115 HR 10526 IH: Medicare for America Act of 2024 U.S. House of Representatives 2024-12-19 text/xml EN Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.

I118th CONGRESS2d SessionH. R. 10526IN THE HOUSE OF REPRESENTATIVESDecember 19, 2024Ms. DeLauro (for herself and Ms. Schakowsky) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committees on Energy and Commerce, the Judiciary, Natural Resources, Education and the Workforce, and House Administration, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concernedA BILLTo amend the Social Security Act to establish a Medicare for America health program to provide for comprehensive health coverage for all Americans.

1.

Short title; table of contents

(a)

Short title

This Act may be cited as the Medicare for America Act of 2024.(b)

Table of contents

The table of contents of this Act is as follows:Sec. 1. Short title; table of contents.Title I—Transitioning to and establishing medicare for AmericaSubtitle A—Transitional Public Health OptionSec. 101. Establishment.Sec. 102. Eligibility.Sec. 103. Benefits.Sec. 104. Premiums.Sec. 105. Providers and reimbursement rates.Sec. 106. Account; funding.Subtitle B—Medicare for AmericaSec. 111. Establishment and administration of Medicare for America.Sec. 112. Modifications to and coordination with existing Federal health programs.Subtitle C—Targeted ReformsSec. 121. Limitation on removal of Medicare Advantage providers by MA organizations.Sec. 122. Network adequacy.Sec. 123. Eliminating the 24-month waiting period for Medicare coverage for individuals with disabilities.Sec. 124. Eliminating the waiting period for individuals on State Medicaid waiting lists.Sec. 125. Employer health plan options.Sec. 127. Medicare outpatient observation services.Sec. 128. Abortion coverage.Sec. 129. Applicability of mental health parity.Sec. 130. Student loan forgiveness for health care providers participating in Medicare for America.Sec. 131. Clarification of the definition of pediatric medical necessity in qualifying group coverage.Sec. 132. Safe staffing requirements.Sec. 133. Enhancements for reduced cost-sharing.Sec. 134. Repeal of bonus payments for Medicare Advantage plans.Title II—Tax provisionsSec. 201. Sunset of Public Law 115–97.Sec. 202. Surtax.Sec. 203. Basis of property acquired from a decedent.Sec. 204. Medicare payroll tax.Sec. 205. Net investment income tax.Sec. 206. Termination of deduction for contributions to health savings accounts.Sec. 207. Increase in excise tax on small cigars and cigarettes and other tobacco products.Sec. 208. Excise tax on alcohol.Sec. 209. Tax on sugared drinks.Sec. 210. Repeal of excise tax on high-cost employer-sponsored health coverage.Title III—Drug-related provisionsSec. 301. Establishment of the Prescription Drug and Medical Device review Board.Sec. 302. Membership; staff.Sec. 303. Prohibition against excessive price.Sec. 304. Enforcement provisions.Sec. 305. Authority.Sec. 306. Regulations.Sec. 307. Report to Federal agencies.Sec. 308. Definitions.Sec. 309. Moratorium on direct-to-consumer drug advertising.Sec. 310. Reporting on justification for drug price increases.Title IV—Outcomes and reportingSec. 401. Sense of Congress.Sec. 402. Evaluation of bill’s outcome.

.

112.

Modifications to and coordination with existing federal health programs

(a)

Medicare, medicaid, and state children’s health insurance program (SCHIP)

(1)

In general

Notwithstanding any other provision of law, subject to paragraphs (2) and (3) and section 2202(c) of the Social Security Act, as added by section 111—(A)no benefits shall be available under title XVIII of the Social Security Act for any item or service furnished—(i)beginning on or after January 1, 2029 (except in the case of an individual enrolled under such title and title XIX of such Act); and(ii)beginning on or after January 1, 2031, with respect to all individuals, including individuals enrolled under such title and title XIX of such Act;(B)no individual is entitled to medical assistance under a State plan approved under title XIX of such Act—(i)for any item or service furnished on or after January 1, 2031, in the case of an individual enrolled under such title and title XVIII of the Social Security Act or an individual described in subclause (VIII) of section 1902(a)(10)(A)(i); and(ii)for any item or service furnished on or after January 1, 2033;(C)no individual is entitled to medical assistance under a State child health plan under title XXI of such Act for any item or service furnished on or after January 1, 2031; and(D)no payment shall be made to a State under section 1903(a) or 2105(a) of such Act with respect to medical assistance or child health assistance—(i)for any item or service furnished on or after January 1, 2031, in the case of an individual enrolled under such title and title XVIII of the Social Security Act or an individual described in subclause (VIII) of section 1902(a)(10)(A)(i); and(ii)for any item or service furnished on or after January 1, 2033.(2)

