Sec. 111. Establishment and administration of Medicare for America
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The Social Security Act is amended by adding at the end the following new title: The Secretary shall establish a public health insurance program, to be known as Medicare for America , which shall for calendar year 2022 and each subsequent calendar year provide comprehensive health benefits in accordance with this part to individuals enrolled for coverage under this title. For purposes of this title, every individual who is a resident of the United States is entitled to benefits for health care services under this title.
The Secretary shall promulgate a rule that provides criteria for determining residency for eligibility purposes under this title. Subject to subsection (c): Beginning in 2022, 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 card which may be used for purposes of identification and processing of claims for benefits under this title. As a condition of participation in the program, participating providers shall facilitate enrollment as specified by the Secretary.
The mechanism provided under paragraph
(1)shall, subject to paragraph (4), provide, for plan years beginning with plan year 2022, for the following automatic enrollments under Medicare for America: For plan years (beginning with plan year 2022), 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. For plan years (beginning with plan year 2022), 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). For plan years (beginning with plan year 2022), a process established by the Secretary for the automatic enrollment of eligible individuals who attain the age of 65 during such plan year. For plan years (beginning with plan year 2024), 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. For plan years (beginning with plan year 2022), 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. The mechanism provided under paragraph
(1)shall provide for the following: Enrollment periods and processes for each plan year (beginning with plan year 2022) for enrollment under Medicare for America of any eligible individual not otherwise described in paragraph (2). For plan years (beginning with plan year 2022), a process and methodology under which a small employer, as defined in section 124(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 the previous sentence, 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. For plan years (beginning with plan year 2026), 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. 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. For purposes of this section, the term qualified health coverage means coverage under any of the following: For plan years 2022 and 2023: Qualified employer coverage, as defined in section 124 of the Medicare for America Act. Medical coverage under chapter 55 of title 10, United States Code, including coverage under the TRICARE program. 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. The health benefit program under chapter 89 of title 5, United States Code. Medical benefits and services provided by or through the Indian Health Service. The Medicaid program under title XIX of the Social Security Act. The CHIP program under title XXI of the Social Security Act. For plan years 2024 and 2025: Coverage described in subclause (I), (II), (III), (IV), or
(V)of clause (i). 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. For each subsequent plan year, coverage described in subclause (I), (II), (III), (IV), or
(V)of clause (i). 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. Medicare for America shall, in accordance with this section, provide coverage for all the benefits, as determined to be medically necessary and reasonable, 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: Ambulatory patient services. Emergency care and urgent care services. Hospitalization. Maternity and newborn care. Behavioral health, mental health and substance use disorder services, including the following: Home-based services. Acute services for mental health crises, including crisis stabilization services such as mobile crisis services, including emergency mobile psychiatric services. 23-hour observation. Outpatient services provided by hospitals, freestanding clinics, and behavioral health providers in independent practice. Smoking and tobacco cessation. Case management. Peer support services. Counseling. Other intensive outpatient community-based services, such as Assertive Community Treatment and supported employment, provided through the LTSS benefit. Other intensive community-based services provided through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit (as defined in subpart B of part 441 of title 42 of the Code of Federal Regulations). Medication assisted treatment and maintenance services. Inpatient detoxification. Ambulatory detoxification. Psychological testing. Home health agency services. Prescription drugs. Rehabilitative and habilitative services and devices, including the following: Physical therapy. Speech therapy. Occupational therapy. Laboratory services. Preventive and wellness services and chronic disease management. Pediatric services, including oral and vision care and all services that would otherwise be covered under Early and Periodic Screening, Diagnostic, and Treatment under the Medicaid program under title XIX. Dental. Hearing health services including aids and exams. Home and community-based long-term supports and services. Chiropractic services. Durable medical equipment, including the following: Wheelchairs and accessories. Walking aides such as walkers, canes, and crutches. Bathroom equipment such as commodes and safety equipment. Inhalation therapy equipment such as nebulizers. Hospital beds and accessories. Other devices such as continuous positive airway pressure
