[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10526 Introduced in House (IH)]
<DOC>
118th CONGRESS
2d Session
H. R. 10526
To amend the Social Security Act to establish a Medicare for America
health program to provide for comprehensive health coverage for all
Americans.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 19, 2024
Ms. DeLauro (for herself and Ms. Schakowsky) introduced the following
bill; which was referred to the Committee on Ways and Means, and in
addition to the Committees on Energy and Commerce, the Judiciary,
Natural Resources, Education and the Workforce, and House
Administration, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend the Social Security Act to establish a Medicare for America
health program to provide for comprehensive health coverage for all
Americans.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare for
America Act of 2024''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--TRANSITIONING TO AND ESTABLISHING MEDICARE FOR AMERICA
Subtitle A--Transitional Public Health Option
Sec. 101. Establishment.
Sec. 102. Eligibility.
Sec. 103. Benefits.
Sec. 104. Premiums.
Sec. 105. Providers and reimbursement rates.
Sec. 106. Account; funding.
Subtitle B--Medicare for America
Sec. 111. Establishment and administration of Medicare for America.
Sec. 112. Modifications to and coordination with existing Federal
health programs.
Subtitle C--Targeted Reforms
Sec. 121. Limitation on removal of Medicare Advantage providers by MA
organizations.
Sec. 122. Network adequacy.
Sec. 123. Eliminating the 24-month waiting period for Medicare coverage
for individuals with disabilities.
Sec. 124. Eliminating the waiting period for individuals on State
Medicaid waiting lists.
Sec. 125. Employer health plan options.
Sec. 127. Medicare outpatient observation services.
Sec. 128. Abortion coverage.
Sec. 129. Applicability of mental health parity.
Sec. 130. Student loan forgiveness for health care providers
participating in Medicare for America.
Sec. 131. Clarification of the definition of pediatric medical
necessity in qualifying group coverage.
Sec. 132. Safe staffing requirements.
Sec. 133. Enhancements for reduced cost-sharing.
Sec. 134. Repeal of bonus payments for Medicare Advantage plans.
TITLE II--TAX PROVISIONS
Sec. 201. Sunset of Public Law 115-97.
Sec. 202. Surtax.
Sec. 203. Basis of property acquired from a decedent.
Sec. 204. Medicare payroll tax.
Sec. 205. Net investment income tax.
Sec. 206. Termination of deduction for contributions to health savings
accounts.
Sec. 207. Increase in excise tax on small cigars and cigarettes and
other tobacco products.
Sec. 208. Excise tax on alcohol.
Sec. 209. Tax on sugared drinks.
Sec. 210. Repeal of excise tax on high-cost employer-sponsored health
coverage.
TITLE III--DRUG-RELATED PROVISIONS
Sec. 301. Establishment of the Prescription Drug and Medical Device
review Board.
Sec. 302. Membership; staff.
Sec. 303. Prohibition against excessive price.
Sec. 304. Enforcement provisions.
Sec. 305. Authority.
Sec. 306. Regulations.
Sec. 307. Report to Federal agencies.
Sec. 308. Definitions.
Sec. 309. Moratorium on direct-to-consumer drug advertising.
Sec. 310. Reporting on justification for drug price increases.
TITLE IV--OUTCOMES AND REPORTING
Sec. 401. Sense of Congress.
Sec. 402. Evaluation of bill's outcome.
TITLE I--TRANSITIONING TO AND ESTABLISHING MEDICARE FOR AMERICA
Subtitle A--Transitional Public Health Option
SEC. 101. ESTABLISHMENT.
The Secretary of Health and Human Services (in this subtitle
referred to as the ``Secretary'') shall establish a public health plan
option that is offered in the individual market through the Federal and
State Exchanges under title I of the Patient Protection and Affordable
Care Act to eligible individuals for plan years 2025 and 2026 in
accordance with this subtitle.
SEC. 102. ELIGIBILITY.
Subject to subsection (b), an individual is eligible to enroll in
such public health plan option if the individual is otherwise eligible
to purchase individual health insurance coverage through an Exchange
and the individual resides in a rating area in which the Secretary
makes the public health plan option available.
SEC. 103. BENEFITS.
(a) In General.--The public health plan option shall be a qualified
health plan within the meaning of section 1301(a) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18021(a)) that--
(1) meets all requirements applicable to qualified health
plans under subtitle D of title I of the Patient Protection and
Affordable Care Act (other than the requirement under section
1301(a)(1)(C)(ii) of such Act (42 U.S.C. 18021(a)(1)(C)(ii)))
and title XXVII of the Public Health Service Act;
(2) provides coverage of the essential health benefits
described in section 1302(b) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18022(b));
(3) provides silver and gold-level coverage described in
section 1302(d)(1)(C) of the Patient Protection and Affordable
Care Act (42 U.S.C. 18022(d)(1)(C)); and
(4) provides coverage of comprehensive reproductive health
services, including abortion.
(b) Preemption.--Notwithstanding section 1303(a)(1) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18023(a)(1))--
(1) a State may not prohibit the public health plan option
from offering the coverage described in subsection (a)(4); and
(2) no State law that would prohibit such a plan from
offering such coverage shall apply to such plan.
SEC. 104. PREMIUMS.
(a) In General.--The Secretary shall establish premium rates for
the public health plan option that--
(1) are adjusted based on the applicable rating area;
(2) are at a level sufficient to fully finance--
(A) the costs of health benefits provided by such
plans; and
(B) administrative costs related to operating the
plans;
(3) comply with the requirements under section 2701 of the
Public Health Service Act (42 U.S.C. 300gg); and
(4) ensure that no individual or household will pay more
than 8 percent of adjusted gross monthly income toward the
monthly premium.
(b) Federal Subsidies.--Federal subsidies shall be provided to
ensure that the premium shall be--
(1) zero in the case of an individual whose annual
household income is below 200 percent of the poverty line;
(2) determined by a linear sliding scale, in the case of an
individual whose household income is at least 200 percent of
the poverty line, but not more than 600 percent of the poverty
line; and
(3) no individual or household above 600 percent of poverty
level will pay more than 8 percent of adjusted gross monthly
income toward such monthly premium.
SEC. 105. PROVIDERS AND REIMBURSEMENT RATES.
(a) In General.--The Secretary shall establish a rate schedule for
reimbursing types of health care providers furnishing items and
services under the public health insurance plan option at rates based
on rates applied for such items and services under title XVIII of the
Social Security Act, as of the date of the enactment of this Act, that
are necessary to maintain network adequacy. The Secretary shall
establish a rate schedule for items and services not currently covered
under title XVIII of the Social Security Act, such as dental, vision,
and hearing benefits, well child visits, and reproductive health
services, at a level to ensure adequate access to providers.
(b) Participating Providers.--
(1) 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
or under the Medicaid program under title XIX of such Act on
the date of enactment of this title shall be a participating
provider for the public health insurance plan option.
(2) Additional providers.--The Secretary shall establish a
process to allow health care providers not described in
paragraph (1) to become participating providers for the public
health insurance plan option.
(3) Clarification.--Notwithstanding any other provision of
law, health care providers may not be prohibited from
participating in the public health insurance option for reasons
other than their ability to provide covered services. Health
care providers and institutions are prohibited from denying
covered individuals access to any covered benefits and services
because of their religious objections.
(c) Prescription Drugs.--The Secretary shall apply the provisions
of section 1860D-11(i) of the Social Security Act (42 U.S.C. 1395w-
111(i)) to prescription drugs under the public health plan option in
the same manner as such provisions apply with respect to applicable
covered part D drugs under such section.
SEC. 106. ACCOUNT; FUNDING.
(a) Establishment.--There is established in the Treasury of the
United States an account for the receipts and disbursements
attributable to the operation of the public health plan option.
(b) Appropriation.--There is appropriated to the account
established under subsection (a), out of any funds in the Treasury not
otherwise obligated, such sums as may be necessary to be used by the
Secretary for purposes of carrying out this part.
(c) Prohibition of State Imposition of Taxes.--Section 1854(g) of
the Social Security Act (42 U.S.C. 1395w-24(g)) shall apply to receipts
and disbursements described in subsection (a) in the same manner as
such section applies to payments or premiums described in such section.
(d) Clarification.--Any provision of law restricting the use of
Federal funds with respect to any reproductive health service shall not
apply to funds appropriated under subsection (b) or with respect to the
account under subsection (a).
Subtitle B--Medicare for America
SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDICARE FOR AMERICA.
The Social Security Act is amended by adding at the end the
following new title:
``TITLE XXII--MEDICARE FOR AMERICA
``PART A--COMPREHENSIVE HEALTH COVERAGE
``SEC. 2201. ESTABLISHMENT.
``The Secretary shall establish a public health insurance program,
to be known as `Medicare for America', which shall for calendar year
2026 and each subsequent calendar year provide comprehensive health
benefits in accordance with this part to individuals enrolled for
coverage under this title.
``SEC. 2202. ELIGIBILITY; AUTOMATIC ENROLLMENT.
``(a) Eligible Individuals.--For purposes of this title, every
individual who is--
``(1) a resident of the United States or a territory of the
United States;
``(2) an individual who is lawfully present, as defined in
section 152.2 of title 45 of the Code of Federal Regulations;
or
``(3) an individual who would be eligible for coverage
under a State Medicaid plan pursuant to section 1903(v) (as
such section was in effect as of the date of the enactment of
this title), is entitled to benefits for health care services
under this title. The Secretary shall promulgate a rule that
provides criteria for applying this subsection, including
determining residency for eligibility purposes under this
title. Nothing in this title shall preclude a State from using
State funds to provide for an individual's health coverage who
is not eligible under this subsection.
``(b) Enrollments.--Subject to subsection (c):
``(1) In general.--Beginning in 2027, the Secretary shall
provide a mechanism for the enrollment of individuals entitled
to benefits under this title and, in conjunction with such
enrollment, the issuance of a Medicare for America card which
may be used for purposes of identification and processing of
claims for benefits under this title. The card shall not use
the individual's social security number as an identifier. As a
condition of participation in the program, participating
providers shall facilitate enrollment as specified by the
Secretary. The State entities responsible for enrolling
individuals in the Medicaid program under title XIX and the
Children's Health Insurance Program under title XXI shall serve
as the enrolling entity for Medicare for America within each
State.
``(2) Automatic enrollments.--The mechanism provided under
paragraph (1) shall, subject to paragraph (4), provide, for
plan years, for the following automatic enrollments under
Medicare for America:
``(A) Enrollment at birth.--For plan years
(beginning with plan year 2027), a process, established
by the Secretary in consultation with the Commissioner
of Social Security, for the automatic enrollment of
eligible individuals born during such plan year.
``(B) Current medicare beneficiaries.--
``(i) Current medicare beneficiaries.--For
plan years (beginning with plan year 2027), a
process established by the Secretary for the
automatic enrollment of all individuals who are
enrolled for benefits under part A or B of
title XVIII (other than individuals who are
enrolled for such benefits and receiving
benefits under title XIX).
``(ii) Continuing population.--For plan
years (beginning with plan year 2027), a
process established by the Secretary for the
automatic enrollment of eligible individuals
who attain the age of 65 during such plan year.
``(iii) Duals.--For plan years (beginning
with plan year 2029), a process established by
the Secretary for the automatic enrollment of
eligible individuals who are enrolled for
benefits under part A or B of title XVIII and
receiving benefits under title XIX.
``(C) Other individuals without qualified health
coverage.--For plan years (beginning with plan year
2027), a process established by the Secretary for the
automatic enrollment of eligible individuals who are
not enrolled in other qualified health coverage (as
defined in paragraph (4)(B)) for such plan year.
``(3) Other enrollments.--The mechanism provided under
paragraph (1) shall provide for the following:
``(A) In general.--Enrollment periods and processes
for each plan year (beginning with plan year 2027) for
enrollment under Medicare for America of any eligible
individual not otherwise described in paragraph (2).
``(B) Small employers.--
``(i) In general.--For plan years
(beginning with plan year 2027), a process and
methodology under which a small employer, as
defined in section 126(d)(3) of the Medicare
for America Act, may provide for the enrollment
of the employees of such employer under
Medicare for America. For purposes of this
subparagraph, the term `small employer' means
any employer for any calendar year if the
annual payroll of such employer for the
preceding calendar year does not exceed
$2,000,000 or has fewer than 100 employees.
``(ii) Requirement.--Small employers shall
either provide coverage as defined within the
meaning of section 2791(d)(8) of the Public
Health Service Act or facilitate the enrollment
of their employees into Medicare for America.
Small employers facilitating enrollment into
Medicare for America will not be subject to a
mandatory employer contribution.
``(iii) Authority.--The Secretary may set
standards for determining whether employers are
undertaking any actions to affect the risk pool
within Medicare for America by inducing
individuals to decline coverage under a
qualifying employer-sponsored plan and instead
to enroll in Medicare for America. An employer
violating such standards shall be treated as
not meeting the requirements of qualified
health coverage.
``(C) Large employers.--For plan years (beginning
with plan year 2030), the Secretary shall provide for a
process and methodology under which a large employer
may provide for the enrollment of the employees of such
employer under Medicare for America. For purposes of
the preceding sentence, the term `large employer' means
an employer with at least 100 employees or whose annual
payroll exceeds $2,000,000.
``(D) Members of congress and their staff.--
Beginning for plan year 2027, Members of Congress and
their staff, subject to paragraph (4), shall be
enrolled in Medicare for America.
``(4) Opt-out for individuals enrolled under qualified
health coverage.--
``(A) In general.--The mechanism provided under
paragraph (1) shall provide, with respect to a plan
year, for a process that enables individuals who are
enrolled in qualified health coverage for such plan
year to opt-out of coverage under Medicare for America
for such year.
``(B) Qualified health coverage defined.--For
purposes of this section, the term `qualified health
coverage' means coverage under any of the following:
``(i) For plan years 2027 and 2028:
``(I) Qualified employer coverage,
as defined in section 126 of the
Medicare for America Act.
``(II) Medical coverage under
chapter 55 of title 10, United States
Code, including coverage under the
TRICARE program.
``(III) A health care program under
chapter 17 or 18 of title 38, United
States Code, as determined by the
Secretary of Veterans Affairs, in
coordination with the Secretary of
Health and Human Services and the
Secretary.
``(IV) The health benefit program
under chapter 89 of title 5, United
States Code.
``(V) Medical benefits and services
provided by or through the Indian
Health Service.
``(VI) The Medicaid program under
title XIX of the Social Security Act.
``(VII) The CHIP program under
title XXI of the Social Security Act.
``(ii) For plan years 2029 and 2030:
``(I) Coverage described in
subclause (I), (II), (III), (IV), or
(V) of clause (i).
``(II) Coverage described in
subclause (VI) of clause (i), but only
with respect to coverage that is not
for individuals described in subclause
(VIII) of section 1902(a)(10)(A)(i) or
who are also enrolled for benefits
under title XVIII.
``(iii) For each subsequent plan year,
coverage described in subclause (I), (II),
(III), (IV), or (V) of clause (i).
``(c) Waiver.--The Secretary shall establish a process under which
the Secretary may grant waivers to States for additional time before
populations described in a previous subsection of this section of such
State are automatically enrolled under Medicare for America so long as
the State can demonstrate substantial progress has been made in
transitioning these populations.
``SEC. 2203. BENEFITS.
``(a) In General.--Medicare for America shall, in accordance with
this section, provide coverage for all the benefits, as determined to
be medically necessary, as covered and defined under parts A and B of
title XVIII and title XIX as of the date of the enactment of this
title, including the following:
``(1) Ambulatory patient services.
``(2) Emergency care and urgent care services.
``(3) Hospitalization.
``(4) Maternity and newborn care.
``(5) Behavioral health services, including mental health,
substance use disorder services, and intensive home- and
community-based services.
``(6) Prescription drugs approved by the Food and Drug
Administration.
``(7) Rehabilitative and habilitative services and devices,
including the following:
``(A) Physical therapy.
``(B) Speech therapy.
``(C) Occupational therapy.
``(8) Laboratory services.
``(9) Preventive and wellness services and chronic disease
management.
``(10) Pediatric services, all services that would
otherwise be coverable under early and periodic screening,
diagnostic, and treatment under the Medicaid program under
title XIX and services otherwise included under the maternal,
infant, and early childhood home visiting program under section
511, as of the date of the enactment of this title.
``(11) Dental care, at a minimum the services necessary to
prevent disease and promote oral health, restore oral
structures to health and function, and treat emergency
conditions, nightguards, mouthguards, and dentures.
``(12) Hearing health services including aids and exams.
``(13) Vision services.
``(14) Home- and community-based long-term services and
supports.
``(15) Chiropractic services.
``(16) Durable medical equipment (as defined for purposes
of title XIX), including the following:
``(A) Wheelchairs and accessories.
``(B) Walking aides such as walkers, canes, and
crutches.
``(C) Bathroom equipment such as commodes and
safety equipment.
``(D) Inhalation therapy equipment such as
nebulizers.
``(E) Hospital beds and accessories.
``(F) Other devices such as Continuous Positive
Airway Pressure (CPAP) machines, apnea monitors, and
ventilators.
``(G) Insulin pumps and glucometers.
``(H) Breast pumps.
``(I) Lymphedema compression treatment items.
``(J) Wigs for medical conditions.
``(K) Augmentative and alternative communication
devices, including dual-use devices.
``(L) Oxygen.
``(M) Orthotic and prosthetic devices.
``(N) Disposable medical supplies.
``(17) Family planning, including the following:
``(A) Reproductive health exams.
``(B) Patient counseling and education related to
family planning.
``(C) Abortion.
``(D) Screening, testing, treatment, and pre- and
post-test counseling for sexually transmitted diseases
and HIV.
``(E) Contraceptives including pill, patch,
medication, condom, implant, or other devices used to
prevent pregnancy.
``(F) Voluntary sterilization for beneficiaries
over the age of 21.
``(G) Infertility treatment.
``(18) Gender-confirming medical procedures and treatment.
``(19) Screening, testing, treatment, and pre- and post-
test counseling for sexually transmitted diseases and HIV.
``(20) Dietary and nutrition counseling.
``(21) Medically necessary food and vitamins for digestive
and inherited metabolic disorders.
``(22) Nursing facilities.
``(23) Acupuncture.
``(24) Digital health therapeutics, as approved by the
Center for Healthcare and the Center for Medicare and Medicaid
Innovation.
``(25) Telehealth.
``(26) Non-emergency medical transportation.
``(27) Care coordination, including services defined in
section 440.169 of title 42, Code of Federal Regulations.
``(28) Palliative care.
``(29) Any additional benefit or service not included in
this section that is coverable by any State plan (or waiver of
such State plan) under title XIX on the date of the enactment
of this title.
``(b) Updates.--Benefits coverable under Medicare for America shall
be updated in accordance with the National Coverage Determination
process that had, as of the date before the date of the enactment of
this title, applied with respect to benefits covered under title XVIII.
