[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 981 Introduced in Senate (IS)]

<DOC>






116th CONGRESS
  1st Session
                                 S. 981

                   To establish a public health plan.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             April 2, 2019

  Mr. Bennet (for himself, Mr. Kaine, Mr. Cardin, Ms. Klobuchar, Mr. 
Leahy, Ms. Smith, Ms. Stabenow, Ms. Harris, Mr. Booker, Mr. Peters, Mr. 
Durbin, and Mrs. Shaheen) introduced the following bill; which was read 
             twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
                   To establish a public health plan.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare-X Choice Act of 2019''.

SEC. 2. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH PLAN.

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

              ``TITLE XXII--MEDICARE EXCHANGE HEALTH PLAN

``SEC. 2201. ESTABLISHMENT.

    ``(a) Establishment of Plan.--
            ``(1) In general.--The Secretary shall establish a 
        coordinated and low-cost health plan, to be known as the 
        `Medicare Exchange health plan' (referred to in this section as 
        the `health plan') to provide access to quality health care for 
        enrollees.
            ``(2) Timeframe.--
                    ``(A) Individual market availability.--
                            ``(i) In general.--In accordance with 
                        clause (ii), the Secretary shall make the 
                        health plan available in the individual market, 
                        in certain rating areas, for plan year 2021 and 
                        each subsequent plan year, and increase the 
                        availability such that the plan is available in 
                        the individual market to all residents of all 
                        rating areas in the United States for plan year 
                        2024 and each subsequent plan year.
                            ``(ii) Priority areas.--In determining in 
                        which rating areas the Secretary initially will 
                        make the health plan available, the Secretary 
                        shall give priority to rating areas in which--
                                    ``(I) not more than 1 health 
                                insurance issuer offers plans on the 
                                applicable State or Federal American 
                                Health Benefit Exchange (referred to in 
                                this title as the `Exchange'); or
                                    ``(II) there is a shortage of 
                                health providers or lack of competition 
                                that results in a high cost of health 
                                care services, including health 
                                professional shortage areas and rural 
                                areas.
                    ``(B) Small group market.--The Secretary shall make 
                the health plan available in the small group market in 
                all rating areas for plan year 2025.
    ``(b) Establishment of Funds.--
            ``(1) Plan reserve fund.--
                    ``(A) In general.--There is established in the 
                Treasury of the United States a `Plan Reserve Fund', to 
                be administered by the Secretary of Health and Human 
                Services, for purposes of establishing the Medicare 
                Exchange health plan and administering such plan, 
                consisting of amounts appropriated to such fund.
                    ``(B) Appropriation.--There is appropriated 
                $1,000,000,000, out of monies in the Treasury not 
                otherwise obligated, to the Plan Reserve Fund for 
                fiscal year 2020.
            ``(2) Data and technology fund.--There is established in 
        the Treasury of the United States a `Data and Technology Fund', 
        to be administered by the Secretary of Health and Human 
        Services, acting through the Chief Actuary of the Centers for 
        Medicare & Medicaid Services, for purposes of updating 
        technology and performing data collection under section 2205 in 
        order to establish appropriate premiums for all geographic 
        regions of the United States. There are authorized to be 
        appropriated to the Data and Technology Fund such sums as may 
        be necessary for fiscal year 2020.
    ``(c) Rulemaking.--The Secretary may promulgate such regulations as 
may be necessary to carry out this title.

``SEC. 2202. AVAILABILITY OF PLAN.

    ``(a) Eligibility.--An individual shall be eligible to enroll in 
the health plan if such individual, for the entire period for which 
enrollment is sought--
            ``(1) is a qualified individual within the meaning of 
        section 1312 of the Patient Protection and Affordable Care Act 
        (42 U.S.C. 18032); and
            ``(2) is not eligible for benefits under the Medicare 
        program under title XVIII.
    ``(b) Exchanges.--In accordance with the timeframe under section 
2201(a)(2), the health plan shall be made available through the 
American Health Benefit Exchanges described in sections 1311 and 1321 
of the Patient Protection and Affordable Care Act (42 U.S.C. 18031, 
18041), including the Small Business Health Options Program Exchange.

``SEC. 2203. PLAN REQUIREMENTS.

