,,ii #aaith ,,congress #ast ,session ,s4 #ccfi ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #d1 #bjbe,mr4 ,bennet 7for himself1 ,mr4 ,kaine1 ,mr4 ,booker1 ,ms4 ,duckworth1 ,ms4 ,smith1 ,mr4 ,warnock1 ,mr4 ,hickenlooper1 and ,ms4 ,klobuchar7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to establish a public health plan4 #a4 ,short title ,this ,act may be cited as the ,medicare-,x ,choice ,act of #bjbe4 #b4 ,establishment and administration of a public health plan ,the ,social ,security ,act is amended by adding at the end the following new title3 ,,xxii ,medicare ,exchange ,health ,plan #bbja4 ,establishment 7a7 ,establishment of plan 7#a7 ,in general ,the ,secretary shall establish a coordinated and low-cost health plan1 to be known as the ,medicare ,exchange health plan 7referred to in this section as the health plan7 to provide access to quality health care for enrollees4 7#b7 ,timeframe 7,a7 ,individual market availability ,the ,secretary shall make the health plan available in the individual market1 in all rating areas1 for plan year #bjbh and each subsequent plan year4 7,b7 ,small group market ,the ,secretary shall make the health plan available in the small group market1 in all rating areas1 for plan year #bjbh and each subsequent plan year4 7b7 ,establishment of funds 7#a7 ,plan ,reserve ,fund 7,a7 ,in general ,there is established in the ,treasury of the ,united ,states a ,plan ,reserve ,fund1 to be administered by the ,secretary of ,health and ,human ,services1 for purposes of establishing the ,medicare ,exchange health plan and administering such plan1 consisting of amounts appropriated to such fund during the period of fiscal years #bjbg through #bjcf4 7,b7 ,appropriation ,there is appropriated #a1jjj1jjj1jjj1 out of monies in the ,treasury not otherwise obligated1 to the ,plan ,reserve ,fund for fiscal year #bjbg1 to remain available until expended4 7#b7 ,data and ,technology ,fund 7,a7 ,in general ,there is established in the ,treasury of the ,united ,states a ,data and ,technology ,fund1 to be administered by the ,secretary of ,health and ,human ,services1 acting through the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services1 for purposes of updating technology and performing data collection under section #bbje in order to establish appropriate premiums for all geographic regions of the ,united ,states1 consisting of amounts appropriated to such fund during the period of fiscal years #bjbg through #bjcf4 7,b7 ,appropriation ,there is appropriated #a1jjj1jjj1jjj1 out of amounts in the ,treasury not otherwise appropriated1 to the ,data and ,technology ,fund for fiscal year #bjbg1 to remain available until expended4 7c7 ,rulemaking ,not later than #ahj days after the date of enactment of the ,medicare-,x ,choice ,act of #bjbe1 the ,secretary shall promulgate such regulations as may be necessary to carry out this title4 ,rules promulgated under this subsection shall be finalized not later than #bgj days after the date of enactment of the ,medicare-,x ,choice ,act of #bjbe4 #bbjb4 ,availability of plan 7a7 ,eligibility ,an individual shall be eligible to enroll in the health plan if such individual1 for the entire period for which enrollment is sought-- 7#a7 is a qualified individual within the meaning of section #acab of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjcb72 and 7#b7 is not eligible for benefits under the ,medicare program under title ,,xviii4 7b7 ,exchanges ,in accordance with the timeframe under section #bbja7;a77#b71 the health plan shall be made available through the ,american ,health ,benefit ,exchanges described in sections #acaa and #acba of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca1 #ahjda71 including the ,small ,business ,health ,options ,program ,exchange4 #bbjc4 ,plan requirements 7a7 ,general requirements ,the health plan shall comply with all requirements1 as applicable1 of subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act and title ,,xxvii of the ,public ,health ,service ,act applicable to qualified health plans1 and such health plan shall be a qualified health plan1 including for purposes of the ,internal ,revenue ,code of #aihf4 7b7 ,levels of coverage ,the ,secretary-- 7#a7 shall make available a silver level and gold level version of the plan1 in accordance with section #acja7;a77#a77;,c77ii7 of the ,patient ,protection and ,affordable ,care ,act2 and 7#b7 may make available no more than #b versions of the plan for each of the #d levels of coverage described in subparagraphs 7,a7 through 7,d7 of section #acjb7;d77#a7 of the ,patient ,protection and ,affordable ,care ,act4 7c7 ,primary care services ,the health plan shall provide coverage for primary care services1 and shall not impose any cost-sharing requirements for such services4 #bbjd4 ,administrative contracting 7a7 ,in general ,the ,secretary may enter into contracts for