``(c) Implementing Policies.--The Secretary shall establish payment
models, quality measures, and other implementing policies that provide
further access to the coverage under this title. For purposes of the
previous sentence, the Secretary shall consult with stakeholders,
including those covering pediatrics, disabilities, and seniors.
``(d) Prohibition Against Duplicating Coverage.--
``(1) In general.--It is unlawful for a private health
insurer (other than an insurer with respect to a Medicare
Advantage for America plan under part C of this title or
qualified employer-based coverage) to sell health insurance
coverage that duplicates the benefits provided under Medicare
for America under this part.
``(2) Construction.--Nothing in paragraph (1) shall be
construed as prohibiting the sale of health insurance coverage
for any additional benefits not covered by this part, insofar
as the coverage satisfies the conditions of paragraphs (3) and
(4). Nothing shall preclude employers meeting the requirements
under section 126 of the Medicare for America Act from
providing supplemental coverage under this section to their
employees.
``(3) Application of protections.--For purposes of
paragraph (2), health insurance coverage for any additional
benefits must satisfy the following conditions:
``(A) The provisions of section 2718 of the Public
Health Service Act, relating to a medical loss ratio.
``(B) The provisions of section 2702 of the Public
Health Service Act, relating to guaranteed issue.
``(C) The provisions of section 2701 of the Public
Health Service Act, relating to community rating.
``(D) The provisions of section 2704 of the Public
Health Service Act, relating to the ban on pre-existing
conditions exclusions.
``(4) No fees to brokers.--For purposes of paragraph (2),
the condition described in this paragraph is that health
insurance coverage described in such paragraph does not pay
fees to insurance brokers.
``(e) States May Provide Additional Benefits.--Individual States
may provide additional benefits for the residents of such States at the
expense of the State.
``(f) Prohibition Against Step Therapy and Prior Authorization.--
Items and services covered under Medicare for America shall be covered
without any need for any prior authorization determination and without
any limitation applied through the use of step therapy protocols.
``SEC. 2204. PREMIUMS.
``(a) In General.--
``(1) In general.--Subject to paragraph (2), each
individual enrolled for benefits under this title for a year
shall pay monthly community-rated premiums for such year in an
amount determined by the Secretary in accordance with
subsection (b).
``(2) Grandfathered medicare beneficiaries.--In the case of
an individual enrolled under part B of title XVIII as of the
date of the enactment of this part, the premium applied under
this section for such individual for benefits under this title
shall be the lesser of--
``(A) the premium otherwise applicable to such
individual under such title XVIII if this title had not
been enacted; or
``(B) the premium that would be applied to such
individual under this title without the application of
this paragraph.
``(b) Premium Contribution Based on Income.--The amount of a
monthly premium, with respect to a plan year (beginning with 2027),
under this section shall be established by the Secretary in accordance
with the following:
``(1) Such premium shall be determined such that the
collective premiums for the plan year are with respect to the
costs of health benefits provided under this title for such
year and related administrative costs.
``(2) Premiums shall vary by family composition only.
``(3) Federal subsidies shall be provided to ensure that
the premium shall be--
``(A) zero in the case of an individual whose
annual household income is below 200 percent of the
poverty line;
``(B) determined by a linear sliding scale, in the
case of an individual whose household income is at
least 200 percent of the poverty line, but not more
than 600 percent of the poverty line; and
``(C) no individual or household will pay more than
8 percent of adjusted gross monthly income toward such
premium.
``(4) For an individual whose employer will be making a
firm-wide contribution under this title in lieu of offering
employer-sponsored insurance (as specified in section
126(b)(1)(B) of the Medicare for America Act), such individual
shall pay a premium in accordance with this subsection.
``(5) For an individual who has opted out of their
employer-sponsored insurance in order to enroll in Medicare for
America as specified in section 126(c) of such Act, the
individual shall pay the lesser of--
``(A) the premium described in this subsection; or
``(B) the amount owed after the amount of employer
contribution (as specified in section 126(b)(1)(B) of
the Medicare for America Act) is subtracted from the
premium established by the Secretary of Health and
Human Services as described in paragraph (1), whichever
is less.
``(c) Deposits.--Amounts paid under this section for coverage under
this title shall be deposited in the Treasury to the credit of the
Trust Fund established under section 2206.
``(d) Appeals for Certain Medicare Grandfathered Population.--In
calculating premiums for purposes of subsection (a)(2):
``(1) Any individual that was subject to a late enrollment
penalty under part B of title XVIII shall have the right to
appeal the assessment of the penalty for good faith enrollment
mistakes.
``(2) The Secretary, in consultation with the Commissioner
of Social Security, shall develop and publish a formal
application for requesting an action of the Secretary under
paragraph (1) to correct or eliminate the effects of an error,
misrepresentation, or inaction described in such paragraph and
determine and publish specific timelines for timely resolution
of such a request.
``(3) The Secretary shall also require that all such
determinations with respect to such requests shall be reached
within 15 business days of the submission of such application.
All determinations shall be in writing through a standard
decision notice which shall include an explanation of the
reasons for the determination.
``(4) The Commissioner of Social Security shall enter into
contracts with independent review organizations in accordance
with this subsection for the purpose of reviewing and
determining individual appeals of determinations under
paragraph (3) with respect to an application relating to
enrollment under part A or part B.
``(5) An individual who receives an adverse determination
under paragraph (3) may appeal to an independent review
organization designated by the Commission. Any such appeal must
be sent to the independent review organization within 90 days
of the date the individual received the determination to be
eligible for review. The independent review organization shall
review and reach a determination of the review in writing
within 45 days of the receipt of any such appeal.
``(6) The Secretary of the Treasury may not enter into a
contract under paragraph (4) with an independent review
organization--
``(A) unless the organization has staff that has
the appropriate knowledge of, and experience with, the
eligibility and coordination of benefits rules and
regulations under this title; and
``(B) to the extent the organization is a fiscal
intermediary under section 1816, a carrier under
section 1842, or a Medicare administrative contractor
under section 1874A.
``(7) The Secretary shall provide for access by independent
review organizations conducting appeal determinations under
this subsection, to the database of the Coordination of
Benefits Contractor of the Centers for Medicare & Medicaid
Services as necessary in order to conduct the duties of such
organizations to determine appeals pursuant to this subsection.
``SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT-OF-POCKET LIMITS.
``(a) Payment of Benefits; Cost-Sharing.--There shall be paid, in
the case of each individual who is enrolled under Medicare for America
and incurs expenses for items and services with respect to which
benefits are payable under this part, subject to subsection (c), 80
percent of the reimbursement rates established pursuant to section 2206
for such items and services, except that for the following services,
the amounts paid under this section shall be equal to 100 percent of
the reimbursement rates established pursuant to section 2206 for such
items and services:
``(1) USPTF recommended preventive and chronic disease
services.
``(2) Long-term services and supports.
``(3) Generic drugs, and prescription drugs if medically
necessary.
``(4) All services for individuals who are medically frail
or otherwise have special medical needs, (including children
with serious emotional disturbance and adults with serious
mental illness), individuals with chronic substance use
disorders, or individuals with serious and complex medical
conditions (such as epilepsy and HIV), individuals with a
physical, intellectual or developmental disability that
significantly impairs their ability to perform one or more
activities of daily living.
``(5) Pregnancy-related services.
``(6) Emergency services.
``(7) Services for children under age 21.
The Secretary shall establish a default monthly payment plan under the
Medicare for America benefits package to ensure the payment owed by the
individual enrolled under Medicare for America is spread-out evenly
throughout the year.
``(b) Deductible.--There shall be no deductible under Medicare for
America.
``(c) Maximum Out-of-Pocket Limit.--
``(1) In general.--The coverage under Medicare shall
provide benefits, after the eligible individual has incurred
out-of-pocket expenses for items and services with respect to
which benefits are payable under this part in a year equal to
the annual out-of-pocket threshold specified in paragraph (2),
with cost-sharing that is equal to $0.
``(2) Annual out-of-pocket threshold.--
``(A) In general.--For purposes of paragraph (1),
subject to subparagraphs (B) and (C), the annual out-
of-pocket threshold specified in this paragraph is a
threshold that shall be determined on a linear sliding
scale for household income that is at least 200 percent
of the poverty line, but not more than 600 percent of
the poverty line, and that shall not exceed--
``(i) with respect to an individual,
$3,500; or
``(ii) with respect to a household, $5,000.
Individuals or households with income above 600
percent of the Federal poverty line shall have
their annual out-of-pocket threshold capped at
$3,500 and $5,000, respectively.
``(B) Indexing.--In the case of plan years
beginning after 2026, the threshold described in
subparagraph (A) (as in effect for the preceding plan
year after application of this subparagraph) shall be
increased by the percentage increase over the previous
year in the medical care expenditure category of the
Consumer Price Index for All Urban Consumers (United
States city average), published by the Bureau of Labor
Statistics.
``(C) Exception.--For purposes of paragraph (1),
the annual out-of-pocket threshold for individuals and
households with annual income below 200 percent of the
Federal poverty line is $0.
``(d) No Lifetime or Annual Limits.--There shall be no lifetime or
annual limits for any services or benefits coverable under Medicare for
America.
``(e) No Balance Billing.--No provider may impose a charge to an
enrolled individual for coverable services for which benefits are
provided under this part in an amount higher than the reimbursement
rate for such services under section 2206 and may not impose a charge
to such individual for such service other than with respect to the
other cost-sharing described in this section.
``(f) No Private Contracting.--A health care provider or health
care institution are prohibited from entering into a private contract
with an individual enrolled under Medicare for America for any item or
service coverable under Medicare for America.
``(g) Limitations on the Use of Flexible Savings Accounts.--
Flexible Savings Accounts shall only be used for benefits and services
not covered by Medicare for America.
``SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT RATES.
``(a) In General.--The Secretary shall establish a rate schedule
for reimbursing types of health care providers furnishing items and
services under Medicare for America at rates that are consistent with
subsection (b) and are necessary to maintain network adequacy.
``(b) Rates.--
``(1) In general.--Except as provided in paragraphs (2) and
(3), the Secretary shall establish rates for benefits and
services to be provided to health care providers and suppliers
furnishing under Medicare for America based on rates that would
be applied (including as computed, updated, and adjusted) under
title XVIII or title XIX, whichever is higher, for such type of
health care providers and suppliers and item and service if
such title remained in effect and, in the case of a type of
provider and supplier or item or service coverable under
Medicare for America but not otherwise coverable under title
XVIII or title XIX, shall provide for rates that ensure
adequate access to care.
``(2) Exceptions.--For purposes of this section, in
applying paragraph (1) the Secretary shall ensure that rates to
hospitals for inpatient services or outpatient services
furnished under Medicare for America are at least 110 percent
of such rates on average or in the aggregate for furnishing
such inpatient or outpatient services otherwise applied under
title XVIII or title XIX, whichever is higher, except that for
hospitals serving underserved areas as specified by the
Secretary, such rates are increased as necessary to ensure
adequate access to care.
``(3) Application.--In applying rates under title XVIII and
title XIX, as applicable, for purposes of this part, the
following shall apply:
``(A) The Secretary shall provide for site-neutral
payments for items and services furnished in an
outpatient hospital and physician office, the rate of
payment for such service shall be the same.
``(B) The Secretary shall provide for a mechanism
to provide payments for direct and indirect costs of
graduate medical education programs without any cap on
the number of residency positions for which payment may
be made, including payments to hospitals for such
programs and to eligible facilities for programs for
population health-based residencies and for nurse
practitioner post-licensure clinical training,
residency, and fellowship programs.
``(C) The Secretary shall increase the average
relative value of primary care and other mental and
behavioral health and cognitive services by not less
than 30 percent in order to ensure adequate access to
inpatient and outpatient care.
``(D) As a condition of participation in the
program, participating providers shall accept Medicare
for America rates paid by employer-sponsored insurance
plans and Medicare Advantage for America plans.
``(E) The Secretary shall semiannually review if
the rates paid by Medicare for America are creating
barriers to care. The Secretary shall have the
authority to raise rates as necessary to ensure
adequate access to care.
``(4) Increased federal match for medicaid and the
children's health insurance program for years 2027 through
2031.--The Secretary of Health and Human Services shall pay the
difference between the Medicare for America rates and the
Medicaid and CHIP rates during the period beginning on January
1, 2026, and ending on December 31, 2031.
``(c) Participating Providers.--
``(1) In general.--A health care provider that is a
participating provider of services or supplier under the
Medicare program under title XVIII or the Medicaid program
under title XIX on the date of enactment of this title shall
remain a participating provider for Medicare for America.
``(2) Additional providers.--The Secretary shall establish
a process to allow health care providers not described in
paragraph (1) to become participating providers for Medicare
for America.
``(d) Prescription Drugs.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall, for plan years beginning on or after
the date of the enactment of this title, negotiate with
pharmaceutical manufacturers the prices (including discounts,
rebates, and other price concessions) that may be charged to
Medicare for America and MA for America organizations during a
negotiated price period (as specified by the Secretary) for
covered drugs for Medicare for America enrollees. In
negotiating such prices under this section, the Secretary shall
take into account the following factors:
``(A) The comparative clinical effectiveness and
cost effectiveness, when available from an impartial
source, of such drug.
``(B) The budgetary impact of providing coverage of
such drug.
``(C) The number of similarly effective drugs or
alternative treatment regimens for each approved use of
such drug.
``(D) The associated financial burden on patients
that utilize such drug.
``(E) The associated unmet patient need for such
drug.
``(F) The total revenues from global sales obtained
by the manufacturer for such drug and the associated
investment in research and development of such drug by
the manufacturer.
``(2) Finalization of negotiated price.--The negotiated
price of each covered drug for a negotiated price period shall
be finalized not later than 30 days before the first plan year
in such negotiated price period.
``(3) Competitive licensing authority.--
``(A) In general.--Notwithstanding any exclusivity
under clause (iii) or (iv) of section 505(j)(5)(F) of
the Federal Food, Drug, and Cosmetic Act, clause (iii)
or (iv) of section 505(c)(3)(E) of such Act, section
351(k)(7)(A) of the Public Health Service Act, or
section 527(a) of the Federal Food, Drug, and Cosmetic
Act, or by an extension of such exclusivity under
section 505A of such Act or section 505E of such Act,
and any other provision of law that provides for market
exclusivity (or extension of market exclusivity) with
respect to a drug, in the case that the Secretary is
unable to successfully negotiate an appropriate price
for a covered drug for a negotiated price period, the
Secretary shall authorize the use of any patent,
clinical trial data, or other exclusivity granted by
the Federal Government with respect to such drug as the
Secretary determines appropriate for purposes of
manufacturing such drug for sale under Medicare for
America. Any entity making use of a competitive license
to use patent, clinical trial data, or other
exclusivity under this section shall provide to the
manufacturer holding such exclusivity reasonable
compensation, as determined by the Secretary based on
the following factors:
``(i) The risk-adjusted value of any
Federal Government subsidies and investments in
research and development used to support the
development of such drug.
``(ii) The risk-adjusted value of any
investment made by such manufacturer in the
research and development of such drug.
``(iii) The impact of the price, including
license compensation payments, on meeting the
medical need of all patients.
``(iv) The relationship between the price
of such drug, including compensation payments,
and the health benefits of such drug.
``(v) Other relevant factors determined
appropriate by the Secretary to provide
reasonable compensation.
``(B) Reasonable compensation.--The manufacturer
described in subparagraph (A) may seek recovery against
the United States in the United States Court of Federal
Claims.
``(C) Interim period.--
``(i) In general.--Until 1 year after a
drug described in subparagraph (A) is approved
under section 505(j) of the Federal Food, Drug,
and Cosmetic Act or section 351(k) of the
Public Health Service Act and is provided under
license issued by the Secretary under such
subparagraph, Medicare for America shall not
pay more for such drug than the average of the
prices available, during the most recent 12-
month period for which data is available prior
to the beginning of such negotiated price
period, from the manufacturer to any
wholesaler, retailer, provider, health
maintenance organization, nonprofit entity, or
governmental entity in the ten OECD
(Organization for Economic Cooperation and
Development) countries that have the largest
gross domestic product with a per capita income
that is not less than half the per capita
income of the United States or the price
established by the Prescription Drug and
Medical Device Review Board established under
title III of the Medicare for America Act of
2019.
``(ii) Federal program licensing.--If such
drug is not made available at the price
determined, the Secretary shall authorize such
entities to use any patent, clinical trial
data, or other exclusivity granted by the
Federal Government with respect to such drug as
the Secretary determines appropriate for
purposes of manufacturing such drug for sale
under any Federal program, including those
provided by Medicare for America, Veterans
Affairs, the Department of Defense, and the
Coast Guard.
``(D) Authorization for secretary to procure drugs
directly.--
``(i) In general.--The Secretary may
procure a drug manufactured pursuant to a
competitive license under subparagraph (A) for
purposes of this part or pursuant to a Federal
program license under subparagraph (C)(ii) for
purposes of a Federal program directly from the
entity manufacturing the drug pursuant to such
a license.
``(ii) Clarification regarding application
of buy american act.--In the case where the
Secretary procures a drug under this
subparagraph, the provisions of chapter 83 of
title 41, United States Code (commonly referred
to as the `Buy American Act'), shall apply.
``(E) Priority for u.s. manufacturers in
authorizing competitive licenses.--In authorizing a
competitive license under this paragraph, the
Secretary--
``(i) shall give preference to entities
that the Secretary determines have the highest
safety and security standards; and
``(ii) may give priority to entities that
will manufacture such drug in the United
States.
``(4) Fda review of licensed drug applications.--The
Secretary shall prioritize review of applications under section
505(j) of the Federal Food, Drug, and Cosmetic Act for drugs
licensed under paragraph (3)(A).
``(5) Prohibition of anticompetitive behavior.--No drug
manufacturer may engage in anticompetitive behavior with
another manufacturer that may interfere with the issuance and
implementation of a competitive license or run contrary to
public policy.
``(6) Required reporting.--The Secretary may require
pharmaceutical manufacturers to disclose to the Secretary such
information that the Secretary determines necessary for
purposes of carrying out this subsection.
``(7) Clarification.--Nothing in this subsection shall be
construed as preventing Medicare for America obtaining a
discount or reduction of the price for a covered drug below the
price negotiated by the Secretary.
``(8) Value or cost-effectiveness assessments.--The use of
Quality-Adjusted Life Years, Disability-Adjusted Life Years, or
other similar mechanisms is prohibited for use in value or
cost-effectiveness assessments for purposes of this subsection.
``(9) Clarification.--There shall be no formulary under
Medicare for America.
``SEC. 2207. TRUST FUND; FUNDING.
``(a) Trust Fund.--There shall be established a unified Medicare
Trust Fund in which funds provided under this title are deposited and
from which expenditures under this title are made. The Trust Fund shall
consist of such gifts and bequests as may be made and such amounts as
may be deposited in, or appropriated to, such Trust Fund as provided in
this Act.