Transition

In the case of inpatient hospital services and extended care services during a continuous period of stay which began before January 1, 2031, for Medicare and 2033 for Medicaid or CHIP, and which had not ended as of such date, for which benefits are provided under title XVIII of the Social Security Act, under a State plan under title XIX of such Act, or under a State child health plan under title XXI such Act, the Secretary of Health and Human Services shall provide for continuation of benefits under such title or plan until the end of the period of stay.(b)

Other federal health programs

(1)

Federal employees health benefits program

Nothing in this Act, or the amendments made by this Act, shall affect benefits made available under chapter 89 of title 5, United States Code.(2)

TRICARE

Nothing in this Act, or the amendments made by this Act, shall affect benefits made available under sections 1079 and 1086 of title 10, United States Code.(3)

Treatment of benefits for veterans and native americans

(A)

In general

Nothing in this Act, or the amendments made by this Act, shall affect the eligibility of veterans for the medical benefits and services provided under title 38, United States Code, or of Indians for the medical benefits and services provided by or through the Indian Health Service.(B)

Reevaluation

No reevaluation of the Indian Health Service shall be undertaken without consultation with tribal leaders and stakeholders.(C)

Supplemental indian health services allocation

The Secretary shall annually determine the need to provide an allotment of supplemental funds to Indian Health Services, including payments to providers, health professional education, administrative expenses, and prevention and public health activities.(4)

Enrollee choice

Nothing in this Act shall preclude individuals enrolled in the Federal Employees Health Benefits Program or TRICARE or individuals receiving benefits provided under title, 38, United States Code or the Indian Health Service from enrolling in Medicare for America. Enrollees shall be entitled to the employer contribution as established under section 126(c) of such Act.(c)

Sunset of provisions related to the state exchanges

Effective January 1, 2031, the Federal and State Exchanges established pursuant to title I of the Patient Protection and Affordable Care Act (Public Law 111–148) shall terminate, and any other provision of law that relies upon participation in or enrollment through such an Exchange, including such provisions of the Internal Revenue Code of 1986, shall cease to have force or effect.(d)

Severability

Every provision in this Act and every application of the provisions in this Act are severable from each other as a matter of Federal law. If any application of any provision in this Act to any person or group of persons or circumstances is found by a court to be invalid, the remainder of this Act and the application of the Act’s provisions to all other persons and circumstances may not be affected.

C

Targeted Reforms

121.

Limitation on removal of medicare advantage providers by ma organizations

(a)

Limitation

Section 1852(d) of the Social Security Act (42 U.S.C. 1395w–22(d)) is amended by adding at the end the following:(7)

Limitation on removal of providers from ma plans by ma organizations

(A)

Removal of providers with cause

Beginning with plan year 2026, 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 2026, 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 2026, an MA organization offering an MA plan shall publish and make accessible the information described in subparagraph (B)—(i)in the annual bid information submitted by the MA organization with respect to the MA plan under section 1854; and(ii)on the Internet Web Site for the MA plan.(B)

Information described

The information described in this subparagraph is the following:(i)Information regarding the measures used by the MA organization to establish or modify the provider network of the MA plan, including measures of the quality and efficiency of providers. Such information shall include the specifications, methodology, and sample size of such measures.(ii)Other information related to the establishment or modification of such provider network that the Secretary determines appropriate.(C)

Limitation

The information described in subparagraph (B) shall not include any individually identifiable information of any provider or supplier of services..(b)

Enforcement

(1)

Sanctions for noncompliance

Section 1857(g)(1) of the Social Security Act (42 U.S.C. 1395w–27(g)(1)) is amended—(A)in subparagraph (J), by striking or;(B)by redesignating subparagraph (K) as subparagraph (L);(C)by inserting after subparagraph (J) the following new subparagraph:(K)fails to comply with section 1852(d)(7) or 1852(d)(8); or; and(D)in subparagraph (L) (as so redesignated), by striking through (J) and inserting through (K).(2)

Sanctions not applicable to part d

Title XVIII of the Social Security Act is amended—(A)in section 1860D–12(b)(3)(E) (42 U.S.C. 1395w—(B)in section 1894(e)(6)(B) (42 U.S.C. 1395eee(e)(6)(B)), by inserting (other than paragraph (1)(K) of such section) after 1857(g)(1).(c)

Medicare advantage plan compare tool

Not later than one year after the date of enactment of this Act, the Secretary of Health and Human Services shall take such measures as are necessary to ensure that the Medicare Advantage Compare Tool takes into account the preferences and utilization needs of such individuals.

