,,ii #aafth ,,congress #ast ,session ,s4 #aabi ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,april #aj1 #bjai,mr4 ,sanders 7for himself1 ,ms4 ,baldwin1 ,mr4 ,blumenthal1 ,mr4 ,booker1 ,mrs4 ,gillibrand1 ,ms4 ,harris1 ,mr4 ,leahy1 ,mr4 ,markey1 ,mr4 ,merkley1 ,mr4 ,schatz1 ,mr4 ,udall1 ,ms4 ,warren1 ,mr4 ,whitehouse1 ,ms4 ,hirono1 and ,mr4 ,heinrich7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to establish a ,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 for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,title ,i--,establishment of the ,universal ,medicare ,program2 ,universal ,entitlement2 ,enrollment ,sec4 #aja4 ,establishment of the ,universal ,medicare ,program4 ,sec4 #ajb4 ,universal entitlement4 ,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 institutional long-term care services under ,medicaid4 ,sec4 #bje4 ,prohibiting recovery of correctly paid ,medicaid benefits4 ,sec4 #bjf4 ,state standards4 ,title ,,iii--,provider ,participation ,sec4 #cja4 ,provider participation and standards4 ,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 ,complementary conduct of related health programs4 ,subtitle ,b--,control ,over ,fraud and ,abuse ,sec4 #daa4 ,application of ,federal sanctions to all fraud and abuse under ,universal ,medicare ,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 and individual providers4 ,sec4 #fab4 ,ensuring accurate valuation of services under the ,medicare physician fee schedule4 ,sec4 #fac4 ,office of primary health care4 ,sec4 #fad4 ,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 ,universal ,medicare ,program2 coordination in case of workers' compensation4 ,sec4 #hjb4 ,repeal 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 ,title ,x--,transition ,subtitle ,a--,transitional ,medicare ,buy-,in ,option and ,transitional ,public ,option ,sec4 #ajja4 ,lowering the ,medicare age4 ,sec4 #ajjb4 ,establishment of the ,medicare transition plan4 ,subtitle ,b--,transitional ,medicare ,reforms ,sec4 #ajaa4 ,medicare protection against high out-of-pocket expenditures for fee-for-service benefits and elimination of parts ,a and ,b deductibles4 ,sec4 #ajab4 ,reduction in ,medicare part ,d annual out-of-pocket threshold and elimination of cost-sharing above that threshold4 ,sec4 #ajac4 ,coverage of dental and vision services and hearing aids and examinations under ,medicare part ,b4 ,sec4 #ajad4 ,eliminating the #bd-month waiting period for ,medicare coverage for individuals with disabilities4 ,sec4 #ajae4 ,guaranteed issue of ,medigap policies4 ,subtitle ,c--,private ,health ,insurance ,availability ,during ,transitional ,period ,sec4 #ajba4 ,continuity of care4 ,title ,,xi--,miscellaneous ,sec4 #aaja4 ,updating resource limits for ,supplemental ,security ,income eligibility 7,,ssi74 ,sec4 #aajb4 ,definitions4 ,i ,establishment of the ,universal ,medicare ,program2 ,universal ,entitlement2 ,enrollment #aja4 ,establishment of the ,universal ,medicare ,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 entitlement 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-- 7#a7 may make eligible for benefits for health care services under this ,act other individuals not described in subsection 7a7 and regulate their eligibility to ensure that every person in the ,united ,states has access to health care2 and 7#b7 shall promulgate a rule1 consistent with ,federal immigration laws1 to prevent an individual from traveling to the ,united ,states for the sole purpose of obtaining health care services provided 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 or sex1 including sex stereotyping1 gender identity1 sexual orientation1 and pregnancy and related medical conditions 7including termination of pregnancy71 be excluded from participation in1 be denied the benefits of1 or be subjected to discrimination by any participating provider as defined in section #cja1 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 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 #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 or upon the establishment of residency in the ,united ,states2 7#b7 provide for the enrollment1 as of the date described in section #ajf1 of all individuals who are eligible to be enrolled as of such date2 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 on ,january #a of the fourth calendar year that begins after the date of enactment of this ,act4 7b7 ,coverage for children 7#a7 ,in general ,for any eligible individual who has not yet attained the age of #ai1 benefits shall first be available under this ,act for items and services furnished on ,january #a of the first calendar year that begins after the date of enactment of this ,act4 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 effective 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 drugs1 medical devices1 biological products1 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 ,pediatrics1 including early and periodic screening1 diagnostic1 and treatment services 7as defined in section #aije7r7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7r7774 7#i7 ,oral health1 audiology1 and vision services4 7#aj7 ,short-term rehabilitative and habilitative services and devices4 7#aa7 ,emergency services and transportation4 7#ab7 ,necessary transportation to receive health care services for individuals with disabilities and low-income individuals4 7#ac7 ,home and community-based long-term services and supports 7to be provided in accordance with the requirements for home and community-based settings under sections #dda4ecj and #dda4gaj of title #db1 ,code of ,federal ,regulations71 including-- 7,a7 services described in paragraphs 7#g71 7#h71 7#ac71 7#ai71 and 7#bd7 of section #aije7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a772 7,b7 home and community-based services described in subsection 7c77#d77;,b7 of section #aiae of the ,social ,security ,act 7including habilitation services defined in subsection 7c77#e7 of such section72 7,c7 self-directed home and community-based services described in subsection 7i7 of section #aiae of the ,social ,security ,act2 7,d7 self-directed personal assistance services 7as defined in subsection 7j77#d77;,a7 of section #aiae of the ,social ,security ,act72 and 7,e7 home and community-based attendant services and supports described in subsection 7k7 of section #aiae of the ,social ,security ,act4 7b7 ,revision and adjustment ,the ,secretary shall1 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 ,complementary and integrative medicine 7#a7 ,in general ,in carrying out subsection 7b71 the ,secretary shall consult with the persons described in paragraph 7#a7 with respect to-- 7,a7 identifying specific complementary and integrative medicine practices that1 on the basis of research findings or promising clinical interventions1 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 integrative 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 7d7 ,states may provide additional benefits ,individual ,states may provide additional benefits for the residents of such ,states at the expense of the ,state4 #bjb4 ,no cost-sharing 7a7 ,in general ,the ,secretary shall ensure that no cost-sharing1 including deductibles1 coinsurance1 copayments1 or similar charges1 be imposed on an individual for any benefits provided under this ,act1 except as described in subsection 7b74 7b7 ,exceptions ,the ,secretary may set a cost-sharing schedule for prescription drugs and biological products-- 7#a7 provided that-- 7,a7 such schedule is evidence-based and encourages the use of generic drugs2 7,b7 such cost-sharing does not apply to preventive drugs2 