II 116TH CONGRESS 1ST SESSION S. 1129 To establish a Medicare-for-all national health insurance program. IN THE SENATE OF THE UNITED STATES APRIL 10, 2019 Mr. SANDERS (for himself, Ms. BALDWIN, Mr. BLUMENTHAL, Mr. BOOKER, Mrs. GILLIBRAND, Ms. HARRIS, Mr. LEAHY, Mr. MARKEY, Mr. MERKLEY, Mr. SCHATZ, Mr. UDALL, Ms. WARREN, Mr. WHITEHOUSE, Ms. HIRONO, and Mr. HEINRICH) introduced the following bill; which was read twice and referred to the Committee on Finance 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 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 4 (a) SHORT TITLE.—This Act may be cited as the 5 ‘‘Medicare for All Act of 2019’’. 6 (b) TABLE OF CONTENTS.—The table of contents for pamtmann on DSKBFK8HB2PROD with BILLS 7 this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM; UNIVERSAL ENTITLEMENT; ENROLLMENT VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6211 E:\BILLS\S1129.IS S1129 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. Sec. 201. 202. 203. 204. 205. 206. Comprehensive benefits. No cost-sharing. Exclusions and limitations. Coverage of institutional long-term care services under Medicaid. Prohibiting recovery of correctly paid Medicaid benefits. 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. pamtmann on DSKBFK8HB2PROD with BILLS 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. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6211 E:\BILLS\S1129.IS S1129 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. Sec. 1015. Guaranteed issue of Medigap policies. Subtitle C—Private Health Insurance Availability During Transitional Period Sec. 1021. Continuity of care. TITLE XI—MISCELLANEOUS pamtmann on DSKBFK8HB2PROD with BILLS Sec. 1101. Updating resource limits for Supplemental Security Income eligibility (SSI). Sec. 1102. Definitions. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6211 E:\BILLS\S1129.IS S1129 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 PROGRAM. 7 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 SEC. 102. UNIVERSAL ENTITLEMENT. 13 (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- pamtmann on DSKBFK8HB2PROD with BILLS 19 retary— 20 (1) may make eligible for benefits for health 21 care services under this Act other individuals not de- 22 scribed in subsection (a) and regulate their eligibility 23 to ensure that every person in the United States has 24 access to health care; and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 5 1 (2) shall promulgate a rule, consistent with 2 Federal immigration laws, to prevent an individual 3 from traveling to the United States for the sole pur- 4 pose of obtaining health care services provided under 5 this Act. 6 SEC. 103. FREEDOM OF CHOICE. 7 Any individual entitled to benefits under this Act may 8 obtain health services from any institution, agency, or in9 dividual qualified to participate under this Act. 10 SEC. 104. NON-DISCRIMINATION. 11 (a) IN GENERAL.—No person shall, on the basis of 12 race, color, national origin, age, disability, or sex, includ13 ing sex stereotyping, gender identity, sexual orientation, 14 and pregnancy and related medical conditions (including 15 termination of pregnancy), be excluded from participation 16 in, be denied the benefits of, or be subjected to discrimina17 tion by any participating provider as defined in section 18 301, or any entity conducting, administering, or funding 19 a health program or activity, including contracts of insur20 ance, pursuant to this Act. 21 (b) CLAIMS OF DISCRIMINATION.— pamtmann on DSKBFK8HB2PROD with BILLS 22 (1) IN GENERAL.—The Secretary shall establish 23 a procedure for adjudication of administrative com- 24 plaints alleging a violation of subsection (a). •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 6 1 (2) JURISDICTION.—Any person aggrieved by a 2 violation of subsection (a) by a covered entity may 3 file suit in any district court of the United States 4 having jurisdiction of the parties. 5 (3) DAMAGES.—If the court finds a violation of 6 subsection (a), the court may grant compensatory 7 and punitive damages, declaratory relief, injunctive 8 relief, attorneys’ fees and costs, or other relief as ap- 9 propriate. 10 SEC. 105. ENROLLMENT. 11 (a) IN GENERAL.—The Secretary shall provide a 12 mechanism for the enrollment of individuals eligible for pamtmann on DSKBFK8HB2PROD with BILLS 13 benefits under this Act. The mechanism shall— 14 (1) include a process for the automatic enroll- 15 ment of individuals at the time of birth in the 16 United States or upon the establishment of resi- 17 dency in the United States; 18 (2) provide for the enrollment, as of the date 19 described in section 106, of all individuals who are 20 eligible to be enrolled as of such date; and 21 (3) include a process for the enrollment of indi- 22 viduals made eligible for health care services under 23 section 102(b). 24 (b) ISSUANCE OF UNIVERSAL MEDICARE CARDS.— 25 In conjunction with an individual’s enrollment for benefits •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 7 1 under this Act, the Secretary shall provide for the issuance 2 of a Universal Medicare card that shall be used for pur3 poses of identification and processing of claims for bene4 fits under this program. The card shall not include an in5 dividual’s Social Security number. 6 SEC. 106. EFFECTIVE DATE OF BENEFITS. 7 (a) IN GENERAL.—Except as provided in subsection 8 (b), benefits shall first be available under this Act for 9 items and services furnished on January 1 of the fourth 10 calendar year that begins after the date of enactment of 11 this Act. 12 (b) COVERAGE FOR CHILDREN.— 13 (1) IN any eligible individual 14 who has not yet attained the age of 19, benefits 15 shall first be available under this Act for items and 16 services furnished on January 1 of the first calendar 17 year that begins after the date of enactment of this 18 Act. 19 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—For (2) OPTION TO CONTINUE IN OTHER COVERAGE 20 DURING TRANSITION PERIOD.—Any 21 eligible to receive benefits as described in paragraph 22 (1) may opt to maintain any coverage described in 23 section 901, private health insurance coverage, or 24 coverage offered pursuant to subtitle A of title X person who is •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 8 1 (including the amendments made by such subtitle) 2 until the effective date described in subsection (a). 3 SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. 4 (a) IN GENERAL.—Beginning on the effective date 5 described in section 106(a), it shall be unlawful for— 6 (1) a private health insurer to sell health insur- 7 ance coverage that duplicates the benefits provided 8 under this Act; or 9 (2) an employer to provide benefits for an em- 10 ployee, former employee, or the dependents of an 11 employee or former employee that duplicate the ben- 12 efits provided under this Act. 13 (b) CONSTRUCTION.—Nothing in this Act shall be 14 construed as prohibiting the sale of health insurance cov15 erage for any additional benefits not covered by this Act, 16 including additional benefits that an employer may provide 17 to employees or their dependents, or to former employees 18 or their dependents. 22 TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND BENEFITS FOR LONG-TERM CARE 23 SEC. 201. COMPREHENSIVE BENEFITS. 19 20 pamtmann on DSKBFK8HB2PROD with BILLS 21 24 (a) IN GENERAL.—Subject to the other provisions of 25 this title and titles IV through IX, individuals enrolled for •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 9 1 benefits under this Act are entitled to have payment made 2 by the Secretary to an eligible provider for the following 3 items and services if medically necessary or appropriate 4 for the maintenance of health or for the diagnosis, treat5 ment, or rehabilitation of a health condition: 6 (1) Hospital services, including inpatient and 7 outpatient hospital care, including 24-hour-a-day 8 emergency services and inpatient prescription drugs. 9 (2) Ambulatory patient services. 10 11 (3) Primary and preventive services, including chronic disease management. 12 (4) Prescription drugs, medical devices, biologi- 13 cal products, including outpatient prescription drugs, 14 medical devices, and biological products. 15 16 ment services, including inpatient care. 17 (6) Laboratory and diagnostic services. 18 (7) Comprehensive reproductive, maternity, and 19 pamtmann on DSKBFK8HB2PROD with BILLS (5) Mental health and substance abuse treat- newborn care. 20 (8) Pediatrics, including early and periodic 21 screening, diagnostic, and treatment services (as de- 22 fined in section 1905(r) of the Social Security Act 23 (42 U.S.C. 1396d(r))). 24 (9) Oral health, audiology, and vision services. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 10 1 pamtmann on DSKBFK8HB2PROD with BILLS 2 (10) Short-term rehabilitative and habilitative services and devices. 3 (11) Emergency services and transportation. 4 (12) Necessary transportation to receive health 5 care services for individuals with disabilities and low- 6 income individuals. 7 (13) Home and community-based long-term 8 services and supports (to be provided in accordance 9 with the requirements for home and community- 10 based settings under sections 441.530 and 441.710 11 of title 42, Code of Federal Regulations), includ- 12 ing— 13 (A) services described in paragraphs (7), 14 (8), (13), (19), and (24) of section 1905(a) of 15 the Social Security Act (42 U.S.C. 1396d(a)); 16 (B) home and community-based services 17 described in subsection (c)(4)(B) of section 18 1915 of the Social Security Act (including ha- 19 bilitation services defined in subsection (c)(5) of 20 such section); 21 (C) self-directed home and community- 22 based services described in subsection (i) of sec- 23 tion 1915 of the Social Security Act; •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 11 1 (D) self-directed personal assistance serv- 2 ices (as defined in subsection (j)(4)(A) of sec- 3 tion 1915 of the Social Security Act); and 4 (E) home and community-based attendant 5 services and supports described in subsection 6 (k) of section 1915 of the Social Security Act. 7 (b) REVISION AND ADJUSTMENT.—The Secretary 8 shall, on a regular basis, evaluate whether the benefits 9 package should be improved or adjusted to promote the 10 health of beneficiaries, account for changes in medical 11 practice or new information from medical research, or re12 spond to other relevant developments in health science, 13 and shall make recommendations to Congress regarding 14 any such improvements or adjustments. 15 16 (c) COMPLEMENTARY INTEGRATIVE MEDI- CINE.— 17 pamtmann on DSKBFK8HB2PROD with BILLS AND (1) IN GENERAL.—In carrying out subsection 18 (b), the Secretary shall consult with the persons de- 19 scribed in paragraph (1) with respect to— 20 (A) identifying specific complementary and 21 integrative medicine practices that, on the basis 22 of research findings or promising clinical inter- 23 ventions, are appropriate to include in the bene- 24 fits package; and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 12 1 (B) identifying barriers to the effective 2 provision and integration of such practices into 3 the delivery of health care, and identifying 4 mechanisms for overcoming such barriers. 5 (2) CONSULTATION.—In accordance with para- 6 graph (1), the Secretary shall consult with— 7 (A) the Director of the National Center for 8 Complementary and Integrative Health; 9 (B) the Commissioner of Food and Drugs; 10 (C) institutions of higher education, pri- 11 vate research institutes, and individual re- 12 searchers with extensive experience in com- 13 plementary and integrative medicine and the in- 14 tegration of such practices into the delivery of 15 health care; 16 (D) nationally recognized providers of com- 17 plementary and integrative medicine; and 18 (E) such other officials, entities, and indi- 19 viduals with expertise on complementary and 20 integrative medicine as the Secretary deter- 21 mines appropriate. 