``(b) Funding.--
``(1) Taxes.--There are hereby appropriated to the Trust
Fund for each fiscal year beginning with fiscal year 2027, out
of any moneys in the Treasury not otherwise appropriated,
amounts equivalent to 100 percent of the net increase in
revenues to the Treasury which is attributable to the
amendments made by title II of the Medicare for America Act and
premiums collected under this title. The amounts appropriated
by the preceding sentence shall be transferred from time to
time (but not less frequently than monthly) from the general
fund in the Treasury to the Trust Fund, such amounts to be
determined on the basis of estimates by the Secretary of the
Treasury of the taxes paid to or deposited into the Treasury;
and proper adjustments shall be made in amounts subsequently
transferred to the extent prior estimates were in excess of or
were less than the amounts that should have been so
transferred.
``(2) Current program receipts.--Notwithstanding any other
provision of law, there are hereby appropriated to the Trust
Fund for each fiscal year, beginning with fiscal year 2026, the
amounts that would otherwise have been appropriated to carry
out the following programs:
``(A) The Medicare program under title XVIII.
``(B) The Medicaid program under title XIX,
beginning as of 2031.
``(3) Additional appropriations.--Additional sums are
authorized to be appropriated annually as needed to maintain
maximum quality, efficiency, and access under this part.
``(4) Medicaid maintenance of effort payments.--There shall
be transferred to the Trust Fund the maintenance of effort
payments made under section 2209.
``(c) Restrictions Shall Not Apply.--Any other provision of law in
effect on the date of enactment of this title restricting the use of
Federal funds for any reproductive health service, including abortion,
shall not apply to monies in the Trust Fund.
``(d) Incorporation of Provisions.--The provisions of subsections
(b) through (i) of section 1817 shall apply to the Trust Fund under
this section in the same manner as such provisions applied to the
Federal Hospital Insurance Trust Fund under such section 1817, except
that, for purposes of applying such subsections to this section, the
`Board of Trustees of the Trust Fund' shall mean the `Secretary'.
``(e) Transfer of Funds.--Any amounts remaining in the Federal
Hospital Insurance Trust Fund under section 1817 or the Federal
Supplementary Medical Insurance Trust Fund under section 1841 after the
payment of claims for items and services furnished under title XVIII
have been completed, shall be transferred into the Trust Fund under
this section.
``SEC. 2208. ADMINISTRATIVE PROVISIONS.
``(a) Center for Health Care.--Beginning 2027, the Centers for
Medicare & Medicaid Services shall be renamed the Center for Health
Care and all references in law and regulation to such Centers shall be
deemed a reference to such Center. All powers, duties, and
responsibilities of the Centers for Medicare & Medicaid Services shall
be transferred to the Center for Health Care.
``(b) Authority.--The Secretary shall have the authority to issue
interim final rules with respect to any provision in this part.
``(c) Administrative Law Judges.--
``(1) In general.--The Center for Health Care is not
authorized to appoint administrative law judges, in accordance
with pages 11420 through 11499 of title 70 of the Federal
Register (March 8, 2005).
``(2) Timing.--Under this title, administrative law judges
must issue a decision within 90 days of receipt of a hearing
request, as specified in subsections (a) and (c) of section
405.1016 of title 2, Code of Federal Regulations.
``(d) Coverage Determinations Appeals.--
``(1) Individuals may appeal a coverage determination under
this title before the individual obtains the service or item
that is the subject of the appeal. Individuals shall continue
to receive the service or item if an appeal is filed before the
provision of the service or item is terminated.
``(2) The Secretary shall eliminate the redetermination by
a Medicare administrative contractor from the appeals process
under the Medicare program for beneficiaries.
``(e) Private Right of Action.--
``(1) In general.--An applicant or recipient denied a right
conferred by this title may bring a civil action seeking any
remedy available in law or equity to remedy that violation.
State courts and district courts of the United States shall
have concurrent jurisdiction of such actions.
``(2) Right defined.--Rights are created by any provision
of this title that--
``(A) prescribes, establishes, or confers a benefit
or protection in favor of the individual or individuals
seeking to enforce the provision; or
``(B) prescribes, establishes, or imposes a duty or
obligation on a person or entity to act or conduct
operations in a manner that benefits the individual or
individuals seeking to enforce the provision.
``(3) Reasonable attorney fees.--In any action or
proceeding to enforce this title, the court may award
reasonable attorneys' fees and litigation costs (including
expert fees) reasonably incurred against the defendant or
defendants.
``(4) Appeal.--Any civil action brought under this section
shall be subject to appeal as provided in sections 1291 and
1292 of title 28 of the United States Code.
``(5) Continued application of other laws.--Nothing in this
title (or an amendment made by this title) shall be construed
to invalidate or limit the rights, remedies, procedures, or
legal standards available to individuals aggrieved under
section 1979 of the Revised Statutes (42 U.S.C. 1983), or to
supersede State laws causes of action.
``(f) Non-Discrimination.--
``(1) In general.--Except as otherwise provided for in this
title, an individual shall not, on the ground prohibited under
title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et
seq.), title IX of the Education Amendments of 1972 (20 U.S.C.
1681 et seq.), the Age Discrimination Act of 1975 (42 U.S.C.
6101 et seq.), section 504 of the Rehabilitation Act of 1973
(29 U.S.C. 794), or section 1557 of the Affordable Care Act (42
U.S.C. 18116), be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under, any
health program or activity, any part of which is receiving
Federal financial assistance, including credits, subsidies, or
contracts of insurance, or under any program or activity that
is administered by an Executive Agency or any entity
established under this title (or amendments) or any employer-
sponsored insurance. The enforcement mechanisms provided for
and available under such title VI, title IX, section 794, Age
Discrimination Act, or such section 1557 shall apply for
purposes of violations of this subsection.
``(2) Continued application of laws.--Nothing in this title
(or an amendment made by this title) shall be construed to
invalidate or limit the rights, remedies, procedures, or legal
standards available to individuals aggrieved under title VI of
the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title
VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.),
title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et
seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
794), the Age Discrimination Act of 1975 (42 U.S.C. 611 et
seq.), or section 1557 of the Affordable Care Act (42 U.S.C.
18116) or to supersede State laws that provide additional
protections against discrimination on any basis described in
paragraph (1).
``(3) Health care providers.--Health care providers may not
be prohibited from participating in the Medicare for America
for reasons other than their ability to provide covered
services. Health care providers and institutions are prohibited
from denying covered individuals access to covered benefits and
services because of their religious objections. This subsection
supercedes any provision of law that allows for conscience
protection.
``(4) Regulations.--The Secretary may promulgate
regulations to implement this subsection.
``SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT.
``(a) In General.--A State is not eligible for payment under any
program specified in subsection (c) for a calendar quarter in a plan
year beginning after 2036 unless the State makes to the Secretary for
transfer to the unified Medicare Trust Fund under section 2207 the
maintenance of effort payment applicable to such State and plan year
under subsection (b). The Secretary shall extend such a waiver
(including the availability of Federal financial participation under
such waiver) for such period as may be required for a State to meet the
requirement of the previous sentence.
``(b) Maintenance of Effort Payments.--For purposes of this
section, a maintenance of effort payment with respect to a State and
plan year is--
``(1) for plan year 2037 and a State, a payment in an
amount equal to the total amount of expenditures of the State
for medical assistance under title XIX and child health
assistance under title XXI including administrative costs for
the plan year before the date of the enactment of this title;
``(2) for plan year 2038 and each subsequent plan year
before plan year 2041--
``(A) in the case of a State that is a PPACA
expansion State, the payment amount applied under this
subsection for the previous plan year, increased by
growth in GDP per capita plus 0.4 percent; and
``(B) in the case of a State that is not a PPACA
expansion State, the payment amount applied under this
subsection for the previous plan year, increased by
growth in GDP per capita plus 0.7 percent; and
``(3) beginning in 2041, for each subsequent plan year,
with respect to any State, the payment amount applied under
this subsection for the previous year, increased by growth in
GDP per capita plus 0.7 percent.
``(c) Programs Specified.--For purposes of this section, the
programs specified in this subsection are each of the following:
``(1) Block grants for community mental health services
under subpart I of part B of title XIX of the Public Health
Service Act.
``(2) Block grants and programs for social services and
elder justice under title XX.
``(3) Maternal and child health services block grants under
title V.
``(4) Block grants for prevention and treatment of
substance abuse under subpart II of part B of title XIX of the
Public Health Service Act.
``(5) State Targeted Response to Opioid Crisis Grant
Community Services Block Grant.
``(6) Grants under section 330 of the Public Health Service
Act.
``(7) Ryan White HIV/AIDS Program grants under title XXVI
of the Public Health Service Act.
``SEC. 2210. APPLICATION OF TITLE XVIII PROVISIONS.
``Except as specified otherwise in this title, in implementing
Medicare for America, the Secretary shall to the greatest extent
practicable apply the following provisions of title XVIII to the
program under this title, benefits covered under this title,
individuals entitled to benefits under this title, and providers of
services and suppliers participating under the program under this title
in a similar manner as such provisions applied to the program under
title XVIII, benefits covered under such title, individuals entitled to
benefits or enrolled under such title, and providers of services and
suppliers participating under the program under such title:
``(1) Section 1801.
``(2) Section 1805.
``(3) Section 1806.
``(4) Section 1807.
``(5) Section 1809.
``(6) Section 1814.
``(7) Section 1815.
``(8) Section 1816.
``(9) Section 1818.
``(10) Section 1818A.
``(11) Section 1819.
``(12) Section 1820.
``(13) Section 1834.
``(14) Section 1834A.
``(15) Section 1843.
``(16) Section 1846.
``(17) Section 1847.
``(18) Section 1851.
``(19) Section 1852.
``(20) Section 1855.
``(21) Section 1856.
``(22) Section 1857.
``(23) Section 1858.
``(24) Section 1861.
``(25) Section 1863.
``(26) Section 1864.
``(27) Section 1866B.
``(28) Section 1866C.
``(29) Section 1866E.
``(30) Section 1867.
``(31) Section 1868.
``(32) Section 1869.
``(33) Section 1871.
``(34) Section 1874A.
``(35) Section 1880.
``(36) Section 1881.
``(37) Section 1881A.
``(38) Section 1891.
``(39) Section 1894.
``(40) Section 1895.
``(41) Section 1896.
``PART B--HOME- AND COMMUNITY-BASED LONG-TERM SERVICES AND SUPPORTS
``SEC. 2231. HOME- AND COMMUNITY-BASED LONG-TERM SERVICES AND SUPPORTS
BENEFIT.
``All individuals enrolled under Medicare for America under this
title shall have coverage for home- and community-based long-term
services and supports benefits. Nothing in this part shall be construed
to limit an enrollee's entitlement to any other benefit that is covered
pursuant to section 2203, including nursing facility benefits.
``SEC. 2232. ELIGIBILITY.
``(a) Eligible Individuals.--An individual who is eligible for
home- and community-based long-term services and supports benefits
under this part is an individual who satisfies each of the following:
``(1) The individual is eligible for Medicare for America.
``(2) The individual is determined by a licensed health
care practitioner to be unable to perform, without substantial
assistance, at least one Activity of Daily Living as described
in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986,
or to require substantial assistance with one or more of the
following areas:
``(A) Communication.
``(B) Social interaction.
``(C) Learning.
``(D) Self-care.
``(E) Self-management.
``(F) Impairments that affect the person's capacity
for social or economic participation.
``(b) Clarification.--Under this part, in the case of an individual
described in subsection (a) who experiences periods in which their
functional capacity changes or improves, such individual shall continue
to have access to benefits under this part as needed. If such an
individual's functional capacity improves to a point in which the
individual no longer requires home- and community-based long-term
services and supports, or requires fewer services, the individual shall
be able to immediately and seamlessly resume receiving all needed
services if and when their functional needs recur. Eligibility for
services shall be maintained if, without the services, the individual
would have reduced functional capacity. When assessing functional
impairment, the individual will be assessed without regard to any
current services or the ameliorative effects of other mitigating
measures described in section 3(4)(E)(i)(I) of the Americans With
Disabilities Act of 1990.
``(c) Benefits.--
``(1) Definition.--For purposes of this title, the term
`home- and community-based long-term services and supports
benefit' means the daily living supports needed by eligible
individuals in order to live, work, and participate in their
communities, and includes all home- and community-based
services and supports coverable as of the date of the enactment
of this title, under any State plan or waiver under title XIX,
including--
``(A) home health aides and homemakers;
``(B) direct support professionals and personal
attendant care services;
``(C) hospice;
``(D) nursing care;
``(E) medical social services;
``(F) care coordination, including case management,
fiscal intermediary, and support brokerage services;
``(G) short-term inpatient care, including respite
care and care for pain control;
``(H) behavioral health home- and community-based
long-term services and supports, including assertive
community treatment; peer support services; intensive
care coordination, including case management; supported
employment; and supported housing wraparound;
``(I) private-duty nursing;
``(J) respite services provided in the individual's
home or broader community; and
``(K) transitional services to support an
individual's transition from an institutional setting
to the community.
``(2) Non-application.--The provisions of sections
424.22(a)(1)(i) and 424.22(a)(1)(ii) of title 42 of the Code of
Federal Regulations does not apply in the case of the benefit
described in paragraph (1)(A).
``(d) Home- and Community-Based Long-Term Services and Supports
Workforce Development.--
``(1) In general.--The Secretary shall ensure that the
number of individuals in the home- and community-based long-
term services and supports workforce is adequate to ensure
community integration for all beneficiaries under Medicare for
America. In so doing, the Secretary may consider a wide range
of factors, including payment rates for direct care workers,
career pipelines and credentialing, worker rights, and the
impact of national labor policies.
``(2) Self-directed model.--All eligible individuals shall
be defaulted into a self-directed care option (as defined by
the Secretary). The Secretary must consult with eligible
individuals, caregivers, workers and their representatives,
including unions, and state entities responsible for
administering the LTSS benefit to establish this model.
``(3) Community first.--The benefit under this part shall
be arranged for and provided with a community first presumption
and eligible individuals shall be provided home- and community-
based long-term services and support available under this
section, regardless of type or level of disability or service
need. No eligible individual may be referred to an institution
without first being offered and, if chosen, provided home- and
community-based long-term services and supports. Individuals in
an institution on the effective date of the bill, and at least
annually or upon any change in condition thereafter, shall be
informed of, and if chosen, provided with home- and community-
based long-term services and supports.
``(e) Administration of Services and Supports.--State entities
responsible for administering home- and community-based long-term
services and support benefits under any State plan or waiver under
title XIX as of the date of the enactment of this title shall continue
to administer the benefits and services coverable under this section.
``(f) Coordination With Other Federal Benefits.--
``(1) Rule of construction.--Nothing in this part shall be
construed as prohibiting benefits paid under this part from
being used to compensate a caregiver who provides community
living assistance services and supports to a dependent relative
for providing community living assistance services and supports
to an eligible individual under this part.
``(2) Dependent relative defined.--The term `dependent
relative' means a child, grandchild, niece, nephew, parent,
grandparent, sibling, aunt, or uncle (of such caregiver or his
or her spouse or domestic partner); such caregiver's spouse or
domestic partner, if such child, grandchild, niece, nephew,
parent, grandparent, sibling, aunt, uncle, spouse, or domestic
partner is an eligible individual.
``(3) Supplement not supplant.--Benefits received under
this part by a caregiver shall supplement, but not supplant,
other benefits for which the individual is eligible under any
other federally funded program that provides benefits or
assistance.
``(4) Disregard.--The benefit paid under this part shall be
disregarded for purposes of determining or continuing the
eligibility of the individual or the spouse of the individual
for receipt of benefits under any other Federal, State, or
locally funded assistance program, including benefits paid
under title II or XVI, under the laws administered by the
Secretary of Veterans Affairs, under low-income housing
assistance programs, under the supplemental nutrition
assistance program established under the Food and Nutrition Act
of 2008, or under programs administered by State vocational
rehabilitation agencies.
``(5) Regulations.--Not later than one year after the date
of the enactment of this section, the Secretary shall
promulgate such regulations as are necessary to carry out this
part and to prevent fraud and abuse with respect to the
benefits under this part.
``PART C--MEDICARE ADVANTAGE FOR AMERICA
``SEC. 2221. ALL PRIVATE PLANS.
``(a) In General.--For plan years beginning with plan year 2029, a
health insurance issuer may offer health insurance coverage in the
individual market only if such issuer has entered into a contract with
the Secretary under subsection (b) to offer such coverage.
``(b) Agreements.--The Secretary shall enter into an agreement with
an MA for America sponsor to offer MA for America plans under this part
for the coverage of individuals enrolled under Medicare for America who
elect to receive benefits under part A through such a plan.
``(c) MA for America Plan; MA for America Sponsor.--For purposes of
this part:
``(1) MA for america plan.--An MA for America plan is a
Medicare Advantage plan under part C of title XVIII, except
such plan shall provide coverage for individuals enrolled under
Medicare for America under part A of this title, with respect
to at least the benefits covered under such part A.
``(2) MA for america sponsor.--An MA for America sponsor is
a sponsor of an MA for America plan.
``SEC. 2222. APPLICATION OF MEDICARE ADVANTAGE PROVISIONS.
``For purposes of applying this part, except as otherwise specified
under this part, the provisions of part C of title XVIII, as in effect
as of the date of the enactment of this title shall apply with respect
to an MA for America sponsor, MA for America plan, individuals eligible
for coverage under this part, individuals enrolled under such plan, and
benefits covered under part A in a similar manner and to a similar
extent as such provisions applied to an MA organization, MA plan,
individuals eligible for under part C of such title, individuals
enrolled under an MA plan, and benefits covered under fee-for-service
Medicare as of such date.
``SEC. 2223. MEDICARE ADVANTAGE FOR AMERICA PAYMENT RATES.
``The rates for Medicare Advantage for America plans shall be equal
to the rates paid by Medicare for America. The Administrator of the
Center for Healthcare shall pay Medicare Advantage for America plans 95
percent of average Medicare for America costs in each county.
``SEC. 2224. SEPARATE PREMIUM FOR MEDICARE ADVANTAGE FOR AMERICA PLANS
FURNISHING SUPPLEMENTAL BENEFITS.
``Nothing in this part shall preclude an individual from choosing a
Medicare Advantage for America plan which requires the individual to
pay an additional, separate amount because of supplemental benefits or
because it is a more expensive plan. In such case the individual
enrolled under such plan would be responsible for a separate monthly
premium.
``SEC. 2225. PRESCRIPTION DRUG PRICING UNDER MEDICARE ADVANTAGE FOR
AMERICA PLANS.
``Medicare Advantage for America plans, for prescription drugs,
shall pay no more than the price negotiated under Medicare for America.