the purpose of performing administrative functions 7including functions described in subsection 7a77#d7 of section #ahgd;,a7 with respect to the health plan in the same manner as the ,secretary may enter into contracts under subsection 7a77#a7 of such section4 ,the ,secretary shall have the same authority with respect to the public health insurance option as the ,secretary has under such subsection 7a77#a7 and subsection 7b7 of section #ahgd;,a with respect to title ,,xviii4 7b7 ,transfer of insurance risk ,any contract under subsection 7a7 shall not involve the transfer of insurance risk from the ,secretary to the entity entering into such contract with the ,secretary1 except in the case of an alternative payment model under section #bbji7;h74 #bbje4 ,data collection ,subject to all applicable privacy requirements1 including the requirements under the regulations promulgated pursuant to section #bfd7;c7 of the ,health ,insurance ,portability and ,accountability ,act of #aiif 7#db ,u4,s4,c4 #acbj;d-#b note71 the ,secretary may collect data from ,state insurance commissioners and other relevant entities to establish rates for premiums and for other purposes1 including to improve quality1 and reduce racial1 ethnic1 socioeconomic1 geographic1 gender1 sexual identity1 and other health disparities1 including such disparities experienced by people with disabilities and older adults1 with respect to the health plan4 #bbjf4 ,premiums2 risk pool 7a7 ,setting premiums 7#a7 ,in general ,the ,secretary shall establish premiums for the health plan that cover the full actuarial cost of offering such plan1 including the administrative costs of offering such plan4 ,such premiums shall vary geographically and between the small group market and the individual market in accordance with differences in the cost of providing such coverage4 ,if1 for any plan year1 the amount collected in premiums exceeds the amount required for health care benefits and administrative costs in that plan year1 such excess amounts shall remain available to the ,secretary to administer the health plan and finance beneficiary costs in subsequent years4 7#b7 ,initial plan year ,for plan year #bjbh1 the ,secretary shall set premiums for the health plan for each rating area in which the health plan is available for such plan year1 taking into consideration the premium rates for plans offered in each such rating area for plan year #bjbg4 7b7 ,risk pool ,after plan year #bjbh1 all enrollees in the health plan within a ,state shall be members of a single risk pool1 except that the ,secretary may establish separate risk pools for the individual market and small group market if the ,state has not exercised its authority under section #acab7;c77#c7 of the ,patient ,protection and ,affordable ,care ,act4 #bbjg4 ,reimbursement rates 7a7 ,medicare rates 7#a7 ,in general ,except as provided in paragraph 7#b7 and subsections 7b7 and 7c7 and subject to subsection 7d71 the ,secretary shall reimburse health care providers furnishing items and services under the health plan at rates determined for equivalent items and services under the original ,medicare fee-for-service program under parts ,a and ,b of title ,,xviii4 7#b7 ,authority to increase payments rates in rural areas ,if the ,secretary determines appropriate1 the ,secretary may increase the reimbursements rates described in paragraph 7#a7 by up to #ej percent for items and services furnished in rural areas 7as defined in section #ahhf7;d77#b77;,d774 7b7 ,prescription drugs ,subject to subsection 7d71 payment rates for prescription drugs shall be at a rate negotiated by the ,secretary4 ,such negotiations may be in conjunction with negotiations for selected drugs under part ,e of title ,,xi4 7c7 ,additional items and services ,subject to subsection 7d71 the ,secretary shall establish reimbursement rates for any items and services provided under the health plan that are not items and services provided under the original ,medicare fee-for-service program under parts ,a and ,b of title ,,xviii4 7d7 ,innovative payment methods ,the ,secretary may utilize innovative payment methods1 including value-based payment arrangements1 in making payments for items and services 7including prescription drugs7 furnished under the health plan4 7e7 ,comprehensive study on covering additional services 7#a7 ,in general ,the ,secretary1 acting through the ,administrator of the ,centers for ,medicare ,medicaid ,services1 shall conduct a comprehensive study1 in consultation with stakeholders1 and develop recommendations for ,congress on the need for1 and cost of providing coverage for1 additional services under the health plan4 7#b7 ,content ,the study shall under paragraph 7#a7 shall include-- 7,a7 consideration of providing coverage for long-term services and supports1 home and community based services1 assistive and enabling technologies1 and