122.

Network adequacy

(a)

In general

Section 1852(d) of the Social Security Act (42 U.S.C. 1395w–22(d)) is amended by adding at the end the following:(9)

Network adequacy requirements

Beginning in plan year 2024, notwithstanding any other provision of law, the following shall apply:(A)

Provider availability

When establishing a plan network, a Medicare Advantage organization offering an MA plan shall, among other factors determined by the Secretary, consider the following:(i)The anticipated enrollment in the plan.(ii)The expected types of services provided and utilization of services by enrollees under the plan.(iii)The number and types of providers needed to provide such services.(iv)The number of network providers who are not accepting new patients.(v)The location of providers and enrollees, taking into account geographic disbursement.(vi)The full-time equivalent availability of a provider to provide such services.(B)

Provision of care in a timely manner

A Medicare Advantage organization offering an MA plan shall ensure that providers are able to provide services in a timely manner, as defined by the Secretary, under the plan.(C)

Application of network access adequacy standards

In applying the network access adequacy standards pursuant to paragraph (1), the Secretary shall seek input from patient advocacy groups, providers of services and suppliers, and MA plans under this part.(D)

Certification

Each plan year, a Medicare Advantage organization shall certify to the Secretary, with respect to each MA plan offered by the organization, that the providers, including specialists and subspecialists, in the plan network are able to provide the services required under the organization’s contract with the Secretary under section 1857 with respect to the offering of such plan and to meet the needs of the enrollees within the plan service area during the year.(E)

Annual reporting

Each plan year, a Medicare Advantage organization shall report to the Secretary, and make public the following with respect to each MA plan offered by the organization:(i)

Average wait time

The average wait time for primary and specialty care for enrollees under the plan.(ii)

Utilization of out-of-network providers

The utilization of out-of-network providers under the plan.(iii)

Average cost per patient

The average annual spending per patient for primary and specialty care for enrollees under the plan.(F)

Certification

In advance of the annual, coordinated election period under section 1851(e)(3), a Medicare Advantage organization shall certify to the Secretary the accuracy of provider directories for each plan offered by the organization.(G)

Network review

The Secretary shall ensure that the network of each MA plan offered by a Medicare Advantage organization meets the network adequacy guidelines established under this paragraph and under section 422.112(a)(4) of title 42, Code of Federal Regulations (or any successor regulation to such section) at least once every 3 years or when a material change in network occurs.(H)

Authority

The Secretary shall have the authority to stop any further enrollment in a Medicare Advantage plan if there is a pattern of excessive violations of this paragraph..(b)

Enforcement

Section 1857(g)(1)(K) of the Social Security Act (42 U.S.C. 1395w–27(g)(1)(K)), as added by section 2(b), is amended by striking or 1852(d)(8) and inserting , 1852(d)(8), or 1852(d)(9).

123.

Eliminating the 24-month waiting period for medicare coverage for individuals with disabilities

(a)

In general

Section 226(b) of the Social Security Act (42 U.S.C. 426(b)) is amended—(1)in paragraph (2)(A), by striking , and has for 24 calendar months been entitled to,;(2)in paragraph (2)(B), by striking , and has been for not less than 24 months,;(3)in paragraph (2)(C)(ii), by striking , including the requirement that he has been entitled to the specified benefits for 24 months,;(4)in the first sentence, by striking for each month beginning with the later of (I) July 1973 or (II) the twenty-fifth month of his entitlement or status as a qualified railroad retirement beneficiary described in paragraph (2), and and inserting for each month for which the individual meets the requirements of paragraph (2), beginning with the month following the month in which the individual meets the requirements of such paragraph, and; and(5)in the second sentence, by striking the twenty-fifth month of his entitlement and all that follows through paragraph (2)(C) and.(b)

Conforming amendments

(1)

