HR3069-119

1. Short title; table of contents This Act may be cited as the Medicare for All Act. The table of contents of this Act is as follows:

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

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

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

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

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

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

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

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

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

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

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

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

615. Office of Health Equity Title XVII of the Public Health Service Act (42 U.S.C. 300u et seq.) is amended by adding at the end the following: There is established, in the Office of the Secretary of Health and Human Services, an Office of Health Equity, to be headed by a Director, to ensure coordination and collaboration across the programs and activities of the Department of Health and Human Services with respect to ensuring health equity. In carrying out subsection (a), the Director of the Office of Health Equity shall monitor, track, and make publicly available data on— the disproportionate burden of disease and death among people of color, disaggregated by race, major ethnic group, Tribal affiliation, national origin, primary language use, English proficiency status, immigration status, length of stay in the United States age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status; barriers to health, including such barriers relating to income, education, housing, food insecurity (including availability, access, utilization, and stability), employment status, working conditions, and conditions related to the physical environment (including pollutants and population density); barriers to health care access, including— lack of trust and awareness; lack of transportation; geography; hospital and service closures; lack of health care infrastructure and facilities; and lack of health care professional staffing and recruitment; disparities in quality of care received, including discrimination in health care settings and the use of racially-biased practice guidelines and algorithms; and disparities in utilization of care. The Director of the Office of Health Equity shall ensure that the data collection and reporting process under paragraph (1) allows for the analysis of cross-sectional information on people’s identities. In carrying out subsection (a), the Director of the Office of Health Equity shall develop, coordinate, and promote policies that enhance health equity, including by— providing recommendations on— cultural competence, implicit bias, and ethics training with respect to health care workers; increasing diversity in the health care workforce; and ensuring sufficient health care professionals and facilities; and ensuring adequate public health funding at the local and State levels to address health disparities. In carrying out subsection (a), the Director of the Office of Health Equity, in coordination with the Director of the Indian Health Service, shall consult with Indian Tribes and with Urban Indian organizations on data collection, reporting, and implementation of policies. In carrying out subsection (a), the Director of the Office of Health Equity shall develop and publish an annual report on— statistics collected by the Office; proposed evidence-based solutions to mitigate health inequities; and health care professional staffing levels and access to facilities. In carrying out subsection (a), the Director of the Office of Health Equity shall— establish and maintain a centralized electronic repository to incorporate data collected across Federal departments and agencies on race, ethnicity, Tribal affiliation, national origin, primary language use, English proficiency status, immigration status, length of stay in the United States age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status; and make such data available for public use and analysis. Notwithstanding any other Federal or State law, no Federal or State official or employee or other entity shall disclose, or use, for any law enforcement or immigration purpose, any personally identifiable information (including with respect to an individual’s religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status) that is collected or maintained pursuant to this section. 1712.Office of Health Equity(a)In generalThere is established, in the Office of the Secretary of Health and Human Services, an Office of Health Equity, to be headed by a Director, to ensure coordination and collaboration across the programs and activities of the Department of Health and Human Services with respect to ensuring health equity.(b)Monitoring, tracking, and availability of data(1)In generalIn carrying out subsection (a), the Director of the Office of Health Equity shall monitor, track, and make publicly available data on—(A)the disproportionate burden of disease and death among people of color, disaggregated by race, major ethnic group, Tribal affiliation, national origin, primary language use, English proficiency status, immigration status, length of stay in the United States age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status;(B)barriers to health, including such barriers relating to income, education, housing, food insecurity (including availability, access, utilization, and stability), employment status, working conditions, and conditions related to the physical environment (including pollutants and population density);(C)barriers to health care access, including—(i)lack of trust and awareness;(ii)lack of transportation;(iii)geography;(iv)hospital and service closures;(v)lack of health care infrastructure and facilities; and(vi)lack of health care professional staffing and recruitment;(D)disparities in quality of care received, including discrimination in health care settings and the use of racially-biased practice guidelines and algorithms; and(E)disparities in utilization of care.(2)Analysis of cross-sectional informationThe Director of the Office of Health Equity shall ensure that the data collection and reporting process under paragraph (1) allows for the analysis of cross-sectional information on people’s identities.(c)PoliciesIn carrying out subsection (a), the Director of the Office of Health Equity shall develop, coordinate, and promote policies that enhance health equity, including by—(1)providing recommendations on—(A)cultural competence, implicit bias, and ethics training with respect to health care workers;(B)increasing diversity in the health care workforce; and(C)ensuring sufficient health care professionals and facilities; and(2)ensuring adequate public health funding at the local and State levels to address health disparities.(d)ConsultationIn carrying out subsection (a), the Director of the Office of Health Equity, in coordination with the Director of the Indian Health Service, shall consult with Indian Tribes and with Urban Indian organizations on data collection, reporting, and implementation of policies.(e)Annual reportIn carrying out subsection (a), the Director of the Office of Health Equity shall develop and publish an annual report on—(1)statistics collected by the Office;(2)proposed evidence-based solutions to mitigate health inequities; and(3)health care professional staffing levels and access to facilities.(f)Centralized electronic repositoryIn carrying out subsection (a), the Director of the Office of Health Equity shall—(1)establish and maintain a centralized electronic repository to incorporate data collected across Federal departments and agencies on race, ethnicity, Tribal affiliation, national origin, primary language use, English proficiency status, immigration status, length of stay in the United States age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status; and(2)make such data available for public use and analysis.(g)PrivacyNotwithstanding any other Federal or State law, no Federal or State official or employee or other entity shall disclose, or use, for any law enforcement or immigration purpose, any personally identifiable information (including with respect to an individual’s religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status) that is collected or maintained pursuant to this section..

