Sec. 2. Establishment and administration of a public health plan
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The Social Security Act is amended by adding at the end the following new title: The Secretary shall establish a coordinated and low-cost health plan, to be known as the Medicare Exchange health plan (referred to in this section as the health plan ) to provide access to quality health care for enrollees. The Secretary shall make the health plan available in the individual market, in all rating areas, for plan year 2028 and each subsequent plan year. The Secretary shall make the health plan available in the small group market, in all rating areas, for plan year 2028 and each subsequent plan year.
There is established in the Treasury of the United States a Plan Reserve Fund , to be administered by the Secretary of Health and Human Services, for purposes of establishing the Medicare Exchange health plan and administering such plan, consisting of amounts appropriated to such fund during the period of fiscal years 2027 through 2036. There is appropriated $1,000,000,000, out of monies in the Treasury not otherwise obligated, to the Plan Reserve Fund for fiscal year 2027, to remain available until expended.
There is established in the Treasury of the United States a Data and Technology Fund , to be administered by the Secretary of Health and Human Services, acting through the Chief Actuary of the Centers for Medicare & Medicaid Services, for purposes of updating technology and performing data collection under section 2205 in order to establish appropriate premiums for all geographic regions of the United States, consisting of amounts appropriated to such fund during the period of fiscal years 2027 through 2036.
There is appropriated $1,000,000,000, out of amounts in the Treasury not otherwise appropriated, to the Data and Technology Fund for fiscal year 2027, to remain available until expended. Not later than 180 days after the date of enactment of the Medicare-X Choice Act of 2025 , the Secretary shall promulgate such regulations as may be necessary to carry out this title. Rules promulgated under this subsection shall be finalized not later than 270 days after the date of enactment of the Medicare-X Choice Act of 2025 .
An individual shall be eligible to enroll in the health plan if such individual, for the entire period for which enrollment is sought— is a qualified individual within the meaning of section 1312 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18032 ); and is not eligible for benefits under the Medicare program under title XVIII. In accordance with the timeframe under section 2201(a)(2), the health plan shall be made available through the American Health Benefit Exchanges described in sections 1311 and 1321 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031 , 18041), including the Small Business Health Options Program Exchange.
The health plan shall comply with all requirements, as applicable, of subtitle D of title I of the Patient Protection and Affordable Care Act and title XXVII of the Public Health Service Act applicable to qualified health plans, and such health plan shall be a qualified health plan, including for purposes of the Internal Revenue Code of 1986. The Secretary— shall make available a silver level and gold level version of the plan, in accordance with section 1301(a)(1)(C)(ii) of the Patient Protection and Affordable Care Act; and may make available no more than 2 versions of the plan for each of the 4 levels of coverage described in subparagraphs
(A)through
(D)of section 1302(d)(1) of the Patient Protection and Affordable Care Act. The health plan shall provide coverage for primary care services, and shall not impose any cost-sharing requirements for such services. The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A) with respect to the health plan in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary shall have the same authority with respect to the public health insurance option as the Secretary has under such subsection (a)(1) and subsection
(b)of section 1874A with respect to title XVIII. Any contract under subsection
(a)shall not involve the transfer of insurance risk from the Secretary to the entity entering into such contract with the Secretary, except in the case of an alternative payment model under section 2209(h). Subject to all applicable privacy requirements, including the requirements under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 ( 42 U.S.C. 1320d–2 note), the Secretary may collect data from State insurance commissioners and other relevant entities to establish rates for premiums and for other purposes, including to improve quality, and reduce racial, ethnic, socioeconomic, geographic, gender, sexual identity, and other health disparities, including such disparities experienced by people with disabilities and older adults, with respect to the health plan. The Secretary shall establish premiums for the health plan that cover the full actuarial cost of offering such plan, including the administrative costs of offering such plan. Such premiums shall vary geographically and between the small group market and the individual market in accordance with differences in the cost of providing such coverage. If, for any plan year, the amount collected in premiums exceeds the amount required for health care benefits and administrative costs in that plan year, such excess amounts shall remain available to the Secretary to administer the health plan and finance beneficiary costs in subsequent years. For plan year 2028, the Secretary shall set premiums for the health plan for each rating area in which the health plan is available for such plan year, taking into consideration the premium rates for plans offered in each such rating area for plan year 2027. After plan year 2028, all enrollees in the health plan within a State shall be members of a single risk pool, except that the Secretary may establish separate risk pools for the individual market and small group market if the State has not exercised its authority under section 1312(c)(3) of the Patient Protection and Affordable Care Act. Except as provided in paragraph
(2)and subsections
(b)and
(c)and subject to subsection (d), the Secretary shall reimburse health care providers furnishing items and services under the health plan at rates determined for equivalent items and services under the original Medicare fee-for-service program under parts A and B of title XVIII. If the Secretary determines appropriate, the Secretary may increase the reimbursements rates described in paragraph
(1)by up to 50 percent for items and services furnished in rural areas (as defined in section 1886(d)(2)(D)). Subject to subsection (d), payment rates for prescription drugs shall be at a rate negotiated by the Secretary. Such negotiations may be in conjunction with negotiations for selected drugs under part E of title XI. Subject to subsection (d), the Secretary shall establish reimbursement rates for any items and services provided under the health plan that are not items and services provided under the original Medicare fee-for-service program under parts A and B of title XVIII. The Secretary may utilize innovative payment methods, including value-based payment arrangements, in making payments for items and services (including prescription drugs) furnished under the health plan. The Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall conduct a comprehensive study, in consultation with stakeholders, and develop recommendations for Congress on the need for, and cost of providing coverage for, additional services under the health plan. The study shall under paragraph