(CPAP)machines, apnea monitors, and ventilators. Insulin pumps and glucometers. Breast pumps. Lymphedema compression treatment items. Wigs. Augmentative and alternative communication devices, including dual-use devices. Family planning, including the following: Reproductive health exams. Patient counseling and education related to family planning. Abortion. Screening, testing, treatment, and pre- and post-test counseling for sexually transmitted diseases and HIV. Contraceptives including pill, patch, medication, condom, implant, or other devices used to prevent pregnancy. Sterilization for beneficiaries over the age of 21. Infertility treatment. Gender-confirming medical procedures and treatment. Dietary and nutrition counseling. Medically necessary food and vitamins for digestive and inherited metabolic disorders. Nursing facilities. Orthotic and prosthetics devices. Oxygen. Acupuncture. Telehealth. Services otherwise included under the maternal, infant, and early childhood home visiting program under section 511 of the Social Security Act, as of the date of the enactment of this title. Any additional benefit or service not included in this section that is covered by any State plan (or waiver of such State plan) under title XIX on the date of the enactment of this title. Benefits covered 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. 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. 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 paragraph (3). For purposes of paragraph (2), health insurance coverage for any additional benefits must satisfy the following conditions: The provisions of section 2718 of the Public Health Service Act, relating to a medical loss ratio. The provisions of section 2702 of the Public Health Service Act, relating to guaranteed issue. The provisions of section 2701 of the Public Health Service Act, relating to community rating. The provisions of section 2704 of the Public Health Service Act, relating to the ban on pre-existing conditions exclusions. Individual States may provide additional benefits for the residents of such States at the expense of the State. 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. 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). 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— the premium otherwise applicable to such individual under such title XVIII if this title had not been enacted; or the premium that would be applied to such individual under this title without the application of this paragraph. The amount of a monthly premium, with respect to a plan year (beginning with 2022), under this section shall be established by the Secretary in accordance with the following: 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. Premiums shall vary by family composition only. Federal subsidies shall be provided to ensure that the premium shall be— zero in the case of an individual whose annual household income is below 200 percent of the poverty line; 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, with the premiums ranging between the amount determined for individuals described in clause
(i)and for individuals described in clause (iii); and no individual or household will pay more than 9.69 percent of monthly income toward such monthly premium. 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 124(b)(1)(B) of the Medicare for America Act), such individual shall pay a premium in accordance with this subsection. For an individual who has opted out of their employer sponsored insurance in order to enroll in Medicare for America as specified in section 124(c) of such Act, the individual shall pay the premium described in this subsection. 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. In calculating premiums for purposes of subsection (a)(2): 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. In any case in which the Secretary finds that an individual’s enrollment or nonenrollment in the insurance program established by this part or part A of title XVIII pursuant to section 1818 is unintentional, inadvertent, or erroneous, whether the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Federal Government or its instrumentalities, an employer, a representative of a group health plan, a State, or for any other good faith reason on the part of such individual, the Secretary shall take such action (including the designation for such individual of a special initial or subsequent enrollment period, including retroactive enrollment, with a coverage period determined on the basis thereof and with appropriate adjustments of premiums) as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction. The failure of an individual to enroll in the insurance program established by this part or part A pursuant to section 1818 due to enrollment under a group health plan; coverage pursuant to title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986, title VI of the Employee Retirement Income Security Act of 1974, or title XIX; or enrollment under a qualified health plan offered through an Exchange established under title I of the Patient Protection and Affordable Care Act shall under this subsection absent exceptional circumstances, as determined by the Secretary. 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. 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. 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 submitted pursuant to paragraph
(2)relating to enrollment under part A or part B. An individual who receives an adverse determination under paragraph
(3)with respect to an application submitted pursuant to paragraph
(2)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. The Secretary of the Treasury may not enter into a contract under paragraph
(5)with an independent review organization— 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 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. The Secretary of Health and Human Services 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. 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, after application of subsection
(b)and subject to subsection (c), 80 percent of the reimbursement rates established pursuant to section 2206 for such items and services, except that with respect to USPTF recommended preventive and chronic disease services, and generic drugs, 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. There shall be a deductible applied under this part for each plan year 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 shall not exceed, subject to paragraphs
(2)and (3)— $350 for an individual; or $500 total for all members of a household. In the case of plan years beginning after 2021, the dollar amounts described in paragraph