1712. Office of Health Equity There is established, in the Office of the Secretary of Health and Human Services, an Office of Health Equity, to be headed by a Director, to ensure coordination and collaboration across the programs and activities of the Department of Health and Human Services with respect to ensuring health equity. In carrying out subsection (a), the Director of the Office of Health Equity shall monitor, track, and make publicly available data on— the disproportionate burden of disease and death among people of color, disaggregated by race, major ethnic group, Tribal affiliation, national origin, primary language use, English proficiency status, immigration status, length of stay in the United States age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status; barriers to health, including such barriers relating to income, education, housing, food insecurity (including availability, access, utilization, and stability), employment status, working conditions, and conditions related to the physical environment (including pollutants and population density); barriers to health care access, including— lack of trust and awareness; lack of transportation; geography; hospital and service closures; lack of health care infrastructure and facilities; and lack of health care professional staffing and recruitment; disparities in quality of care received, including discrimination in health care settings and the use of racially-biased practice guidelines and algorithms; and disparities in utilization of care. The Director of the Office of Health Equity shall ensure that the data collection and reporting process under paragraph (1) allows for the analysis of cross-sectional information on people’s identities. In carrying out subsection (a), the Director of the Office of Health Equity shall develop, coordinate, and promote policies that enhance health equity, including by— providing recommendations on— cultural competence, implicit bias, and ethics training with respect to health care workers; increasing diversity in the health care workforce; and ensuring sufficient health care professionals and facilities; and ensuring adequate public health funding at the local and State levels to address health disparities. In carrying out subsection (a), the Director of the Office of Health Equity, in coordination with the Director of the Indian Health Service, shall consult with Indian Tribes and with Urban Indian organizations on data collection, reporting, and implementation of policies. In carrying out subsection (a), the Director of the Office of Health Equity shall develop and publish an annual report on— statistics collected by the Office; proposed evidence-based solutions to mitigate health inequities; and health care professional staffing levels and access to facilities. In carrying out subsection (a), the Director of the Office of Health Equity shall— establish and maintain a centralized electronic repository to incorporate data collected across Federal departments and agencies on race, ethnicity, Tribal affiliation, national origin, primary language use, English proficiency status, immigration status, length of stay in the United States age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status; and make such data available for public use and analysis. Notwithstanding any other Federal or State law, no Federal or State official or employee or other entity shall disclose, or use, for any law enforcement or immigration purpose, any personally identifiable information (including with respect to an individual’s religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status) that is collected or maintained pursuant to this section.