22 pamtmann on DSKBFK8HB2PROD with BILLS 23 (d) STATES MAY PROVIDE ADDITIONAL BENEFITS.—Individual States may provide additional benefits 24 for the residents of such States at the expense of the 25 State. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 13 1 SEC. 202. NO COST-SHARING. 2 (a) IN GENERAL.—The Secretary shall ensure that 3 no cost-sharing, including deductibles, coinsurance, copay4 ments, or similar charges, be imposed on an individual for 5 any benefits provided under this Act, except as described 6 in subsection (b). 7 (b) EXCEPTIONS.—The Secretary may set a cost- 8 sharing schedule for prescription drugs and biological 9 products— 10 (1) provided that— 11 (A) such schedule is evidence-based and 12 encourages the use of generic drugs; 13 (B) such cost-sharing does not apply to pamtmann on DSKBFK8HB2PROD with BILLS 14 preventive drugs; 15 (C) such cost-sharing does not exceed $200 16 annually per individual, adjusted annually for 17 inflation; and 18 (D) such cost-sharing is not imposed on in- 19 dividuals with a household income equal to or 20 below 200 percent of the poverty line for a fam- 21 ily of the size involved; and 22 (2) under which the Secretary may exempt 23 brand-name drugs from consideration in determining 24 whether an individual has reached any out-of-pocket 25 limit if a generic version of such drug is available. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 14 1 (c) NO BALANCE BILLING.—Notwithstanding con- 2 tracts in accordance with section 303, no provider may 3 impose a charge to an enrolled individual for covered serv4 ices for which benefits are provided under this Act. 5 SEC. 203. EXCLUSIONS AND LIMITATIONS. 6 (a) IN GENERAL.—Benefits for services are not avail- 7 able under this Act unless the services meet the standards 8 specified in section 201(a), as defined by the Secretary. 9 (b) TREATMENT EXPERIMENTAL SERVICES OF AND 10 DRUGS.— 11 (1) IN applying subsection (a), 12 the Secretary shall make national coverage deter- 13 minations with respect to services that are experi- 14 mental in nature. Such determinations shall be con- 15 sistent with the national coverage determination 16 process as defined in section 1869(f)(1)(B) of the 17 Social Security Act (42 U.S.C. 1395ff(f)(1)(B)). 18 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—In (2) APPEALS PROCESS.—The Secretary shall 19 establish a process by which individuals can appeal 20 coverage decisions. The process shall, as much as is 21 feasible, follow process for appeals under the Medi- 22 care program described in section 1869 of the Social 23 Security Act (42 U.S.C. 1395ff). 24 (c) APPLICATION OF PRACTICE GUIDELINES.—In the 25 case of services for which the Department of Health and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 15 1 Human Services has recognized a national practice guide2 line, the services are considered to meet the standards 3 specified in section 201(a) if they have been provided in 4 accordance with such guideline. For purposes of this sub5 section, a service shall be considered to have been provided 6 in accordance with a practice guideline if the health care 7 provider providing the service exercised appropriate pro8 fessional discretion to deviate from the guideline in a man9 ner authorized or anticipated by the guideline. 10 SEC. 204. COVERAGE OF INSTITUTIONAL LONG-TERM CARE 11 12 SERVICES UNDER MEDICAID. Title XIX of the Social Security Act (42 U.S.C. 1396 13 et seq.) is amended by inserting the following section after 14 section 1946: 15 ‘‘STATE PLAN FOR PROVIDING INSTITUTIONAL LONG- 16 17 TERM CARE SERVICES ‘‘SEC. 1947. (a) IN GENERAL.—For quarters begin- 18 ning on or after date on which benefits are first available 19 under section 106(a) of the Medicare for All Act of 2019, pamtmann on DSKBFK8HB2PROD with BILLS 20 notwithstanding any other provision of this title— 21 ‘‘(1) a State plan for medical assistance shall 22 provide for making medical assistance available for 23 services that are institutional long-term care services 24 in a manner consistent with this section; and 25 ‘‘(2) no payment to a State shall be made 26 under this title with respect to expenditures incurred •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 16 1 by the State in providing medical assistance on or 2 after such date for services that are not— 3 ‘‘(A) institutional long-term care services; 4 or 5 ‘‘(B) other services for which benefits are 6 not available under the Medicare for All Act of 7 2019 and which are furnished under a State 8 plan for medical assistance which provided for 9 medical assistance for such services on Sep- 10 11 tember 1, 2018. ‘‘(b) INSTITUTIONAL LONG-TERM CARE SERVICES 12 DEFINED.—In this section, the term ‘institutional long13 term care services’ means the following: 14 ‘‘(1) Nursing facility services for individuals 21 15 years of age or over described in subparagraph (A) 16 of section 1905(a)(4). 17 ‘‘(2) Inpatient services for individuals 65 years 18 of age or over provided in an institution for mental 19 disease described in section 1905(a)(14). 20 pamtmann on DSKBFK8HB2PROD with BILLS 21 ‘‘(3) Intermediate care facility services described in section 1905(a)(15). 22 ‘‘(4) Inpatient psychiatric hospital services for 23 individuals under age 21 described in section 24 1905(a)(16). •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 17 1 ‘‘(5) Nursing facility services described in sec- 2 tion 1905(a)(29). 3 ‘‘(c) MAINTENANCE OF EFFORT.— 4 ‘‘(1) ELIGIBILITY 5 ‘‘(A) IN GENERAL.—Beginning on the date 6 described in subsection (a), no payment may be 7 made under section 1903 with respect to med- 8 ical assistance provided under a State plan for 9 medical assistance if the State adopts income, 10 resource, or other standards and methodologies 11 for purposes of determining an individual’s eli- 12 gibility for medical assistance under the State 13 plan that are more restrictive than those ap- 14 plied as of January 1, 2019. 15 pamtmann on DSKBFK8HB2PROD with BILLS STANDARDS.— ‘‘(B) INDEXING OF AMOUNTS OF INCOME 16 AND RESOURCE STANDARDS.—In 17 whether a State has adopted income or resource 18 standards that are more restrictive than the 19 standards which applied as of January 1, 2019, 20 the Secretary shall deem the amount of any 21 such standard that was applied as of such date 22 to be increased by the percentage increase in 23 the medical care component of the consumer 24 price index for all urban consumers (U.S. city 25 average) from September of 2018 to September determining •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 18 1 of the fiscal year for which the Secretary is 2 making such determination. 3 ‘‘(2) EXPENDITURES.— 4 ‘‘(A) IN each fiscal year 5 or portion of a fiscal year that occurs during 6 the period that begins on the first day of the 7 first fiscal quarter that begins on or after the 8 date on which benefits are first available under 9 section 106(a) of the Medicare for All Act of 10 2019, as a condition of receiving payments 11 under section 1903(a), a State shall make ex- 12 penditures for medical assistance for services 13 that are institutional long-term care services in 14 an amount that is not less than the expenditure 15 floor determined for the State and fiscal year 16 (or portion of a fiscal year) under subparagraph 17 (B). 18 ‘‘(B) EXPENDITURE 19 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—For ‘‘(i) IN FLOOR.— GENERAL.—For each fiscal 20 year or portion of a fiscal year described in 21 subparagraph (A), the Secretary shall de- 22 termine for each State an expenditure floor 23 that shall be equal to— 24 ‘‘(I) the amount of the State’s 25 expenditures for fiscal year 2018 on •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 19 1 medical assistance for institutional 2 long-term care services; increased by 3 ‘‘(II) the growth factor deter- 4 mined under subclause (ii). 5 ‘‘(ii) GROWTH cal year or portion of a fiscal year de- 7 scribed in subparagraph (A), the Secretary 8 shall, not later than September 1 of the 9 fiscal year preceding such fiscal year or 10 portion of a fiscal year, determine a 11 growth factor for each State that takes 12 into account— ‘‘(I) the percentage increase in 14 health care costs in the State; 15 ‘‘(II) the total amount expended 16 by the State for the previous fiscal 17 year on medical assistance for institu- 18 tional long-term care services; 19 ‘‘(III) the increase, if any, in the 20 total population of the State from 21 July of 2018 to July of the fiscal year 22 preceding the fiscal year involved; 23 ‘‘(IV) the increase, if any, in the 24 population of individuals aged 65 and 25 older of the State from July of 2018 •S 1129 IS VerDate Sep 11 2014 each fis- 6 13 pamtmann on DSKBFK8HB2PROD with BILLS FACTOR.—For 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 20 1 to July of the fiscal year preceding 2 the fiscal year involved; and 3 ‘‘(V) the decrease, if any, in the 4 population of the State that requires 5 medical assistance for institutional 6 long-term care services that is attrib- 7 utable to the availability of coverage 8 for the services described in section 9 201(a)(13) of the Medicare for All 10 Act of 2019. 11 ‘‘(iii) PRORATION RULE.—Any 12 amount determined under this subpara- 13 graph for a portion of a fiscal year shall be 14 prorated based on the length of such por- 15 tion of a fiscal year relative to a complete 16 fiscal year. 17 18 ‘‘(d) NONAPPLICATION MENTS.—Beginning OF CERTAIN REQUIRE- on the date described in subsection 19 (a), any provision of this title requiring a State plan for 20 medical assistance to make available medical assistance 21 for services that are not institutional long-term care serv22 ices or services described in section 901(a)(3)(A)(ii) of the pamtmann on DSKBFK8HB2PROD with BILLS 23 Medicare for All Act of 2019 shall have no effect.’’. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 21 1 SEC. 205. PROHIBITING RECOVERY OF CORRECTLY PAID 2 MEDICAID BENEFITS. 3 Section 1917 of the Social Security Act (42 U.S.C. 4 1396p) is amended— 5 (1) by amending subsection (a) to read as fol- 6 lows: 7 ‘‘(a) No lien may be imposed against the property 8 of any individual prior to his death on account of medical 9 assistance paid or to be paid on his behalf under the State 10 plan, except pursuant to the judgment of a court on ac11 count of benefits incorrectly paid on behalf of such indi12 vidual.’’; and 13 (2) by amending subsection (b) to read as fol- 14 lows: 15 ‘‘(b) No adjustment or recovery of any medical assist- 16 ance correctly paid on behalf of an individual under the 17 State plan may be made.’’. 18 SEC. 206. STATE STANDARDS. 19 (a) IN GENERAL.—Nothing in this Act shall prohibit 20 individual States from setting additional standards, with 21 respect to eligibility, benefits, and minimum provider 22 standards, consistent with the purposes of this Act, pro- pamtmann on DSKBFK8HB2PROD with BILLS 23 vided that such standards do not restrict eligibility or re24 duce access to benefits or services. 25 (b) RESTRICTIONS ON PROVIDERS.—With respect to 26 any individuals or entities certified to provide services cov•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 22 1 ered under section 201(a)(7), a State may not prohibit 2 an individual or entity from participating in the program 3 under this Act, for reasons other than the ability of the 4 individual or entity to provide such services. TITLE III—PROVIDER PARTICIPATION 5 6 7 SEC. 301. PROVIDER PARTICIPATION AND STANDARDS. 8 (a) IN GENERAL.—An individual or other entity fur- 9 nishing any covered service under this Act is not a quali10 fied provider unless the individual or entity— 11 (1) is a qualified provider of the services under 12 section 302; 13 (2) has filed with the Secretary a participation 14 agreement described in subsection (b); and 15 (3) meets, as applicable, such other qualifica- 16 tions and conditions with respect to a provider of 17 services under title XVIII of the Social Security Act 18 as described in section 1866 of the Social Security 19 Act (42 U.S.C. 1395cc). 