,i #aafth ,,congress #ast ,session ,h4 ,r4 #achd ,,in ,,the ,,house ,,of ,,representatives ,february #bg1 #bjai,ms4 ,jayapal 7for herself1 ,mrs4 ,dingell1 ,ms4 ,adams1 ,ms4 ,barragn1 ,ms4 ,bass1 ,mrs4 ,beatty1 ,mr4 ,beyer1 ,mr4 ,blumenauer1 ,ms4 ,bonamici1 ,mr4 ,brendan ,f4 ,boyle of ,pennsylvania1 ,mr4 ,brown of ,maryland1 ,mr4 ,carson of ,indiana1 ,mr4 ,cartwright1 ,ms4 ,judy ,chu of ,california1 ,mr4 ,cicilline1 ,ms4 ,clark of ,massachusetts1 ,ms4 ,clarke of ,new ,york1 ,mr4 ,clay1 ,mr4 ,cleaver1 ,mr4 ,cohen1 ,mr4 ,danny ,k4 ,davis of ,illinois1 ,mr4 ,de,fazio1 ,ms4 ,de,gette1 ,mr4 ,de,saulnier1 ,mr4 ,michael ,f4 ,doyle of ,pennsylvania1 ,mr4 ,engel1 ,ms4 ,escobar1 ,mr4 ,espaillat1 ,ms4 ,frankel1 ,ms4 ,fudge1 ,ms4 ,gabbard1 ,mr4 ,gallego1 ,mr4 ,garca of ,illinois1 ,mr4 ,golden1 ,mr4 ,gomez1 ,mr4 ,gonzalez of ,texas1 ,mr4 ,green of ,texas1 ,mr4 ,grijalva1 ,ms4 ,haaland1 ,mr4 ,harder of ,california1 ,mr4 ,hastings1 ,mrs4 ,hayes1 ,mr4 ,higgins of ,new ,york1 ,ms4 ,hill of ,california1 ,ms4 ,norton1 ,mr4 ,huffman1 ,ms4 ,jackson ,lee1 ,mr4 ,johnson of ,georgia1 ,mr4 ,keating1 ,ms4 ,kelly of ,illinois1 ,mr4 ,kennedy1 ,mr4 ,khanna1 ,mrs4 ,kirkpatrick1 ,mr4 ,langevin1 ,mrs4 ,lawrence1 ,ms4 ,lee of ,california1 ,mr4 ,levin of ,california1 ,mr4 ,levin of ,michigan1 ,mr4 ,lewis1 ,mr4 ,ted ,lieu of ,california1 ,mr4 ,lowenthal1 ,mrs4 ,lowey1 ,mrs4 ,carolyn ,b4 ,maloney of ,new ,york1 ,mr4 ,mc,govern1 ,mr4 ,mc,nerney1 ,mr4 ,meeks1 ,ms4 ,meng1 ,mr4 ,nadler1 ,mrs4 ,napolitano1 ,mr4 ,neguse1 ,ms4 ,ocasio-,cortez1 ,ms4 ,omar1 ,mr4 ,panetta1 ,mr4 ,payne1 ,mr4 ,perlmutter1 ,ms4 ,pingree1 ,mr4 ,pocan1 ,ms4 ,porter1 ,ms4 ,pressley1 ,mr4 ,raskin1 ,ms4 ,roybal-,allard1 ,mr4 ,rush1 ,mr4 ,ryan1 ,mr4 ,sablan1 ,ms4 ,snchez1 ,mr4 ,sarbanes1 ,ms4 ,schakowsky1 ,mr4 ,schiff1 ,mr4 ,scott of ,virginia1 ,mr4 ,serrano1 ,mr4 ,smith of ,washington1 ,ms4 ,speier1 ,mr4 ,swalwell of ,california1 ,mr4 ,takano1 ,mr4 ,thompson of ,california1 ,mr4 ,thompson of ,mississippi1 ,ms4 ,titus1 ,ms4 ,tlaib1 ,mr4 ,tonko1 ,mr4 ,veasey1 ,ms4 ,velzquez1 ,mr4 ,visclosky1 ,ms4 ,waters1 ,mrs4 ,watson ,coleman1 ,mr4 ,welch1 ,ms4 ,wild1 and ,ms4 ,wilson of ,florida7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 ,education and ,labor1 ,rules1 ,oversight and ,reform1 and ,armed ,services1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to establish an improved ,medicare for ,all national health insurance program4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,medicare for ,all ,act of #bjai4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,title ,i--,establishment of the ,medicare for ,all ,program2 ,universal ,coverage2 ,enrollment ,sec4 #aja4 ,establishment of the ,medicare for ,all ,program4 ,sec4 #ajb4 ,universal coverage4 ,sec4 #ajc4 ,freedom of choice4 ,sec4 #ajd4 ,non-discrimination4 ,sec4 #aje4 ,enrollment4 ,sec4 #ajf4 ,effective date of benefits4 ,sec4 #ajg4 ,prohibition against duplicating coverage4 ,title ,,ii--,comprehensive ,benefits1 ,including ,preventive ,benefits and ,benefits for ,long-,term ,care ,sec4 #bja4 ,comprehensive benefits4 ,sec4 #bjb4 ,no cost-sharing4 ,sec4 #bjc4 ,exclusions and limitations4 ,sec4 #bjd4 ,coverage of long-term care services4 ,title ,,iii--,provider ,participation ,sec4 #cja4 ,provider participation and standards2 whistleblower protections4 ,sec4 #cjb4 ,qualifications for providers4 ,sec4 #cjc4 ,use of private contracts4 ,title ,,iv--,administration ,subtitle ,a--,general ,administration ,provisions ,sec4 #dja4 ,administration4 ,sec4 #djb4 ,consultation4 ,sec4 #djc4 ,regional administration4 ,sec4 #djd4 ,beneficiary ombudsman4 ,sec4 #dje4 ,conduct of related health programs4 ,subtitle ,b--,control ,over ,fraud and ,abuse ,sec4 #daa4 ,application of ,federal sanctions to all fraud and abuse under the ,medicare for ,all ,program4 ,title ,v--,quality ,assessment ,sec4 #eja4 ,quality standards4 ,sec4 #ejb4 ,addressing health care disparities4 ,title ,,vi--,health ,budget2 ,payments2 ,cost ,containment ,measures ,subtitle ,a--,budgeting ,sec4 #fja4 ,national health budget4 ,subtitle ,b--,payments to ,providers ,sec4 #faa4 ,payments to institutional providers based on global budgets4 ,sec4 #fab4 ,payment to individual providers through fee-for-service4 ,sec4 #fac4 ,ensuring accurate valuation of services under the ,medicare physician fee schedule4 ,sec4 #fad4 ,payment prohibitions2 capital expenditures2 special projects4 ,sec4 #fae4 ,office of primary health care4 ,sec4 #faf4 ,payments for prescription drugs and approved devices and equipment4 ,title ,,vii--,universal ,medicare ,trust ,fund ,sec4 #gja4 ,universal ,medicare ,trust ,fund4 ,title ,,viii--,conforming ,amendments to the ,employee ,retirement ,income ,security ,act of #aigd ,sec4 #hja4 ,prohibition of employee benefits duplicative of benefits under the ,medicare for ,all ,program2 coordination in case of workers' compensation4 ,sec4 #hjb4 ,application of continuation coverage requirements under ,,erisa and certain other requirements relating to group health plans4 ,sec4 #hjc4 ,effective date of title4 ,title ,,ix--,additional ,conforming ,amendments ,sec4 #ija4 ,relationship to existing ,federal health programs4 ,sec4 #ijb4 ,sunset of provisions related to the ,state ,exchanges4 ,sec4 #ijc4 ,sunset of provisions related to pay for performance programs4 ,title ,x--,transition ,subtitle ,a--,medicare for ,all ,transition over #b ,years and ,transitional ,buy-,in ,option ,sec4 #ajja4 ,medicare for all transition over two years4 ,sec4 #ajjb4 ,establishment of the ,medicare transition buy-in4 ,subtitle ,b--,transitional ,medicare ,reforms ,sec4 #ajaa4 ,eliminating the #bd-month waiting period for ,medicare coverage for individuals with disabilities4 ,sec4 #ajab4 ,ensuring continuity of care4 ,title ,,xi--,miscellaneous ,sec4 #aaja4 ,definitions4 ,sec4 #aajb4 ,rules of construction4 ,i ,establishment of the ,medicare for ,all ,program2 ,universal ,coverage2 ,enrollment #aja4 ,establishment of the ,medicare for ,all ,program ,there is hereby established a national health insurance program to provide comprehensive protection against the costs of health care and health-related services1 in accordance with the standards specified in1 or established under1 this ,act4 #ajb4 ,universal coverage 7a7 ,in general ,every individual who is a resident of the ,united ,states is entitled to benefits for health care services under this ,act4 ,the ,secretary shall promulgate a rule that provides criteria for determining residency for eligibility purposes under this ,act4 7b7 ,treatment of other individuals ,the ,secretary may make eligible for benefits for health care services under this ,act other individuals not described in subsection 7a71 and regulate the eligibility of such individuals1 to ensure that every person in the ,united ,states has access to health care4 ,in regulating such eligibility1 the ,secretary shall ensure that individuals are not allowed to travel to the ,united ,states for the sole purpose of obtaining health care items and services provided under the program established under this ,act4 #ajc4 ,freedom of choice ,any individual entitled to benefits under this ,act may obtain health services from any institution1 agency1 or individual qualified to participate under this ,act4 #ajd4 ,non-discrimination 7a7 ,in general ,no person shall1 on the basis of race1 color1 national origin1 age1 disability1 marital status1 citizenship status1 primary language use1 genetic conditions1 previous or existing medical conditions1 religion1 or sex1 including sex stereotyping1 gender identity1 sexual orientation1 and pregnancy and related medical conditions 7including termination of pregnancy71 be excluded from participation in or be denied the benefits of the program established under this ,act 7except as expressly authorized by this ,act for purposes of enforcing eligibility standards described in section #ajb71 or be subject to any reduction of benefits or other discrimination by any participating provider 7as defined in section #cja71 or any entity conducting1 administering1 or funding a health program or activity1 including contracts of insurance1 pursuant to this ,act4 7b7 ,claims of discrimination 7#a7 ,in general ,the ,secretary shall establish a procedure for adjudication of administrative complaints alleging a violation of subsection 7a74 7#b7 ,jurisdiction ,any person aggrieved by a violation of subsection 7a7 by a covered entity may file suit in any district court of the ,united ,states having jurisdiction of the parties4 ,a person may bring an action under this paragraph concurrently as such administrative remedies as established in paragraph 7#a74 7#c7 ,damages ,if the court finds a violation of subsection 7a71 the court may grant compensatory and punitive damages1 declaratory relief1 injunctive relief1 attorneys' fees and costs1 or other relief as appropriate4 7c7 ,continued application of laws ,nothing in this title 7or an amendment made by this title7 shall be construed to invalidate or otherwise limit any of the rights1 remedies1 procedures1 or legal standards available to individuals aggrieved under section #aeeg of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,vii of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;e et seq471 title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq471 section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 or the ,age ,discrimination ,act of #aige 7#db ,u4,s4,c4 #faa et seq474 ,nothing in this title 7or an amendment to this title7 shall be construed to supersede ,state laws that provide additional protections against discrimination on any basis described in subsection 7a74 #aje4 ,enrollment 7a7 ,in general ,the ,secretary shall provide a mechanism for the enrollment of individuals eligible for benefits under this ,act4 ,the mechanism shall-- 7#a7 include a process for the automatic enrollment of individuals at the time of birth in the ,united ,states 7or upon establishment of residency in the ,united ,states72 7#b7 provide for the enrollment1 as of the dates described in section #ajf1 of all individuals who are eligible to be enrolled as of such dates1 as applicable2 and 7#c7 include a process for the enrollment of individuals made eligible for health care services under section #ajb7;b74 7b7 ,issuance of ,universal ,medicare cards ,in conjunction with an individual's enrollment for benefits under this ,act1 the ,secretary shall provide for the issuance of a ,universal ,medicare card that shall be used for purposes of identification and processing of claims for benefits under this program4 ,the card shall not include an individual's ,social ,security number4 #ajf4 ,effective date of benefits 7a7 ,in general ,except as provided in subsection 7b71 benefits shall first be available under this ,act for items and services furnished #b years after the date of the enactment of this ,act4 7b7 ,coverage for certain individuals 7#a7 ,in general ,for any eligible individual who-- 7,a7 has not yet attained the age of #ai as of the date that is #a year after the date of the enactment of this ,act2 or 7,b7 has attained the age of #ee as of the date that is #a year after the date of the enactment of this ,act1 benefits shall first be available under this ,act for items and services furnished as of such date4 7#b7 ,option to continue in other coverage during transition period ,any person who is eligible to receive benefits as described in paragraph 7#a7 may opt to maintain any coverage described in section #ija1 private health insurance coverage1 or coverage offered pursuant to subtitle ,a of title ,x 7including the amendments made by such subtitle7 until the date described in subsection 7a74 #ajg4 ,prohibition against duplicating coverage 7a7 ,in general ,beginning on the effective date described in section #ajf7;a71 it shall be unlawful for-- 7#a7 a private health insurer to sell health insurance coverage that duplicates the benefits provided under this ,act2 or 7#b7 an employer to provide benefits for an employee1 former employee1 or the dependents of an employee or former employee that duplicate the benefits provided under this ,act4 7b7 ,construction ,nothing in this ,act shall be construed as prohibiting the sale of health insurance coverage for any additional benefits not covered by this ,act1 including additional benefits that an employer may provide to employees or their dependents1 or to former employees or their dependents4 ,,ii ,comprehensive ,benefits1 ,including ,preventive ,benefits and ,benefits for ,long-,term ,care #bja4 ,comprehensive benefits 7a7 ,in general ,subject to the other provisions of this title and titles ,,iv through ,,ix1 individuals enrolled for benefits under this ,act are entitled to have payment made by the ,secretary to an eligible provider for the following items and services if medically necessary or appropriate for the maintenance of health or for the diagnosis1 treatment1 or rehabilitation of a health condition3 7#a7 ,hospital services1 including inpatient and outpatient hospital care1 including #bd-;hour-a-day emergency services and inpatient prescription drugs4 7#b7 ,ambulatory patient services4 7#c7 ,primary and preventive services1 including chronic disease management4 7#d7 ,prescription drugs and medical devices1 including outpatient prescription drugs1 medical devices1 and biological products4 7#e7 ,mental health and substance abuse treatment services1 including inpatient care4 7#f7 ,laboratory and diagnostic services4 7#g7 ,comprehensive reproductive1 maternity1 and newborn care4 7#h7 ,pediatrics4 7#i7 ,oral health1 audiology1 and vision services4 7#aj7 ,rehabilitative and habilitative services and devices4 7#aa7 ,emergency services and transportation4 7#ab7 ,early and periodic screening1 diagnostic1 and treatment services1 as described in sections #aijb7;a77#aj77;,a71 #aijb7;a77#dc71 #aije7;a77#d77;,b71 and #aije7r7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77;,a72 #acif;a7a77#dc72 #acif;d7a77#d77;,b72 #acif;d7r774 7#ac7 ,necessary transportation to receive health care services for persons with disabilities or low-income individuals 7as determined by the ,secretary74 7#ad7 ,long-term care services and support 7as described in section #bjd74 7b7 ,revision and adjustment ,the ,secretary shall1 at least annually1 and on a regular basis1 evaluate whether the benefits package should be improved or adjusted to promote the health of beneficiaries1 account for changes in medical practice or new information from medical research1 or respond to other relevant developments in health science1 and shall make recommendations to ,congress regarding any such improvements or adjustments4 7c7 ,hearings 7#a7 ,in general ,the ,committee on ,energy and ,commerce and the ,committee on ,ways and ,means of the ,house of ,representatives shall1 not less frequently than annually1 hold a hearing on the recommendations submitted by the ,secretary under subsection 7b74 7#b7 ,exercise of rulemaking authority ,paragraph 7#a7 is enacted-- 7,a7 as an exercise of rulemaking power of the ,house of ,representatives1 and1 as such1 shall be considered as part of the rules of the ,house1 and such rules shall supersede any other rule of the ,house only to the extent that rule is inconsistent therewith2 and 7,b7 