Medicare for America Act of 2019 [sic]
This bill establishes several health insurance programs and otherwise modifies certain requirements relating to health care coverage, costs, and services.
In particular, the bill establishes a national health insurance program to be administered by the Department of Health and Human Services (HHS). Among other requirements, the program must (1) cover all U.S. residents; (2) cover specified items and services, including hospital services, prescription drugs, dental services, and home- and community-based long-term care; and (3) be fully implemented in 2026. HHS must also offer a transitional public health option that provides certain minimum coverage through health insurance exchanges in 2024 and 2025.
The bill also makes a series of other changes to health care and tax provisions. For example, the bill (1) allows federal funds to be used for abortions; (2) sunsets a specified tax reform law that, among other things, repealed the penalty for failing to maintain minimum essential health coverage; and (3) prohibits excessive prices for prescription drugs and medical devices, as determined by a newly established federal regulatory board.
To amend the Social Security Act to establish a Medicare for America 
  health program to provide for comprehensive health coverage for all 
                               Americans.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Medicare for 
America Act of 2019''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
    TITLE I--TRANSITIONING TO AND ESTABLISHING MEDICARE FOR AMERICA

             Subtitle A--Transitional Public Health Option

Sec. 101. Establishment.
Sec. 102. Eligibility.
Sec. 103. Benefits.
Sec. 104. Premiums.
Sec. 105. Providers and reimbursement rates.
Sec. 106. Account; funding.
                    Subtitle B--Medicare for America

Sec. 111. Establishment and administration of Medicare for America.
Sec. 112. Modifications to and coordination with existing Federal 
                            health programs.
                      Subtitle C--Targeted Reforms

Sec. 121. Limitation on removal of Medicare Advantage providers by MA 
                            organizations.
Sec. 122. Network adequacy.
Sec. 123. Eliminating the 24-month waiting period for Medicare coverage 
                            for individuals with disabilities.
Sec. 124. Eliminating the waiting period for individuals on State 
                            Medicaid waiting lists.
Sec. 125. Employer health plan options.
Sec. 126. Prohibition on step therapy and prior authorization under 
                            group health plans.
Sec. 127. Medicare outpatient observation services.
Sec. 128. Abortion coverage.
Sec. 129. Applicability of mental health parity.
Sec. 130. Student loan forgiveness for health care providers 
                            participating in Medicare for America.
Sec. 131. Clarification of the definition of pediatric medical 
                            necessity in qualifying group coverage.
Sec. 132. Safe staffing requirements.
Sec. 133. Enhancements for reduced cost-sharing.
Sec. 134. Repeal of bonus payments for Medicare Advantage plans.
                        TITLE II--TAX PROVISIONS

Sec. 201. Sunset of Public Law 115-97.
Sec. 202. Surtax.
Sec. 203. Basis of property acquired from a decedent.
Sec. 204. Medicare payroll tax.
Sec. 205. Net investment income tax.
Sec. 206. Termination of deduction for contributions to health savings 
                            accounts.
Sec. 207. Increase in excise tax on small cigars and cigarettes and 
                            other tobacco products.
Sec. 208. Excise tax on alcohol.
Sec. 209. Tax on sugared drinks.
Sec. 210. Repeal of excise tax on high-cost employer-sponsored health 
                            coverage.
                   TITLE III--DRUG-RELATED PROVISIONS

Sec. 301. Establishment of the Prescription Drug and Medical Device 
                            Review Board.
Sec. 302. Membership; staff.
Sec. 303. Prohibition against excessive price.
Sec. 304. Enforcement provisions.
Sec. 305. Authority.
Sec. 306. Regulations.
Sec. 307. Report to Federal agencies.
Sec. 308. Definitions.
Sec. 309. Moratorium on direct-to-consumer drug advertising.
Sec. 310. Reporting on justification for drug price increases.
                    TITLE IV--OUTCOMES AND REPORTING

Sec. 401. Sense of Congress.
Sec. 402. Evaluation of bill's outcome.

    TITLE I--TRANSITIONING TO AND ESTABLISHING MEDICARE FOR AMERICA

             Subtitle A--Transitional Public Health Option

SEC. 101. ESTABLISHMENT.

    The Secretary of Health and Human Services (in this subtitle 
referred to as the ``Secretary'') shall establish a public health plan 
option that is offered in the individual market through the Federal and 
State Exchanges under title I of the Patient Protection and Affordable 
Care Act to eligible individuals for plan years 2024 and 2025 in 
accordance with this subtitle.

SEC. 102. ELIGIBILITY.

    Subject to subsection (b), an individual is eligible to enroll in 
such public health plan option if the individual is otherwise eligible 
to purchase individual health insurance coverage through an Exchange 
and the individual resides in a rating area in which the Secretary 
makes the public health plan option available.

SEC. 103. BENEFITS.

    (a) In General.--The public health plan option shall be a qualified 
health plan within the meaning of section 1301(a) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18021(a)) that--
            (1) meets all requirements applicable to qualified health 
        plans under subtitle D of title I of the Patient Protection and 
        Affordable Care Act (other than the requirement under section 
        1301(a)(1)(C)(ii) of such Act (42 U.S.C. 18021(a)(1)(C)(ii))) 
        and title XXVII of the Public Health Service Act;
            (2) provides coverage of the essential health benefits 
        described in section 1302(b) of the Patient Protection and 
        Affordable Care Act (42 U.S.C. 18022(b));
            (3) provides silver and gold-level coverage described in 
        section 1302(d)(1)(C) of the Patient Protection and Affordable 
        Care Act (42 U.S.C. 18022(d)(1)(C)); and
            (4) provides coverage of comprehensive reproductive health 
        services, including abortion.
    (b) Preemption.--Notwithstanding section 1303(a)(1) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18023(a)(1))--
            (1) a State may not prohibit the public health plan option 
        from offering the coverage described in subsection (a)(4); and
            (2) no State law that would prohibit such a plan from 
        offering such coverage shall apply to such plan.

SEC. 104. PREMIUMS.

    (a) In General.--The Secretary shall establish premium rates for 
the public health plan option that--
            (1) are adjusted based on the applicable rating area;
            (2) are at a level sufficient to fully finance--
                    (A) the costs of health benefits provided by such 
                plans; and
                    (B) administrative costs related to operating the 
                plans;
            (3) comply with the requirements under section 2701 of the 
        Public Health Service Act (42 U.S.C. 300gg); and
            (4) ensure that no individual or household will pay more 
        than 8 percent of adjusted gross monthly income toward the 
        monthly premium.
    (b) Federal Subsidies.--Federal subsidies shall be provided to 
ensure that the premium shall be--
            (1) zero in the case of an individual whose annual 
        household income is below 200 percent of the poverty line;
            (2) determined by a linear sliding scale, in the case of an 
        individual whose household income is at least 200 percent of 
        the poverty line, but not more than 600 percent of the poverty 
        line; and
            (3) no individual or household above 600 percent of poverty 
        level will pay more than 8 percent of adjusted gross monthly 
        income toward such monthly premium.

SEC. 105. PROVIDERS AND REIMBURSEMENT RATES.

    (a) In General.--The Secretary shall establish a rate schedule for 
reimbursing types of health care providers furnishing items and 
services under the public health insurance plan option at rates based 
on rates applied for such items and services under title XVIII of the 
Social Security Act, as of the date of the enactment of this Act, that 
are necessary to maintain network adequacy. The Secretary shall 
establish a rate schedule for items and services not currently covered 
under title XVIII of the Social Security Act, such as dental, vision, 
and hearing benefits, well child visits, and reproductive health 
services, at a level to ensure adequate access to providers.
    (b) Participating Providers.--
            (1) In general.--A health care provider that is a 
        participating provider of services or supplier under the 
        Medicare program under title XVIII of the Social Security Act 
        or under the Medicaid program under title XIX of such Act on 
        the date of enactment of this title shall be a participating 
        provider for the public health insurance plan option.
            (2) Additional providers.--The Secretary shall establish a 
        process to allow health care providers not described in 
        paragraph (1) to become participating providers for the public 
        health insurance plan option.
            (3) Clarification.--Notwithstanding any other provision of 
        law, health care providers may not be prohibited from 
        participating in the public health insurance option for reasons 
        other than their ability to provide covered services. Health 
        care providers and institutions are prohibited from denying 
        covered individuals access to any covered benefits and services 
        because of their religious objections.
    (c) Prescription Drugs.--The Secretary shall apply the provisions 
of section 1860D-11(i) of the Social Security Act (42 U.S.C. 1395w-
111(i)) to prescription drugs under the public health plan option in 
the same manner as such provisions apply with respect to applicable 
covered part D drugs under such section.

SEC. 106. ACCOUNT; FUNDING.

    (a) Establishment.--There is established in the Treasury of the 
United States an account for the receipts and disbursements 
attributable to the operation of the public health plan option.
    (b) Appropriation.--There is appropriated to the account 
established under subsection (a), out of any funds in the Treasury not 
otherwise obligated, such sums as may be necessary to be used by the 
Secretary for purposes of carrying out this part.
    (c) Prohibition of State Imposition of Taxes.--Section 1854(g) of 
the Social Security Act (42 U.S.C. 1395w-24(g)) shall apply to receipts 
and disbursements described in subsection (a) in the same manner as 
such section applies to payments or premiums described in such section.
    (d) Clarification.--Any provision of law restricting the use of 
Federal funds with respect to any reproductive health service shall not 
apply to funds appropriated under subsection (b) or with respect to the 
account under subsection (a).

                    Subtitle B--Medicare for America

SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDICARE FOR AMERICA.

    The Social Security Act is amended by adding at the end the 
following new title:

                   ``TITLE XXII--MEDICARE FOR AMERICA

                ``PART A--COMPREHENSIVE HEALTH COVERAGE

``SEC. 2201. ESTABLISHMENT.

    ``The Secretary shall establish a public health insurance program, 
to be known as `Medicare for America', which shall for calendar year 
2026 and each subsequent calendar year provide comprehensive health 
benefits in accordance with this part to individuals enrolled for 
coverage under this title.

``SEC. 2202. ELIGIBILITY; AUTOMATIC ENROLLMENT.

    ``(a) Eligible Individuals.--For purposes of this title, every 
individual who is--
            ``(1) a resident of the United States or a territory of the 
        United States;
            ``(2) an individual who is lawfully present, as defined in 
        section 152.2 of title 45 of the Code of Federal Regulations; 
        or
            ``(3) an individual who would be eligible for coverage 
        under a State Medicaid plan pursuant to section 1903(v) (as 
        such section was in effect as of the date of the enactment of 
        this title),
is entitled to benefits for health care services under this title. The 
Secretary shall promulgate a rule that provides criteria for applying 
this subsection, including determining residency for eligibility 
purposes under this title. Nothing in this title shall preclude a State 
from using State funds to provide for an individual's health coverage 
who is not eligible under this subsection.
    ``(b) Enrollments.--Subject to subsection (c):
            ``(1) In general.--Beginning in 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.
            ``(2) Automatic enrollments.--The mechanism provided under 
        paragraph (1) shall, subject to paragraph (4), provide, for 
        plan years, for the following automatic enrollments under 
        Medicare for America:
                    ``(A) Enrollment at birth.--For plan years 
                (beginning with plan year 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.
                    ``(B) Current medicare beneficiaries.--
                            ``(i) Current medicare beneficiaries.--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).
                            ``(ii) Continuing population.--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.
                            ``(iii) Duals.--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.
                    ``(C) Other individuals without qualified health 
                coverage.--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.
            ``(3) Other enrollments.--The mechanism provided under 
        paragraph (1) shall provide for the following:
                    ``(A) In general.--Enrollment periods and processes 
                for each plan year (beginning with plan year 2026) for 
                enrollment under Medicare for America of any eligible 
                individual not otherwise described in paragraph (2).
                    ``(B) Small employers.--
                            ``(i) In general.--For plan years 
                        (beginning with plan year 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.
                            ``(ii) Requirement.--Small employers shall 
                        either provide coverage as defined within the 
                        meaning of section 2791(d)(8) of the Public 
                        Health Service Act or facilitate the enrollment 
                        of their employees into Medicare for America. 
                        Small employers facilitating enrollment into 
                        Medicare for America will not be subject to a 
                        mandatory employer contribution.
                            ``(iii) Authority.--The Secretary may set 
                        standards for determining whether employers are 
                        undertaking any actions to affect the risk pool 
                        within Medicare for America by inducing 
                        individuals to decline coverage under a 
                        qualifying employer-sponsored plan and instead 
                        to enroll in Medicare for America. An employer 
                        violating such standards shall be treated as 
                        not meeting the requirements of qualified 
                        health coverage.
                    ``(C) Large employers.--For plan years (beginning 
                with plan year 2030), the Secretary shall provide for a 
                process and methodology under which a large employer 
                may provide for the enrollment of the employees of such 
                employer under Medicare for America. For purposes of 
                the preceding sentence, the term `large employer' means 
                an employer with at least 100 employees or whose annual 
                payroll exceeds $2,000,000.
                    ``(D) Members of congress and their staff.--
                Beginning for plan year 2026, Members of Congress and 
                their staff, subject to paragraph (4), shall be 
                enrolled in Medicare for America.
            ``(4) Opt out for individuals enrolled under qualified 
        health coverage.--
                    ``(A) In general.--The mechanism provided under 
                paragraph (1) shall provide, with respect to a plan 
                year, for a process that enables individuals who are 
                enrolled in qualified health coverage for such plan 
                year to opt out of coverage under Medicare for America 
                for such year.
                    ``(B) Qualified health coverage defined.--For 
                purposes of this section, the term `qualified health 
                coverage' means coverage under any of the following:
                            ``(i) For plan years 2026 and 2027:
                                    ``(I) Qualified employer coverage, 
                                as defined in section 126 of the 
                                Medicare for America Act.
                                    ``(II) Medical coverage under 
                                chapter 55 of title 10, United States 
                                Code, including coverage under the 
                                TRICARE program.
                                    ``(III) A health care program under 
                                chapter 17 or 18 of title 38, United 
                                States Code, as determined by the 
                                Secretary of Veterans Affairs, in 
                                coordination with the Secretary of 
                                Health and Human Services and the 
                                Secretary.
                                    ``(IV) The health benefit program 
                                under chapter 89 of title 5, United 
                                States Code.
                                    ``(V) Medical benefits and services 
                                provided by or through the Indian 
                                Health Service.
                                    ``(VI) The Medicaid program under 
                                title XIX of the Social Security Act.
                                    ``(VII) The CHIP program under 
                                title XXI of the Social Security Act.
                            ``(ii) For plan years 2028 and 2029:
                                    ``(I) Coverage described in 
                                subclause (I), (II), (III), (IV), or 
                                (V) of clause (i).
                                    ``(II) Coverage described in 
                                subclause (VI) of clause (i), but only 
                                with respect to coverage that is not 
                                for individuals described in subclause 
                                (VIII) of section 1902(a)(10)(A)(i) or 
                                who are also enrolled for benefits 
                                under title XVIII.
                            ``(iii) For each subsequent plan year, 
                        coverage described in subclause (I), (II), 
                        (III), (IV), or (V) of clause (i).
    ``(c) Waiver.--The Secretary shall establish a process under which 
the Secretary may grant waivers to States for additional time before 
populations described in a previous subsection of this section of such 
State are automatically enrolled under Medicare for America so long as 
the State can demonstrate substantial progress has been made in 
transitioning these populations.

``SEC. 2203. BENEFITS.

    ``(a) In General.--Medicare for America shall, in accordance with 
this section, provide coverage for all the benefits, as determined to 
be medically necessary, as covered and defined under parts A and B of 
title XVIII and title XIX as of the date of the enactment of this 
title, including the following:
            ``(1) Ambulatory patient services.
            ``(2) Emergency care and urgent care services.
            ``(3) Hospitalization.
            ``(4) Maternity and newborn care.
            ``(5) Behavioral health services, including mental health, 
        substance use disorder services, and intensive home and 
        community based services.
            ``(6) Prescription drugs approved by the Food and Drug 
        Administration.
            ``(7) Rehabilitative and habilitative services and devices, 
        including the following:
                    ``(A) Physical therapy.
                    ``(B) Speech therapy.
                    ``(C) Occupational therapy.
            ``(8) Laboratory services.
            ``(9) Preventive and wellness services and chronic disease 
        management.
            ``(10) Pediatric services, all services that would 
        otherwise be coverable under early and periodic screening, 
        diagnostic, and treatment under the Medicaid program under 
        title XIX and services otherwise included under the maternal, 
        infant, and early childhood home visiting program under section 
        511, as of the date of the enactment of this title.
            ``(11) Dental care, at a minimum the services necessary to 
        prevent disease and promote oral health, restore oral 
        structures to health and function, and treat emergency 
        conditions, nightguards, mouthguards, and dentures.
            ``(12) Hearing health services including aids and exams.
            ``(13) Vision services.
            ``(14) Home and community based long-term services and 
        supports.
            ``(15) Chiropractic services.
            ``(16) Durable medical equipment (as defined for purposes 
        of title XIX), including the following:
                    ``(A) Wheelchairs and accessories.
                    ``(B) Walking aides such as walkers, canes, and 
                crutches.
                    ``(C) Bathroom equipment such as commodes and 
                safety equipment.
                    ``(D) Inhalation therapy equipment such as 
                nebulizers.
                    ``(E) Hospital beds and accessories.
                    ``(F) Other devices such as Continuous Positive 
                Airway Pressure (CPAP) machines, apnea monitors, and 
                ventilators.
                    ``(G) Insulin pumps and glucometers.
                    ``(H) Breast pumps.
                    ``(I) Lymphedema compression treatment items.
                    ``(J) Wigs for medical conditions.
                    ``(K) Augmentative and alternative communication 
                devices, including dual-use devices.
                    ``(L) Oxygen.
                    ``(M) Orthotic and prosthetic devices.
                    ``(N) Disposable medical supplies.
            ``(17) Family planning, including the following:
                    ``(A) Reproductive health exams.
                    ``(B) Patient counseling and education related to 
                family planning.
                    ``(C) Abortion.
                    ``(D) Screening, testing, treatment, and pre- and 
                post-test counseling for sexually transmitted diseases 
                and HIV.
                    ``(E) Contraceptives including pill, patch, 
                medication, condom, implant, or other devices used to 
                prevent pregnancy.
                    ``(F) Voluntary sterilization for beneficiaries 
                over the age of 21.
                    ``(G) Infertility treatment.
            ``(18) Gender-confirming medical procedures and treatment.
            ``(19) Screening, testing, treatment, and pre- and post-
        test counseling for sexually transmitted diseases and HIV.
            ``(20) Dietary and nutrition counseling.
            ``(21) Medically necessary food and vitamins for digestive 
        and inherited metabolic disorders.
            ``(22) Nursing facilities.
            ``(23) Acupuncture.
            ``(24) Digital health therapeutics, as approved by the 
        Center for Healthcare and the Center for Medicare and Medicaid 
        Innovation.
            ``(25) Telehealth.
            ``(26) Non-emergency medical transportation.
            ``(27) Care coordination, including services defined in 
        section 440.169 of title 42, Code of Federal Regulations.
            ``(28) Palliative care.
            ``(29) Any additional benefit or service not included in 
        this section that is coverable by any State plan (or waiver of 
        such State plan) under title XIX on the date of the enactment 
        of this title.
    ``(b) Updates.--Benefits coverable under Medicare for America shall 
be updated in accordance with the National Coverage Determination 
process that had, as of the date before the date of the enactment of 
this title, applied with respect to benefits covered under title XVIII.
    ``(c) Implementing Policies.--The Secretary shall establish payment 
models, quality measures, and other implementing policies that provide 
further access to the coverage under this title. For purposes of the 
previous sentence, the Secretary shall consult with stakeholders, 
including those covering pediatrics, disabilities, and seniors.
    ``(d) Prohibition Against Duplicating Coverage.--
            ``(1) In general.--It is unlawful for a private health 
        insurer (other than an insurer with respect to a Medicare 
        Advantage for America plan under part C of this title or 
        qualified employer-based coverage) to sell health insurance 
        coverage that duplicates the benefits provided under Medicare 
        for America under this part.
            ``(2) Construction.--Nothing in paragraph (1) shall be 
        construed as prohibiting the sale of health insurance coverage 
        for any additional benefits not covered by this part, insofar 
        as the coverage satisfies the conditions of paragraphs (3) and 
        (4). Nothing shall preclude employers meeting the requirements 
        under section 126 of the Medicare for America Act from 
        providing supplemental coverage under this section to their 
        employees.
            ``(3) Application of protections.--For purposes of 
        paragraph (2), health insurance coverage for any additional 
        benefits must satisfy the following conditions:
                    ``(A) The provisions of section 2718 of the Public 
                Health Service Act, relating to a medical loss ratio.
                    ``(B) The provisions of section 2702 of the Public 
                Health Service Act, relating to guaranteed issue.
                    ``(C) The provisions of section 2701 of the Public 
                Health Service Act, relating to community rating.
                    ``(D) The provisions of section 2704 of the Public 
                Health Service Act, relating to the ban on pre-existing 
                conditions exclusions.
            ``(4) No fees to brokers.--For purposes of paragraph (2), 
        the condition described in this paragraph is that health 
        insurance coverage described in such paragraph does not pay 
        fees to insurance brokers.
    ``(e) States May Provide Additional Benefits.--Individual States 
may provide additional benefits for the residents of such States at the 
expense of the State.
    ``(f) Prohibition Against Step Therapy and Prior Authorization.--
Items and services covered under Medicare for America shall be covered 
without any need for any prior authorization determination and without 
any limitation applied through the use of step therapy protocols.