vision1 hearing1 and dental services2 7,b7 consideration of providing coverage for other services in addition to the services described in subparagraph 7,a7 that could most benefit the health and financial well-being of beneficiaries1 including by reducing health disparities1 if included for coverage under the plan2 7,c7 the costs associated with covering additional services described in subparagraphs 7,a7 and 7,b71 for beneficiaries through cost-sharing and premiums1 and for the ,federal ,government2 and 7,d7 an assessment of the implications of covering such additional services for the risk pool of the health plan and for the individual and small group markets4 7#c7 ,submission of report ,not later than #b years after the date of enactment of this title1 the ,secretary shall submit to ,congress a report on the findings and recommendations of the study under this subsection and shall make such report publicly available on the website of the ,department of ,health and ,human ,services4 #bbjh4 ,participating providers 7a7 ,requirement ,to participate in order ,to be enrolled under ,medicare ,subject to subsection 7d71 beginning ,january #a1 #bjbh1 a health care provider may not be enrolled under the ,medicare program under section #ahff7;j7 unless the provider is also a participating provider under the health plan4 7b7 ,requirement ,to participate in order ,to participate in ,medicaid ,subject to subsection 7d71 beginning ,january #a1 #bjbh1 a health care provider may not be a participating provider under a ,state ,medicaid plan under title ,,xix 7or a waiver of such a plan7 unless the provider is also a participating provider under the health plan4 7c7 ,additional providers ,the ,secretary shall establish a process to allow health care providers not described in subsection 7a7 or 7b7 to become a participating provider under the health plan4 7d7 ,opt-,out ,the ,secretary shall establish a process by which a health care provider described in subsection 7a7 or 7b7 may opt out of being a participating provider under the health plan1 under exceptional circumstances where participation in the health plan threatens the provider's ability to operate4 #bbji4 ,delivery system reform for an enhanced health plan 7a7 ,in general ,for plan years beginning with plan year #bjbh1 the ,secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the health plan4 ,the payment mechanisms and policies under this section may include patient-centered medical home and other care management payments1 accountable care organizations1 accountable communities for health1 value-based purchasing1 bundling of services1 differential payment rates1 performance or utilization based payments1 telehealth1 remote patient monitoring1 partial capitation1 and direct contracting with providers4 7b7 ,requirements for innovative payments ,the ,secretary shall design and implement the payment mechanisms and policies under this section in a manner that-- 7#a7 seeks to-- 7,a7 improve health outcomes2 7,b7 reduce health disparities 7including racial1 ethnic1 socioeconomic1 geographic1 gender1 sexual identity1 and other disparities1 including such disparities experienced by people with disabilities and older adults72 7,c7 improve coordination to provide more efficient and affordable quality care2 7,d7 address geographic variation in the provision of health services2 or 7,e7 prevent or manage chronic illness2 7#b7 promotes care that is integrated1 patient-centered1 quality1 and efficient2 7#c7 implements patient feedback mechanisms1 including culturally- and disability-competent mechanisms2 and 7#d7 uses person-reported experiences to improve service delivery4 7c7 ,encouraging the use of high-,value services ,to the extent allowed by the benefit standards applied to all health benefits plans participating in the ,exchanges 7as described in section #bbjb7;b771 the health plan may modify cost-sharing and payment rates to encourage the use of services that promote health and value4 7d7 ,promotion of delivery system reform ,the ,secretary shall monitor and evaluate the progress of payment and delivery system reforms under this section and shall seek to implement such reforms subject to the following3 7#a7 ,to the extent that the ,secretary finds a payment and delivery system reform successful in improving quality and reducing costs1 the ,secretary shall implement such reform on as large a geographic scale as practical and economical4 7#b7 ,the ,secretary may delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage4 7#c7 ,the ,secretary may prioritize implementation of such a reform in high-cost geographic areas or otherwise in order to reduce total program costs or to promote high-value care4 7#d7 ,the ,secretary may prioritize implementation of such a reform to reduce racial1 ethnic1 socioeconomic1 geographic1 gender1 sexual identity1 or other health disparities1 including such