Side by Side Comparison of Medicare for all and Public Plan Proposals Introduced in the 116th Congress

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1 Updated as of 5/2/2019 - Side Side Comparison of Medicare - for - a ll and Public Plan Proposals by - th 6 Congress Introduced in the 11 Public Plan Option Single Payer Medicaid Buy for Older Adults In In Medicare - Buy - ll) a - for - (Medicare (Federal/Medicare) Sanders Mer Jayapal Cardin k ley/Richmond Bennet and Schakowsky/Whitehouse Stabenow Higgins Schatz/ Luján Kaine/Delgado S. 489 In - Medicare Buy , H.R. 1346 , Medicare at 50 S. 470 The S. 1033 / S. 3 , State H.R. 1277 H.R. 2085 , H.R. 2000 / S.1129 , Medicare for All Act S. 981 H.R. 1384 , Medicare for All , H.R. 2463 / , Keeping Health / S. 1261 Number Title & Bill X Choice Act of of 2019 and Act of 2019 Choose Medicare Act Medicare - Insurance Affordable Act of CHOICE Act Health Care Act Public Option Act 2019 2019 Stabilization Act of 2019 ELIGIBILITY All individuals eligible Individuals ages 50 to 64 All US residents, as defined Individuals who are All individuals eligible to Individuals ages 50 to 64 All US residents, as defined All individuals eligible to All US residents who are to Individuals by the Secretary , not eligible for Medicaid participate in the residents of states by the Secretary who are U.S. citizens or participate in the marketplace who are U.S. citizens or participate in the marketplace nationals re nationals residing in the U.S. siding in the (citizens, lawfully admitted not entitled to the current marketplace (citizens, electing to establish the lawfully admitted permanent residents, Medicare program, or lawfully admitted for Medicaid buy or not - in option, U.S. or lawfully admitted who are eligible to enrolled in CHIP are for permanent residence permanent residents, not permanent residence in the not individuals who are ic eligible to enroll in publ incarcerated) participate in the incarcerated) and not U.S., and who are not in the U.S., and who are plan called Medicare Part marketplace, and who are otherwise entitled to/eligible otherwise eligible for not otherwise entitled for benefits under Medicar not concurrently enrolled Medicare E e to/eligible for benefits e Parts A in other health coverage Parts A or B under Medicar Medicare - X offered to or B in the States are prohibited from individuals in - beginning in marketplace purchasing Medicare buy States are prohibited - coverage on behalf of full from purchasing 2021 in areas with one benefit Medicaid enrollees in - Medicare buy issuer or high costs due to - ages 50 provider shortages, then in coverage on behalf of 64 edicaid all areas by 2024 full - benefit M enrollees ages 50 - 64 No provision No provision Small employers and their No provision No provision Not applicable Not applicable No provision Employers (large and Employers employees and small firms) can offer Medicare Part E option to dependents have access their employees. through the SHOP Exchange Secretary also authorized to act as third party X offered - to Medicare - administrator for self small group s beginning in insured group plans 2025 Individuals enrolled in Medicare Part E through employer sponsored plans - remain enrolled after may termination of employment relationship ENROLLMENT Enrollment generally for one Enrollment generally for Enrollment generally for one Enrollment generally for Enrollment generally for Lifetime enrollment Enrollment generally for Enrollment generally for one Lifetime enrollment Duration one year at a time one year at a time year at a time year at a time year at a time one year at a time. The one year at a time Secretary shall establish enrollment and coverage periods in coordination with the marketplace and with Medicare Advantage and Medicare Part D plans ll and Public Plan Proposals Introduced in the 116th Congress : 1 a Side Comparison of Medicare - for Side - by - -