``SEC. 2204. PREMIUMS.

    ``(a) In General.--
            ``(1) In general.--Subject to paragraph (2), each 
        individual enrolled for benefits under this title for a year 
        shall pay monthly community-rated premiums for such year in an 
        amount determined by the Secretary in accordance with 
        subsection (b).
            ``(2) Grandfathered medicare beneficiaries.--In the case of 
        an individual enrolled under part B of title XVIII as of the 
        date of the enactment of this part, the premium applied under 
        this section for such individual for benefits under this title 
        shall be the lesser of--
                    ``(A) the premium otherwise applicable to such 
                individual under such title XVIII if this title had not 
                been enacted; or
                    ``(B) the premium that would be applied to such 
                individual under this title without the application of 
                this paragraph.
    ``(b) Premium Contribution Based on Income.--The amount of a 
monthly premium, with respect to a plan year (beginning with 2026), 
under this section shall be established by the Secretary in accordance 
with the following:
            ``(1) Such premium shall be determined such that the 
        collective premiums for the plan year are with respect to the 
        costs of health benefits provided under this title for such 
        year and related administrative costs.
            ``(2) Premiums shall vary by family composition only.
            ``(3) Federal subsidies shall be provided to ensure that 
        the premium shall be--
                    ``(A) zero in the case of an individual whose 
                annual household income is below 200 percent of the 
                poverty line;
                    ``(B) determined by a linear sliding scale, in the 
                case of an individual whose household income is at 
                least 200 percent of the poverty line, but not more 
                than 600 percent of the poverty line; and
                    ``(C) no individual or household will pay more than 
                8 percent of adjusted gross monthly income toward such 
                premium.
            ``(4) For an individual whose employer will be making a 
        firm-wide contribution under this title in lieu of offering 
        employer-sponsored insurance (as specified in section 
        126(b)(1)(B) of the Medicare for America Act), such individual 
        shall pay a premium in accordance with this subsection.
            ``(5) For an individual who has opted out of their 
        employer-sponsored insurance in order to enroll in Medicare for 
        America as specified in section 126(c) of such Act, the 
        individual shall pay the lesser of--
                    ``(A) the premium described in this subsection; or
                    ``(B) the amount owed after the amount of employer 
                contribution (as specified in section 126(b)(1)(B) of 
                the Medicare for America Act) is subtracted from the 
                premium established by the Secretary of Health and 
                Human Services as described in paragraph (1), whichever 
                is less.
    ``(c) Deposits.--Amounts paid under this section for coverage under 
this title shall be deposited in the Treasury to the credit of the 
Trust Fund established under section 2206.
    ``(d) Appeals for Certain Medicare Grandfathered Population.--In 
calculating premiums for purposes of subsection (a)(2):
            ``(1) Any individual that was subject to a late enrollment 
        penalty under part B of title XVIII shall have the right to 
        appeal the assessment of the penalty for good faith enrollment 
        mistakes.
            ``(2) The Secretary, in consultation with the Commissioner 
        of Social Security, shall develop and publish a formal 
        application for requesting an action of the Secretary under 
        paragraph (1) to correct or eliminate the effects of an error, 
        misrepresentation, or inaction described in such paragraph and 
        determine and publish specific timelines for timely resolution 
        of such a request.
            ``(3) The Secretary shall also require that all such 
        determinations with respect to such requests shall be reached 
        within 15 business days of the submission of such application. 
        All determinations shall be in writing through a standard 
        decision notice which shall include an explanation of the 
        reasons for the determination.
            ``(4) The Commissioner of Social Security shall enter into 
        contracts with independent review organizations in accordance 
        with this subsection for the purpose of reviewing and 
        determining individual appeals of determinations under 
        paragraph (3) with respect to an application relating to 
        enrollment under part A or part B.
            ``(5) An individual who receives an adverse determination 
        under paragraph (3) may appeal to an independent review 
        organization designated by the Commission. Any such appeal must 
        be sent to the independent review organization within 90 days 
        of the date the individual received the determination to be 
        eligible for review. The independent review organization shall 
        review and reach a determination of the review in writing 
        within 45 days of the receipt of any such appeal.
            ``(6) The Secretary of the Treasury may not enter into a 
        contract under paragraph (4) with an independent review 
        organization--
                    ``(A) unless the organization has staff that has 
                the appropriate knowledge of, and experience with, the 
                eligibility and coordination of benefits rules and 
                regulations under this title; and
                    ``(B) to the extent the organization is a fiscal 
                intermediary under section 1816, a carrier under 
                section 1842, or a Medicare administrative contractor 
                under section 1874A.
            ``(7) The Secretary shall provide for access by independent 
        review organizations conducting appeal determinations under 
        this subsection, to the database of the Coordination of 
        Benefits Contractor of the Centers for Medicare & Medicaid 
        Services as necessary in order to conduct the duties of such 
        organizations to determine appeals pursuant to this subsection.

``SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT-OF-POCKET LIMITS.

    ``(a) Payment of Benefits; Cost-Sharing.--There shall be paid, in 
the case of each individual who is enrolled under Medicare for America 
and incurs expenses for items and services with respect to which 
benefits are payable under this part, subject to subsection (c), 80 
percent of the reimbursement rates established pursuant to section 2206 
for such items and services, except that for the following services, 
the amounts paid under this section shall be equal to 100 percent of 
the reimbursement rates established pursuant to section 2206 for such 
items and services:
            ``(1) USPTF recommended preventive and chronic disease 
        services.
            ``(2) Long-term services and supports.
            ``(3) Generic drugs, and prescription drugs if medically 
        necessary.
            ``(4) All services for individuals who are medically frail 
        or otherwise have special medical needs, (including children 
        with serious emotional disturbance and adults with serious 
        mental illness), individuals with chronic substance use 
        disorders, or individuals with serious and complex medical 
        conditions (such as epilepsy and HIV), individuals with a 
        physical, intellectual or developmental disability that 
        significantly impairs their ability to perform one or more 
        activities of daily living.
            ``(5) Pregnancy related services.
            ``(6) Emergency services.
            ``(7) Services for children under age 21.
The Secretary shall establish a default monthly payment plan under the 
Medicare for America benefits package to ensure the payment owed by the 
individual enrolled under Medicare for America is spread-out evenly 
throughout the year.
    ``(b) Deductible.--There shall be no deductible under Medicare for 
America.
    ``(c) Maximum Out-of-Pocket Limit.--
            ``(1) In general.--The coverage under Medicare shall 
        provide benefits, after the eligible individual has incurred 
        out-of-pocket expenses for items and services with respect to 
        which benefits are payable under this part in a year equal to 
        the annual out-of-pocket threshold specified in paragraph (2), 
        with cost-sharing that is equal to $0.
            ``(2) Annual out-of-pocket threshold.--
                    ``(A) In general.--For purposes of paragraph (1), 
                subject to subparagraphs (B) and (C), the annual out-
                of-pocket threshold specified in this paragraph is a 
                threshold that shall be determined on a linear sliding 
                scale for household income that is at least 200 percent 
                of the poverty line, but not more than 600 percent of 
                the poverty line, and that shall not exceed--
                            ``(i) with respect to an individual, 
                        $3,500; or
                            ``(ii) with respect to a household, $5,000.
                Individuals or households with income above 600 percent 
                of the Federal poverty line shall have their annual 
                out-of-pocket threshold capped at $3,500 and $5,000 
                respectively.
                    ``(B) Indexing.--In the case of plan years 
                beginning after 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.
                    ``(C) Exception.--For purposes of paragraph (1), 
                the annual out-of-pocket threshold for individuals and 
                households with annual income below 200 percent of the 
                Federal poverty line is $0.
    ``(d) No Lifetime or Annual Limits.--There shall be no lifetime or 
annual limits for any services or benefits coverable under Medicare for 
America.
    ``(e) No Balance Billing.--No provider may impose a charge to an 
enrolled individual for coverable services for which benefits are 
provided under this part in an amount higher than the reimbursement 
rate for such services under section 2206 and may not impose a charge 
to such individual for such service other than with respect to the 
other cost-sharing described in this section.
    ``(f) No Private Contracting.--A health care provider or health 
care institution are prohibited from entering into a private contract 
with an individual enrolled under Medicare for America for any item or 
service coverable under Medicare for America.
    ``(g) Limitations on the Use of Flexible Savings Accounts.--
Flexible Savings Accounts shall only be used for benefits and services 
not covered by Medicare for America.

``SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT RATES.

    ``(a) In General.--The Secretary shall establish a rate schedule 
for reimbursing types of health care providers furnishing items and 
services under Medicare for America at rates that are consistent with 
subsection (b) and are necessary to maintain network adequacy.
    ``(b) Rates.--
            ``(1) In general.--Except as provided in paragraphs (2) and 
        (3), the Secretary shall establish rates for benefits and 
        services to be provided to health care providers and suppliers 
        furnishing under Medicare for America based on rates that would 
        be applied (including as computed, updated, and adjusted) under 
        title XVIII or title XIX, whichever is higher, for such type of 
        health care providers and suppliers and item and service if 
        such title remained in effect and, in the case of a type of 
        provider and supplier or item or service coverable under 
        Medicare for America but not otherwise coverable under title 
        XVIII or title XIX, shall provide for rates that ensure 
        adequate access to care.
            ``(2) Exceptions.--For purposes of this section, in 
        applying paragraph (1) the Secretary shall ensure that rates to 
        hospitals for inpatient services or outpatient services 
        furnished under Medicare for America are at least 110 percent 
        of such rates on average or in the aggregate for furnishing 
        such inpatient or outpatient services otherwise applied under 
        title XVIII or title XIX, whichever is higher, except that for 
        hospitals serving underserved areas as specified by the 
        Secretary, such rates are increased as necessary to ensure 
        adequate access to care.
            ``(3) Application.--In applying rates under title XVIII and 
        title XIX, as applicable, for purposes of this part, the 
        following shall apply:
                    ``(A) The Secretary shall provide for site-neutral 
                payments for items and services furnished in an 
                outpatient hospital and physician office, the rate of 
                payment for such service shall be the same.
                    ``(B) The Secretary shall provide for a mechanism 
                to provide payments for direct and indirect costs of 
                graduate medical education programs without any cap on 
                the number of residency positions for which payment may 
                be made, including payments to hospitals for such 
                programs and to eligible facilities for programs for 
                population health-based residencies and for nurse 
                practitioner post-licensure clinical training, 
                residency, and fellowship programs.
                    ``(C) The Secretary shall increase the average 
                relative value of primary care and other mental and 
                behavioral health and cognitive services by not less 
                than 30 percent in order to ensure adequate access to 
                inpatient and outpatient care.
                    ``(D) As a condition of participation in the 
                program, participating providers shall accept Medicare 
                for America rates paid by employer-sponsored insurance 
                plans and Medicare Advantage for America plans.
                    ``(E) The Secretary shall semiannually review if 
                the rates paid by Medicare for America are creating 
                barriers to care. The Secretary shall have the 
                authority to raise rates as necessary to ensure 
                adequate access to care.
            ``(4) Increased federal match for medicaid and the 
        children's health insurance program for years 2026 through 
        2030.--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.
    ``(c) Participating Providers.--
            ``(1) In general.--A health care provider that is a 
        participating provider of services or supplier under the 
        Medicare program under title XVIII or the Medicaid program 
        under title XIX on the date of enactment of this title shall 
        remain a participating provider for Medicare for America.
            ``(2) Additional providers.--The Secretary shall establish 
        a process to allow health care providers not described in 
        paragraph (1) to become participating providers for Medicare 
        for America.
    ``(d) Prescription Drugs.--
            ``(1) In general.--Notwithstanding any other provision of 
        law, the Secretary shall, for plan years beginning on or after 
        the date of the enactment of this title, negotiate with 
        pharmaceutical manufacturers the prices (including discounts, 
        rebates, and other price concessions) that may be charged to 
        Medicare for America and MA for America organizations during a 
        negotiated price period (as specified by the Secretary) for 
        covered drugs for Medicare for America enrollees. In 
        negotiating such prices under this section, the Secretary shall 
        take into account the following factors:
                    ``(A) The comparative clinical effectiveness and 
                cost effectiveness, when available from an impartial 
                source, of such drug.
                    ``(B) The budgetary impact of providing coverage of 
                such drug.
                    ``(C) The number of similarly effective drugs or 
                alternative treatment regimens for each approved use of 
                such drug.
                    ``(D) The associated financial burden on patients 
                that utilize such drug.
                    ``(E) The associated unmet patient need for such 
                drug.
                    ``(F) The total revenues from global sales obtained 
                by the manufacturer for such drug and the associated 
                investment in research and development of such drug by 
                the manufacturer.
            ``(2) Finalization of negotiated price.--The negotiated 
        price of each covered drug for a negotiated price period shall 
        be finalized not later than 30 days before the first plan year 
        in such negotiated price period.
            ``(3) Competitive licensing authority.--
                    ``(A) In general.--Notwithstanding any exclusivity 
                under clause (iii) or (iv) of section 505(j)(5)(F) of 
                the Federal Food, Drug, and Cosmetic Act, clause (iii) 
                or (iv) of section 505(c)(3)(E) of such Act, section 
                351(k)(7)(A) of the Public Health Service Act, or 
                section 527(a) of the Federal Food, Drug, and Cosmetic 
                Act, or by an extension of such exclusivity under 
                section 505A of such Act or section 505E of such Act, 
                and any other provision of law that provides for market 
                exclusivity (or extension of market exclusivity) with 
                respect to a drug, in the case that the Secretary is 
                unable to successfully negotiate an appropriate price 
                for a covered drug for a negotiated price period, the 
                Secretary shall authorize the use of any patent, 
                clinical trial data, or other exclusivity granted by 
                the Federal Government with respect to such drug as the 
                Secretary determines appropriate for purposes of 
                manufacturing such drug for sale under Medicare for 
                America. Any entity making use of a competitive license 
                to use patent, clinical trial data, or other 
                exclusivity under this section shall provide to the 
                manufacturer holding such exclusivity reasonable 
                compensation, as determined by the Secretary based on 
                the following factors:
                            ``(i) The risk-adjusted value of any 
                        Federal Government subsidies and investments in 
                        research and development used to support the 
                        development of such drug.
                            ``(ii) The risk-adjusted value of any 
                        investment made by such manufacturer in the 
                        research and development of such drug.
                            ``(iii) The impact of the price, including 
                        license compensation payments, on meeting the 
                        medical need of all patients.
                            ``(iv) The relationship between the price 
                        of such drug, including compensation payments, 
                        and the health benefits of such drug.
                            ``(v) Other relevant factors determined 
                        appropriate by the Secretary to provide 
                        reasonable compensation.
                    ``(B) Reasonable compensation.--The manufacturer 
                described in subparagraph (A) may seek recovery against 
                the United States in the United States Court of Federal 
                Claims.
                    ``(C) Interim period.--
                            ``(i) In general.--Until 1 year after a 
                        drug described in subparagraph (A) is approved 
                        under section 505(j) of the Federal Food, Drug, 
                        and Cosmetic Act or section 351(k) of the 
                        Public Health Service Act and is provided under 
                        license issued by the Secretary under such 
                        subparagraph, Medicare for America shall not 
                        pay more for such drug than the average of the 
                        prices available, during the most recent 12-
                        month period for which data is available prior 
                        to the beginning of such negotiated price 
                        period, from the manufacturer to any 
                        wholesaler, retailer, provider, health 
                        maintenance organization, nonprofit entity, or 
                        governmental entity in the ten OECD 
                        (Organization for Economic Cooperation and 
                        Development) countries that have the largest 
                        gross domestic product with a per capita income 
                        that is not less than half the per capita 
                        income of the United States or the price 
                        established by the Prescription Drug and 
                        Medical Device Review Board established under 
                        title III of the Medicare for America Act of 
                        2019.
                            ``(ii) Federal program licensing.--If such 
                        drug is not made available at the price 
                        determined, the Secretary shall authorize such 
                        entities to use any patent, clinical trial 
                        data, or other exclusivity granted by the 
                        Federal Government with respect to such drug as 
                        the Secretary determines appropriate for 
                        purposes of manufacturing such drug for sale 
                        under any Federal program, including those 
                        provided by Medicare for America, Veterans 
                        Affairs, the Department of Defense, and the 
                        Coast Guard.
                    ``(D) Authorization for secretary to procure drugs 
                directly.--
                            ``(i) In general.--The Secretary may 
                        procure a drug manufactured pursuant to a 
                        competitive license under subparagraph (A) for 
                        purposes of this part or pursuant to a Federal 
                        program license under subparagraph (C)(ii) for 
                        purposes of a Federal program directly from the 
                        entity manufacturing the drug pursuant to such 
                        a license.
                            ``(ii) Clarification regarding application 
                        of buy american act.--In the case where the 
                        Secretary procures a drug under this 
                        subparagraph, the provisions of chapter 83 of 
                        title 41, United States Code (commonly referred 
                        to as the `Buy American Act'), shall apply.
                    ``(E) Priority for u.s. manufacturers in 
                authorizing competitive licenses.--In authorizing a 
                competitive license under this paragraph, the 
                Secretary--
                            ``(i) shall give preference to entities 
                        that the Secretary determines have the highest 
                        safety and security standards; and
                            ``(ii) may give priority to entities that 
                        will manufacture such drug in the United 
                        States.
            ``(4) FDA review of licensed drug applications.--The 
        Secretary shall prioritize review of applications under section 
        505(j) of the Federal Food, Drug, and Cosmetic Act for drugs 
        licensed under paragraph (3)(A).
            ``(5) Prohibition of anticompetitive behavior.--No drug 
        manufacturer may engage in anticompetitive behavior with 
        another manufacturer that may interfere with the issuance and 
        implementation of a competitive license or run contrary to 
        public policy.
            ``(6) Required reporting.--The Secretary may require 
        pharmaceutical manufacturers to disclose to the Secretary such 
        information that the Secretary determines necessary for 
        purposes of carrying out this subsection.
            ``(7) Clarification.--Nothing in this subsection shall be 
        construed as preventing Medicare for America obtaining a 
        discount or reduction of the price for a covered drug below the 
        price negotiated by the Secretary.
            ``(8) Value or cost-effectiveness assessments.--The use of 
        Quality-Adjusted Life Years, Disability-Adjusted Life Years, or 
        other similar mechanisms is prohibited for use in value or 
        cost-effectiveness assessments for purposes of this subsection.
            ``(9) Clarification.--There shall be no formulary under 
        Medicare for America.

``SEC. 2207. TRUST FUND; FUNDING.