616. Office of Primary Care Title XVII of the Public Health Service Act (42 U.S.C. 300u et seq.) is amended by adding at the end the following: There is established, in the Office of Health Equity established under section 1712, an Office of Primary Health Care, to be headed by a Director, to ensure coordination and collaboration across the programs and activities of the Department of Health and Human Services with respect to increasing access to high-quality primary health care, particularly in underserved areas and for underserved populations. Not later than 1 year after the date of enactment of this section, the Director of the Office of Primary Health Care shall publish national goals— to increase access to high-quality primary health care, particularly in underserved areas and for underserved populations; and to address health disparities, including with respect to race, ethnicity, national origin (disaggregated by major ethnic group and Tribal affiliation), primary language use, English proficiency status, immigration status, length of stay in the United States, age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status. In carrying out subsections (a) and (b), the Director of the Office of Primary Health Care shall— coordinate, in consultation with the Secretary, health professional education policies and goals to achieve the national goals published pursuant to subsection (b); develop and maintain a system to monitor the number and specialties of individuals pursuing careers in, or practicing, primary health care through their health professional education, any postgraduate training, and professional practice; develop, coordinate, and promote policies that expand the number of primary health care practitioners, registered nurses, advance practice clinicians, and dentists; recommend appropriate training, technical assistance, and patient protection enhancements for primary care health professionals, including registered nurses, to achieve uniform high quality and patient safety; provide recommendations on targeted programs and resources for Federally qualified health centers, rural health centers, community health centers, and other community-based organizations; provide recommendations for broader patient referral to additional resources, not limited to health care, and collaboration with other organizations and sectors that influence health outcomes; and consult with the Secretary on the allocation of the special projects budget under section 601(a)(2)(C) of the Medicare for All Act. Nothing in this section shall be construed— to preempt any provision of State law establishing practice standards or guidelines for health care professionals, including professional licensing or practice laws or regulations; or to require that any State impose additional educational standards or guidelines for health care professionals. 1713.Office of Primary Care(a)In generalThere is established, in the Office of Health Equity established under section 1712, an Office of Primary Health Care, to be headed by a Director, to ensure coordination and collaboration across the programs and activities of the Department of Health and Human Services with respect to increasing access to high-quality primary health care, particularly in underserved areas and for underserved populations.(b)National GoalsNot later than 1 year after the date of enactment of this section, the Director of the Office of Primary Health Care shall publish national goals—(1)to increase access to high-quality primary health care, particularly in underserved areas and for underserved populations; and(2)to address health disparities, including with respect to race, ethnicity, national origin (disaggregated by major ethnic group and Tribal affiliation), primary language use, English proficiency status, immigration status, length of stay in the United States, age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status.(c)Other responsibilitiesIn carrying out subsections (a) and (b), the Director of the Office of Primary Health Care shall—(1)coordinate, in consultation with the Secretary, health professional education policies and goals to achieve the national goals published pursuant to subsection (b);(2)develop and maintain a system to monitor the number and specialties of individuals pursuing careers in, or practicing, primary health care through their health professional education, any postgraduate training, and professional practice;(3)develop, coordinate, and promote policies that expand the number of primary health care practitioners, registered nurses, advance practice clinicians, and dentists;(4)recommend appropriate training, technical assistance, and patient protection enhancements for primary care health professionals, including registered nurses, to achieve uniform high quality and patient safety;(5)provide recommendations on targeted programs and resources for Federally qualified health centers, rural health centers, community health centers, and other community-based organizations;(6)provide recommendations for broader patient referral to additional resources, not limited to health care, and collaboration with other organizations and sectors that influence health outcomes; and(7)consult with the Secretary on the allocation of the special projects budget under section 601(a)(2)(C) of the Medicare for All Act.(d)Rule of constructionNothing in this section shall be construed—(1)to preempt any provision of State law establishing practice standards or guidelines for health care professionals, including professional licensing or practice laws or regulations; or(2)to require that any State impose additional educational standards or guidelines for health care professionals..

1713. Office of Primary Care There is established, in the Office of Health Equity established under section 1712, an Office of Primary Health Care, to be headed by a Director, to ensure coordination and collaboration across the programs and activities of the Department of Health and Human Services with respect to increasing access to high-quality primary health care, particularly in underserved areas and for underserved populations. Not later than 1 year after the date of enactment of this section, the Director of the Office of Primary Health Care shall publish national goals— to increase access to high-quality primary health care, particularly in underserved areas and for underserved populations; and to address health disparities, including with respect to race, ethnicity, national origin (disaggregated by major ethnic group and Tribal affiliation), primary language use, English proficiency status, immigration status, length of stay in the United States, age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status. In carrying out subsections (a) and (b), the Director of the Office of Primary Health Care shall— coordinate, in consultation with the Secretary, health professional education policies and goals to achieve the national goals published pursuant to subsection (b); develop and maintain a system to monitor the number and specialties of individuals pursuing careers in, or practicing, primary health care through their health professional education, any postgraduate training, and professional practice; develop, coordinate, and promote policies that expand the number of primary health care practitioners, registered nurses, advance practice clinicians, and dentists; recommend appropriate training, technical assistance, and patient protection enhancements for primary care health professionals, including registered nurses, to achieve uniform high quality and patient safety; provide recommendations on targeted programs and resources for Federally qualified health centers, rural health centers, community health centers, and other community-based organizations; provide recommendations for broader patient referral to additional resources, not limited to health care, and collaboration with other organizations and sectors that influence health outcomes; and consult with the Secretary on the allocation of the special projects budget under section 601(a)(2)(C) of the Medicare for All Act. Nothing in this section shall be construed— to preempt any provision of State law establishing practice standards or guidelines for health care professionals, including professional licensing or practice laws or regulations; or to require that any State impose additional educational standards or guidelines for health care professionals.