(1)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. There shall be no deductible applied under this part for months in a plan year for individuals and households with annual income below 200 percent of the federal poverty line. 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. 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— with respect to an individual, $3,500; or with respect to a household, $5,000. In the case of plan years beginning after 2021, 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. 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. No provider may impose a charge to an enrolled individual for covered 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 deductible or other cost-sharing described in this section. 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. Except as provided in paragraphs
(2)and (3), the Secretary shall provide for rates to be provided to health care providers and suppliers furnishing items and services under Medicare for America based on rates that would be applied (including as computed, updated, and adjusted) under title XVIII 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 covered under Medicare for America but not otherwise covered under title XVIII, shall provide for rates that ensure adequate access to care. 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, except that for hospitals serving underserved areas as specified by the Secretary, such rates are increased as necessary to ensure adequate access to care. In applying rates under title XVIII for purposes of this part, the following shall apply: 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. The Secretary shall increase the average relative value of primary care and other mental and behavioral health and cognitive services by not less than 20 percent in order to ensure adequate access to inpatient and outpatient care. 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 plans. A health care provider that is a participating provider of services or supplier under the Medicare program under title XVIII on the date of enactment of this title shall remain a participating provider for Medicare for America. The Secretary shall establish a process to allow health care providers not described in paragraph
(1)to become participating providers for Medicare for America. Any payment rate under this part for a prescription drug shall be at a rate negotiated by the Secretary based on value assessments by one or more independent nonprofit organizations certified by the National Academy of Medicine and MedPAC. If the Secretary is unable to reach a negotiated agreement on such a reimbursement rate, the Secretary shall apply prices paid by the Department of Veterans Affairs for such drugs or the average price of such drugs in nations which are members of the Organization for Economic Cooperation and Development, whichever is lower. If a drug manufacturer refuses to negotiate with the Secretary, then Medicare for America will not cover any of the manufacturer’s products. There shall be an exceptions process for drugs that are otherwise unavailable for people with chronic conditions. Individuals shall continue to have access to drugs during the appeals process. The Secretary shall modify such rates in order to accommodate payments for drugs that are not otherwise covered under the original Medicare fee-for-service program under title XVIII. 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. 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. There are hereby appropriated to the Trust Fund for each fiscal year beginning with fiscal year 2022, 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. Notwithstanding any other provision of law, there are hereby appropriated to the Trust Fund for each fiscal year, beginning with fiscal year 2022, the amounts that would otherwise have been appropriated to carry out the following programs: The Medicare program under title XVIII. The Medicaid program under title XIX, beginning as of 2026. Additional sums are authorized to be appropriated annually as needed to maintain maximum quality, efficiency, and access under this part. There shall be transferred to the Trust Fund the maintenance of effort payments made under section 2209. 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. 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 . 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. Beginning 2022, the Centers for Medicare & Medicaid Services shall be renamed the Center for Medicare 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 Medicare. The Secretary shall have the authority to issue interim final rules with respect to any provision in this part. The Center for Medicare is not authorized to appoint administrative law judges, in accordance with pages 11420 through 499 of title 70 of the Federal Register (March 8, 2005). 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. Individuals may appeal a coverage determination under this title before the individual obtains the service or item that is the subject of the appeal. The Secretary shall eliminate the redetermination by a Medicare administrative contractor from the appeals process under the Medicare program for beneficiaries. An applicant or recipient aggrieved by any law, regulation, policy or practice in violation of a provision of this title may bring a civil action seeking any remedy available in law or equity to remedy that violation. In addition to any cause of action that may be available in a State court, the district courts of the United States shall have concurrent jurisdiction in the matters under the provisions of this title. 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. 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. A State is not eligible for payment under any program specified in subsection