Section 226

Section 226 of the Social Security Act (42 U.S.C. 426) is amended by—(A)striking subsections (e)(1)(B), (f), and (h); and(B)redesignating subsections (g) and (i) as subsections (f) and (g), respectively.(2)

Medicare description

Section 1811(2) of the Social Security Act (42 U.S.C. 1395c(2)) is amended by striking have been entitled for not less than 24 months and inserting are entitled.(3)

Medicare coverage

Section 1837(g)(1) of the Social Security Act (42 U.S.C. 1395p(g)(1)) is amended by striking 25th month of and inserting month following the first month of.(4)

Railroad retirement system

Section 7(d)(2)(ii) of the Railroad Retirement Act of 1974 (45 U.S.C. 231f(d)(2)(ii)) is amended—(A)by striking has been entitled to an annuity and inserting is entitled to an annuity;(B)by striking , for not less than 24 months; and(C)by striking could have been entitled for 24 calendar months, and.(c)

Effective date

The amendments made by this section shall apply to insurance benefits under title XVIII of the Social Security Act with respect to items and services furnished in months beginning after the date of enactment of this Act.

124.

Eliminating the waiting period for individuals on state medicaid waiting lists

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

125.

Employer health plan options

(a)

Definition

A qualifying employer-sponsored plan is—(1)a governmental plan (within the meaning of section 2791(d)(8) of the Public Health Service Act); or(2)any other plan or coverage that meets the criteria under subsection (b), includes vision, dental, and hearing benefits, and provides health coverage that is equivalent to an actuarial value of at least 80 percent of the coverage provided under title XXII of the Social Security Act and makes a premium contribution of at least 70 percent.Such plan shall require a premium contribution from the employer of at least 70 percent regardless of whether coverage is for single, spousal, or dependent care.(b)

Obligation

Large employers shall, with respect to any full-time employee of such employer—(1)offer a qualifying employer-sponsored plan to such employee, in accordance with subsection (a); or(2)make a contribution of 8 percent of their annual payroll to the Medicare Trust Fund under title XXII of the Social Security Act.(c)

Employee choice

An employee may opt-out of a qualifying employer-sponsored plan as satisfied by subsection (b)(1) in order to enroll in Medicare for America. The employer shall make a contribution equal to the contribution it shall make in order to meet the requirements established by subsection (a)(1) or (a)(2). The Secretary of Health and Human Services shall have authority to set standards for determining whether employers or insurers are undertaking any actions to affect the risk pool within Medicare for America by inducing individuals to decline coverage under a qualifying employer-sponsored plan and instead to enroll in Medicare for America. An employer violating such standards shall be treated as not meeting the requirements of subsection (a).(d)

Employee education on health coverage options

Large employers shall disseminate to employees such publicly available information on coverage options under Medicare for America as the Secretary deems appropriate, including contact information for assistance.(e)

Special rules

(1)

Annual payroll

For purposes of this paragraph, the term annual payroll means, with respect to any employer for any calendar year, the aggregate wages paid by the employer during such calendar year.(2)

Aggregation rules

Related employers and predecessors shall be treated as a single employer for purposes of this subsection.(3)

Reduction for part-time employees

In the case of a part-time employee, the employer contribution requirements of paragraph (1) shall be treated as satisfied if the employer contribution with respect to such employee is not less than the part-time employment ratio of the contribution required under paragraph (1).(4)

Rules related to part-time employment

For purposes of this subsection—(A)

Part-time employee

The term part-time employee means, with respect to any month, an employee who works on average fewer than 30 hours per week.(B)

Part-time employment ratio

The term part-time employment ratio means, with respect to a part-time employee of an employer in a month, a fraction—(i)the numerator of which is the number of hours in the employee’s normal work week; and(ii)the denominator of which is 30 hours.(C)

Special rules

Under rules prescribed by the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury, in the case of an employee for an employer whose defined work week for full-time employees is less than 30 hours, any reference in this subsection to 30 hours is deemed a reference to the number of hours in the work week so defined.(D)

Conversion to hours of employment

The Secretary of Health and Human Services, in consultation with the Secretary of the Treasury, shall establish rules for the conversion of compensation to hours of employment, for purposes of this subsection in the case of employees that receive compensation on a salaried basis, or on the basis of a commission, or other contingent or bonus basis, rather than based on an hourly wage.(f)