20 (b) REQUIREMENTS 21 PARTICIPATION AGREE- MENT.— 22 pamtmann on DSKBFK8HB2PROD with BILLS IN (1) IN GENERAL.—A participation agreement 23 described in this subsection between the Secretary 24 and a provider shall provide at least for the fol- 25 lowing: •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 23 1 (A) Services to eligible persons will be fur- 2 nished by the provider without discrimination, 3 in accordance with section 104(a). Nothing in 4 this subparagraph shall be construed as requir- 5 ing the provision of a type or class of services 6 that are outside the scope of the provider’s nor- 7 mal practice. 8 (B) No charge will be made to any enrolled 9 individual for any covered services other than 10 for payment authorized by this Act. 11 (C) The provider agrees to furnish such in- 12 formation as may be reasonably required by the 13 Secretary, in accordance with uniform reporting 14 standards established under section 401(b)(1), 15 for— 16 (i) quality review by designated enti- pamtmann on DSKBFK8HB2PROD with BILLS 17 ties; 18 (ii) making payments under this Act, 19 including the examination of records as 20 may be necessary for the verification of in- 21 formation on which such payments are 22 based; 23 (iii) statistical or other studies re- 24 quired for the implementation of this Act; 25 and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 24 1 (iv) such other purposes as the Sec- 2 retary may specify. 3 (D) In the case of a provider that is not 4 an individual, the provider agrees not to employ 5 or use for the provision of health services any 6 individual or other provider that has had a par- 7 ticipation agreement under this subsection ter- 8 minated for cause. 9 (E) In the case of a provider paid under 10 a fee-for-service basis, the provider agrees to 11 submit bills and any required supporting docu- 12 mentation relating to the provision of covered 13 services within 30 days after the date of pro- 14 viding such services. 15 (2) TERMINATION 16 MENT.— 17 (A) IN GENERAL.—Participation ments may be terminated, with appropriate no- 19 tice— (i) by the Secretary for failure to meet 21 the requirements of this Act; or 22 (ii) by a provider. 23 (B) TERMINATION PROCESS.—Providers 24 shall be provided notice and a reasonable oppor- 25 tunity to correct deficiencies before the Sec- •S 1129 IS VerDate Sep 11 2014 agree- 18 20 pamtmann on DSKBFK8HB2PROD with BILLS OF PARTICIPATION AGREE- 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 pamtmann on DSKBFK8HB2PROD with BILLS 25 1 retary terminates an agreement unless a more 2 immediate termination is required for public 3 safety or similar reasons. 4 (C) PROVIDER PROTECTIONS.— 5 (i) PROHIBITION.—The Secretary may 6 not terminate a participation agreement or 7 in any other way discriminate against, or 8 cause to be discriminated against, any cov- 9 ered provider or authorized representative 10 of the provider, on account of such pro- 11 vider or representative— 12 (I) providing, causing to be pro- 13 vided, or being about to provide or 14 cause to be provided to the provider, 15 the Federal Government, or the attor- 16 ney general of a State information re- 17 lating to any violation of, or any act 18 or omission the provider or represent- 19 ative reasonably believes to be a viola- 20 tion of, any provision of this title (or 21 an amendment made by this title); 22 (II) testifying or being about to 23 testify in a proceeding concerning 24 such violation; •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 26 1 (III) assisting or participating, or 2 being about to assist or participate, in 3 such a proceeding; or 4 (IV) objecting to, or refusing to 5 participate in, any activity, policy, 6 practice, or assigned task that the 7 provider or representative reasonably 8 believes to be in violation of any provi- 9 sion of this Act (including any amend- 10 ment made by this Act), or any order, 11 rule, regulation, standard, or ban 12 under this Act (including any amend- 13 ment made by this Act). 14 (ii) COMPLAINT pro- 15 vider or representative who believes that he 16 or she has been discriminated against in 17 violation of this section may seek relief in 18 accordance with the procedures, notifica- 19 tions, burdens of proof, remedies, and stat- 20 utes of limitation set forth in section 21 2087(b) of title 15, United States Code. 22 SEC. 302. QUALIFICATIONS FOR PROVIDERS. 23 pamtmann on DSKBFK8HB2PROD with BILLS PROCEDURE.—A (a) IN GENERAL.—A health care provider is consid- 24 ered to be qualified to provide covered services if the pro25 vider is licensed or certified and meets— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 27 1 2 (1) all the requirements of State law to provide such services; and 3 (2) applicable requirements of Federal law to 4 provide such services. 5 (b) MINIMUM PROVIDER STANDARDS.— 6 (1) IN Secretary shall estab- 7 lish, evaluate, and update national minimum stand- 8 ards to ensure the quality of services provided under 9 this Act and to monitor efforts by States to ensure 10 the quality of such services. A State may also estab- 11 lish additional minimum standards which providers 12 shall meet with respect to services provided in such 13 State. 14 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—The (2) NATIONAL MINIMUM STANDARDS.—The 15 tional minimum standards under paragraph (1) shall 16 be established for institutional providers of services 17 and individual health care practitioners. Except as 18 the Secretary may specify in order to carry out this 19 Act, a hospital, skilled nursing facility, or other in- 20 stitutional provider of services shall meet standards 21 for such a provider under the Medicare program 22 under title XVIII of the Social Security Act (42 23 U.S.C. 1395 et seq.). Such standards also may in- 24 clude, where appropriate, elements relating to— 25 (A) adequacy and quality of facilities; •S 1129 IS VerDate Sep 11 2014 na- 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 28 1 (B) training and competence of personnel 2 (including continuing education requirements); 3 (C) comprehensiveness of service; 4 (D) continuity of service; 5 (E) patient satisfaction, including waiting 6 time and access to services; and 7 (F) performance standards, including orga- 8 nization, facilities, structure of services, effi- 9 ciency of operation, and outcome in palliation, 10 improvement of health, stabilization, cure, or 11 rehabilitation. 12 (3) TRANSITION retary provides for additional requirements for pro- 14 viders under this subsection, any such additional re- 15 quirement shall be implemented in a manner that 16 provides for a reasonable period during which a pre- 17 viously qualified provider is permitted to meet such 18 an additional requirement. (4) ABILITY TO PROVIDE SERVICES.—With re- 20 spect to any entity or provider certified to provide 21 services described in section 201(a)(7), the Secretary 22 may not prohibit such entity or provider from par- 23 ticipating for reasons other than its ability to pro- 24 vide such services. •S 1129 IS VerDate Sep 11 2014 the Sec- 13 19 pamtmann on DSKBFK8HB2PROD with BILLS IN APPLICATION.—If 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 29 1 (c) FEDERAL PROVIDERS.—Any provider qualified to 2 provide health care services through the Department of 3 Veterans Affairs or Indian Health Service is a qualifying 4 provider under this section with respect to any individual 5 who qualifies for such services under applicable Federal 6 law. 7 SEC. 303. USE OF PRIVATE CONTRACTS. 8 (a) IN GENERAL.—Subject to the provisions of this 9 subsection, nothing in this Act shall prohibit an institu10 tional or individual provider from entering into a private 11 contract with an enrolled individual for any item or serv12 ice— 13 14 (1) for which no claim for payment is to be submitted under this Act; and 15 (2) for which the provider receives— 16 (A) no reimbursement under this Act di- 17 rectly or on a capitated basis; and 18 (B) receives no amount for such item or 19 service from an organization which receives re- 20 imbursement for such items or service under 21 this Act directly or on a capitated basis. 22 (b) BENEFICIARY PROTECTIONS.— pamtmann on DSKBFK8HB2PROD with BILLS 23 24 (1) IN GENERAL.—Subsection (a) shall not apply to any contract unless— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00029 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 30 1 (A) the contract is in writing and is signed 2 by the beneficiary before any item or service is 3 provided pursuant to the contract; 4 (B) the contract contains the items de- pamtmann on DSKBFK8HB2PROD with BILLS 5 scribed in paragraph (2); and 6 (C) the contract is not entered into at a 7 time when the beneficiary is facing an emer- 8 gency health care situation. 9 (2) ITEMS REQUIRED TO BE INCLUDED IN CON- 10 TRACT.—Any 11 to which subsection (a) applies shall clearly indicate 12 to the beneficiary that by signing such contract the 13 beneficiary— contract to provide items and services 14 (A) agrees not to submit a claim (or to re- 15 quest that the provider submit a claim) under 16 this Act for such items or services even if such 17 items or services are otherwise covered by this 18 Act; 19 (B) agrees to be responsible, whether 20 through insurance offered under section 107(b) 21 or otherwise, for payment of such items or serv- 22 ices and understands that no reimbursement 23 will be provided under this Act for such items 24 or services; •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 31 1 (C) acknowledges that no limits under this 2 Act apply to amounts that may be charged for 3 such items or services; 4 (D) if the provider is a non-participating 5 provider, acknowledges that the beneficiary has 6 the right to have such items or services pro- 7 vided by other providers for whom payment 8 would be made under this Act; and 9 (E) acknowledges that the provider is pro- 10 viding services outside the scope of the program 11 under this Act. 12 (c) PROVIDER REQUIREMENTS.— 13 (1) IN (a) shall not 14 apply to any contract unless an affidavit described 15 in paragraph (2) is in effect during the period any 16 item or service is to be provided pursuant to the 17 contract. 18 19 (2) AFFIDAVIT.—An affidavit is described in this subparagraph shall— 20 (A) identify the practitioner, and be signed 21 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—Subsection by such practitioner; 22 (B) provide that the practitioner will not 23 submit any claim under this title for any item 24 or service provided to any beneficiary (and will 25 not receive any reimbursement or amount de- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00031 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 pamtmann on DSKBFK8HB2PROD with BILLS 32 1 scribed in paragraph (1)(B) for any such item 2 or service) during the 1-year period beginning 3 on the date the affidavit is signed; and 4 (C) be filed with the Secretary no later 5 than 10 days after the first contract to which 6 such affidavit applies is entered into. 7 (3) ENFORCEMENT.—If a physician or practi- 8 tioner signing an affidavit described in paragraph 9 (2) knowingly and willfully submits a claim under 10 this title for any item or service provided during the 11 1-year period described in paragraph (2)(B) (or re- 12 ceives any reimbursement or amount described in 13 subsection (a)(2) for any such item or service) with 14 respect to such affidavit— 15 (A) this subsection shall not apply with re- 16 spect to any items and services provided by the 17 physician or practitioner pursuant to any con- 18 tract on and after the date of such submission 19 and before the end of such period; and 20 (B) no payment shall be made under this 21 title for any item or service furnished by the 22 physician or practitioner during the period de- 23 scribed in clause (i) (and no reimbursement or 24 payment of any amount described in subsection •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 33 1 (a)(2) shall be made for any such item or serv- 2 ice). TITLE IV—ADMINISTRATION Subtitle A—General Administration Provisions 3 4 5 6 SEC. 401. ADMINISTRATION. 