with full recognition of the constitutional right of either ,house to change such rules 7so far as relating to the procedure in such ,house7 at any time1 in the same manner1 and to the same extent as in the case of any other rule of the ,house4 7d7 ,complementary and ,integrative ,medicine 7#a7 ,in general ,in carrying out subsection 7b71 the ,secretary shall consult with the persons described in paragraph 7#b7 with respect to-- 7,a7 identifying specific complementary and integrative medicine practices that are appropriate to include in the benefits package2 and 7,b7 identifying barriers to the effective provision and integration of such practices into the delivery of health care1 and identifying mechanisms for overcoming such barriers4 7#b7 ,consultation ,in accordance with paragraph 7#a71 the ,secretary shall consult with-- 7,a7 the ,director of the ,national ,center for ,complementary and ,integrative ,health2 7,b7 the ,commissioner of ,food and ,drugs2 7,c7 institutions of higher education1 private research institutes1 and individual researchers with extensive experience in complementary and alternative medicine and the integration of such practices into the delivery of health care2 7,d7 nationally recognized providers of complementary and integrative medicine2 and 7,e7 such other officials1 entities1 and individuals with expertise on complementary and integrative medicine as the ,secretary determines appropriate4 7e7 ,states may provide additional benefits ,individual ,states may provide additional benefits for the residents of such ,states1 as determined by such ,state1 and may provide benefits to individuals not eligible for benefits under this ,act1 at the expense of the ,state1 subject to the requirements specified in section #aajb4 #bjb4 ,no cost-sharing 7a7 ,in general ,the ,secretary shall ensure that no cost-sharing1 including deductibles1 coinsurance1 copayments1 or similar charges1 is imposed on an individual for any benefits provided under this ,act4 7b7 ,no balance billing ,no provider may impose a charge to an enrolled individual for covered services for which benefits are provided under this ,act4 #bjc4 ,exclusions and limitations 7a7 ,in general ,benefits for items and services are not available under this ,act unless the items and services meet the standards developed by the ,secretary pursuant to section #bja7;a74 7b7 ,treatment of experimental items and services and drugs 7#a7 ,in general ,in applying subsection 7a71 the ,secretary shall make national coverage determinations with respect to items and services that are experimental in nature4 ,such determinations shall be consistent with the national coverage determination process as defined in section #ahfi7;f77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7f77#a77;,b774 7#b7 ,appeals process ,the ,secretary shall establish a process by which individuals can appeal coverage decisions4 ,the process shall1 as much as is feasible1 follow the process for appeals under the ,medicare program described in section #ahfi of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff74 7c7 ,application of practice guidelines 7#a7 ,in general ,in the case of items and services for which the ,department of ,health and ,human ,services has recognized a national practice guideline1 such items and services shall be deemed to meet the standards specified in section #bja7;a7 if they have been provided in accordance with such guideline4 ,for purposes of this subsection1 an item or service not provided in accordance with a practice guideline shall be deemed to have been provided in accordance with the guideline if the health care provider providing the item or service-- 7,a7 exercised appropriate professional judgment in accordance with the laws and requirements of the ,state in which such item or service is furnished in deviating from the guideline2 7,b7 acted in the best interest of the individual receiving the item or service2 and 7,c7 acted in a manner consistent with the individual's wishes4 7#b7 ,override of standards 7,a7 ,in general ,an individual's treating physician or other health care professional authorized to exercise independent professional judgment in implementing a patient's medical or nursing care plan in accordance with the scope of practice1 licensure1 and other law of the ,state where items and services are to be furnished may override practice standards established pursuant to section #bja7;a7 or practice guidelines described in paragraph 7#a71 including such standards and guidelines that are implemented by a provider through the use of health information technology1 such as electronic health record technology1 clinical decision support technology1 and computerized order entry programs4 7,b7 ,limitation ,an override described in subparagraph 7,a7 shall1 in the professional judgment of such physician1 nurse1 or health care professional1 be-- 7i7 consistent with such physician's1 nurse's1 or health care professional's determination of medical necessity and appropriateness or nursing assessment2 7ii7 in the best interests of the individual2 and 7iii7 consistent with the individual's wishes4 #bjd4 ,coverage of long-term care services 7a7 ,in general ,subject to the other provisions of this ,act1 individuals enrolled for benefits under this ,act are entitled to the following long-term services and supports and to have payment made by the ,secretary to an eligible provider for such services and supports if medically necessary and appropriate and in accordance with the standards established in this ,act1 for maintenance of health or for care1 services1 diagnosis1 treatment1 or rehabilitation that is related to a medically determinable condition1 whether physical or mental1 of health1 injury1 or age that-- 7#a7 causes a functional limitation in performing one or more activities of daily living2 or 7#b7 requires a similar need of assistance in performing instrumental activities of daily living due to cognitive or other impairments4 7b7 ,eligibility ,the ,secretary shall promulgate rules that provide for the following3 7#a7 ,the determination of individual eligibility for long-term services and supports under this section4 7#b7 ,the assessment of the long-term services and supports needed for eligible individuals4 7c7 ,services and supports ,long-term services and supports under this section shall be tailored to an individual's needs1 as determined through assessment1 and shall be defined by the ,secretary to-- 7#a7 include any long-term nursing services for the enrollee1 whether provided in an institution or in a home and community-based setting2 7#b7 provide coverage for a broad spectrum of long-term services and supports1 including for home and community-based services and other care provided through non-institutional settings2 7#c7 provide coverage that meets the physical1 mental1 and social needs of recipients while allowing recipients their maximum possible autonomy and their maximum possible civic1 social1 and economic participation2 7#d7 prioritize delivery of long-term services and supports through home and community-based services over institutionalization2 7#e7 unless an individual elects otherwise1 ensure that recipients will receive home and community based long-term services and supports 7as defined in subsection 7f77#d771 regardless of the individuals's type or level of disability1 service need1 or age2 7#f7 be provided with the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the individual's needs2 7#g7 be provided in such a manner that allows persons with disabilities to maintain their independence1 self-determination1 and dignity2 7#h7 provide long-term services and supports that are of equal quality and equally accessible across geographic regions2 and 7#i7 ensure that long-term services and supports provide recipient's the option of self-direction of services from either the recipient or care coordinators of the recipient's choosing4 7d7 ,public consultation ,in developing regulations to implement this section1 the ,secretary shall consult with an advisory commission on long-term services and supports that includes-- 7#a7 people with disabilities who use long-term services and supports and older adults who use long-term services and supports2 7#b7 representatives of people with disabilities and representatives of older adults2 7#c7 groups that represent the diversity of the population of people living with disabilities1 including gender1 racial1 and economic diversity2 7#d7 providers of long-term services and supports1 including family attendants and family caregivers1 and members of organized labor2 7#e7 disability rights organizations2 and 7#f7 relevant academic institutions and researchers4 7e7 ,budgeting and payments ,budgeting and payments for long-term services and supports provided under this section shall be made in accordance with the provisions under title ,,vi4 7f7 ,definitions ,in this section3 7#a7 ,the term long-term services and supports means long-term care1 treatment1 maintenance1 or services needed to support the activities of daily living and instrumental activities of daily living1 including all long-term services and supports available under section #aiae of the ,social ,security ,act 7#db ,u4,s4,c4 #acifn71 home and community-based services1 and any additional services and supports identified by the ,secretary to support people with disabilities to live1 work1 and participate in their communities4 7#b7 ,the term activities of daily living means basic personal everyday activities1 including tasks such as eating1 toileting1 grooming1 dressing1 bathing1 and transferring4 7#c7 ,the term instrumental activities of daily living means activities related to living independently in the community1 including but not limited to1 meal planning and preparation1 managing finances1 shopping for food1 clothing1 and other essential items1 performing essential household chores1 communicating by phone or other media1 and traveling around and participating in the community4 7#d7 ,the term home and community-based services means the home and community-based services that are coverable under subsections 7c71 7d71 7i71 and 7k7 of section #aiae of the ,social ,security ,act 7#db ,u4,s4,c4 #acifn71 and as defined by the ,secretary1 including as defined in the home and community-based services settings rule in sections #dda4ecj and #dda4gaj of title #db1 ,code of ,federal ,regulations 7or a successor regulation74 ,,iii ,provider ,participation #cja4 ,provider participation and standards2 whistleblower protections 7a7 ,in general ,an individual or other entity furnishing any covered item or service under this ,act is not a qualified provider unless the individual or entity-- 7#a7 is a qualified provider of the items or services under section #cjb2 7#b7 has filed with the ,secretary a participation agreement described in subsection 7b72 and 7#c7 meets1 as applicable1 such other qualifications and conditions with respect to a provider of services under title ,,xviii of the ,social ,security ,act as described in section #ahff of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc74 7b7 ,requirements in participation agreement 7#a7 ,in general ,a participation agreement described in this subsection between the ,secretary and a provider shall provide at least for the following3 7,a7 ,items and services to eligible persons shall be furnished by the provider without discrimination1 in accordance with section #ajd7;a74 ,nothing in this subparagraph shall be construed as requiring the provision of a type or class of items or services that are outside the scope of the provider's normal practice4 7,b7 ,no charge will be made to any enrolled individual for any covered items or services other than for payment authorized by this ,act4 7,c7 ,the provider agrees to furnish such information as may be reasonably required by the ,secretary1 in accordance with uniform reporting standards established under section #dja7;b77#a71 for-- 7i7 quality review by designated entities2 7ii7 making payments under this ,act1 including the examination of records as may be necessary for the verification of information on which such payments are based2 7iii7 statistical or other studies required for the implementation of this ,act2 and 7iv7 such other purposes as the ,secretary may specify4 7,d7 ,in the case of a provider that is not an individual1 the provider agrees not to employ or use for the provision of health services any individual or other provider that has had a participation agreement under this subsection terminated for cause4 ,the ,secretary may authorize such employment or use on a case-by-case basis4 7,e7 ,in the case of a provider paid under a fee-for-service basis for items and services furnished under this ,act1 the provider agrees to submit bills and any required supporting documentation relating to the provision of covered items and services within #cj days after the date of providing such items and services4 7,f7 ,in the case of an institutional provider paid pursuant to section #faa1 the provider agrees to submit information and any other required supporting documentation as may be reasonably required by the ,secretary within #cj days after the date of providing such items and services and in accordance with the uniform reporting standards established under section #dja7;b77#a71 including information on a quarterly basis that-- 7i7 relates to the provision of covered items and services2 and 7ii7 describes items and services furnished with respect to specific individuals4 7,g7 ,in the case of a provider that receives payment for items and services furnished under this ,act based on diagnosis-related coding1 procedure coding1 or other coding system or data1 the provider agrees-- 7i7 to disclose to the ,secretary any system or index of coding or classifying patient symptoms1 diagnoses1 clinical interventions1 episodes1 or procedures that such provider utilizes for global budget negotiations under title ,,vi or for meeting any other payment1 documentation1 or data collection requirements under this ,act2 and 7ii7 not to use any such system or index to establish financial incentives or disincentives for health care professionals1 or that is proprietary1 interferes with the medical or nursing process1 or is designed to increase the amount or number of payments4 7,h7 ,the provider complies with the duty of provider ethics and reporting requirements described in paragraph 7#b74 7,i7 ,in the case of a provider that is not an individual1 the provider agrees that no board member1 executive1 or administrator of such provider receives compensation from1 owns stock or has other financial investments in1 or serves as a board member of any entity that contracts with or provides items or services1 including pharmaceutical products and medical devices or equipment1 to such provider4 7#b7 ,provider duty of ethics ,each health care provider1 including institutional providers1 has a duty to advocate for and to act in the exclusive interest of each individual under the care of such provider according to the applicable legal standard of care1 such that no financial interest or relationship impairs any health care provider's ability to furnish necessary and appropriate care to such