Timing and manner

Each employer that makes a financial contribution under subsection (b)(2) and (c) under this section (other than with respect to coverage under a group health plan) shall pay such contribution in a form and manner, specified by the Secretary of the Treasury, based upon the form and manner in which employer excise taxes are required to be paid under section 3111 of the Internal Revenue Code of 1986.(g)

Non-Discrimination

(1)

In general

Except as otherwise provided for in this title (or an amendment made by this title), an individual shall not, on the ground prohibited under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), or section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or under any program or activity that is administered by an Executive Agency or any entity established under this title (or amendments) or any employer-sponsored insurance.(2)

Continued application of laws

Nothing in this title (or an amendment made by this title) shall be construed to invalidate or limit the rights, remedies, procedures, or legal standards available to individuals aggrieved under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of 1975 (42 U.S.C. 611 et seq.), or to supersede State laws that provide additional protections against discrimination on any basis described in paragraph (1).(3)

Limitation

A group health plan may not establish rules relating to the health insurance coverage eligibility (including continued eligibility) or contribution requirements of any full-time employee under the terms of the plan that have the effect of discriminating in favor of higher-wage employees.(4)

Regulations

The Secretary of Health and Human Services, in conjunction with the Secretary of Labor, may promulgate regulations to implement this subsection.

126.

Prohibition on step therapy and prior authorization under group health plans

Section 2719A of the Public Health Service Act (42 U.S.C. 300gg–19a) is amended by adding at the end the following new subsection:(e)

Prohibition Against Step Therapy and Prior Authorization

Beginning with the first plan year following the date of the enactment of this subsection, a group health plan may not require a prior authorization determination for coverage of any benefit under such plan and may not apply treatment limitations through the use of step therapy protocols..

127.

Medicare outpatient observation services

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

128.

Abortion coverage

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

129.

Applicability of mental health parity

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

130.

Student loan forgiveness for health care providers participating in medicare for america

(a)

In general

Beginning on the date after the date of the enactment of this Act, after the conclusion of each plan year, the Secretary of Health and Human Services, in conjunction with the Secretary of Education, shall cancel the applicable percent specified in subsection (b) of the total amount due on any eligible Federal loan made 20 years prior to date of enactment and any date after the date of enactment of this Act for a borrower who is a Medicare for America participating provider and submits an employment certification form described in subsection (d).(b)

Applicable percent

For purposes of subsection (a), the applicable percent is 10 percent of any eligible Federal loan for each year the health care provider participates in Medicare for America.(c)

Definitions

In this section:(1)

Eligible federal loan

The term eligible Federal loan means any loan made under part D of title IV of the Higher Education Act of 1965 (20 U.S.C. 1087a).(2)

Health care provider

The term health care provider means a physician, physician assistant, registered nurse, nurse practitioner, advanced practice nurse, licensed practical nurse, psychologist, mental health counselor, marriage and family therapist, direct care worker, health social worker, dentist, dental hygienist, pharmacist, physical therapist, occupational therapist, or any other health care provider specified by the Secretary of Health and Human Services if the Secretary determines such specification for purposes of this section is necessary to ensure workforce adequacy.(3)

Medicare for america participating provider

The term Medicare for America participating provider means a health care provider that meets the definition of such term under section 105 or works at a participating provider or entity as defined under section 105.(d)

Employment certification form

(1)

In general

In order to receive loan cancellation under this paragraph, a borrower shall submit to the Secretary of Education an employment certification form that is developed by the Secretary of Education and includes self-certification of employment and a separate part for employer certification that indicates the dates of employment.(2)

Deferment

If a borrower submits to the Secretary of Education the employment certification form described in paragraph (1), during the period in which the borrower is employed as a Medicare for America participating provider for which loan cancellation is eligible under this section, the borrower’s eligible Federal Direct Loan shall be placed in deferment.(e)

Interest canceled

If a portion of a loan is canceled under this section for any year, the entire amount of interest on such loan that accrues for such year shall be canceled.(f)

Regulations

The Secretary of Health and Human Services and the Secretary of Education may promulgate regulations to implement this section.

131.