``SEC. 2226. BAN ON PAYING BROKERS' FEES.
``Medicare Advantage for America plans may not pay fees to
insurance brokers.
``SEC. 2227. CLARIFICATION ON MEDICARE ADVANTAGE EMPLOYER GROUP WAIVER
PLANS AND THE MEDICARE SECONDARY PAYER REQUIREMENT.
``Such plans shall be exempt from the MSP Requirement, and nothing
in this section shall be construed as prohibiting such plans from
contributing to the payment of premiums and cost-sharing.
``SEC. 2228. REFERENCES.
``Beginning in 2029, all references in law and regulation to
Medicare Advantage shall be deemed a reference to Medicare Advantage
for America."''.
SEC. 112. MODIFICATIONS TO AND COORDINATION WITH EXISTING FEDERAL
HEALTH PROGRAMS.
(a) Medicare, Medicaid, and State Children's Health Insurance
Program (SCHIP).--
(1) In general.--Notwithstanding any other provision of
law, subject to paragraphs (2) and (3) and section 2202(c) of
the Social Security Act, as added by section 111--
(A) no benefits shall be available under title
XVIII of the Social Security Act for any item or
service furnished--
(i) beginning on or after January 1, 2029
(except in the case of an individual enrolled
under such title and title XIX of such Act);
and
(ii) beginning on or after January 1, 2031,
with respect to all individuals, including
individuals enrolled under such title and title
XIX of such Act;
(B) no individual is entitled to medical assistance
under a State plan approved under title XIX of such
Act--
(i) for any item or service furnished on or
after January 1, 2031, in the case of an
individual enrolled under such title and title
XVIII of the Social Security Act or an
individual described in subclause (VIII) of
section 1902(a)(10)(A)(i); and
(ii) for any item or service furnished on
or after January 1, 2033;
(C) 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
January 1, 2031; and
(D) no payment shall be made to a State under
section 1903(a) or 2105(a) of such Act with respect to
medical assistance or child health assistance--
(i) for any item or service furnished on or
after January 1, 2031, in the case of an
individual enrolled under such title and title
XVIII of the Social Security Act or an
individual described in subclause (VIII) of
section 1902(a)(10)(A)(i); and
(ii) for any item or service furnished on
or after January 1, 2033.
(2) Transition.--In the case of inpatient hospital services
and extended care services during a continuous period of stay
which began before January 1, 2031, for Medicare and 2033 for
Medicaid or CHIP, and which had not ended as of such date, for
which benefits are provided under title XVIII of the Social
Security Act, under a State plan under title XIX of such Act,
or under a State child health plan under title XXI such Act,
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 stay.
(b) Other Federal Health Programs.--
(1) Federal employees health benefits program.--Nothing in
this Act, or the amendments made by this Act, shall affect
benefits made available under chapter 89 of title 5, United
States Code.
(2) TRICARE.--Nothing in this Act, or the amendments made
by this Act, shall affect benefits made available under
sections 1079 and 1086 of title 10, United States Code.
(3) Treatment of benefits for veterans and native
americans.--
(A) In general.--Nothing in this Act, or the
amendments made by this Act, shall affect the
eligibility of veterans for the medical benefits and
services provided under title 38, United States Code,
or of Indians for the medical benefits and services
provided by or through the Indian Health Service.
(B) Reevaluation.--No reevaluation of the Indian
Health Service shall be undertaken without consultation
with tribal leaders and stakeholders.
(C) Supplemental indian health services
allocation.--The Secretary shall annually determine the
need to provide an allotment of supplemental funds to
Indian Health Services, including payments to
providers, health professional education,
administrative expenses, and prevention and public
health activities.
(4) Enrollee choice.--Nothing in this Act shall preclude
individuals enrolled in the Federal Employees Health Benefits
Program or TRICARE or individuals receiving benefits provided
under title, 38, United States Code or the Indian Health
Service from enrolling in Medicare for America. Enrollees shall
be entitled to the employer contribution as established under
section 126(c) of such Act.
(c) Sunset of Provisions Related to the State Exchanges.--Effective
January 1, 2031, the Federal and State Exchanges established pursuant
to title I of the Patient Protection and Affordable Care Act (Public
Law 111-148) shall terminate, and any other provision of law that
relies upon participation in or enrollment through such an Exchange,
including such provisions of the Internal Revenue Code of 1986, shall
cease to have force or effect.
(d) Severability.--Every provision in this Act and every
application of the provisions in this Act are severable from each other
as a matter of Federal law. If any application of any provision in this
Act to any person or group of persons or circumstances is found by a
court to be invalid, the remainder of this Act and the application of
the Act's provisions to all other persons and circumstances may not be
affected.
Subtitle C--Targeted Reforms
SEC. 121. LIMITATION ON REMOVAL OF MEDICARE ADVANTAGE PROVIDERS BY MA
ORGANIZATIONS.
(a) Limitation.--Section 1852(d) of the Social Security Act (42
U.S.C. 1395w-22(d)) is amended by adding at the end the following:
``(7) Limitation on removal of providers from ma plans by
ma organizations.--
``(A) Removal of providers with cause.--Beginning
with plan year 2026, except as provided in subparagraph
(C), an MA organization offering an MA plan may only
remove a provider of services or a supplier from a
network of such plan if the organization has cause to
remove such provider or supplier.
``(B) Cause to remove providers.--
``(i) In general.--An MA organization
offering an MA plan has cause to remove a
provider of services or a supplier from a
network of such plan if the Secretary
determines that the provider or supplier is--
``(I) medically negligent;
``(II) in violation of any legal or
contractual requirement applicable to
the provider or supplier acting within
the lawful scope of practice, including
any participation or other requirement
applicable to such provider or supplier
under this title or under any
contractual term for such plan; or
``(III) otherwise unfit to furnish
items and services in accordance with
requirements of this title.
``(ii) Consideration of cost to ma
organizations.--For purposes of subparagraph
(A), cost to an MA organization offering an MA
plan due to the participation of a provider of
services or supplier in a network of such plan
does not constitute cause for the MA
organization to remove such provider or
supplier from the network mid-year, and such
cost may not be considered as a factor in favor
of a determination that such organization has
cause to remove the provider.
``(C) Exception.--With respect to each upcoming
plan year, beginning with plan year 2026, an MA
organization offering an MA plan may only remove a
provider of services or supplier from a network of such
plan for reasons not specified in subparagraph (B)(i)
before the date that is 60 days before the first day of
the annual coordinated election period for such plan
year under section 1851(e)(3).
``(D) Notice and appeal process.--
``(i) In general.--Any removal of a
provider of services or supplier from a network
of an MA plan may occur only after the
completion of a fair notice and appeal process
that the Secretary shall establish by
regulation. Such process shall require the MA
organization to provide to such provider or
supplier and to the Secretary an explanation of
the reason or reasons for the removal. The
Secretary shall make this information publicly
available.
``(ii) Application.--
``(I) Application of new process.--
In the case of a removal of a provider
of services or supplier from a network
of an MA plan occurring on or after the
effective date published in a final
rule for such fair notice and appeal
process, such process shall apply in
lieu of the process for the termination
or suspension of a provider contract
under section 422.202(a) of title 42,
Code of Federal Regulations.
``(II) Continuation of old
process.--In the case of a removal of a
provider of services or supplier from a
network of an MA plan occurring before
such effective date, the process for
the termination or suspension of a
provider contract under section
422.202(a) of title 42, Code of Federal
Regulations, shall apply.
``(E) Participant notice and protection.--
``(i) Notice to participants of provider
removal.--Not less than 60 days before the date
on which a provider of services or supplier is
removed from a network of an MA plan, the MA
organization offering such plan shall provide
written notification of the removal to each
individual enrolled in such plan receiving
items or services from the provider or supplier
during the plan year in effect on the date of
removal or during the previous plan year. Such
notification shall include at the minimum--
``(I) the names and telephone
numbers of available in-network
providers of services and suppliers
offering items and services that are
the same or similar to the items and
services offered by the removed
provider or supplier;
``(II) information regarding the
options available to an individual
enrolled in such plan to request the
continuation of medical treatment or
therapy with the removed provider or
supplier; and
``(III) one or more customer
service telephone numbers that an
individual enrolled in such plan may
access to obtain information regarding
changes to the network of the plan.
``(ii) Annual notice of change.--In
addition to providing the notification of
removal as required under clause (i), the MA
organization offering such MA plan shall
include such notification in the annual notice
of change for the MA plan for the upcoming plan
year.
``(iii) Continuity of care.--In any case in
which a provider of services or supplier is
removed from a network of an MA plan, such plan
shall ensure that the removal satisfies the
continuity of care requirements under paragraph
(1)(A) with respect to each individual enrolled
in such plan receiving items or services from
the provider or supplier during the plan year
in effect on the date of removal or during the
previous plan year.
``(F) Rule of construction.--Nothing in this
paragraph shall be construed as affecting the ability
of a provider of services or supplier to decline to
participate in a network of an MA plan.
``(8) Transparency in measures used by ma organizations to
establish or modify provider networks.--
``(A) In general.--Beginning with plan year 2026,
an MA organization offering an MA plan shall publish
and make accessible the information described in
subparagraph (B)--
``(i) in the annual bid information
submitted by the MA organization with respect
to the MA plan under section 1854; and
``(ii) on the Internet Web Site for the MA
plan.
``(B) Information described.--The information
described in this subparagraph is the following:
``(i) Information regarding the measures
used by the MA organization to establish or
modify the provider network of the MA plan,
including measures of the quality and
efficiency of providers. Such information shall
include the specifications, methodology, and
sample size of such measures.
``(ii) Other information related to the
establishment or modification of such provider
network that the Secretary determines
appropriate.
``(C) Limitation.--The information described in
subparagraph (B) shall not include any individually
identifiable information of any provider or supplier of
services.''.
(b) Enforcement.--
(1) Sanctions for noncompliance.--Section 1857(g)(1) of the
Social Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(A) in subparagraph (J), by striking ``or'';
(B) by redesignating subparagraph (K) as
subparagraph (L);
(C) by inserting after subparagraph (J) the
following new subparagraph:
``(K) fails to comply with section 1852(d)(7) or
1852(d)(8); or''; and
(D) in subparagraph (L) (as so redesignated), by
striking ``through (J)'' and inserting ``through (K)''.
(2) Sanctions not applicable to part d.--Title XVIII of the
Social Security Act is amended--
(A) in section 1860D-12(b)(3)(E) (42 U.S.C. 1395w--
(B) in section 1894(e)(6)(B) (42 U.S.C.
1395eee(e)(6)(B)), by inserting ``(other than paragraph
(1)(K) of such section)'' after ``1857(g)(1)''.
(c) Medicare Advantage Plan Compare Tool.--Not later than one year
after the date of enactment of this Act, the Secretary of Health and
Human Services shall take such measures as are necessary to ensure that
the Medicare Advantage Compare Tool takes into account the preferences
and utilization needs of such individuals.
SEC. 122. NETWORK ADEQUACY.
(a) In General.--Section 1852(d) of the Social Security Act (42
U.S.C. 1395w-22(d)) is amended by adding at the end the following:
``(9) Network adequacy requirements.--Beginning in plan
year 2024, notwithstanding any other provision of law, the
following shall apply:
``(A) Provider availability.--When establishing a
plan network, a Medicare Advantage organization
offering an MA plan shall, among other factors
determined by the Secretary, consider the following:
``(i) The anticipated enrollment in the
plan.
``(ii) The expected types of services
provided and utilization of services by
enrollees under the plan.
``(iii) The number and types of providers
needed to provide such services.
``(iv) The number of network providers who
are not accepting new patients.
``(v) The location of providers and
enrollees, taking into account geographic
disbursement.
``(vi) The full-time equivalent
availability of a provider to provide such
services.
``(B) Provision of care in a timely manner.--A
Medicare Advantage organization offering an MA plan
shall ensure that providers are able to provide
services in a timely manner, as defined by the
Secretary, under the plan.
``(C) Application of network access adequacy
standards.--In applying the network access adequacy
standards pursuant to paragraph (1), the Secretary
shall seek input from patient advocacy groups,
providers of services and suppliers, and MA plans under
this part.
``(D) Certification.--Each plan year, a Medicare
Advantage organization shall certify to the Secretary,
with respect to each MA plan offered by the
organization, that the providers, including specialists
and subspecialists, in the plan network are able to
provide the services required under the organization's
contract with the Secretary under section 1857 with
respect to the offering of such plan and to meet the
needs of the enrollees within the plan service area
during the year.
``(E) Annual reporting.--Each plan year, a Medicare
Advantage organization shall report to the Secretary,
and make public the following with respect to each MA
plan offered by the organization:
``(i) Average wait time.--The average wait
time for primary and specialty care for
enrollees under the plan.
``(ii) Utilization of out-of-network
providers.--The utilization of out-of-network
providers under the plan.
``(iii) Average cost per patient.--The
average annual spending per patient for primary
and specialty care for enrollees under the
plan.
``(F) Certification.--In advance of the annual,
coordinated election period under section 1851(e)(3), a
Medicare Advantage organization shall certify to the
Secretary the accuracy of provider directories for each
plan offered by the organization.
``(G) Network review.--The Secretary shall ensure
that the network of each MA plan offered by a Medicare
Advantage organization meets the network adequacy
guidelines established under this paragraph and under
section 422.112(a)(4) of title 42, Code of Federal
Regulations (or any successor regulation to such
section) at least once every 3 years or when a material
change in network occurs.
``(H) Authority.--The Secretary shall have the
authority to stop any further enrollment in a Medicare
Advantage plan if there is a pattern of excessive
violations of this paragraph.''.
(b) Enforcement.--Section 1857(g)(1)(K) of the Social Security Act
(42 U.S.C. 1395w-27(g)(1)(K)), as added by section 2(b), is amended by
striking ``or 1852(d)(8)'' and inserting ``, 1852(d)(8), or
1852(d)(9)''.
SEC. 123. ELIMINATING THE 24-MONTH WAITING PERIOD FOR MEDICARE COVERAGE
FOR INDIVIDUALS WITH DISABILITIES.
(a) In General.--Section 226(b) of the Social Security Act (42
U.S.C. 426(b)) is amended--
(1) in paragraph (2)(A), by striking ``, and has for 24
calendar months been entitled to,'';
(2) in paragraph (2)(B), by striking ``, and has been for
not less than 24 months,'';
(3) in paragraph (2)(C)(ii), by striking ``, including the
requirement that he has been entitled to the specified benefits
for 24 months,'';
(4) in the first sentence, by striking ``for each month
beginning with the later of (I) July 1973 or (II) the twenty-
fifth month of his entitlement or status as a qualified
railroad retirement beneficiary described in paragraph (2),
and'' and inserting ``for each month for which the individual
meets the requirements of paragraph (2), beginning with the
month following the month in which the individual meets the
requirements of such paragraph, and''; and
(5) in the second sentence, by striking ``the'' twenty-
fifth month of his entitlement``'' and all that follows through
``paragraph (2)(C) and''.
(b) Conforming Amendments.--
(1) Section 226.--Section 226 of the Social Security Act
(42 U.S.C. 426) is amended by--
(A) striking subsections (e)(1)(B), (f), and (h);
and
(B) redesignating subsections (g) and (i) as
subsections (f) and (g), respectively.
(2) Medicare description.--Section 1811(2) of the Social
Security Act (42 U.S.C. 1395c(2)) is amended by striking ``have
been entitled for not less than 24 months'' and inserting ``are
entitled''.
(3) Medicare coverage.--Section 1837(g)(1) of the Social
Security Act (42 U.S.C. 1395p(g)(1)) is amended by striking
``25th month of'' and inserting ``month following the first
month of''.
(4) Railroad retirement system.--Section 7(d)(2)(ii) of the
Railroad Retirement Act of 1974 (45 U.S.C. 231f(d)(2)(ii)) is
amended--
(A) by striking ``has been entitled to an annuity''
and inserting ``is entitled to an annuity'';
(B) by striking ``, for not less than 24 months'';
and
(C) by striking ``could have been entitled for 24
calendar months, and''.
(c) 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 the date of enactment of this Act.
SEC. 124. ELIMINATING THE WAITING PERIOD FOR INDIVIDUALS ON STATE
MEDICAID WAITING LISTS.
The Secretary of Health and Human Services is appropriated such
sums as are necessary to facilitate enrollment, not later than 90 days
after the date of the enactment of this Act, all eligible individuals
who, as of the date of the enactment of this Act, are on State Medicaid
waiting lists or State Medicaid waiver waiting lists.
SEC. 125. EMPLOYER HEALTH PLAN OPTIONS.
(a) Definition.--A qualifying employer-sponsored plan is--
(1) a governmental plan (within the meaning of section
2791(d)(8) of the Public Health Service Act); or
(2) any other plan or coverage that meets the criteria
under subsection (b), includes vision, dental, and hearing
benefits, and provides health coverage that is equivalent to an
actuarial value of at least 80 percent of the coverage provided
under title XXII of the Social Security Act and makes a premium
contribution of at least 70 percent.
Such plan shall require a premium contribution from the employer of at
least 70 percent regardless of whether coverage is for single, spousal,
or dependent care.
(b) Obligation.--Large employers shall, with respect to any full-
time employee of such employer--
(1) offer a qualifying employer-sponsored plan to such
employee, in accordance with subsection (a); or
(2) make a contribution of 8 percent of their annual
payroll to the Medicare Trust Fund under title XXII of the
Social Security Act.
(c) Employee Choice.--An employee may opt-out of a qualifying
employer-sponsored plan as satisfied by subsection (b)(1) in order to
enroll in Medicare for America. The employer shall make a contribution
equal to the contribution it shall make in order to meet the
requirements established by subsection (a)(1) or (a)(2). The Secretary
of Health and Human Services shall have authority to set standards for
determining whether employers or insurers are undertaking any actions
to affect the risk pool within Medicare for America by inducing
individuals to decline coverage under a qualifying employer-sponsored
plan and instead to enroll in Medicare for America. An employer
violating such standards shall be treated as not meeting the
requirements of subsection (a).
(d) Employee Education on Health Coverage Options.--Large employers
shall disseminate to employees such publicly available information on
coverage options under Medicare for America as the Secretary deems
appropriate, including contact information for assistance.
(e) Special Rules.--
(1) Annual payroll.--For purposes of this paragraph, the
term ``annual payroll'' means, with respect to any employer for
any calendar year, the aggregate wages paid by the employer
during such calendar year.
(2) Aggregation rules.--Related employers and predecessors
shall be treated as a single employer for purposes of this
subsection.
(3) Reduction for part-time employees.--In the case of a
part-time employee, the employer contribution requirements of
paragraph (1) shall be treated as satisfied if the employer
contribution with respect to such employee is not less than the
part-time employment ratio of the contribution required under
paragraph (1).
(4) Rules related to part-time employment.--For purposes of
this subsection--
(A) Part-time employee.--The term ``part-time
employee'' means, with respect to any month, an
employee who works on average fewer than 30 hours per
week.