7 (a) GENERAL DUTIES OF THE SECRETARY.— 8 9 10 (1) IN Secretary shall develop policies, procedures, guidelines, and requirements to carry out this Act, including related to— 11 (A) eligibility for benefits; 12 (B) enrollment; 13 (C) benefits provided; 14 (D) provider participation standards and 15 qualifications, as described in title III; 16 (E) levels of funding; 17 (F) methods for determining amounts of 18 payments to providers of covered services, con- 19 sistent with subtitle B; 20 (G) the determination of medical necessity 21 and appropriateness with respect to coverage of 22 certain services; 23 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—The (H) planning for capital expenditures and 24 service delivery; •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 34 1 (I) planning for health professional edu- 2 cation funding; 3 (J) encouraging States to develop regional 4 planning mechanisms; and 5 (K) any other regulations necessary to 6 carry out the purpose of this Act. 7 (2) REGULATIONS.—Regulations authorized by 8 this Act shall be issued by the Secretary in accord- 9 ance with section 553 of title 5, United States Code. 10 (b) UNIFORM REPORTING STANDARDS; ANNUAL RE- 11 PORT; STUDIES.— 12 (1) UNIFORM pamtmann on DSKBFK8HB2PROD with BILLS 13 (A) IN REPORTING STANDARDS.— GENERAL.—The Secretary shall es- 14 tablish uniform State reporting requirements 15 and national standards to ensure an adequate 16 national database containing information per- 17 taining to health services practitioners, ap- 18 proved providers, the costs of facilities and 19 practitioners providing such services, the qual- 20 ity of such services, the outcomes of such serv- 21 ices, and the equity of health among population 22 groups. Such standards shall include, to the 23 maximum extent feasible without compromising 24 patient privacy, health outcome measures, and 25 to the maximum extent feasible without exces- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00034 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 35 1 sively burdening providers, the measures de- 2 scribed in subparagraphs (D) through (F) of 3 subsection (a)(1). 4 (B) REPORTS.—The Secretary shall regu- 5 larly analyze information reported to it and 6 shall define rules and procedures to allow re- 7 searchers, scholars, health care providers, and 8 others to access and analyze data for purposes 9 consistent with quality and outcomes research, 10 without compromising patient privacy. 11 (2) ANNUAL January 1 of 12 the second year beginning after the effective date of 13 this Act, the Secretary shall annually report to Con- 14 gress on the following: 15 (A) The status of implementation of the 16 Act. 17 (B) Enrollment under this Act. 18 (C) Benefits under this Act. 19 (D) Expenditures and financing under this 20 Act. 21 (E) 22 Cost-containment measures achievements under this Act. 23 pamtmann on DSKBFK8HB2PROD with BILLS REPORT.—Beginning (F) Quality assurance. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00035 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 and 36 1 (G) Health care utilization patterns, in- 2 cluding any changes attributable to the pro- 3 gram. 4 (H) Changes in the per-capita costs of 5 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 (K) Necessary changes in the education of 14 health personnel. 15 (L) Plans for improving service to medi- 16 cally underserved populations. 17 (M) Transition problems as a result of im- 18 plementation of this Act. pamtmann on DSKBFK8HB2PROD with BILLS 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- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 37 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 evidence-based policymaking. 10 (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, pamtmann on DSKBFK8HB2PROD with BILLS 23 Indian tribes and urban Indian health organizations, and 24 private entities, such as professional societies, national as25 sociations, nationally recognized associations of experts, •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00037 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 38 1 medical schools and academic health centers, consumer 2 and patient groups, and labor and business organizations 3 in the formulation of guidelines, regulations, policy initia4 tives, and information gathering to ensure the broadest 5 and most informed input in the administration of this Act. 6 Nothing in this Act shall prevent the Secretary from 7 adopting guidelines developed by such a private entity if, 8 in the Secretary’s judgment, such guidelines are generally 9 accepted as reasonable and prudent and consistent with 10 this Act. 11 SEC. 403. REGIONAL ADMINISTRATION. 12 (a) COORDINATION WITH REGIONAL OFFICES.—The 13 Secretary shall establish and maintain regional offices to 14 promote adequate access to, and efficient use of, tertiary 15 care facilities, equipment, and services. Wherever possible, 16 the Secretary shall incorporate regional offices of the Cen17 ters for Medicare & Medicaid Services for this purpose. 18 19 (b) APPOINTMENT TORS.—In 20 21 pamtmann on DSKBFK8HB2PROD with BILLS AND STATE DIREC- each such regional office there shall be— retary; (2) for each State in the region, a deputy director; and 24 25 REGIONAL (1) one regional director appointed by the Sec- 22 23 OF (3) one deputy director to represent the Native American and Alaska Native tribes in the region. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 39 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. pamtmann on DSKBFK8HB2PROD with BILLS 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; •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 40 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 SEC. 405. 21 22 COMPLEMENTARY CONDUCT OF RELATED HEALTH PROGRAMS. In performing functions with respect to health per- pamtmann on DSKBFK8HB2PROD with BILLS 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•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 41 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 (1) Section 1128 (relating to exclusion of indi- 15 viduals 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 ership and related information). 20 (5) Section 1126 (relating to disclosure of cer- 21 tain owners). TITLE V—QUALITY ASSESSMENT 22 pamtmann on DSKBFK8HB2PROD with BILLS 23 SEC. 501. QUALITY STANDARDS. 24 (a) IN GENERAL.—All standards and quality meas- 25 ures under this Act shall be performed by the Center for •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00041 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 42 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 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 pamtmann on DSKBFK8HB2PROD with BILLS GUIDELINES.—The (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, •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00042 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 43 1 and the validity, reliability, and feasibility of meas- 2 uring the standard. pamtmann on DSKBFK8HB2PROD with BILLS 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- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00043 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 44 1 mination of coverage of services under section 2 401(a)(1)(G). 3 SEC. 502. ADDRESSING HEALTH CARE DISPARITIES. 4 5 (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.— pamtmann on DSKBFK8HB2PROD with BILLS 22 (1) REPORT ON EVALUATION.—Not 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 •S 1129 IS VerDate Sep 11 2014 later than 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 pamtmann on DSKBFK8HB2PROD with BILLS 45 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•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 46 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 TITLE VI—HEALTH BUDGET; PAYMENTS; COST CONTAINMENT MEASURES Subtitle A—Budgeting SEC. 601. NATIONAL HEALTH BUDGET. 11 (a) NATIONAL HEALTH BUDGET.— 12 (1) IN 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 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—By (A) Quality assessment activities under 24 title V. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 47 1 (B) Health professional education expendi- 2 tures. 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 15 Secretary shall allocate the budget among the com- 16 ponents in a manner that— 17 (A) ensures a fair allocation for quality as- 18 pamtmann on DSKBFK8HB2PROD with BILLS AMONG COMPONENTS.—The sessment 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 to 5 years following the date on which benefits first •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 up Jkt 089200 PO 00000 Frm 00047 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 48 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 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 pamtmann on DSKBFK8HB2PROD with BILLS FUND.—The (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- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 49 1 Subtitle B—Payments to Providers 2 SEC. 611. PAYMENTS TO INSTITUTIONAL AND INDIVIDUAL 3 PROVIDERS. 4 (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 Af- pamtmann on DSKBFK8HB2PROD with BILLS 22 fordable Care Act (Public Law 111–148). •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00049 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 50 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 ‘‘(P) STANDARDIZED 9 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 pamtmann on DSKBFK8HB2PROD with BILLS AND DOCUMENTED ‘‘(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 •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00050 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 51 1 U.S.C. 1305w–4(c)(2)(M)) is amended by adding at the 2 end the following new clause: 3 ‘‘(x) PLANNED 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 pamtmann on DSKBFK8HB2PROD with BILLS AND (2) MINIMUM REQUIREMENTS.—The 23 shall include, at a minimum, plans and a timeline 24 for achieving the ability to systematically and inter- 25 nally track the following: •S 1129 IS VerDate Sep 11 2014 proposal 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 52 1 (A) When, how, and by whom services are 2 identified for review. 3 (B) When services are reviewed or when 4 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 decisions. 10 (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 (1) in subparagraph (B)(i), by striking ‘‘5’’ and 14 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 VISORY pamtmann on DSKBFK8HB2PROD with BILLS 19 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 •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00052 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 53 1 (B) in subparagraph (K)(i)(I), as amended 2 by subsection (d)(2), by inserting ‘‘, in coordi- 3 nation with the Medicare Payment Advisory 4 Commission,’’ after ‘‘annually’’. 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 subpara- pamtmann on DSKBFK8HB2PROD with BILLS 23 graph: 24 ‘‘(Q) PERIODIC 25 AUDIT BY THE TROLLER GENERAL.— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 COMP- 54 1 ‘‘(i) IN GENERAL.—The Comptroller 2 General of the United States (in this sub- 3 paragraph 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 SEC. 613. OFFICE OF PRIMARY HEALTH CARE. 15 (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 nec- pamtmann on DSKBFK8HB2PROD with BILLS 20 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); •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00054 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 55 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 SEC. 614. PAYMENTS FOR PRESCRIPTION DRUGS AND AP- 20 21 PROVED DEVICES AND EQUIPMENT. (a) NEGOTIATED PRICES.