7,c7 such cost-sharing does not exceed #bjj annually per individual1 adjusted annually for inflation2 and 7,d7 such cost-sharing is not imposed on individuals with a household income equal to or below #bjj percent of the poverty line for a family of the size involved2 and 7#b7 under which the ,secretary may exempt brand-name drugs from consideration in determining whether an individual has reached any out-of-pocket limit if a generic version of such drug is available4 7c7 ,no balance billing ,notwithstanding contracts in accordance with section #cjc1 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 services are not available under this ,act unless the services meet the standards specified in section #bja7;a71 as defined by the ,secretary4 7b7 ,treatment of experimental services and drugs 7#a7 ,in general ,in applying subsection 7a71 the ,secretary shall make national coverage determinations with respect to 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 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 ,in the case of services for which the ,department of ,health and ,human ,services has recognized a national practice guideline1 the services are considered to meet the standards specified in section #bja7;a7 if they have been provided in accordance with such guideline4 ,for purposes of this subsection1 a service shall be considered to have been provided in accordance with a practice guideline if the health care provider providing the service exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline4 #bjd4 ,coverage of institutional long-term care services under ,medicaid ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended by inserting the following section after section #aidf3 #aidg4 ,state ,plan for ,providing ,institutional ,long-,term ,care ,services 7a7 ,in general ,for quarters beginning on or after date on which benefits are first available under section #ajf7;a7 of the ,medicare for ,all ,act of #bjai1 notwithstanding any other provision of this title-- 7#a7 a ,state plan for medical assistance shall provide for making medical assistance available for services that are institutional long-term care services in a manner consistent with this section2 and 7#b7 no payment to a ,state shall be made under this title with respect to expenditures incurred by the ,state in providing medical assistance on or after such date for services that are not-- 7,a7 institutional long-term care services2 or 7,b7 other services for which benefits are not available under the ,medicare for ,all ,act of #bjai and which are furnished under a ,state plan for medical assistance which provided for medical assistance for such services on ,september #a1 #bjah4 7b7 ,institutional long-,term care services defined ,in this section1 the term institutional long-term care services means the following3 7#a7 ,nursing facility services for individuals #ba years of age or over described in subparagraph 7,a7 of section #aije7;a77#d74 7#b7 ,inpatient services for individuals #fe years of age or over provided in an institution for mental disease described in section #aije7;a77#ad74 7#c7 ,intermediate care facility services described in section #aije7;a77#ae74 7#d7 ,inpatient psychiatric hospital services for individuals under age #ba described in section #aije7;a77#af74 7#e7 ,nursing facility services described in section #aije7;a77#bi74 7c7 ,maintenance of effort 7#a7 ,eligibility standards 7,a7 ,in general ,beginning on the date described in subsection 7a71 no payment may be made under section #aijc with respect to medical assistance provided under a ,state plan for medical assistance if the ,state adopts income1 resource1 or other standards and methodologies for purposes of determining an individual's eligibility for medical assistance under the ,state plan that are more restrictive than those applied as of ,january #a1 #bjai4 7,b7 ,indexing of amounts of income and resource standards ,in determining whether a ,state has adopted income or resource standards that are more restrictive than the standards which applied as of ,january #a1 #bjai1 the ,secretary shall deem the amount of any such standard that was applied as of such date to be increased by the percentage increase in the medical care component of the consumer price index for all urban consumers 7,u4,s4 city average7 from ,september of #bjah to ,september of the fiscal year for which the ,secretary is making such determination4 7#b7 ,expenditures 7,a7 ,in general ,for each fiscal year or portion of a fiscal year that occurs during the period that begins on the first day of the first fiscal quarter that begins on or after the date on which benefits are first available under section #ajf7;a7 of the ,medicare for ,all ,act of #bjai1 as a condition of receiving payments under section #aijc7;a71 a ,state shall make expenditures for medical assistance for services that are institutional long-term care services in an amount that is not less than the expenditure floor determined for the ,state and fiscal year 7or portion of a fiscal year7 under subparagraph 7,b74 7,b7 ,expenditure floor 7i7 ,in general ,for each fiscal year or portion of a fiscal year described in subparagraph 7,a71 the ,secretary shall determine for each ,state an expenditure floor that shall be equal to-- 7,i7 the amount of the ,state's expenditures for fiscal year #bjah on medical assistance for institutional long-term care services2 increased by 7,,ii7 the growth factor determined under subclause 7ii74 7ii7 ,growth factor ,for each fiscal year or portion of a fiscal year described in subparagraph 7,a71 the ,secretary shall1 not later than ,september #a of the fiscal year preceding such fiscal year or portion of a fiscal year1 determine a growth factor for each ,state that takes into account-- 7,i7 the percentage increase in health care costs in the ,state2 7,,ii7 the total amount expended by the ,state for the previous fiscal year on medical assistance for institutional long-term care services2 7,,iii7 the increase1 if any1 in the total population of the ,state from ,july of #bjah to ,july of the fiscal year preceding the fiscal year involved2 7,,iv7 the increase1 if any1 in the population of individuals aged #fe and older of the ,state from ,july of #bjah to ,july of the fiscal year preceding the fiscal year involved2 and 7,v7 the decrease1 if any1 in the population of the ,state that requires medical assistance for institutional long-term care services that is attributable to the availability of coverage for the services described in section #bja7;a77#ac7 of the ,medicare for ,all ,act of #bjai4 7iii7 ,proration rule ,any amount determined under this subparagraph for a portion of a fiscal year shall be prorated based on the length of such portion of a fiscal year relative to a complete fiscal year4 7d7 ,nonapplication of certain requirements ,beginning on the date described in subsection 7a71 any provision of this title requiring a ,state plan for medical assistance to make available medical assistance for services that are not institutional long-term care services or services described in section #ija7;a77#c77;,a77ii7 of the ,medicare for ,all ,act of #bjai shall have no effect4 4 #bje4 ,prohibiting recovery of correctly paid ,medicaid benefits ,section #aiag of the ,social ,security ,act 7#db ,u4,s4,c4 #acifp7 is amended-- 7#a7 by amending subsection 7a7 to read as follows3 7a7 ,no lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the ,state plan1 except pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual4 2 and 7#b7 by amending subsection 7b7 to read as follows3 7b7 ,no adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the ,state plan may be made4 4 #bjf4 ,state standards 7a7 ,in general ,nothing in this ,act shall prohibit individual ,states from setting additional standards1 with respect to eligibility1 benefits1 and minimum provider standards1 consistent with the purposes of this ,act1 provided that such standards do not restrict eligibility or reduce access to benefits or services4 7b7 ,restrictions on providers ,with respect to any individuals or entities certified to provide services covered under section #bja7;a77#g71 a ,state may not prohibit an individual or entity from participating in the program under this ,act1 for reasons other than the ability of the individual or entity to provide such services4 ,,iii ,provider ,participation #cja4 ,provider participation and standards 7a7 ,in general ,an individual or other entity furnishing any covered service under this ,act is not a qualified provider unless the individual or entity-- 7#a7 is a qualified provider of the 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 ,services to eligible persons will 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 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 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 7,e7 ,in the case of a provider paid under a fee-for-service basis1 the provider agrees to submit bills and any required supporting documentation relating to the provision of covered services within #cj days after the date of providing such services4 7#b7 ,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 or 7ii7 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 #cjb4 ,qualifications for providers 7a7 ,in general ,a health care provider is considered to be qualified to provide covered services if the provider is licensed or certified and meets-- 7#a7 all the requirements of ,state law to provide such services2 and 7#b7 applicable requirements of ,federal law to provide such services4 7b7 ,minimum provider standards 7#a7 ,in general ,the ,secretary shall establish1 evaluate1 and update national minimum standards to ensure the quality of services provided under this ,act and to monitor efforts by ,states to ensure the quality of such services4 ,a ,state may also establish additional minimum standards which providers shall meet with respect to services provided in such ,state4 7#b7 ,national minimum standards ,the national minimum standards under paragraph 7#a7 shall be established 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 for 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 training and competence of personnel 7including continuing education requirements72 7,c7 comprehensiveness of service2 7,d7 continuity of service2 7,e7 patient satisfaction1 including waiting time and access to services2 and 7,f7 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 services described in section #bja7;a77#g71 the ,secretary may not prohibit such entity or provider from participating for reasons other than its ability to provide such services4 7c7 ,federal providers ,any provider qualified to provide health care 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 services under applicable ,federal law4 #cjc4 ,use of private contracts 7a7 ,in general ,subject to the provisions of this subsection1 nothing in this ,act shall prohibit an institutional or individual provider from entering into a private contract with an enrolled individual for any item or service-- 7#a7 for which no claim for payment is to be submitted under this ,act2 and 7#b7 for which the provider receives-- 7,a7 no reimbursement under this ,act directly or on a capitated basis2 and 7,b7 receives no amount for such item or service from an organization which receives reimbursement for such items or service under this ,act directly or on a capitated basis4 7b7 ,beneficiary protections 7#a7 ,in general ,subsection 7a7 shall not apply to any contract unless-- 7,a7 the contract is in writing and is signed by the beneficiary before any item or service is provided pursuant to the contract2 7,b7 the contract contains the items described in paragraph 7#b72 and 7,c7 the contract is not entered into at a time when the beneficiary is facing an emergency health care situation4 7#b7 ,items required to be included in contract ,any contract to provide items and services to which subsection 7a7 applies shall clearly indicate to the beneficiary that by signing such contract the beneficiary-- 7,a7 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 7,b7 agrees to be responsible1 whether through insurance offered under section #ajg7;b7 or otherwise1 for payment of such items or services and understands that no reimbursement will be provided under this ,act for such items or services2 7,c7 acknowledges that no limits under this ,act apply to amounts that may be charged for such items or services2 7,d7 if the provider is a non-participating provider1 acknowledges that the beneficiary has the right to have such items or services provided by other providers for whom payment would be made under this ,act2 and 7,e7 acknowledges that the provider is providing services outside the scope of the program under this ,act4 7c7 ,provider requirements 7#a7 ,in general ,subsection 7a7 shall not apply to any contract unless an affidavit described in paragraph 7#b7 is in effect during the period any item or service is to be provided pursuant to the contract4 7#b7 ,affidavit ,an affidavit is described in this subparagraph shall-- 7,a7 identify the practitioner1 and be signed by such practitioner2 7,b7 provide that the practitioner will not submit any claim under this title for any item or service provided to any beneficiary 7and will not receive any reimbursement or amount described in paragraph 7#a77;,b7 for any such item or service7 during the #a-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#c7 ,enforcement ,if a physician or practitioner signing an affidavit described in paragraph 7#b7 knowingly and willfully submits a claim under this title for any item or service provided during the #a-year period described in paragraph 7#b77;,b7 7or receives any reimbursement or amount described in subsection 7a77#b7 for any such item or service7 with respect to such affidavit-- 7,a7 this subsection shall not apply with respect to any items and services provided by the physician or practitioner pursuant to any contract on and after the date of such submission and before the end of such period2 and 7,b7 no payment shall be made under this title for any item or service furnished by the physician or practitioner during the period described in clause 7i7 7and no reimbursement or payment of any amount described in subsection 7a77#b7 shall be made for any such item or service74 ,,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 services1 consistent with subtitle ,b2 7,g7 the determination of medical necessity and appropriateness with respect to coverage of certain services2 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 purpose 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 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 such services1 the quality of such services1 the outcomes of such services1 and the equity of health among population groups4 ,such standards shall include1 to the maximum extent feasible without compromising patient privacy1 health outcome measures1 and to the maximum extent feasible without excessively burdening providers1 the measures described in subparagraphs 7,d7 through 7,f7 of subsection 7a77#a74 7,b7 ,reports ,the ,secretary shall regularly analyze information reported to it 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 ,january #a of the second year beginning after the effective date 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 ,necessary changes in the education of health personnel4 7,l7 ,plans for improving service to medically underserved populations4 7,m7 ,transition problems as a result of implementation of this ,act4 7,n7 ,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 payment or delivery as it 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 evidence-based policymaking4 7c7 ,audits 7#a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct an audit of the ,board 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 professional societies1 national associations1 nationally recognized associations of experts1 medical schools and academic health centers1 consumer and patient groups1 and labor 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 guidelines 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 to promote adequate access to1 and efficient use of1 tertiary care facilities1 equipment1 and services4 ,wherever possible1 the ,secretary shall incorporate regional offices of the ,centers for ,medicare ,medicaid ,services for this purpose4 7b7 ,appointment of regional and ,state directors ,in each such regional office there shall be-- 7#a7 one regional director appointed by the ,secretary2 7#b7 for each ,state in the region1 a deputy director2 and 7#c7 one deputy director to represent the ,native ,american and ,alaska ,native tribes in the region4 7c7 ,regional office duties ,regional offices shall be responsible for-- 7#a7 providing an annual ,state health care needs assessment report to the ,secretary1 after a thorough examination of health needs1 in consultation with public health officials1 clinicians1 patients1 and patient advocates2 7#b7 recommending changes in provider reimbursement or payment for delivery of health services in the ,states within the region2 and 7#c7 establishing a quality assurance mechanism in the ,state in order to minimize both under-utilization and over-utilization and to ensure that all providers meet high-quality standards4 #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 entitled to benefits under this ,act4 7b7 ,duties ,the ,beneficiary ,ombudsman shall-- 7#a7 receive complaints1 grievances1 and requests for information submitted by individuals entitled to benefits under this ,act with respect to any aspect of the ,universal ,medicare ,program2 7#b7 provide assistance with respect to complaints1 grievances1 and requests referred to in subparagraph 7a71 including-- 7,a7 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,b7 assistance to such individuals in presenting information under relating to cost-sharing2 and 7#c7 submit annual reports to ,congress and the ,secretary that describe the activities of the ,office 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 ,complementary 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 ,universal ,medicare ,program ,the following sections of the ,social ,security ,act shall apply to this ,act in the same manner as they apply to ,state medical assistance plans under title ,,xix of such ,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 ,v ,quality ,assessment #eja4 ,quality standards 7a7 ,in general ,all standards and quality measures under this ,act shall be performed by the ,center for ,clinical ,standards and ,quality of the ,centers for ,medicare ,medicaid ,services 7referred to in this title as the ,center71 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 ,practice guidelines ,the ,center shall review and evaluate each practice guideline developed under part ,b of title ,,ix of the ,public ,health ,service ,act4 ,the ,center shall determine whether the guideline should be recognized as a national practice guideline4 7#b7 ,standards of quality1 performance measures1 and medical review criteria ,the ,center shall 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 ,the ,center shall determine whether the standard1 measure1 or criterion is appropriate for use in assessing or reviewing the quality of services provided by health care institutions or health care professionals4 ,in evaluating such standards1 the ,center shall consider the evidentiary basis for the standard1 and the validity1 reliability1 and feasibility of measuring the standard4 7#c7 ,profiling of patterns of practice2 identification of outliers ,the ,center shall adopt methodologies for profiling the patterns of practice of health care professionals and for identifying and notifying outliers4 7#d7 ,criteria for entities conducting quality reviews ,the ,center shall develop 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 ,reporting ,the ,center shall 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 or socioeconomic status4 ,in conducting such evaluation1 the ,secretary 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 ,universal ,medicare ,program 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 ,universal ,medicare ,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 #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 the total expenditures to be made for covered health care services under this ,act4 7#b7 ,division of budget into components ,in addition to the cost of covered health services1 the national health budget shall consist of at least the following components3 7,a7 ,quality assessment activities under title ,v4 7,b7 ,health professional education expenditures4 7,c7 ,administrative costs4 7,d7 ,innovation1 including in accordance with section #aaae;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a74 7,e7 ,operating and other expenditures not described in subparagraphs 7,a7 through 7,d7 7referred to in this ,act as the operating component71 consisting of amounts not included in the other components4 7,f7 ,capital expenditures4 7,g7 ,prevention and public health activities4 7#c7 ,allocation among components ,the ,secretary shall allocate the budget among the components in a manner that-- 7,a7 ensures a fair allocation for quality assessment activities2 and 7,b7 ensures 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 ,temporary worker assistance ,for up to #e years following the date on which benefits first become available as described in section #ajf7;a71 up to #a percent of the budget may be allocated to programs providing assistance to workers who perform functions in the administration of the health insurance system and who may experience economic dislocation as a result of the implementation of this ,act4 7#e7 ,reserve fund ,the ,secretary shall establish and maintain a reserve fund to respond to the costs of treating an epidemic1 pandemic1 natural disaster1 or other such health emergency4 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 equipment and includes return on equity capital4 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 activities4 ,b ,payments to ,providers #faa4 ,payments to institutional and individual providers 7a7 ,application of payment processes under title ,,xviii ,except as otherwise provided in this section1 the ,secretary shall establish1 by regulation1 fee schedules that establish payment amounts for benefits under this ,act in a manner that is consistent with processes for determining payments for items and services under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 including the application of the provisions of1 and amendments made by1 section #fab4 7b7 ,application of current and planned payment reforms ,any payment reform activities or demonstrations planned or implemented with respect to such title ,,xviii as of the date of the