2 for by - Side Comparison of Medicare - - - a ll and Public Plan Proposals Side th Introduced in the 11 6 Congress Single Payer Public Plan Option Medicaid Buy In Medicare Buy - In for Older Adults - for - a ll) (Medicare (Federal/Medicare) - k Schatz/ Luján Sanders Jayapal Cardin Mer ley/Richmond Bennet and Higgins Schakowsky/Whitehouse Stabenow Kaine/Delgado - Auto Public health insurance Medicare Part E offered in Enrollment will be Medicare - X offered enrollment at birth or - Auto Public plan offered only in plan - Medicaid buy enrollment of ACA enrollment periods, Enrollment Process individual and small group option offered exclusively marketplace procedures and newborns at birth; ordinated with through the marketplace offered through the ACA co through the individual and upon establishment of US marketplace in states Secretary shall provide for SHOP marketplaces through the marketplaces rules apply for Medicare and large group markets marketplace and residency Follows ACA marketplace buy - and through the individual electing the option in option enrollment of others Medicare enrollment - Enrollment at site enrollment procedures and of Follows ACA marketplace - service CA marketplace Follows A periods. Secretary may marketplace and SHOP th States may lim rules Benefits begin 4 for other individuals it and SHOP enrollment enrollment procedures and year after Eligible individuals can marketplace expand enrollment in enactment, children have - enrollment to the ACA procedures and rules are buy rules enroll in Medic period, if appropriate Enrollment for all individuals 64 option to begin enrollment marketplace enrollment Follows ACA enrollment option for people 50 - begins two years after date of in year one procedures and rules Eligible individuals can periods (Parts A, B and D, similar to enactment. Children under enroll in Medicare buy - in traditional Medicare) or in age 19 and adults age 55 option for people 50 Medicare Advantage 64 - and older have option to (Parts A, B and D, s Prescription Drug plan similar enroll earlier, beginning one - (MA to traditional Medicare) or PD) fter date of enactment year a in Medicare Advantage - in plan The Medicare buy plans Medigap policies for the and - dividuals Eligible in Medicare buy n population i continue to have option would be offered on the m ketplace website to enroll in private a r coverage and could do Eligible individuals continue so during the to have option to enroll in marketplace open private coverage and could enrollment period do so during the marketplace open enrollment period BENEFITS AND COST SHARING ACA 10 essential health All medically necessary All medically necessary or ACA 10 essential health Medicaid alternative ACA 10 e ssential health Medicare Parts A, B and D Comprehensive benefit Medicare Parts A, B and Benefits benefits and D benefits benefits benefits appropriate services in 14 benefit plan, which must Medicare benefits services in 13 benefit package that meets the categories, including home health care needs of patients include ACA 10 essential including benefit categories Parts A, B and D benefits; and includes health benefits - institutional and community ACA 10 and community - based covers abortions and all long - term services and other reproductive essential health benefits term services and - based long supports, dental, hearing, Hyde limitations supports (LTSS), dental, services . State laws prohibiting v hearing, vision, ision, comprehensive do not apply and state qualified health plans from laws restricting coverage comprehensive reproductive services (Hyde covering abortion are limits repealed), EPSDT, and reproductive services of abortion and preempted for the public transportation to receive (Hyde limits repealed), reproductive health health insur ance option health care services for services under QHPs and EPSDT, and transportation Medicare Part E are people with low incomes and to health services for Any provision of law individuals with disabilities people with disabilities preempted restricting use of Federal income individuals and low - funds with respect to any Secretary reviews benefits at reproductive health service - Institutional long least annually and makes term shall not apply to public services and supports recommendations to health insurance option Congress regarding (LTSS) covered under improvements Medicaid Secretary makes national Secretary make s national coverage determinations for coverage determinations for experimental items, experimental items, services services and drugs and drugs Side Introduced in the 116th Congress : ll and Public Plan Proposals a - for - Medicare Side Comparison of - by - 2