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

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

801. Prohibition of employee benefits duplicative of benefits under the Medicare for All Program; coordination in case of workers’ compensation Part 5 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is amended by adding at the end the following new section: Subject to subsection (b), no employee benefit plan may provide benefits that duplicate payment for any items or services for which payment may be made under the Medicare for All Act. Each workers compensation carrier that is liable for payment for workers compensation services furnished in a State shall reimburse the Medicare for All Program for the cost of such services. In this subsection— the term workers compensation carrier means an insurance company that underwrite workers compensation medical benefits with respect to one or more employers and includes an employer or fund that is financially at risk for the provision of workers compensation medical benefits; the term workers compensation medical benefits means, with respect to an enrollee who is an employee subject to the workers compensation laws of a State, the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee; and the term workers compensation services means items and services included in workers compensation medical benefits and includes items and services (including rehabilitation services and long-term care services) commonly used for treatment of work-related injuries and illnesses. Section 4(b) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1003(b)) is amended by adding at the end the following: Paragraph (3) shall apply subject to section 522(b) (relating to reimbursement of the Medicare for All Program by workers compensation carriers).. The table of contents in section 1 of such Act is amended by inserting after the item relating to section 521 the following new item: 522.Prohibition of employee benefits duplicative of Universal Medicare Program benefits; coordination in case of workers’ compensation(a)In generalSubject to subsection (b), no employee benefit plan may provide benefits that duplicate payment for any items or services for which payment may be made under the Medicare for All Act.(b)ReimbursementEach workers compensation carrier that is liable for payment for workers compensation services furnished in a State shall reimburse the Medicare for All Program for the cost of such services.(c)DefinitionsIn this subsection—(1)the term workers compensation carrier means an insurance company that underwrite workers compensation medical benefits with respect to one or more employers and includes an employer or fund that is financially at risk for the provision of workers compensation medical benefits;(2)the term workers compensation medical benefits means, with respect to an enrollee who is an employee subject to the workers compensation laws of a State, the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee; and(3)the term workers compensation services means items and services included in workers compensation medical benefits and includes items and services (including rehabilitation services and long-term care services) commonly used for treatment of work-related injuries and illnesses.. Sec. 522. Prohibition of employee benefits duplicative of Universal Medicare Program benefits; coordination in case of workers’ compensation..

522. Prohibition of employee benefits duplicative of Universal Medicare Program benefits; coordination in case of workers’ compensation Subject to subsection (b), no employee benefit plan may provide benefits that duplicate payment for any items or services for which payment may be made under the Medicare for All Act. Each workers compensation carrier that is liable for payment for workers compensation services furnished in a State shall reimburse the Medicare for All Program for the cost of such services. In this subsection— the term workers compensation carrier means an insurance company that underwrite workers compensation medical benefits with respect to one or more employers and includes an employer or fund that is financially at risk for the provision of workers compensation medical benefits; the term workers compensation medical benefits means, with respect to an enrollee who is an employee subject to the workers compensation laws of a State, the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee; and the term workers compensation services means items and services included in workers compensation medical benefits and includes items and services (including rehabilitation services and long-term care services) commonly used for treatment of work-related injuries and illnesses.

802. Application of continuation coverage requirements under ERISA and certain other requirements relating to group health plans Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) shall apply only with respect to any employee health benefit plan that does not duplicate payments for any items or services for which payment may be made under the this Act. Section 601 of part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (19 U.S.C. 1161) is amended by adding the following subsection at the end: Subsection (a) shall apply to any group health plan that does not duplicate payments for any items or services for which payment may be made under the Medicare for All Act. (c)Subsection (a) shall apply to any group health plan that does not duplicate payments for any items or services for which payment may be made under the Medicare for All Act..

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

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

902. Sunset of provisions related to the State Exchanges Effective on the date that is 2 years after the date of the enactment of this Act, the Federal and State Exchanges established pursuant to title I of the Patient Protection and Affordable Care Act (Public Law 111–148) shall terminate, and any other provision of law that relies upon participation in or enrollment through such an Exchange, including such provisions of the Internal Revenue Code of 1986, shall cease to have force or effect.