(B) Part-time employment ratio.--The term ``part-
time employment ratio'' means, with respect to a part-
time employee of an employer in a month, a fraction--
(i) the numerator of which is the number of
hours in the employee's normal work week; and
(ii) the denominator of which is 30 hours.
(C) Special rules.--Under rules prescribed by the
Secretary of Health and Human Services, in consultation
with the Secretary of the Treasury, in the case of an
employee for an employer whose defined work week for
full-time employees is less than 30 hours, any
reference in this subsection to 30 hours is deemed a
reference to the number of hours in the work week so
defined.
(D) Conversion to hours of employment.--The
Secretary of Health and Human Services, in consultation
with the Secretary of the Treasury, shall establish
rules for the conversion of compensation to hours of
employment, for purposes of this subsection in the case
of employees that receive compensation on a salaried
basis, or on the basis of a commission, or other
contingent or bonus basis, rather than based on an
hourly wage.
(f) Timing and Manner.--Each employer that makes a financial
contribution under subsection (b)(2) and (c) under this section (other
than with respect to coverage under a group health plan) shall pay such
contribution in a form and manner, specified by the Secretary of the
Treasury, based upon the form and manner in which employer excise taxes
are required to be paid under section 3111 of the Internal Revenue Code
of 1986.
(g) Non-Discrimination.--
(1) In general.--Except as otherwise provided for in this
title (or an amendment made by this title), an individual shall
not, on the ground prohibited under title VI of the Civil
Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX of the
Education Amendments of 1972 (20 U.S.C. 1681 et seq.), the Age
Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), or section
504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), be
excluded from participation in, be denied the benefits of, or
be subjected to discrimination under, any health program or
activity, any part of which is receiving Federal financial
assistance, including credits, subsidies, or contracts of
insurance, or under any program or activity that is
administered by an Executive Agency or any entity established
under this title (or amendments) or any employer-sponsored
insurance.
(2) Continued application of laws.--Nothing in this title
(or an amendment made by this title) shall be construed to
invalidate or limit the rights, remedies, procedures, or legal
standards available to individuals aggrieved under title VI of
the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title
VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.),
title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et
seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
794), or the Age Discrimination Act of 1975 (42 U.S.C. 611 et
seq.), or to supersede State laws that provide additional
protections against discrimination on any basis described in
paragraph (1).
(3) Limitation.--A group health plan may not establish
rules relating to the health insurance coverage eligibility
(including continued eligibility) or contribution requirements
of any full-time employee under the terms of the plan that have
the effect of discriminating in favor of higher-wage employees.
(4) Regulations.--The Secretary of Health and Human
Services, in conjunction with the Secretary of Labor, may
promulgate regulations to implement this subsection.
SEC. 126. PROHIBITION ON STEP THERAPY AND PRIOR AUTHORIZATION UNDER
GROUP HEALTH PLANS.
Section 2719A of the Public Health Service Act (42 U.S.C. 300gg-
19a) is amended by adding at the end the following new subsection:
``(e) Prohibition Against Step Therapy and Prior Authorization.--
Beginning with the first plan year following the date of the enactment
of this subsection, a group health plan may not require a prior
authorization determination for coverage of any benefit under such plan
and may not apply treatment limitations through the use of step therapy
protocols.''.
SEC. 127. MEDICARE OUTPATIENT OBSERVATION SERVICES.
Section 1861(i) of the Social Security Act (42 U.S.C. 1395x(i)) is
amended by adding at the end the following: ``For purposes of this
subsection, an individual receiving outpatient observation services
shall be deemed to be an inpatient during such period, and the date
such individual ceases receiving such services shall be deemed the
hospital discharge date (unless such individual is admitted as a
hospital inpatient at the end of such period)''.
SEC. 128. ABORTION COVERAGE.
Notwithstanding any other provision of law, Federal funds may be
used to provide for abortion services under any health program or
activity.
SEC. 129. APPLICABILITY OF MENTAL HEALTH PARITY.
Section 2726 of the Public Health Service Act shall apply to all
health coverage in the same manner and to the same extent as such
section applies to health insurance issuers and group health plans
under title XXVII of such Act.
SEC. 130. STUDENT LOAN FORGIVENESS FOR HEALTH CARE PROVIDERS
PARTICIPATING IN MEDICARE FOR AMERICA.
(a) In General.--Beginning on the date after the date of the
enactment of this Act, after the conclusion of each plan year, the
Secretary of Health and Human Services, in conjunction with the
Secretary of Education, shall cancel the applicable percent specified
in subsection (b) of the total amount due on any eligible Federal loan
made 20 years prior to date of enactment and any date after the date of
enactment of this Act for a borrower who is a Medicare for America
participating provider and submits an employment certification form
described in subsection (d).
(b) Applicable Percent.--For purposes of subsection (a), the
applicable percent is 10 percent of any eligible Federal loan for each
year the health care provider participates in Medicare for America.
(c) Definitions.--In this section:
(1) Eligible federal loan.--The term ``eligible Federal
loan'' means any loan made under part D of title IV of the
Higher Education Act of 1965 (20 U.S.C. 1087a).
(2) Health care provider.--The term ``health care
provider'' means a physician, physician assistant, registered
nurse, nurse practitioner, advanced practice nurse, licensed
practical nurse, psychologist, mental health counselor,
marriage and family therapist, direct care worker, health
social worker, dentist, dental hygienist, pharmacist, physical
therapist, occupational therapist, or any other health care
provider specified by the Secretary of Health and Human
Services if the Secretary determines such specification for
purposes of this section is necessary to ensure workforce
adequacy.
(3) Medicare for america participating provider.--The term
``Medicare for America participating provider'' means a health
care provider that meets the definition of such term under
section 105 or works at a participating provider or entity as
defined under section 105.
(d) Employment Certification Form.--
(1) In general.--In order to receive loan cancellation
under this paragraph, a borrower shall submit to the Secretary
of Education an employment certification form that is developed
by the Secretary of Education and includes self-certification
of employment and a separate part for employer certification
that indicates the dates of employment.
(2) Deferment.--If a borrower submits to the Secretary of
Education the employment certification form described in
paragraph (1), during the period in which the borrower is
employed as a Medicare for America participating provider for
which loan cancellation is eligible under this section, the
borrower's eligible Federal Direct Loan shall be placed in
deferment.
(e) Interest Canceled.--If a portion of a loan is canceled under
this section for any year, the entire amount of interest on such loan
that accrues for such year shall be canceled.
(f) Regulations.--The Secretary of Health and Human Services and
the Secretary of Education may promulgate regulations to implement this
section.
SEC. 131. CLARIFICATION OF THE DEFINITION OF PEDIATRIC MEDICAL
NECESSITY IN QUALIFYING GROUP COVERAGE.
(a) Definition.--The following definition of pediatric medical
necessity shall be incorporated into benefit standards of all plans
subject to the requirements of section 1302 of the Patient Protection
and Affordable Care Act (42 U.S.C. 18022) and all group plans by 2026.
(b) Development of Definition.--Pediatric medical necessity, or
pediatric medically necessary care, shall be defined as health care
interventions that are evidence based, evidence informed, or based on
consensus advisory opinion and that are recommended by recognized
health care professionals, to promote optimal growth and development in
a child and to prevent, detect, diagnose, treat, ameliorate, or
palliate the effects of physical, genetic, congenital, developmental,
behavioral, or mental conditions, injuries, or disabilities.
(c) Updates to Definition.--The Secretary of Health and Human
Services, in consultation with experts in the field of pediatric care
and key stakeholders, including patient and family groups, shall review
and update this definition on a biennial basis, consistent with up-to-
date standards of pediatric healthcare practice that are based on--
(1) the views of pediatric healthcare providers and experts
practicing in relevant clinical areas;
(2) recommendations of medical-specialty societies, other
pediatric healthcare provider organizations, and family and
patient groups; and
(3) credible scientific evidence published in peer-reviewed
literature that is generally recognized by the relevant health
care provider community.
SEC. 132. SAFE STAFFING REQUIREMENTS.
(a) Minimum Direct Care Registered Nurse Staffing Requirements.--
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by
adding at the end the following new title:
``TITLE XXXIV--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING
REQUIREMENT
``SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.
``(a) Staffing Plan.--
``(1) In general.--A hospital shall implement a staffing
plan that--
``(A) provides adequate, appropriate, and quality
delivery of health care services and protects patient
safety; and
``(B) is consistent with the requirements of this
title.
``(2) Effective dates.--
``(A) Implementation of staffing plan.--Subject to
subparagraph (B), the requirements under paragraph (1)
shall take effect on a date to be determined by the
Secretary, but not later than 1 year after the date of
the enactment of this title.
``(B) Application of minimum direct care registered
nurse-to-patient ratios.--The requirements under
subsection (b) shall take effect as soon as
practicable, as determined by the Secretary, but not
later than--
``(i) 2028; and
``(ii) in the case of a hospital in a rural
area (as defined in section 1886(d)(2)(D) of
the Social Security Act), 2030.
``(b) Minimum Direct Care Registered Nurse-to-Patient Ratios.--
``(1) In general.--Except as provided in paragraph (4) and
other provisions of this section, a hospital's staffing plan
shall provide that, at all times during each shift within a
unit of the hospital, and with a full complement of ancillary
and support staff, a direct care registered nurse may be
assigned to not more than the following number of patients in
that unit:
``(A) One patient in trauma emergency units.
``(B) One patient in operating room units, provided
that a minimum of 1 additional person serves as a scrub
assistant in such unit.
``(C) Two patients in critical care units,
including neonatal intensive care units, emergency
critical care and intensive care units, labor and
delivery units, coronary care units, acute respiratory
care units, postanesthesia units, and burn units.
``(D) Three patients in emergency room units,
pediatrics units, stepdown units, telemetry units,
antepartum units, and combined labor, delivery, and
postpartum units.
``(E) Four patients in medical-surgical units,
intermediate care nursery units, acute care psychiatric
units, and other specialty care units.
``(F) Five patients in rehabilitation units and
skilled nursing units.
``(G) Six patients in postpartum (3 couplets) units
and well-baby nursery units.
``(2) Similar units with different names.--The Secretary
may apply minimum direct care registered nurse-to-patient
ratios established in paragraph (1) for a hospital unit
referred to in such paragraph to a type of hospital unit not
referred to in such paragraph if such type of hospital unit
provides a level of care to patients whose needs are similar to
the needs of patients cared for in the hospital unit referred
to in such paragraph.
``(3) Application of ratios to hospital nursing practice
standards.--
``(A) In general.--A patient assignment may be
included in the calculation of the direct care
registered nurse-to-patient ratios required in this
subsection only if care is provided by a direct care
registered nurse and the provision of care to the
particular patient is within that direct care
registered nurse's competence.
``(B) Demonstration of unit-specific competence.--A
hospital shall not assign a direct care registered
nurse to a hospital unit unless that hospital
determines that the direct care registered nurse has
demonstrated current competence in providing care in
that unit, and has also received orientation to that
hospital's unit sufficient to provide competent care to
patients in that unit.
``(C) Duties of the assigned direct care registered
nurse.--Each patient shall be assigned to a direct care
registered nurse who shall directly provide the
assessment, planning, supervision, implementation, and
evaluation of the nursing care provided to the patient
at least every shift and has the responsibility for the
provision of care to a particular patient within his or
her scope of practice.
``(D) Nurse administrators and supervisors.--A
registered nurse who is a nurse administrator, nurse
supervisor, nurse manager, charge nurse, case manager,
or any other hospital administrator or supervisor,
shall not be included in the calculation of the direct
care registered nurse-to-patient ratio unless that
nurse has a current and active direct patient care
assignment and provides direct patient care in
compliance with the requirements of this section,
including competency requirements. The exemption in
this subsection shall apply only during the hours in
which the individual registered nurse has the principal
responsibility of providing direct patient care and has
no additional job duties as would a direct care
registered nurse.
``(E) Other personnel.--Other personnel may perform
patient care tasks based on their training and
demonstrated skill but may not perform or assist in
direct care registered nurse functions unless
authorized to do in accordance with State scope of
practice laws and regulations.
``(F) Temporary nursing personnel.--A hospital
shall not assign any nursing personnel from temporary
nursing agencies patient care to any hospital unit
without such personnel having demonstrated competence
on the assigned unit and received orientation to that
hospital's unit sufficient to provide competent care to
patients in that unit.
``(G) Ancillary and additional staffing.--The need
for additional staffing of direct care registered
nurses, licensed vocational or practical nurses,
licensed psychiatric technicians, certified nursing or
patient care assistants, or other licensed or
unlicensed ancillary staff above the minimum registered
nurse-to-patient ratios shall be based on the
assessment of the individual patient's nursing care
requirement, the individual patient's nursing care
plan, and acuity level.
``(4) Restrictions.--
``(A) Prohibition against averaging.--A hospital
shall not average the number of patients and the total
number of direct care registered nurses assigned to
patients in a hospital unit during any 1 shift or over
any period of time for purposes of meeting the
requirements under this subsection.
``(B) Prohibition against imposition of mandatory
overtime requirements.--A hospital shall not impose
mandatory overtime requirements to meet the hospital
unit direct care registered nurse-to-patient ratios
required under this subsection.
``(C) Relief during routine absences.--A hospital
shall ensure that only a direct care registered nurse
who has demonstrated current competence to the hospital
in providing care on a particular unit and has also
received orientation to that hospital's unit sufficient
to provide competent care to patients in that unit may
relieve another direct care registered nurse during
breaks, meals, and other routine, expected absences
from a hospital unit.
``(D) Application of direct care registered nurse-
to-patient ratios in patient-acuity adjustable units.--
Patients shall be cared for only on units or patient
care areas where the direct care registered nurse-to-
patient ratios meet the level of intensity, type of
care, and the individual requirements and needs of each
patient. Notwithstanding paragraph (2), hospitals that
provide patient care in units or patient care areas
that are acuity adaptable or acuity adjustable shall
apply the direct care registered nurse-to-patient ratio
required in this section for the highest patient acuity
level or level of care in that unit or patient care
area, and shall comply with all other requirements of
this section.
``(E) Use of video monitors.--A hospital shall not
employ video monitors or any form of electronic
visualization of a patient as a substitute for the
direct observation required for patient assessment by
the direct care registered nurse or required for
patient protection. Video monitors or any form of
electronic visualization of a patient shall not be
included in the calculation of the direct care
registered nurse-to-patient ratio required in this
subsection and shall not replace the requirement of
paragraph (3)(D) that each patient shall be assigned to
a direct care registered nurse who shall directly
provide the assessment, planning, supervision,
implementation, and evaluation of the nursing care
provided to the patient at least every shift and have
the responsibility for the provision of care to a
particular patient within his or her scope of practice.
``(F) Use of other technology.--A hospital shall
not employ technology that substitutes for the assigned
registered nurse's professional judgment in assessment,
planning, implementation, and evaluation of care.
``(5) Adjustment of ratios.--
``(A) In general.--If necessary to protect patient
safety, the Secretary may prescribe regulations that--
``(i) increase minimum direct care
registered nurse-to-patient ratios under this
subsection to reduce the number of patients
that may be assigned to each direct care nurse;
or
``(ii) add minimum direct care registered
nurse-to-patient ratios for units not referred
to in paragraphs (1) and (2).
``(B) Consultation.--Such regulations shall be
prescribed after consultation with affected hospitals
and registered nurses.
``(6) Ancillary and additional staffing.--
``(A) In general.--The Secretary may prescribe
regulations requiring additional staffing of direct
care registered nurses, licensed vocational or practice
nurses, licensed psychiatric technicians, certified
nursing or patient care assistants, or other licensed
or unlicensed ancillary staff above the minimum
registered nurse-to-patient ratios that is based on the
assessment of the individual patient's nursing care
needs, the individual patient's nursing care plan, and
acuity level.
``(B) Consultation.--Such regulations shall be
prescribed after consultation with affected hospitals,
registered nurses, and ancillary staff.
``(7) Relationship to state-imposed ratios.--Nothing in
this title shall preempt State standards that the Secretary
determines to be as stringent as Federal requirements for a
staffing plan established under this title. Minimum direct care
registered nurse-to-patient ratios established under this
subsection shall not preempt State requirements that the
Secretary determines are as stringent as to Federal
requirements for direct care registered nurse-to-patient ratios
established under this title.
``(8) Exemption in emergencies.--The requirements
established under this subsection shall not apply during a
state of emergency if a hospital is requested or expected to
provide an exceptional level of emergency or other medical
services. If a hospital seeks to apply the exemption under this
paragraph in response to a complaint filed against the hospital
for a violation of the provisions of this title, the hospital
must demonstrate that prompt and diligent efforts were made to
maintain required staffing levels. The Secretary shall issue
guidance to hospitals that describes situations that constitute
a state of emergency for purposes of the exemption under this
paragraph and shall establish necessary penalties for
violations of this paragraph consistent with section 3406.
``(c) Development and Reevaluation of Staffing Plan.--
``(1) Considerations in development of plan.--In developing
the staffing plan, a hospital shall provide for direct care
registered nurse-to-patient ratios above the minimum direct
care registered nurse-to-patient ratios required under
subsection (b) if appropriate based upon consideration of, at a
minimum, the following factors:
``(A) The number of patients on a particular unit
on a shift-by-shift basis.
``(B) The acuity level and nursing care plan of
patients on a particular unit on a shift-by-shift
basis.
``(C) The anticipated admissions, discharges, and
transfers of patients during each shift that impacts
direct patient care.
``(D) Specialized experience required of direct
care registered nurses on a particular unit.
``(E) Staffing levels and services provided by
licensed vocational or practical nurses, licensed
psychiatric technicians, certified nurse assistants, or
other ancillary staff in meeting direct patient care
needs not required by a direct care registered nurse.
``(F) The level of familiarity with hospital
practices, policies, and procedures by temporary agency
direct care registered nurses used during a shift.
``(G) Obstacles to efficiency in the delivery of
patient care presented by physical layout.
``(2) Documentation of staffing.--A hospital shall specify
the system used to document actual staffing in each unit for
each shift.
``(3) Annual reevaluation of plan.--
``(A) In general.--A hospital shall annually
evaluate its staffing plan in each unit in relation to
actual patient care requirements.
``(B) Update.--A hospital shall update its staffing
plan to the extent appropriate based on such
evaluation.
``(4) Transparency.--
``(A) In general.--Any staffing plan or method used
to create and evaluate acuity-level and adopted by a
hospital under this section shall be transparent in all
respects, including disclosure of detailed
documentation of the methodology used to determine
nursing staffing, identifying each factor, assumption,
and value used in applying such methodology.
``(B) Public availability.--The Secretary shall
establish procedures to provide that the documentation
submitted under subsection (d) is available for public
inspection in its entirety.