individual4 ,to implement the duty established in this paragraph1 the ,secretary shall-- 7,a7 promulgate reasonable reporting rules to evaluate participating provider compliance with this paragraph2 7,b7 prohibit participating providers1 spouses1 and immediate family members of participating providers1 from accepting or entering into any arrangement for any bonus1 incentive payment1 profit-sharing1 or compensation based on patient utilization or based on financial outcomes of any other provider or entity2 and 7,c7 prohibit participating providers or any board member or representative of such provider from serving as board members for or receiving any compensation1 stock1 or other financial investment in an entity that contracts with or provides items or services 7including pharmaceutical products and medical devices or equipment7 to such provider4 7#c7 ,termination of participation agreement 7,a7 ,in general ,participation agreements may be terminated1 with appropriate notice-- 7i7 by the ,secretary for failure to meet the requirements of this ,act2 7ii7 in accordance with the provisions described in section #daa2 or 7iii7 by a provider4 7,b7 ,termination process ,providers shall be provided notice and a reasonable opportunity to correct deficiencies before the ,secretary terminates an agreement unless a more immediate termination is required for public safety or similar reasons4 7,c7 ,provider protections 7i7 ,prohibition ,the ,secretary may not terminate a participation agreement or in any other way discriminate against1 or cause to be discriminated against1 any covered provider or authorized representative of the provider1 on account of such provider or representative-- 7,i7 providing1 causing to be provided1 or being about to provide or cause to be provided to the provider1 the ,federal ,government1 or the attorney general of a ,state information relating to any violation of1 or any act or omission the provider or representative reasonably believes to be a violation of1 any provision of this title 7or an amendment made by this title72 7,,ii7 testifying or being about to testify in a proceeding concerning such violation2 7,,iii7 assisting or participating1 or being about to assist or participate1 in such a proceeding2 or 7,,iv7 objecting to1 or refusing to participate in1 any activity1 policy1 practice1 or assigned task that the provider or representative reasonably believes to be in violation of any provision of this ,act 7including any amendment made by this ,act71 or any order1 rule1 regulation1 standard1 or ban under this ,act 7including any amendment made by this ,act74 7ii7 ,complaint procedure ,a provider or representative who believes that he or she has been discriminated against in violation of this section may seek relief in accordance with the procedures1 notifications1 burdens of proof1 remedies1 and statutes of limitation set forth in section #bjhg7;b7 of title #ae1 ,united ,states ,code4 7c7 ,whistleblower protections 7#a7 ,retaliation prohibited ,no person may discharge or otherwise discriminate against any employee because the employee or any person acting pursuant to a request of the employee-- 7,a7 notified the ,secretary or the employee's employer of any alleged violation of this title1 including communications related to carrying out the employee's job duties2 7,b7 refused to engage in any practice made unlawful by this title1 if the employee has identified the alleged illegality to the employer2 7,c7 testified before or otherwise provided information relevant for ,congress or for any ,federal or ,state proceeding regarding any provision 7or proposed provision7 of this title2 7,d7 commenced1 caused to be commenced1 or is about to commence or cause to be commenced a proceeding under this title2 7,e7 testified or is about to testify in any such proceeding2 or 7,f7 assisted or participated or is about to assist or participate in any manner in such a proceeding or in any other manner in such a proceeding or in any other action to carry out the purposes of this title4 7#b7 ,enforcement action ,any employee covered by this section who alleges discrimination by an employer in violation of paragraph 7#a7 may bring an action1 subject to the statute of limitations in the anti-retaliation provisions of the ,false ,claims ,act and the rules and procedures1 legal burdens of proof1 and remedies applicable under the employee protections provisions of the ,surface ,transportation ,assistance ,act4 7#c7 ,application 7,a7 ,nothing in this subsection shall be construed to diminish the rights1 privileges1 or remedies of any employee under any ,federal or ,state law or regulation1 including the rights and remedies against retaliatory action under the ,false ,claims ,act 7#ca ,u4,s4,c4 #cgcj7;h771 or under any collective bargaining agreement4 ,the rights and remedies in this section may not be waived by any agreement1 policy1 form1 or condition of employment4 7,b7 ,nothing in this subsection shall be construed to preempt or diminish any other ,federal or ,state law or regulation against discrimination1 demotion1 discharge1 suspension1 threats1 harassment1 reprimand1 retaliation1 or any other manner of discrimination1 including the rights and remedies against retaliatory action under the ,false ,claims ,act 7#ca ,u4,s4,c4 #cgcj7;h774 7#d7 ,definitions ,in this subsection3 7,a7 ,employer ,the term employer means any person engaged in profit or nonprofit business or industry1 including one or more individuals1 partnerships1 associations1 corporations1 trusts1 professional membership organization including a certification1 disciplinary1 or other professional body1 unincorporated organizations1 nongovernmental organizations1 or trustees1 and subject to liability for violating the provisions of this ,act4 7,b7 ,employee ,the term employee means any individual performing activities under this ,act on behalf of an employer4 #cjb4 ,qualifications for providers 7a7 ,in general ,a health care provider is considered to be qualified to furnish covered items and services under this ,act if the provider is licensed or certified to furnish such items and services in the ,state in which such items or services are furnished and meets-- 7#a7 the requirements of such ,state's law to furnish such items and services2 and 7#b7 applicable requirements of ,federal law to furnish such items and services4 7b7 ,limitation ,an entity or provider shall not be qualified to furnish covered items and services under this ,act if the entity or provider provides no items and services directly to individuals1 including-- 7#a7 entities or providers that contract with other entities or providers to provide such items and services2 and 7#b7 entities that are currently approved to coordinate care plans under the ,medicare ,advantage program established in part ,c of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #ahea et seq47 but do not directly provide items and services of such care plans4 7c7 ,minimum provider standards 7#a7 ,in general ,the ,secretary shall establish1 evaluate1 and update national minimum standards to ensure the quality of items and services provided under this ,act and to monitor efforts by ,states to ensure the quality of such items and services4 ,a ,state may establish additional minimum standards which providers shall meet with respect to items and services provided in such ,state4 7#b7 ,national minimum standards ,the ,secretary shall establish national minimum standards under paragraph 7#a7 for institutional providers of services and individual health care practitioners4 ,except as the ,secretary may specify in order to carry out this ,act1 a hospital1 skilled nursing facility1 or other institutional provider of services shall meet standards applicable to such a provider under the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 ,such standards also may include1 where appropriate1 elements relating to-- 7,a7 adequacy and quality of facilities2 7,b7 mandatory minimum safe registered nurse-to-patient staffing ratios and optimal staffing levels for physicians and other health care practitioners2 7,c7 training and competence of personnel 7including requirements related to the number of or type of required continuing education hours72 7,d7 comprehensiveness of service2 7,e7 continuity of service2 7,f7 patient waiting time1 access to services1 and preferences2 and 7,g7 performance standards1 including organization1 facilities1 structure of services1 efficiency of operation1 and outcome in palliation1 improvement of health1 stabilization1 cure1 or rehabilitation4 7#c7 ,transition in application ,if the ,secretary provides for additional requirements for providers under this subsection1 any such additional requirement shall be implemented in a manner that provides for a reasonable period during which a previously qualified provider is permitted to meet such an additional requirement4 7#d7 ,ability to provide services ,with respect to any entity or provider certified to provide items and services described in section #bja7;a77#g71 the ,secretary may not prohibit such entity or provider from participating for reasons other than such entity's or provider's ability to provide such items and services4 7d7 ,federal providers ,any provider qualified to provide health care items and services through the ,department of ,veterans ,affairs or ,indian ,health ,service is a qualifying provider under this section with respect to any individual who qualifies for such items and services under applicable ,federal law4 #cjc4 ,use of private contracts 7a7 ,in general ,this section shall apply beginning #b years after the date of the enactment of this ,act4 7b7 ,participating providers 7#a7 ,private contracts for covered items and services for eligible individuals ,an institutional or individual provider with an agreement in effect under section #cja may not bill or enter into any private contract with any individual eligible for benefits under the ,act for any item or service that is a benefit under this ,act4 7#b7 ,private contracts for noncovered items and services for eligible individuals ,an institutional or individual provider with an agreement in effect under section #cja may bill or enter into a private contract with an individual eligible for benefits under the ,act for any item or service that is not a benefit under this ,act only if-- 7,a7 the contract and provider meet the requirements specified in paragraphs 7#c7 and 7#d71 respectively2 7,b7 such item or service is not payable or available under this ,act2 and 7,c7 the provider receives-- 7i7 no reimbursement under this ,act directly or indirectly for such item or service1 and 7ii7 receives no amount for such item or service from an organization which receives reimbursement for such items or service under this ,act directly or indirectly4 7#c7 ,contract requirements ,any contract to provide items and services described in paragraph 7#b7 shall-- 7,a7 be in writing and signed by the individual 7or authorized representative of the individual7 receiving the item or service before the item or service is furnished pursuant to the contract2 7,b7 not be entered into at a time when the individual is facing an emergency health care situation2 and 7,c7 clearly indicate to the individual receiving such items and services that by signing such a contract the individual-- 7i7 agrees not to submit a claim 7or to request that the provider submit a claim7 under this ,act for such items or services2 7ii7 agrees to be responsible for payment of such items or services and understands that no reimbursement will be provided under this ,act for such items or services2 7iii7 acknowledges that no limits under this ,act apply to amounts that may be charged for such items or services2 and 7iv7 acknowledges that the provider is providing services outside the scope of the program under this ,act4 7#d7 ,affidavit ,a participating provider who enters into a contract described in paragraph 7#b7 shall have in effect during the period any item or service is to be provided pursuant to the contract an affidavit that shall-- 7,a7 identify the provider who is to furnish such noncovered item or service1 and be signed by such provider2 7,b7 state that the provider will not submit any claim under this ,act for any noncovered item or service provided to any individual enrolled under this ,act2 and 7,c7 be filed with the ,secretary no later than #aj days after the first contract to which such affidavit applies is entered into4 7#e7 ,enforcement ,if a provider signing an affidavit described in paragraph 7#d7 knowingly and willfully submits a claim under this title for any item or service provided or receives any reimbursement or amount for any such item or service provided pursuant to a private contract described in paragraph 7#b7 with respect to such affidavit-- 7,a7 any contract described in paragraph 7#b7 shall be null and void2 7,b7 no payment shall be made under this title for any item or service furnished by the provider during the #a-year period beginning on the date the affidavit was signed2 and 7,c7 any payment received under this title for any item or service furnished during such period shall be remitted4 7#f7 ,private contracts for ineligible individuals ,an institutional or individual provider with an agreement in effect under section #cja may bill or enter into a private contract with any individual ineligible for benefits under the ,act for any item or service4 7c7 ,nonparticipating providers 7#a7 ,private contracts for covered items and services for eligible individuals ,an institutional or individual provider with no agreement in effect under section #cja may bill or enter into any private contract with any individual eligible for benefits under the ,act for any item or service that is a benefit under this ,act described in title ,,ii only if the contract and provider meet the requirements specified in paragraphs 7#b7 and 7#c71 respectively4 7#b7 ,items required to be included in contract ,any contract to provide items and services described in paragraph 7#a7 shall-- 7,a7 be in writing and signed by the individual 7or authorized representative of the individual7 receiving the item or service before the item or service is furnished pursuant to the contract2 7,b7 not be entered into at a time when the individual is facing an emergency health care situation2 and 7,c7 clearly indicate to the individual receiving such items and services that by signing such a contract the individual-- 7i7 acknowledges that the individual has the right to have such items or services provided by other providers for whom payment would be made under this ,act2 7ii7 agrees not to submit a claim 7or to request that the provider submit a claim7 under this ,act for such items or services even if such items or services are otherwise covered by this ,act2 7iii7 agrees to be responsible for payment of such items or services and understands that no reimbursement will be provided under this ,act for such items or services2 7iv7 acknowledges that no limits under this ,act apply to amounts that may be charged for such items or services2 and 7v7 acknowledges that the provider is providing services outside the scope of the program under this ,act4 7#c7 ,affidavit ,a provider who enters into a contract described in paragraph 7#a7 shall have in effect during the period any item or service is to be provided pursuant to the contract an affidavit that shall-- 7,a7 identify the provider who is to furnish such covered item or service1 and be signed by such provider2 7,b7 state that the provider will not submit any claim under this ,act for any covered item or service provided to any individual enrolled under this ,act during the #b-year period beginning on the date the affidavit is signed2 and 7,c7 be filed with the ,secretary no later than #aj days after the first contract to which such affidavit applies is entered into4 7#d7 ,enforcement ,if a provider signing an affidavit described in paragraph 7#c7 knowingly and willfully submits a claim under this title for any item or service provided or receives any reimbursement or amount for any such item or service provided pursuant to a private contract described in paragraph 7#a7 with respect to such affidavit-- 7,a7 any contract described in paragraph 7#a7 shall be null and void2 and 7,b7 no payment shall be made under this title for any item or service furnished by the provider during the #b-year period beginning on the date the affidavit was signed4 7#e7 ,private contracts for noncovered items and services for any individual ,an institutional or individual provider with no agreement in effect under section #cja may bill or enter into a private contract with any individual for a item or service that is not a benefit under this ,act4 ,,iv ,administration ,a ,general ,administration ,provisions #dja4 ,administration 7a7 ,general duties of the ,secretary 7#a7 ,in general ,the ,secretary shall develop policies1 procedures1 guidelines1 and requirements to carry out this ,act1 including related to-- 7,a7 eligibility for benefits2 7,b7 enrollment2 7,c7 benefits provided2 7,d7 provider participation standards and qualifications1 as described in title ,,iii2 7,e7 levels of funding2 7,f7 methods for determining amounts of payments to providers of covered items and services1 consistent with subtitle ,b2 7,g7 a process for appealing or petitioning for a determination of coverage or noncoverage of items and services under this ,act2 7,h7 planning for capital expenditures and service delivery2 7,i7 planning for health professional education funding2 7,j7 encouraging ,states to develop regional planning mechanisms2 and 7,k7 any other regulations necessary to carry out the purposes of this ,act4 7#b7 ,regulations ,regulations authorized by this ,act shall be issued by the ,secretary in accordance with section #eec of title #e1 ,united ,states ,code4 7#c7 ,accessibility ,the ,secretary shall have the obligation to ensure the timely and accessible provision of items and services that all eligible individuals are entitled to under this ,act4 7b7 ,uniform reporting standards2 annual report2 studies 7#a7 ,uniform reporting standards 7,a7 ,in general ,the ,secretary shall establish uniform ,state reporting requirements and national standards to ensure an adequate national database containing information pertaining to health services practitioners1 approved providers1 the costs of facilities and practitioners providing items and services1 the quality of such items and services1 the outcomes of such items and services1 and the equity of health among population groups4 ,such database shall include1 to the maximum extent feasible without compromising patient privacy1 health outcome measures used under this ,act1 and to the maximum extent feasible without excessively burdening providers1 a description of the standards and qualifications1 levels of finding1 and methods described in subparagraphs 7,d7 through 7,f7 of subsection 7a77#a74 7,b7 ,required data disclosures ,in establishing reporting requirements and standards under subparagraph 7,a71 the ,secretary shall require a provider with an agreement in effect under section #cja to disclose to the ,secretary1 in a time and manner specified by the ,secretary1 the following 7as applicable to the type of provider73 7i7 ,any data the provider is required to report or does report to any ,state or local agency1 or1 as of ,january #a1 #bjai1 to the ,secretary or any entity that is part of the ,department of ,health and ,human ,services1 except data that are required under the programs terminated in section #ijc4 7ii7 ,annual financial data that includes information on employees 7including the number of employees1 hours worked1 and wage information7 by job title and by each patient care unit or department within each facility 7including outpatient units or departments72 the number of registered nurses per staffed bed by each such unit or department2 information on the dollar value and annual spending 7including purchases1 upgrades1 and maintenance7 for health information technology2 and risk-adjusted and raw patient outcome data 7including data on medical1 surgical1 obstetric1 and other procedures74 7,c7 ,reports ,the ,secretary shall regularly analyze information reported to the ,secretary and shall define rules and procedures to allow researchers1 scholars1 health care providers1 and others to access and analyze data for purposes consistent with quality and outcomes research1 without compromising patient privacy4 7#b7 ,annual report ,beginning #b years after the date of the enactment of this ,act1 the ,secretary shall annually report to ,congress on the following3 7,a7 ,the status of implementation of the ,act4 7,b7 ,enrollment under this ,act4 7,c7 ,benefits under this ,act4 7,d7 ,expenditures and financing under this ,act4 7,e7 ,cost-containment measures and achievements under this ,act4 7,f7 ,quality assurance4 7,g7 ,health care utilization patterns1 including any changes attributable to the program4 7,h7 ,changes in the per-capita costs of health care4 7,i7 ,differences in the health status of the populations of the different ,states1 including income and racial characteristics1 and other population health inequities4 7,j7 ,progress on quality and outcome measures1 and long-range plans and goals for achievements in such areas4 7,k7 ,plans for improving service to medically underserved populations4 7,l7 ,transition problems as a result of implementation of this ,act4 7,m7 ,opportunities for improvements under this ,act4 7#c7 ,statistical analyses and other studies ,the ,secretary may1 either directly or by contract-- 7,a7 make statistical and other studies1 on a nationwide1 regional1 ,state1 or local basis1 of any aspect of the operation of this ,act2 7,b7 develop and test methods of delivery of items and services as the ,secretary may consider necessary or promising for the evaluation1 or for the improvement1 of the operation of this ,act2 and 7,c7 develop methodological standards for policymaking4 7c7 ,audits 7#a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct an audit of the ,department of ,health and ,human ,services every fifth fiscal year following the effective date of this ,act to determine the effectiveness of the program in carrying out the duties under subsection 7a74 7#b7 ,reports ,the ,comptroller ,general of the ,united ,states shall submit a report to ,congress concerning the results of each audit conducted under this subsection4 #djb4 ,consultation ,the ,secretary shall consult with ,federal agencies1 ,indian tribes and urban ,indian health organizations1 and private entities1 such as labor organizations representing health care workers1 professional societies1 national associations1 nationally recognized associations of health care experts1 medical schools and academic health centers1 consumer groups1 and business organizations in the formulation of guidelines1 regulations1 policy initiatives1 and information gathering to ensure the broadest and most informed input in the administration of this ,act4 ,nothing in this ,act shall prevent the ,secretary from adopting guidelines1 consistent with the provisions of section #bjc7;c71 developed by such a private entity if1 in the ,secretary's judgment1 such guidelines are generally accepted as reasonable and prudent and consistent with this ,act4 #djc4 ,regional administration 7a7 ,coordination with regional offices ,the ,secretary shall establish and maintain regional offices for purposes of carrying out the duties specified in subsection 7c7 and promoting adequate access to1 and efficient use of1 tertiary care facilities1 equipment1 and services by individuals enrolled under this ,act4 ,wherever possible1 the ,secretary shall incorporate regional offices of the ,centers for ,medicare ,medicaid ,services for this purpose4 7b7 ,appointment of regional directors ,in each such regional office there shall be-- 7#a7 one regional director appointed by the ,secretary2 and 7#b7 one deputy director appointed by the regional director to represent the ,indian and ,alaska ,native tribes in the region1 if any4 7c7 ,regional office duties ,each regional director shall-- 7#a7 provide an annual health care needs assessment with respect to the region under the director's jurisdiction to the ,secretary after a thorough examination of health needs and in consultation with public health officials1 clinicians1 patients1 and patient advocates2 7#b7 recommend any changes in provider reimbursement or payment for delivery of health services determined appropriate by the regional director1 subject to the provisions of title ,,vi2 and 7#c7 establish a quality assurance mechanism in each such region in order to minimize both underutilization and overutilization of health care items and services and to ensure that all providers meet quality standards established pursuant to this ,act4 #djd4 ,beneficiary ombudsman 7a7 ,in general ,the ,secretary shall appoint a ,beneficiary ,ombudsman who shall have expertise and experience in the fields of health care and education of1 and assistance to1 individuals enrolled under this ,act4 7b7 ,duties ,the ,beneficiary ,ombudsman shall-- 7#a7 receive complaints1 grievances1 and requests for information submitted by individuals enrolled under this ,act or eligible to enroll under this ,act with respect to any aspect of the ,medicare for ,all ,program2 7#b7 provide assistance with respect to complaints1 grievances1 and requests referred to in paragraph 7#a71 including assistance in collecting relevant information for such individuals1 to seek an appeal of a decision or determination made by a regional office or the ,secretary2 and 7#c7 submit annual reports to ,congress and the ,secretary that describe the activities of the ,ombudsman and that include such recommendations for improvement in the administration of this ,act as the ,ombudsman determines appropriate4 ,the ,ombudsman shall not serve as an advocate for any increases in payments or new coverage of services1 but may identify issues and problems in payment or coverage policies4 #dje4 ,conduct of related health programs ,in performing functions with respect to health personnel education and training1 health research1 environmental health1 disability insurance1 vocational rehabilitation1 the regulation of food and drugs1 and all other matters pertaining to health1 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 ,act4 ,b ,control ,over ,fraud and ,abuse #daa4 ,application of ,federal sanctions to all fraud and abuse under the ,medicare for ,all ,program ,the following sections of the ,social ,security ,act shall apply to this ,act in the same manner as they apply to title ,,xviii or ,state plans under title ,,xix of the ,social ,security ,act3 7#a7 ,section #aabh 7relating to exclusion of individuals and entities74 7#b7 ,section #aabh;,a 7civil monetary penalties74 7#c7 ,section #aabh;,b 7criminal penalties74 7#d7 ,section #aabd 7relating to disclosure of ownership and related information74 7#e7 ,section #aabf 7relating to disclosure of certain owners74 7#f7 ,section #ahgg 7relating to physician referrals74 ,v ,quality ,assessment #eja4 ,quality standards 7a7 ,in general ,all standards and quality measures under this ,act shall be implemented and evaluated by the ,center for ,clinical ,standards and ,quality of the ,centers for ,medicare ,medicaid ,services 7referred to in this title as the ,center7 or such other agency determined appropriate by the ,secretary1 in coordination with the ,agency for ,healthcare ,research and ,quality and other offices of the ,department of ,health and ,human ,services4 7b7 ,duties of the center ,the ,center shall perform the following duties3 7#a7 ,review and evaluate each practice guideline developed under part ,b of title ,,ix of the ,public ,health ,service ,act4 ,in so reviewing and evaluating1 the ,center shall determine whether the guideline should be recognized as a national practice guideline in accordance with and subject to the provisions of section #bjc7;c74 7#b7 ,review and evaluate each standard of quality1 performance measure1 and medical review criterion developed under part ,b of title ,,ix of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bii et seq474 ,in so reviewing and evaluating1 the ,center shall determine whether the standard1 measure1 or criterion is appropriate for use in assessing or reviewing the quality of items and services provided by health care institutions or health care professionals4 ,the use of ,quality-,adjusted ,life ,years1 ,disability-,adjusted ,life ,years1 or other similar mechanisms that discriminate against people with disabilities is prohibited for use in any value or cost-effectiveness assessments4 ,the ,center shall consider the evidentiary basis for the standard1 and the validity1 reliability1 and feasibility of measuring the standard4 7#c7 ,adoption of methodologies for profiling the patterns of practice of health care professionals and for identifying and notifying outliers4 7#d7 ,development of minimum criteria for competence for entities that can qualify to conduct ongoing and continuous external quality reviews in the administrative regions4 ,such criteria shall require such an entity to be administratively independent of the individual or board that administers the region and shall ensure that such entities do not provide financial incentives to reviewers to favor one pattern of practice over another4 ,the ,center shall ensure coordination and reporting by such entities to ensure national consistency in quality standards4 7#e7 ,submission of a report to the ,secretary annually specifically on findings from outcomes research and development of practice guidelines that may affect the ,secretary's determination of coverage of services under section #dja7;a77#a77;,g74 #ejb4 ,addressing health care disparities 7a7 ,evaluating data collection approaches ,the ,center shall evaluate approaches for the collection of data under this ,act1 to be performed in conjunction with existing quality reporting requirements and programs under this ,act1 that allow for the ongoing1 accurate1 and timely collection of data on disparities in health care services and performance on the basis of race1 ethnicity1 gender1 geography1 disability1 or socioeconomic status4 ,in conducting such evaluation1 the ,center shall consider the following objectives3 7#a7 ,protecting patient privacy4 7#b7 ,minimizing the administrative burdens of data