semicolon at 21 the end the following: ‘‘, and (DD) with respect 22 to 23 1861(s)(2)(II), the amount paid shall be an 24 amount equal to 80 percent of the lesser of the 25 actual charge for the services or the amount de- vision services described in section TAM17H14 S.L.C. 93 1 termined under the fee schedule established 2 under section 1848(b).’’. 3 (3) EFFECTIVE DATE.—The amendments made 4 by this subsection shall apply to items and services 5 furnished on or after January 1 following the date 6 of the enactment of this Act. 7 (c) HEARING AIDS 8 9 AND EXAMINATIONS THERE- FOR.— (1) IN GENERAL.—Section 1862(a)(7) of the 10 Social Security Act (42 U.S.C. 1395y(a)(7)) is 11 amended by striking ‘‘hearing aids or examinations 12 therefor,’’. 13 (2) EFFECTIVE DATE.—The amendment made 14 by this subsection shall apply to items and services 15 furnished on or after January 1 following the date 16 of the enactment of this Act. 17 SEC. 1014. ELIMINATING THE 24-MONTH WAITING PERIOD 18 FOR MEDICARE COVERAGE FOR INDIVID- 19 UALS WITH DISABILITIES. 20 (a) IN GENERAL.—Section 226(b) of the Social Secu- 21 rity Act (42 U.S.C. 426(b)) is amended— 22 23 24 25 (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,’’; TAM17H14 S.L.C. 94 1 (3) in paragraph (2)(C)(ii), by striking ‘‘, in- 2 cluding the requirement that he has been entitled to 3 the specified benefits for 24 months,’’; 4 (4) in the first sentence, by striking ‘‘for each 5 month beginning with the later of (I) July 1973 or 6 (II) the twenty-fifth month of his entitlement or sta- 7 tus as a qualified railroad retirement beneficiary de- 8 scribed in paragraph (2), and’’ and inserting ‘‘for 9 each month for which the individual meets the re- 10 quirements of paragraph (2), beginning with the 11 month following the month in which the individual 12 meets the requirements of such paragraph, and’’; 13 and 14 (5) in the second sentence, by striking ‘‘the 15 ‘twenty-fifth month of his entitlement’ ’’ and all that 16 follows through ‘‘paragraph (2)(C) and’’. 17 (b) CONFORMING AMENDMENTS.— 18 19 20 21 22 (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) 23 as subsections (f) and (g), respectively. 24 (2) MEDICARE 25 DESCRIPTION.—Section 1811(2) of the Social Security Act (42 U.S.C. 1395c(2)) is TAM17H14 S.L.C. 95 1 amended by striking ‘‘have been entitled for not less 2 than 24 months’’ and inserting ‘‘are entitled’’. 3 (3) MEDICARE COVERAGE.—Section 1837(g)(1) 4 of the Social Security Act (42 U.S.C. 1395p(g)(1)) 5 is amended by striking ‘‘25th month of’’ and insert- 6 ing ‘‘month following the first month of’’. 7 (4) RAILROAD RETIREMENT SYSTEM.—Section 8 7(d)(2)(ii) of the Railroad Retirement Act of 1974 9 (45 U.S.C. 231f(d)(2)(ii)) is amended— 10 (A) by striking ‘‘has been entitled to an 11 annuity’’ and inserting ‘‘is entitled to an annu- 12 ity’’; 13 14 (B) by striking ‘‘, for not less than 24 months’’; and 15 16 17 (C) by striking ‘‘could have been entitled for 24 calendar months, and’’. (c) EFFECTIVE DATE.—The amendments made by 18 this section shall apply to insurance benefits under title 19 XVIII of the Social Security Act with respect to items and 20 services furnished in months beginning after December 1 21 following the date of enactment of this Act, and before 22 January 1 of the year that is 4 years after such date of 23 enactment. TAM17H14 S.L.C. 96 1 TITLE XI—MISCELLANEOUS 2 SEC. 1101. DEFINITIONS. 3 In this Act— 4 5 (1) the term ‘‘Secretary’’ means the Secretary of Health and Human Services; 6 (2) the term ‘‘State’’ means a State, the Dis- 7 trict of Columbia, or a territory of the United 8 States; and 9 (3) the term ‘‘United States’’ shall include the 10 States, the District of Columbia, and the territories 11 of the United States.