``(5) Registered nurse participation.--A staffing plan of a
hospital--
``(A) shall be developed and subsequent
reevaluations shall be conducted under this subsection
on the basis of input from direct care registered
nurses at the hospital from each unit or patient care
area; and
``(B) where such nurses are represented through
collective bargaining, shall require bargaining with
the applicable recognized or certified collective
bargaining representative of such nurses. Nothing in
this title shall be construed to permit conduct
prohibited under the National Labor Relations Act or
chapter 71 of title 5, United States Code.
``(6) Staffing committees.--If a hospital maintains a
staffing committee, then the committee shall include at least
one registered nurse from each hospital unit and shall be
composed of at least 50 percent direct care registered nurses.
The staffing committee shall include meaningful representation
of other direct care nonmanagement staff. Direct care
registered nurses who serve on the committee shall be selected
by other direct care registered nurses from their unit. Other
direct care nonmanagement staff shall be selected by other
direct care nonmanagement staff. Participation on staffing
committees shall be considered a part of the employee's
regularly scheduled work week.
``(d) Submission of Plan to Secretary.--A hospital shall submit to
the Secretary its staffing plan and any annual updates under subsection
(c)(3)(B). A federally operated hospital may submit its staffing plan
through the department or agency operating the hospital.
``SEC. 3402. POSTING, RECORDS, AND AUDITS.
``(a) Posting Requirements.--In each unit, a hospital shall post a
uniform notice in a form specified by the Secretary in regulation
that--
``(1) explains requirements imposed under section 3401;
``(2) includes actual direct care registered nurse-to-
patient ratios during each shift;
``(3) includes the actual number and titles of direct care
registered nurses assigned during each shift; and
``(4) is visible, conspicuous, and accessible to staff,
patients, and the public.
``(b) Records.--
``(1) Maintenance of records.--Each hospital shall maintain
accurate records of actual direct care registered nurse-to-
patient ratios in each unit for each shift for no less than 3
years. Such records shall include--
``(A) the number of patients in each unit;
``(B) the identity and duty hours of--
``(i) each direct care registered nurse
assigned to each patient in each unit in each
shift; and
``(ii) ancillary staff who are under the
coordination of the direct care registered
nurse;
``(C) certification that each nurse received rest
and meal breaks and the identity and duty hours of each
direct care registered nurse who provided such relief;
and
``(D) a copy of each notice posted under subsection
(a).
``(2) Availability of records.--Each hospital shall make
its records maintained under paragraph (1) available to--
``(A) the Secretary;
``(B) registered nurses and their collective
bargaining representatives (if any); and
``(C) the public under regulations established by
the Secretary, or in the case of a federally operated
hospital, under section 552 of title 5, United States
Code (commonly known as the Freedom of Information
Act).
``(c) Audits.--The Secretary shall conduct periodic audits to
ensure--
``(1) implementation of the staffing plan in accordance
with this title; and
``(2) accuracy in records maintained under this section.
``SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL NURSE STAFFING
REQUIREMENTS.
``(a) Establishment.--A hospital's staffing plan shall comply with
minimum direct care licensed practical nurse staffing requirements that
the Secretary establishes for units in hospitals. Such staffing
requirements shall be established not later than 18 months after the
date of the enactment of this title, and shall be based on the study
conducted under subsection (b).
``(b) Study.--Not later than 1 year after the date of the enactment
of this title, the Secretary, acting through the Director of the Agency
for Healthcare Research and Quality, shall complete a study of licensed
practical nurse staffing and its effects on patient care in hospitals.
The Director may contract with a qualified entity or organization to
carry out such study under this paragraph. The Director shall consult
with licensed practical nurses and organizations representing licensed
practical nurses regarding the design and conduct of the study.
``(c) Application of Registered Nurse Provisions to Licensed
Practical Nurse Staffing Requirements.--Paragraphs (2), (4)(A), (4)(B),
(4)(C), and (6) of section 3401(b), paragraphs (1), (2), (3), and (4)
of section 3401(c), and section 3402 shall apply to the establishment
and application of direct care licensed practical nurse staffing
requirements under this section pursuant to the additional staffing
requirements under subsection (b)(3)(G) of section 3401 and in the same
manner that they apply to the establishment and application of direct
care registered nurse-to-patient ratios under sections 3401 and 3402.
``(d) Effective Date.--The requirements of this section shall take
effect as soon as practicable, as determined by the Secretary, but not
later than--
``(1) 2 years after the date of the enactment of this
title; and
``(2) in the case of a hospital in a rural area (as defined
in section 1886(d)(2)(D) of the Social Security Act), 4 years
after the date of the enactment of this title.
``(e) Study.--Not later than 1 year after the date of the enactment
of this title, the Secretary, acting through the Director of the Agency
for Healthcare Research and Quality, shall complete a study of
registered and practical nurse staffing requirements in clinics and
other outpatient settings, and its effects on patient care in
outpatient settings. The Director may contract with a qualified entity
or organization to carry out such study under this subsection. The
Director shall consult with registered nurses and licensed practice
nurses working in outpatient settings, including professional nursing
associations and labor organizations representing both registered and
practice nurses working in outpatient settings regarding the design and
conduct of the study.
``SEC. 3404. WHISTLEBLOWER AND PATIENT PROTECTIONS.
``(a) Professional Obligation and Rights.--All nurses have a duty
and right to act based on their professional judgment in accordance
with State nursing laws and regulations of the State in which the
direct nursing care is being performed and to provide care in the
exclusive interests of the patients and to act as the patient's
advocate.
``(b) Acceptance of Patient Care Assignments.--The nurse is
responsible for providing competent, safe, therapeutic, and effective
nursing care to assigned patients. Before accepting a patient
assignment, a nurse shall--
``(1) have the necessary professional knowledge, judgment,
skills, and ability to provide the required care;
``(2) determine using professional judgment in accordance
with State nursing laws and regulations of the State in which
the direct nursing care is being performed whether the nurse is
competent to perform the nursing care required; and
``(3) determine whether acceptance of a patient assignment
would expose the patient or nurse to risk of harm.
``(c) Objection to or Refusal of Assignment.--A nurse may object
to, or refuse to participate in, any activity, policy, practice,
assignment, or task if in good faith--
``(1) the nurse reasonably believes it to be in violation
of section 3401 or 3403; or
``(2) the nurse is not prepared by education, training, or
experience to fulfill the assignment without compromising the
safety of any patient or jeopardizing the license of the nurse.
``(d) Retaliation for Objection to or Refusal of Assignment
Barred.--
``(1) No discharge, discrimination, or retaliation.--No
hospital shall discharge, retaliate, discriminate, or otherwise
take adverse action in any manner with respect to any aspect of
a nurse's employment (as defined in section 3407), including
discharge, promotion, compensation, or terms, conditions, or
privileges of employment, based on the nurse's refusal of a
work assignment under subsection (c).
``(2) No filing of complaint.--No hospital shall file a
complaint or a report against a nurse with a State professional
disciplinary agency because of the nurse's refusal of a work
assignment under subsection (c).
``(e) Cause of Action.--Any nurse, collective bargaining
representative, or legal representative of any nurse who has been
discharged, discriminated against, or retaliated against in violation
of subsection (d)(1) or against whom a complaint or report has been
filed in violation of subsection (d)(2) may (without regard to whether
a complaint has been filed under subsection (f) of this section or
subsection (b) of section 3406) bring a cause of action in a United
States district court. A nurse who prevails on the cause of action
shall be entitled to one or more of the following:
``(1) Reinstatement.
``(2) Reimbursement of lost wages, compensation, and
benefits.
``(3) Attorneys' fees.
``(4) Court costs.
``(5) Other damages.
``(f) Complaint to Secretary.--A nurse, patient, collective
bargaining representative, or other individual may file a complaint
with the Secretary against a hospital that violates the provisions of
this title. For any complaint filed, the Secretary shall--
``(1) receive and investigate the complaint;
``(2) determine whether a violation of this title as
alleged in the complaint has occurred; and
``(3) if such a violation has occurred, issue an order that
the complaining nurse or individual shall not suffer any
discharge, retaliation, discrimination, or other adverse action
prohibited by subsection (d) or subsection (h).
``(g) Toll-Free Telephone Number.--
``(1) In general.--The Secretary shall provide for the
establishment of a toll-free telephone hotline to provide
information regarding the requirements under sections 3401
through 3403 and to receive reports of violations of such
section.
``(2) Notice to patients.--A hospital shall provide each
patient admitted to the hospital for inpatient care with the
hotline described in paragraph (1), and shall give notice to
each patient that such hotline may be used to report inadequate
staffing or care.
``(h) Protection for Reporting.--
``(1) Prohibition on retaliation or discrimination.--A
hospital shall not discriminate or retaliate in any manner
against any patient, employee, or contract employee of the
hospital, or any other individual, on the basis that such
individual, in good faith, individually or in conjunction with
another person or persons, has presented a grievance or
complaint, or has initiated or cooperated in any investigation
or proceeding of any governmental entity, regulatory agency, or
private accreditation body, made a civil claim or demand, or
filed an action relating to the care, services, or conditions
of the hospital or of any affiliated or related facilities.
``(2) Good faith defined.--For purposes of this subsection,
an individual shall be deemed to be acting in good faith if the
individual reasonably believes--
``(A) the information reported or disclosed is
true; and
``(B) a violation of this title has occurred or may
occur.
``(i) Prohibition on interference with
rights.--
``(1) Exercise of rights.--It shall be unlawful for any
hospital to--
``(A) interfere with, restrain, or deny the
exercise, or attempt to exercise, by any person of any
right provided or protected under this title; or
``(B) coerce or intimidate any person regarding the
exercise or attempt to exercise such right.
``(2) Opposition to unlawful policies or practices.--It
shall be unlawful for any hospital to discriminate or retaliate
against any person for opposing any hospital policy, practice,
or actions which are alleged to violate, breach, or fail to
comply with any provision of this title.
``(3) Prohibition on interference with protected
communications.--A hospital (or an individual representing a
hospital) shall not make, adopt, or enforce any rule,
regulation, policy, or practice which in any manner directly or
indirectly prohibits, impedes, or discourages a direct care
nurse from, or intimidates, coerces, or induces a direct care
nurse regarding, engaging in free speech activities or
disclosing information as provided under this title.
``(4) Prohibition on interference with collective action.--
A hospital (or an individual representing a hospital) shall not
in any way interfere with the rights of nurses to organize,
bargain collectively, and engage in concerted activity under
section 7 of the National Labor Relations Act (29 U.S.C. 157).
``(j) Notice.--A hospital shall post in an appropriate location in
each unit a conspicuous notice in a form specified by the Secretary
that--
``(1) explains the rights of nurses, patients, and other
individuals under this section;
``(2) includes a statement that a nurse, patient, or other
individual may file a complaint with the Secretary against a
hospital that violates the provisions of this title; and
``(3) provides instructions on how to file such a
complaint.
``(k) Effective Date.--
``(1) Refusal; retaliation; cause of action.--
``(A) In general.--Subsections (c) through (e)
shall apply to objections and refusals occurring on or
after the effective date of the provision of this title
to which the objection or refusal relates.
``(B) Exception.--Subsection (c)(2) shall not apply
to objections or refusals in any hospital before the
requirements of section 3401(a) or 3403(a), as
applicable, apply to that hospital.
``(2) Protections for reporting.--Subsection (h)(1) shall
apply to actions occurring on or after the effective date of
the provision to which the violation relates, except that such
subsection shall apply to initiation, cooperation, or
participation in an investigation or proceeding on or after the
date of enactment of this title.
``(3) Notice.--Subsection (j) shall take effect 18 months
after the date of enactment of this title.
``SEC. 3405. ENFORCEMENT.
``(a) In General.--The Secretary shall enforce the requirements and
prohibitions of this title in accordance with this section.
``(b) Procedures for Receiving and Investigating Complaints.--The
Secretary shall establish procedures under which--
``(1) any person may file a complaint alleging that a
hospital has violated a requirement or a prohibition of this
title; and
``(2) such complaints shall be investigated by the
Secretary.
``(c) Remedies.--If the Secretary determines that a hospital has
violated a requirement of this title, the Secretary--
``(1) shall require the facility to establish a corrective
action plan to prevent the recurrence of such violation; and
``(2) may impose civil money penalties, as described in
subsection (d).
``(d) Civil Penalties.--
``(1) In general.--In addition to any other penalties
prescribed by law, the Secretary may impose civil penalties as
follows:
``(A) Hospital liability.--The Secretary may impose
on a hospital found to be in violation of this title a
civil money penalty of--
``(i) not more than $25,000 for the first
knowing violation of this title by such
hospital; and
``(ii) not more than $50,000 for any
subsequent knowing violation of this title by
such hospital.
``(B) Individual liability.--The Secretary may
impose on an individual who--
``(i) is employed by a hospital found by
the Secretary to have violated this title; and
``(ii) knowingly violates this title, a
civil money penalty of not more than $20,000
for each such violation by the individual.
``(2) Procedures.--The provisions of section 1128A of the
Social Security Act (other than subsections (a) and (b)) shall
apply with respect to a civil money penalty or proceeding under
this subsection in the same manner as such provisions apply
with respect to a civil money penalty or proceeding under such
section 1128A.
``(e) Public Notice of Violations.--
``(1) Internet website.--The Secretary shall publish on the
internet website of the Department of Health and Human Services
the names of hospitals on which a civil money penalty has been
imposed under this section, the violation for which such
penalty was imposed, and such additional information as the
Secretary determines appropriate.
``(2) Change of ownership.--With respect to a hospital that
had a change of ownership, as determined by the Secretary,
penalties imposed on the hospital while under previous
ownership shall no longer be published by the Secretary
pursuant to paragraph (1) after the 1-year period beginning on
the date of change of ownership.
``(f) Use of Funds.--Funds collected by the Secretary pursuant to
this section are authorized to be appropriated to carry out this title.
``SEC. 3406. DEFINITIONS.
``For purposes of this title:
``(1) Acuity level.--The term `acuity level' means the
determination, using a hospital acuity measurement tool that
has been developed and established in coordination with direct
care registered nurses and made transparent pursuant to section
3401(c)(4), of nursing care requirements, based on the assigned
direct care registered nurse's professional judgment of--
``(A) the severity and complexity of an individual
patient's illness or injury;
``(B) the need for specialized equipment; and
``(C) the intensity of nursing interventions
required.
``(2) Competence.--The term `competence' or `competent'
means the satisfactory application of the duties and
responsibilities of a registered nurse in providing nursing
care to specific patient populations and for acuity levels for
each patient care unit or area pursuant to the State nursing
laws and regulations of the State in which the direct nursing
care is being performed.
``(3) Direct care licensed practical nurse.--The term
`direct care licensed practical nurse' means an individual who
has been granted a license by at least one State to practice as
a licensed practical nurse or a licensed vocational nurse and
who provides bedside care for one or more patients.
``(4) Direct care registered nurse.--The term `direct care
registered nurse' means an individual who has been granted a
license by at least one State to practice as a registered nurse
and who provides bedside care for one or more patients.
``(5) Employment.--The term `employment' includes the
provision of services under a contract or other arrangement.
``(6) Hospital.--The term `hospital' has the meaning given
that term in section 1861(e) of the Social Security Act.
``(7) Nurse.--The term `nurse' means any direct care
registered nurse or direct care licensed practice nurse (as the
case may be), regardless of whether or not the nurse is an
employee.
``(8) Nursing care plan.--The term `nursing care plan'
means a plan developed by the assigned direct care registered
nurse (in accordance with nursing law in the State in which the
nursing care is performed) that indicates the nursing care to
be given to individual patients that--
``(A) considers the acuity level of the patient;
``(B) is developed in coordination with the
patient, the patient's family, or other representatives
when appropriate, and staff of other disciplines
involved in the care of the patient;
``(C) reflects all elements of the nursing process;
and
``(D) recommends the number and skill mix of
additional licensed and unlicensed direct care staff
needed to fully implement the nursing care plan.
``(9) Professional judgment.--The term `professional
judgment' means, in accordance with State nursing laws and
regulations of the State in which the direct nursing care is
being performed, the direct care registered nurse's application
of knowledge, expertise, and experience in conducting a
comprehensive nursing assessment of each patient and in making
independent decisions about patient care including the need for
additional staff.
``(10) Staffing plan.--The term `staffing plan' means a
staffing plan required under section 3401.
``(11) State of emergency.--The term `state of emergency'--
``(A) means a state of emergency that is an
unpredictable or unavoidable occurrence at an
unscheduled or unpredictable interval, relating to
health care delivery and requiring immediate medical
interventions and care; and
``(B) does not include a state of emergency that
results from a labor dispute in the health care
industry or consistent understaffing.
``SEC. 3407. RULE OF CONSTRUCTION.
``Nothing in this title shall be construed to authorize disclosure
of private and confidential patient information, if such disclosure is
not authorized or required by other applicable law.''.
(b) Recommendations to Congress.--Not later than 1 year after the
date of enactment of this Act, the Secretary of Health and Human
Services shall submit to Congress a report containing recommendations
for ensuring that sufficient numbers of nurses are available to meet
the requirements imposed by title XXXIV of the Public Health Service
Act, as added by subsection (a).
(c) Report by HRSA.--
(1) In general.--Not later than 2 years after the date of
enactment of this Act, the Administrator of the Health
Resources and Services Administration, in consultation with the
National Health Care Workforce Commission, shall submit to
Congress a report regarding the relationship between nurse
staffing levels and nurse retention in hospitals.
(2) Updated report.--Not later than 5 years after the date
of enactment of this Act, the Administrator of the Health
Resources and Services Administration, in consultation with the
National Health Care Workforce Commission, shall submit to
Congress an update of the report submitted under paragraph (1).
(d) Enforcement of Requirements Through Federal Programs.--
(1) Medicare program.--Section 1866(a)(1) of the Social
Security Act (42 U.S.C. 1395cc(a)(1)) is amended--
(A) in subparagraph (X), by striking ``, and'' and
inserting a comma;
(B) in subparagraph (Y), by striking the period at
the end and inserting ``, and''; and
(C) by inserting after subparagraph (Y) the
following new subparagraph:
``(Z) in the case of a hospital, to comply with the
provisions of title XXXIV of the Public Health Service
Act.''.
(2) Medicaid program.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)) is amended--
(A) by striking ``and'' at the end of paragraph
(82);
(B) by striking the period at the end of paragraph
(83) and inserting ``; and''; and
(C) by inserting after paragraph (83) the following
new paragraph:
``(84) provide that any hospital that receives a payment
under such plan comply with the provisions of title XXXIV of
the Public Health Service Act (relating to minimum direct care
registered nurse staffing requirements).''.
(e) Nursing Homes.--No later than one year after enactment of this
Act, the Secretary of Health and Human Services shall promulgate a rule
for minimum staffing standards for skilled nursing facilities under the
Medicare program and for nursing facilities under the Medicaid program
that align with the standards set in this section.