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

1001. Medicare for all transition over two years Title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.) is amended by adding at the end the following new section: Every individual who meets the requirements described in paragraph (3) shall be eligible to enroll in the Medicare for All Program under this section during the transition period starting one year after the date of enactment of the Medicare for All Act. An individual enrolled under this section is entitled to the benefits established under title II of the Medicare for All Act. The requirements described in this paragraph are the following: The individual meets the eligibility requirements established by the Secretary under title I of the Medicare for All Act. The individual has attained the applicable year of age, or is currently enrolled in Medicare at the time of the transition to Medicare for All. For purposes of this section, the term applicable year of age means one year after the date of enactment of the Medicare for All Act, the age of 55 or older, the age 18 or younger. The Secretary shall establish enrollment periods and coverage under this section consistent with the principles for establishment of enrollment periods and coverage for individuals under other provisions of this title. The Secretary shall establish such periods so that coverage under this section shall first begin on January 1 of the year on which an individual first becomes eligible to enroll under this section. For purposes of applying section 5000A of the Internal Revenue Code of 1986, the coverage provided under this section constitutes minimum essential coverage under subsection (f)(1)(A)(i) of such section 5000A. In promulgating regulations to implement this section, the Secretary shall consult with interested parties, including groups representing beneficiaries, health care providers, employers, and insurance companies. 1899C.Medicare for all transition over 2 years(a)Transition(1)In generalEvery individual who meets the requirements described in paragraph (3) shall be eligible to enroll in the Medicare for All Program under this section during the transition period starting one year after the date of enactment of the Medicare for All Act.(2)BenefitsAn individual enrolled under this section is entitled to the benefits established under title II of the Medicare for All Act.(3)Requirements for eligibilityThe requirements described in this paragraph are the following:(A)The individual meets the eligibility requirements established by the Secretary under title I of the Medicare for All Act.(B)The individual has attained the applicable year of age, or is currently enrolled in Medicare at the time of the transition to Medicare for All.(4)Applicable year of age definedFor purposes of this section, the term applicable year of age means one year after the date of enactment of the Medicare for All Act, the age of 55 or older, the age 18 or younger.(b)Enrollment; coverageThe Secretary shall establish enrollment periods and coverage under this section consistent with the principles for establishment of enrollment periods and coverage for individuals under other provisions of this title. The Secretary shall establish such periods so that coverage under this section shall first begin on January 1 of the year on which an individual first becomes eligible to enroll under this section.(c)Satisfaction of individual mandateFor purposes of applying section 5000A of the Internal Revenue Code of 1986, the coverage provided under this section constitutes minimum essential coverage under subsection (f)(1)(A)(i) of such section 5000A.(d)ConsultationIn promulgating regulations to implement this section, the Secretary shall consult with interested parties, including groups representing beneficiaries, health care providers, employers, and insurance companies..

1899C. Medicare for all transition over 2 years Every individual who meets the requirements described in paragraph (3) shall be eligible to enroll in the Medicare for All Program under this section during the transition period starting one year after the date of enactment of the Medicare for All Act. An individual enrolled under this section is entitled to the benefits established under title II of the Medicare for All Act. The requirements described in this paragraph are the following: The individual meets the eligibility requirements established by the Secretary under title I of the Medicare for All Act. The individual has attained the applicable year of age, or is currently enrolled in Medicare at the time of the transition to Medicare for All. For purposes of this section, the term applicable year of age means one year after the date of enactment of the Medicare for All Act, the age of 55 or older, the age 18 or younger. The Secretary shall establish enrollment periods and coverage under this section consistent with the principles for establishment of enrollment periods and coverage for individuals under other provisions of this title. The Secretary shall establish such periods so that coverage under this section shall first begin on January 1 of the year on which an individual first becomes eligible to enroll under this section. For purposes of applying section 5000A of the Internal Revenue Code of 1986, the coverage provided under this section constitutes minimum essential coverage under subsection (f)(1)(A)(i) of such section 5000A. In promulgating regulations to implement this section, the Secretary shall consult with interested parties, including groups representing beneficiaries, health care providers, employers, and insurance companies.