(d)for a calendar quarter in a plan year beginning after 2026 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. For purposes of this section, a maintenance of effort payment with respect to a State and plan year is— for plan year 2027 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; for plan year 2028 and each subsequent plan year before plan year 2032— 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 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 beginning in 2032, 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. For purposes of this section, the programs specified in this subsection are each of the following: Block grants for community mental health services under subpart I of part B of title XIX of the Public Health Service Act. Block grants and programs for social services and elder justice under title XX of the Social Security Act. Maternal and child health services block grants under title V of the Social Security Act. Block grants for prevention and treatment of substance abuse under subpart II of part B of title XIX of the Public Health Service Act. State Targeted Response to Opioid Crisis Grant Community Services Block Grant. Grants under section 330 of the Public Health Service Act. Ryan White HIV/AIDS Program grants under title XXVI of the Public Health Service Act. 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: Section 1801. Section 1805. Section 1806. Section 1807. Section 1809. Section 1812. Section 1814. Section 1815. Section 1816. Section 1818. Section 1818A. Section 1819. Section 1820. Section 1832. Section 1834. Section 1834A. Section 1835. Section 1843. Section 1846. Section 1847. Section 1851. Section 1852. Section 1855. Section 1856. Section 1857. Section 1858. Section 1861. Section 1863. Section 1864. Section 1866B. Section 1866C. Section 1866E. Section 1867. Section 1868. Section 1869. Section 1871. Section 1874A. Section 1880. Section 1881. Section 1881A. Section 1891. Section 1894. Section 1895. Section 1896. All individuals enrolled under Medicare for America under this title shall have coverage for long-term services and supports benefits. An individual who is eligible for long-term care benefits under this part is an individual who satisfies each of the following: The individual is eligible for Medicare for America. The individual is determined to have a condition, as certified by a licensed health care practitioner, that results in substantially reduced functional capacity in one or more of the following areas: Communication. Social interaction. Learning. Mobility. Self-care. Self-management. Impairments that affect the person’s capacity for social or economic participation. Under this part, in the case of an individual described in subsection
(a)who, due to the nature of the condition of the individual, experience 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 long term supports and services, 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. The presence of supports and services or other mitigating measures shall not be taken into account when looking at functional impairment. For purposes of this title, the term long-term services and supports benefit means the daily living supports needed by eligible individuals and includes all long-term services and supports covered, as of the date of the enactment of this title, under any State plan under title XIX, including— home and community-based services; and any additional services and supports developed to help people with disabilities live, work, and participate in their communities, including— home health aides and homemakers; direct support professionals and personal attendant care services; hospice; nursing care; medical social services; case management, fiscal intermediary, and support brokerage services; short-term inpatient care, including respite care and care for pain control; behavioral health long-term services and supports, including assertive community treatment, peer support services, intensive case management, supported employment, and supported housing wraparound; and all additional services coverable in Medicaid under state plan services, sections 1115, 1915(c), 1915(k), 1915(i), and 1915(j), for people with disabilities. All eligible individuals shall be defaulted into a self-directed care option (as defined by the Secretary). The benefit under this part shall be provided with a community-first presumption and eligible individuals should be initially provided home and community-based services, as defined for purposes of section 1915(i). Before an eligible individual is admitted into a long term care institution, the State mental health or developmental disability authority or State agency that administers the State plan under title XIX shall conduct a mandatory assessment to determine whether their needs could be met through home and community-based services and if so, the services would have to be arranged for by the State and the coverage would not be provided for the individual with respect to such an admission. This assessment shall be conducted at least annually or upon a change in condition for all individual already admitted to an institution. 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 not less than 80 hours a month for providing community living assistance services and supports to an eligible individual under this part. The term dependent relative means— a child, grandchild, niece, or nephew (of such caregiver or such caregiver’s spouse or domestic partner); a child to which the caregiver or the caregiver's spouse or domestic partner is standing in loco parentis; a parent, grandparent, sibling, aunt, or uncle (of such caregiver or his or her spouse or domestic partner); or 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. 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. Benefits paid to a caregiver 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 titles 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. For plan years beginning with plan year 2026, 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. 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. For purposes of this part— 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. An MA for America sponsor is a sponsor of an MA for America plan. 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. Nothing in this part shall preclude an individual from choosing a Medicare Advantage for America plan which requires the individual to pay an additional 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 the increased monthly premium. Beginning in 2022, all references in law and regulation to Medicare Advantage shall be deemed a reference to Medicare Advantage for America. .