3 Side Side Comparison of Medicare - for - a ll and Public Plan Proposals - - by th Congress Introduced in the 11 6 Single Payer Public Plan Option Medicare Buy - In for Older Adults Medicaid Buy - In a ll) (Medicare - (Federal/Medicare) for - Bennet and Sanders Jayapal Cardin Mer k ley/Richmond Luján Schatz/ Schakowsky/Whitehouse Stabenow Higgins Kaine/Delgado Items and services not Items and services not provided in accordance with provided in accordance with practice guidelines will be practice guidelines will be deemed to be in deemed to be in accordance er accordance if the health if the health care provid demonstrates appropriate care provider exercised professional judgement, propriate professional ap n to deviate from provided in the best interest discretio the guideline of patients, and consistent with patient wishes States may provide additional benefits at state States may provide additional expense benefits at state expense No cost sharing, except Cost sharing same as Cost sharing set by state No cost sharing Cost sharing follows ACA Public plan offered at Gold Cost sharing follows ACA Cost sharing same as under Cost sharing follows ACA Cost S haring marketplace rules to be actuarially fair Secretary has authority to marketplace rules marketpl under current Medicare current level Medicare for ace rules require cost sharing for covered benefits for covered benefits Annual out of - Annual out pocket limit - of - Annual out of pocket limit - of pocket limit - of - Annual out - Annual out pocket limit - pocket limit - - prescription drugs and - applies ($7,900 in 2019) applies ($7,900 in 2019) - of - No annual limit on out - applies ($7,900 in 2019) of No annual limit on out cannot exceed the ACA applies ($7,900 in 2019) , not biologics to exceed limit ($7, ) 900 pocket cost sharing, unless in 201 aring, pocket cost sh 9 $200/year, indexed for Sets benchmark plan at Public plan offered at the Public health insurance Medicare - X offered at ACA unless enrolled in enrolled in Medicare inflation; cost sharing must Silver option shall be offered at levels, Silver and Gold levels; Gold level for all and Gold Medicare Advantage Advantage plan, or if ACA encourage use of generic Secretary may offer at Bronze Silver and Gold , Bronze marketplace participants may also be offered at sharing subsidies apply - cost - plan, or if ACA cost drugs, cannot apply to ; Bronze and Platinum level level levels may also be offered at sharing subsidies apply (see below) preventive drugs, and m level Platinu (see below) cannot be imposed on Secretary may offer up to Individuals who voluntarily individuals with household two Medicare - X options at Individuals who enroll in Medigap would income at or below 200% each metal level voluntarily enroll in have limited exposure to FPL. Secretary may - out Medigap would have of - pocket costs for exclude the cost of brand covered benefits limited exposure to out - drugs from calculating the - pocket costs for of pocket limit, if a - of out - covered benefits generic ver sion of that brand is available PREMIUMS AND PREMIUM SUBSIDIES/TAX CREDITS Premium set to cover 100% Single, national premium Premiums for Medicare - X Premiums for public plan set health e Premium for public Premiums for Medicar No premiums No premiums Premiums set by states to Premiums Part E would be set be actuarially fair set by Secretary to cover by Secretary to cover 100% of benefits and insurance option set by set at average annual per by the capita amount for administrative costs for the to cover 100% Secretary to cover 100% of Secretary of benefits and administrative 100% of benefits and States may vary administrative costs buy costs plus a contingency in population, based on - of benefits and benefits and benefits and administrative premiums by factors average per capita costs for costs plus contingency administrative costs admini strative costs for margin Premiums can vary only by allowed by ACA rating margin expenses under Parts A, B in population, - the buy Premiums for public plan Premiums can vary only by factors allowed by ACA rules (age, up to 3:1, based on average per and D shall be geographic ally Premium can vary only by rati ng rules (age up to 3:1, geography, family size, factors allowed by ACA capita costs for expenses ily adjusted and can vary only by No adjustment for fam tobacco use) family size, tobacco use) factors allowed by ACA rating rating rules (age up to 3:1, under Parts A, B and D , status or tobacco use rules (age up to 3:1 Single risk pool factors allowed by ACA rating geography, family size , Annual premiums limited rules (age up to 3:1, requirement is specified geography, family size, and No adjustment for age, and tobacco use) and to no more than 9.5% of Premium for buy - in plan geography, geography, family status whether plan is offered in tobacco use) family size, shall be adjusted for household income the individual, small group, tobacco use) or tobacco use geography. Secretary may or large group market in enrollees who adjust premiums by age Public plan exempt from state Buy - select Medicare premium taxes Extends ACA rating rules in enrollees who select - Buy Advantage or Part D to large group market Medicare Advantage or Part prescription drug plans Introduced in the 116th Congress 3 Side : ll and Public Plan Proposals a - for - Medicare Side Comparison of - by -