1002. Establishment of the Medicare transition buy-in To carry out the purpose of this section, for the year beginning one year after the date of enactment of this Act and ending with the effective date described in section 106(a), the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid (referred to in this section as the Administrator), shall establish, and provide for the offering through the Exchanges, an option to buy in to the Medicare for All Program (in this Act referred to as the Medicare Transition buy-in). The Administrator shall administer the Medicare Transition buy-in in accordance with this section. Consistent with this section, the Medicare Transition buy-in shall comply with requirements under title I of the Patient Protection and Affordable Care Act (and the amendments made by that title) and title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) that are applicable to qualified health plans offered through the Exchanges, subject to the limitation under subsection (e)(2). The Medicare Transition buy-in shall be made available only through the Exchanges, and shall be available to individuals wishing to enroll and to qualified employers (as defined in section 1312(f)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18032)) who wish to make such plan available to their employees. Any United States resident may enroll in the Medicare Transition buy-in. In carrying out this section, the Administrator shall ensure that the Medicare Transition buy-in provides— coverage for the benefits required to be covered under title II of this Act; and coverage of benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan. With respect to the reimbursement provided to health care providers for covered benefits, as described in section 201, provided under the Medicare Transition buy-in, the Administrator shall reimburse such providers at rates determined for equivalent items and services under the Medicare for All fee-for-service schedule established in section 612(b) of this Act. Any payment rate under this subsection for a prescription drug shall be at the prices negotiated under section 616 of this Act. A health care provider that is a participating provider of services or supplier under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) or under a State Medicaid plan under title XIX of such Act (42 U.S.C. 1396 et seq.) on the date of enactment of this Act shall be a participating provider in the Medicare Transition buy-in. The Administrator shall establish a process to allow health care providers not described in subparagraph (A) to become participating providers in the Medicare Transition buy-in. Such process shall be similar to the process applied to new providers under the Medicare program. The Administrator shall determine the premium amount for enrolling in the Medicare Transition buy-in, which— may vary according to family or individual coverage, age, and tobacco status (consistent with clauses (i), (iii), and (iv) of section 2701(a)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(a)(1)(A))); and shall take into account the cost-sharing reductions and premium tax credits which will be available with respect to the plan under section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) and section 36B of the Internal Revenue Code of 1986, as amended by subsection (g). Variation in premium rates of the Medicare Transition buy-in by rating area, as described in clause (ii) of section 2701(a)(1)(A)(iii) of the Public Health Service Act (42 U.S.C. 300gg(a)(1)(A)) is not permitted. This section shall cease to have force or effect on the effective date described in section 106(a). Paragraph (1) of section 36B(c) of the Internal Revenue Code of 1986 is amended by redesignating subparagraphs (C) and (D) as subparagraphs (D) and (E), respectively, and by inserting after subparagraph (B) the following new subparagraph: In the case of a taxpayer who is covered, or whose spouse or dependent (as defined in section 152) is covered, by the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act for all months in the taxable year, subparagraph (A) shall be applied without regard to but does not exceed 400 percent. In the case of a taxpayer residing in a State which (as of the date of the enactment of the Medicare for All Act) does not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) of the Social Security Act for medical assistance under title XIX of such Act (or a waiver of the State plan approved under section 1115) who is covered, or whose spouse or dependent (as defined in section 152) is covered, by the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act for all months in the taxable year, subparagraphs (A) and (B) shall be applied by substituting 0 percent for 100 percent each place it appears. Subparagraph (A) of section 36B(b)(3) of such Code is amended—(I) by redesignating clause (ii) as clause (iii), (II) by striking clause (ii) in clause (i) and inserting clauses (ii) and (iii), and (III) by inserting after clause (i) the following new clause: In the case of a taxpayer who is covered, or whose spouse or dependent (as defined in section 152) is covered, by the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act for all months in the taxable year, the applicable percentage for any taxable year shall be determined in the same manner as under clause (i), except that the following table shall apply in lieu of the table contained in such clause: Subclause (I) of clause (iii) of section 36B(b)(3) of such Code, as redesignated by subparagraph (A)(i), is amended by inserting , and determined after the application of clause (ii) after after application of this clause. Subsection (b) of section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071(b)) is amended— by inserting , or in the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act, after coverage in paragraph (1); by redesignating paragraphs (1) (as so amended) and (2) as subparagraphs (A) and (B), respectively, and by moving such subparagraphs 2 ems to the right; by striking insured.—In this section and inserting “insured.— In this section by striking the flush language; and by adding at the end the following new paragraph: In the case of an individual described in section 36B(c)(1)(B) of the Internal Revenue Code of 1986, the individual shall be treated as having household income equal to 100 percent of the poverty line for a family of the size involved for purposes of applying this section. In the case of an individual residing in a State which (as of the date of the enactment of the Medicare for All Act) does not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) of the Social Security Act for medical assistance under title XIX of such Act (or a waiver of the State plan approved under section 1115) who enrolls in such Medicare Transition buy-in, the preceding sentence, paragraph (1)(B), and paragraphs (1)(A)(i) and (2)(A) of subsection (c) shall each be applied by substituting 0 percent for 100 percent each place it appears. Section 1301(a)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18021(a)(2)) is amended— in the paragraph heading, by inserting The Medicare transition buy-in, before and; and by inserting The Medicare Transition buy-in, before and a multi-State plan. Section 1324(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18044(a)) is amended by inserting the Medicare Transition buy-in, before or a multi-State qualified health plan. (C)Special rules for medicare transition buy-in enrollees(i)In generalIn the case of a taxpayer who is covered, or whose spouse or dependent (as defined in section 152) is covered, by the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act for all months in the taxable year, subparagraph (A) shall be applied without regard to but does not exceed 400 percent.(ii)Enrollees in medicaid nonexpansion statesIn the case of a taxpayer residing in a State which (as of the date of the enactment of the Medicare for All Act) does not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) of the Social Security Act for medical assistance under title XIX of such Act (or a waiver of the State plan approved under section 1115) who is covered, or whose spouse or dependent (as defined in section 152) is covered, by the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act for all months in the taxable year, subparagraphs (A) and (B) shall be applied by substituting 0 percent for 100 percent each place it appears.. (ii)Special rules for taxpayers enrolled in medicare transition buy-inIn the case of a taxpayer who is covered, or whose spouse or dependent (as defined in section 152) is covered, by the Medicare Transition buy-in established under section 1002(a) of the Medicare for All Act for all months in the taxable year, the applicable percentage for any taxable year shall be determined in the same manner as under clause (i), except that the following table shall apply in lieu of the table contained in such clause:In the case of household income (expressed as a percent of poverty line) within the following income tier:The initial premium percentage is—The final premium percentage is—Up to 100 percent2.002.00100 percent up to 138 percent2.042.04138 percent up to 150 percent3.064.08150 percent and above4.085.00.. (1)In generalIn this section; (2)Special rules(A)Individuals lawfully presentIn the case of an individual described in section 36B(c)(1)(B) of the Internal Revenue Code of 1986, the individual shall be treated as having household income equal to 100 percent of the poverty line for a family of the size involved for purposes of applying this section.(B)Medicare transition buy-in enrollees in medicaid non-expansion statesIn the case of an individual residing in a State which (as of the date of the enactment of the Medicare for All Act) does not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) of the Social Security Act for medical assistance under title XIX of such Act (or a waiver of the State plan approved under section 1115) who enrolls in such Medicare Transition buy-in, the preceding sentence, paragraph (1)(B), and paragraphs (1)(A)(i) and (2)(A) of subsection (c) shall each be applied by substituting 0 percent for 100 percent each place it appears..