—The prices to be paid for 22 covered pharmaceuticals, medical supplies, and medically pamtmann on DSKBFK8HB2PROD with BILLS 23 necessary assistive equipment shall be negotiated annually 24 by the Secretary. 25 (b) PRESCRIPTION DRUG FORMULARY.— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00055 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 56 1 (1) IN 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. TITLE VII—UNIVERSAL MEDICARE TRUST FUND 21 22 23 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—The SEC. 701. UNIVERSAL MEDICARE TRUST FUND. 24 (a) IN GENERAL.—There is hereby created on the 25 books of the Treasury of the United States a trust fund •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00056 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 57 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. pamtmann on DSKBFK8HB2PROD with BILLS 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. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 58 1 (2) CURRENT 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 (B) The Medicaid program, under State 13 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 (D) The TRICARE program, under chap- 18 pamtmann on DSKBFK8HB2PROD with BILLS PROGRAM RECEIPTS.—Notwith- ter 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 •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00058 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 59 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) pamtmann on DSKBFK8HB2PROD with BILLS 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•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00059 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 60 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 pamtmann on DSKBFK8HB2PROD with BILLS 23 be made under the Medicare for All Act of 2019. 24 ‘‘(b) REIMBURSEMENT.—Each workers compensation 25 carrier that is liable for payment for workers compensa•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00060 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 61 1 tion services furnished in a State shall reimburse the Uni2 versal Medicare Program for the cost of such services. pamtmann on DSKBFK8HB2PROD with BILLS 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 7 one or more employers and includes an employer or 8 fund that is financially at risk for the provision of 9 workers 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•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00061 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 62 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 (b) CONFORMING AMENDMENTS.— 15 pamtmann on DSKBFK8HB2PROD with BILLS 16 (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,’’. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00062 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 63 1 (3) Section 514(b) of such Act (29 U.S.C. 2 1144(b)) is amended— 3 (A) in paragraph (7), by striking ‘‘section 4 206(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 SEC. 803. EFFECTIVE DATE OF TITLE. 11 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).— pamtmann on DSKBFK8HB2PROD with BILLS 19 (1) IN GENERAL.—Notwithstanding 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 •S 1129 IS VerDate Sep 11 2014 any other 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 64 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 pamtmann on DSKBFK8HB2PROD with BILLS 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- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00064 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 65 1 ices shall provide for continuation of benefits under 2 such title or plan until the end of the period of stay. 3 (3) SERVICES 4 (A) IN 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 (i) institutional long-term care serv- 9 ices (as defined in section 1947(b) of such 10 pamtmann on DSKBFK8HB2PROD with BILLS UNDER MEDICAID.— Act); or 11 (ii) any other service for which bene- 12 fits are not available under this Act and 13 which is furnished under a State plan 14 under title XIX of the Social Security Act 15 which provided for medical assistance for 16 such service on January 1, 2019. 17 (B) COORDINATION BETWEEN SECRETARY 18 AND STATES.—The 19 with the directors of State agencies responsible 20 for administering State plans under title XIX 21 of the Social Security Act to— Secretary shall coordinate 22 (i) identify services described in sub- 23 paragraph (A)(ii) with respect to each 24 State plan; and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 66 1 (ii) ensure that such services continue 2 to be made available under such plan. 3 (C) MAINTENANCE OF EFFORT REQUIRE- 4 MENT.—With 5 in subparagraph (A)(ii) that is made available 6 under a State plan under title XIX of the So- 7 cial Security Act, the maintenance of effort re- 8 quirements described in section 1947(c) of such 9 Act (related to eligibility standards and re- 10 quired expenditures) shall apply to such service 11 in the same manner that such requirements 12 apply to institutional long-term care services (as 13 defined in section 1947(b) of such Act). 14 15 respect to any service described (b) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM.—No benefits shall be made available under chapter 16 89 of title 5, United States Code, for any part of a cov17 erage period occurring on or after the effective date. 18 (c) TRICARE.—No benefits shall be made available 19 under sections 1079 and 1086 of title 10, United States 20 Code, for items or services furnished on or after the effec21 tive date. 22 (d) TREATMENT OF BENEFITS FOR VETERANS AND pamtmann on DSKBFK8HB2PROD with BILLS 23 NATIVE AMERICANS.— 24 25 (1) IN GENERAL.—Nothing in this Act shall af- fect the eligibility of veterans for the medical bene- •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00066 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 67 1 fits and services provided under title 38, United 2 States Code, or of Indians for the medical benefits 3 and services provided by or through the Indian 4 Health Service. 5 (2) REEVALUATION.—No reevaluation of the 6 Indian Health Service shall be undertaken without 7 consultation with tribal leaders and stakeholders. 8 SEC. 902. SUNSET OF PROVISIONS RELATED TO THE STATE 9 EXCHANGES. 10 Effective on the date described in section 106, the 11 Federal and State Exchanges established pursuant to title 12 I of the Patient Protection and Affordable Care Act (Pub13 lic Law 111–148) shall terminate, and any other provision 14 of law that relies upon participation in or enrollment 15 through such an Exchange, including such provisions of 16 the Internal Revenue Code of 1986, shall cease to have 17 force or effect. 21 TITLE X—TRANSITION Subtitle A—Transitional Medicare Buy-In Option and Transitional Public Option 22 SEC. 1001. LOWERING THE MEDICARE AGE. 18 19 20 pamtmann on DSKBFK8HB2PROD with BILLS 23 (a) IN GENERAL.—Title XVIII of the Social Security 24 Act (42 U.S.C. 1395c et seq.) is amended by adding at 25 the end the following new section: •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00067 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 68 1 ‘‘TRANSITIONAL MEDICARE BUY-IN OPTION FOR CERTAIN 2 3 INDIVIDUALS ‘‘SEC. 1899C. (a) OPTION.— 4 ‘‘(1) IN individual who meets 5 the requirements described in paragraph (3) shall be 6 eligible to enroll under this section. 7 ‘‘(2) PART A, B, AND D BENEFITS.—An vidual enrolled under this section is entitled to the 9 same benefits (and shall receive the same protec- 10 tions) under this title as an individual who is enti- 11 tled to benefits under part A and enrolled under 12 parts B and D, including the ability to enroll in a 13 Medicare Advantage plan that provides qualified pre- 14 scription drug coverage (an MA–PD plan). ‘‘(3) REQUIREMENTS FOR ELIGIBILITY.—The 16 requirements described in this paragraph are the fol- 17 lowing: 18 ‘‘(A) The individual is a resident of the 19 United States. 20 ‘‘(B) The individual is— 21 ‘‘(i) a citizen or national of the United 22 States; or 23 ‘‘(ii) an alien lawfully admitted for 24 permanent residence. •S 1129 IS VerDate Sep 11 2014 indi- 8 15 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—Every 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00068 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 69 1 ‘‘(C) The individual is not otherwise enti- 2 tled to benefits under part A or eligible to en- 3 roll under part A or part B. 4 ‘‘(D) The individual has attained the appli- 5 cable years of age but has not attained 65 years 6 of age. 7 ‘‘(4) APPLICABLE YEARS OF AGE DEFINED.— 8 For purposes of this section, the term ‘applicable 9 years of age’ means— 10 ‘‘(A) effective January 1 of the first year 11 following the date of enactment of the Medicare 12 for All Act of 2019, the age of 55; 13 ‘‘(B) effective January 1 of the second 14 year following such date of enactment, the age 15 of 45; and 16 ‘‘(C) effective January 1 of the third year 17 following such date of enactment, the age of 35. 18 ‘‘(b) ENROLLMENT; COVERAGE.—The Secretary shall 19 establish enrollment periods and coverage under this sec20 tion consistent with the principles for establishment of en21 rollment periods and coverage for individuals under other 22 provisions of this title. The Secretary shall establish such pamtmann on DSKBFK8HB2PROD with BILLS 23 periods so that coverage under this section shall first begin 24 on January 1 of the year on which an individual first be25 comes eligible to enroll under this section. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00069 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 70 1 ‘‘(c) PREMIUM.— 2 ‘‘(1) AMOUNT 3 Secretary shall, during September of each year (be- 4 ginning with the first September following the date 5 of enactment of the Medicare for All Act of 2019), 6 determine a monthly premium for all individuals en- 7 rolled under this section. Such monthly premium 8 shall be equal to 1⁄12 of the annual premium com- 9 puted under paragraph (2)(B), which shall apply 10 with respect to coverage provided under this section 11 for any month in the succeeding year. 12 ‘‘(2) ANNUAL 13 PREMIUM.— ‘‘(A) COMBINED PER CAPITA AVERAGE FOR 14 ALL MEDICARE BENEFITS.—The 15 estimate the average, annual per capita amount 16 for benefits and administrative expenses that 17 will be payable under parts A, B, and D (in- 18 cluding, as applicable, under part C) in the year 19 for all individuals enrolled under this section. 20 pamtmann on DSKBFK8HB2PROD with BILLS OF MONTHLY PREMIUMS.—The ‘‘(B) ANNUAL Secretary shall PREMIUM.—The annual pre- 21 mium under this subsection for months in a 22 year is equal to the average, annual per capita 23 amount estimated under subparagraph (A) for 24 the year. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00070 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 71 1 ‘‘(3) INCREASED 2 C AND D PLANS.—Nothing 3 clude an individual from choosing a Medicare Advan- 4 tage plan or a prescription drug plan which requires 5 the individual to pay an additional amount (because 6 of supplemental benefits or because it is a more ex- 7 pensive plan). In such case the individual would be 8 responsible for the increased monthly premium. 9 ‘‘(d) PAYMENT OF PREMIUMS.— 10 ‘‘(1) IN PREMIUM FOR CERTAIN PART in this section shall pre- GENERAL.—Premiums for enrollment 11 under this section shall be paid to the Secretary at 12 such times, and in such manner, as the Secretary 13 determines appropriate. 14 ‘‘(2) DEPOSIT.