4 a Side Side Comparison of Medicare - for - - ll and Public Plan Proposals by - th Introduced in the 11 Congress 6 Single Payer Public Plan Option In Medicaid Buy for Older Adults - In - Medicare Buy (Federal/Medicare) ll) a - for (Medicare - Sanders Jayapal Cardin Mer k ley/Richmond Bennet and Luján Schakowsky/Whitehouse Stabenow Higgins Schatz/ Kaine/Delgado with premiums above the D prescription drug plans Gives Secretary of HHS authority to deny average would be with premiums above the average would be required unreasonable rate required to pay additional amount to p increases in states where ay additional amount ot state regulators do n take action to correct unreasonable rate increases Extends ACA rate review to grandfathered health plans Not applicable ACA premiu ACA premium subsidies ACA premium subsidies ACA premium subsidies ACA premium subsidies ACA premium subsidies m subsidies premium subsidies ACA Not applicable Applicability of apply to the generally apply apply apply apply apply generally apply to the Premium Subsidies/Tax - in plan Medicare buy in plan - buy Medicare Credits to Public P lan Deems Medicaid buy - in - plan as the second Secretary shall determine Secretary shall determine lowest cost Silver plan in amount of marketplace amount of marketplace - areas where no other subsidies that would subsidies t hat would have have been made on been made on behalf of an Silver plan is offered behalf of an individual individual Amounts will be will be transferred Amounts - to a new Medicare Buy transferred to a new In - Medicare Buy Trust Fund, and used to In Trust provide financial assistance Fund, and used to provide financial that is substantially similar to what enrollees would have assistance that is received in the marketplace s ubstantially similar to what enrollees would have received in the marketplace Secretary shall determine - the applicable second lowest cost Silver plan for - purposes of determining premium tax credit amounts for buy - in individuals. Coverage buy - under the Medicare in shall not be taken into ilver S account as a marketplace plan in determining the - applicable second - cost Silver plan lowest No provision No provision No provision No provision Expands premium tax credit Not applicable Not applicable Expands premium tax Enhances tax credits for all Changes to ACA - credit eligibility to people eligibility to income 100% marketplace plans by ubsidies Premium S Caps premiums for changing benchmark plan 600% with income above 400% FPL and extends cap - in plan at Medicaid buy from second lowest cost - on tax credit FPL by capping their 9.5% of income for required contribution for 4 Side Introduced in the 116th Congress : ll and Public Plan Proposals a - for - Medicare Side Comparison of - by -

5 Side - Side Comparison of Medicare - for - a ll and Public Plan Proposals by - th Congress 6 Introduced in the 11 Single Payer Public Plan Option Medicare - In for Older Adults Buy Medicaid Buy - In (Medicare - (Federal/Medicare) for - a ll) Jayapal Sanders Cardin Mer k ley/Richmond Bennet and Luján Schakowsky/Whitehouse Stabenow Higgins Schatz/ Kaine/Delgado reconciliation/repayment to all Silver to second - lowest individuals who are not to the benchmark plan income 13% of ; eligible for ACA premium income levels cost Gold plan also enhances tax credit tax credits Expands premium tax amount for people at lower y to income credit eligibilit income levels - 100% 600% FPL and Caps tax credit increases income threshold for cap on tax reconciliation/repayment credit reconciliation/ amount for people with repayment to 600% FPL income above 400% FPL to no more than $5,000 COST - S HARING (CSR) SUBSIDIES REDUCTION CSR sub to CSR subsidies apply CSR subsidies apply to CSR subsidies generally to CSR subsidies apply to sidies generally CSR subsidies apply CSR subsidies apply to Not applicable Not applicable