    ``(a) Trust Fund.--There shall be established a unified Medicare 
Trust Fund in which funds provided under this title are deposited and 
from which expenditures under this title are made. The Trust Fund shall 
consist of such gifts and bequests as may be made and such amounts as 
may be deposited in, or appropriated to, such Trust Fund as provided in 
this Act.
    ``(b) Funding.--
            ``(1) Taxes.--There are hereby appropriated to the Trust 
        Fund for each fiscal year beginning with fiscal year 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.
            ``(2) Current program receipts.--Notwithstanding any other 
        provision of law, there are hereby appropriated to the Trust 
        Fund for each fiscal year, beginning with fiscal year 2026, the 
        amounts that would otherwise have been appropriated to carry 
        out the following programs:
                    ``(A) The Medicare program under title XVIII.
                    ``(B) The Medicaid program under title XIX, 
                beginning as of 2030.
            ``(3) Additional appropriations.--Additional sums are 
        authorized to be appropriated annually as needed to maintain 
        maximum quality, efficiency, and access under this part.
            ``(4) Medicaid maintenance of effort payments.--There shall 
        be transferred to the Trust Fund the maintenance of effort 
        payments made under section 2209.
    ``(c) Restrictions Shall Not Apply.--Any other provision of law in 
effect on the date of enactment of this title restricting the use of 
Federal funds for any reproductive health service, including abortion, 
shall not apply to monies in the Trust Fund.
    ``(d) Incorporation of Provisions.--The provisions of subsections 
(b) through (i) of section 1817 shall apply to the Trust Fund under 
this section in the same manner as such provisions applied to the 
Federal Hospital Insurance Trust Fund under such section 1817, except 
that, for purposes of applying such subsections to this section, the 
`Board of Trustees of the Trust Fund' shall mean the `Secretary'.
    ``(e) Transfer of Funds.--Any amounts remaining in the Federal 
Hospital Insurance Trust Fund under section 1817 or the Federal 
Supplementary Medical Insurance Trust Fund under section 1841 after the 
payment of claims for items and services furnished under title XVIII 
have been completed, shall be transferred into the Trust Fund under 
this section.

``SEC. 2208. ADMINISTRATIVE PROVISIONS.

    ``(a) Center for Health Care.--Beginning 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.
    ``(b) Authority.--The Secretary shall have the authority to issue 
interim final rules with respect to any provision in this part.
    ``(c) Administrative Law Judges.--
            ``(1) In general.--The Center for Health Care is not 
        authorized to appoint administrative law judges, in accordance 
        with pages 11420 through 11499 of title 70 of the Federal 
        Register (March 8, 2005).
            ``(2) Timing.--Under this title, administrative law judges 
        must issue a decision within 90 days of receipt of a hearing 
        request, as specified in subsections (a) and (c) of section 
        405.1016 of title 2, Code of Federal Regulations.
    ``(d) Coverage Determinations Appeals.--
            ``(1) Individuals may appeal a coverage determination under 
        this title before the individual obtains the service or item 
        that is the subject of the appeal. Individuals shall continue 
        to receive the service or item if an appeal is filed before the 
        provision of the service or item is terminated.
            ``(2) The Secretary shall eliminate the redetermination by 
        a Medicare administrative contractor from the appeals process 
        under the Medicare program for beneficiaries.
    ``(e) Private Right of Action.--
            ``(1) In general.--An applicant or recipient denied a right 
        conferred by this title may bring a civil action seeking any 
        remedy available in law or equity to remedy that violation. 
        State courts and district courts of the United States shall 
        have concurrent jurisdiction of such actions.
            ``(2) Right defined.--Rights are created by any provision 
        of this title that--
                    ``(A) prescribes, establishes, or confers a benefit 
                or protection in favor of the individual or individuals 
                seeking to enforce the provision; or
                    ``(B) prescribes, establishes, or imposes a duty or 
                obligation on a person or entity to act or conduct 
                operations in a manner that benefits the individual or 
                individuals seeking to enforce the provision.
            ``(3) Reasonable attorney fees.--In any action or 
        proceeding to enforce this title, the court may award 
        reasonable attorneys' fees and litigation costs (including 
        expert fees) reasonably incurred against the defendant or 
        defendants.
            ``(4) Appeal.--Any civil action brought under this section 
        shall be subject to appeal as provided in sections 1291 and 
        1292 of title 28 of the United States Code.
            ``(5) Continued application of other laws.--Nothing in this 
        title (or an amendment made by this title) shall be construed 
        to invalidate or limit the rights, remedies, procedures, or 
        legal standards available to individuals aggrieved under 
        section 1979 of the Revised Statutes (42 U.S.C. 1983), or to 
        supersede State laws causes of action.
    ``(f) Non-Discrimination.--
            ``(1) In general.--Except as otherwise provided for in this 
        title, an individual shall not, on the ground prohibited under 
        title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et 
        seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 
        1681 et seq.), the Age Discrimination Act of 1975 (42 U.S.C. 
        6101 et seq.), section 504 of the Rehabilitation Act of 1973 
        (29 U.S.C. 794), or section 1557 of the Affordable Care Act (42 
        U.S.C. 18116), be excluded from participation in, be denied the 
        benefits of, or be subjected to discrimination under, any 
        health program or activity, any part of which is receiving 
        Federal financial assistance, including credits, subsidies, or 
        contracts of insurance, or under any program or activity that 
        is administered by an Executive Agency or any entity 
        established under this title (or amendments) or any employer-
        sponsored insurance. The enforcement mechanisms provided for 
        and available under such title VI, title IX, section 794, Age 
        Discrimination Act, or such section 1557 shall apply for 
        purposes of violations of this subsection.
            ``(2) Continued application of laws.--Nothing in this title 
        (or an amendment made by this title) shall be construed to 
        invalidate or limit the rights, remedies, procedures, or legal 
        standards available to individuals aggrieved under title VI of 
        the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title 
        VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.), 
        title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et 
        seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 
        794), the Age Discrimination Act of 1975 (42 U.S.C. 611 et 
        seq.), or section 1557 of the Affordable Care Act (42 U.S.C. 
        18116) or to supersede State laws that provide additional 
        protections against discrimination on any basis described in 
        paragraph (1).
            ``(3) Health care providers.--Health care providers may not 
        be prohibited from participating in the Medicare for America 
        for reasons other than their ability to provide covered 
        services. Health care providers and institutions are prohibited 
        from denying covered individuals access to covered benefits and 
        services because of their religious objections. This subsection 
        supercedes any provision of law that allows for conscience 
        protection.
            ``(4) Regulations.--The Secretary may promulgate 
        regulations to implement this subsection.

``SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT.

    ``(a) In General.--A State is not eligible for payment under any 
program specified in subsection (c) for a calendar quarter in a plan 
year beginning after 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.
    ``(b) Maintenance of Effort Payments.--For purposes of this 
section, a maintenance of effort payment with respect to a State and 
plan year is--
            ``(1) for plan year 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;
            ``(2) for plan year 2037 and each subsequent plan year 
        before plan year 2041--
                    ``(A) in the case of a State that is a PPACA 
                expansion State, the payment amount applied under this 
                subsection for the previous plan year, increased by 
                growth in GDP per capita plus 0.4 percent; and
                    ``(B) in the case of a State that is not a PPACA 
                expansion State, the payment amount applied under this 
                subsection for the previous plan year, increased by 
                growth in GDP per capita plus 0.7 percent; and
            ``(3) beginning in 2041, for each subsequent plan year, 
        with respect to any State, the payment amount applied under 
        this subsection for the previous year, increased by growth in 
        GDP per capita plus 0.7 percent.
    ``(c) Programs Specified.--For purposes of this section, the 
programs specified in this subsection are each of the following:
            ``(1) Block grants for community mental health services 
        under subpart I of part B of title XIX of the Public Health 
        Service Act.
            ``(2) Block grants and programs for social services and 
        elder justice under title XX.
            ``(3) Maternal and child health services block grants under 
        title V.
            ``(4) Block grants for prevention and treatment of 
        substance abuse under subpart II of part B of title XIX of the 
        Public Health Service Act.
            ``(5) State Targeted Response to Opioid Crisis Grant 
        Community Services Block Grant.
            ``(6) Grants under section 330 of the Public Health Service 
        Act.
            ``(7) Ryan White HIV/AIDS Program grants under title XXVI 
        of the Public Health Service Act.

``SEC. 2210. APPLICATION OF TITLE XVIII PROVISIONS.

    ``Except as specified otherwise in this title, in implementing 
Medicare for America, the Secretary shall to the greatest extent 
practicable apply the following provisions of title XVIII to the 
program under this title, benefits covered under this title, 
individuals entitled to benefits under this title, and providers of 
services and suppliers participating under the program under this title 
in a similar manner as such provisions applied to the program under 
title XVIII, benefits covered under such title, individuals entitled to 
benefits or enrolled under such title, and providers of services and 
suppliers participating under the program under such title:
            ``(1) Section 1801.
            ``(2) Section 1805.
            ``(3) Section 1806.
            ``(4) Section 1807.
            ``(5) Section 1809.
            ``(6) Section 1814.
            ``(7) Section 1815.
            ``(8) Section 1816.
            ``(9) Section 1818.
            ``(10) Section 1818A.
            ``(11) Section 1819.
            ``(12) Section 1820.
            ``(13) Section 1834.
            ``(14) Section 1834A.
            ``(15) Section 1843.
            ``(16) Section 1846.
            ``(17) Section 1847.
            ``(18) Section 1851.
            ``(19) Section 1852.
            ``(20) Section 1855.
            ``(21) Section 1856.
            ``(22) Section 1857.
            ``(23) Section 1858.
            ``(24) Section 1861.
            ``(25) Section 1863.
            ``(26) Section 1864.
            ``(27) Section 1866B.
            ``(28) Section 1866C.
            ``(29) Section 1866E.
            ``(30) Section 1867.
            ``(31) Section 1868.
            ``(32) Section 1869.
            ``(33) Section 1871.
            ``(34) Section 1874A.
            ``(35) Section 1880.
            ``(36) Section 1881.
            ``(37) Section 1881A.
            ``(38) Section 1891.
            ``(39) Section 1894.
            ``(40) Section 1895.
            ``(41) Section 1896.

   ``PART B--HOME AND COMMUNITY BASED LONG-TERM SERVICES AND SUPPORTS

``SEC. 2231. HOME AND COMMUNITY BASED LONG-TERM SERVICES AND SUPPORTS 
              BENEFIT.

    ``All individuals enrolled under Medicare for America under this 
title shall have coverage for home and community based long-term 
services and supports benefits. Nothing in this part shall be construed 
to limit an enrollee's entitlement to any other benefit that is covered 
pursuant to section 2203, including nursing facility benefits.

``SEC. 2232. ELIGIBILITY.

    ``(a) Eligible Individuals.--An individual who is eligible for home 
and community based long-term services and supports benefits under this 
part is an individual who satisfies each of the following:
            ``(1) The individual is eligible for Medicare for America.
            ``(2) The individual is determined by a licensed health 
        care practitioner to be unable to perform, without substantial 
        assistance, at least one Activity of Daily Living as described 
        in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986, 
        or to require substantial assistance with one or more of the 
        following areas:
                    ``(A) Communication.
                    ``(B) Social interaction.
                    ``(C) Learning.
                    ``(D) Self-care.
                    ``(E) Self-management.
                    ``(F) Impairments that affect the person's capacity 
                for social or economic participation.
    ``(b) Clarification.--Under this part, in the case of an individual 
described in subsection (a) who experiences periods in which their 
functional capacity changes or improves, such individual shall continue 
to have access to benefits under this part as needed. If such an 
individual's functional capacity improves to a point in which the 
individual no longer requires home and community based long-term 
services and supports, or requires fewer services, the individual shall 
be able to immediately and seamlessly resume receiving all needed 
services if and when their functional needs recur. Eligibility for 
services shall be maintained if, without the services, the individual 
would have reduced functional capacity. When assessing functional 
impairment, the individual will be assessed without regard to any 
current services or the ameliorative effects of other mitigating 
measures described in section 3(4)(E)(i)(I) of the Americans With 
Disabilities Act of 1990.
    ``(c) Benefits.--
            ``(1) Definition.--For purposes of this title, the term 
        `home and community based long-term services and supports 
        benefit' means the daily living supports needed by eligible 
        individuals in order to live, work, and participate in their 
        communities, and includes all home and community based services 
        and supports coverable as of the date of the enactment of this 
        title, under any State plan or waiver under title XIX, 
        including--
                    ``(A) home health aides and homemakers;
                    ``(B) direct support professionals and personal 
                attendant care services;
                    ``(C) hospice;
                    ``(D) nursing care;
                    ``(E) medical social services;
                    ``(F) care coordination, including case management, 
                fiscal intermediary, and support brokerage services;
                    ``(G) short-term inpatient care, including respite 
                care and care for pain control;
                    ``(H) behavioral health home and community based 
                long-term services and supports, including assertive 
                community treatment; peer support services; intensive 
                care coordination, including case management; supported 
                employment; and supported housing wraparound;
                    ``(I) private-duty nursing;
                    ``(J) respite services provided in the individual's 
                home or broader community; and
                    ``(K) transitional services to support an 
                individual's transition from an institutional setting 
                to the community.
            ``(2) Non-application.--The provisions of sections 
        424.22(a)(1)(i) and 424.22(a)(1)(ii) of title 42 of the Code of 
        Federal Regulations does not apply in the case of the benefit 
        described in paragraph (1)(A).
    ``(d) Home and Community Based Long-Term Services and Supports 
Workforce Development.--
            ``(1) In general.--The Secretary shall ensure that the 
        number of individuals in the home and community based long-term 
        services and supports workforce is adequate to ensure community 
        integration for all beneficiaries under Medicare for America. 
        In so doing, the Secretary may consider a wide range of 
        factors, including payment rates for direct care workers, 
        career pipelines and credentialing, worker rights, and the 
        impact of national labor policies.
            ``(2) Self-directed model.--All eligible individuals shall 
        be defaulted into a self-directed care option (as defined by 
        the Secretary). The Secretary must consult with eligible 
        individuals, caregivers, workers and their representatives, 
        including unions, and state entities responsible for 
        administering the LTSS benefit to establish this model.
            ``(3) Community first.--The benefit under this part shall 
        be arranged for and provided with a community first presumption 
        and eligible individuals shall be provided home and community 
        based long-term services and support available under this 
        section, regardless of type or level of disability or service 
        need. No eligible individual may be referred to an institution 
        without first being offered and, if chosen, provided home and 
        community based long-term services and supports. Individuals in 
        an institution on the effective date of the bill, and at least 
        annually or upon any change in condition thereafter, shall be 
        informed of, and if chosen, provided with home and community 
        based long-term services and supports.
    ``(e) Administration of Services and Supports.--State entities 
responsible for administering home and community based long-term 
services and support benefits under any State plan or waiver under 
title XIX as of the date of the enactment of this title shall continue 
to administer the benefits and services coverable under this section.
    ``(f) Coordination With Other Federal Benefits.--
            ``(1) Rule of construction.--Nothing in this part shall be 
        construed as prohibiting benefits paid under this part from 
        being used to compensate a caregiver who provides community 
        living assistance services and supports to a dependent relative 
        for providing community living assistance services and supports 
        to an eligible individual under this part.
            ``(2) Dependent relative defined.--The term `dependent 
        relative' means a child, grandchild, niece, nephew, parent, 
        grandparent, sibling, aunt, or uncle (of such caregiver or his 
        or her spouse or domestic partner); such caregiver's spouse or 
        domestic partner, if such child, grandchild, niece, nephew, 
        parent, grandparent, sibling, aunt, uncle, spouse, or domestic 
        partner is an eligible individual.
            ``(3) Supplement not supplant.--Benefits received under 
        this part by a caregiver shall supplement, but not supplant, 
        other benefits for which the individual is eligible under any 
        other federally funded program that provides benefits or 
        assistance.
            ``(4) Disregard.--The benefit paid under this part shall be 
        disregarded for purposes of determining or continuing the 
        eligibility of the individual or the spouse of the individual 
        for receipt of benefits under any other Federal, State, or 
        locally funded assistance program, including benefits paid 
        under title II or XVI, under the laws administered by the 
        Secretary of Veterans Affairs, under low-income housing 
        assistance programs, under the supplemental nutrition 
        assistance program established under the Food and Nutrition Act 
        of 2008, or under programs administered by State vocational 
        rehabilitation agencies.
            ``(5) Regulations.--Not later than one year after the date 
        of the enactment of this section, the Secretary shall 
        promulgate such regulations as are necessary to carry out this 
        part and to prevent fraud and abuse with respect to the 
        benefits under this part.

                ``PART C--MEDICARE ADVANTAGE FOR AMERICA

``SEC. 2221. ALL PRIVATE PLANS.

    ``(a) In General.--For plan years beginning with plan year 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.
    ``(b) Agreements.--The Secretary shall enter into an agreement with 
an MA for America sponsor to offer MA for America plans under this part 
for the coverage of individuals enrolled under Medicare for America who 
elect to receive benefits under part A through such a plan.
    ``(c) MA for America Plan; MA for America Sponsor.--For purposes of 
this part:
            ``(1) MA for america plan.--An MA for America plan is a 
        Medicare Advantage plan under part C of title XVIII, except 
        such plan shall provide coverage for individuals enrolled under 
        Medicare for America under part A of this title, with respect 
        to at least the benefits covered under such part A.
            ``(2) MA for america sponsor.--An MA for America sponsor is 
        a sponsor of an MA for America plan.

``SEC. 2222. APPLICATION OF MEDICARE ADVANTAGE PROVISIONS.

    ``For purposes of applying this part, except as otherwise specified 
under this part, the provisions of part C of title XVIII, as in effect 
as of the date of the enactment of this title shall apply with respect 
to an MA for America sponsor, MA for America plan, individuals eligible 
for coverage under this part, individuals enrolled under such plan, and 
benefits covered under part A in a similar manner and to a similar 
extent as such provisions applied to an MA organization, MA plan, 
individuals eligible for under part C of such title, individuals 
enrolled under an MA plan, and benefits covered under fee-for-service 
Medicare as of such date.

``SEC. 2223. MEDICARE ADVANTAGE FOR AMERICA PAYMENT RATES.

    ``The rates for Medicare Advantage for America plans shall be equal 
to the rates paid by Medicare for America. The Administrator of the 
Center for Healthcare shall pay Medicare Advantage for America plans 95 
percent of average Medicare for America costs in each county.

``SEC. 2224. SEPARATE PREMIUM FOR MEDICARE ADVANTAGE FOR AMERICA PLANS 
              FURNISHING SUPPLEMENTAL BENEFITS.

    ``Nothing in this part shall preclude an individual from choosing a 
Medicare Advantage for America plan which requires the individual to 
pay an additional, separate amount because of supplemental benefits or 
because it is a more expensive plan. In such case the individual 
enrolled under such plan would be responsible for a separate monthly 
premium.

``SEC. 2225. PRESCRIPTION DRUG PRICING UNDER MEDICARE ADVANTAGE FOR 
              AMERICA PLANS.

    ``Medicare Advantage for America plans, for prescription drugs, 
shall pay no more than the price negotiated under Medicare for America.

``SEC. 2226. BAN ON PAYING BROKERS' FEES.

    ``Medicare Advantage for America plans may not pay fees to 
insurance brokers.

``SEC. 2227. CLARIFICATION ON MEDICARE ADVANTAGE EMPLOYER GROUP WAIVER 
              PLANS AND THE MEDICARE SECONDARY PAYER REQUIREMENT.

    ``Such plans shall be exempt from the MSP Requirement, and nothing 
in this section shall be construed as prohibiting such plans from 
contributing to the payment of premiums and cost-sharing.

``SEC. 2228. REFERENCES.

    ``Beginning in 2028, all references in law and regulation to 
Medicare Advantage shall be deemed a reference to Medicare Advantage 
for America.''.

SEC. 112. MODIFICATIONS TO AND COORDINATION WITH EXISTING FEDERAL 
              HEALTH PROGRAMS.