    ``(a) General Requirements.--The health plan shall comply with all 
requirements, as applicable, of subtitle D of title I of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18021 et seq.) and title 
XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) 
applicable to qualified health plans, and such health plan shall be a 
qualified health plan, including for purposes of the Internal Revenue 
Code of 1986.
    ``(b) Levels of Coverage.--The Secretary--
            ``(1) shall make available a silver level and gold level 
        version of the plan, in accordance with section 
        1301(a)(1)(C)(ii); and
            ``(2) may make available no more than 2 versions of the 
        plan for each of the 4 levels of coverage described in 
        subparagraphs (A) through (D) of section 1302(d)(1) of the 
        Patient Protection and Affordable Care Act (42 U.S.C. 
        18022(d)(1)).

``SEC. 2204. ADMINISTRATIVE CONTRACTING.

    ``(a) In General.--The Secretary may enter into contracts for the 
purpose of performing administrative functions (including functions 
described in subsection (a)(4) of section 1874A) with respect to the 
health plan in the same manner as the Secretary may enter into 
contracts under subsection (a)(1) of such section. The Secretary shall 
have the same authority with respect to the public health insurance 
option as the Secretary has under such subsection (a)(1) and subsection 
(b) of section 1874A with respect to title XVIII.
    ``(b) Transfer of Insurance Risk.--Any contract under subsection 
(a) shall not involve the transfer of insurance risk from the Secretary 
to the entity entering into such contract with the Secretary, except in 
the case of an alternative payment model under section 2209(h).

``SEC. 2205. DATA COLLECTION.

    ``Subject to all applicable privacy requirements, including the 
requirements under the regulations promulgated pursuant to section 
264(c) of the Health Insurance Portability and Accountability Act of 
1996 (42 U.S.C. 1320d-2 note), the Secretary may collect data from 
State insurance commissioners and other relevant entities to establish 
rates for premiums and for other purposes including to improve quality, 
and reduce racial, ethnic, and other disparities, with respect to the 
health plan.

``SEC. 2206. PREMIUMS; RISK POOL.

    ``(a) Setting Premiums.--
            ``(1) In general.--The Secretary shall establish premiums 
        for the health plan that cover the full actuarial cost of 
        offering such plan, including the administrative costs of 
        offering such plan. Such premiums shall vary geographically and 
        between the small group market and the individual market in 
        accordance with differences in the cost of providing such 
        coverage. If, for any plan year, the amount collected in 
        premiums exceeds the amount required for health care benefits 
        and administrative costs in that plan year, such excess amounts 
        shall remain available to the Secretary to administer the 
        health plan and finance beneficiary costs in subsequent years.
            ``(2) Initial plan year.--For plan year 2021, the Secretary 
        shall set premiums for the health plan for each rating area in 
        which the health plan is available for such plan year, taking 
        into consideration the premium rates for plans offered in each 
        such rating area for plan year 2020.
    ``(b) Risk Pool.--After plan year 2021, all enrollees in the health 
plan within a State shall be members of a single risk pool, except that 
the Secretary may establish separate risk pools for the individual 
market and small group market if the State has not exercised its 
authority under section 1312(c)(3) of the Patient Protection and 
Affordable Care Act.

``SEC. 2207. REIMBURSEMENT RATES.

    ``(a) Medicare Rates.--
            ``(1) In general.--Except as provided in paragraph (2) and 
        subsections (b) and (c) and subject to subsection (d), the 
        Secretary shall reimburse health care providers furnishing 
        items and services under the health plan at rates determined 
        for equivalent items and services under the original Medicare 
        fee-for-service program under parts A and B of title XVIII.
            ``(2) Authority to increase payments rates in rural 
        areas.--If the Secretary determines appropriate, the Secretary 
        may increase the reimbursements rates described in paragraph 
        (1) by up to 25 percent for items and services furnished in 
        rural areas (as defined in section 1886(d)(2)(D)).
    ``(b) Prescription Drugs.--Subject to subsection (d), payment rates 
for prescription drugs shall be at a rate negotiated by the Secretary. 
Such negotiations may be in conjunction with negotiations for covered 
part D drugs under part D of title XVIII.
    ``(c) Additional Items and Services.--Subject to subsection (d), 
the Secretary shall establish reimbursement rates for any items and 
services provided under the health plan that are not items and services 
provided under the original Medicare fee-for-service program under 
parts A and B of title XVIII.
    ``(d) Innovative Payment Methods.--The Secretary may utilize 
innovative payment methods, including value-based payment arrangements, 
in making payments for items and services (including prescription 
drugs) furnished under the health plan.

``SEC. 2208. PARTICIPATING PROVIDERS.