Applicability of CSR - - Silver - level plan options in plan Gold - level plan options Silver - level plan options in Medicaid buy Silver - level plan options apply to Medicare buy - in apply to Medicare buy ublic Subsidies to P plan plan P lan - Buy in plan is considered - level Secretary shall determine Secretary shall determine to be a Silver amount of marketplace marketplace health plan ount of marketplace am subsidies that would subsidies that would have in determining an individual’s eligibility for - been provided to each buy have been provided to CSR subsidies each buy in enrollee (see applicability in enrollee (see - applicability of APTC of APTC subsidies, above) subsidies, above) and and provide financial assistance that is provide financial substantia lly similar to what assistance that is enrollees would have substantially similar to received in the marketplace what enrollees would have received in the marketplace Not applicable Not applicable No provision Enhances CSR subsidies for No provision No provision provision No Effective 1/1/2020, No provision Changes to ACA C SR enhances CSR subsidies all marketplace participants Subsidies for marketplace by increasing actuarial values for CSR Silver plans participants by applying as follows: level plans them to Gold - and changes actuarial  200% FPL: 95% AV - 100 values for CSR Gold plans 300% FPL: 90% AV - 200  as follows: - 300  400% FPL: 85% AV Above 400% FPL: AV   100 - 133% FPL: 94% AV remains at 70% 150% FPL: 92% AV  133 - 200% FPL: 90% AV  150 - (Current law sets AV for - 300% FPL: 85% AV  200 CSR Silver plan at 94% for  Above 300% FPL: AV 150% FPL; 87% - income 100 remains at 80% 200% FPL, for income 150 - (Current law sets AV for 250% - 73% for income 200 CSR Silver plan at 94% for ) FPL, and 70% for all others 150% FPL; - income 100 200% 87% for income 150 - FPL, 73% for income 200 - by Side Comparison of Medicare - for - a ll and Public Plan Proposals : Introduced in the 116th Congress - 5 - Side

6 Side Side Comparison of Medicare - for - a ll and Public Plan Proposals - - by th Congress Introduced in the 11 6 Single Payer Public Plan Option Medicare Buy - In for Older Adults Medicaid Buy - In a ll) (Medicare - (Federal/Medicare) for - Sanders Schakowsky/Whitehouse Bennet and ley/Richmond Luján Schatz/ Higgins Stabenow k Jayapal Cardin Mer Kaine/Delgado 250% FPL, and 70% for all others) PROVIDER PARTICIPATION, PROVIDER PAYMENTS , A ND BALANCE BILLING licensed and Medicare participating - Medicare and Medicaid All Medicare and Medicaid state - licensed and Medicare participating Medicare participating Medicaid providers, Medicare participating All state Provider Participation participating providers also partic providers and facilities also certified providers who meet providers and facilities including Medicaid certified providers who s and facilities also provider providers and facilities ipating providers and - participate in public plan managed care participate in the buy participate in the public health applicable provider standards meet applicable provider shall also participate in facilities also participate in in plan also participate in the organizations (MCOs) - and file a participation buy insurance option; Secretary Medicare Part E X; Secretary - Medicare standards and file a , unless they opt out under a in plan also participate in the shall establish a process to participation agreement can shall establish a process to agreement can participate process established by the Secretary shall allow in - buy participate etary Secr allow health care providers to allow health care providers Federal standards that apply additional providers to opt out of the public plan to opt out of the public under the current Medicare participate in Medicare Federal standards that Secretary shall establish plan; however, once fully apply under the current process for allowing other program and those pertaining Secretary shall develop Part E implemented, a provider process to allow additional to non - Medicare program and providers to participate; discrimination, quality, who opts out of public plan - those pertaining to non , and requirements and ethics providers must be licensed or providers to participate in would not be allowed to certified under state quality, to submit data and other public health insurance option discrimination and law participate in Medicare information also apply an d requirements to submit Secretary shall develop data and other