    (a) Medicare, Medicaid, and State Children's Health Insurance 
Program (SCHIP).--
            (1) In general.--Notwithstanding any other provision of 
        law, subject to paragraphs (2) and (3) and section 2202(c) of 
        the Social Security Act, as added by section 111--
                    (A) no benefits shall be available under title 
                XVIII of the Social Security Act for any item or 
                service furnished--
                            (i) beginning on or after January 1, 2028 
                        (except in the case of an individual enrolled 
                        under such title and title XIX of such Act); 
                        and
                            (ii) beginning on or after January 1, 2030, 
                        with respect to all individuals, including 
                        individuals enrolled under such title and title 
                        XIX of such Act;
                    (B) no individual is entitled to medical assistance 
                under a State plan approved under title XIX of such 
                Act--
                            (i) for any item or service furnished on or 
                        after January 1, 2030, in the case of an 
                        individual enrolled under such title and title 
                        XVIII of the Social Security Act or an 
                        individual described in subclause (VIII) of 
                        section 1902(a)(10)(A)(i); and
                            (ii) for any item or service furnished on 
                        or after January 1, 2032;
                    (C) no individual is entitled to medical assistance 
                under a State child health plan under title XXI of such 
                Act for any item or service furnished on or after 
                January 1, 2030; and
                    (D) no payment shall be made to a State under 
                section 1903(a) or 2105(a) of such Act with respect to 
                medical assistance or child health assistance--
                            (i) for any item or service furnished on or 
                        after January 1, 2030, in the case of an 
                        individual enrolled under such title and title 
                        XVIII of the Social Security Act or an 
                        individual described in subclause (VIII) of 
                        section 1902(a)(10)(A)(i); and
                            (ii) for any item or service furnished on 
                        or after January 1, 2032.
            (2) Transition.--In the case of inpatient hospital services 
        and extended care services during a continuous period of stay 
        which began before January 1, 2030, for Medicare and 2032 for 
        Medicaid or CHIP, and which had not ended as of such date, for 
        which benefits are provided under title XVIII of the Social 
        Security Act, under a State plan under title XIX of such Act, 
        or under a State child health plan under title XXI such Act, 
        the Secretary of Health and Human Services shall provide for 
        continuation of benefits under such title or plan until the end 
        of the period of stay.
    (b) Other Federal Health Programs.--
            (1) Federal employees health benefits program.--Nothing in 
        this Act, or the amendments made by this Act, shall affect 
        benefits made available under chapter 89 of title 5, United 
        States Code.
            (2) TRICARE.--Nothing in this Act, or the amendments made 
        by this Act, shall affect benefits made available under 
        sections 1079 and 1086 of title 10, United States Code.
            (3) Treatment of benefits for veterans and native 
        americans.--
                    (A) In general.--Nothing in this Act, or the 
                amendments made by this Act, shall affect the 
                eligibility of veterans for the medical benefits and 
                services provided under title 38, United States Code, 
                or of Indians for the medical benefits and services 
                provided by or through the Indian Health Service.
                    (B) Reevaluation.--No reevaluation of the Indian 
                Health Service shall be undertaken without consultation 
                with tribal leaders and stakeholders.
                    (C) Supplemental indian health services 
                allocation.--The Secretary shall annually determine the 
                need to provide an allotment of supplemental funds to 
                Indian Health Services, including payments to 
                providers, health professional education, 
                administrative expenses, and prevention and public 
                health activities.
            (4) Enrollee choice.--Nothing in this Act shall preclude 
        individuals enrolled in the Federal Employees Health Benefits 
        Program or TRICARE or individuals receiving benefits provided 
        under title, 38, United States Code or the Indian Health 
        Service from enrolling in Medicare for America. Enrollees shall 
        be entitled to the employer contribution as established under 
        section 126(c) of such Act.
    (c) Sunset of Provisions Related to the State Exchanges.--Effective 
January 1, 2030, the Federal and State Exchanges established pursuant 
to title I of the Patient Protection and Affordable Care Act (Public 
Law 111-148) shall terminate, and any other provision of law that 
relies upon participation in or enrollment through such an Exchange, 
including such provisions of the Internal Revenue Code of 1986, shall 
cease to have force or effect.
    (d) Severability.--Every provision in this Act and every 
application of the provisions in this Act are severable from each other 
as a matter of Federal law. If any application of any provision in this 
Act to any person or group of persons or circumstances is found by a 
court to be invalid, the remainder of this Act and the application of 
the Act's provisions to all other persons and circumstances may not be 
affected.

                      Subtitle C--Targeted Reforms

SEC. 121. LIMITATION ON REMOVAL OF MEDICARE ADVANTAGE PROVIDERS BY MA 
              ORGANIZATIONS.

    (a) Limitation.--Section 1852(d) of the Social Security Act (42 
U.S.C. 1395w-22(d)) is amended by adding at the end the following:
            ``(7) Limitation on removal of providers from ma plans by 
        ma organizations.--
                    ``(A) Removal of providers with cause.--Beginning 
                with plan year 2025, except as provided in subparagraph 
                (C), an MA organization offering an MA plan may only 
                remove a provider of services or a supplier from a 
                network of such plan if the organization has cause to 
                remove such provider or supplier.
                    ``(B) Cause to remove providers.--
                            ``(i) In general.--An MA organization 
                        offering an MA plan has cause to remove a 
                        provider of services or a supplier from a 
                        network of such plan if the Secretary 
                        determines that the provider or supplier is--
                                    ``(I) medically negligent;
                                    ``(II) in violation of any legal or 
                                contractual requirement applicable to 
                                the provider or supplier acting within 
                                the lawful scope of practice, including 
                                any participation or other requirement 
                                applicable to such provider or supplier 
                                under this title or under any 
                                contractual term for such plan; or
                                    ``(III) otherwise unfit to furnish 
                                items and services in accordance with 
                                requirements of this title.
                            ``(ii) Consideration of cost to ma 
                        organizations.--For purposes of subparagraph 
                        (A), cost to an MA organization offering an MA 
                        plan due to the participation of a provider of 
                        services or supplier in a network of such plan 
                        does not constitute cause for the MA 
                        organization to remove such provider or 
                        supplier from the network mid-year, and such 
                        cost may not be considered as a factor in favor 
                        of a determination that such organization has 
                        cause to remove the provider.
                    ``(C) Exception.--With respect to each upcoming 
                plan year, beginning with plan year 2025 an MA 
                organization offering an MA plan may only remove a 
                provider of services or supplier from a network of such 
                plan for reasons not specified in subparagraph (B)(i) 
                before the date that is 60 days before the first day of 
                the annual coordinated election period for such plan 
                year under section 1851(e)(3).
                    ``(D) Notice and appeal process.--
                            ``(i) In general.--Any removal of a 
                        provider of services or supplier from a network 
                        of an MA plan may occur only after the 
                        completion of a fair notice and appeal process 
                        that the Secretary shall establish by 
                        regulation. Such process shall require the MA 
                        organization to provide to such provider or 
                        supplier and to the Secretary an explanation of 
                        the reason or reasons for the removal. The 
                        Secretary shall make this information publicly 
                        available.
                            ``(ii) Application.--
                                    ``(I) Application of new process.--
                                In the case of a removal of a provider 
                                of services or supplier from a network 
                                of an MA plan occurring on or after the 
                                effective date published in a final 
                                rule for such fair notice and appeal 
                                process, such process shall apply in 
                                lieu of the process for the termination 
                                or suspension of a provider contract 
                                under section 422.202(a) of title 42, 
                                Code of Federal Regulations.
                                    ``(II) Continuation of old 
                                process.--In the case of a removal of a 
                                provider of services or supplier from a 
                                network of an MA plan occurring before 
                                such effective date, the process for 
                                the termination or suspension of a 
                                provider contract under section 
                                422.202(a) of title 42, Code of Federal 
                                Regulations, shall apply.
                    ``(E) Participant notice and protection.--
                            ``(i) Notice to participants of provider 
                        removal.--Not less than 60 days before the date 
                        on which a provider of services or supplier is 
                        removed from a network of an MA plan, the MA 
                        organization offering such plan shall provide 
                        written notification of the removal to each 
                        individual enrolled in such plan receiving 
                        items or services from the provider or supplier 
                        during the plan year in effect on the date of 
                        removal or during the previous plan year. Such 
                        notification shall include at the minimum--
                                    ``(I) the names and telephone 
                                numbers of available in-network 
                                providers of services and suppliers 
                                offering items and services that are 
                                the same or similar to the items and 
                                services offered by the removed 
                                provider or supplier;
                                    ``(II) information regarding the 
                                options available to an individual 
                                enrolled in such plan to request the 
                                continuation of medical treatment or 
                                therapy with the removed provider or 
                                supplier; and
                                    ``(III) one or more customer 
                                service telephone numbers that an 
                                individual enrolled in such plan may 
                                access to obtain information regarding 
                                changes to the network of the plan.
                            ``(ii) Annual notice of change.--In 
                        addition to providing the notification of 
                        removal as required under clause (i), the MA 
                        organization offering such MA plan shall 
                        include such notification in the annual notice 
                        of change for the MA plan for the upcoming plan 
                        year.
                            ``(iii) Continuity of care.--In any case in 
                        which a provider of services or supplier is 
                        removed from a network of an MA plan, such plan 
                        shall ensure that the removal satisfies the 
                        continuity of care requirements under paragraph 
                        (1)(A) with respect to each individual enrolled 
                        in such plan receiving items or services from 
                        the provider or supplier during the plan year 
                        in effect on the date of removal or during the 
                        previous plan year.
                    ``(F) Rule of construction.--Nothing in this 
                paragraph shall be construed as affecting the ability 
                of a provider of services or supplier to decline to 
                participate in a network of an MA plan.
            ``(8) Transparency in measures used by ma organizations to 
        establish or modify provider networks.--
                    ``(A) In general.--Beginning with plan year 2025, 
                an MA organization offering an MA plan shall publish 
                and make accessible the information described in 
                subparagraph (B)--
                            ``(i) in the annual bid information 
                        submitted by the MA organization with respect 
                        to the MA plan under section 1854; and
                            ``(ii) on the Internet Web Site for the MA 
                        plan.
                    ``(B) Information described.--The information 
                described in this subparagraph is the following:
                            ``(i) Information regarding the measures 
                        used by the MA organization to establish or 
                        modify the provider network of the MA plan, 
                        including measures of the quality and 
                        efficiency of providers. Such information shall 
                        include the specifications, methodology, and 
                        sample size of such measures.
                            ``(ii) Other information related to the 
                        establishment or modification of such provider 
                        network that the Secretary determines 
                        appropriate.
                    ``(C) Limitation.--The information described in 
                subparagraph (B) shall not include any individually 
                identifiable information of any provider or supplier of 
                services.''.
    (b) Enforcement.--
            (1) Sanctions for noncompliance.--Section 1857(g)(1) of the 
        Social Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
                    (A) in subparagraph (J), by striking ``or'';
                    (B) by redesignating subparagraph (K) as 
                subparagraph (L);
                    (C) by inserting after subparagraph (J) the 
                following new subparagraph:
                    ``(K) fails to comply with section 1852(d)(7) or 
                1852(d)(8); or''; and
                    (D) in subparagraph (L) (as so redesignated), by 
                striking ``through (J)'' and inserting ``through (K)''.
            (2) Sanctions not applicable to part D.--Title XVIII of the 
        Social Security Act is amended--
                    (A) in section 1860D-12(b)(3)(E) (42 U.S.C. 1395w-
                112(b)(3)(E)), by striking ``paragraph (1)(F)'' and 
                inserting ``paragraphs (1)(F) and (1)(K)''; and
                    (B) in section 1894(e)(6)(B) (42 U.S.C. 
                1395eee(e)(6)(B)), by inserting ``(other than paragraph 
                (1)(K) of such section)'' after ``1857(g)(1)''.
    (c) Medicare Advantage Plan Compare Tool.--Not later than one year 
after the date of enactment of this Act, the Secretary of Health and 
Human Services shall take such measures as are necessary to ensure that 
the Medicare Advantage Compare Tool takes into account the preferences 
and utilization needs of such individuals.

SEC. 122. NETWORK ADEQUACY.

    (a) In General.--Section 1852(d) of the Social Security Act (42 
U.S.C. 1395w-22(d)) is amended by adding at the end the following:
            ``(9) Network adequacy requirements.--Beginning in plan 
        year 2024, notwithstanding any other provision of law, the 
        following shall apply:
                    ``(A) Provider availability.--When establishing a 
                plan network, a Medicare Advantage organization 
                offering an MA plan shall, among other factors 
                determined by the Secretary, consider the following:
                            ``(i) The anticipated enrollment in the 
                        plan.
                            ``(ii) The expected types of services 
                        provided and utilization of services by 
                        enrollees under the plan.
                            ``(iii) The number and types of providers 
                        needed to provide such services.
                            ``(iv) The number of network providers who 
                        are not accepting new patients.
                            ``(v) The location of providers and 
                        enrollees, taking into account geographic 
                        disbursement.
                            ``(vi) The full-time equivalent 
                        availability of a provider to provide such 
                        services.
                    ``(B) Provision of care in a timely manner.--A 
                Medicare Advantage organization offering an MA plan 
                shall ensure that providers are able to provide 
                services in a timely manner, as defined by the 
                Secretary, under the plan.
                    ``(C) Application of network access adequacy 
                standards.--In applying the network access adequacy 
                standards pursuant to paragraph (1), the Secretary 
                shall seek input from patient advocacy groups, 
                providers of services and suppliers, and MA plans under 
                this part.
                    ``(D) Certification.--Each plan year, a Medicare 
                Advantage organization shall certify to the Secretary, 
                with respect to each MA plan offered by the 
                organization, that the providers, including specialists 
                and subspecialists, in the plan network are able to 
                provide the services required under the organization's 
                contract with the Secretary under section 1857 with 
                respect to the offering of such plan and to meet the 
                needs of the enrollees within the plan service area 
                during the year.
                    ``(E) Annual reporting.--Each plan year, a Medicare 
                Advantage organization shall report to the Secretary, 
                and make public the following with respect to each MA 
                plan offered by the organization:
                            ``(i) Average wait time.--The average wait 
                        time for primary and specialty care for 
                        enrollees under the plan.
                            ``(ii) Utilization of out of network 
                        providers.--The utilization of out-of-network 
                        providers under the plan.
                            ``(iii) Average cost per patient.--The 
                        average annual spending per patient for primary 
                        and specialty care for enrollees under the 
                        plan.
                    ``(F) Certification.--In advance of the annual, 
                coordinated election period under section 1851(e)(3), a 
                Medicare Advantage organization shall certify to the 
                Secretary the accuracy of provider directories for each 
                plan offered by the organization.
                    ``(G) Network review.--The Secretary shall ensure 
                that the network of each MA plan offered by a Medicare 
                Advantage organization meets the network adequacy 
                guidelines established under this paragraph and under 
                section 422.112(a)(4) of title 42, Code of Federal 
                Regulations (or any successor regulation to such 
                section) at least once every 3 years or when a material 
                change in network occurs.
                    ``(H) Authority.--The Secretary shall have the 
                authority to stop any further enrollment in a Medicare 
                Advantage plan if there is a pattern of excessive 
                violations of this paragraph.''.
    (b) Enforcement.--Section 1857(g)(1)(K) of the Social Security Act 
(42 U.S.C. 1395w-27(g)(1)(K)), as added by section 2(b), is amended by 
striking ``or 1852(d)(8)'' and inserting ``, 1852(d)(8), or 
1852(d)(9)''.

SEC. 123. ELIMINATING THE 24-MONTH WAITING PERIOD FOR MEDICARE COVERAGE 
              FOR INDIVIDUALS WITH DISABILITIES.

    (a) In General.--Section 226(b) of the Social Security Act (42 
U.S.C. 426(b)) is amended--
            (1) in paragraph (2)(A), by striking ``, and has for 24 
        calendar months been entitled to,'';
            (2) in paragraph (2)(B), by striking ``, and has been for 
        not less than 24 months,'';
            (3) in paragraph (2)(C)(ii), by striking ``, including the 
        requirement that he has been entitled to the specified benefits 
        for 24 months,'';
            (4) in the first sentence, by striking ``for each month 
        beginning with the later of (I) July 1973 or (II) the twenty-
        fifth month of his entitlement or status as a qualified 
        railroad retirement beneficiary described in paragraph (2), 
        and'' and inserting ``for each month for which the individual 
        meets the requirements of paragraph (2), beginning with the 
        month following the month in which the individual meets the 
        requirements of such paragraph, and''; and
            (5) in the second sentence, by striking ``the `twenty-fifth 
        month of his entitlement''' and all that follows through 
        ``paragraph (2)(C) and''.
    (b) Conforming Amendments.--
            (1) Section 226.--Section 226 of the Social Security Act 
        (42 U.S.C. 426) is amended by--
                    (A) striking subsections (e)(1)(B), (f), and (h); 
                and
                    (B) redesignating subsections (g) and (i) as 
                subsections (f) and (g), respectively.
            (2) Medicare description.--Section 1811(2) of the Social 
        Security Act (42 U.S.C. 1395c(2)) is amended by striking ``have 
        been entitled for not less than 24 months'' and inserting ``are 
        entitled''.
            (3) Medicare coverage.--Section 1837(g)(1) of the Social 
        Security Act (42 U.S.C. 1395p(g)(1)) is amended by striking 
        ``25th month of'' and inserting ``month following the first 
        month of''.
            (4) Railroad retirement system.--Section 7(d)(2)(ii) of the 
        Railroad Retirement Act of 1974 (45 U.S.C. 231f(d)(2)(ii)) is 
        amended--
                    (A) by striking ``has been entitled to an annuity'' 
                and inserting ``is entitled to an annuity'';
                    (B) by striking ``, for not less than 24 months''; 
                and
                    (C) by striking ``could have been entitled for 24 
                calendar months, and''.
    (c) Effective Date.--The amendments made by this section shall 
apply to insurance benefits under title XVIII of the Social Security 
Act with respect to items and services furnished in months beginning 
after the date of enactment of this Act.

SEC. 124. ELIMINATING THE WAITING PERIOD FOR INDIVIDUALS ON STATE 
              MEDICAID WAITING LISTS.

    The Secretary of Health and Human Services is appropriated such 
sums as are necessary to facilitate enrollment, not later than 90 days 
after the date of the enactment of this Act, all eligible individuals 
who, as of the date of the enactment of this Act, are on State Medicaid 
waiting lists or State Medicaid waiver waiting lists.

SEC. 125. EMPLOYER HEALTH PLAN OPTIONS.

    (a) Definition.--A qualifying employer-sponsored plan is--
            (1) a governmental plan (within the meaning of section 
        2791(d)(8) of the Public Health Service Act); or
            (2) any other plan or coverage that meets the criteria 
        under subsection (b), includes vision, dental, and hearing 
        benefits, and provides health coverage that is equivalent to an 
        actuarial value of at least 80 percent of the coverage provided 
        under title XXII of the Social Security Act and makes a premium 
        contribution of at least 70 percent.
Such plan shall require a premium contribution from the employer of at 
least 70 percent regardless of whether coverage is for single, spousal, 
or dependent care.
    (b) Obligation.--Large employers shall, with respect to any full-
time employee of such employer--
            (1) offer a qualifying employer-sponsored plan to such 
        employee, in accordance with subsection (a); or
            (2) make a contribution of 8 percent of their annual 
        payroll to the Medicare Trust Fund under title XXII of the 
        Social Security Act.
    (c) Employee Choice.--An employee may opt out of a qualifying 
employer-sponsored plan as satisfied by subsection (b)(1) in order to 
enroll in Medicare for America. The employer shall make a contribution 
equal to the contribution it shall make in order to meet the 
requirements established by subsection (a)(1) or (a)(2). The Secretary 
of Health and Human Services shall have authority to set standards for 
determining whether employers or insurers are undertaking any actions 
to affect the risk pool within Medicare for America by inducing 
individuals to decline coverage under a qualifying employer-sponsored 
plan and instead to enroll in Medicare for America. An employer 
violating such standards shall be treated as not meeting the 
requirements of subsection (a).
    (d) Employee Education on Health Coverage Options.--Large employers 
shall disseminate to employees such publicly available information on 
coverage options under Medicare for America as the Secretary deems 
appropriate, including contact information for assistance.
    (e) Special Rules.--
            (1) Annual payroll.--For purposes of this paragraph, the 
        term ``annual payroll'' means, with respect to any employer for 
        any calendar year, the aggregate wages paid by the employer 
        during such calendar year.
            (2) Aggregation rules.--Related employers and predecessors 
        shall be treated as a single employer for purposes of this 
        subsection.
            (3) Reduction for part-time employees.--In the case of a 
        part-time employee, the employer contribution requirements of 
        paragraph (1) shall be treated as satisfied if the employer 
        contribution with respect to such employee is not less than the 
        part-time employment ratio of the contribution required under 
        paragraph (1).
            (4) Rules related to part-time employment.--For purposes of 
        this subsection--
                    (A) Part-time employee.--The term ``part-time 
                employee'' means, with respect to any month, an 
                employee who works on average fewer than 30 hours per 
                week.
                    (B) Part-time employment ratio.--The term ``part-
                time employment ratio'' means, with respect to a part-
                time employee of an employer in a month, a fraction--
                            (i) the numerator of which is the number of 
                        hours in the employee's normal work week; and
                            (ii) the denominator of which is 30 hours.
                    (C) Special rules.--Under rules prescribed by the 
                Secretary of Health and Human Services, in consultation 
                with the Secretary of the Treasury, in the case of an 
                employee for an employer whose defined work week for 
                full-time employees is less than 30 hours, any 
                reference in this subsection to 30 hours is deemed a 
                reference to the number of hours in the work week so 
                defined.
                    (D) Conversion to hours of employment.--The 
                Secretary of Health and Human Services, in consultation 
                with the Secretary of the Treasury, shall establish 
                rules for the conversion of compensation to hours of 
                employment, for purposes of this subsection in the case 
                of employees that receive compensation on a salaried 
                basis, or on the basis of a commission, or other 
                contingent or bonus basis, rather than based on an 
                hourly wage.
    (f) Timing and Manner.--Each employer that makes a financial 
contribution under subsection (b)(2) and (c) under this section (other 
than with respect to coverage under a group health plan) shall pay such 
contribution in a form and manner, specified by the Secretary of the 
Treasury, based upon the form and manner in which employer excise taxes 
are required to be paid under section 3111 of the Internal Revenue Code 
of 1986.
    (g) Non-Discrimination.--
            (1) In general.--Except as otherwise provided for in this 
        title (or an amendment made by this title), an individual shall 
        not, on the ground prohibited under title VI of the Civil 
        Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX of the 
        Education Amendments of 1972 (20 U.S.C. 1681 et seq.), the Age 
        Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), or section 
        504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), be 
        excluded from participation in, be denied the benefits of, or 
        be subjected to discrimination under, any health program or 
        activity, any part of which is receiving Federal financial 
        assistance, including credits, subsidies, or contracts of 
        insurance, or under any program or activity that is 
        administered by an Executive Agency or any entity established 
        under this title (or amendments) or any employer-sponsored 
        insurance.
            (2) Continued application of laws.--Nothing in this title 
        (or an amendment made by this title) shall be construed to 
        invalidate or limit the rights, remedies, procedures, or legal 
        standards available to individuals aggrieved under title VI of 
        the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title 
        VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.), 
        title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et 
        seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 
        794), or the Age Discrimination Act of 1975 (42 U.S.C. 611 et 
        seq.), or to supersede State laws that provide additional 
        protections against discrimination on any basis described in 
        paragraph (1).
            (3) Limitation.--A group health plan may not establish 
        rules relating to the health insurance coverage eligibility 
        (including continued eligibility) or contribution requirements 
        of any full-time employee under the terms of the plan that have 
        the effect of discriminating in favor of higher-wage employees.
            (4) Regulations.--The Secretary of Health and Human 
        Services, in conjunction with the Secretary of Labor, may 
        promulgate regulations to implement this subsection.