collection and reporting on providers under this ,act4 7#c7 ,improving data on race1 ethnicity1 gender1 geography1 and socioeconomic status4 7b7 ,reports to congress 7#a7 ,report on evaluation ,not later than #ah months after the date on which benefits first become available as described in section #ajf7;a71 the ,center shall submit to ,congress and the ,secretary a report on the evaluation conducted under subsection 7a74 ,such report shall1 taking into consideration the results of such evaluation-- 7,a7 identify approaches 7including defining methodologies7 for identifying and collecting and evaluating data on health care disparities on the basis of race1 ethnicity1 gender1 geography1 or socioeconomic status under the ,medicare for ,all ,program2 and 7,b7 include recommendations on the most effective strategies and approaches to reporting quality measures1 as appropriate1 on the basis of race1 ethnicity1 gender1 geography1 or socioeconomic status4 7#b7 ,report on data analyses ,not later than #d years after the submission of the report under subsection 7b77#a71 and every #d years thereafter1 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 7c74 7c7 ,implementing effective approaches ,not later than #b years after the date on which benefits first become available as described in section #ajf7;a71 the ,secretary shall implement the approaches identified in the report submitted under subsection 7b77#a7 for the ongoing1 accurate1 and timely collection and evaluation of data on health care disparities on the basis of race1 ethnicity1 gender1 geography1 or socioeconomic status4 ,,vi ,health ,budget2 ,payments2 ,cost ,containment ,measures ,a ,budgeting #fja4 ,national health budget 7a7 ,national health budget 7#a7 ,in general ,by not later than ,september #a of each year1 beginning with the year prior to the date on which benefits first become available as described in section #ajf7;a71 the ,secretary shall establish a national health budget1 which specifies a budget for the total expenditures to be made for covered health care items and services under this ,act4 7#b7 ,division of budget into components ,the national health budget shall consist of the following components3 7,a7 ,an operating budget4 7,b7 ,a capital expenditures budget4 7,c7 ,a special projects budget for purposes of allocating funds for capital expenditures and staffing needs of providers located in rural or medically underserved areas 7as defined in section #ccj7;b77#c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b7b77#c7771 including areas designated as health professional shortage areas 7as defined in section #ccb7;a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;e7a7774 7,d7 ,quality assessment activities under title ,v4 7,e7 ,health professional education expenditures4 7,f7 ,administrative costs1 including costs related to the operation of regional offices4 7,g7 ,a reserve fund to respond to the costs of treating an epidemic1 pandemic1 natural disaster1 or other such health emergency1 or market-shift adjustments related to patient volume4 7,h7 ,prevention and public health activities4 7#c7 ,allocation among components ,the ,secretary shall allocate the funds received for purposes of carrying out this ,act among the components described in paragraph 7#b7 in a manner that ensures-- 7,a7 that the operating budget allows for every participating provider in the ,medicare for ,all ,program to meet the needs of their respective patient populations2 7,b7 that the special projects budget is sufficient to meet the health care needs within areas described in paragraph 7#b77;,c7 through the construction1 renovation1 and staffing of health care facilities in a reasonable timeframe2 7,c7 a fair allocation for quality assessment activities2 and 7,d7 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 services4 7#d7 ,regional allocation ,the ,secretary shall annually provide each regional office with an allotment the ,secretary determines appropriate for purposes of carrying out this ,act in such region1 including payments to providers in such region1 capital expenditures in such region1 special projects in such region1 health professional education in such region1 administrative expenses in such region1 and prevention and public health activities in such region4 7#e7 ,operating budget ,the operating budget described in paragraph 7#b77;,a7 shall be used for-- 7,a7 payments to institutional providers pursuant to section #faa2 and 7,b7 payments to individual providers pursuant to section #fab4 7#f7 ,capital expenditures budget ,the capital expenditures budget described in paragraph 7#b77;,b7 shall be used for-- 7,a7 the construction or renovation of health care facilities1 excluding congregate or segregated facilities for individuals with disabilities who receive long-term care services and support2 and 7,b7 major equipment purchases4 7#g7 ,special projects budget ,the special projects budget shall be used for the construction of new facilities1 major equipment purchases1 and staffing in rural or medically underserved areas 7as defined in section #ccj7;b77#c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b7b77#c7771 including areas designated as health professional shortage areas 7as defined in section #ccb7;a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;e7a7774 7#h7 ,temporary worker assistance 7,a7 ,in general ,for up to #e years following the date on which benefits first become available as described in section #ajf7;a71 at least #a percent of the budget shall be allocated to programs providing assistance to workers who perform functions in the administration of the health insurance system1 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 ,act4 7,b7 ,clarification ,assistance described in subparagraph 7,a7 shall include wage replacement1 retirement benefits1 job training1 and education benefits4 7b7 ,definitions ,in this section3 7#a7 ,capital expenditures ,the term capital expenditures means expenses for the purchase1 lease1 construction1 or renovation of capital facilities and for major equipment4 7#b7 ,health professional education expenditures ,the term health professional education expenditures means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities1 including the impact of workforce diversity on patient outcomes4 ,b ,payments to ,providers #faa4 ,payments to institutional providers based on global budgets 7a7 ,in general ,not later than the beginning of each fiscal quarter during which an institutional provider of care 7including hospitals1 skilled nursing facilities1 ,federally qualified health centers1 home health agencies1 and independent dialysis facilities7 is to furnish items and services under this ,act1 the ,secretary shall pay to such institutional provider a lump sum in accordance with the succeeding provisions of this subsection and consistent with the following3 7#a7 ,payment in ,full ,such payment shall be considered as payment in full for all operating expenses for items and services furnished under this ,act1 whether inpatient or outpatient1 by such provider for such quarter1 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 7#c74 7#b7 ,quarterly ,review ,the regional director1 on a quarterly basis1 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 warranted4 ,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 value4 ,the review shall also include an assessment of any adjustments made to ensure that accuracy and need for adjustment was appropriate4 7#c7 ,agreements for ,salaried ,payments for ,certain ,providers ,certain group practices and other health care providers1 as determined by the ,secretary1 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 #fab of this title4 ,any-- 7,a7 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 provider2 and 7,b7 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 provider4 7b7 ,payment amount 7#a7 ,in general ,the amount of each payment to a provider described in subsection 7a7 shall be determined before the start of each fiscal year through negotiations between the provider and the regional director with jurisdiction over such provider4 ,such amount shall be based on factors specified in paragraph 7#b74 7#b7 ,payment factors ,payments negotiated pursuant to paragraph 7#a7 shall take into account1 with respect to a provider-- 7,a7 the historical volume of services provided for each item and services in the previous #c-year period2 7,b7 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-- 7i7 such expenditures for other institutional providers in the director's jurisdiction2 and 7ii7 normative payment rates established under comparative payment rate systems1 including any adjustments1 for such items and services2 7,c7 projected changes in the volume and type of items and services to be furnished2 7,d7 wages for employees1 including any necessary increases mandatory minimum safe registered nurse-to-patient ratios and optimal staffing levels for physicians and other health care workers2 7,e7 the provider's maximum capacity to provide items and services2 7,f7 education and prevention programs2 7,g7 permissible adjustment to the provider's operating budget due to factors such as-- 7i7 an increase in primary or specialty care access2 7ii7 efforts to decrease health care disparities in rural or medically underserved areas2 7iii7 a response to emergent epidemic conditions2 and 7iv7 proposed new and innovative patient care programs at the institutional level2 and 7,h7 any other factor determined appropriate by the ,secretary4 7#c7 ,limitation ,payment amounts negotiated pursuant to paragraph 7#a7 may not-- 7,a7 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 individual2 7,b7 be used by a provider for capital expenditures or such other expenditures2 7,c7 exceed the provider's capacity to provide care under this ,act2 or 7,d7 be used to pay or otherwise compensate any board member1 executive1 or administrator of the institutional provider who has any interest or relationship prohibited under section #cja7;b77#b7 of this ,act or disclosed under section #cja of this ,act4 7#d7 ,operating expenses ,for purposes of this subsection1 operating expenses of a provider include the following3 7,a7 ,the cost of all items and services associated with the provision of inpatient care and outpatient care1 including the following3 7i7 ,wages and salary costs for physicians1 nurses1 and other health care practitioners employed by an institutional provider1 including mandatory minimum safe registered nurse-to-patient staffing ratios and optimal staffing levels for physicians and other healthcare workers4 7ii7 ,wages and salary costs for all ancillary staff and services4 7iii7 ,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 operates4 7iv7 ,purchasing and maintenance of medical devices1 supplies1 and other health care technologies1 including diagnostic testing equipment4 7v7 ,costs of all incidental services necessary for safe patient care and handling4 7vi7 ,costs of patient care1 education1 and prevention programs1 including occupational health and safety programs1 public health programs1 and necessary staff to implement such programs1 for the continued education and health and safety of clinicians and other individuals employed by the institutional provider4 7,b7 ,administrative costs for the institutional provider4 7#e7 ,limitation on ,compensation ,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 #gjb of the ,bipartisan ,budget ,act of #bjac 7#da ,u4,s4,c4 #dcjd7;a77#af77 and implementing regulations4 7#f7 ,regional negotiations permitted ,subject to section #fad1 a regional director may negotiate changes to an institutional provider's global budget1 including any adjustments to address unforeseen market-shifts related to patient volume4 7c7 ,baseline rates and adjustments 7#a7 ,in general ,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 7b74 ,the ,secretary shall update such comparative payment rate systems annually4 7#b7 ,specifications ,in developing the comparative payment rate system1 the ,secretary shall use only the operating base payment rates under each such prospective payment systems with applicable adjustments4 7#c7 ,limitation ,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 system4 7#d7 ,initial year ,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 provider1 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 adjustments1 excluding value-based payment adjustments1 based on such prospective payment system4 #fab4 ,payment to individual providers through fee-for-service 7a7 ,in general ,in the case of a provider not described in section #faa7;a7 7including those in group practices who are not receiving payment on a salaried basis described in section #faa7;a77#c771 payment for items and services furnished under this ,act for which payment is not otherwise made under section #faa shall be made by the ,secretary in amounts determined under the fee schedule established pursuant to subsection 7b74 ,such payment shall be considered to be payment in full for such items and services1 and a provider receiving such payment may not charge the individual receiving such item or service in any amount4 7b7 ,fee schedule 7#a7 ,establishment ,not later than #a year after the date of the enactment of this ,act1 and in consultation with providers and regional office directors1 the ,secretary shall establish a national fee schedule for items and services payable under this ,act4 ,the ,secretary shall evaluate the effectiveness of the fee-for-service structure and update such fee schedule annually4 7#b7 ,amounts ,in establishing payment amounts for items and services under the fee schedule established under paragraph 7#a71 the ,secretary shall take into account-- 7,a7 the amounts payable for such items and services under title ,,xviii of the ,social ,security ,act2 and 7,b7 the expertise of providers and value of items and services furnished by such providers4 7c7 ,electronic billing ,the ,secretary shall establish a uniform national system for electronic billing for purposes of making payments under this subsection4 7d7 ,physician practice review board ,each director of a regional office1 in consultation with representatives of physicians practicing in that region1 shall establish and appoint a physician practice review board to assure quality1 cost effectiveness1 and fair reimbursements for physician-delivered items and services4 ,the use of ,quality-,adjusted ,life ,years1 ,disability-,adjusted ,life ,years1 or other similar mechanisms that discriminate against people with disabilities is prohibited for use in any value or cost-effectiveness assessments4 #fac4 ,ensuring accurate valuation of services under the ,medicare physician fee schedule 7a7 ,standardized and documented review process ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended by adding at the end the following new subparagraph3 7,p7 ,standardized and documented review process 7i7 ,in general ,not later than one year after the date of enactment of this subparagraph1 the ,secretary shall establish1 document1 and make publicly available1 in consultation with the ,office of ,primary ,health ,care1 a standardized process for reviewing the relative values of physicians' services