(1)shall include— consideration of providing coverage for long-term services and supports, home and community based services, assistive and enabling technologies, and vision, hearing, and dental services; consideration of providing coverage for other services in addition to the services described in subparagraph
(A)that could most benefit the health and financial well-being of beneficiaries, including by reducing health disparities, if included for coverage under the plan; the costs associated with covering additional services described in subparagraphs
(A)and (B), for beneficiaries through cost-sharing and premiums, and for the Federal Government; and an assessment of the implications of covering such additional services for the risk pool of the health plan and for the individual and small group markets. Not later than 2 years after the date of enactment of this title, the Secretary shall submit to Congress a report on the findings and recommendations of the study under this subsection and shall make such report publicly available on the website of the Department of Health and Human Services. Subject to subsection (d), beginning January 1, 2028, a health care provider may not be enrolled under the Medicare program under section 1866(j) unless the provider is also a participating provider under the health plan. Subject to subsection (d), beginning January 1, 2028, a health care provider may not be a participating provider under a State Medicaid plan under title XIX (or a waiver of such a plan) unless the provider is also a participating provider under the health plan. The Secretary shall establish a process to allow health care providers not described in subsection
(a)or
(b)to become a participating provider under the health plan. The Secretary shall establish a process by which a health care provider described in subsection
(a)or
(b)may opt out of being a participating provider under the health plan, under exceptional circumstances where participation in the health plan threatens the provider’s ability to operate. For plan years beginning with plan year 2028, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the health plan. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, accountable communities for health, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, telehealth, remote patient monitoring, partial capitation, and direct contracting with providers. The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that— seeks to— improve health outcomes; reduce health disparities (including racial, ethnic, socioeconomic, geographic, gender, sexual identity, and other disparities, including such disparities experienced by people with disabilities and older adults); improve coordination to provide more efficient and affordable quality care; address geographic variation in the provision of health services; or prevent or manage chronic illness; promotes care that is integrated, patient-centered, quality, and efficient; implements patient feedback mechanisms, including culturally- and disability-competent mechanisms; and uses person-reported experiences to improve service delivery. To the extent allowed by the benefit standards applied to all health benefits plans participating in the Exchanges (as described in section 2202(b)), the health plan may modify cost-sharing and payment rates to encourage the use of services that promote health and value. The Secretary shall monitor and evaluate the progress of payment and delivery system reforms under this section and shall seek to implement such reforms subject to the following: To the extent that the Secretary finds a payment and delivery system reform successful in improving quality and reducing costs, the Secretary shall implement such reform on as large a geographic scale as practical and economical. The Secretary may delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage. The Secretary may prioritize implementation of such a reform in high-cost geographic areas or otherwise in order to reduce total program costs or to promote high-value care. The Secretary may prioritize implementation of such a reform to reduce racial, ethnic, socioeconomic, geographic, gender, sexual identity, or other health disparities, including such disparities experienced by people with disabilities or older adults. Nothing in this section shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the health plan for different geographic areas. The Secretary shall establish processes and, when appropriate, collaborate with other agencies to integrate medical care under the health plan with food, housing, transportation, and income assistance if the Secretary determines that such integration is expected to— reduce spending without reducing the quality of patient care; improve the quality of patient care without increasing spending; or reduce racial, ethnic, socioeconomic, geographic, gender, sexual identity, or other health disparities, including any such disparities experienced by people with disabilities or older adults. The Secretary may establish a grant program to permit broader experimentation with accountable communities for health model. The Secretary may award a grant under this section to— an institution of higher learning (as defined in section 3452(f) of title 38, United States Code); a local educational agency (as defined in section 8101 of the Elementary and Secondary Education Act of 1965); a health care agency; a nonprofit entity that the Secretary determines has a demonstrated history of community engagement; or any other entity, as the Secretary determines appropriate. A recipient of a grant under this section may use the grant to— support community needs assessment; establish social service partnerships; or establish interactive data systems across health and social service providers. There are authorized to be appropriated such sums as may be necessary to carry out this paragraph. If the Secretary establishes a grant program under this section, the Secretary shall promulgate regulations on— the evaluation of applications for grants under the program; and administration of the program. The Secretary shall ensure the integration of telehealth tools, including technology-enabled collaborative learning and capacity building models, that increase patient access to medical care (including specialty care), particularly in remote or underserved areas, if the Secretary determines that such integration is expected to— reduce spending without reducing the quality of patient care; or improve the quality of patient care without increasing spending. The Secretary shall evaluate the possibility of providing incentives, and, if appropriate, apply incentives, for enrollees in the health plan who receive services from providers who are participating in an alternative payment model (as defined in section 1833(z)(3)(C)). Nothing in this section shall preclude the Secretary from using alternative payment models (as so defined) under this title that are in use under title XVIII. Nothing in this title shall— affect the benefits available under title XVIII; or impact the Federal Hospital Insurance Trust Fund under section 1817 or the Federal Supplementary Medical Insurance Trust Fund under section 1841 (including the Medicare Prescription Drug Account within such Trust Fund). .
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- 42 USC 1320d–2
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Sec. 2
Establishment and administration of a public health plan
Cite42 USC 1320d–2
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