SEC. 126. PROHIBITION ON STEP THERAPY AND PRIOR AUTHORIZATION UNDER 
              GROUP HEALTH PLANS.

    Section 2719A of the Public Health Service Act (42 U.S.C. 300gg-
19a) is amended by adding at the end the following new subsection:
    ``(e) Prohibition Against Step Therapy and Prior Authorization.--
Beginning with the first plan year following the date of the enactment 
of this subsection, a group health plan may not require a prior 
authorization determination for coverage of any benefit under such plan 
and may not apply treatment limitations through the use of step therapy 
protocols.''.

SEC. 127. MEDICARE OUTPATIENT OBSERVATION SERVICES.

    Section 1861(i) of the Social Security Act (42 U.S.C. 1395x(i)) is 
amended by adding at the end the following: ``For purposes of this 
subsection, an individual receiving outpatient observation services 
shall be deemed to be an inpatient during such period, and the date 
such individual ceases receiving such services shall be deemed the 
hospital discharge date (unless such individual is admitted as a 
hospital inpatient at the end of such period)''.

SEC. 128. ABORTION COVERAGE.

    Notwithstanding any other provision of law, Federal funds may be 
used to provide for abortion services under any health program or 
activity.

SEC. 129. APPLICABILITY OF MENTAL HEALTH PARITY.

    Section 2726 of the Public Health Service Act shall apply to all 
health coverage in the same manner and to the same extent as such 
section applies to health insurance issuers and group health plans 
under title XXVII of such Act.

SEC. 130. STUDENT LOAN FORGIVENESS FOR HEALTH CARE PROVIDERS 
              PARTICIPATING IN MEDICARE FOR AMERICA.

    (a) In General.--Beginning on the date after the date of the 
enactment of this Act, after the conclusion of each plan year, the 
Secretary of Health and Human Services, in conjunction with the 
Secretary of Education, shall cancel the applicable percent specified 
in subsection (b) of the total amount due on any eligible Federal Loan 
made 20 years prior to date of enactment and any date after the date of 
enactment of this Act for a borrower who is a Medicare for America 
participating provider and submits an employment certification form 
described in subsection (d).
    (b) Applicable Percent.--For purposes of subsection (a), the 
applicable percent is 10 percent of any eligible Federal Loan for each 
year the health care provider participates in Medicare for America.
    (c) Definitions.--In this section:
            (1) Eligible federal loan.--The term ``eligible Federal 
        loan'' means any loan made under part D of title IV of the 
        Higher Education Act of 1965 (20 U.S.C. 1087a).
            (2) Health care provider.--The term ``health care 
        provider'' means a physician, physician assistant, registered 
        nurse, nurse practitioner, advanced practice nurse, licensed 
        practical nurse, psychologist, mental health counselor, 
        marriage and family therapist, direct care worker, health 
        social worker, dentist, dental hygienist, pharmacist, physical 
        therapist, occupational therapist, or any other health care 
        provider specified by the Secretary of Health and Human 
        Services if the Secretary determines such specification for 
        purposes of this section is necessary to ensure workforce 
        adequacy.
            (3) Medicare for america participating provider.--The term 
        ``Medicare for America participating provider'' means a health 
        care provider that meets the definition of such term under 
        section 105 or works at a participating provider or entity as 
        defined under section 105.
    (d) Employment Certification Form.--
            (1) In general.--In order to receive loan cancellation 
        under this paragraph, a borrower shall submit to the Secretary 
        of Education an employment certification form that is developed 
        by the Secretary of Education and includes self-certification 
        of employment and a separate part for employer certification 
        that indicates the dates of employment.
            (2) Deferment.--If a borrower submits to the Secretary of 
        Education the employment certification form described in 
        paragraph (1), during the period in which the borrower is 
        employed as a Medicare for America participating provider for 
        which loan cancellation is eligible under this section, the 
        borrower's eligible Federal Direct Loan shall be placed in 
        deferment.
    (e) Interest Canceled.--If a portion of a loan is canceled under 
this section for any year, the entire amount of interest on such loan 
that accrues for such year shall be canceled.
    (f) Regulations.--The Secretary of Health and Human Services and 
Secretary of Education may promulgate regulations to implement this 
section.

SEC. 131. CLARIFICATION OF THE DEFINITION OF PEDIATRIC MEDICAL 
              NECESSITY IN QUALIFYING GROUP COVERAGE.

    (a) Definition.--The following definition of pediatric medical 
necessity shall be incorporated into benefit standards of all plans 
subject to the requirements of section 1302 of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18022) and all group plans by 2023.
    (b) Development of Definition.--Pediatric medical necessity, or 
pediatric medically necessary care, shall be defined as health care 
interventions that are evidence based, evidence informed, or based on 
consensus advisory opinion and that are recommended by recognized 
health care professionals, to promote optimal growth and development in 
a child and to prevent, detect, diagnose, treat, ameliorate, or 
palliate the effects of physical, genetic, congenital, developmental, 
behavioral, or mental conditions, injuries, or disabilities.
    (c) Updates to Definition.--The Secretary of Health and Human 
Services, in consultation with experts in the field of pediatric care 
and key stakeholders, including patient and family groups, shall review 
and update this definition on a biennial basis, consistent with up-to-
date standards of pediatric healthcare practice that are based on--
            (1) the views of pediatric healthcare providers and experts 
        practicing in relevant clinical areas;
            (2) recommendations of medical-specialty societies, other 
        pediatric healthcare provider organizations, and family and 
        patient groups; and
            (3) credible scientific evidence published in peer-reviewed 
        literature that is generally recognized by the relevant health 
        care provider community.

SEC. 132. SAFE STAFFING REQUIREMENTS.

    (a) Minimum Direct Care Registered Nurse Staffing Requirements.--
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by 
adding at the end the following new title:

     ``TITLE XXXIV--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING 
                              REQUIREMENT

``SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.

    ``(a) Staffing Plan.--
            ``(1) In general.--A hospital shall implement a staffing 
        plan that--
                    ``(A) provides adequate, appropriate, and quality 
                delivery of health care services and protects patient 
                safety; and
                    ``(B) is consistent with the requirements of this 
                title.
            ``(2) Effective dates.--
                    ``(A) Implementation of staffing plan.--Subject to 
                subparagraph (B), the requirements under paragraph (1) 
                shall take effect on a date to be determined by the 
                Secretary, but not later than 1 year after the date of 
                the enactment of this title.
                    ``(B) Application of minimum direct care registered 
                nurse-to-patient ratios.--The requirements under 
                subsection (b) shall take effect as soon as 
                practicable, as determined by the Secretary, but not 
                later than--
                            ``(i) 2027; and
                            ``(ii) in the case of a hospital in a rural 
                        area (as defined in section 1886(d)(2)(D) of 
                        the Social Security Act), 2029.
    ``(b) Minimum Direct Care Registered Nurse-to-Patient Ratios.--
            ``(1) In general.--Except as provided in paragraph (4) and 
        other provisions of this section, a hospital's staffing plan 
        shall provide that, at all times during each shift within a 
        unit of the hospital, and with a full complement of ancillary 
        and support staff, a direct care registered nurse may be 
        assigned to not more than the following number of patients in 
        that unit:
                    ``(A) One patient in trauma emergency units.
                    ``(B) One patient in operating room units, provided 
                that a minimum of 1 additional person serves as a scrub 
                assistant in such unit.
                    ``(C) Two patients in critical care units, 
                including neonatal intensive care units, emergency 
                critical care and intensive care units, labor and 
                delivery units, coronary care units, acute respiratory 
                care units, postanesthesia units, and burn units.
                    ``(D) Three patients in emergency room units, 
                pediatrics units, stepdown units, telemetry units, 
                antepartum units, and combined labor, deliver, and 
                postpartum units.
                    ``(E) Four patients in medical-surgical units, 
                intermediate care nursery units, acute care psychiatric 
                units, and other specialty care units.
                    ``(F) Five patients in rehabilitation units and 
                skilled nursing units.
                    ``(G) Six patients in postpartum (3 couplets) units 
                and well-baby nursery units.
            ``(2) Similar units with different names.--The Secretary 
        may apply minimum direct care registered nurse-to-patient 
        ratios established in paragraph (1) for a hospital unit 
        referred to in such paragraph to a type of hospital unit not 
        referred to in such paragraph if such type of hospital unit 
        provides a level of care to patients whose needs are similar to 
        the needs of patients cared for in the hospital unit referred 
        to in such paragraph.
            ``(3) Application of ratios to hospital nursing practice 
        standards.--
                    ``(A) In general.--A patient assignment may be 
                included in the calculation of the direct care 
                registered nurse-to-patient ratios required in this 
                subsection only if care is provided by a direct care 
                registered nurse and the provision of care to the 
                particular patient is within that direct care 
                registered nurse's competence.
                    ``(B) Demonstration of unit-specific competence.--A 
                hospital shall not assign a direct care registered 
                nurse to a hospital unit unless that hospital 
                determines that the direct care registered nurse has 
                demonstrated current competence in providing care in 
                that unit, and has also received orientation to that 
                hospital's unit sufficient to provide competent care to 
                patients in that unit.
                    ``(C) Duties of the assigned direct care registered 
                nurse.--Each patient shall be assigned to a direct care 
                registered nurse who shall directly provide the 
                assessment, planning, supervision, implementation, and 
                evaluation of the nursing care provided to the patient 
                at least every shift and has the responsibility for the 
                provision of care to a particular patient within his or 
                her scope of practice.
                    ``(D) Nurse administrators and supervisors.--A 
                registered nurse who is a nurse administrator, nurse 
                supervisor, nurse manager, charge nurse, case manager, 
                or any other hospital administrator or supervisor, 
                shall not be included in the calculation of the direct 
                care registered nurse-to-patient ratio unless that 
                nurse has a current and active direct patient care 
                assignment and provides direct patient care in 
                compliance with the requirements of this section, 
                including competency requirements. The exemption in 
                this subsection shall apply only during the hours in 
                which the individual registered nurse has the principal 
                responsibility of providing direct patient care and has 
                no additional job duties as would a direct care 
                registered nurse.
                    ``(E) Other personnel.--Other personnel may perform 
                patient care tasks based on their training and 
                demonstrated skill but may not perform or assist in 
                direct care registered nurse functions unless 
                authorized to do in accordance with State scope of 
                practice laws and regulations.
                    ``(F) Temporary nursing personnel.--A hospital 
                shall not assign any nursing personnel from temporary 
                nursing agencies patient care to any hospital unit 
                without such personnel having demonstrated competence 
                on the assigned unit and received orientation to that 
                hospital's unit sufficient to provide competent care to 
                patients in that unit.
                    ``(G) Ancillary and additional staffing.--The need 
                for additional staffing of direct care registered 
                nurses, licensed vocational or practical nurses, 
                licensed psychiatric technicians, certified nursing or 
                patient care assistants, or other licensed or 
                unlicensed ancillary staff above the minimum registered 
                nurse-to-patient ratios shall be based on the 
                assessment of the individual patient's nursing care 
                requirement, the individual patient's nursing care 
                plan, and acuity level.
            ``(4) Restrictions.--
                    ``(A) Prohibition against averaging.--A hospital 
                shall not average the number of patients and the total 
                number of direct care registered nurses assigned to 
                patients in a hospital unit during any 1 shift or over 
                any period of time for purposes of meeting the 
                requirements under this subsection.
                    ``(B) Prohibition against imposition of mandatory 
                overtime requirements.--A hospital shall not impose 
                mandatory overtime requirements to meet the hospital 
                unit direct care registered nurse-to-patient ratios 
                required under this subsection.
                    ``(C) Relief during routine absences.--A hospital 
                shall ensure that only a direct care registered nurse 
                who has demonstrated current competence to the hospital 
                in providing care on a particular unit and has also 
                received orientation to that hospital's unit sufficient 
                to provide competent care to patients in that unit may 
                relieve another direct care registered nurse during 
                breaks, meals, and other routine, expected absences 
                from a hospital unit.
                    ``(D) Application of direct care registered nurse-
                to-patient ratios in patient-acuity adjustable units.--
                Patients shall be cared for only on units or patient 
                care areas where the direct care registered nurse-to-
                patient ratios meet the level of intensity, type of 
                care, and the individual requirements and needs of each 
                patient. Notwithstanding paragraph (2), hospitals that 
                provide patient care in units or patient care areas 
                that are acuity adaptable or acuity adjustable shall 
                apply the direct care registered nurse-to-patient ratio 
                required in this section for the highest patient acuity 
                level or level of care in that unit or patient care 
                area, and shall comply with all other requirements of 
                this section.
                    ``(E) Use of video monitors.--A hospital shall not 
                employ video monitors or any form of electronic 
                visualization of a patient as a substitute for the 
                direct observation required for patient assessment by 
                the direct care registered nurse or required for 
                patient protection. Video monitors or any form of 
                electronic visualization of a patient shall not be 
                included in the calculation of the direct care 
                registered nurse-to-patient ratio required in this 
                subsection and shall not replace the requirement of 
                paragraph (3)(D) that each patient shall be assigned to 
                a direct care registered nurse who shall directly 
                provide the assessment, planning, supervision, 
                implementation, and evaluation of the nursing care 
                provided to the patient at least every shift and have 
                the responsibility for the provision of care to a 
                particular patient within his or her scope of practice.
                    ``(F) Use of other technology.--A hospital shall 
                not employ technology that substitutes for the assigned 
                registered nurse's professional judgment in assessment, 
                planning, implementation, and evaluation of care.
            ``(5) Adjustment of ratios.--
                    ``(A) In general.--If necessary to protect patient 
                safety, the Secretary may prescribe regulations that--
                            ``(i) increase minimum direct care 
                        registered nurse-to-patient ratios under this 
                        subsection to reduce the number of patients 
                        that may be assigned to each direct care nurse; 
                        or
                            ``(ii) add minimum direct care registered 
                        nurse-to-patient ratios for units not referred 
                        to in paragraphs (1) and (2).
                    ``(B) Consultation.--Such regulations shall be 
                prescribed after consultation with affected hospitals 
                and registered nurses.
            ``(6) Ancillary and additional staffing.--
                    ``(A) In general.--The Secretary may prescribe 
                regulations requiring additional staffing of direct 
                care registered nurses, licensed vocational or practice 
                nurses, licensed psychiatric technicians, certified 
                nursing or patient care assistants, or other licensed 
                or unlicensed ancillary staff above the minimum 
                registered nurse-to-patient ratios that is based on the 
                assessment of the individual patient's nursing care 
                needs, the individual patient's nursing care plan, and 
                acuity level.
                    ``(B) Consultation.--Such regulations shall be 
                prescribed after consultation with affected hospitals, 
                registered nurses, and ancillary staff.
            ``(7) Relationship to state-imposed ratios.--Nothing in 
        this title shall preempt State standards that the Secretary 
        determines to be as stringent as Federal requirements for a 
        staffing plan established under this title. Minimum direct care 
        registered nurse-to-patient ratios established under this 
        subsection shall not preempt State requirements that the 
        Secretary determines are as stringent as to Federal 
        requirements for direct care registered nurse-to-patient ratios 
        established under this title.
            ``(8) Exemption in emergencies.--The requirements 
        established under this subsection shall not apply during a 
        state of emergency if a hospital is requested or expected to 
        provide an exceptional level of emergency or other medical 
        services. If a hospital seeks to apply the exemption under this 
        paragraph in response to a complaint filed against the hospital 
        for a violation of the provisions of this title, the hospital 
        must demonstrate that prompt and diligent efforts were made to 
        maintain required staffing levels. The Secretary shall issue 
        guidance to hospitals that describes situations that constitute 
        a state of emergency for purposes of the exemption under this 
        paragraph and shall establish necessary penalties for 
        violations of this paragraph consistent with section 3406.
    ``(c) Development and Reevaluation of Staffing Plan.--
            ``(1) Considerations in development of plan.--In developing 
        the staffing plan, a hospital shall provide for direct care 
        registered nurse-to-patient ratios above the minimum direct 
        care registered nurse-to-patient ratios required under 
        subsection (b) if appropriate based upon consideration of, at a 
        minimum, the following factors:
                    ``(A) The number of patients on a particular unit 
                on a shift-by-shift basis.
                    ``(B) The acuity level and nursing care plan of 
                patients on a particular unit on a shift-by-shift 
                basis.
                    ``(C) The anticipated admissions, discharges, and 
                transfers of patients during each shift that impacts 
                direct patient care.
                    ``(D) Specialized experience required of direct 
                care registered nurses on a particular unit.
                    ``(E) Staffing levels and services provided by 
                licensed vocational or practical nurses, licensed 
                psychiatric technicians, certified nurse assistants, or 
                other ancillary staff in meeting direct patient care 
                needs not required by a direct care registered nurse.
                    ``(F) The level of familiarity with hospital 
                practices, policies, and procedures by temporary agency 
                direct care registered nurses used during a shift.
                    ``(G) Obstacles to efficiency in the delivery of 
                patient care presented by physical layout.
            ``(2) Documentation of staffing.--A hospital shall specify 
        the system used to document actual staffing in each unit for 
        each shift.
            ``(3) Annual reevaluation of plan.--
                    ``(A) In general.--A hospital shall annually 
                evaluate its staffing plan in each unit in relation to 
                actual patient care requirements.
                    ``(B) Update.--A hospital shall update its staffing 
                plan to the extent appropriate based on such 
                evaluation.
            ``(4) Transparency.--
                    ``(A) In general.--Any staffing plan or method used 
                to create and evaluate acuity-level and adopted by a 
                hospital under this section shall be transparent in all 
                respects, including disclosure of detailed 
                documentation of the methodology used to determine 
                nursing staffing, identifying each factor, assumption, 
                and value used in applying such methodology.
                    ``(B) Public availability.--The Secretary shall 
                establish procedures to provide that the documentation 
                submitted under subsection (d) is available for public 
                inspection in its entirety.
            ``(5) Registered nurse participation.--A staffing plan of a 
        hospital--
                    ``(A) shall be developed and subsequent 
                reevaluations shall be conducted under this subsection 
                on the basis of input from direct care registered 
                nurses at the hospital from each unit or patient care 
                area; and
                    ``(B) where such nurses are represented through 
                collective bargaining, shall require bargaining with 
                the applicable recognized or certified collective 
                bargaining representative of such nurses.
        Nothing in this title shall be construed to permit conduct 
        prohibited under the National Labor Relations Act or chapter 71 
        of title 5, United States Code.
            ``(6) Staffing committees.--If a hospital maintains a 
        staffing committee, then the committee shall include at least 
        one registered nurse from each hospital unit and shall be 
        composed of at least 50 percent direct care registered nurses. 
        The staffing committee shall include meaningful representation 
        of other direct care nonmanagement staff. Direct care 
        registered nurses who serve on the committee shall be selected 
        by other direct care registered nurses from their unit. Other 
        direct care nonmanagement staff shall be selected by other 
        direct care nonmanagement staff. Participation on staffing 
        committees shall be considered a part of the employee's 
        regularly scheduled workweek.
    ``(d) Submission of Plan to Secretary.--A hospital shall submit to 
the Secretary its staffing plan and any annual updates under subsection 
(c)(3)(B). A federally operated hospital may submit its staffing plan 
through the department or agency operating the hospital.