enactment of this ,act shall apply to benefits under this ,act1 including any reform activities or demonstrations planned or implemented under the provisions of1 or amendments made by1 the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae 7,public ,law #aad-aj7 and the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh74 #fab4 ,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 available 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 #acjew-#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 one year after the date of enactment of this ,act1 the ,secretary shall submit to ,congress a proposed plan for systematically and internally tracking its 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 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 subparagraph 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 nonproprietary data related to the activities carried out under this paragraph1 in a timely manner1 upon request4 4 #fac4 ,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 and 7#d7 recommend the appropriate training1 education1 technical assistance1 and patient advocacy enhancements of primary care health professionals1 including registered nurses1 to achieve uniform high-quality and patient safety4 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 #fad4 ,payments for prescription drugs and approved devices and equipment 7a7 ,negotiated prices ,the prices to be paid for covered pharmaceuticals1 medical supplies1 and medically necessary assistive equipment shall be negotiated annually by the ,secretary4 7b7 ,prescription drug formulary 7#a7 ,in general ,the ,secretary shall establish a prescription drug formulary system1 which shall encourage best-practices in prescribing and discourage the use of ineffective1 dangerous1 or excessively costly medications when better alternatives are available4 7#b7 ,promotion of use of generics ,the formulary under this subsection shall promote the use of generic medications to the greatest extent possible4 7#c7 ,formulary updates and petition rights ,the formulary under this subsection shall be updated frequently and clinicians and patients may petition the ,secretary to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary4 7#d7 ,use of off-formulary medications ,the ,secretary shall promulgate rules regarding the use of off-formulary medications which allow for patient access but do not compromise the formulary4 ,,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 hereby 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 ,treasury2 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 ,notwithstanding any other provision of law1 there are hereby appropriated to the ,trust ,fund for each fiscal year1 beginning with the first fiscal year beginning on or after the effective date of benefits under section #ajf1 the amounts that would otherwise have been appropriated to carry out the following programs3 7,a7 ,the ,medicare program under title ,,xviii of the ,social ,security ,act 7other than amounts attributable to any premiums under such title74 7,b7 ,the ,medicaid program1 under ,state plans approved under title ,,xix of such ,act4 7,c7 ,the ,federal employees health benefit program1 under chapter #hi of title #e1 ,united ,states ,code4 7,d7 ,the ,,tricare program1 under chapter #ee of title #aj1 ,united ,states ,code4 7,e7 ,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#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 ,universal ,medicare ,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 ,universal ,medicare ,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 ,universal ,medicare ,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 ,sec #ebb4 ,prohibition of employee benefits duplicative of ,universal ,medicare ,program benefits2 coordination in case of workers' compensation4 4 #hjb4 ,repeal 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 is repealed4 7b7 ,conforming amendments 7#a7 ,section #ejb7;a7 of such ,act 7#bi ,u4,s4,c4 #aacb7;a77 is amended-- 7,a7 by striking paragraph 7#g72 and 7,b7 by redesignating paragraphs 7#h71 7#i71 and 7#aj7 as paragraphs 7#g71 7#h71 and 7#i71 respectively4 7#b7 ,section #ejb7;c77#a7 of such ,act 7#bi ,u4,s4,c4 #aacb7;c77#a77 is amended by striking paragraph 7#a7 or 7#d7 of section #fjf14 7#c7 ,section #ead7;b7 of such ,act 7#bi ,u4,s4,c4 #aadd7;b77 is amended-- 7,a7 in paragraph 7#g71 by striking section #bjf7;d77#c77;,b77i7742 and 7,b7 by striking paragraph 7#h74 7#d7 ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd is amended by striking the items relating to part #f of subtitle ,b of title ,i of such ,act4 #hjc4 ,effective date of title ,the amendments made by this title shall take effect on effective date of benefits under 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 law1 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 or after the effective date of benefits under section #ajf7;a72 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 such ,act1 the ,secretary of ,health and ,human ,services shall provide for continuation of benefits under such title or plan until the end of the period of stay4 7#c7 ,services under ,medicaid 7,a7 ,in general ,this subsection shall not apply to entitlement to medical assistance provided under title ,,xix of the ,social ,security ,act for-- 7i7 institutional long-term care services 7as defined in section #aidg7;b7 of such ,act72 or 7ii7 any other service for which benefits are not available under this ,act and which is furnished under a ,state plan under title ,,xix of the ,social ,security ,act which provided for medical assistance for such service on ,january #a1 #bjai4 7,b7 ,coordination between ,secretary and ,states ,the ,secretary shall coordinate with the directors of ,state agencies responsible for administering ,state plans under title ,,xix of the ,social ,security ,act to-- 7i7 identify services described in subparagraph 7,a77ii7 with respect to each ,state plan2 and 7ii7 ensure that such services continue to be made available under such plan4 7,c7 ,maintenance of effort requirement ,with respect to any service described in subparagraph 7,a77ii7 that is made available under a ,state plan under title ,,xix of the ,social ,security ,act1 the maintenance of effort requirements described in section #aidg7;c7 of such ,act 7related to eligibility standards and required expenditures7 shall apply to such service in the same manner that such requirements apply to institutional long-term care services 7as defined in section #aidg7;b7 of such ,act74 7b7 ,federal employees health benefits program ,no benefits shall be made available under chapter #hi of title #e1 ,united ,states ,code1 for any part of a coverage period occurring on or after the effective date4 7c7 ,,tricare ,no benefits shall be made available under sections #ajgi and #ajhf of title #aj1 ,united ,states ,code1 for items or services furnished on or after the effective date4 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 described in section #ajf1 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 ,x ,transition ,a ,transitional ,medicare ,buy-,in ,option and ,transitional ,public ,option #ajja4 ,lowering the ,medicare age 7a7 ,in general ,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 ,transitional ,medicare ,buy-,in ,option for ,certain ,individuals 7a7 ,option 7#a7 ,in general ,every individual who meets the requirements described in paragraph 7#c7 shall be eligible to enroll under this section4 7#b7 ,part ,a1 ,b1 and ,d benefits ,an individual enrolled under this section is entitled to the same benefits 7and shall receive the same protections7 