SEC. 133. ENHANCEMENTS FOR REDUCED COST-SHARING.
(a) In General.--Section 1402 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18071) is amended--
(1) in subsection (b)(1), by striking ``silver'' and
inserting ``gold'';
(2) by amending subsection (c)(1)(B) to read as follows:
``(B) Coordination with actuarial limits.--The
Secretary shall ensure the reduction under this
paragraph shall not result in the plan's share of the
total allowed costs of benefits provided under the plan
becoming less than--
``(i) 95 percent in the case of an eligible
insured described in paragraph (2)(A);
``(ii) 90 percent in the case of an
eligible insured described in paragraph (2)(B);
and
``(iii) 85 percent in the case of an
eligible insured described in paragraph
(2)(C).''; and
(3) by amending subsection (c)(2) to read as follows:
``(2) Additional reduction.--The Secretary shall establish
procedures under which the issuer of a qualified health plan to
which this section applies shall further reduce cost-sharing
under the plan in a manner sufficient to--
``(A) in the case of an eligible insured whose
household income is not less than 100 percent but not
more than 200 percent of the poverty line for a family
of the size involved, increase the plan's share of the
total allowed costs of benefits provided under the plan
to 95 percent of such costs;
``(B) in the case of an eligible insured whose
household income is more than 200 percent but not more
than 300 percent of the poverty line for a family of
the size involved, increase the plan's share of the
total allowed costs of benefits provided under the plan
to 90 percent of such costs; and
``(C) in the case of an eligible insured whose
household income is more than 300 percent but not more
than 400 percent of the poverty line for a family of
the size involved, increase the plan's share of the
total allowed costs of benefits provided under the plan
to 85 percent of such costs.''.
(b) Effective Date.--The amendments made by this subsection shall
apply to plan years beginning after December 31, 2025.
(c) Funding.--Section 1402 of the Patient Protection and Affordable
Care Act (42 U.S.C. 18071) is amended by adding at the end the
following new subsection:
``(g) Funding.--Out of any funds in the Treasury not otherwise
appropriated, there are appropriated to the Secretary such sums as may
be necessary for payments under this section.''.
SEC. 134. REPEAL OF BONUS PAYMENTS FOR MEDICARE ADVANTAGE PLANS.
Section 1853(o) of the Social Security Act (42 U.S.C. 1395w-23(o))
is repealed.
TITLE II--TAX PROVISIONS
SEC. 201. SUNSET OF PUBLIC LAW 115-97.
(a) In General.--All provisions of, and amendments made by, Public
Law 115-97 shall not apply to calendar, taxable, plan, or limitation
years beginning after December 31, 2026.
(b) Application of Certain Laws.--The Internal Revenue Code of 1986
shall be applied and administered to years described in subsection (a)
as if the provisions and amendments described in subsection (a) had
never been enacted.
SEC. 202. SURTAX.
There is hereby imposed a tax of 5 percent on the adjusted gross
income of each taxpayer to the extent such income exceeds $500,000.
SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECEDENT.
(a) In General.--Section 1014 of the Internal Revenue Code of 1986
is amended by striking ``person, be'' and all that follows through the
period at the end and inserting the following: ``person, be the basis
in the hands of the decedent.''.
(b) Effective Date.--The amendments made by this section to
property acquired or passed after the date of enactment of this Act.
SEC. 204. MEDICARE PAYROLL TAX.
(a) In General.--Section 3101(b)(2) of the Internal Revenue Code of
1986 is amended by striking ``0.9 percent'' and inserting ``4
percent''.
(b) Effective Date.--The amendments made by this section shall
apply with respect to taxable years beginning after the date of the
enactment of this Act.
SEC. 205. NET INVESTMENT INCOME TAX.
(a) In General.--Section 1411(a) of the Internal Revenue Code of
1986 is amended by striking ``3.8 percent'' each place such term
appears and inserting ``6.9 percent''.
(b) Effective Date.--The amendments made by this section shall
apply with respect to taxable years beginning after the date of the
enactment of this Act.
SEC. 206. TERMINATION OF DEDUCTION FOR CONTRIBUTIONS TO HEALTH SAVINGS
ACCOUNTS.
Section 223(b) of the Internal Revenue Code of 1986 is amended by
adding at the end the following new paragraph:
``(9) Termination of deduction.--Notwithstanding any other
provision of this subsection, the monthly limitation for any
month beginning after December 31, 2023, is zero.''.
SEC. 207. INCREASE IN EXCISE TAX ON SMALL CIGARS AND CIGARETTES AND
OTHER TOBACCO PRODUCTS.
(a) Small Cigars.--Section 5701(a)(1) of the Internal Revenue Code
of 1986 is amended by striking ``$50.33'' and inserting ``$100.66''.
(b) Cigarettes.--Section 5701(b) of such Code is amended--
(1) by striking ``$50.33'' in paragraph (1) and inserting
``$100.66''; and
(2) by striking ``$105.69'' in paragraph (2) and inserting
``$211.38''.
(c) Pipe Tobacco.--Section 5701(f) of the Internal Revenue Code of
1986 is amended by striking ``$2.8311 cents'' and inserting ``$50.00''.
(d) Roll-Your-Own Tobacco.--Section 5701(g) of such Code is amended
by striking ``$24.78'' and inserting ``$49.56''.
(e) Large Cigars.--Paragraph (2) of section 5701(a) of the Internal
Revenue Code of 1986 is amended by striking ``52.75 percent'' and all
that follows through the period and inserting ``$24.78 per pound (and a
proportionate tax at the like rate on all fractional parts of a pound)
but not less than 5.033 cents per cigar.''.
(f) Smokeless Tobacco.--
(1) In general.--Section 5701(e) of the Internal Revenue
Code of 1986 is amended--
(A) in paragraph (1), by striking ``$1.51'' and
inserting ``$28.04'';
(B) in paragraph (2), by striking ``50.33 cents''
and inserting ``$12.42''; and
(C) by adding at the end the following:
``(3) Smokeless tobacco sold in discrete single-use
units.--On discrete single-use units, $107.65 per each 1,000
single-use units.''.
(2) Discrete single-use unit.--Section 5702(m) of such Code
is amended--
(A) in paragraph (1), by striking ``or chewing
tobacco'' and inserting ``chewing tobacco, discrete
single-use unit'';
(B) in paragraphs (2) and (3), by inserting ``that
is not a discrete single-use unit'' before the period
in each such paragraph; and
(C) by adding at the end the following:
``(4) Discrete single-use unit.--The term `discrete single-
use unit' means any product containing tobacco that--
``(A) is not intended to be smoked; and
``(B) is in the form of a lozenge, tablet, pill,
pouch, dissolvable strip, or other discrete single-use
or single-dose unit''.
SEC. 208. EXCISE TAX ON ALCOHOL.
(a) Distilled Spirits.--Section 5001(a)(1) of the Internal Revenue
Code of 1986 is amended by striking ``$13.50'' and inserting
``$16.00''.
(b) Wine.--(1) Section 5041(b)(1) of the Internal Revenue Code of
1986 is amended by striking ``$1.07 per wine gallon'' and inserting
``$16.00 per proof gallon''.
(2) Section 5041(b)(2) of the Internal Revenue Code of 1986
is amended by striking ``$1.57 per wine gallon'' and inserting
``$16.00 per proof gallon''.
(3) Section 5041(b)(3) of the Internal Revenue Code of 1986
is amended by striking ``$3.15 per wine gallon'' and inserting
``$16.00 per proof gallon''.
(4) Section 5041(b)(4) of the Internal Revenue Code of 1986
is amended by striking ``$3.40 per wine gallon'' and inserting
``$16.00 per proof gallon''.
(5) Section 5041(b)(5) of the Internal Revenue Code of 1986
is amended by striking ``$3.30 per wine gallon'' and inserting
``$16.00 per proof gallon''.
(6) Section 5041(b)(3) of the Internal Revenue Code of 1986
is amended by striking ``$22.6 cents per wine gallon'' and
inserting ``$16.00 per proof gallon''.
(c) Beer.--Section 5051(B) of the Internal Revenue Code of 1986 is
amended by striking ``$18 for per barrel'' and inserting ``$16 per
proof gallon''.
SEC. 209. TAX ON SUGARED DRINKS.
(a) In General.--Subchapter D of chapter 32 of the Internal Revenue
Code of 1986 is amended by inserting after part I the following new
part:
``PART II--SUGAR-SWEETENED BEVERAGES
``Sec. 4171. Imposition of tax.
``Sec. 4172. Definitions.
``Sec. 4173. Special rules.
``SEC. 4171. IMPOSITION OF TAX.
``(a) In General.--There is hereby imposed a tax on the sale or
transfer of any specified sugar-sweetened beverage product by the
manufacturer, producer, or importer thereof.
``(b) Rate of Tax.--The rate of tax imposed under subsection (a)
shall be equal to one cent per 4.2 grams of caloric sweetener contained
in such specified sugar-sweetened beverage product.
``(c) Persons Liable for Tax.--The manufacturer, producer, or
importer referred to in subsection (a) shall be liable for the tax
imposed by such subsection.
``SEC. 4172. DEFINITIONS.
``(a) Specified Sugar-Sweetened Beverage Product.--For purposes of
this part--
``(1) In general.--For purposes of this part, the term
`specified sugar-sweetened beverage product' means--
``(A) any liquid intended for human consumption
which contains a caloric sweetener, and
``(B) any liquid, or solid mixture of ingredients,
which--
``(i) contains a caloric sweetener, and
``(ii) is intended for use as an ingredient
in a liquid described in subparagraph (A).
``(2) Exceptions.--The following shall not be treated as
liquids described in paragraph (1)(A):
``(A) Any liquid the primary ingredients of which
are milk or soy, rice, or similar plant-based milk
substitute.
``(B) Any liquid composed entirely of one or more
of the following:
``(i) The original liquid resulting from
the pressing of fruit or vegetables.
``(ii) The liquid resulting from the
reconstitution of fruit or vegetable juice
concentrate.
``(iii) The liquid resulting from the
restoration of water to dehydrated fruit or
vegetable juice.
``(C) Infant formula.
``(D) Any liquid products manufactured for use as--
``(i) an oral nutritional therapy for
persons who cannot absorb or metabolize dietary
nutrients from food or beverages,
``(ii) a source of necessary nutrition used
due to a medical condition, or
``(iii) an oral electrolyte solution for
infants and children formulated to prevent
dehydration due to illness.
``(E) Any liquid with respect to which tax is
imposed under chapter 51 (relating to distilled
spirits, wines, and beer) or under section 7652 by
reason of the tax imposed under chapter 51 being
imposed on like articles of domestic manufacture.
``(b) Caloric Sweetener.--For purposes of this part, the term
`caloric sweetener' means monosaccharides, disaccharides, and high-
fructose corn syrup.
``SEC. 4173. SPECIAL RULES.
``(a) Sweetener Taxed Only Once.--In the case of any specified
sugar-sweetened beverage product which is manufactured or produced by
including one or more other specified sugar-sweetened beverage
products, no tax shall be imposed under this section on any caloric
sweetener contained in the resulting specified sugar-sweetened beverage
product if tax was previously imposed under this section on such
caloric sweetener when contained in the specified sugar-sweetened
beverage product so included.
``(b) Inflation Adjustment.--In the case of any sale after December
31, 2015, the one cent amount in section 4171(b) shall be increased by
an amount equal to--
``(1) such amount, multiplied by
``(2) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which such sale
occurs, determined by substituting `calendar year 2014' for
`calendar year 1992' in subparagraph (B) thereof.
Any increase determined under this subsection shall be rounded
to the nearest multiple of one-tenth of a cent.''.
(b) Conforming Amendments.--
(1) Section 4221(a) is amended by adding at the end the
following: ``Paragraphs (1), (4), (5), and (6) shall not apply
to the tax imposed under section 4171.''.
(2) The table of parts for subchapter D of chapter 32 of
such Code is amended by inserting after the item relating to
part I the following new item:
``Part II--Sugar-Sweetened Beverages''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of the enactment of this Act.
(2) Excise tax.--The amendments made by subsections (a) and
(b) shall apply to sales after the date of the enactment of
this Act.
SEC. 210. REPEAL OF EXCISE TAX ON HIGH-COST EMPLOYER-SPONSORED HEALTH
COVERAGE.
(a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is
amended by striking section 4980I.
(b) Conforming Amendment.--Section 6051 of such Code is amended--
(1) in paragraph (14) of subsection (a), by striking
``section 4980I(d)(1)'' and inserting ``subsection (g)'', and
(2) by adding at the end the following:
``(g) Applicable Employer-Sponsored Coverage.--For purposes of
subsection (a)(14)--
``(1) In general.--The term `applicable employer-sponsored
coverage' means, with respect to any employee, coverage under
any group health plan made available to the employee by an
employer which is excludable from the employee's gross income
under section 106, or would be so excludable if it were
employer-provided coverage (within the meaning of such section
106).
``(2) Exceptions.--The term `applicable employer-sponsored
coverage' shall not include--
``(A) any coverage (whether through insurance or
otherwise) described in section 9832(c)(1) (other than
subparagraph (G) thereof) or for long-term care;
``(B) any coverage under a separate policy,
certificate, or contract of insurance which provides
benefits substantially all of which are for treatment
of the mouth (including any organ or structure within
the mouth) or for treatment of the eye; or
``(C) any coverage described in section 9832(c)(3)
the payment for which is not excludable from gross
income and for which a deduction under section 162(l)
is not allowable.
``(3) Coverage includes employee paid portion.--Coverage
shall be treated as applicable employer-sponsored coverage
without regard to whether the employer or employee pays for the
coverage.
``(4) Governmental plans included.--Applicable employer-
sponsored coverage shall include coverage under any group
health plan established and maintained primarily for its
civilian employees by the Government of the United States, by
the government of any State or political subdivision thereof,
or by any agency or instrumentality of any such government.
``(5) Cost of coverage.--
``(A) Health fsas.--In the case of applicable
employer-sponsored coverage consisting of coverage
under a flexible spending arrangement (as defined in
section 2205(g)), the cost of the coverage shall be
equal to the amount determined under rules similar to
the rules of section 4980B(f)(4) with respect to any
reimbursement under the arrangement reduced by the
contributions described in subsection (a)(14)(B).
``(B) Archer msas and hsas.--In the case of
applicable employer-sponsored coverage consisting of
coverage under an arrangement under which the employer
makes contributions described in subsection (b) or (d)
of section 106, the cost of the coverage shall be equal
to the amount of employer contributions under the
arrangement until the termination of HSAs as described
under section 206 of such Act.
``(C) Allocation on a monthly basis.--If cost is
determined on other than a monthly basis, the cost
shall be allocated to months in a taxable period on
such basis as the Secretary may prescribe.''.
(c) Clerical Amendment.--The table of sections for chapter 43 of
such Code is amended by striking the item relating to section 4980I.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2026.
TITLE III--DRUG-RELATED PROVISIONS
SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG AND MEDICAL DEVICE
REVIEW BOARD.
There is established in the Department of Health and Human
Services a board to be known as the Prescription Drug and Medical
Device Price Review Board (in this Act referred to as the ``Board'').
SEC. 302. MEMBERSHIP; STAFF.
(a) Members.--The Board shall be composed of the members as
follows:
(1) The Assistant Secretary for Planning and Evaluation of
the Department of Health and Human Services (or the Assistant
Secretary's designee).
(2) The Administrator of the Centers for Medicare &
Medicaid Services or, beginning with 2025, the Administrator of
the Center for Health Care (or the Administrator's designee).
(3) The Assistant Director for the Health Services Division
of the Federal Bureau of Prisons (or the Assistant Director's
designee).
(4) The Secretary of Defense (or the Secretary's designee).
(5) The Secretary of Veterans Affairs (or the Secretary's
designee).
(6) The Commissioner of Food and Drugs (or the
Commissioner's designee).
(7) The Director of the National Institutes of Health (or
the Director's designee).
(b) Chairperson.--The Board shall designate 1 member of the Board
to serve as the chairperson.
(c) Director and Staff.--
(1) Director.--The Board shall have a director who shall be
appointed by the chairperson of the Board, subject to rules
prescribed by the Board.
(2) Staff.--The director may appoint and fix the pay of
such additional personnel as the chairperson considers
appropriate, subject to rules prescribed by the Board.
(3) Applicability of certain civil service laws.--The
director and staff of the Board shall be appointed subject to
the provisions of title 5, United States Code, governing
appointments in the competitive service, and shall be paid in
accordance with the requirements of chapter 51 and subchapter
III of chapter 53 of such title relating to classification and
General Schedule pay rates; except that an individual so
appointed may not receive pay in excess of the maximum annual
rate of basic pay payable for grade GS-15 of the General
Schedule.
(d) Assistance for the Board.--Subject to section 306(g), in
carrying out this title, the Board--
(1) may seek assistance from outside experts in the fields
of consumer advocacy, medicine, pharmacology, pharmacy, and
prescription drug reimbursement; and
(2) shall establish and maintain an advisory group and a
stakeholder group for purposes of seeking such assistance.
(e) Initial Meeting.--The Board shall hold its initial meeting not
later than 90 days after the date of the enactment of this Act.
(f) Banned Individuals.--
(1) Drug company lobbyists.--No former registered drug
manufacturer lobbyist--
(A) may be appointed to the position of Director of
the Office; or
(B) may be employed by the Office during the 6-year
period beginning on the date on which the registered
lobbyist terminates its registration in accordance with
section 4(d) of the Lobbying Disclosure Act of 1995 (2
U.S.C. 1603(d)) or the agent terminates its status, as
applicable.
(2) Senior executives of law-breaking companies.--No former
senior executive of a covered entity--
(A) may be appointed to the position of Director of
the Office; or
(B) may be employed by the Office during the 6-year
period beginning on the later of--
(i) the date of the settlement; and
(ii) the date on which the enforcement
action has concluded.
(3) Covered entity.--The term ``covered entity'' means any
entity that is--
(A) a drug manufacturer; and
(B)(i) operating under Federal settlement,
including a Federal consent decree; or
(ii) the subject of an enforcement action
in a court of the United States or by an
agency.
SEC. 303. PROHIBITION AGAINST EXCESSIVE PRICE.
(a) Prohibition.--Beginning on the effective date of the regulation
required by subsection (b), the manufacturer of a prescription drug or
medical device shall not charge an excessive price, as determined
pursuant to such regulation, for such drug or device.
(b) Formula.--The Board shall by regulation prescribe a formula for
determining whether the average manufacturer price of such drug or
device over an annual quarter is an excessive price.