—Amounts collected by the Sec- 15 retary under this section shall be deposited in the 16 Federal Hospital Insurance Trust Fund and the 17 Federal Supplementary Medical Insurance Trust 18 Fund (including the Medicare Prescription Drug Ac- 19 count within such Trust Fund) in such proportion 20 as the Secretary determines appropriate. 21 ‘‘(e) NOT ELIGIBLE FOR MEDICARE COST-SHARING 22 ASSISTANCE.—An individual enrolled under this section pamtmann on DSKBFK8HB2PROD with BILLS 23 shall not be treated as enrolled under any part of this title 24 for purposes of obtaining medical assistance for Medicare 25 cost-sharing or otherwise under title XIX. •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00071 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 72 1 ‘‘(f) TREATMENT IN RELATION TO THE AFFORDABLE 2 CARE ACT.— 3 ‘‘(1) OF INDIVIDUAL DATE.—For 5 the Internal Revenue Code of 1986, the coverage 6 provided under this section constitutes minimum es- 7 sential coverage under subsection (f)(1)(A)(i) of 8 such section 5000A. 10 purposes of applying section 5000A of ‘‘(2) ELIGIBILITY FOR PREMIUM ASSISTANCE.— Coverage provided under this section— 11 ‘‘(A) shall be treated as coverage under a 12 qualified health plan in the individual market 13 enrolled in through the Exchange where the in- 14 dividual resides for all purposes of section 36B 15 of the Internal Revenue Code of 1986 other 16 than subsection (c)(2)(B) thereof; and 17 ‘‘(B) shall not be treated as eligibility for 18 other minimum essential coverage for purposes 19 of subsection (c)(2)(B) of such section 36B. 20 The Secretary shall determine the applicable second 21 lowest cost silver plan which shall apply to coverage 22 under this section for purposes of section 36B of 23 such Code. 24 25 ‘‘(3) ELIGIBILITY SIDIES.—For FOR COST-SHARING 01:32 Apr 23, 2019 Jkt 089200 PO 00000 SUB- purposes of applying section 1402 of •S 1129 IS VerDate Sep 11 2014 MAN- 4 9 pamtmann on DSKBFK8HB2PROD with BILLS SATISFACTION Frm 00072 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 73 1 the Patient Protection and Affordable Care Act (42 2 U.S.C. 18071)— 3 ‘‘(A) coverage provided under this section 4 shall be treated as coverage under a qualified 5 health plan in the silver level of coverage in the 6 individual market offered through an Exchange; 7 and 8 ‘‘(B) the Secretary shall be treated as the 9 10 issuer of such plan. ‘‘(g) NO EFFECT 11 OTHERWISE ELIGIBLE ON BENEFITS OR ON FOR INDIVIDUALS TRUST FUNDS.—The Sec- 12 retary shall implement the provisions of this section in pamtmann on DSKBFK8HB2PROD with BILLS 13 such a manner to ensure that such provisions— 14 ‘‘(1) have no effect on the benefits under this 15 title for individuals who are entitled to, or enrolled 16 for, such benefits other than through this section; 17 and 18 ‘‘(2) have no negative impact on the Federal 19 Hospital Insurance Trust Fund or the Federal Sup- 20 plementary Medical Insurance Trust Fund (includ- 21 ing the Medicare Prescription Drug Account within 22 such Trust Fund). 23 ‘‘(h) CONSULTATION.—In promulgating regulations 24 to implement this section, the Secretary shall consult with 25 interested parties, including groups representing bene•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00073 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 74 1 ficiaries, health care providers, employers, and insurance 2 companies.’’. 3 SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSI- 4 TION PLAN. 5 (a) IN GENERAL.—To carry out the purpose of this 6 section, for plan years beginning with the first plan year 7 that begins after the date of enactment of this Act and 8 ending with the effective date described in section 106, 9 the Secretary, acting through the Administrator of the 10 Centers for Medicare & Medicaid (referred to in this sec11 tion as the ‘‘Administrator’’), shall establish, and provide 12 for the offering through the Exchanges, of a public health 13 plan (in this Act referred to as the ‘‘Medicare Transition 14 plan’’) that provides affordable, high-quality health bene15 fits coverage throughout the United States. 16 (b) 17 TION.— THE MEDICARE (1) ADMINISTRATOR.—The Administrator shall 19 administer the Medicare Transition plan in accord- 20 ance with this section. (2) APPLICATION OF ACA REQUIREMENTS.— 22 Consistent with this section, the Medicare Transition 23 plan shall comply with requirements under title I of 24 the Patient Protection and Affordable Care Act (and 25 the amendments made by that title) and title XXVII •S 1129 IS VerDate Sep 11 2014 TRANSI- 18 21 pamtmann on DSKBFK8HB2PROD with BILLS ADMINISTRATING 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 75 1 of the Public Health Service Act (42 U.S.C. 300gg 2 et seq.) that are applicable to qualified health plans 3 offered through the Exchanges, subject to the limita- 4 tion under subsection (e)(2). 5 (3) OFFERING THROUGH EXCHANGES.—The 6 Medicare Transition plan shall be made available 7 only through the Exchanges, and shall be available 8 to individuals wishing to enroll and to qualified em- 9 ployers (as defined in section 1312(f)(2) of the Pa- 10 tient Protection and Affordable Care Act (42 U.S.C. 11 18032)) who wish to make such plan available to 12 their employees. 13 (4) ELIGIBILITY TO PURCHASE.—Any United 14 States resident may enroll in the Medicare Transi- 15 tion plan. 16 (c) BENEFITS; ACTUARIAL VALUE.—In carrying out 17 this section, the Administrator shall ensure that the Medi18 care Transition plan provides— 19 pamtmann on DSKBFK8HB2PROD with BILLS 20 (1) coverage for the benefits required to be covered under title II; and 21 (2) coverage of benefits that are actuarially 22 equivalent to 90 percent of the full actuarial value 23 of the benefits provided under the plan. 24 (d) PROVIDERS AND REIMBURSEMENT RATES.— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00075 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 76 1 (1) IN respect to the reim- 2 bursement provided to health care providers for cov- 3 ered benefits, as described in section 201, provided 4 under the Medicare Transition plan, the Adminis- 5 trator shall reimburse such providers at rates deter- 6 mined for equivalent items and services under the 7 original Medicare fee-for-service program under 8 parts A and B of title XVIII of the Social Security 9 Act (42 U.S.C. 1395c et seq.). For items and serv- 10 ices covered under the Medicare Transition plan but 11 not covered under such parts A and B, the Adminis- 12 trator shall reimburse providers at rates set by the 13 Administrator in a manner consistent with the man- 14 ner in which rates for other items and services were 15 set under the original Medicare fee-for-service pro- 16 gram. 17 pamtmann on DSKBFK8HB2PROD with BILLS GENERAL.—With (2) PRESCRIPTION DRUGS.—Any payment rate 18 under this subsection for a prescription drug shall be 19 at a rate negotiated by the Administrator with the 20 manufacturer of the drug. If the Administrator is 21 unable to reach a negotiated agreement on such a 22 reimbursement rate, the Administrator shall estab- 23 lish the rate at an amount equal to the lesser of— 24 (A) the price paid by the Secretary of Vet- 25 erans Affairs to procure the drug under the •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00076 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 77 1 laws administered by the Secretary of Veterans 2 Affairs; 3 (B) the price paid to procure the drug 4 under section 8126 of title 38, United States 5 Code; or 6 (C) the best price determined under sec- 7 tion 1927(c)(1)(C) of the Social Security Act 8 (42 U.S.C. 1396r–8(c)(1)(C)) for the drug. 9 (3) PARTICIPATING 10 (A) IN GENERAL.—A health care provider 11 that is a participating provider of services or 12 supplier under the Medicare program under 13 title XVIII of the Social Security Act (42 14 U.S.C. 1395 et seq.) or under a State Medicaid 15 plan under title XIX of such Act (42 U.S.C. 16 1396 et seq.) on the date of enactment of this 17 Act shall be a participating provider in the 18 Medicare Transition plan. 19 pamtmann on DSKBFK8HB2PROD with BILLS PROVIDERS.— (B) ADDITIONAL PROVIDERS.—The 20 ministrator shall establish a process to allow 21 health care providers not described in subpara- 22 graph (A) to become participating providers in 23 the Medicare Transition plan. Such process 24 shall be similar to the process applied to new 25 providers under the Medicare program. •S 1129 IS VerDate Sep 11 2014 Ad- 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00077 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 78 1 (e) PREMIUMS.— 2 (1) DETERMINATION.—The Administrator shall 3 determine the premium amount for enrolling in the 4 Medicare Transition plan, which— 5 (A) may vary according to family or indi- 6 vidual coverage, age, and tobacco status (con- 7 sistent with clauses (i), (iii), and (iv) of section 8 2701(a)(1)(A) of the Public Health Service Act 9 (42 U.S.C. 300gg(a)(1)(A))); and 10 (B) shall take into account the cost-shar- 11 ing reductions and premium tax credits which 12 will be available with respect to the plan under 13 section 1402 of the Patient Protection and Af- 14 fordable Care Act (42 U.S.C. 18071) and sec- 15 tion 36B of the Internal Revenue Code of 1986, 16 as amended by subsection (g). 17 (2) LIMITATION.—Variation in premium rates 18 of the Medicare Transition plan by rating area, as 19 described in clause (ii) of section 2701(a)(1)(A)(iii) 20 of the Public Health Service Act (42 U.S.C. 21 300gg(a)(1)(A)) is not permitted. 22 (f) TERMINATION.—This section shall cease to have pamtmann on DSKBFK8HB2PROD with BILLS 23 force or effect on the effective date described in section 24 106. 25 (g) TAX CREDITS AND COST-SHARING SUBSIDIES.— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00078 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 79 1 (1) PREMIUM 2 (A) CREDITS ALLOWED TO TRANSITION PLAN ENROLLEES AT OR ABOVE 44 4 PERCENT 5 STATES.—Paragraph 6 the Internal Revenue Code of 1986 is amended 7 by redesignating subparagraphs (C) and (D) as 8 subparagraphs (D) and (E), respectively, and 9 by inserting after subparagraph (B) the fol- OF POVERTY IN NON-EXPANSION (1) of section 36B(c) of 10 lowing new subparagraph: 11 ‘‘(C) SPECIAL RULES FOR MEDICARE TRANSITION PLAN ENROLLEES.— 13 ‘‘(i) IN GENERAL.—In the case of a 14 taxpayer who is covered, or whose spouse 15 or dependent (as defined in section 152) is 16 covered, by the Medicare Transition plan 17 established under section 1002(a) of the 18 Medicare for All Act of 2019 for all 19 months in the taxable year, subparagraph 20 (A) shall be applied without regard to ‘but 21 does not exceed 400 percent’. 22 ‘‘(ii) ENROLLEES IN MEDICAID NON- 23 EXPANSION STATES.—In 24 payer residing in a State which (as of the 25 date of the enactment of the Medicare for the case of a tax- •S 1129 IS VerDate Sep 11 2014 MEDICARE 3 12 pamtmann on DSKBFK8HB2PROD with BILLS ASSISTANCE TAX CREDITS.— 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00079 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 80 1 All Act of 2019) does not provide for eligi- 2 bility under clause (i)(VIII) or (ii)(XX) of 3 section 1902(a)(10)(A) of the Social Secu- 4 rity Act for medical assistance under title 5 XIX of such Act (or a waiver of the State 6 plan approved under section 1115) who is 7 covered, or whose spouse or dependent (as 8 defined in section 152) is covered, by the 9 Medicare Transition plan established under 10 section 1002(a) of the Medicare for All Act 11 of 2019 for all months in the taxable year, 12 subparagraphs (A) and (B) shall be ap- 13 plied by substituting ‘0 percent’ for ‘100 14 percent’ each place it appears.’’. 15 (B) PREMIUM 16 TAXPAYERS ENROLLED IN MEDICARE TRANSI- 17 TION PLAN.— 18 (i) IN GENERAL.—Subparagraph of section 36B(b)(3) of such Code is 20 amended— (I) by redesignating clause (ii) as 22 clause (iii); 23 (II) by striking ‘‘clause (ii)’’ in 24 clause (i) and inserting ‘‘clauses (ii) 25 and (iii)’’; and •S 1129 IS VerDate Sep 11 2014 (A) 19 21 pamtmann on DSKBFK8HB2PROD with BILLS ASSISTANCE AMOUNTS FOR 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00080 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 81 1 (III) by inserting after clause (i) 2 the following new clause: 3 ‘‘(ii) SPECIAL RULES FOR TAXPAYERS 4 ENROLLED 5 PLAN.