Clarification of the definition of pediatric medical necessity in qualifying group coverage

(a)

Definition

The following definition of pediatric medical necessity shall be incorporated into benefit standards of all plans subject to the requirements of section 1302 of the Patient Protection and Affordable Care Act (42 U.S.C. 18022) and all group plans by 2026.(b)

Development of definition

Pediatric medical necessity, or pediatric medically necessary care, shall be defined as health care interventions that are evidence based, evidence informed, or based on consensus advisory opinion and that are recommended by recognized health care professionals, to promote optimal growth and development in a child and to prevent, detect, diagnose, treat, ameliorate, or palliate the effects of physical, genetic, congenital, developmental, behavioral, or mental conditions, injuries, or disabilities.(c)

Updates to definition

The Secretary of Health and Human Services, in consultation with experts in the field of pediatric care and key stakeholders, including patient and family groups, shall review and update this definition on a biennial basis, consistent with up-to-date standards of pediatric healthcare practice that are based on—(1)the views of pediatric healthcare providers and experts practicing in relevant clinical areas;(2)recommendations of medical-specialty societies, other pediatric healthcare provider organizations, and family and patient groups; and(3)credible scientific evidence published in peer-reviewed literature that is generally recognized by the relevant health care provider community.

132.

Safe staffing requirements

(a)

Minimum direct care registered nurse staffing requirements

The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following new title:.(b)

Recommendations to congress

Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report containing recommendations for ensuring that sufficient numbers of nurses are available to meet the requirements imposed by title XXXIV of the Public Health Service Act, as added by subsection (a).(c)

Report by HRSA

(1)

In general

Not later than 2 years after the date of enactment of this Act, the Administrator of the Health Resources and Services Administration, in consultation with the National Health Care Workforce Commission, shall submit to Congress a report regarding the relationship between nurse staffing levels and nurse retention in hospitals.(2)

Updated report

Not later than 5 years after the date of enactment of this Act, the Administrator of the Health Resources and Services Administration, in consultation with the National Health Care Workforce Commission, shall submit to Congress an update of the report submitted under paragraph (1).(d)

Enforcement of requirements through federal programs

(1)

Medicare program

Section 1866(a)(1) of the Social Security Act (42 U.S.C. 1395cc(a)(1)) is amended—(A)in subparagraph (X), by striking , and and inserting a comma;(B)in subparagraph (Y), by striking the period at the end and inserting , and; and(C)by inserting after subparagraph (Y) the following new subparagraph:(Z)in the case of a hospital, to comply with the provisions of title XXXIV of the Public Health Service Act..(2)

Medicaid program

Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended—(A)by striking and at the end of paragraph (82);(B)by striking the period at the end of paragraph (83) and inserting ; and; and(C)by inserting after paragraph (83) the following new paragraph:(84)provide that any hospital that receives a payment under such plan comply with the provisions of title XXXIV of the Public Health Service Act (relating to minimum direct care registered nurse staffing requirements)..(e)

Nursing homes

No later than one year after enactment of this Act, the Secretary of Health and Human Services shall promulgate a rule for minimum staffing standards for skilled nursing facilities under the Medicare program and for nursing facilities under the Medicaid program that align with the standards set in this section.

133.

Enhancements for reduced cost-sharing

(a)

In general

Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended—(1)in subsection (b)(1), by striking silver and inserting gold;(2)by amending subsection (c)(1)(B) to read as follows:(B)

Coordination with actuarial limits

The Secretary shall ensure the reduction under this paragraph shall not result in the plan’s share of the total allowed costs of benefits provided under the plan becoming less than—(i)95 percent in the case of an eligible insured described in paragraph (2)(A);(ii)90 percent in the case of an eligible insured described in paragraph (2)(B); and(iii)85 percent in the case of an eligible insured described in paragraph (2)(C).; and(3) by amending subsection (c)(2) to read as follows:(2)

Additional reduction

The Secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall further reduce cost-sharing under the plan in a manner sufficient to—(A)in the case of an eligible insured whose household income is not less than 100 percent but not more than 200 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 95 percent of such costs;(B)in the case of an eligible insured whose household income is more than 200 percent but not more than 300 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 90 percent of such costs; and(C)in the case of an eligible insured whose household income is more than 300 percent but not more than 400 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 85 percent of such costs..(b)

Effective date

The amendments made by this subsection shall apply to plan years beginning after December 31, 2025.(c)

Funding

Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended by adding at the end the following new subsection:(g)

Funding

Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary such sums as may be necessary for payments under this section..

134.

Repeal of bonus payments for medicare advantage plans

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