disparities experienced by people with disabilities or older adults4 7e7 ,non-,uniformity permitted ,nothing in this section shall prevent the ,secretary from varying payments based on different payment structure models 7such as accountable care organizations and medical homes7 under the health plan for different geographic areas4 7f7 ,integration with social services 7#a7 ,in general ,the ,secretary shall establish processes and1 when appropriate1 collaborate with other agencies to integrate medical care under the health plan with food1 housing1 transportation1 and income assistance if the ,secretary determines that such integration is expected to-- 7,a7 reduce spending without reducing the quality of patient care2 7,b7 improve the quality of patient care without increasing spending2 or 7,c7 reduce racial1 ethnic1 socioeconomic1 geographic1 gender1 sexual identity1 or other health disparities1 including any such disparities experienced by people with disabilities or older adults4 7#b7 ,authorization of a grant program 7,a7 ,in general ,the ,secretary may establish a grant program to permit broader experimentation with accountable communities for health model4 7,b7 ,eligible recipients ,the ,secretary may award a grant under this section to-- 7i7 an institution of higher learning 7as defined in section #cdeb7;f7 of title #ch1 ,united ,states ,code72 7ii7 a local educational agency 7as defined in section #haja of the ,elementary and ,secondary ,education ,act of #aife72 7iii7 a health care agency2 7iv7 a nonprofit entity that the ,secretary determines has a demonstrated history of community engagement2 or 7v7 any other entity1 as the ,secretary determines appropriate4 7,c7 ,use of funds ,a recipient of a grant under this section may use the grant to-- 7i7 support community needs assessment2 7ii7 establish social service partnerships2 or 7iii7 establish interactive data systems across health and social service providers4 7,d7 ,authorization of appropriations ,there are authorized to be appropriated such sums as may be necessary to carry out this paragraph4 7#c7 ,regulations ,if the ,secretary establishes a grant program under this section1 the ,secretary shall promulgate regulations on-- 7,a7 the evaluation of applications for grants under the program2 and 7,b7 administration of the program4 7g7 ,telehealth ,the ,secretary shall ensure the integration of telehealth tools1 including technology-enabled collaborative learning and capacity building models1 that increase patient access to medical care 7including specialty care71 particularly in remote or underserved areas1 if the ,secretary determines that such integration is expected to-- 7#a7 reduce spending without reducing the quality of patient care2 or 7#b7 improve the quality of patient care without increasing spending4 7h7 ,alternative payment model 7#a7 ,in general ,the ,secretary shall evaluate the possibility of providing incentives1 and1 if appropriate1 apply incentives1 for enrollees in the health plan who receive services from providers who are participating in an alternative payment model 7as defined in section #ahcc7z77#c77;,c774 7#b7 ,authority to use apms in use under traditional ,medicare ,nothing in this section shall preclude the ,secretary from using alternative payment models 7as so defined7 under this title that are in use under title ,,xviii4 #bbaj4 ,no effect on ,medicare benefits or ,medicare ,trust ,funds ,nothing in this title shall-- 7#a7 affect the benefits available under title ,,xviii2 or 7#b7 impact the ,federal ,hospital ,insurance ,trust ,fund under section #ahag or the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda 7including the ,medicare ,prescription ,drug ,account within such ,trust ,fund74 4 #c4 ,exclusion of providers that place additional restrictions on ,medicare exchange health plan patients from ,federal health care programs ,section #aabh7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g7;b77 is amended by adding at the end the following new paragraph3 7#ah7 ,placement of restrictions on ,medicare ,exchange health plan patients ,any individual or entity that places restrictions on the individuals the individual or provider will accept for treatment and fails to either-- 7,a7 exempt enrollees in the ,medicare ,exchange health plan established under title ,,xxii from such restrictions2 or 7,b7 apply such restrictions to enrollees in the ,medicare ,exchange health plan in the same manner and to the same extent the restrictions are applied to all other individuals seeking care4 4 #d4 ,reinsurance 7a7 ,in general ,the ,secretary of ,health and ,human ,services shall establish a mechanism to pool1 on a nationwide basis1 the costs of the highest-cost patients enrolled in individual health insurance coverage 7as defined in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia77 offered on or off the ,exchanges1 to the extent