under this title as an individual who is entitled to benefits under part ,a and enrolled under parts ,b and ,d1 including the ability to enroll in a ,medicare ,advantage plan that provides qualified prescription drug coverage 7an ,,ma-,,pd plan74 7#c7 ,requirements for eligibility ,the requirements described in this paragraph are the following3 7,a7 ,the individual is a resident of the ,united ,states4 7,b7 ,the individual is-- 7i7 a citizen or national of the ,united ,states2 or 7ii7 an alien lawfully admitted for permanent residence4 7,c7 ,the individual is not otherwise entitled to benefits under part ,a or eligible to enroll under part ,a or part ,b4 7,d7 ,the individual has attained the applicable years of age but has not attained #fe years of age4 7#d7 ,applicable years of age defined ,for purposes of this section1 the term applicable years of age means-- 7,a7 effective ,january #a of the first year following the date of enactment of the ,medicare for ,all ,act of #bjai1 the age of #ee2 7,b7 effective ,january #a of the second year following such date of enactment1 the age of #de2 and 7,c7 effective ,january #a of the third year following such date of enactment1 the age of #ce4 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 ,premium 7#a7 ,amount of monthly premiums ,the ,secretary shall1 during ,september of each year 7beginning with the first ,september following the date of enactment of the ,medicare for ,all ,act of #bjai71 determine a monthly premium for all individuals enrolled under this section4 ,such monthly premium shall be equal to #a_/ab of the annual premium computed under paragraph 7#b77;,b71 which shall apply with respect to coverage provided under this section for any month in the succeeding year4 7#b7 ,annual premium 7,a7 ,combined per capita average for all ,medicare benefits ,the ,secretary shall estimate the average1 annual per capita amount for benefits and administrative expenses that will be payable under parts ,a1 ,b1 and ,d 7including1 as applicable1 under part ,c7 in the year for all individuals enrolled under this section4 7,b7 ,annual premium ,the annual premium under this subsection for months in a year is equal to the average1 annual per capita amount estimated under subparagraph 7,a7 for the year4 7#c7 ,increased premium for certain part ,c and ,d plans ,nothing in this section shall preclude an individual from choosing a ,medicare ,advantage plan or a prescription drug plan which requires the individual to pay an additional amount 7because of supplemental benefits or because it is a more expensive plan74 ,in such case the individual would be responsible for the increased monthly premium4 7d7 ,payment of premiums 7#a7 ,in general ,premiums for enrollment under this section shall be paid to the ,secretary at such times1 and in such manner1 as the ,secretary determines appropriate4 7#b7 ,deposit ,amounts collected by the ,secretary under this section shall be deposited in the ,federal ,hospital ,insurance ,trust ,fund and the ,federal ,supplementary ,medical ,insurance ,trust ,fund 7including the ,medicare ,prescription ,drug ,account within such ,trust ,fund7 in such proportion as the ,secretary determines appropriate4 7e7 ,not eligible for ,medicare cost-,sharing assistance ,an individual enrolled under this section shall not be treated as enrolled under any part of this title for purposes of obtaining medical assistance for ,medicare cost-sharing or otherwise under title ,,xix4 7f7 ,treatment in relation to the ,affordable ,care ,act 7#a7 ,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 7#b7 ,eligibility for premium assistance ,coverage provided under this section-- 7,a7 shall be treated as coverage under a qualified health plan in the individual market enrolled in through the ,exchange where the individual resides for all purposes of section #cf;,b of the ,internal ,revenue ,code of #aihf other than subsection 7c77#b77;,b7 thereof2 and 7,b7 shall not be treated as eligibility for other minimum essential coverage for purposes of subsection 7c77#b77;,b7 of such section #cf;,b4 ,the ,secretary shall determine the applicable second lowest cost silver plan which shall apply to coverage under this section for purposes of section #cf;,b of such ,code4 7#c7 ,eligibility for cost-sharing subsidies ,for purposes of applying section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7-- 7,a7 coverage provided under this section shall be treated as coverage under a qualified health plan in the silver level of coverage in the individual market offered through an ,exchange2 and 7,b7 the ,secretary shall be treated as the issuer of such plan4 7g7 ,no effect on benefits for individuals otherwise eligible or on ,trust funds ,the ,secretary shall implement the provisions of this section in such a manner to ensure that such provisions-- 7#a7 have no effect on the benefits under this title for individuals who are entitled to1 or enrolled for1 such benefits other than through this section2 and 7#b7 have no negative impact on the ,federal ,hospital ,insurance ,trust ,fund or the ,federal ,supplementary ,medical ,insurance ,trust ,fund 7including the ,medicare ,prescription ,drug ,account within such ,trust ,fund74 7h7 ,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 plan 7a7 ,in general ,to carry out the purpose of this section1 for plan years beginning with the first plan year that begins after the date of enactment of this ,act and ending with the effective date described in section #ajf1 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 of a public health plan 7in this ,act referred to as the ,medicare ,transition plan7 that provides affordable1 high-quality health benefits coverage throughout the ,united ,states4 7b7 ,administrating the ,medicare transition 7#a7 ,administrator ,the ,administrator shall administer the ,medicare ,transition plan in accordance with this section4 7#b7 ,application of ,,aca requirements ,consistent with this section1 the ,medicare ,transition plan 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 plan 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 plan4 7c7 ,benefits2 actuarial value ,in carrying out this section1 the ,administrator shall ensure that the ,medicare ,transition plan provides-- 7#a7 coverage for the benefits required to be covered under title ,,ii2 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 plan1 the ,administrator shall reimburse such providers at rates determined for equivalent items and services under the original ,medicare fee-for-service program under parts ,a and ,b of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq474 ,for items and services covered under the ,medicare ,transition plan but not covered under such parts ,a and ,b1 the ,administrator shall reimburse providers at rates set by the ,administrator in a manner consistent with the manner in which rates for other items and services were set under the original ,medicare fee-for-service program4 7#b7 ,prescription drugs ,any payment rate under this subsection for a prescription drug shall be at a rate negotiated by the ,administrator with the manufacturer of the drug4 ,if the ,administrator is unable to reach a negotiated agreement on such a reimbursement rate1 the ,administrator shall establish the rate at an amount equal to the lesser of-- 7,a7 the price paid by the ,secretary of ,veterans ,affairs to procure the drug under the laws administered by the ,secretary of ,veterans ,affairs2 7,b7 the price paid to procure the drug under section #habf of title #ch1 ,united ,states ,code2 or 7,c7 the best price determined under section #aibg7;c77#a77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#h7;c77#a77;,c77 for the drug4 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 plan4 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 plan4 ,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 plan1 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 plan 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 #ajf4 7g7 ,tax credits and cost-,sharing subsidies 7#a7 ,premium assistance tax credits 7,a7 ,credits allowed to ,medicare ,transition plan enrollees at or above #dd percent of poverty 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 plan 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 plan 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 non-expansion ,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 plan 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 plan 7i7 ,in general ,subparagraph 7,a7 of section #cf;,b7b77#c7 of such ,code is amended-- 7,i7 by redesignating clause 7ii7 as clause 7iii72 7,,ii7 by striking clause 7ii7 in clause 7i7 and inserting clauses 7ii7 and 7iii72 and 7,,iii7 by inserting after clause 7i7 the following new clause3 7ii7 ,special rules for taxpayers enrolled in ,medicare ,transition plan ,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 plan 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#bb #ajj percent up to #ach percent#b4jdb4jd #ach percent up to #aej percent#c4jfd4jh #aej percent and above#d4jhe 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 plan 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 plan 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 plan1 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 7,c7 ,adjusted cost-sharing for ,medicare ,transition plan enrollees ,in the case of any individual who enrolls in such ,medicare ,transition plan1 in lieu of the percentages under subsection 7c77#a77;,b77i7 and 7c77#b71 the ,secretary shall prescribe a method of determining the cost-sharing reduction for any such individual such that the total of the cost-sharing and the premiums paid by the individual under such ,medicare ,transition plan does not exceed the percentage of the total allowed costs of benefits provided under the plan equal to the final premium percentage applicable to such individual under section #cf;,b7b77#c77;,a77ii7 of the ,internal ,revenue ,code of #aihf4 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 1 the ,medicare ,transition plan1 before and2 and 7,b7 by inserting ,the ,medicare ,transition plan1 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 plan1 before or a multi-,state qualified health plan4 ,b ,transitional ,medicare ,reforms #ajaa4 ,medicare protection against high out-of-pocket expenditures for fee-for-service benefits and elimination of parts ,a and ,b deductibles 7a7 ,protection against high out-of-,pocket expenditures ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 as amended by section #ajja1 is amended by adding at the end the following new section3 #ahii;,d4 ,protection ,against ,high ,out-of-,pocket ,expenditures 7a7 ,in general ,notwithstanding any other provision of this title1 in the case of an individual entitled to1 or enrolled for1 benefits under part ,a or enrolled in part ,b1 if the amount of the out-of-pocket cost-sharing of such individual for a year 7effective the year beginning ,january #a of the year following the date of enactment of the ,medicare for ,all ,act of #bjai7 equals or exceeds #a1ejj1 the individual shall not be responsible for additional out-of-pocket cost-sharing occurred during that year4 7b7 ,out-of-,pocket cost-,sharing defined 7#a7 ,in general ,subject to paragraphs 7#b7 and 7#c71 in this section1 the term out-of-pocket cost-sharing means1 with respect to an individual1 the amount of the expenses incurred by the individual that are attributable to-- 7,a7 coinsurance and copayments applicable under part ,a or ,b2 or 7,b7 for items and services that would have otherwise been covered under part ,a or ,b but for the exhaustion of those benefits4 7#b7 ,certain costs not included 7,a7 ,non-covered items and services ,expenses incurred for items and services which are not included 7or treated as being included7 under part ,a or ,b shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph 7#a74 7,b7 ,items and services not furnished on an assignment-related basis ,if an item or service is furnished to an individual under this title and is not furnished on an assignment-related basis1 any additional expenses the individual incurs above the amount the individual would have incurred if the item or service was furnished on an assignment-related basis shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph 7#a74 7#c7 ,source of payment ,for purposes of paragraph 7#a71 the ,secretary shall consider expenses to be incurred by the individual without regard to whether the individual or another person1 including a ,state program or other third-party coverage1 has paid for such expenses4 4 7b7 ,elimination of parts ,a and ,b deductibles 7#a7 ,part ,a ,section #ahac7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;e7b77 is amended by adding at the end the following new paragraph3 7#d7 ,for each year 7beginning ,january #a of the year following the date of enactment of the ,medicare for ,all ,act of #bjai71 the inpatient hospital deductible for the year shall be #j4 4 7#b7 ,part ,b ,section #ahcc7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7b77 is amended1 in the first sentence-- 7,a7 by striking and for a subsequent year and inserting for each of #bjjf through the year that includes the date of enactment of the ,medicare for ,all ,act of #bjai2 and 7,b7 by inserting 1 and #j for each year subsequent year after #a74 #ajab4 ,reduction in ,medicare part ,d annual out-of-pocket threshold and elimination of cost-sharing above that threshold 7a7 ,reduction ,section #ahfj;,d-#b7;b77#d77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;b77#d77;,b77 is amended-- 7#a7 in clause 7i71 by striking ,for purposes and inserting ,subject to clause 7iii71 for purposes2 and 7#b7 by adding at the end the following new clause3 7iii7 ,reduction in threshold during transition period 7,i7 ,in general ,subject to subclause 7,,ii71 for plan years beginning on or after ,january #a following the date of enactment of the ,medicare for ,all ,act of #bjai and before ,january #a of the year that is #d years following such date of enactment1 notwithstanding clauses 7i7 and 7ii71 the annual out-of-pocket threshold specified in this subparagraph is equal to #cje4 7,,ii7 ,authority to exempt brand-name drugs if generic available ,in applying subclause 7,i71 the ,secretary may exempt costs incurred for a covered part ,d drug that is an applicable drug under section #ahfj;,d-#ad;,a7g77#b7 if the ,secretary determines that a generic version of that drug is available4 4 7b7 ,elimination of cost-,sharing ,section #ahfj;,d-#b7;b77#d77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;b77#d77;,a77 is amended-- 7#a7 in clause 7i7-- 7,a7 by redesignating subclauses 7,i7 and 7,,ii7 as items 7aa7 and 7bb71 respectively2 7,b7 by striking subparagraph 7,b71 with cost-sharing and inserting the following3 8subparagraph 7,b7-- 7,i7 for plan years #bjjf through the plan year ending ,december #ca following the date of enactment of the ,medicare for ,all ,act of #bjai1 with cost-sharing 2 7,c7 in item 7bb71 as redesignated by subparagraph 7,a71 by striking the period at the end and inserting 2 and2 and 7,d7 by adding at the end the following new subclause3 7,,ii7 for the plan year beginning ,january #a following the date