1011. Eliminating the 24-month waiting period for Medicare coverage for individuals with disabilities Section 226(b) of the Social Security Act (42 U.S.C. 426(b)) is amended— in paragraph (2)(A), by striking , and has for 24 calendar months been entitled to,; in paragraph (2)(B), by striking , and has been for not less than 24 months,; in paragraph (2)(C)(ii), by striking , including the requirement that he has been entitled to the specified benefits for 24 months,; in the first sentence, by striking for each month beginning with the later of (I) July 1973 or (II) the twenty-fifth month of his entitlement or status as a qualified railroad retirement beneficiary described in paragraph (2), and and inserting for each month for which the individual meets the requirements of paragraph (2), beginning with the month following the month in which the individual meets the requirements of such paragraph, and; and in the second sentence, by striking the twenty-fifth month of his entitlement and all that follows through paragraph (2)(C) and. Section 226 of the Social Security Act (42 U.S.C. 426) is amended by— striking subsections (e)(1)(B), (f), and (h); and redesignating subsections (g) and (i) as subsections (f) and (g), respectively. Section 1811(2) of the Social Security Act (42 U.S.C. 1395c(2)) is amended by striking have been entitled for not less than 24 months and inserting are entitled. Section 1837(g)(1) of the Social Security Act (42 U.S.C. 1395p(g)(1)) is amended by striking 25th month of and inserting month following the first month of. Section 7(d)(2)(ii) of the Railroad Retirement Act of 1974 (45 U.S.C. 231f(d)(2)(ii)) is amended— by striking has been entitled to an annuity and inserting is entitled to an annuity; by striking , for not less than 24 months; and by striking could have been entitled for 24 calendar months, and. The amendments made by this section shall apply to insurance benefits under title XVIII of the Social Security Act with respect to items and services furnished in months beginning after December 1 following the date of enactment of this Act, and before the date that is 2 years after the date of the enactment of such Act.