under this paragraph4 7ii7 ,minimum requirements ,the standardized process shall include1 at a minimum1 methods and criteria for identifying services for review1 prioritizing the review of services1 reviewing stakeholder recommendations1 and identifying additional resources to be considered during the review process4 4 7b7 ,planned and documented use of funds ,section #ahdh7;c77#b77,m7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77,m77 is amended by adding at the end the following new clause3 7x7 ,planned and documented use of funds ,for each fiscal year 7beginning with the first fiscal year beginning on or after the date of enactment of this clause71 the ,secretary shall provide to ,congress a written plan for using the funds provided under clause 7ix7 to collect and use information on physicians' services in the determination of relative values under this subparagraph4 4 7c7 ,internal tracking of reviews 7#a7 ,in general ,not later than #a year after the date of enactment of this ,act1 the ,secretary shall submit to ,congress a proposed plan for systematically and internally tracking the ,secretary's review of the relative values of physicians' services1 such as by establishing an internal database1 under section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 as amended by this section4 7#b7 ,minimum requirements ,the proposal shall include1 at a minimum1 plans and a timeline for achieving the ability to systematically and internally track the following3 7,a7 ,when1 how1 and by whom services are identified for review4 7,b7 ,when services are reviewed or reviewed or when new services are added4 7,c7 ,the resources1 evidence1 data1 and recommendations used in reviews4 7,d7 ,when relative values are adjusted4 7,e7 ,the rationale for final relative value decisions4 7d7 ,frequency of review ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended-- 7#a7 in subparagraph 7,b77i71 by striking #e and inserting #d2 and 7#b7 in subparagraph 7,k77i77,i71 by striking periodically and inserting annually4 7e7 ,consultation with ,medicare ,payment ,advisory ,commission 7#a7 ,in general ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended-- 7,a7 in subparagraph 7,b77i71 by inserting in consultation with the ,medicare ,payment ,advisory ,commission1 after ,the ,secretary12 and 7,b7 in subparagraph 7,k77i77,i71 as amended by subsection 7d77#b71 by inserting 1 in coordination with the ,medicare ,payment ,advisory ,commission1 after annually4 7#b7 ,conforming amendments ,section #ahje of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#f7 is amended-- 7,a7 in subsection 7b77#a77;,a71 by inserting the following before the semicolon at the end3 and including coordinating with the ,secretary in accordance with section #ahdh7;c77#b7 to systematically review the relative values established for physicians' services1 identify potentially misvalued services1 and propose adjustments to the relative values for physicians' services2 and 7,b7 in subsection 7e77#a71 in the second sentence1 by inserting or the ,ranking ,minority ,member after the ,chairman4 7f7 ,periodic audit by the ,comptroller ,general ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 as amended by subsection 7a71 is amended by adding at the end the following new subparagraph3 7,q7 ,periodic audit by the ,comptroller ,general 7i7 ,in general ,the ,comptroller ,general of the ,united ,states 7in this subsection referred to as the ,comptroller ,general7 shall periodically audit the review by the ,secretary of relative values established under this paragraph for physicians' services4 7ii7 ,access to information ,the ,comptroller ,general shall have unrestricted access to all deliberations1 records1 and data related to the activities carried out under this paragraph1 in a timely manner1 upon request4 4 #fad4 ,payment prohibitions2 capital expenditures2 special projects 7a7 ,sense of ,congress ,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 profit4 ,there is a moral imperative to correct the massive deficiencies in our current health system and to eliminate profit from the provision of health care4 7b7 ,prohibitions ,payments to providers under this ,act may not take into account1 include any process for the provision of funding for1 or be used by a provider for-- 7#a7 marketing of the provider2 7#b7 the profit or net revenue of the provider1 or increasing the profit or net revenue of the provider2 7#c7 incentive payments1 bonuses1 or other compensation based on patient utilization of items and services or any financial measure applied with respect to the provider 7or any group practice1 integrated health care delivery system1 or other provider with which the provider contracts or has a pecuniary interest71 including any value-based payment or employment-based compensation2 7#d7 any agreement or arrangement described in section #bjc7;a77#d7 of the ,labor-,management ,reporting and ,disclosure ,act of #aiei 7#bi ,u4,s4,c4 #dcc7;a77#d772 or 7#e7 political or contributions prohibited under section #cag of the ,federal ,elections ,campaign ,act of #aiga 7#eb ,u4,s4,c4 #cjaai7;a77#a774 7c7 ,payments for capital expenditures 7#a7 ,in general ,the ,secretary shall pay1 from amounts made available for capital expenditures pursuant to section #fja7;a77#b77;,b71 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 providers4 7#b7 ,priority ,the ,secretary shall prioritize allocation of funding under paragraph 7#a7 to projects that propose to use such funds to improve service in a medically underserved area 7as defined in section #ccj7;b77#c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b7b77#c777 or to address health disparities among racial1 income1 or ethnic groups1 or based on geographic regions4 7#c7 ,limitation ,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 patients1 including reductions in registered nursing staffing patterns and changes in emergency room or primary care services or availability4 7#d7 ,capital projects funded by charitable donations ,operating expenses and funds shall not by used by an institutional provider receiving payment for capital expenditures under this subsection for a capital project funded by charitable donations without the approval of the regional director or directors of the region or regions where the capital project is located4 7d7 ,prohibition against co-,mingling operating and capital funds ,providers that receive payment under this title shall be prohibited from using1 with respect to funds made available under this ,act-- 7#a7 funds designated for operating expenditures for capital expenditures or for profit2 or 7#b7 funds designated for capital expenditures for operating expenditures4 7e7 ,payments for special projects 7#a7 ,in general ,the ,secretary shall allocate to each regional director1 from amounts made available for special projects pursuant to section #fja7;a77#b77;,c71 such sums determined appropriate by the ,secretary for purposes of funding projects described in such section1 including the construction1 renovation1 or staffing of health care facilities1 in rural1 underserved1 or health professional or medical shortage areas within such region4 ,each regional director shall1 prior to distributing such funds in accordance with paragraph 7#b71 present a budget describing how such funds will be distributed to the ,secretary4 7#b7 ,distribution ,a regional director shall distribute funds to providers operating in the region of such director's jurisdiction in a manner determined appropriate by the director4 7f7 ,prohibition on financial incentive metrics in payment determinations ,the ,secretary may not utilize any quality metrics or standards for the purposes of establishing provider payment methodologies1 programs1 modifiers1 or adjustments for provider payments under this title4 #fae4 ,office of primary health care 7a7 ,in general ,there is established within the ,agency for ,healthcare ,research and ,quality an ,office of ,primary ,health ,care1 responsible for coordinating with the ,secretary1 the ,health ,resources and ,services ,administration1 and other offices in the ,department as necessary1 in order to-- 7#a7 coordinate health professional education policies and goals1 in consultation with the ,secretary to achieve the national goals specified in subsection 7b72 7#b7 develop and maintain a system to monitor the number and specialties of individuals through their health professional education1 any postgraduate training1 and professional practice2 7#c7 develop1 coordinate1 and promote policies that expand the number of primary care practitioners1 registered nurses1 midlevel practitioners1 and dentists2 7#d7 recommend the appropriate training1 technical assistance1 and patient protection enhancements of primary care health professionals1 including registered nurses1 to achieve uniform high quality and patient safety2 and 7#e7 consult with the ,secretary on the allocation of the special projects budget under section #fja7;a77#b77;,c74 7b7 ,national goals ,not later than #a year after the date of enactment of this ,act1 the ,office of ,primary ,health ,care shall set forth national goals to increase access to high quality primary health care1 particularly in underserved areas and for underserved populations4 7c7 ,clarification ,nothing in this-- 7#a7 section shall be construed to preempt any provision of ,state law establishing practice standards or guidelines for health care professionals1 including professional licensing or practice laws or regulations2 and 7#b7 ,act shall be construed to require that any ,state impose additional educational standards or guidelines for health care professionals4 #faf4 ,payments for prescription drugs and approved devices and equipment ,the prices to be paid for covered pharmaceuticals1 medical supplies1 medical technologies1 and medically necessary equipment covered under this ,act shall be negotiated annually by the ,secretary4 7#a7 ,in general ,notwithstanding any other provision of law1 the ,secretary shall1 for fiscal years beginning on or after the date of the enactment of this subsection1 negotiate with pharmaceutical manufacturers the prices 7including discounts1 rebates1 and other price concessions7 that may be charged to the ,medicare for ,all ,program during a negotiated price period 7as specified by the ,secretary7 for covered drugs for eligible individuals under the ,medicare for ,all ,program4 ,in negotiating such prices under this section1 the ,secretary shall take into account the following factors3 7,a7 ,the comparative clinical effectiveness and cost effectiveness1 when available from an impartial source1 of such drug4 7,b7 ,the budgetary impact of providing coverage of such drug4 7,c7 ,the number of similarly effective drugs or alternative treatment regimens for each approved use of such drug4 7,d7 ,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 manufacturer4 7#b7 ,finalization of negotiated price ,the negotiated price of each covered drug for a negotiated price period shall be finalized not later than #cj days before the first fiscal year in such negotiated price period4 7#c7 ,competitive licensing authority 7,a7 ,in general ,notwithstanding any exclusivity under clause 7iii7 or 7iv7 of section #eje7;j77#e77;,f7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act1 clause 7iii7 or 7iv7 of section #eje7;c77#c77;,e7 of such ,act1 section #cea7k77#g77;,a7 of the ,public ,health ,service ,act1 or section #ebg7;a7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act1 or by an extension of such exclusivity under section #eje;,a of such ,act or section #eje;,e of such ,act1 and any other provision of law that provides for market exclusivity 7or extension of market exclusivity7 with respect to a drug1 in the case that the ,secretary is unable to success fully negotiate an appropriate price for a covered drug for a negotiated price period1 the ,secretary shall authorize the use of any patent1 clinical trial data1 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 ,program4 ,any entity making use of a competitive license to use patent1 clinical trial data1 or other exclusivity under this section shall provide to the manufacturer holding such exclusivity reasonable compensation1 as determined by the ,secretary based on the following factors3 7i7 ,the risk-adjusted value of any ,federal ,government subsidies and investments in research and development used to support the development of such drug4 7ii7 ,the risk-adjusted value of any investment made by such manufacturer in the research and development of such drug4 7iii7 ,the impact of the price1 including license compensation payments1 on meeting the medical need of all patients at a reasonable cost4 7iv7 ,the relationship between the price of such drug1 including compensation payments1 and the health benefits of such drug4 7v7 ,other relevant factors determined appropriate by the ,secretary to provide reasonable compensation4 7,b7 ,reasonable compensation ,the manufacturer described in subparagraph 7,a7 may seek recovery against the ,united ,states in the ,united ,states ,court of ,federal ,claims4 7,c7 ,interim period ,until #a year after a drug described in subparagraph 7,a7 is approved under section #eje7;j7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act or section #cea7k7 of the ,public ,health ,service ,act and is provided under license issued by the ,secretary under such subparagraph1 the ,medicare for ,all ,program shall not pay more for such drug than the average of the prices available1 during the most recent #ab-month period for which data is available prior to the beginning of such negotiated price period1 from the manufacturer to any wholesaler1 retailer1 provider1 health maintenance organization1 nonprofit entity1 or governmental entity in the ten ,,oecd 7,organization for ,economic ,cooperation and ,development7 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 ,states4 7,d7 ,authorization for ,secretary to procure drugs directly ,the ,secretary may procure a drug manufactured pursuant to a competitive license under subparagraph 7,a7 for purposes of this ,act4 7#d7 ,,fda review of licensed drug applications ,the ,secretary shall prioritize review of applications under section #eje7;j7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act for drugs licensed under paragraph 7#c77;,a74 7#e7 ,prohibition of anticompetitive behavior ,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 policy4 7#f7 ,required reporting ,the ,secretary may require pharmaceutical manufacturers to disclose to the ,secretary such information that the ,secretary determines necessary for purposes of carrying out this subsection4 ,,vii ,universal ,medicare ,trust ,fund #gja4 ,universal ,medicare ,trust ,fund 7a7 ,in general ,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 7in this section referred to as the ,trust ,fund74 ,the ,trust ,fund shall consist of such gifts and bequests as may be made and such amounts as may be deposited in1 or appropriated to1 such ,trust ,fund as provided in this ,act4 7b7 ,appropriations into trust fund 7#a7 ,taxes ,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 #ajf1 out of any moneys in the ,treasury not otherwise appropriated1 amounts equivalent to #ajj percent of the net increase in revenues to the ,treasury which is attributable to the amendments made by sections #hja and #ijb4 ,the amounts appropriated by the preceding sentence shall be transferred from time to time 7but not less frequently than monthly7 from the general fund in the ,treasury to the ,trust ,fund1 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 ,treasury1 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 transferred4 7#b7 ,current program receipts 7,a7 ,initial year ,notwithstanding any other provision of law1 there is appropriated to the ,trust ,fund for the fiscal year containing ,january #a of the first year following the date of the enactment of this ,act1 an amount equal to the aggregate amount appropriated for the preceding fiscal year for the following 7increased by the consumer price index for all urban consumers for the fiscal year involved73 7i7 ,the ,medicare program under title ,,xviii of the ,social ,security ,act 7other than amounts attributable to any premiums under such title74 7ii7 ,the ,medicaid program under ,state plans approved under title ,,xix of such ,act4 7iii7 ,the ,federal ,employees ,health ,benefits program1 under chapter #hi of title #e1 ,united ,states ,code4 7iv7 ,the ,,tricare program1 under chapter #ee of title #aj1 ,united ,states ,code4 7v7 ,the maternal and child health program 7under title ,v of the ,social ,security ,act71 vocational rehabilitation programs1 programs for drug abuse and mental health services under the ,public ,health ,service ,act1 programs providing general hospital or medical assistance1 and any other ,federal program identified by the ,secretary1 in consultation with the ,secretary of the ,treasury1 to the extent the programs provide for payment for health services the payment of which may be made under this ,act4 7,b7 ,subsequent years ,notwithstanding any other provision of law1 there is appropriated to the trust fund for the fiscal year containing ,january #a of the second year following the date of the enactment of this ,act1 and for each fiscal year thereafter1 an amount equal to the amount appropriated to the ,trust ,fund for the previous year1 adjusted for reductions in costs resulting from the implementation of this ,act1 changes in the consumer price index for all urban consumers for the fiscal year involved1 and other factors determined appropriate by the ,secretary4 7#c7 ,restrictions shall not apply ,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 ,fund4 7c7 ,incorporation of provisions ,the provisions of subsections 7b7 through 7i7 of section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 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 #ahag1 except that1 for purposes of applying such subsections to this section1 the ,board of ,trustees of the ,trust ,fund shall mean the ,secretary4 7d7 ,transfer of funds ,any amounts remaining in the ,federal ,hospital ,insurance ,trust ,fund under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 or the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda of such ,act 7#db ,u4,s4,c4 #aciet7 after the payment of claims for items and services furnished under title ,,xviii of such ,act have been completed1 shall be transferred into the ,universal ,medicare ,trust ,fund under this section4 ,,viii ,conforming ,amendments to the ,employee ,retirement ,income ,security ,act of #aigd #hja4 ,prohibition of employee benefits duplicative of benefits under the ,medicare for ,all ,program2 coordination in case of workers' compensation 7a7 ,in general ,part #e of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaca et seq47 is amended by adding at the end the following new section3 #ebb4 ,prohibition of employee benefits duplicative of ,universal ,medicare ,program benefits2 coordination in case of workers' compensation 7a7 ,in general ,subject to subsection 7b71 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 of #bjai4 7b7 ,reimbursement ,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 services4 7c7 ,definitions ,in this subsection-- 7#a7 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 benefits2 7#b7 the term workers compensation medical benefits means1 with respect to an enrollee who is an employee subject to the workers compensation laws of a ,state1 the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee2 and 7#c7 the term workers compensation services means items and services included in workers compensation medical benefits and includes items and services 7including rehabilitation services and long-term care services7 commonly used for treatment of work-related injuries and illnesses4 4 7b7 ,conforming amendment ,section #d7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajjc7;b77 is amended by adding at the end the following3 ,paragraph 7#c7 shall apply subject to section #ebb7;b7 7relating to reimbursement of the ,medicare for ,all ,program by workers compensation carriers744 7c7 ,clerical amendment ,the table of contents in section #a of such ,act is amended by inserting after the item relating to section #eba the following new item3 ,sec4 #ebb4 ,prohibition of employee benefits duplicative of ,universal ,medicare ,program benefits2 coordination in case of workers' compensation4 4 #hjb4 ,application of continuation coverage requirements under ,,erisa and certain other requirements relating to group health plans 7a7 ,in general ,part #f of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aafa et seq47 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 ,act4 7b7 ,conforming amendment ,section #fja of part #f of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#ai ,u4,s4,c4 #aafa7 is amended by adding the following subsection at the end3 7c7 ,subsection 7a7 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 ,universal ,health ,insurance ,act of #bjag4 4 #hjc4 ,effective date of title ,the provisions of and amendments made by this title shall take effect on the date described in section #ajf7;a74 ,,ix ,additional ,conforming ,amendments #ija4 ,relationship to existing ,federal health programs 7a7 ,medicare1 ,medicaid1 and ,state ,children's ,health ,insurance ,program 7,,schip7 7#a7 ,in general ,notwithstanding any other provision of law and with respect to an individual eligible to enroll under this ,act1 subject to paragraphs 7#b7 and 7#c7-- 7,a7 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 #b years after the date of the enactment of this ,act2 7,b7 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 date2 7,c7 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 date2 and 7,d7 no payment shall be made to a ,state under section #aijc7;a7 or #baje7;a7 of such ,act with respect to medical assistance or child health assistance for any item or service furnished on or after such date4 7#b7 ,transition ,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 #ajf1 and which had not ended as of such date1 for which benefits are provided under title ,,xviii of the ,social ,security ,act1 under a ,state plan under title ,,xix of such ,act1 or under a ,state child health plan under title ,,xxi of such ,act1 the ,secretary shall provide for continuation of benefits under such title or plan until the end of the period of stay4 7#c7 ,school programs ,all school related health programs1 centers1 initiatives1 services1 or other activities or work provided under title ,,xix or title ,,xxi of the ,social ,security ,act as of ,january #a1 #bjai1 shall be continued and covered by the ,medicare for ,all ,program4 7b7 ,federal employees health benefits program ,no benefits shall be made available under chapter #hi of title #e1 ,united ,states ,code1 with respect to items and services furnished to any individual eligible to enroll under this ,act4 7c7 ,,tricare ,no benefits shall be made available under sections #ajgi and #ajhf of title #aj1 ,united ,states ,code1 for items or services furnished to any individual eligible to enroll under this ,act4 7d7 ,treatment of benefits for veterans and ,native ,americans 7#a7 ,in general ,nothing in this ,act shall affect the eligibility of veterans for the medical benefits and services provided under title #ch1 ,united ,states ,code1 or of ,indians for the medical benefits and services provided by or through the ,indian ,health ,service4 7#b7 ,reevaluation ,no reevaluation of the ,indian ,health ,service shall be undertaken without consultation with tribal leaders and stakeholders4 #ijb4 ,sunset of provisions related to the ,state ,exchanges ,effective on the date that is #b years after the date of the enactment of this ,act1 the ,federal and ,state ,exchanges established pursuant to title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 shall terminate1 and any other provision of law that relies upon participation in or enrollment through such an ,exchange1 including such provisions of the ,internal ,revenue ,code of #aihf1 shall cease to have force or effect4 #ijc4 ,sunset of provisions related to pay for performance programs 7a7 ,effective on the date described in section #ajf7;a71 the ,federal programs related to pay for performance programs and value-based purchasing shall terminate1 and any other provision of law that relies upon participation in or enrollment in such program shall cease to have force or effect4 ,programs that shall terminate include-- 7#a7 the ,merit-based ,incentive ,payment ,system established pursuant to subsection 7q7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q772 7#b7 the incentives for meaningful use of certified ,,ehr technology established pursuant to subsection 7a77#g7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#g772 7#c7 the incentives for adoption and meaningful use of certified ,,ehr technology established pursuant to subsection 7o7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o772 7#d7 alternative payment models established under section #ahcc7z7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie7z772 and 7#e7 the following programs as established pursuant to the following sections of the ,patient ,protection and ,affordable ,care ,act3 7,a7 ,section #bgja 7adult health quality measures74 7,b7 ,section #bgjb 7payment adjustments for health care acquired conditions74 7,c7 ,section #bgjf 7,pediatric ,accountable ,care ,organization ,demonstration ,projects for the purposes of receiving incentive payments74 7,d7 ,section #cjjb7;b7 7#db ,u4,s4,c4 #aciew-#d7;a77#h77 7incentive payments for quality reporting74 7,e7 ,section #cjja7;a7 7#db ,u4,s4,c4 #acieww7o77 7,hospital ,value-,based ,purchasing74 7,f7 ,section #cjjf 7value-based purchasing program for skilled nursing facilities and home health agencies74 7,g7 ,section #cjjg 7#db ,u4,s4,c4 #aciew-#d7p77 7value based payment modifier under physician fee schedule74 7,h7 ,section #cjjh 7#db ,u4,s4,c4 #acieww7p77 7payment adjustments for health care-acquired condition74 7,i7 ,section #cjbb 7#db ,u4,s4,c4 #acie;jjj7 7,medicare shared savings programs74 7,j7 ,section #cjbc 7#db ,u4,s4,c4 #acie;cc-#d7 7,national ,pilot ,program on ,payment ,bundling74 7,k7 ,section #cjbd 7#db ,u4,s4,c4 #acie;cc-#e7 7,independence at home demonstration program74 7,l7 ,section #cjbe 7#db ,u4,s4,c4 #acieww7q77 7hospital readmissions reduction program74 7,m7 ,section #ajcja 7plans for value-based purchasing program for ambulatory surgical centers74 ,x ,transition ,a ,medicare for ,all ,transition over #b ,years and ,transitional ,buy-,in ,option #ajja4 ,medicare for all transition over two years ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq47 is amended by adding at the end the following new section3 #ahii;,c4 ,medicare for all transition over #b years 7a7 ,transition 7#a7 ,in general ,every individual who meets the requirements described in paragraph 7#c7 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 of #bjai4 7#b7 ,benefits ,an individual enrolled under this section is entitled to the benefits established under title ,,ii of the ,medicare for ,all ,act of #bjai4 7#c7 ,requirements for eligibility ,the requirements described in this paragraph are the following3 7,a7 ,the individual meets the eligibility requirements established by the ,secretary under title ,i of the ,medicare for ,all ,act of #bjai4 7,b7 ,the individual has attained the applicable year of age1 or is currently enrolled in ,medicare at the time of the transition to ,medicare for ,all4 7#d7 ,applicable year of age defined ,for purposes of this section1 the term applicable year of age means one year after the date of enactment of the ,medicare for ,all ,act of #bjai1 the age of #ee or older1 the age #ah or younger4 7b7 ,enrollment2 coverage ,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 title4 ,the ,secretary shall establish such periods so that coverage under this section shall first begin on ,january #a of the year on which an individual first becomes eligible to enroll under this section4 7c7 ,satisfaction of individual mandate ,for purposes of applying section #ejjj;,a of the ,internal ,revenue ,code of #aihf1 the coverage provided under this section constitutes minimum essential coverage under subsection 7f77#a77;,a77i7 of such section #ejjj;,a4 7d7 ,consultation ,in promulgating regulations to implement this section1 the ,secretary shall consult with interested parties1 including groups representing beneficiaries1 health care providers1 employers1 and insurance companies4 4 #ajjb4 ,establishment of the ,medicare transition buy-in 7a7 ,in general ,to carry out the purpose of this section1 for the year beginning one year after the date of enactment of this ,act and ending with the effective date described in section #ajf7;a71 the ,secretary1 acting through the ,administrator of the ,centers for ,medicare ,medicaid 7referred to in this section as the ,administrator71 shall establish1 and provide for the offering through the ,exchanges1 an option to buy in to the ,medicare for ,all ,program 7in this ,act referred to as the ,medicare ,transition buy-in74 7b7 ,administering the medicare transition buy-,in 7#a7 ,administrator ,the ,administrator shall administer the ,medicare ,transition buy-in in accordance with this section4 7#b7 ,application of ,,aca requirements ,consistent with this section1 the ,medicare ,transition buy-in shall comply with requirements under title ,i of the ,patient ,protection and ,affordable ,care ,act 7and the amendments made by that title7 and title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 that are applicable to qualified health plans offered through the ,exchanges1 subject to the limitation under subsection 7e77#b74 7#c7 ,offering through exchanges ,the ,medicare ,transition buy-in shall be made available only through the ,exchanges1 and shall be available to individuals wishing to enroll and to qualified employers 7as defined in section #acab7;f77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjcb77 who wish to make such plan available to their employees4 7#d7 ,eligibility to purchase ,any ,united ,states resident may enroll in the ,medicare ,transition buy-in4 7c7 ,benefits2 actuarial value ,in carrying out this section1 the ,administrator shall ensure that the ,medicare ,transition buy-in provides-- 7#a7 coverage for the benefits required to be covered under title ,,ii of this ,act2 and 