of enactment of the ,medicare for ,all ,act of #bjai and the two subsequent plan years1 without any cost-sharing4 2 and 7#b7 in clause 7ii7-- 7,a7 by striking clause 7i77,i7 and inserting clause 7i77,i77aa72 and 7,b7 by adding at the end the following new sentence3 ,the ,secretary shall continue to calculate the dollar amounts specified in clause 7i77,i77aa71 including with the adjustment under this clause1 after plan year #bjah for purposes of #ahfj;,d-#ad7;a77#a77;,d77iii744 7c7 ,conforming amendments to low-,income subsidy ,section #ahfj;,d-#ad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,d77iii71 by striking #ahfj;,d-#b7;b77#d77;,a77i77,i7 and inserting #ahfj;,d-#b7;b77#d77;,a77i77,i77aa72 and 7,b7 in subparagraph 7,e7-- 7i7 in the heading1 by inserting prior to the elimination of such cost-sharing for all individuals after threshold2 and 7ii7 by striking ,the elimination and inserting ,for plan years #bjjf through the plan year ending ,december #ca following the date of enactment of the ,medicare for ,all ,act of #bjai1 the elimination2 and 7#b7 in paragraph 7#b77;,e7-- 7,a7 in the heading1 by inserting prior to the elimination of such cost-sharing for all individuals after threshold2 7,b7 by striking ,subject to and inserting ,for plan years #bjjf through the plan year ending ,december #ca following the date of enactment of the ,medicare for ,all ,act of #bjai1 subject to2 and 7,c7 by striking #ahfj;,d-#b7;b77#d77;,a77i77,i7 and inserting #ahfj;,d-#b7;b77#d77;,a77i77,i77aa74 #ajac4 ,coverage of dental and vision services and hearing aids and examinations under ,medicare part ,b 7a7 ,dental services 7#a7 ,removal of exclusion from coverage ,section #ahfb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is amended by striking paragraph 7#ab74 7#b7 ,coverage 7,a7 ,in general ,section #ahfa7s77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77 is amended-- 7i7 in subparagraph 7,,gg71 by striking and at the end2 7ii7 in subparagraph 7,,hh71 by striking the period at the end and inserting 2 and2 and 7iii7 by adding at the end the following new subparagraph3 7,,ii7 dental services2 4 7,b7 ,payment ,section #ahcc7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is amended-- 7i7 by striking and before 7,,cc72 and 7ii7 by inserting before the semicolon at the end the following3 1 and 7,,dd7 with respect to dental services described in section #ahfa7s77#b77;,,ii71 the amount paid shall be an amount equal to #hj percent of the lesser of the actual charge for the services or the amount determined under the fee schedule established under section #ahdh7;b744 7,c7 ,effective date ,the amendments made by this subsection shall apply to items and services furnished on or after ,january #a following the date of the enactment of this ,act4 7b7 ,vision services 7#a7 ,in general ,section #ahfa7s77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b771 as amended by subsection 7a71 is amended-- 7,a7 in subparagraph 7,,hh71 by striking and at the end2 7,b7 in subparagraph 7,,ii71 by inserting and at the end2 and 7,c7 by adding at the end the following new subparagraph3 7,,jj7 vision services2 4 7#b7 ,payment ,section #ahcc7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a771 as amended by subsection 7a71 is amended-- 7,a7 by striking and before 7,,dd72 and 7,b7 by inserting before the semicolon at the end the following3 1 and 7,,ee7 with respect to vision services described in section #ahfa7s77#b77;,,jj71 the amount paid shall be an amount equal to #hj percent of the lesser of the actual charge for the services or the amount determined under the fee schedule established under section #ahdh7;b744 7#c7 ,effective date ,the amendments made by this subsection shall apply to items and services furnished on or after ,january #a following the date of the enactment of this ,act4 7c7 ,hearing aids and examinations therefor 7#a7 ,in general ,section #ahfb7;a77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77#g77 is amended by striking hearing aids or examinations therefor14 7#b7 ,effective date ,the amendment made by this subsection shall apply to items and services furnished on or after ,january #a following the date of the enactment of this ,act4 #ajad4 ,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 ,january #a of the year that is #d years after such date of enactment4 #ajae4 ,guaranteed issue of ,medigap policies ,section #ahhb of the ,social ,security ,act 7#db ,u4,s4,c4 #aciess7 is amended by adding at the end the following new subsection3 7aa7 ,guaranteed issue for all ,medigap-,eligible ,medicare beneficiaries ,notwithstanding paragraphs 7#b77;,a7 and 7#b77;,d7 of subsection 7s7 or any other provision of this section1 on or after the date of enactment of this subsection1 the issuer of a medicare supplemental policy may not deny or condition the issuance or effectiveness of a medicare supplemental policy1 or discriminate in the pricing of the policy1 because of health status1 claims experience1 receipt of health care1 or medical condition in the case of any individual entitled to1 or enrolled for1 benefits under part ,a and enrolled for benefits under part ,b4 4 ,c ,private ,health ,insurance ,availability ,during ,transitional ,period #ajba4 ,continuity of care 7a7 ,in general ,the ,secretary shall ensure that all individuals enrolled in1 or who seek to enroll in1 a group health plan1 health insurance coverage offered by a health insurance issuer1 or the plan established under section #ajjb during the transition period of this ,act are protected from disruptions in their care during the transition period4 7b7 ,public consultation during transition ,the ,secretary shall consult with communities and advocacy organizations of individuals living with disabilities and other patient advocacy organizations to ensure the transition described in this section takes into account the continuity of care for individuals with disabilities1 complex medical needs1 or chronic conditions4 7c7 ,definitions ,in this section1 the terms health insurance coverage1 health insurance issuer1 and group health plans have the meanings given such terms in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 ,,xi ,miscellaneous #aaja4 ,updating resource limits for ,supplemental ,security ,income eligibility 7,,ssi7 ,section #afaa7;a77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #achb7;a77#c77 is amended-- 7#a7 in subparagraph 7,a7-- 7,a7 by striking and after ,january #a1 #aihh12 and 7,b7 by inserting 1 and to #f1bjj on ,january #a1 #bjai before the period2 7#b7 in subparagraph 7,b7-- 7,a7 by striking and after ,january #a1 #aihh12 and 7,b7 by inserting 1 and to #d1ajj on ,january #a1 #bjai before the period2 and 7#c7 by adding at the end the following new subparagraph3 7,c7 ,beginning with ,december of #bjai1 whenever the dollar amounts in effect under paragraphs 7#a77;,a7 and 7#b77;,a7 of this subsection are increased for a month by a percentage under section #afag7;a77#b71 each of the dollar amounts in effect under this paragraph shall be increased1 effective with such month1 by the same percentage 7and rounded1 if not a multiple of #aj1 to the closest multiple of #aj74 ,each increase under this subparagraph shall be based on the unrounded amount for the prior #ab-month period4 4 #aajb4 ,definitions ,in this ,act-- 7#a7 the term ,secretary means the ,secretary of ,health and ,human ,services2 7#b7 the term ,state means a ,state1 the ,district of ,columbia1 or a territory of the ,united ,states2 and 7#c7 the term ,united ,states shall include the ,states1 the ,district of ,columbia1 and the territories of the ,united ,states4