``SEC. 3402. POSTING, RECORDS, AND AUDITS.

    ``(a) Posting Requirements.--In each unit, a hospital shall post a 
uniform notice in a form specified by the Secretary in regulation 
that--
            ``(1) explains requirements imposed under section 3401;
            ``(2) includes actual direct care registered nurse-to-
        patient ratios during each shift;
            ``(3) includes the actual number and titles of direct care 
        registered nurses assigned during each shift; and
            ``(4) is visible, conspicuous, and accessible to staff, 
        patients, and the public.
    ``(b) Records.--
            ``(1) Maintenance of records.--Each hospital shall maintain 
        accurate records of actual direct care registered nurse-to-
        patient ratios in each unit for each shift for no less than 3 
        years. Such records shall include--
                    ``(A) the number of patients in each unit;
                    ``(B) the identity and duty hours of--
                            ``(i) each direct care registered nurse 
                        assigned to each patient in each unit in each 
                        shift; and
                            ``(ii) ancillary staff who are under the 
                        coordination of the direct care registered 
                        nurse;
                    ``(C) certification that each nurse received rest 
                and meal breaks and the identity and duty hours of each 
                direct care registered nurse who provided such relief; 
                and
                    ``(D) a copy of each notice posted under subsection 
                (a).
            ``(2) Availability of records.--Each hospital shall make 
        its records maintained under paragraph (1) available to--
                    ``(A) the Secretary;
                    ``(B) registered nurses and their collective 
                bargaining representatives (if any); and
                    ``(C) the public under regulations established by 
                the Secretary, or in the case of a federally operated 
                hospital, under section 552 of title 5, United States 
                Code (commonly known as the Freedom of Information 
                Act).
    ``(c) Audits.--The Secretary shall conduct periodic audits to 
ensure--
            ``(1) implementation of the staffing plan in accordance 
        with this title; and
            ``(2) accuracy in records maintained under this section.

``SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL NURSE STAFFING 
              REQUIREMENTS.

    ``(a) Establishment.--A hospital's staffing plan shall comply with 
minimum direct care licensed practical nurse staffing requirements that 
the Secretary establishes for units in hospitals. Such staffing 
requirements shall be established not later than 18 months after the 
date of the enactment of this title, and shall be based on the study 
conducted under subsection (b).
    ``(b) Study.--Not later than 1 year after the date of the enactment 
of this title, the Secretary, acting through the Director of the Agency 
for Healthcare Research and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in hospitals. 
The Director may contract with a qualified entity or organization to 
carry out such study under this paragraph. The Director shall consult 
with licensed practical nurses and organizations representing licensed 
practical nurses regarding the design and conduct of the study.
    ``(c) Application of Registered Nurse Provisions to Licensed 
Practical Nurse Staffing Requirements.--Paragraphs (2), (4)(A), (4)(B), 
(4)(C), and (6) of section 3401(b), paragraphs (1), (2), (3), and (4) 
of section 3401(c), and section 3402 shall apply to the establishment 
and application of direct care licensed practical nurse staffing 
requirements under this section pursuant to the additional staffing 
requirements under subsection (b)(3)(G) of section 3401 and in the same 
manner that they apply to the establishment and application of direct 
care registered nurse-to-patient ratios under sections 3401 and 3402.
    ``(d) Effective Date.--The requirements of this section shall take 
effect as soon as practicable, as determined by the Secretary, but not 
later than--
            ``(1) 2 years after the date of the enactment of this 
        title; and
            ``(2) in the case of a hospital in a rural area (as defined 
        in section 1886(d)(2)(D) of the Social Security Act), 4 years 
        after the date of the enactment of this title.
    ``(e) Study.--Not later than 1 year after the date of the enactment 
of this title, the Secretary, acting through the Director of the Agency 
for Healthcare Research and Quality shall complete a study of 
registered and practical nurse staffing requirements in clinics and 
other outpatient settings, and its effects on patient care in 
outpatient settings. The Director may contract with a qualified entity 
or organization to carry out such study under this subsection. The 
Director shall consult with registered nurses and licensed practice 
nurses working in outpatient settings, including professional nursing 
associations and labor organizations representing both registered and 
practice nurses working in outpatient settings regarding the design and 
conduct of the study.

``SEC. 3404. WHISTLEBLOWER AND PATIENT PROTECTIONS.

    ``(a) Professional Obligation and Rights.--All nurses have a duty 
and right to act based on their professional judgment in accordance 
with State nursing laws and regulations of the State in which the 
direct nursing care is being performed and to provide care in the 
exclusive interests of the patients and to act as the patient's 
advocate.
    ``(b) Acceptance of Patient Care Assignments.--The nurse is 
responsible for providing competent, safe, therapeutic, and effective 
nursing care to assigned patients. Before accepting a patient 
assignment, a nurse shall--
            ``(1) have the necessary professional knowledge, judgment, 
        skills, and ability to provide the required care;
            ``(2) determine using professional judgment in accordance 
        with State nursing laws and regulations of the State in which 
        the direct nursing care is being performed whether the nurse is 
        competent to perform the nursing care required; and
            ``(3) determine whether acceptance of a patient assignment 
        would expose the patient or nurse to risk of harm.
    ``(c) Objection to or Refusal of Assignment.--A nurse may object 
to, or refuse to participate in, any activity, policy, practice, 
assignment, or task if in good faith--
            ``(1) the nurse reasonably believes it to be in violation 
        of section 3401 or 3403; or
            ``(2) the nurse is not prepared by education, training, or 
        experience to fulfill the assignment without compromising the 
        safety of any patient or jeopardizing the license of the nurse.
    ``(d) Retaliation for Objection to or Refusal of Assignment 
Barred.--
            ``(1) No discharge, discrimination, or retaliation.--No 
        hospital shall discharge, retaliate, discriminate, or otherwise 
        take adverse action in any manner with respect to any aspect of 
        a nurse's employment (as defined in section 3407), including 
        discharge, promotion, compensation, or terms, conditions, or 
        privileges of employment, based on the nurse's refusal of a 
        work assignment under subsection (c).
            ``(2) No filing of complaint.--No hospital shall file a 
        complaint or a report against a nurse with a State professional 
        disciplinary agency because of the nurse's refusal of a work 
        assignment under subsection (c).
    ``(e) Cause of Action.--Any nurse, collective bargaining 
representative, or legal representative of any nurse who has been 
discharged, discriminated against, or retaliated against in violation 
of subsection (d)(1) or against whom a complaint or report has been 
filed in violation of subsection (d)(2) may (without regard to whether 
a complaint has been filed under subsection (f) of this section or 
subsection (b) of section 3406) bring a cause of action in a United 
States district court. A nurse who prevails on the cause of action 
shall be entitled to one or more of the following:
            ``(1) Reinstatement.
            ``(2) Reimbursement of lost wages, compensation, and 
        benefits.
            ``(3) Attorneys' fees.
            ``(4) Court costs.
            ``(5) Other damages.
    ``(f) Complaint to Secretary.--A nurse, patient, collective 
bargaining representative, or other individual may file a complaint 
with the Secretary against a hospital that violates the provisions of 
this title. For any complaint filed, the Secretary shall--
            ``(1) receive and investigate the complaint;
            ``(2) determine whether a violation of this title as 
        alleged in the complaint has occurred; and
            ``(3) if such a violation has occurred, issue an order that 
        the complaining nurse or individual shall not suffer any 
        discharge, retaliation, discrimination, or other adverse action 
        prohibited by subsection (d) or subsection (h).
    ``(g) Toll-Free Telephone Number.--
            ``(1) In general.--The Secretary shall provide for the 
        establishment of a toll-free telephone hotline to provide 
        information regarding the requirements under sections 3401 
        through 3403 and to receive reports of violations of such 
        section.
            ``(2) Notice to patients.--A hospital shall provide each 
        patient admitted to the hospital for inpatient care with the 
        hotline described in paragraph (1), and shall give notice to 
        each patient that such hotline may be used to report inadequate 
        staffing or care.
    ``(h) Protection for Reporting.--
            ``(1) Prohibition on retaliation or discrimination.--A 
        hospital shall not discriminate or retaliate in any manner 
        against any patient, employee, or contract employee of the 
        hospital, or any other individual, on the basis that such 
        individual, in good faith, individually or in conjunction with 
        another person or persons, has presented a grievance or 
        complaint, or has initiated or cooperated in any investigation 
        or proceeding of any governmental entity, regulatory agency, or 
        private accreditation body, made a civil claim or demand, or 
        filed an action relating to the care, services, or conditions 
        of the hospital or of any affiliated or related facilities.
            ``(2) Good faith defined.--For purposes of this subsection, 
        an individual shall be deemed to be acting in good faith if the 
        individual reasonably believes--
                    ``(A) the information reported or disclosed is 
                true; and
                    ``(B) a violation of this title has occurred or may 
                occur.
    ``(i) Prohibition on Interference With Rights.--
            ``(1) Exercise of rights.--It shall be unlawful for any 
        hospital to--
                    ``(A) interfere with, restrain, or deny the 
                exercise, or attempt to exercise, by any person of any 
                right provided or protected under this title; or
                    ``(B) coerce or intimidate any person regarding the 
                exercise or attempt to exercise such right.
            ``(2) Opposition to unlawful policies or practices.--It 
        shall be unlawful for any hospital to discriminate or retaliate 
        against any person for opposing any hospital policy, practice, 
        or actions which are alleged to violate, breach, or fail to 
        comply with any provision of this title.
            ``(3) Prohibition on interference with protected 
        communications.--A hospital (or an individual representing a 
        hospital) shall not make, adopt, or enforce any rule, 
        regulation, policy, or practice which in any manner directly or 
        indirectly prohibits, impedes, or discourages a direct care 
        nurse from, or intimidates, coerces, or induces a direct care 
        nurse regarding, engaging in free speech activities or 
        disclosing information as provided under this title.
            ``(4) Prohibition on interference with collective action.--
        A hospital (or an individual representing a hospital) shall not 
        in any way interfere with the rights of nurses to organize, 
        bargain collectively, and engage in concerted activity under 
        section 7 of the National Labor Relations Act (29 U.S.C. 157).
    ``(j) Notice.--A hospital shall post in an appropriate location in 
each unit a conspicuous notice in a form specified by the Secretary 
that--
            ``(1) explains the rights of nurses, patients, and other 
        individuals under this section;
            ``(2) includes a statement that a nurse, patient, or other 
        individual may file a complaint with the Secretary against a 
        hospital that violates the provisions of this title; and
            ``(3) provides instructions on how to file such a 
        complaint.
    ``(k) Effective Date.--
            ``(1) Refusal; retaliation; cause of action.--
                    ``(A) In general.--Subsections (c) through (e) 
                shall apply to objections and refusals occurring on or 
                after the effective date of the provision of this title 
                to which the objection or refusal relates.
                    ``(B) Exception.--Subsection (c)(2) shall not apply 
                to objections or refusals in any hospital before the 
                requirements of section 3401(a) or 3403(a), as 
                applicable, apply to that hospital.
            ``(2) Protections for reporting.--Subsection (h)(1) shall 
        apply to actions occurring on or after the effective date of 
        the provision to which the violation relates, except that such 
        subsection shall apply to initiation, cooperation, or 
        participation in an investigation or proceeding on or after the 
        date of enactment of this title.
            ``(3) Notice.--Subsection (j) shall take effect 18 months 
        after the date of enactment of this title.

``SEC. 3405. ENFORCEMENT.

    ``(a) In General.--The Secretary shall enforce the requirements and 
prohibitions of this title in accordance with this section.
    ``(b) Procedures for Receiving and Investigating Complaints.--The 
Secretary shall establish procedures under which--
            ``(1) any person may file a complaint alleging that a 
        hospital has violated a requirement or a prohibition of this 
        title; and
            ``(2) such complaints shall be investigated by the 
        Secretary.
    ``(c) Remedies.--If the Secretary determines that a hospital has 
violated a requirement of this title, the Secretary--
            ``(1) shall require the facility to establish a corrective 
        action plan to prevent the recurrence of such violation; and
            ``(2) may impose civil money penalties, as described in 
        subsection (d).
    ``(d) Civil Penalties.--
            ``(1) In general.--In addition to any other penalties 
        prescribed by law, the Secretary may impose civil penalties as 
        follows:
                    ``(A) Hospital liability.--The Secretary may impose 
                on a hospital found to be in violation of this title a 
                civil money penalty of--
                            ``(i) not more than $25,000 for the first 
                        knowing violation of this title by such 
                        hospital; and
                            ``(ii) not more than $50,000 for any 
                        subsequent knowing violation of this title by 
                        such hospital.
                    ``(B) Individual liability.--The Secretary may 
                impose on an individual who--
                            ``(i) is employed by a hospital found by 
                        the Secretary to have violated this title; and
                            ``(ii) knowingly violates this title,
                a civil money penalty of not more than $20,000 for each 
                such violation by the individual.
            ``(2) Procedures.--The provisions of section 1128A of the 
        Social Security Act (other than subsections (a) and (b)) shall 
        apply with respect to a civil money penalty or proceeding under 
        this subsection in the same manner as such provisions apply 
        with respect to a civil money penalty or proceeding under such 
        section 1128A.
    ``(e) Public Notice of Violations.--
            ``(1) Internet website.--The Secretary shall publish on the 
        internet website of the Department of Health and Human Services 
        the names of hospitals on which a civil money penalty has been 
        imposed under this section, the violation for which such 
        penalty was imposed, and such additional information as the 
        Secretary determines appropriate.
            ``(2) Change of ownership.--With respect to a hospital that 
        had a change of ownership, as determined by the Secretary, 
        penalties imposed on the hospital while under previous 
        ownership shall no longer be published by the Secretary 
        pursuant to paragraph (1) after the 1-year period beginning on 
        the date of change of ownership.
    ``(f) Use of Funds.--Funds collected by the Secretary pursuant to 
this section are authorized to be appropriated to carry out this title.

``SEC. 3406. DEFINITIONS.

    ``For purposes of this title:
            ``(1) Acuity level.--The term `acuity level' means the 
        determination, using a hospital acuity measurement tool that 
        has been developed and established in coordination with direct 
        care registered nurses and made transparent pursuant to section 
        3401(c)(4), of nursing care requirements, based on the assigned 
        direct care registered nurse's professional judgment of--
                    ``(A) the severity and complexity of an individual 
                patient's illness or injury;
                    ``(B) the need for specialized equipment; and
                    ``(C) the intensity of nursing interventions 
                required.
            ``(2) Competence.--The term `competence' or `competent' 
        means the satisfactory application of the duties and 
        responsibilities of a registered nurse in providing nursing 
        care to specific patient populations and for acuity levels for 
        each patient care unit or area pursuant to the State nursing 
        laws and regulations of the State in which the direct nursing 
        care is being performed.
            ``(3) Direct care licensed practical nurse.--The term 
        `direct care licensed practical nurse' means an individual who 
        has been granted a license by at least one State to practice as 
        a licensed practical nurse or a licensed vocational nurse and 
        who provides bedside care for one or more patients.
            ``(4) Direct care registered nurse.--The term `direct care 
        registered nurse' means an individual who has been granted a 
        license by at least one State to practice as a registered nurse 
        and who provides bedside care for one or more patients.
            ``(5) Employment.--The term `employment' includes the 
        provision of services under a contract or other arrangement.
            ``(6) Hospital.--The term `hospital' has the meaning given 
        that term in section 1861(e) of the Social Security Act.
            ``(7) Nurse.--The term `nurse' means any direct care 
        registered nurse or direct care licensed practice nurse (as the 
        case may be), regardless of whether or not the nurse is an 
        employee.
            ``(8) Nursing care plan.--The term `nursing care plan' 
        means a plan developed by the assigned direct care registered 
        nurse (in accordance with nursing law in the State in which the 
        nursing care is performed) that indicates the nursing care to 
        be given to individual patients that--
                    ``(A) considers the acuity level of the patient;
                    ``(B) is developed in coordination with the 
                patient, the patient's family, or other representatives 
                when appropriate, and staff of other disciplines 
                involved in the care of the patient;
                    ``(C) reflects all elements of the nursing process; 
                and
                    ``(D) recommends the number and skill mix of 
                additional licensed and unlicensed direct care staff 
                needed to fully implement the nursing care plan.
            ``(9) Professional judgment.--The term `professional 
        judgment' means, in accordance with State nursing laws and 
        regulations of the State in which the direct nursing care is 
        being performed, the direct care registered nurse's application 
        of knowledge, expertise, and experience in conducting a 
        comprehensive nursing assessment of each patient and in making 
        independent decisions about patient care including the need for 
        additional staff.
            ``(10) Staffing plan.--The term `staffing plan' means a 
        staffing plan required under section 3401.
            ``(11) State of emergency.--The term `state of emergency'--
                    ``(A) means a state of emergency that is an 
                unpredictable or unavoidable occurrence at an 
                unscheduled or unpredictable interval, relating to 
                health care delivery and requiring immediate medical 
                interventions and care; and
                    ``(B) does not include a state of emergency that 
                results from a labor dispute in the health care 
                industry or consistent understaffing.

``SEC. 3407. RULE OF CONSTRUCTION.

    ``Nothing in this title shall be construed to authorize disclosure 
of private and confidential patient information, if such disclosure is 
not authorized or required by other applicable law.''.
    (b) Recommendations to Congress.--Not later than 1 year after the 
date of enactment of this Act, the Secretary of Health and Human 
Services shall submit to Congress a report containing recommendations 
for ensuring that sufficient numbers of nurses are available to meet 
the requirements imposed by title XXXIV of the Public Health Service 
Act, as added by subsection (a).
    (c) Report by HRSA.--
            (1) In general.--Not later than 2 years after the date of 
        enactment of this Act, the Administrator of the Health 
        Resources and Services Administration, in consultation with the 
        National Health Care Workforce Commission, shall submit to 
        Congress a report regarding the relationship between nurse 
        staffing levels and nurse retention in hospitals.
            (2) Updated report.--Not later than 5 years after the date 
        of enactment of this Act, the Administrator of the Health 
        Resources and Services Administration, in consultation with the 
        National Health Care Workforce Commission, shall submit to 
        Congress an update of the report submitted under paragraph (1).
    (d) Enforcement of Requirements Through Federal Programs.--
            (1) Medicare program.--Section 1866(a)(1) of the Social 
        Security Act (42 U.S.C. 1395cc(a)(1)) is amended--
                    (A) in subparagraph (X), by striking ``, and'' and 
                inserting a comma;
                    (B) in subparagraph (Y), by striking the period at 
                the end and inserting ``, and''; and
                    (C) by inserting after subparagraph (Y) the 
                following new subparagraph:
                    ``(Z) in the case of a hospital, to comply with the 
                provisions of title XXXIV of the Public Health Service 
                Act.''.
            (2) Medicaid program.--Section 1902(a) of the Social 
        Security Act (42 U.S.C. 1396a(a)) is amended--
                    (A) by striking ``and'' at the end of paragraph 
                (82);
                    (B) by striking the period at the end of paragraph 
                (83) and inserting ``; and''; and
                    (C) by inserting after paragraph (83) the following 
                new paragraph:
            ``(84) provide that any hospital that receives a payment 
        under such plan comply with the provisions of title XXXIV of 
        the Public Health Service Act (relating to minimum direct care 
        registered nurse staffing requirements).''.
    (e) Nursing Homes.--No later than one year after enactment of this 
Act, the Secretary of Health and Human Services shall promulgate a rule 
for minimum staffing standards for skilled nursing facilities under the 
Medicare program and for nursing facilities under the Medicaid program 
that align with the standards set in this section.

SEC. 133. ENHANCEMENTS FOR REDUCED COST-SHARING.