such costs are not already pooled pursuant to section #acdc of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjfc71 for the purpose of reducing premiums for such individual health insurance coverage4 7b7 ,authorization of appropriations ,for purposes of carrying out paragraph 7#a71 there is authorized to be appropriated #aj1jjj1jjj1jjj for each of fiscal years #bjbh1 #bjbi1 and #bjcj4 #e4 ,expansion of tax credit 7a7 ,in general ,subparagraph 7,a7 of section #cf;,b7c77#a7 of the ,internal ,revenue ,code of #aihf is amended by striking but does not exceed #djj percent4 7b7 ,applicable percentages ,section #cf;,b7b77#c77;,a7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7,a7 ,applicable percentage ,the applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase1 on a sliding scale in a linear manner1 from the initial premium percentage to the final premium percentage specified in such table for such income tier3 ,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 #aej percent#jjaej percent up to #bjj percent#jb4jbjj percent up to #bej percent#b4jd4jbej percent up to #cjj percent#d4jf4jcjj percent up to #djj percent#f4jh4edjj percent and up#h4eh4e4 4 7c7 ,limitation on recapture ,clause 7i7 of section #cf;,b7f77#b77;,b7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking ,in the case of a taxpayer and all that follows through the amount of the increase and inserting ,the amount of the increase2 7#b7 by striking the period at the end of the last row of the table2 and 7#c7 by adding at the end of the table the following new row3 #djj percent and up#e1jjj4 4 7d7 ,fixing the family glitch 7#a7 ,in general ,clause 7i7 of section #cf;,b7c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7i7 ,coverage must be affordable 7,i7 ,employees ,an employee shall not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employer-sponsored plan 7as defined in section #ejjj;,a7f77#b77 and the employee's required contribution 7within the meaning of section #ejjj;,a7e77#a77;,b77 with respect to the plan exceeds #i4e percent of the employee's household income4 7,,ii7 ,family members ,an individual who is eligible to enroll in an eligible employer-sponsored plan 7as defined in section #ejjj;,a7f77#b77 by reason of a relationship the individual bears to the employee shall not be treated as eligible for minimum essential coverage by reason of such eligibility to enroll if the employee's required contribution 7within the meaning of section #ejjj;,a7e77#a77;,b71 determined by substituting family for self-only7 with respect to the plan exceeds #i4e percent of the employee's household income4 4 7#b7 ,conforming amendments 7,a7 ,clause 7ii7 of section #cf;,b7c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended by striking ,except as provided in clause 7iii71 an employee and inserting ,an individual4 7,b7 ,clause 7iii7 of section #cf;,b7c77#b77;,c7 of such ,code is amended by striking the last sentence of clause 7i7 and inserting clause 7i77,,ii74 7,c7 ,clause 7iv7 of section #cf;,b7c77#b77;,c7 of such ,code is amended by striking the #i4e percent under clause 7i77,,ii7 and inserting the #i4e percent under clauses 7i77,i7 and 7i77,,ii74 7e7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #f4 ,authority to negotiate fair prices for ,medicare prescription drugs 7a7 ,in general ,section #ahfj;,d-#aa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aaa7 is amended by striking subsection 7i74 7b7 ,effective date ,the amendment made by this section shall take effect on the date of enactment of this ,act4 #g4 ,strengthening antitrust enforcement in health care markets ,there are authorized to be appropriated for the purpose of studying health care markets1 including anticompetitive practices within those markets1 and taking appropriate antitrust enforcement action for each of fiscal years #bjbg through #bjca1 to remain available until expended-- 7#a7 #ej1jjj1jjj to the ,antitrust ,division of the ,department of ,justice2 and 7#b7 #ajj1jjj1jjj to the ,federal ,trade ,commission4 #h4 ,reports ,the ,antitrust ,division of the ,department of ,justice and the ,federal ,trade ,commission shall submit to ,congress a report-- 7#a7 not later than the date that is #a year after the date of enactment of this ,act1 detailing the activities on which the ,antitrust ,division or the ,commission spent funds authorized under section #g2 and 7#b7 not later than ,september #cj1 #bjcb1 that includes-- 7,a7 the findings of any study conducted by the ,antitrust ,division or the ,commission on or after the date of enactment of this ,act2 7,b7 the activities on which the ,antitrust ,division or the ,commission spent funds authorized under section #g2 and 7,c7 the impact of any enforcement action taken on or after the date of enactment of this ,act by the ,antitrust ,division or the ,commission on improving consumer access to affordable health care4