1012. Ensuring continuity of care The Secretary shall ensure that all persons enrolled or who seek to enroll in a health plan during the transition period of the Medicare for All Program are protected from disruptions in their care during the transition period, including continuity of care with such persons’ current health care provider teams. During the transition period of the Medicare for All Act, group health plans and health insurance issuers offering group or individual health insurance coverage shall not end coverage for an enrollee during the transition period described in the Act until all ages are eligible to enroll in the Medicare for All Program except as expressly agreed upon under the terms of the plan. The Secretary shall ensure that persons’ with disabilities, complex medical needs, or chronic conditions are protected from disruptions in their care during the transition period, including continuity of care with such persons current health care provider teams. During the transition period of the Medicare for All Act group health plans and health insurance issuers offering group or individual health insurance coverage shall not— end coverage for an enrollee who has a disability, complex medical need, or chronic condition during the transition period described in the Act until all ages are eligible to enroll in the Medicare for All Program; or impose any exclusion with respect to such plan or coverage on the basis of a person’s disability, complex medical need, or chronic condition during the transition period described under this Act until all ages are eligible to enroll in the Medicare for All Program. The Secretary shall consult with communities and advocacy organizations of persons living with disabilities as well as other patient advocacy organizations to ensure that the transition buy-in takes into account the continuity of care for persons with disabilities, complex medical needs, or chronic conditions.

1101. Definitions In this Act— the term global budget means the payment negotiated between an institutional provider and as described in section 611(b); the term group practice has the meaning given such term in section 1877(h)(4) of the Social Security Act (42 U.S.C. 1395nn(h)(4)); the term individual provider means a supplier (as defined in section 1861(d) of such Act (42 U.S.C. 1395x(d))); the term institutional provider means— providers of services described in section 1861(u) of such Act (42 U.S.C. 1395x(u)); hospitals as defined in section 1861(e) of the Social Security Act (42 U.S.C. 1395x(e)), and any outpatient settings or clinics operating within a hospital license or any setting or clinic that provides outpatient hospital services; psychiatric hospitals (as defined in section 1861(e) of the Social Security Act (42 U.S.C. 1395x(f))); rehabilitation hospitals (as defined by the Secretary of Health and Human Services under section 1886(d)(1)(B)(ii) of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)(ii))); long-term care hospitals as defined in section 1861 of the Social Security Act (42 U.S.C. 1395x(ccc)); and independent dialysis facilities and independent end-stage renal disease facilities as described in 42 CFR 413.174(b); the term medically necessary or appropriate means the health care items and services or supplies that are needed or appropriate to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms for an individual and are determined to be necessary or appropriate for such individual by the physician or other health care professional treating such individual, after such professional performs an assessment of such individual’s condition, in a manner that meets— the scope of practice, licensing, and other law of the State in which the individual receiving such items and services is located; and appropriate standards established by the Secretary for purposes of carrying out this Act; the term provider means an institutional provider or a supplier (as defined in section 1861(d) of such Act (42 U.S.C. 1395x(d)) if the reference to this title were a reference to the Medicare for All Program); the term Secretary means the Secretary of Health and Human Services; the term State means a State, the District of Columbia, or a territory of the United States; the term TRICARE Overseas Program means the element of the TRICARE program administered by International SOS (or such successor administrator) under which care and health benefits are furnished to TRICARE beneficiaries located in a TRICARE overseas region; the term TRICARE program has the meaning given such term in section 1072 of title 10, United States Code; the term uniformed services has the meaning given such term in section 101 of title 10, United States Code; and the term United States shall include the States, the District of Columbia, and the territories of the United States.

1102. Rules of construction A State or local government may set additional standards or apply other State or local laws with respect to eligibility, benefits, and minimum provider standards, only if such State or local standards— provide equal or greater eligibility than is available under this Act; provide equal or greater in-person access to benefits under this Act; do not reduce access to benefits under this Act; allow for the effective exercise of the professional judgment of physicians or other health care professionals; and are otherwise consistent with this Act. Nothing in this Act shall be construed to preempt State licensing, practice, or educational laws or regulations with respect to health care professionals and health care providers, for such professionals and providers who practice in that State. Nothing in this Act shall be construed to diminish or alter the rights, privileges, remedies, or obligations of any employee or employer under any Federal or State law or regulation or under any collective bargaining agreement. With respect to any individuals or entities certified to provide items and services covered under section 201(a)(7), a State may not prohibit an individual or entity from participating in the program under this Act for reasons other than the ability of the individual or entity to provide such services.

1103. No use of resources for law enforcement of certain registration requirements Notwithstanding any provision of Federal or State law, no Federal or State law enforcement official or employee shall use any funds, facilities, property, equipment, or personnel made available pursuant to this Act (or any amendment made thereby) to investigate, enforce, or assist in the investigation or enforcement of any criminal, civil, or administrative violation or warrant for a violation of any requirement that individuals register with the Federal Government based on religion, national origin, ethnicity, immigration status, or other protected category.