—In 6 covered, or whose spouse or dependent (as 7 defined in section 152) is covered, by the 8 Medicare Transition plan established under 9 section 1002(a) of the Medicare for All Act 10 of 2019 for all months in the taxable year, 11 the applicable percentage for any taxable 12 year shall be determined in the same man- 13 ner as under clause (i), except that the fol- 14 lowing table shall apply in lieu of the table 15 contained in such clause: IN MEDICARE the case of a taxpayer who is ‘‘In the case of household income (expressed as a percent of poverty line) within the following income tier: The initial premium percentage is— The final premium percentage is— 2 2.04 3.06 4.08 2 2.04 4.08 5’’. Up to 100 percent .................................. 100 percent up to 138 percent ............... 138 percent up to 150 percent ............... 150 percent and above ............................ pamtmann on DSKBFK8HB2PROD with BILLS 16 TRANSITION (ii) CONFORMING AMENDMENT.—Sub- 17 clause 18 36B(b)(3) of such Code, as redesignated 19 by subparagraph (A)(i), is amended by in- 20 serting ‘‘, and determined after the appli- (I) of clause (iii) of •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00081 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 section 82 1 cation of clause (ii)’’ after ‘‘after applica- 2 tion of this clause’’. 3 (2) COST-SHARING of section 1402 of the Patient Protection and Af- 5 fordable Care Act (42 U.S.C. 18071(b)) is amend- 6 ed— (A) by inserting ‘‘, or in the Medicare 8 Transition 9 1002(a) of the Medicare for All Act of 2019,’’ 10 plan established under section after ‘‘coverage’’ in paragraph (1); 11 (B) by redesignating paragraphs (1) (as so 12 amended) and (2) as subparagraphs (A) and 13 (B), respectively, and by moving such subpara- 14 graphs 2 ems to the right; 15 (C) by striking ‘‘INSURED.—In this sec- 16 tion’’ and inserting ‘‘INSURED.— 17 ‘‘(1) IN GENERAL.—In this section’’; 18 (D) by striking the flush language; and 19 (E) by adding at the end the following new 20 paragraph: 21 ‘‘(2) SPECIAL 22 RULES.— ‘‘(A) INDIVIDUALS LAWFULLY PRESENT.— 23 In the case of an individual described in section 24 36B(c)(1)(B) of the Internal Revenue Code of 25 1986, the individual shall be treated as having •S 1129 IS VerDate Sep 11 2014 (b) 4 7 pamtmann on DSKBFK8HB2PROD with BILLS SUBSIDIES.—Subsection 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00082 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 83 1 household income equal to 100 percent of the 2 poverty line for a family of the size involved for 3 purposes of applying this section. 4 ‘‘(B) MEDICARE EN- ROLLEES 6 STATES.—In 7 in a State which (as of the date of the enact- 8 ment of the Medicare for All Act of 2019) does 9 not provide for eligibility under clause (i)(VIII) 10 or (ii)(XX) of section 1902(a)(10)(A) of the So- 11 cial Security Act for medical assistance under 12 title XIX of such Act (or a waiver of the State 13 plan approved under section 1115) who enrolls 14 in such Medicare Transition plan, the preceding 15 sentence, paragraph (1)(B), and paragraphs 16 (1)(A)(i) and (2)(A) of subsection (c) shall each 17 be applied by substituting ‘0 percent’ for ‘100 18 percent’ each place it appears. IN MEDICAID NON-EXPANSION the case of an individual residing ‘‘(C) ADJUSTED COST-SHARING FOR MEDI- 20 CARE TRANSITION PLAN ENROLLEES.—In 21 case of any individual who enrolls in such Medi- 22 care Transition plan, in lieu of the percentages 23 under subsection (c)(1)(B)(i) and (c)(2), the 24 Secretary shall prescribe a method of deter- 25 mining the cost-sharing reduction for any such •S 1129 IS VerDate Sep 11 2014 PLAN 5 19 pamtmann on DSKBFK8HB2PROD with BILLS TRANSITION 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00083 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 the 84 1 individual such that the total of the cost-shar- 2 ing and the premiums paid by the individual 3 under such Medicare Transition plan does not 4 exceed the percentage of the total allowed costs 5 of benefits provided under the plan equal to the 6 final premium percentage applicable to such in- 7 dividual under section 36B(b)(3)(A)(ii) of the 8 Internal Revenue Code of 1986.’’. 9 (h) CONFORMING AMENDMENTS.— 10 (1) TREATMENT A QUALIFIED PLAN.—Section 12 and Affordable Care Act (42 U.S.C. 18021(a)(2)) is 13 amended— 1301(a)(2) of the Patient Protection (A) in the paragraph heading, by inserting 15 ‘‘, 16 ‘‘AND’’; and THE MEDICARE TRANSITION PLAN,’’ 17 before (B) by inserting ‘‘The Medicare Transition 18 plan,’’ before ‘‘and a multi-State plan’’. 19 (2) LEVEL PLAYING FIELD.—Section 1324(a) 20 of the Patient Protection and Affordable Care Act 21 (42 U.S.C. 18044(a)) is amended by inserting ‘‘the 22 Medicare Transition plan,’’ before ‘‘or a multi-State 23 qualified health plan’’. •S 1129 IS VerDate Sep 11 2014 HEALTH 11 14 pamtmann on DSKBFK8HB2PROD with BILLS AS 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00084 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 85 2 Subtitle B—Transitional Medicare Reforms 3 SEC. 1011. MEDICARE PROTECTION AGAINST HIGH OUT-OF- 4 POCKET EXPENDITURES FOR FEE-FOR-SERV- 5 ICE BENEFITS AND ELIMINATION OF PARTS A 6 AND B DEDUCTIBLES. 1 7 (a) PROTECTION AGAINST HIGH OUT-OF-POCKET 8 EXPENDITURES.—Title XVIII of the Social Security Act 9 (42 U.S.C. 1395 et seq.), as amended by section 1001, 10 is amended by adding at the end the following new section: 11 ‘‘PROTECTION 12 13 AGAINST HIGH OUT-OF-POCKET EXPENDITURES ‘‘SEC. 1899D. (a) IN GENERAL.—Notwithstanding 14 any other provision of this title, in the case of an indi15 vidual entitled to, or enrolled for, benefits under part A 16 or enrolled in part B, if the amount of the out-of-pocket 17 cost-sharing of such individual for a year (effective the 18 year beginning January 1 of the year following the date 19 of enactment of the Medicare for All Act of 2019) equals 20 or exceeds $1,500, the individual shall not be responsible 21 for additional out-of-pocket cost-sharing occurred during 22 that year. pamtmann on DSKBFK8HB2PROD with BILLS 23 ‘‘(b) OUT-OF-POCKET COST-SHARING DEFINED.— 24 25 ‘‘(1) IN GENERAL.—Subject to paragraphs (2) and (3), in this section, the term ‘out-of-pocket cost•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00085 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 86 1 sharing’ means, with respect to an individual, the 2 amount of the expenses incurred by the individual 3 that are attributable to— 4 ‘‘(A) coinsurance and copayments applica- 5 ble under part A or B; or 6 ‘‘(B) for items and services that would 7 have otherwise been covered under part A or B 8 but for the exhaustion of those benefits. 9 ‘‘(2) CERTAIN 10 ‘‘(A) NON-COVERED ITEMS AND ICES.—Expenses 12 ices which are not included (or treated as being 13 included) under part A or B shall not be con- 14 sidered incurred expenses for purposes of deter- 15 mining out-of-pocket cost-sharing under para- 16 graph (1). incurred for items and serv- ‘‘(B) ITEMS AND SERVICES NOT FUR- 18 NISHED ON AN ASSIGNMENT-RELATED BASIS.— 19 If an item or service is furnished to an indi- 20 vidual under this title and is not furnished on 21 an assignment-related basis, any additional ex- 22 penses the individual incurs above the amount 23 the individual would have incurred if the item 24 or service was furnished on an assignment-re- 25 lated basis shall not be considered incurred ex- •S 1129 IS VerDate Sep 11 2014 SERV- 11 17 pamtmann on DSKBFK8HB2PROD with BILLS COSTS NOT INCLUDED.— 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00086 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 87 1 penses for purposes of determining out-of-pock- 2 et cost-sharing under paragraph (1). 3 ‘‘(3) SOURCE OF PAYMENT.—For purposes of 4 paragraph (1), the Secretary shall consider expenses 5 to be incurred by the individual without regard to 6 whether the individual or another person, including 7 a State program or other third-party coverage, has 8 paid for such expenses.’’. 9 (b) ELIMINATION OF PARTS A AND B 10 DEDUCTIBLES.— 11 (1) PART A.—Section 1813(b) of the Social Se- 12 curity Act (42 U.S.C. 1395e(b)) is amended by add- 13 ing at the end the following new paragraph: 14 ‘‘(4) For each year (beginning January 1 of the year 15 following the date of enactment of the Medicare for All 16 Act of 2019), the inpatient hospital deductible for the year pamtmann on DSKBFK8HB2PROD with BILLS 17 shall be $0.’’. 18 (2) PART B.—Section 1833(b) of the Social Se- 19 curity Act (42 U.S.C. 1395l(b)) is amended, in the 20 first sentence— 21 (A) by striking ‘‘and for a subsequent 22 year’’ and inserting ‘‘for each of 2006 through 23 the year that includes the date of enactment of 24 the Medicare for All Act of 2019’’; and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00087 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 88 1 (B) by inserting ‘‘, and $0 for each year 2 subsequent year’’ after ‘‘$1)’’. 3 SEC. 1012. REDUCTION IN MEDICARE PART D ANNUAL OUT- 4 OF-POCKET THRESHOLD AND ELIMINATION 5 OF COST-SHARING ABOVE THAT THRESHOLD. 6 (a) REDUCTION.—Section 1860D–2(b)(4)(B) of the 7 Social Security Act (42 U.S.C. 1395w–102(b)(4)(B)) is 8 amended— 9 (1) in clause (i), by striking ‘‘For purposes’’ 10 and inserting ‘‘Subject to clause (iii), for purposes’’; 11 and 12 13 (2) by adding at the end the following new clause: 14 ‘‘(iii) 15 IN THRESHOLD DURING TRANSITION PERIOD.— 16 pamtmann on DSKBFK8HB2PROD with BILLS REDUCTION ‘‘(I) IN GENERAL.—Subject 17 subclause (II), for plan years begin- 18 ning on or after January 1 following 19 the date of enactment of the Medicare 20 for All Act of 2019 and before Janu- 21 ary 1 of the year that is 4 years fol- 22 lowing such date of enactment, not- 23 withstanding clauses (i) and (ii), the 24 ‘annual out-of-pocket threshold’ speci- •S 1129 IS VerDate Sep 11 2014 to 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00088 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 89 1 fied in this subparagraph is equal to 2 $305. 3 ‘‘(II) AUTHORITY TO EXEMPT 4 BRAND-NAME 5 AVAILABLE.—In 6 (I), the Secretary may exempt costs 7 incurred for a covered part D drug 8 that is an applicable drug under sec- 9 tion 1860D–14A(g)(2) if the Sec- 10 retary determines that a generic 11 version of that drug is available.’’. 12 (b) ELIMINATION OF DRUGS IF GENERIC applying subclause COST-SHARING.—Section 13 1860D–2(b)(4)(A) of the Social Security Act (42 U.S.C. 14 1395w–102(b)(4)(A)) is amended— 15 (1) in clause (i)— 16 (A) by redesignating subclauses (I) and pamtmann on DSKBFK8HB2PROD with BILLS 17 (II) as items (aa) and (bb), respectively; 18 (B) by striking ‘‘subparagraph (B), with 19 cost-sharing’’ and inserting the following: ‘‘sub- 20 paragraph (B)— 21 ‘‘(I) for plan years 2006 through 22 the plan year ending December 31 fol- 23 lowing the date of enactment of the 24 Medicare for All Act of 2019, with 25 cost-sharing’’; •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00089 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 90 1 (C) in item (bb), as redesignated by sub- 2 paragraph (A), by striking the period at the 3 end and inserting ‘‘; and’’; and 4 (D) by adding at the end the following new 5 subclause: 6 ‘‘(II) for the plan year beginning 7 January 1 following the date of enact- 8 ment of the Medicare for All Act of 9 2019 and the two subsequent plan 10 years, without any cost-sharing.’’; and 11 (2) in clause (ii)— 12 (A) by striking ‘‘clause (i)(I)’’ and insert- 13 ing ‘‘clause (i)(I)(aa)’’; and 14 (B) by adding at the end the following new 15 sentence: ‘‘The Secretary shall continue to cal- 16 culate the dollar amounts specified in clause 17 (i)(I)(aa), including with the adjustment under 18 this clause, after plan year 2018 for purposes 19 of 1860D–14(a)(1)(D)(iii).’’