Sec. 111. Establishment and administration of Medicare for America

8,205 words·~37 min read·/bill/117/hr/9655/ih/section-111

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

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 2026 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 or a territory of the United States; an individual who is lawfully present, as defined in section 152.2 of title 45 of the Code of Federal Regulations; or 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. Subject to subsection (c): Beginning in 2026, 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. The mechanism provided under paragraph

(1)shall, subject to paragraph (4), provide, for plan years, for the following automatic enrollments under Medicare for America: For plan years (beginning with plan year 2026), 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 2026), 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 2026), 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 2028), 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 2026), 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 2026) for enrollment under Medicare for America of any eligible individual not otherwise described in paragraph (2). For plan years (beginning with plan year 2026), 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. 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. 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. 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. Beginning for plan year 2026, Members of Congress and their staff, subject to paragraph (4), shall be enrolled in Medicare for America. 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 2026 and 2027: Qualified employer coverage, as defined in section 126 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 2028 and 2029: 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 so long as the State can demonstrate substantial progress has been made in transitioning these populations. 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: Ambulatory patient services. Emergency care and urgent care services. Hospitalization. Maternity and newborn care. Behavioral health services, including mental health, substance use disorder services, and intensive home and community based services. Prescription drugs approved by the Food and Drug Administration. 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, 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. 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. Hearing health services including aids and exams. Vision services. Home and community based long-term services and supports. Chiropractic services. Durable medical equipment (as defined for purposes of title XIX), 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 for medical conditions. Augmentative and alternative communication devices, including dual-use devices. Oxygen. Orthotic and prosthetic devices. Disposable medical supplies. 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. Voluntary sterilization for beneficiaries over the age of 21. Infertility treatment. Gender-confirming medical procedures and treatment. Screening, testing, treatment, and pre- and post-test counseling for sexually transmitted diseases and HIV. Dietary and nutrition counseling. Medically necessary food and vitamins for digestive and inherited metabolic disorders. Nursing facilities. Acupuncture. Digital health therapeutics, as approved by the Center for Healthcare and the Center for Medicare and Medicaid Innovation. Telehealth. Non-emergency medical transportation. Care coordination, including services defined in section 440.169 of title 42, Code of Federal Regulations. Palliative care. 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. 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. 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. 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 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. 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. 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. 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 2026), 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; and no individual or household will pay more than 8 percent of adjusted gross monthly income toward such 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 126(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 126(c) of such Act, the individual shall pay the lesser of— the premium described in this subsection; or 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. 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. 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 relating to enrollment under part A or part B. 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. The Secretary of the Treasury may not enter into a contract under paragraph

(4)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 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, 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: USPTF recommended preventive and chronic disease services. Long-term services and supports. Generic drugs, and prescription drugs if medically necessary. 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. Pregnancy related services. Emergency services. 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. There shall be no deductible under Medicare for America. 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. 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. 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. There shall be no lifetime or annual limits for any services or benefits coverable under Medicare for America. 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. 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. Flexible Savings Accounts shall only be used for benefits and services not covered by Medicare for America. 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 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. 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. In applying rates under title XVIII and title XIX, as applicable, 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 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. 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. 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. 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. 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, 2030. 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. The Secretary shall establish a process to allow health care providers not described in paragraph

(1)to become participating providers for Medicare for America. 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: The comparative clinical effectiveness and cost effectiveness, when available from an impartial source, of such drug. The budgetary impact of providing coverage of such drug. The number of similarly effective drugs or alternative treatment regimens for each approved use of such drug. The associated financial burden on patients that utilize such drug. The associated unmet patient need for such drug. 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. 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. 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: The risk-adjusted value of any Federal Government subsidies and investments in research and development used to support the development of such drug. The risk-adjusted value of any investment made by such manufacturer in the research and development of such drug. The impact of the price, including license compensation payments, on meeting the medical need of all patients. The relationship between the price of such drug, including compensation payments, and the health benefits of such drug. Other relevant factors determined appropriate by the Secretary to provide reasonable compensation. The manufacturer described in subparagraph

(A)may seek recovery against the United States in the United States Court of Federal Claims. 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 . 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. 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. 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. In authorizing a competitive license under this paragraph, the Secretary— shall give preference to entities that the Secretary determines have the highest safety and security standards; and may give priority to entities that will manufacture such drug in the United States. 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). 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. 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. 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. 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 no formulary under Medicare for America. 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 2026, 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 2026, 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 2030. 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 2026, 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. The Secretary shall have the authority to issue interim final rules with respect to any provision in this part. 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). 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. Individuals shall continue to receive the service or item if an appeal is filed before the provision of the service or item is terminated. 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 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. Rights are created by any provision of this title that— prescribes, establishes, or confers a benefit or protection in favor of the individual or individuals seeking to enforce the provision; or 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. 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. 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. 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. 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). 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. The Secretary may promulgate regulations to implement this subsection. A State is not eligible for payment under any program specified in subsection

(c)for a calendar quarter in a plan year beginning after 2035 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 2036 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 2037 and each subsequent plan year before plan year 2041— 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 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. 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. Maternal and child health services block grants under title V. 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 1814. Section 1815. Section 1816. Section 1818. Section 1818A. Section 1819. Section 1820. Section 1834. Section 1834A. 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 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. 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: The individual is eligible for Medicare for America. 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: Communication. Social interaction. Learning. 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 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. 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— home health aides and homemakers; direct support professionals and personal attendant care services; hospice; nursing care; medical social services; care coordination, including case management, fiscal intermediary, and support brokerage services; short-term inpatient care, including respite care and care for pain control; 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; private-duty nursing; respite services provided in the individual’s home or broader community; and transitional services to support an individual’s transition from an institutional setting to the community. 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). 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. 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. 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. 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. 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. 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. 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. 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. 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. For plan years beginning with plan year 2028, 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. 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. 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. Medicare Advantage for America plans, for prescription drugs, shall pay no more than the price negotiated under Medicare for America. Medicare Advantage for America plans may not pay fees to insurance brokers. 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. Beginning in 2028, all references in law and regulation to Medicare Advantage shall be deemed a reference to Medicare Advantage for America. .

Connectionstraces to 8

Traces to 8 documents

U.S. Code

Citation graph

cites case law

Sec. 111

Establishment and administration of Medicare for America

Cites 8Cited by 0 across 0 sources