    (a) In General.--Section 1402 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18071) is amended--
            (1) in subsection (b)(1), by striking ``silver'' and 
        inserting ``gold'';
            (2) by amending subsection (c)(1)(B) to read as follows:
                    ``(B) Coordination with actuarial limits.--The 
                Secretary shall ensure the reduction under this 
                paragraph shall not result in the plan's share of the 
                total allowed costs of benefits provided under the plan 
                becoming less than--
                            ``(i) 95 percent in the case of an eligible 
                        insured described in paragraph (2)(A);
                            ``(ii) 90 percent in the case of an 
                        eligible insured described in paragraph (2)(B); 
                        and
                            ``(iii) 85 percent in the case of an 
                        eligible insured described in paragraph 
                        (2)(C).''; and
            (3) by amending subsection (c)(2) to read as follows:
            ``(2) Additional reduction.--The Secretary shall establish 
        procedures under which the issuer of a qualified health plan to 
        which this section applies shall further reduce cost-sharing 
        under the plan in a manner sufficient to--
                    ``(A) in the case of an eligible insured whose 
                household income is not less than 100 percent but not 
                more than 200 percent of the poverty line for a family 
                of the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 95 percent of such costs;
                    ``(B) in the case of an eligible insured whose 
                household income is more than 200 percent but not more 
                than 300 percent of the poverty line for a family of 
                the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 90 percent of such costs; and
                    ``(C) in the case of an eligible insured whose 
                household income is more than 300 percent but not more 
                than 400 percent of the poverty line for a family of 
                the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 85 percent of such costs.''.
    (b) Effective Date.--The amendments made by this subsection shall 
apply to plan years beginning after December 31, 2019.
    (c) Funding.--Section 1402 of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18071) is amended by adding at the end the 
following new subsection:
    ``(g) Funding.--Out of any funds in the Treasury not otherwise 
appropriated, there are appropriated to the Secretary such sums as may 
be necessary for payments under this section.''.

SEC. 134. REPEAL OF BONUS PAYMENTS FOR MEDICARE ADVANTAGE PLANS.

    Section 1853(o) of the Social Security Act (42 U.S.C. 1395w-23(o)) 
is repealed.

                        TITLE II--TAX PROVISIONS

SEC. 201. SUNSET OF PUBLIC LAW 115-97.

    (a) In General.--All provisions of, and amendments made by, Public 
Law 115-97 shall not apply to calendar, taxable, plan, or limitation 
years beginning after December 31, 2024.
    (b) Application of Certain Laws.--The Internal Revenue Code of 1986 
shall be applied and administered to years described in subsection (a) 
as if the provisions and amendments described in subsection (a) had 
never been enacted.

SEC. 202. SURTAX.

    There is hereby imposed a tax of 5 percent on the adjusted gross 
income of each taxpayer to the extent such income exceeds $500,000.

SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECEDENT.

    (a) In General.--Section 1014 of the Internal Revenue Code of 1986 
is amended by striking ``person, be'' and all that follows through the 
period at the end and inserting the following: ``person, be the basis 
in the hands of the decedent.''.
    (b) Effective Date.--The amendments made by this section to 
property acquired or passed after the date of enactment of this Act.

SEC. 204. MEDICARE PAYROLL TAX.

    (a) In General.--Section 3101(b)(2) of the Internal Revenue Code of 
1986 is amended by striking ``0.9 percent'' and inserting ``4 
percent''.
    (b) Effective Date.--The amendments made by this section shall 
apply with respect to taxable years beginning after the date of the 
enactment of this Act.

SEC. 205. NET INVESTMENT INCOME TAX.

    (a) In General.--Section 1411(a) of the Internal Revenue Code of 
1986 is amended by striking ``3.8 percent'' each place such term 
appears and inserting ``6.9 percent''.
    (b) Effective Date.--The amendments made by this section shall 
apply with respect to taxable years beginning after the date of the 
enactment of this Act.

SEC. 206. TERMINATION OF DEDUCTION FOR CONTRIBUTIONS TO HEALTH SAVINGS 
              ACCOUNTS.

    Section 223(b) of the Internal Revenue Code of 1986 is amended by 
adding at the end the following new paragraph:
            ``(9) Termination of deduction.--Notwithstanding any other 
        provision of this subsection, the monthly limitation for any 
        month beginning after December 31, 2023, is zero.''.

SEC. 207. INCREASE IN EXCISE TAX ON SMALL CIGARS AND CIGARETTES AND 
              OTHER TOBACCO PRODUCTS.

    (a) Small Cigars.--Section 5701(a)(1) of the Internal Revenue Code 
of 1986 is amended by striking ``$50.33'' and inserting ``$100.66''.
    (b) Cigarettes.--Section 5701(b) of such Code is amended--
            (1) by striking ``$50.33'' in paragraph (1) and inserting 
        ``$100.66''; and
            (2) by striking ``$105.69'' in paragraph (2) and inserting 
        ``$211.38''.
    (c) Pipe Tobacco.--Section 5701(f) of the Internal Revenue Code of 
1986 is amended by striking ``$2.8311 cents'' and inserting ``$50.00''.
    (d) Roll-Your-Own Tobacco.--Section 5701(g) of such Code is amended 
by striking ``$24.78'' and inserting ``$49.56''.
    (e) Large Cigars.--Paragraph (2) of section 5701(a) of the Internal 
Revenue Code of 1986 is amended by striking ``52.75 percent'' and all 
that follows through the period and inserting ``$24.78 per pound (and a 
proportionate tax at the like rate on all fractional parts of a pound) 
but not less than 5.033 cents per cigar.''.
    (f) Smokeless Tobacco.--
            (1) In general.--Section 5701(e) of the Internal Revenue 
        Code of 1986 is amended--
                    (A) in paragraph (1), by striking ``$1.51'' and 
                inserting ``$28.04'';
                    (B) in paragraph (2), by striking ``50.33 cents'' 
                and inserting ``$12.42''; and
                    (C) by adding at the end the following:
            ``(3) Smokeless tobacco sold in discrete single-use 
        units.--On discrete single-use units, $107.65 per each 1,000 
        single-use units.''.
            (2) Discrete single-use unit.--Section 5702(m) of such Code 
        is amended--
                    (A) in paragraph (1), by striking ``or chewing 
                tobacco'' and inserting ``chewing tobacco, discrete 
                single-use unit'';
                    (B) in paragraphs (2) and (3), by inserting ``that 
                is not a discrete single-use unit'' before the period 
                in each such paragraph; and
                    (C) by adding at the end the following:
            ``(4) Discrete single-use unit.--The term `discrete single-
        use unit' means any product containing tobacco that--
                    ``(A) is not intended to be smoked; and
                    ``(B) is in the form of a lozenge, tablet, pill, 
                pouch, dissolvable strip, or other discrete single-use 
                or single-dose unit''.

SEC. 208. EXCISE TAX ON ALCOHOL.

    (a) Distilled Spirits.--Section 5001(a)(1) of the Internal Revenue 
Code of 1986 is amended by striking ``$13.50'' and inserting 
``$16.00''.
    (b) Wine.--(1) Section 5041(b)(1) of the Internal Revenue Code of 
1986 is amended by striking ``$1.07 per wine gallon'' and inserting 
``$16.00 per proof gallon''.
    (2) Section 5041(b)(2) of the Internal Revenue Code of 1986 is 
amended by striking ``$1.57 per wine gallon'' and inserting ``$16.00 
per proof gallon''.
    (3) Section 5041(b)(3) of the Internal Revenue Code of 1986 is 
amended by striking ``$3.15 per wine gallon'' and inserting ``$16.00 
per proof gallon''.
    (4) Section 5041(b)(4) of the Internal Revenue Code of 1986 is 
amended by striking ``$3.40 per wine gallon'' and inserting ``$16.00 
per proof gallon''.
    (5) Section 5041(b)(5) of the Internal Revenue Code of 1986 is 
amended by striking ``$3.30 per wine gallon'' and inserting ``$16.00 
per proof gallon''.
    (6) Section 5041(b)(3) of the Internal Revenue Code of 1986 is 
amended by striking ``$22.6 cents per wine gallon'' and inserting 
``$16.00 per proof gallon''.
    (c) Beer.--Section 5051(B) of the Internal Revenue Code of 1986 is 
amended by striking ``$18 for per barrel'' and inserting ``$16 per 
proof gallon''.

SEC. 209. TAX ON SUGARED DRINKS.

    (a) In General.--Subchapter D of chapter 32 of the Internal Revenue 
Code of 1986 is amended by inserting after part I the following new 
part:

                  ``PART II--SUGAR-SWEETENED BEVERAGES

``Sec. 4171. Imposition of tax.
``Sec. 4172. Definitions.
``Sec. 4173. Special rules.

``SEC. 4171. IMPOSITION OF TAX.

    ``(a) In General.--There is hereby imposed a tax on the sale or 
transfer of any specified sugar-sweetened beverage product by the 
manufacturer, producer, or importer thereof.
    ``(b) Rate of Tax.--The rate of tax imposed under subsection (a) 
shall be equal to one cent per 4.2 grams of caloric sweetener contained 
in such specified sugar-sweetened beverage product.
    ``(c) Persons Liable for Tax.--The manufacturer, producer, or 
importer referred to in subsection (a) shall be liable for the tax 
imposed by such subsection.

``SEC. 4172. DEFINITIONS.

    ``(a) Specified Sugar-Sweetened Beverage Product.--For purposes of 
this part--
            ``(1) In general.--For purposes of this part, the term 
        `specified sugar-sweetened beverage product' means--
                    ``(A) any liquid intended for human consumption 
                which contains a caloric sweetener, and
                    ``(B) any liquid, or solid mixture of ingredients, 
                which--
                            ``(i) contains a caloric sweetener, and
                            ``(ii) is intended for use as an ingredient 
                        in a liquid described in subparagraph (A).
            ``(2) Exceptions.--The following shall not be treated as 
        liquids described in paragraph (1)(A):
                    ``(A) Any liquid the primary ingredients of which 
                are milk or soy, rice, or similar plant-based milk 
                substitute.
                    ``(B) Any liquid composed entirely of one or more 
                of the following:
                            ``(i) The original liquid resulting from 
                        the pressing of fruit or vegetables.
                            ``(ii) The liquid resulting from the 
                        reconstitution of fruit or vegetable juice 
                        concentrate.
                            ``(iii) The liquid resulting from the 
                        restoration of water to dehydrated fruit or 
                        vegetable juice.
                    ``(C) Infant formula.
                    ``(D) Any liquid products manufactured for use as--
                            ``(i) an oral nutritional therapy for 
                        persons who cannot absorb or metabolize dietary 
                        nutrients from food or beverages,
                            ``(ii) a source of necessary nutrition used 
                        due to a medical condition, or
                            ``(iii) an oral electrolyte solution for 
                        infants and children formulated to prevent 
                        dehydration due to illness.
                    ``(E) Any liquid with respect to which tax is 
                imposed under chapter 51 (relating to distilled 
                spirits, wines, and beer) or under section 7652 by 
                reason of the tax imposed under chapter 51 being 
                imposed on like articles of domestic manufacture.
    ``(b) Caloric Sweetener.--For purposes of this part, the term 
`caloric sweetener' means monosaccharides, disaccharides, and high-
fructose corn syrup.

``SEC. 4173. SPECIAL RULES.

    ``(a) Sweetener Taxed Only Once.--In the case of any specified 
sugar-sweetened beverage product which is manufactured or produced by 
including one or more other specified sugar-sweetened beverage 
products, no tax shall be imposed under this section on any caloric 
sweetener contained in the resulting specified sugar-sweetened beverage 
product if tax was previously imposed under this section on such 
caloric sweetener when contained in the specified sugar-sweetened 
beverage product so included.
    ``(b) Inflation Adjustment.--In the case of any sale after December 
31, 2015, the one cent amount in section 4171(b) shall be increased by 
an amount equal to--
            ``(1) such amount, multiplied by
            ``(2) the cost-of-living adjustment determined under 
        section 1(f)(3) for the calendar year in which such sale 
        occurs, determined by substituting `calendar year 2014' for 
        `calendar year 1992' in subparagraph (B) thereof.
Any increase determined under this subsection shall be rounded to the 
nearest multiple of one-tenth of a cent.''.
    (b) Conforming Amendments.--
            (1) Section 4221(a) is amended by adding at the end the 
        following: ``Paragraphs (1), (4), (5), and (6) shall not apply 
        to the tax imposed under section 4171.''.
            (2) The table of parts for subchapter D of chapter 32 of 
        such Code is amended by inserting after the item relating to 
        part I the following new item:

                ``Part II--Sugar-Sweetened Beverages''.

    (c) Effective Date.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall take effect on the date 
        of the enactment of this Act.
            (2) Excise tax.--The amendments made by subsections (a) and 
        (b) shall apply to sales after the date of the enactment of 
        this Act.

SEC. 210. REPEAL OF EXCISE TAX ON HIGH-COST EMPLOYER-SPONSORED HEALTH 
              COVERAGE.

    (a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is 
amended by striking section 4980I.
    (b) Conforming Amendment.--Section 6051 of such Code is amended--
            (1) in paragraph (14) of subsection (a), by striking 
        ``section 4980I(d)(1)'' and inserting ``subsection (g)'', and
            (2) by adding at the end the following:
    ``(g) Applicable Employer-Sponsored Coverage.--For purposes of 
subsection (a)(14)--
            ``(1) In general.--The term `applicable employer-sponsored 
        coverage' means, with respect to any employee, coverage under 
        any group health plan made available to the employee by an 
        employer which is excludable from the employee's gross income 
        under section 106, or would be so excludable if it were 
        employer-provided coverage (within the meaning of such section 
        106).
            ``(2) Exceptions.--The term `applicable employer-sponsored 
        coverage' shall not include--
                    ``(A) any coverage (whether through insurance or 
                otherwise) described in section 9832(c)(1) (other than 
                subparagraph (G) thereof) or for long-term care;
                    ``(B) any coverage under a separate policy, 
                certificate, or contract of insurance which provides 
                benefits substantially all of which are for treatment 
                of the mouth (including any organ or structure within 
                the mouth) or for treatment of the eye; or
                    ``(C) any coverage described in section 9832(c)(3) 
                the payment for which is not excludable from gross 
                income and for which a deduction under section 162(l) 
                is not allowable.
            ``(3) Coverage includes employee paid portion.--Coverage 
        shall be treated as applicable employer-sponsored coverage 
        without regard to whether the employer or employee pays for the 
        coverage.
            ``(4) Governmental plans included.--Applicable employer-
        sponsored coverage shall include coverage under any group 
        health plan established and maintained primarily for its 
        civilian employees by the Government of the United States, by 
        the government of any State or political subdivision thereof, 
        or by any agency or instrumentality of any such government.
            ``(5) Cost of coverage.--
                    ``(A) Health fsas.--In the case of applicable 
                employer-sponsored coverage consisting of coverage 
                under a flexible spending arrangement (as defined in 
                section 2205(g)), the cost of the coverage shall be 
                equal to the amount determined under rules similar to 
                the rules of section 4980B(f)(4) with respect to any 
                reimbursement under the arrangement reduced by the 
                contributions described in subsection (a)(14)(B).
                    ``(B) Archer msas and hsas.--In the case of 
                applicable employer-sponsored coverage consisting of 
                coverage under an arrangement under which the employer 
                makes contributions described in subsection (b) or (d) 
                of section 106, the cost of the coverage shall be equal 
                to the amount of employer contributions under the 
                arrangement until the termination of HSAs as described 
                under section 206 of such Act.
                    ``(C) Allocation on a monthly basis.--If cost is 
                determined on other than a monthly basis, the cost 
                shall be allocated to months in a taxable period on 
                such basis as the Secretary may prescribe.''.
    (c) Clerical Amendment.--The table of sections for chapter 43 of 
such Code is amended by striking the item relating to section 4980I.
    (d) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2019.

                   TITLE III--DRUG-RELATED PROVISIONS

SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG AND MEDICAL DEVICE 
              REVIEW BOARD.

    There is established in the Department of Health and Human Services 
a board to be known as the Prescription Drug and Medical Device Price 
Review Board (in this Act referred to as the ``Board'').

SEC. 302. MEMBERSHIP; STAFF.

    (a) Members.--The Board shall be composed of the members as 
follows:
            (1) The Assistant Secretary for Planning and Evaluation of 
        the Department of Health and Human Services (or the Assistant 
        Secretary's designee).
            (2) The Administrator of the Centers for Medicare & 
        Medicaid Services or, beginning with 2022, the Administrator of 
        the Center for Health Care (or the Administrator's designee).
            (3) The Assistant Director for the Health Services Division 
        of the Federal Bureau of Prisons (or the Assistant Director's 
        designee).
            (4) The Secretary of Defense (or the Secretary's designee).
            (5) The Secretary of Veterans Affairs (or the Secretary's 
        designee).
            (6) The Commissioner of Food and Drugs (or the 
        Commissioner's designee).
            (7) The Director of the National Institutes of Health (or 
        the Director's designee).
    (b) Chairperson.--The Board shall designate 1 member of the Board 
to serve as the chairperson.
    (c) Director and Staff.--
            (1) Director.--The Board shall have a director who shall be 
        appointed by the chairperson of the Board, subject to rules 
        prescribed by the Board.
            (2) Staff.--The director may appoint and fix the pay of 
        such additional personnel as the chairperson considers 
        appropriate, subject to rules prescribed by the Board.
            (3) Applicability of certain civil service laws.--The 
        director and staff of the Board shall be appointed subject to 
        the provisions of title 5, United States Code, governing 
        appointments in the competitive service, and shall be paid in 
        accordance with the requirements of chapter 51 and subchapter 
        III of chapter 53 of such title relating to classification and 
        General Schedule pay rates; except that an individual so 
        appointed may not receive pay in excess of the maximum annual 
        rate of basic pay payable for grade GS-15 of the General 
        Schedule.
    (d) Assistance for the Board.--Subject to section 306(g), in 
carrying out this title, the Board--
            (1) may seek assistance from outside experts in the fields 
        of consumer advocacy, medicine, pharmacology, pharmacy, and 
        prescription drug reimbursement; and
            (2) shall establish and maintain an advisory group and a 
        stakeholder group for purposes of seeking such assistance.
    (e) Initial Meeting.--The Board shall hold its initial meeting not 
later than 90 days after the date of the enactment of this Act.
    (f) Banned Individuals.--
            (1) Drug company lobbyists.--No former registered drug 
        manufacturer lobbyist--
                    (A) may be appointed to the position of Director of 
                the Office; or
                    (B) may be employed by the Office during the 6-year 
                period beginning on the date on which the registered 
                lobbyist terminates its registration in accordance with 
                section 4(d) of the Lobbying Disclosure Act of 1995 (2 
                U.S.C. 1603(d)) or the agent terminates its status, as 
                applicable.
            (2) Senior executives of law-breaking companies.--No former 
        senior executive of a covered entity--
                    (A) may be appointed to the position of Director of 
                the Office; or
                    (B) may be employed by the Office during the 6-year 
                period beginning on the later of--
                            (i) the date of the settlement; and
                            (ii) the date on which the enforcement 
                        action has concluded.
            (3) Covered entity.--The term ``covered entity'' means any 
        entity that is--
                    (A) a drug manufacturer; and
                    (B)(i) operating under Federal settlement, 
                including a Federal consent decree; or
                    (ii) the subject of an enforcement action in a 
                court of the United States or by an agency.

SEC. 303. PROHIBITION AGAINST EXCESSIVE PRICE.