. 20 (c) CONFORMING AMENDMENTS TO LOW-INCOME 21 SUBSIDY.—Section 1860D–14(a) of the Social Security 22 Act (42 U.S.C. 1395w–114(a)) is amended— pamtmann on DSKBFK8HB2PROD with BILLS 23 (1) in paragraph (1)— •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00090 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 91 1 (A) in subparagraph (D)(iii), by striking 2 ‘‘1860D–2(b)(4)(A)(i)(I)’’ 3 ‘‘1860D–2(b)(4)(A)(i)(I)(aa)’’; and 4 (i) in the heading, by inserting 6 ‘‘PRIOR 7 COST-SHARING 8 after ‘‘THRESHOLD’’; and TO THE ELIMINATION OF SUCH FOR ALL INDIVIDUALS’’ 9 (ii) by striking ‘‘The elimination’’ and 10 inserting ‘‘For plan years 2006 through 11 the plan year ending December 31 fol- 12 lowing the date of enactment of the Medi- 13 care for All Act of 2019, the elimination’’; 14 and 15 (2) in paragraph (2)(E)— 16 (A) in the heading, by inserting ‘‘PRIOR TO 17 THE ELIMINATION OF SUCH COST-SHARING FOR 18 ALL INDIVIDUALS’’ after ‘‘THRESHOLD’’; 19 (B) by striking ‘‘Subject to’’ and inserting 20 ‘‘For plan years 2006 through the plan year 21 ending December 31 following the date of en- 22 actment of the Medicare for All Act of 2019, 23 subject to’’; and 24 (C) by striking ‘‘1860D–2(b)(4)(A)(i)(I)’’ 25 and inserting ‘‘1860D–2(b)(4)(A)(i)(I)(aa)’’. •S 1129 IS VerDate Sep 11 2014 inserting (B) in subparagraph (E)— 5 pamtmann on DSKBFK8HB2PROD with BILLS and 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00091 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 92 1 SEC. 1013. COVERAGE OF DENTAL AND VISION SERVICES 2 AND 3 UNDER MEDICARE PART B. AIDS 4 (a) DENTAL SERVICES.— 5 (1) REMOVAL OF AND EXAMINATIONS EXCLUSION FROM ERAGE.—Section 7 (42 U.S.C. 1395y(a)) is amended by striking para- 8 graph (12). 1862(a) of the Social Security Act 9 (2) COVERAGE.— 10 (A) IN GENERAL.—Section 1861(s)(2) of 11 the Social Security Act (42 U.S.C. 1395x(s)(2)) 12 is amended— (i) in subparagraph (GG), by striking 14 ‘‘and’’ at the end; 15 (ii) in subparagraph (HH), by strik- 16 ing the period at the end and inserting ‘‘; 17 and’’; and 18 (iii) by adding at the end the fol- 19 lowing new subparagraph: 20 ‘‘(II) dental services;’’. 21 (B) PAYMENT.—Section 1833(a)(1) of the 22 Social Security Act (42 U.S.C. 1395l(a)(1)) is 23 amended— 24 (i) by striking ‘‘and’’ before ‘‘(CC)’’; 25 and •S 1129 IS VerDate Sep 11 2014 COV- 6 13 pamtmann on DSKBFK8HB2PROD with BILLS HEARING 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00092 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 93 1 (ii) by inserting before the semicolon 2 at the end the following: ‘‘, and (DD) with 3 respect to dental services described in sec- 4 tion 1861(s)(2)(II), the amount paid shall 5 be an amount equal to 80 percent of the 6 lesser of the actual charge for the services 7 or the amount determined under the fee 8 schedule 9 1848(b).’’. 10 (C) EFFECTIVE under DATE.—The amendments made by this subsection shall apply to items 12 and services furnished on or after January 1 13 following the date of the enactment of this Act. (b) VISION SERVICES.— 15 (1) IN GENERAL.—Section 1861(s)(2) of the 16 Social Security Act (42 U.S.C. 1395x(s)(2)), as 17 amended by subsection (a), is amended— 18 (A) in subparagraph (HH), by striking 19 ‘‘and’’ at the end; 20 (B) in subparagraph (II), by inserting 21 ‘‘and’’ at the end; and 22 (C) by adding at the end the following new 23 subparagraph: 24 ‘‘(JJ) vision services;’’. •S 1129 IS VerDate Sep 11 2014 section 11 14 pamtmann on DSKBFK8HB2PROD with BILLS established 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00093 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 94 1 (2) PAYMENT.—Section 1833(a)(1) of the So- 2 cial Security Act (42 U.S.C. 1395l(a)(1)), as amend- 3 ed by subsection (a), is amended— 4 (A) by striking ‘‘and’’ before ‘‘(DD)’’; and 5 (B) by inserting before the semicolon at 6 the end the following: ‘‘, and (EE) with respect 7 to 8 1861(s)(2)(JJ), the amount paid shall be an 9 amount equal to 80 percent of the lesser of the 10 actual charge for the services or the amount de- 11 termined under the fee schedule established 12 under section 1848(b).’’. 13 (3) EFFECTIVE services described DATE.—The in amendments made 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 (c) HEARING AIDS AND EXAMINATIONS THERE- FOR.— 19 (1) IN GENERAL.—Section 1862(a)(7) of the 20 Social Security Act (42 U.S.C. 1395y(a)(7)) is 21 amended by striking ‘‘hearing aids or examinations 22 therefor,’’. 23 24 (2) EFFECTIVE DATE.—The amendment made by this subsection shall apply to items and services •S 1129 IS VerDate Sep 11 2014 section 14 18 pamtmann on DSKBFK8HB2PROD with BILLS vision 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00094 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 95 1 furnished on or after January 1 following the date 2 of the enactment of this Act. 3 SEC. 1014. ELIMINATING THE 24-MONTH WAITING PERIOD 4 FOR MEDICARE COVERAGE FOR INDIVID- 5 UALS WITH DISABILITIES. 6 (a) IN GENERAL.—Section 226(b) of the Social Secu- 7 rity Act (42 U.S.C. 426(b)) is amended— 8 9 (1) in paragraph (2)(A), by striking ‘‘, and has for 24 calendar months been entitled to,’’; 10 pamtmann on DSKBFK8HB2PROD with BILLS 11 (2) in paragraph (2)(B), by striking ‘‘, and has been for not less than 24 months,’’; 12 (3) in paragraph (2)(C)(ii), by striking ‘‘, in- 13 cluding the requirement that he has been entitled to 14 the specified benefits for 24 months,’’; 15 (4) in the first sentence, by striking ‘‘for each 16 month beginning with the later of (I) July 1973 or 17 (II) the twenty-fifth month of his entitlement or sta- 18 tus as a qualified railroad retirement beneficiary de- 19 scribed in paragraph (2), and’’ and inserting ‘‘for 20 each month for which the individual meets the re- 21 quirements of paragraph (2), beginning with the 22 month following the month in which the individual 23 meets the requirements of such paragraph, and’’; 24 and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00095 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 96 1 (5) in the second sentence, by striking ‘‘the 2 ‘twenty-fifth month of his entitlement’ ’’ and all that 3 follows through ‘‘paragraph (2)(C) and’’. 4 (b) CONFORMING AMENDMENTS.— 5 6 (1) SECTION 226 of the Social Security Act (42 U.S.C. 426) is amended by— 7 (A) striking subsections (e)(1)(B), (f), and 8 (h); and 9 (B) redesignating subsections (g) and (i) 10 as subsections (f) and (g), respectively. 11 (2) MEDICARE DESCRIPTION.—Section of the Social Security Act (42 U.S.C. 1395c(2)) is 13 amended by striking ‘‘have been entitled for not less 14 than 24 months’’ and inserting ‘‘are entitled’’. (3) MEDICARE COVERAGE.—Section 1837(g)(1) 16 of the Social Security Act (42 U.S.C. 1395p(g)(1)) 17 is amended by striking ‘‘25th month of’’ and insert- 18 ing ‘‘month following the first month of’’. 19 (4) RAILROAD RETIREMENT SYSTEM.—Section 20 7(d)(2)(ii) of the Railroad Retirement Act of 1974 21 (45 U.S.C. 231f(d)(2)(ii)) is amended— 22 (A) by striking ‘‘has been entitled to an 23 annuity’’ and inserting ‘‘is entitled to an annu- 24 ity’’; •S 1129 IS VerDate Sep 11 2014 1811(2) 12 15 pamtmann on DSKBFK8HB2PROD with BILLS 226.—Section 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00096 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 97 1 (B) by striking ‘‘, for not less than 24 2 months’’; and 3 (C) by striking ‘‘could have been entitled 4 for 24 calendar months, and’’. 5 (c) EFFECTIVE DATE.—The amendments made by 6 this section shall apply to insurance benefits under title 7 XVIII of the Social Security Act with respect to items and 8 services furnished in months beginning after December 1 9 following the date of enactment of this Act, and before 10 January 1 of the year that is 4 years after such date of 11 enactment. 12 SEC. 1015. GUARANTEED ISSUE OF MEDIGAP POLICIES. 13 Section 1882 of the Social Security Act (42 U.S.C. 14 1395ss) is amended by adding at the end the following 15 new subsection: 16 17 ‘‘(aa) GUARANTEED ISSUE GIBLE MEDICARE FOR ALL MEDIGAP-ELI- BENEFICIARIES.—Notwithstanding 18 paragraphs (2)(A) and (2)(D) of subsection (s) or any 19 other provision of this section, on or after the date of en20 actment of this subsection, the issuer of a medicare sup21 plemental policy may not deny or condition the issuance 22 or effectiveness of a medicare supplemental policy, or dis- pamtmann on DSKBFK8HB2PROD with BILLS 23 criminate in the pricing of the policy, because of health 24 status, claims experience, receipt of health care, or medical 25 condition in the case of any individual entitled to, or en•S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00097 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 98 1 rolled for, benefits under part A and enrolled for benefits 2 under part B.’’. 5 Subtitle C—Private Health Insurance Availability During Transitional Period 6 SEC. 1021. CONTINUITY OF CARE. 3 4 7 (a) IN GENERAL.—The Secretary shall ensure that 8 all individuals enrolled in, or who seek to enroll in, a group 9 health plan, health insurance coverage offered by a health 10 insurance issuer, or the plan established under section 11 1002 during the transition period of this Act are protected 12 from disruptions in their care during the transition period. 13 (b) PUBLIC CONSULTATION DURING TRANSITION.— 14 The Secretary shall consult with communities and advo15 cacy organizations of individuals living with disabilities 16 and other patient advocacy organizations to ensure the 17 transition described in this section takes into account the 18 continuity of care for individuals with disabilities, complex 19 medical needs, or chronic conditions. 20 (c) DEFINITIONS.—In this section, the terms ‘‘health 21 insurance coverage’’, ‘‘health insurance issuer’’, and 22 ‘‘group health plans’’ have the meanings given such terms pamtmann on DSKBFK8HB2PROD with BILLS 23 in section 2791 of the Public Health Service Act (42 24 U.S.C. 300gg–91). •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00098 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 99 1 TITLE XI—MISCELLANEOUS 2 SEC. 1101. UPDATING RESOURCE LIMITS FOR SUPPLE- 3 MENTAL 4 (SSI). 5 SECURITY INCOME ELIGIBILITY Section 1611(a)(3) of the Social Security Act (42 6 U.S.C. 1382(a)(3)) is amended— 7 (1) in subparagraph (A)— 8 (A) by striking ‘‘and’’ after ‘‘January 1, 9 1988,’’; and 10 (B) by inserting ‘‘, and to $6,200 on Janu- 11 ary 1, 2019’’ before the period; 12 (2) in subparagraph (B)— 13 (A) by striking ‘‘and’’ after ‘‘January 1, 14 1988,’’; and 15 16 ary 1, 2019’’ before the period; and 17 (3) by adding at the end the following new sub- 18 pamtmann on DSKBFK8HB2PROD with BILLS (B) by inserting ‘‘, and to $4,100 on Janu- paragraph: 19 ‘‘(C) Beginning with December of 2019, when- 20 ever the dollar amounts in effect under paragraphs 21 (1)(A) and (2)(A) of this subsection are increased 22 for a month by a percentage under section 23 1617(a)(2), each of the dollar amounts in effect 24 under this paragraph shall be increased, effective 25 with such month, by the same percentage (and •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00099 Fmt 6652 Sfmt 6201 E:\BILLS\S1129.IS S1129 100 1 rounded, if not a multiple of $10, to the closest mul- 2 tiple of $10). Each increase under this subparagraph 3 shall be based on the unrounded amount for the 4 prior 12-month period.’’. 5 SEC. 1102. DEFINITIONS. 6 In this Act— 7 8 (1) the term ‘‘Secretary’’ means the Secretary of Health and Human Services; 9 (2) the term ‘‘State’’ means a State, the Dis- 10 trict of Columbia, or a territory of the United 11 States; and 12 (3) the term ‘‘United States’’ shall include the 13 States, the District of Columbia, and the territories 14 of the United States. pamtmann on DSKBFK8HB2PROD with BILLS Æ •S 1129 IS VerDate Sep 11 2014 01:32 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00100 Fmt 6652 Sfmt 6301 E:\BILLS\S1129.IS S1129