“XXII MEDICARE FOR AMERICA
“A COMPREHENSIVE HEALTH COVERAGE
“2201. Establishment
“The Secretary shall establish a public health insurance program, to be known as “Medicare for America”, which shall for calendar year 2023 and each subsequent calendar year provide comprehensive health benefits in accordance with this part to individuals enrolled for coverage under this title.
“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),
“(b) Enrollments—Subject to subsection (c):
“(1) In general—Beginning in 2023, 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 2023), 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 2023), 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 2023), 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 2025), 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 2023), 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 2023) 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 2023), 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 2027), 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 2023, 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 2023 and 2024:
“(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 2025 and 2026:
“(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.
“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.
“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 2023), 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.
“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.
“(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.
“(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.
“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 2023 through 2027—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, 2023, and ending on December 31, 2027.
“(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.
“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 2023, 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 2023, 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 2027.
“(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.
“2208. Administrative provisions
“(a) Center for health care—Beginning 2023, 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.
“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 2027 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 2028 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 2029 and each subsequent plan year before plan year 2033—
“(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 2033, 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.
“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.
“B Home and Community Based Long-Term Services and Supports
“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.
“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.
“C MEDICARE ADVANTAGE FOR AMERICA
“2221. All private plans
“(a) In general—For plan years beginning with plan year 2023, 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.
“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.
“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.
“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.
“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.
“2226. Ban on paying brokers’ fees
“Medicare Advantage for America plans may not pay fees to insurance brokers.
“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.
“2228. References
“Beginning in 2023, all references in law and regulation to Medicare Advantage shall be deemed a reference to Medicare Advantage for America.”
“(7) Limitation on removal of providers from ma plans by ma organizations
“(A) Removal of providers with cause—Beginning with plan year 2020, 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 2020 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 2020, 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.”
“(K) fails to comply with section 1852(d)(7) or 1852(d)(8); or”
“(9) Network adequacy requirements—Beginning in plan year 2019, 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.”
“(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.”
“XXXIV Minimum Direct Care Registered Nurse Staffing Requirement
“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) 2023; 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), 2025.
“(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.
“(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.
“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.
“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.
“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.
“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,
“(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.
“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.
“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.”
“(Z) in the case of a hospital, to comply with the provisions of title XXXIV of the Public Health Service Act.”
“(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).”
“(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).”
“(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.”
“(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.”