(c) Determination of Excessive Price.--If the Board determines, on
its own initiative or in response to a petition submitted under
subsection (d), that the manufacturer of a prescription drug or medical
device charges an excessive price for such drug or device in violation
of subsection (a)--
(1) the Board shall give the manufacturer--
(A) notice of such violation; and
(B) subject to subsection (d), a period to correct
such violation; and
(2) if the manufacturer fails to correct the violation by
the end of such period, the manufacturer shall be subject to
section 304, section 1927(c)(2)(E) of the Social Security Act
(as added by subsection (c) of section 304), and section 4192
of the Internal Revenue Code of 1986, as added by subsection
(d) of section 304.
(d) Petitions.--Any person may petition the Board to make a
determination under subsection (c) regarding the pricing of a
prescription drug or medical device. Not later than 90 days after the
date of receipt of such a petition, the Board shall--
(1) make a determination under subsection (c) regarding
such pricing; or
(2) decline to make such a determination.
(e) Continuing Violation.--The Board shall not be required to give
a manufacturer an opportunity to correct a violation, as described in
subsection (c)(1)(B), before the manufacturer becomes subject to the
provisions described in subsection (c)(2) for such violation, if--
(1) the Board has already provided such an opportunity to
correct to the manufacturer; and
(2) the Board finds that the violation of subsection (a) is
a continuation of an earlier violation with respect to which
such an opportunity was provided.
(f) Considerations.--The formula required by subsection (a) shall
at a minimum take into consideration--
(1) the average manufacturer price of the prescription drug
or medical device over the respective annual quarter or
quarters;
(2) the average manufacturer price of other prescription
drugs or medical devices in the same therapeutic class over the
same quarter or quarters;
(3) the average price at which the prescription drug or
medical device and other prescription drugs and medical devices
in the same therapeutic class have been sold by manufacturers
in countries other than the United States;
(4) the costs associated with producing and marketing the
prescription drug or medical device, the value of the drug or
device to patients where sufficient data is available to
determine such value, the total Federal investment in the
development of the drug or device, the size of the patient
population receiving the drug or device, and other factors
determinative as to the true cost of production; and
(5) whether the price of the prescription drug or medical
device increased during any annual quarter by a percentage that
is more than 2 percent greater than the CPI increase percentage
(as defined in section 215(i) of the Social Security Act (42
U.S.C. 415)) for the respective annual quarter.
(g) Value or Cost-Effectiveness Assessments.--The use of Quality-
Adjusted Life Years, Disability-Adjusted Life Years, or other similar
mechanisms is prohibited for use in value or cost-effectiveness
assessments for purposes of this section.
SEC. 304. ENFORCEMENT PROVISIONS.
(a) Reduced Patent Term.--If the Board finds that the manufacturer
of a prescription drug or medical device, who is also an owner of a
patent for such drug or device, charged an excessive price for such
drug or device in violation of section 303(a), the Board may--
(1) reduce the term, by not more than 5 years, of any
patent issued under title 35, United States Code, relating to
such drug or device; or
(2) if the term of each patent for such drug or device has
expired, reduce the term, by not more than 5 years, of another
patent owned by the patent owner relating to a prescription
drug or medical device.
(b) Civil Penalties.--If the Board determines under section 303(c)
that a manufacturer of a prescription drug or medical device charged an
excessive price for a prescription drug or medical device in violation
of section 303(a), the Board may impose a civil penalty on the
manufacturer of not more than 10 percent of the manufacturer's gross
sales of the drug or device during the period beginning on the date on
which an excessive price is first charged and ending on the date on
which the manufacturer ceases to charge an excessive price.
(c) Tax on Excess Prescription Drug and Medical Device Profits.--
(1) Determination of amount.--If the Board determines under
section 303(a) that a manufacturer, producer, or importer of a
prescription drug or medical device charged an excessive price
for such prescription drug or medical device during a taxable
year, the Board may determine under this paragraph a reasonable
price for such drug or device for such taxable year.
(2) Imposition of tax.--
(A) In general.--The Internal Revenue Code of 1986
is amended by inserting after section 4191 the
following new section:
``SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL DEVICE PRICE.
``(a) In General.--There is hereby imposed on the sale of any
prescription drug or medical device by the manufacturer, producer, or
importer a tax equal to the difference between the price at which such
drug or device is so sold and the reasonable price determined by the
Prescription Drug and Medical Device Price Review Board under section
303(c)(1) of the Medicare for America Act for such drug or device for
the taxable year for sales after the determination.
``(b) Prescription Drug or Medical Device.--For purposes of this
section, the term `prescription drug or medical device' means any
prescription drug (as defined in section 9008 of the Patient Protection
and Affordable Care Act) or device (as defined in section 201(h) of the
Federal Food, Drug, and Cosmetic Act) intended for humans.''.
(B) Clerical amendment.--The table of parts for
chapter 32 of such Code is amended--
(i) in the item relating to subchapter E,
by striking ``Medical'' and inserting ``Drugs
and medical''; and
(ii) by inserting after the item relating
to section 4191 the following new item:
``SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL DEVICE PRICE.''.
(3) Effective date.--This subsection and the amendments
made by this subsection shall apply with respect to sales after
December 31, 2025.
SEC. 305. AUTHORITY.
(a) Obtaining Official Data.--The chairperson of the Board may
secure directly from any Federal agency information necessary to enable
the Board to carry out its duties. Upon request of the chairperson, the
head of the agency shall furnish such information to the Board to the
extent such information is not prohibited from disclosure by law.
(b) Mails.--The Board may use the United States mails in the same
manner and under the same conditions as other Federal agencies.
(c) Administrative Support Services.--Upon the request of the
chairperson of the Board, the Administrator of General Services shall
provide to the Board, on a reimbursable basis, the administrative
support services necessary for the Board to carry out its duties.
(d) Contract Authority.--The Board may contract with and compensate
government and private agencies or persons for the purpose of
conducting research, surveys, and other services necessary to enable
the Board to carry out its duties.
(e) Investigations.--The Board may make such investigations as it
considers necessary to determine whether there is or may be a violation
of any regulation promulgated under this Act and may require or permit
any person to file with it a statement in writing, under oath or
otherwise as the Board shall determine, as to all the facts and
circumstances concerning the matter to be investigated.
(f) Subpoena Power.--
(1) In general.--The Board may issue subpoenas requiring
the attendance and testimony of witnesses and the production of
any evidence relating to any matter under investigation by the
Board. The attendance of witnesses and the production of
evidence may be required from any place within the United
States at any designated place of hearing within the United
States.
(2) Failure to obey a subpoena.--If a person refuses to
obey a subpoena issued under paragraph (1), the Board may apply
to a United States district court for an order requiring that
person to appear before the Board to give testimony, produce
evidence, or both, relating to the matter under investigation.
The application may be made within the judicial district where
the hearing is conducted or where that person is found,
resides, or transacts business. Any failure to obey the order
of the court may be punished by the court as civil contempt.
(3) Service of subpoenas.--The subpoenas of the Board shall
be served in the manner provided for subpoenas issued by a
United States district court under the Federal Rules of Civil
Procedure for the United States district courts.
(4) Service of process.--All process of any court to which
application is made under paragraph (2) may be served in the
judicial district in which the person required to be served
resides or may be found.
(5) Notice.--Upon issuing any subpoena under this
subsection, the Board shall give notice of such issuance to the
appropriate committees of Congress, including the Committee on
Appropriations of the House of Representatives and the
Committee on Appropriations of the Senate.
(g) Confidentiality.--Under this title, the Secretary shall enforce
applicable law concerning a trade secret or confidential information
subject to section 552(b)(4) of title 5, United States Code, or section
1905 of title 18.
SEC. 306. REGULATIONS.
(a) In General.--Not later than 1 year after the date of the
initial meeting held under section 302(e), the Board shall issue final
regulations to carry out this Act.
(b) Notice and Comment Requirement.--The regulations developed
under subsection (a) shall be issued in accordance with the notice and
comment procedures established under section 553 of title 5, United
States Code.
SEC. 307. REPORT TO FEDERAL AGENCIES.
Not later than 1 year after the effective date of the regulations
under section 306 and annually thereafter, the Board shall submit to
each Federal agency that dispenses or makes payments for the dispensing
of prescription drugs or medical devices a report containing a list of
each prescription drug and medical device for which an excessive price
was charged during the preceding calendar year, as determined by the
Board under section 303. The Secretary shall make this report publicly
available.
SEC. 308. DEFINITIONS.
In this title:
(1) Affiliate.--The term ``affiliate'' means, with respect
to a manufacturer, any entity that controls, is controlled by,
or is under common control with such manufacturer.
(2) Average manufacturer price.--The term ``average
manufacturer price'' means the average price charged by the
manufacturer of a prescription drug or medical device, as
applicable, for sales of the drug or device by the manufacturer
in the United States over the respective annual quarter.
(3) Medical device.--The term ``medical device'' means a
device (as defined in section 201 of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 321)).
(4) Prescription drug.--The term ``prescription drug''
means a drug (as defined in section 201 of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 321)) that is subject to
section 503(b)(1) of such Act (21 U.S.C. 353(b)(1)).
(5) Manufacturer.--The term ``manufacturer'' means the
person--
(A) that holds the application for a drug approved
under section 505 of the Federal Food, Drug, and
Cosmetic Act or the license issued under section 351 of
the Public Health Service Act; or
(B) who is responsible for setting the price for
the drug.
(6) Wholesale acquisition cost.--The term ``wholesale
acquisition cost'' has the meaning given that term in section
1847A(c)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
3a(c)(6)(B)).
SEC. 309. MORATORIUM ON DIRECT-TO-CONSUMER DRUG ADVERTISING.
The Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.)
is amended--
(1) in section 301 (21 U.S.C. 331), by adding at the end
the following:
``(eee) The conduct of direct-to-consumer advertising of a drug in
violation of section 506J.''; and''.
(2) in chapter V, by inserting after section 506I (21
U.S.C. 356f) the following:
``SEC. 506J. DIRECT-TO-CONSUMER DRUG ADVERTISING.
``(a) Prohibitions.--
``(1) First three years.--
``(A) In general.--Subject to subparagraph (B), no
person shall conduct direct-to-consumer advertising of
a drug for which an application is submitted under
section 505(b) before the end of the 3-year period
beginning on the date of the approval of such
application.
``(B) Waiver.--The Secretary may waive the
application of subparagraph (A) to a drug during the
third year of the 3-year period described in such
subparagraph if--
``(i) the sponsor of the drug submits an
application to the Secretary pursuant to
subparagraph (C); and
``(ii) the Secretary, after considering the
application and any accompanying materials,
determines that direct-to-consumer advertising
of the drug would have an affirmative value to
public health.
``(C) Application for waiver.--To seek a waiver
under subparagraph (B), the sponsor of a drug shall
submit an application to the Secretary at such time, in
such manner, and containing such information as the
Secretary may require.
``(2) Subsequent years.--The Secretary may prohibit direct-
to-consumer advertising of a drug during the period beginning
at the end of the 3-year period described in paragraph (1)(A)
if the Secretary determines that the drug has significant
adverse health effects based on post-approval studies, risk-
benefit analyses, adverse event reports, the scientific
literature, any clinical or observational studies, or any other
appropriate resource.
``(b) Regulations.--Not later than 1 year after the date of the
enactment of this section, the Secretary shall revise the regulations
promulgated under this Act governing drug advertisements to the extent
necessary to implement this section.
``(c) Rule of Construction.--This section shall not be construed to
diminish the authority of the Secretary to prohibit or regulate direct-
to-consumer advertising of drugs under other provisions of law.''.
SEC. 310. REPORTING ON JUSTIFICATION FOR DRUG PRICE INCREASES.
Title III of the Public Health Service Act (42 U.S.C. 241 et seq.)
is amended by adding at the end the following:
``PART W--DRUG PRICE REPORTING; DRUG VALUE FUND
``SEC. 399OO. REPORTING ON JUSTIFICATION FOR DRUG PRICE INCREASES.
``(a) Definitions.--In this section:
``(1) Manufacturer.--The term `manufacturer' means the
person--
``(A) that holds the application for a drug
approved under section 505 of the Federal Food, Drug,
and Cosmetic Act or the license issued under section
351 of the Public Health Service Act; or
``(B) who is responsible for setting the price for
the drug.
``(2) Qualifying drug.--The term `qualifying drug' means
any drug that is approved under subsection (c) or (j) of
section 505 of the Federal Food, Drug, and Cosmetic Act or
licensed under subsection (a) or (k) of section 351 of this
Act--
``(A) that has a wholesale acquisition cost of $100
or more per month supply or per a course of treatment
that lasts less than a month and is--
``(i)(I) subject to section 503(b)(1) of
the Federal Food, Drug, and Cosmetic Act; or
``(II) commonly administered by
hospitals (as determined by the
Secretary);
``(ii) not designated as a drug for a rare
disease or condition under section 526 of the
Federal Food, Drug, and Cosmetic Act; and
``(iii) not designated by the Secretary as
a vaccine; and
``(B) for which, during the previous calendar year,
at least 1 dollar of the total amount of sales were for
individuals enrolled under the Medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.) or under a State Medicaid plan under title XIX
of such Act (42 U.S.C. 1396 et seq.) or under a waiver
of such plan.
``(3) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given that term in section
1847A(c)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
3a(c)(6)(B)).
``(b) Report.--
``(1) Report required.--The manufacturer of a qualifying
drug shall submit a report to the Secretary for each price
increase of a qualifying drug that will result in an increase
in the wholesale acquisition cost of that drug that is equal
to--
``(A) 10 percent or more over a 12-month period; or
``(B) 25 percent or more over a 36-month period.
``(2) Report deadline.--Each report described in paragraph
(1) shall be submitted to the Secretary not later than 30 days
prior to the planned effective date of such price increase.
``(c) Contents.--A report under subsection (b) shall, at a minimum,
include--
``(1) with respect to the qualifying drug--
``(A) the percentage by which the manufacturer will
raise the wholesale acquisition cost of the drug on the
planned effective date of such price increase;
``(B) a justification for, and description of, each
manufacturer's price increase that will occur during
the 12-month period described in subsection (b)(1)(A)
or the 36-month period described in subsection
(b)(1)(B), as applicable;
``(C) the identity of the initial developer of the
drug;
``(D) a description of the history of the
manufacturer's price increases for the drug since the
approval of the application for the drug under section
505 of the Federal Food, Drug, and Cosmetic Act or the
issuance of the license for the drug under section 351,
or since the manufacturer acquired such approved
application or license;
``(E) the current list price of the drug;
``(F) the total expenditures of the manufacturer
on--
``(i) materials and manufacturing for such
drug; and
``(ii) acquiring patents and licensing for
such drug;
``(G) the percentage of total expenditures of the
manufacturer on research and development for such drug
that was derived from Federal funds;
``(H) the total expenditures of the manufacturer on
research and development for such drug that is used
for--
``(i) basic and preclinical research;
``(ii) clinical research;
``(iii) new drug development;
``(iv) pursuing new or expanded indications
for such drug through supplemental applications
under section 505 of the Federal Food, Drug,
and Cosmetic Act or section 351 of the Public
Health Service Act; and
``(v) carrying out postmarket requirements
related to such drug, including those under
section 505(o)(3) of the Federal Food, Drug,
and Cosmetic Act;
``(I) the total revenue and the net
profit generated from the qualifying
drug for each calendar year since the
approval of the application for the
drug under section 505 of the Federal
Food, Drug, and Cosmetic Act or the
issuance of the license for the drug
under section 351, or since the
manufacturer acquired such approved
application or license; and
``(J) the total costs associated with marketing and
advertising for the qualifying drug;
``(2) with respect to the manufacturer--
``(A) the total revenue and the net profit of the
manufacturer for each of the 12- and 36-month periods
preceding the submission of the report;
``(B) all stock-based performance metrics used by
the manufacturer to determine executive compensation
for each of the 12- and 36-month periods preceding the
submission of the report; and
``(C) any additional information the manufacturer
chooses to provide related to drug pricing decisions,
such as total expenditures on--
``(i) drug research and development; or
``(ii) clinical trials on drugs that failed
to receive approval by the Food and Drug
Administration; and
``(3) such other related information as the Secretary
considers appropriate.
``(d) Civil Penalty.--Any manufacturer of a qualifying drug that
fails to submit a report for the drug as required by this section shall
be subject to a civil penalty of $100,000 for each day on which the
violation continues.
``(e) Public Posting.--
``(1) In general.--Subject to paragraph (3), not later than
30 days after the submission of a report under subsection (b),
the Secretary shall post the report on the public website of
the Department of Health and Human Services.
``(2) Format.--In developing the format of such report for
public posting, the Secretary shall consult stakeholders,
including beneficiary groups, and shall seek feedback on the
content and format from consumer advocates and readability
experts to ensure such public reports are user-friendly to the
public and are written in plain language that consumers can
readily understand.
``(3) Trade secrets and confidential information.--In
carrying out this section, the Secretary shall enforce
applicable law concerning the protection of confidential
commercial information and trade secrets.
``SEC. 399OO-1. USE OF CIVIL PENALTY AMOUNTS.
``The Secretary shall, without further appropriation, collect civil
penalties under section 399OO and use the funds derived from such civil
penalties, in addition to any other amounts available to the Secretary,
to carry out activities described in this part and to improve consumer
and provider information about drug value and drug price transparency.
``SEC. 399OO-2. ANNUAL REPORT TO CONGRESS.
``(a) In General.--Subject to subsection (b), the Secretary shall
submit to Congress, and post on the public website of the Department of
Health and Human Services in a way that is easy to use and understand,
an annual report--
``(1) summarizing the information reported pursuant to
section 399OO; and
``(2) including copies of the reports and supporting
detailed economic analyses submitted pursuant to such section.
``(b) Trade Secrets and Confidential Information.--In carrying out
this section, the Secretary shall enforce applicable law concerning the
protection of confidential commercial information and trade secrets.''.
TITLE IV--OUTCOMES AND REPORTING
SEC. 401. SENSE OF CONGRESS.
It is the sense of Congress that Medicare for America will have a
significant impact on the health and well-being of the United States
population and the social determinants of the health of beneficiaries
of Medicare for America.
SEC. 402. EVALUATION OF BILL'S OUTCOME.
(a) In General.--To assess the impact of this Act on the health of
the population, not later than 2 years after the date of the enactment
of this Act, the Secretary of Health and Human Services shall allow for
analysis of administrative records that have removed all personally
identifiable information from the Center for Health Care to existing
population surveys conducted by the Federal Government and federally
supported surveys.
(b) CDC and NIH.--The Directors of the Centers for Disease Control
and Prevention and the National Institutes of Health shall solicit a
comprehensive, longitudinal study to evaluate any differential
individual impact on coverage expansion based on--
(1) race and ethnicity;
(2) socioeconomic status; or
(3) health status.
(c) Report.--Ten years after the date of the enactment of this Act
and every ten years thereafter, the Secretary shall submit a report to
the House Committee on Energy and Commerce and the Senate Committee on
Health, Education, Labor, and Pensions regarding the impact of this Act
on the health of the United States population based on the results of
subsection (b) contributions from all other relevant agencies.
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