    ``(a) Requirement To Participate in Order To Be Enrolled Under 
Medicare.--Subject to subsection (d), beginning January 1, 2021, a 
health care provider may not be enrolled under the Medicare program 
under section 1866(j) unless the provider is also a participating 
provider under the health plan.
    ``(b) Requirement To Participate in Order To Participate in 
Medicaid.--Subject to subsection (d), beginning January 1, 2021, a 
health care provider may not be a participating provider under a State 
Medicaid plan under title XIX unless the provider is also a 
participating provider under the health plan.
    ``(c) Additional Providers.--The Secretary shall establish a 
process to allow health care providers not described in subsection (a) 
or (b) to become a participating provider under the health plan.
    ``(d) Opt-Out.--The Secretary shall establish a process by which a 
health care provider described in subsection (a) or (b) may opt out of 
being a participating provider under the health plan.

``SEC. 2209. DELIVERY SYSTEM REFORM FOR AN ENHANCED HEALTH PLAN.

    ``(a) In General.--For plan years beginning with plan year 2021, 
the Secretary may utilize innovative payment mechanisms and policies to 
determine payments for items and services under the health plan. The 
payment mechanisms and policies under this section may include patient-
centered medical home and other care management payments, accountable 
care organizations, accountable communities for health, value-based 
purchasing, bundling of services, differential payment rates, 
performance or utilization based payments, telehealth, remote patient 
monitoring, partial capitation, and direct contracting with providers.
    ``(b) Requirements for Innovative Payments.--The Secretary shall 
design and implement the payment mechanisms and policies under this 
section in a manner that--
            ``(1) seeks to--
                    ``(A) improve health outcomes;
                    ``(B) reduce health disparities (including racial, 
                ethnic, and other disparities);
                    ``(C) provide efficient and affordable care;
                    ``(D) address geographic variation in the provision 
                of health services; or
                    ``(E) prevent or manage chronic illness; and
            ``(2) promotes care that is integrated, patient-centered, 
        quality, and efficient.
    ``(c) Encouraging the Use of High Value Services.--To the extent 
allowed by the benefit standards applied to all health benefits plans 
participating in the Exchanges (as described in section 2202(b)), the 
health plan may modify cost-sharing and payment rates to encourage the 
use of services that promote health and value.
    ``(d) Promotion of Delivery System Reform.--The Secretary shall 
monitor and evaluate the progress of payment and delivery system 
reforms under this section and shall seek to implement such reforms 
subject to the following:
            ``(1) To the extent that the Secretary finds a payment and 
        delivery system reform successful in improving quality and 
        reducing costs, the Secretary shall implement such reform on as 
        large a geographic scale as practical and economical.
            ``(2) The Secretary may delay the implementation of such a 
        reform in geographic areas in which such implementation would 
        place the public health insurance option at a competitive 
        disadvantage.
            ``(3) The Secretary may prioritize implementation of such a 
        reform in high-cost geographic areas or otherwise in order to 
        reduce total program costs or to promote high value care.
    ``(e) Non-Uniformity Permitted.--Nothing in this section shall 
prevent the Secretary from varying payments based on different payment 
structure models (such as accountable care organizations and medical 
homes) under the health plan for different geographic areas.
    ``(f) Integration With Social Services.--
            ``(1) In general.--The Secretary shall establish processes 
        and, when appropriate, collaborate with other agencies to 
        integrate medical care under the health plan with food, 
        housing, transportation, and income assistance if the Secretary 
        determines that such integration is expected to--
                    ``(A) reduce spending without reducing the quality 
                of patient care; or
                    ``(B) improve the quality of patient care without 
                increasing spending.
            ``(2) Authorization of a grant program.--
                    ``(A) In general.--The Secretary may establish a 
                grant program to permit broader experimentation with 
                accountable communities for health model.
                    ``(B) Eligible recipients.--The Secretary may award 
                a grant under this section to--
                            ``(i) an institution of higher learning (as 
                        defined in section 3452(f) of title 38, United 
                        States Code);
                            ``(ii) a local educational agency (as 
                        defined in section 8101 of the Elementary and 
                        Secondary Education Act of 1965) or health care 
                        agency;
                            ``(iii) a nonprofit entity that the 
                        Secretary determines has a demonstrated history 
                        of community engagement; or
                            ``(iv) any other entity, as the Secretary 
                        determines appropriate.
                    ``(C) Use of funds.--A recipient of a grant under 
                this section may use the grant to--
                            ``(i) support community needs assessment;
                            ``(ii) establish social service 
                        partnerships; or
                            ``(iii) establish interactive data systems 
                        across health and social service providers.
                    ``(D) Authorization of appropriations.--There are 
                authorized to be appropriated such sums as may be 
                necessary to carry out this paragraph.
            ``(3) Regulations.--If the Secretary establishes a grant 
        program under this section, the Secretary shall promulgate 
        regulations on--
                    ``(A) the evaluation of applications for grants 
                under the program; and
                    ``(B) administration of the program.
    ``(g) Telehealth.--The Secretary shall ensure the integration of 
telehealth tools that increase patient access to medical care, 
particularly in remote or underserved areas, if the Secretary 
determines that such integration is expected to--
            ``(1) reduce spending without reducing the quality of 
        patient care; or
            ``(2) improve the quality of patient care without 
        increasing spending.
    ``(h) Alternative Payment Model.--
            ``(1) In general.--The Secretary shall evaluate the 
        possibility of providing incentives, and, if appropriate, apply 
        incentives, for enrollees in the health plan who receive 
        services from providers who are participating in an alternative 
        payment model (as defined in section 1833(z)(3)(C)).
            ``(2) Authority to use apms in use under traditional 
        medicare.--Nothing in this section shall preclude the Secretary 
        from using alternative payment models (as so defined) under 
        this title that are in use under title XVIII.