    (a) Prohibition.--Beginning on the effective date of the regulation 
required by subsection (b), the manufacturer of a prescription drug or 
medical device shall not charge an excessive price, as determined 
pursuant to such regulation, for such drug or device.
    (b) Formula.--The Board shall by regulation prescribe a formula for 
determining whether the average manufacturer price of such drug or 
device over an annual quarter is an excessive price.
    (c) Determination of Excessive Price.--If the Board determines, on 
its own initiative or in response to a petition submitted under 
subsection (d), that the manufacturer of a prescription drug or medical 
device charges an excessive price for such drug or device in violation 
of subsection (a)--
            (1) the Board shall give the manufacturer--
                    (A) notice of such violation; and
                    (B) subject to subsection (d), a period to correct 
                such violation; and
            (2) if the manufacturer fails to correct the violation by 
        the end of such period, the manufacturer shall be subject to 
        section 304, section 1927(c)(2)(E) of the Social Security Act 
        (as added by subsection (c) of section 304), and section 4192 
        of the Internal Revenue Code of 1986, as added by subsection 
        (d) of section 304.
    (d) Petitions.--Any person may petition the Board to make a 
determination under subsection (c) regarding the pricing of a 
prescription drug or medical device. Not later than 90 days after the 
date of receipt of such a petition, the Board shall--
            (1) make a determination under subsection (c) regarding 
        such pricing; or
            (2) decline to make such a determination.
    (e) Continuing Violation.--The Board shall not be required to give 
a manufacturer an opportunity to correct a violation, as described in 
subsection (c)(1)(B), before the manufacturer becomes subject to the 
provisions described in subsection (c)(2) for such violation, if--
            (1) the Board has already provided such an opportunity to 
        correct to the manufacturer; and
            (2) the Board finds that the violation of subsection (a) is 
        a continuation of an earlier violation with respect to which 
        such an opportunity was provided.
    (f) Considerations.--The formula required by subsection (a) shall 
at a minimum take into consideration--
            (1) the average manufacturer price of the prescription drug 
        or medical device over the respective annual quarter or 
        quarters;
            (2) the average manufacturer price of other prescription 
        drugs or medical devices in the same therapeutic class over the 
        same quarter or quarters;
            (3) the average price at which the prescription drug or 
        medical device and other prescription drugs and medical devices 
        in the same therapeutic class have been sold by manufacturers 
        in countries other than the United States;
            (4) the costs associated with producing and marketing the 
        prescription drug or medical device, the value of the drug or 
        device to patients where sufficient data is available to 
        determine such value, the total Federal investment in the 
        development of the drug or device, the size of the patient 
        population receiving the drug or device, and other factors 
        determinative as to the true cost of production; and
            (5) whether the price of the prescription drug or medical 
        device increased during any annual quarter by a percentage that 
        is more than 2 percent greater than the CPI increase percentage 
        (as defined in section 215(i) of the Social Security Act (42 
        U.S.C. 415)) for the respective annual quarter.
    (g) Value or Cost-Effectiveness Assessments.--The use of Quality-
Adjusted Life Years, Disability-Adjusted Life Years, or other similar 
mechanisms is prohibited for use in value or cost-effectiveness 
assessments for purposes of this section.

SEC. 304. ENFORCEMENT PROVISIONS.

    (a) Reduced Patent Term.--If the Board finds that the manufacturer 
of a prescription drug or medical device, who is also an owner of a 
patent for such drug or device, charged an excessive price for such 
drug or device in violation of section 303(a), the Board may--
            (1) reduce the term, by not more than 5 years, of any 
        patent issued under title 35, United States Code, relating to 
        such drug or device; or
            (2) if the term of each patent for such drug or device has 
        expired, reduce the term, by not more than 5 years, of another 
        patent owned by the patent owner relating to a prescription 
        drug or medical device.
    (b) Civil Penalties.--If the Board determines under section 303(c) 
that a manufacturer of a prescription drug or medical device charged an 
excessive price for a prescription drug or medical device in violation 
of section 303(a), the Board may impose a civil penalty on the 
manufacturer of not more than 10 percent of the manufacturer's gross 
sales of the drug or device during the period beginning on the date on 
which an excessive price is first charged and ending on the date on 
which the manufacturer ceases to charge an excessive price.
    (c) Tax on Excess Prescription Drug and Medical Device Profits.--
            (1) Determination of amount.--If the Board determines under 
        section 303(a) that a manufacturer, producer, or importer of a 
        prescription drug or medical device charged an excessive price 
        for such prescription drug or medical device during a taxable 
        year, the Board may determine under this paragraph a reasonable 
        price for such drug or device for such taxable year.
            (2) Imposition of tax.--
                    (A) In general.--The Internal Revenue Code of 1986 
                is amended by inserting after section 4191 the 
                following new section:

``SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL DEVICE PRICE.

    ``(a) In General.--There is hereby imposed on the sale of any 
prescription drug or medical device by the manufacturer, producer, or 
importer a tax equal to the difference between the price at which such 
drug or device is so sold and the reasonable price determined by the 
Prescription Drug and Medical Device Price Review Board under section 
303(c)(1) of the Medicare for America Act for such drug or device for 
the taxable year for sales after the determination.
    ``(b) Prescription Drug or Medical Device.--For purposes of this 
section, the term `prescription drug or medical device' means any 
prescription drug (as defined in section 9008 of the Patient Protection 
and Affordable Care Act) or device (as defined in section 201(h) of the 
Federal Food, Drug, and Cosmetic Act) intended for humans.''.
                    (B) Clerical amendment.--The table of parts for 
                chapter 32 of such Code is amended--
                            (i) in the item relating to subchapter E, 
                        by striking ``Medical'' and inserting ``Drugs 
                        and medical''; and
                            (ii) by inserting after the item relating 
                        to section 4191 the following new item:

``Sec. 4192. Excessive prescription drug and medical device price.''.
            (3) Effective date.--This subsection and the amendments 
        made by this subsection shall apply with respect to sales after 
        December 31, 2019.

SEC. 305. AUTHORITY.

    (a) Obtaining Official Data.--The chairperson of the Board may 
secure directly from any Federal agency information necessary to enable 
the Board to carry out its duties. Upon request of the chairperson, the 
head of the agency shall furnish such information to the Board to the 
extent such information is not prohibited from disclosure by law.
    (b) Mails.--The Board may use the United States mails in the same 
manner and under the same conditions as other Federal agencies.
    (c) Administrative Support Services.--Upon the request of the 
chairperson of the Board, the Administrator of General Services shall 
provide to the Board, on a reimbursable basis, the administrative 
support services necessary for the Board to carry out its duties.
    (d) Contract Authority.--The Board may contract with and compensate 
government and private agencies or persons for the purpose of 
conducting research, surveys, and other services necessary to enable 
the Board to carry out its duties.
    (e) Investigations.--The Board may make such investigations as it 
considers necessary to determine whether there is or may be a violation 
of any regulation promulgated under this Act and may require or permit 
any person to file with it a statement in writing, under oath or 
otherwise as the Board shall determine, as to all the facts and 
circumstances concerning the matter to be investigated.
    (f) Subpoena Power.--
            (1) In general.--The Board may issue subpoenas requiring 
        the attendance and testimony of witnesses and the production of 
        any evidence relating to any matter under investigation by the 
        Board. The attendance of witnesses and the production of 
        evidence may be required from any place within the United 
        States at any designated place of hearing within the United 
        States.
            (2) Failure to obey a subpoena.--If a person refuses to 
        obey a subpoena issued under paragraph (1), the Board may apply 
        to a United States district court for an order requiring that 
        person to appear before the Board to give testimony, produce 
        evidence, or both, relating to the matter under investigation. 
        The application may be made within the judicial district where 
        the hearing is conducted or where that person is found, 
        resides, or transacts business. Any failure to obey the order 
        of the court may be punished by the court as civil contempt.
            (3) Service of subpoenas.--The subpoenas of the Board shall 
        be served in the manner provided for subpoenas issued by a 
        United States district court under the Federal Rules of Civil 
        Procedure for the United States district courts.
            (4) Service of process.--All process of any court to which 
        application is made under paragraph (2) may be served in the 
        judicial district in which the person required to be served 
        resides or may be found.
            (5) Notice.--Upon issuing any subpoena under this 
        subsection, the Board shall give notice of such issuance to the 
        appropriate committees of Congress, including the Committee on 
        Appropriations of the House of Representatives and the 
        Committee on Appropriations of the Senate.
    (g) Confidentiality.--Under this title, the Secretary shall enforce 
applicable law concerning a trade secret or confidential information 
subject to section 552(b)(4) of title 5, United States Code, or section 
1905 of title 18.

SEC. 306. REGULATIONS.

    (a) In General.--Not later than 1 year after the date of the 
initial meeting held under section 302(e), the Board shall issue final 
regulations to carry out this Act.
    (b) Notice and Comment Requirement.--The regulations developed 
under subsection (a) shall be issued in accordance with the notice and 
comment procedures established under section 553 of title 5, United 
States Code.

SEC. 307. REPORT TO FEDERAL AGENCIES.

    Not later than 1 year after the effective date of the regulations 
under section 306 and annually thereafter, the Board shall submit to 
each Federal agency that dispenses or makes payments for the dispensing 
of prescription drugs or medical devices a report containing a list of 
each prescription drug and medical device for which an excessive price 
was charged during the preceding calendar year, as determined by the 
Board under section 303. The Secretary shall make this report publicly 
available.

SEC. 308. DEFINITIONS.

    In this title:
            (1) Affiliate.--The term ``affiliate'' means, with respect 
        to a manufacturer, any entity that controls, is controlled by, 
        or is under common control with such manufacturer.
            (2) Average manufacturer price.--The term ``average 
        manufacturer price'' means the average price charged by the 
        manufacturer of a prescription drug or medical device, as 
        applicable, for sales of the drug or device by the manufacturer 
        in the United States over the respective annual quarter.
            (3) Medical device.--The term ``medical device'' means a 
        device (as defined in section 201 of the Federal Food, Drug, 
        and Cosmetic Act (21 U.S.C. 321)).
            (4) Prescription drug.--The term ``prescription drug'' 
        means a drug (as defined in section 201 of the Federal Food, 
        Drug, and Cosmetic Act (21 U.S.C. 321)) that is subject to 
        section 503(b)(1) of such Act (21 U.S.C. 353(b)(1)).
            (5) Manufacturer.--The term ``manufacturer'' means the 
        person--
                    (A) that holds the application for a drug approved 
                under section 505 of the Federal Food, Drug, and 
                Cosmetic Act or the license issued under section 351 of 
                the Public Health Service Act; or
                    (B) who is responsible for setting the price for 
                the drug.
            (6) Wholesale acquisition cost.--The term ``wholesale 
        acquisition cost'' has the meaning given that term in section 
        1847A(c)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
        3a(c)(6)(B)).

SEC. 309. MORATORIUM ON DIRECT-TO-CONSUMER DRUG ADVERTISING.

    The Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) is 
amended--
            (1) in section 301 (21 U.S.C. 331), by adding at the end 
        the following:
    ``(eee) The conduct of direct-to-consumer advertising of a drug in 
violation of section 506J.''; and
            (2) in chapter V, by inserting after section 506I (21 
        U.S.C. 356f) the following:

``SEC. 506J. DIRECT-TO-CONSUMER DRUG ADVERTISING.

    ``(a) Prohibitions.--
            ``(1) First three years.--
                    ``(A) In general.--Subject to subparagraph (B), no 
                person shall conduct direct-to-consumer advertising of 
                a drug for which an application is submitted under 
                section 505(b) before the end of the 3-year period 
                beginning on the date of the approval of such 
                application.
                    ``(B) Waiver.--The Secretary may waive the 
                application of subparagraph (A) to a drug during the 
                third year of the 3-year period described in such 
                subparagraph if--
                            ``(i) the sponsor of the drug submits an 
                        application to the Secretary pursuant to 
                        subparagraph (C); and
                            ``(ii) the Secretary, after considering the 
                        application and any accompanying materials, 
                        determines that direct-to-consumer advertising 
                        of the drug would have an affirmative value to 
                        public health.
                    ``(C) Application for waiver.--To seek a waiver 
                under subparagraph (B), the sponsor of a drug shall 
                submit an application to the Secretary at such time, in 
                such manner, and containing such information as the 
                Secretary may require.
            ``(2) Subsequent years.--The Secretary may prohibit direct-
        to-consumer advertising of a drug during the period beginning 
        at the end of the 3-year period described in paragraph (1)(A) 
        if the Secretary determines that the drug has significant 
        adverse health effects based on post-approval studies, risk-
        benefit analyses, adverse event reports, the scientific 
        literature, any clinical or observational studies, or any other 
        appropriate resource.
    ``(b) Regulations.--Not later than 1 year after the date of the 
enactment of this section, the Secretary shall revise the regulations 
promulgated under this Act governing drug advertisements to the extent 
necessary to implement this section.
    ``(c) Rule of Construction.--This section shall not be construed to 
diminish the authority of the Secretary to prohibit or regulate direct-
to-consumer advertising of drugs under other provisions of law.''.

SEC. 310. REPORTING ON JUSTIFICATION FOR DRUG PRICE INCREASES.

    Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) 
is amended by adding at the end the following:

            ``PART W--DRUG PRICE REPORTING; DRUG VALUE FUND

``SEC. 399OO. REPORTING ON JUSTIFICATION FOR DRUG PRICE INCREASES.

    ``(a) Definitions.--In this section:
            ``(1) Manufacturer.--The term `manufacturer' means the 
        person--
                    ``(A) that holds the application for a drug 
                approved under section 505 of the Federal Food, Drug, 
                and Cosmetic Act or the license issued under section 
                351 of the Public Health Service Act; or
                    ``(B) who is responsible for setting the price for 
                the drug.
            ``(2) Qualifying drug.--The term `qualifying drug' means 
        any drug that is approved under subsection (c) or (j) of 
        section 505 of the Federal Food, Drug, and Cosmetic Act or 
        licensed under subsection (a) or (k) of section 351 of this 
        Act--
                    ``(A) that has a wholesale acquisition cost of $100 
                or more per month supply or per a course of treatment 
                that lasts less than a month and is--
                            ``(i)(I) subject to section 503(b)(1) of 
                        the Federal Food, Drug, and Cosmetic Act; or
                            ``(II) commonly administered by hospitals 
                        (as determined by the Secretary);
                            ``(ii) not designated as a drug for a rare 
                        disease or condition under section 526 of the 
                        Federal Food, Drug, and Cosmetic Act; and
                            ``(iii) not designated by the Secretary as 
                        a vaccine; and
                    ``(B) for which, during the previous calendar year, 
                at least 1 dollar of the total amount of sales were for 
                individuals enrolled under the Medicare program under 
                title XVIII of the Social Security Act (42 U.S.C. 1395 
                et seq.) or under a State Medicaid plan under title XIX 
                of such Act (42 U.S.C. 1396 et seq.) or under a waiver 
                of such plan.
            ``(3) Wholesale acquisition cost.--The term `wholesale 
        acquisition cost' has the meaning given that term in section 
        1847A(c)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
        3a(c)(6)(B)).
    ``(b) Report.--
            ``(1) Report required.--The manufacturer of a qualifying 
        drug shall submit a report to the Secretary for each price 
        increase of a qualifying drug that will result in an increase 
        in the wholesale acquisition cost of that drug that is equal 
        to--
                    ``(A) 10 percent or more over a 12-month period; or
                    ``(B) 25 percent or more over a 36-month period.
            ``(2) Report deadline.--Each report described in paragraph 
        (1) shall be submitted to the Secretary not later than 30 days 
        prior to the planned effective date of such price increase.
    ``(c) Contents.--A report under subsection (b) shall, at a minimum, 
include--
            ``(1) with respect to the qualifying drug--
                    ``(A) the percentage by which the manufacturer will 
                raise the wholesale acquisition cost of the drug on the 
                planned effective date of such price increase;
                    ``(B) a justification for, and description of, each 
                manufacturer's price increase that will occur during 
                the 12-month period described in subsection (b)(1)(A) 
                or the 36-month period described in subsection 
                (b)(1)(B), as applicable;
                    ``(C) the identity of the initial developer of the 
                drug;
                    ``(D) a description of the history of the 
                manufacturer's price increases for the drug since the 
                approval of the application for the drug under section 
                505 of the Federal Food, Drug, and Cosmetic Act or the 
                issuance of the license for the drug under section 351, 
                or since the manufacturer acquired such approved 
                application or license;
                    ``(E) the current list price of the drug;
                    ``(F) the total expenditures of the manufacturer 
                on--
                            ``(i) materials and manufacturing for such 
                        drug; and
                            ``(ii) acquiring patents and licensing for 
                        such drug;
                    ``(G) the percentage of total expenditures of the 
                manufacturer on research and development for such drug 
                that was derived from Federal funds;
                    ``(H) the total expenditures of the manufacturer on 
                research and development for such drug that is used 
                for--
                            ``(i) basic and preclinical research;
                            ``(ii) clinical research;
                            ``(iii) new drug development;
                            ``(iv) pursuing new or expanded indications 
                        for such drug through supplemental applications 
                        under section 505 of the Federal Food, Drug, 
                        and Cosmetic Act or section 351 of the Public 
                        Health Service Act; and
                            ``(v) carrying out postmarket requirements 
                        related to such drug, including those under 
                        section 505(o)(3) of the Federal Food, Drug, 
                        and Cosmetic Act;
                    ``(I) the total revenue and the net profit 
                generated from the qualifying drug for each calendar 
                year since the approval of the application for the drug 
                under section 505 of the Federal Food, Drug, and 
                Cosmetic Act or the issuance of the license for the 
                drug under section 351, or since the manufacturer 
                acquired such approved application or license; and
                    ``(J) the total costs associated with marketing and 
                advertising for the qualifying drug;
            ``(2) with respect to the manufacturer--
                    ``(A) the total revenue and the net profit of the 
                manufacturer for each of the 12- and 36-month periods 
                preceding the submission of the report;
                    ``(B) all stock-based performance metrics used by 
                the manufacturer to determine executive compensation 
                for each of the 12- and 36-month periods preceding the 
                submission of the report; and
                    ``(C) any additional information the manufacturer 
                chooses to provide related to drug pricing decisions, 
                such as total expenditures on--
                            ``(i) drug research and development; or
                            ``(ii) clinical trials on drugs that failed 
                        to receive approval by the Food and Drug 
                        Administration; and
            ``(3) such other related information as the Secretary 
        considers appropriate.
    ``(d) Civil Penalty.--Any manufacturer of a qualifying drug that 
fails to submit a report for the drug as required by this section shall 
be subject to a civil penalty of $100,000 for each day on which the 
violation continues.
    ``(e) Public Posting.--
            ``(1) In general.--Subject to paragraph (3), not later than 
        30 days after the submission of a report under subsection (b), 
        the Secretary shall post the report on the public website of 
        the Department of Health and Human Services.
            ``(2) Format.--In developing the format of such report for 
        public posting, the Secretary shall consult stakeholders, 
        including beneficiary groups, and shall seek feedback on the 
        content and format from consumer advocates and readability 
        experts to ensure such public reports are user-friendly to the 
        public and are written in plain language that consumers can 
        readily understand.
            ``(3) Trade secrets and confidential information.--In 
        carrying out this section, the Secretary shall enforce 
        applicable law concerning the protection of confidential 
        commercial information and trade secrets.

``SEC. 399OO-1. USE OF CIVIL PENALTY AMOUNTS.

    ``The Secretary shall, without further appropriation, collect civil 
penalties under section 399OO and use the funds derived from such civil 
penalties, in addition to any other amounts available to the Secretary, 
to carry out activities described in this part and to improve consumer 
and provider information about drug value and drug price transparency.

``SEC. 399OO-2. ANNUAL REPORT TO CONGRESS.

    ``(a) In General.--Subject to subsection (b), the Secretary shall 
submit to Congress, and post on the public website of the Department of 
Health and Human Services in a way that is easy to use and understand, 
an annual report--
            ``(1) summarizing the information reported pursuant to 
        section 399OO; and
            ``(2) including copies of the reports and supporting 
        detailed economic analyses submitted pursuant to such section.
    ``(b) Trade Secrets and Confidential Information.--In carrying out 
this section, the Secretary shall enforce applicable law concerning the 
protection of confidential commercial information and trade secrets.''.

                    TITLE IV--OUTCOMES AND REPORTING

SEC. 401. SENSE OF CONGRESS.

    It is the sense of Congress that Medicare for America will have a 
significant impact on the health and well-being of the United States 
population and the social determinants of the health of beneficiaries 
of Medicare for America.

SEC. 402. EVALUATION OF BILL'S OUTCOME.

    (a) In General.--To assess the impact of this Act on the health of 
the population, not later than 2 years after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall allow for 
analysis of administrative records that have removed all personally 
identifiable information from the Center for Health Care to existing 
population surveys conducted by the Federal Government and federally 
supported surveys.
    (b) CDC and NIH.--The Directors of the Centers for Disease Control 
and Prevention and the National Institutes of Health shall solicit a 
comprehensive, longitudinal study to evaluate any differential 
individual impact on coverage expansion based on--
            (1) race and ethnicity;
            (2) socioeconomic status; or
            (3) health status.
    (c) Report.--Ten years after the date of the enactment of this Act 
and every ten years thereafter, the Secretary shall submit a report to 
the House Committee on Energy and Commerce and the Senate Committee on 
Health, Education, Labor, and Pensions regarding impact of this Act on 
the health of the United States population based on the results of 
subsection (b) contributions from all other relevant agencies.
                                 <all>
Medicare for America Act of 2019
To amend the Social Security Act to establish a Medicare for America health program to provide for comprehensive health coverage for all Americans.
Medicare for America Act of 2019
Rep. DeLauro, Rosa L.