7#b7 coverage of benefits that are actuarially equivalent to #ij percent of the full actuarial value of the benefits provided under the plan4 7d7 ,providers and reimbursement rates 7#a7 ,in general ,with respect to the reimbursement provided to health care providers for covered benefits1 as described in section #bja1 provided under the ,medicare ,transition buy-in1 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 #fab7;b7 of this ,act4 7#b7 ,prescription drugs ,any payment rate under this subsection for a prescription drug shall be at the prices negotiated under section #faf of this ,act4 7#c7 ,participating providers 7,a7 ,in general ,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 7#db ,u4,s4,c4 #acie et seq47 or under a ,state ,medicaid plan under title ,,xix of such ,act 7#db ,u4,s4,c4 #acif et seq47 on the date of enactment of this ,act shall be a participating provider in the ,medicare ,transition buy-in4 7,b7 ,additional providers ,the ,administrator shall establish a process to allow health care providers not described in subparagraph 7,a7 to become participating providers in the ,medicare ,transition buy-in4 ,such process shall be similar to the process applied to new providers under the ,medicare program4 7e7 ,premiums 7#a7 ,determination ,the ,administrator shall determine the premium amount for enrolling in the ,medicare ,transition buy-in1 which-- 7,a7 may vary according to family or individual coverage1 age1 and tobacco status 7consistent with clauses 7i71 7iii71 and 7iv7 of section #bgja7;a77#a77;,a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a7772 and 7,b7 shall take into account the cost-sharing reductions and premium tax credits which will be available with respect to the plan under section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 and section #cf;,b of the ,internal ,revenue ,code of #aihf1 as amended by subsection 7g74 7#b7 ,limitation ,variation in premium rates of the ,medicare ,transition buy-in by rating area1 as described in clause 7ii7 of section #bgja7;a77#a77;,a77iii7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a77 is not permitted4 7f7 ,termination ,this section shall cease to have force or effect on the effective date described in section #ajf7;a74 7g7 ,tax credits and cost-,sharing subsidies 7#a7 ,premium assistance tax credits 7,a7 ,credits allowed to medicare transition buy-in enrollees in non-expansion states ,paragraph 7#a7 of section #cf;,b7c7 of the ,internal ,revenue ,code of #aihf is amended by redesignating subparagraphs 7,c7 and 7,d7 as subparagraphs 7,d7 and 7,e71 respectively1 and by inserting after subparagraph 7,b7 the following new subparagraph3 7,c7 ,special rules for medicare transition buy-in enrollees 7i7 ,in general ,in the case of a taxpayer who is covered1 or whose spouse or dependent 7as defined in section #aeb7 is covered1 by the ,medicare ,transition buy-in established under section #ajjb7;a7 of the ,medicare for ,all ,act of #bjai for all months in the taxable year1 subparagraph 7,a7 shall be applied without regard to but does not exceed #djj percent4 7ii7 ,enrollees in medicaid nonexpansion states ,in the case of a taxpayer residing in a ,state which 7as of the date of the enactment of the ,medicare for ,all ,act of #bjai7 does not provide for eligibility under clause 7i77,,viii7 or 7ii77,,xx7 of section #aijb7;a77#aj77;,a7 of the ,social ,security ,act for medical assistance under title ,,xix of such ,act 7or a waiver of the ,state plan approved under section #aaae7 who is covered1 or whose spouse or dependent 7as defined in section #aeb7 is covered1 by the ,medicare ,transition buy-in established under section #ajjb7;a7 of the ,medicare for ,all ,act of #bjai for all months in the taxable year1 subparagraphs 7,a7 and 7,b7 shall be applied by substituting #j percent for #ajj percent each place it appears4 4 7,b7 ,premium assistance amounts for taxpayers enrolled in medicare transition buy-in 7i7 ,in general ,subparagraph 7,a7 of section #cf;,b7b77#c7 of such ,code is amended--7,i7 by redesignating clause 7ii7 as clause 7iii71 7,,ii7 by striking clause 7ii7 in clause 7i7 and inserting clauses 7ii7 and 7iii71 and 7,,iii7 by inserting after clause 7i7 the following new clause3 7ii7 ,special rules for taxpayers enrolled in medicare transition buy-in ,in the case of a taxpayer who is covered1 or whose spouse or dependent 7as defined in section #aeb7 is covered1 by the ,medicare ,transition buy-in established under section #ajjb7;a7 of the ,medicare for ,all ,act of #bjai for all months in the taxable year1 the applicable percentage for any taxable year shall be determined in the same manner as under clause 7i71 except that the following table shall apply in lieu of the table contained in such clause3 ,in the case of household income 7expressed as a percent of poverty line7 within the following income tier3,the initial premium percentage is--,the final premium percentage is--,up to #ajj percent#b4jjb4jjajj percent up to #ach percent#b4jdb4jdach percent up to #aej percent#c4jfd4jhaej percent and above#d4jhe4jj4 4 7ii7 ,conforming amendment ,subclause 7,i7 of clause 7iii7 of section #cf;,b7b77#c7 of such ,code1 as redesignated by subparagraph 7,a77i71 is amended by inserting 1 and determined after the application of clause 7ii7 after after application of this clause4 7#b7 ,cost-sharing subsidies ,subsection 7b7 of section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7;b77 is amended-- 7,a7 by inserting 1 or in the ,medicare ,transition buy-in established under section #ajjb7;a7 of the ,medicare for ,all ,act of #bjai1 after coverage in paragraph 7#a72 7,b7 by redesignating paragraphs 7#a7 7as so amended7 and 7#b7 as subparagraphs 7,a7 and 7,b71 respectively1 and by moving such subparagraphs #b ems to the right2 7,c7 by striking insured4--,in this section and inserting 8insured4-- 7#a7 ,in general ,in this section 2 7,d7 by striking the flush language2 and 7,e7 by adding at the end the following new paragraph3 7#b7 ,special rules 7,a7 ,individuals lawfully present ,in the case of an individual described in section #cf;,b7c77#a77;,b7 of the ,internal ,revenue ,code of #aihf1 the individual shall be treated as having household income equal to #ajj percent of the poverty line for a family of the size involved for purposes of applying this section4 7,b7 ,medicare transition buy-in enrollees in medicaid non-expansion states ,in the case of an individual residing in a ,state which 7as of the date of the enactment of the ,medicare for ,all ,act of #bjai7 does not provide for eligibility under clause 7i77,,viii7 or 7ii77,,xx7 of section #aijb7;a77#aj77;,a7 of the ,social ,security ,act for medical assistance under title ,,xix of such ,act 7or a waiver of the ,state plan approved under section #aaae7 who enrolls in such ,medicare ,transition buy-in1 the preceding sentence1 paragraph 7#a77;,b71 and paragraphs 7#a77;,a77i7 and 7#b77;,a7 of subsection 7c7 shall each be applied by substituting #j percent for #ajj percent each place it appears4 4 7h7 ,conforming amendments 7#a7 ,treatment as a qualified health plan ,section #acja7;a77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7;a77#b77 is amended-- 7,a7 in the paragraph heading1 by inserting ,the ,medicare transition buy-in1 before and2 and 7,b7 by inserting ,the ,medicare ,transition buy-in1 before and a multi-,state plan4 7#b7 ,level playing field ,section #acbd7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjdd7;a77 is amended by inserting the ,medicare ,transition buy-in1 before or a multi-,state qualified health plan4 ,b ,transitional ,medicare ,reforms #ajaa4 ,eliminating the #bd-month waiting period for ,medicare coverage for individuals with disabilities 7a7 ,in general ,section #bbf7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dbf7;b77 is amended-- 7#a7 in paragraph 7#b77;,a71 by striking 1 and has for #bd calendar months been entitled to12 7#b7 in paragraph 7#b77;,b71 by striking 1 and has been for not less than #bd months12 7#c7 in paragraph 7#b77;,c77ii71 by striking 1 including the requirement that he has been entitled to the specified benefits for #bd months12 7#d7 in the first sentence1 by striking for each month beginning with the later of 7,i7 ,july #aigc or 7,,ii7 the twenty-fifth month of his entitlement or status as a qualified railroad retirement beneficiary described in paragraph 7#b71 and and inserting for each month for which the individual meets the requirements of paragraph 7#b71 beginning with the month following the month in which the individual meets the requirements of such paragraph1 and2 and 7#e7 in the second sentence1 by striking the twenty-fifth month of his entitlement and all that follows through paragraph 7#b77;,c7 and4 7b7 ,conforming amendments 7#a7 ,section #bbf ,section #bbf of the ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is amended by-- 7,a7 striking subsections 7e77#a77;,b71 7f71 and 7h72 and 7,b7 redesignating subsections 7g7 and 7i7 as subsections 7f7 and 7g71 respectively4 7#b7 ,medicare description ,section #ahaa7b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c7#b77 is amended by striking have been entitled for not less than #bd months and inserting are entitled4 7#c7 ,medicare coverage ,section #ahcg7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciep7g77#a77 is amended by striking #beth month of and inserting month following the first month of4 7#d7 ,railroad retirement system ,section #g7;d77#b77;ii7 of the ,railroad ,retirement ,act of #aigd 7#de ,u4,s4,c4 #bca;f7d77#b77;ii77 is amended-- 7,a7 by striking has been entitled to an annuity and inserting is entitled to an annuity2 7,b7 by striking 1 for not less than #bd months2 and 7,c7 by striking could have been entitled for #bd calendar months1 and4 7c7 ,effective date ,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 #a following the date of enactment of this ,act1 and before the date that is #b years after the date of the enactment of such ,act4 #ajab4 ,ensuring continuity of care 7a7 ,in general ,the ,secretary shall ensure that all persons enrolled or who seeks 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 period1 including continuity of care with such persons current health care provider teams4 7b7 ,continuity of coverage and care in general ,during the transition period of the ,medicare for ,all ,act1 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 plan4 7c7 ,continuity of coverage and care for persons with complex medical needs 7#a7 ,the ,secretary shall ensure that persons with disabilities1 complex medical needs1 or chronic conditions are protected from disruptions in their care during the transition period1 including continuity of care with such persons current health care provider teams4 7#b7 ,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-- 7,a7 end coverage for an enrollee who has a disability1 complex medical need1 or chronic condition during the transition period described in the ,act until all ages are eligible to enroll in the ,medicare for ,all ,program2 or 7,b7 impose any exclusion with respect to such plan or coverage on the basis of a person's disability1 complex medical need1 or chronic condition during the transition period described under this ,act until all ages are eligible to enroll in the ,medicare for ,all ,program4 7d7 ,public consultation during transition ,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 disabilities1 complex medical needs1 or chronic conditions4 ,,xi ,miscellaneous #aaja4 ,definitions ,in this ,act-- 7#a7 the term group practice has the meaning given such term in section #ahgg7;h77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acienn7h77#d772 7#b7 the term individual provider means a supplier 7as defined for purposes of paragraph 7#d772 7#c7 the term institutional provider means-- 7,a7 providers of services described in section #ahfa7u7 of such ,act 7#db ,u4,s4,c4 #aciex7u772 7,b7 hospitals as defined in section #ahfa7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7e771 and any outpatient settings or clinics operating within a hospital license or any setting or clinic that provides outpatient hospital services2 7,c7 psychiatric hospitals 7as defined in section #ahfa7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7f7772 7,d7 rehabilitation hospitals 7as defined by the ,secretary of ,health and ,human ,services under section #ahhf7;d77#a77;,b77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#a77;,b77ii7772 7,e7 long-term care hospitals as defined in section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ccc772 and 7,f7 independent dialysis facilities and independent end-stage renal disease facilities as described in #db ,,cfr #dac4agd7;b72 7#d7 the term medically necessary or appropriate means the health care items and services or supplies are needed or appropriate to prevent1 diagnose1 or treat an illness1 injury1 condition1 disease1 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 individual1 after such professional performs an assessment of such individual's condition1 in a manner that meets-- 7,a7 the scope of practice1 licensing1 and other law of the ,state in which such items and services are to be furnished2 and 7,b7 appropriate standards established by the ,secretary for purposes of carrying out this ,act2 7#e7 the term provider means an institutional provider or a supplier 7as defined in section #ahfa7;d7 of such ,act 7#db ,u4,s4,c4 #aciex7d77 if the reference to this title were a reference to the ,medicare for ,all ,program72 7#f7 the term ,secretary means the ,secretary of ,health and ,human ,services2 7#g7 the term ,state means a ,state1 the ,district of ,columbia1 or a territory of the ,united ,states2 and 7#h7 the term ,united ,states shall include the ,states1 the ,district of ,columbia1 and the territories of the ,united ,states4 #aajb4 ,rules of construction 7a7 ,in general ,a ,state or local government may set additional standards or apply other ,state or local laws with respect to eligibility1 benefits1 and minimum provider standards1 only if such ,state or local standards-- 7#a7 provide equal or greater eligibility than is available under this ,act2 7#b7 provide equal or greater in-person access to benefits under this ,act2 7#c7 do not reduce access to benefits under this ,act2 7#d7 allow for the effective exercise of the professional judgment of physicians or other health care professionals2 and 7#e7 are otherwise consistent with this ,act4 7b7 ,relation to state licensing law ,nothing in this ,act shall be construed to preempt ,state licensing1 practice1 or educational laws or regulations with respect to health care professionals and health care providers1 for such professionals and providers who practice in that ,state4 7c7 ,application to state and federal law on workplace rights ,nothing in this ,act shall be construed to diminish or alter the rights1 privileges1 remedies1 or obligations of any employee or employer under any ,federal or ,state law or regulation or under any collective bargaining agreement4 7d7 ,restrictions on providers ,with respect to any individuals or entities certified to provide items and services covered under section #bja7;a77#g71 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 services4