``SEC. 2210. NO EFFECT ON MEDICARE BENEFITS OR MEDICARE TRUST FUNDS.

    ``Nothing in this title shall--
            ``(1) affect the benefits available under title XVIII; or
            ``(2) impact the Federal Hospital Insurance Trust Fund 
        under section 1817 or the Federal Supplementary Medical 
        Insurance Trust Fund under section 1841 (including the Medicare 
        Prescription Drug Account within such Trust Fund).''.

SEC. 3. REINSURANCE.

    (a) In General.--The Secretary of Health and Human Services shall 
establish a mechanism to pool, on a nationwide basis, the costs of the 
highest-cost patients enrolled in individual health insurance coverage 
(as defined in section 2791 of the Public Health Service Act (42 U.S.C. 
300gg-91)) offered on or off the Exchanges, to the extent such costs 
are not already pooled pursuant to section 1343 of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18063), for the purpose 
of reducing premiums for such individual health insurance coverage.
    (b) Authorization of Appropriations.--For purposes of carrying out 
paragraph (1), there is authorized to be appropriated $10,000,000,000 
for each of fiscal years 2021, 2022, and 2023.

SEC. 4. EXPANSION OF TAX CREDIT.

    (a) In General.--Subparagraph (A) of section 36B(c)(1) of the 
Internal Revenue Code of 1986 is amended by striking ``but does not 
exceed 400 percent''.
    (b) Applicable Percentages.--Clause (i) of section 36B(b)(3)(A) of 
the Internal Revenue Code of 1986 is amended to read as follows:
                            ``(i) In general.--The applicable 
                        percentage for any taxable year shall be the 
                        percentage such that the applicable percentage 
                        for any taxpayer whose household income is 
                        within an income tier specified in the 
                        following table shall increase, on a sliding 
                        scale in a linear manner, from the initial 
                        premium percentage to the final premium 
                        percentage specified in such table for such 
                        income tier:


------------------------------------------------------------------------
                                                The initial   The final
 ``In the case of household income (expressed     premium      premium
   as a percent of poverty line) within the      percentage   percentage
            following income tier:                  is--         is--
------------------------------------------------------------------------
Up to 138 percent.............................          1.5          1.5
138 percent up to 150 percent.................          2.5          3.5
150 percent up to 200 percent.................          3.5          5.8
200 percent up to 250 percent.................          5.8         7.55
250 percent up to 300 percent.................         7.55          9.0
300 percent up to 400 percent.................          9.0          9.0
400 percent up to 600 percent.................          9.0         13.0
600 percent and up............................         13.0     13.0.''.
------------------------------------------------------------------------

    (c) Limitation on Recapture.--Clause (i) of section 36B(f)(2)(B) of 
the Internal Revenue Code of 1986 is amended--
            (1) by striking ``In the case of a taxpayer'' and all that 
        follows through ``the amount of the increase'' and inserting 
        ``The amount of the increase'';
            (2) by striking the period at the end of the last row of 
        the table; and
            (3) by adding at the end of the table the following new 
        row:


 
 
------------------------------------------------------------------------
``400 percent and up.......................................   $5,000.''.
------------------------------------------------------------------------

    (d) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2019.

SEC. 5. AUTHORITY TO NEGOTIATE FAIR PRICES FOR MEDICARE PRESCRIPTION 
              DRUGS.

    (a) In General.--Section 1860D-11 of the Social Security Act (42 
U.S.C. 1395w-111) is amended by striking subsection (i).
    (b) Effective Date.--The amendment made by this section shall take 
effect on the date of the enactment of this Act.
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