information Entities or providers that do process to allow additional also apply not provide items and providers to participate in Private contracting between services directly to individuals - X Medicare institutions or individual may not participate for covered providers Private contracting between services is permitted, participating providers and subject to specified individuals only permitted f or requirements and non - covered services or for limitations ineligible individuals States may set additional Private contracting between standards participating institutions non - or individual providers for covered services is permitted, subject to specified requirements and limitations States may set additional standar ds the extent proposal To Not specified To the extent proposal Balance billing is prohibited Balance billing is prohibited Not specified Medicare balance billing limits Not specified Medicare balance billing Balance Billing apply limits apply to Medicare adopts same protections adopts same protections as To the extent proposal To the extent proposal To the extent proposal adopts as are applied to current are applied to current Part E adopts Medicare payment adopts Medicaid payment Medicare payment rules, Medicare program with Medicare program with rules, Medicare limits on billing rules, balance Medicare limits on balance respect to benefits and respect to benefits and balance billing would apply would be prohibited billing would apply payment rules, Medicare payment rules, Medicare limits on balance billing limits on balance billing would apply would apply Secretary 2022, Medicare payment rates Medicare payment rates - For years 2020 Payments established All states required to pay establishes Secretary negotiates provider a Medicare payment rates The Secretary establishes Provider Payment - used in the buy in plan - primary care providers at Medicare payment rates for used in the buy in plan payment ra fee schedule in a manner X through global budget - used in Medicare payment rates used in tes for the public Rates process and negotiations least Medicare rates plan. If the Secretary is consistent with the Medicare Part E that would services covered under Parts for Secretary has authority to unable to reach a negotiated processes for determining not be l ower than the rates increase provider payment 6 Side : ll and Public Plan Proposals a - for - Medicare Side Comparison of - by - Introduced in the 116th Congress

7 - Side - Side Comparison of Medicare - for by a ll and Public Plan Proposals - th 6 Introduced in the 11 Congress Single Payer Public Plan Option Buy - Medicaid Buy for Older Adults Medicare In - In ll) a - for - (Medicare (Federal/Medicare) Sanders Jayapal Cardin k ley/Richmond Bennet and Luján Schatz/ Schakowsky/Whitehouse Stabenow Higgins Mer Kaine/Delgado in plan and the - the buy agreement with health care rates up to 25% for items paid under the current payments made under A and B will be used in public Hospitals/facilities paid current Medicaid program providers, Medicare payment Medicare and establishes a health insurance option Medicare program and not and services provided in quarterly lump sum to cover new process for updating operating expenses under a rural areas rates will be u higher, in aggregate, than sed. Medicare Medicaid rate used for Secreta ry may make other rates paid by fees global budget; amount of rates modified to other providers Secretary shall establish adjustments for new payments determined by insurers offering health accommodate payment for providers/services not reimbursement rates for annual negotiation between pediatric and other services insurance through the services n ot otherwise currently in Medicare, and for not otherwise covered under marketplaces; rates institutions and regional office graduate medic al education covered under Medicare o account director, taking int established at level Medicare Parts A and B share fee for service and disproportionate multiple factors, including necessary to maintain hospital (DSH) payments network adequacy historical expenditures , data Secretary may utilize on costs, changes in volume, Starting in 2023 and innovative payment Use of altern ative payment other factors methods, such as value subsequently, Secretary shall - models is encouraged set payment rates, and can - based payments, patient Physicians/clinicians in process to adjust establish centered medical home service general paid fee - for - arrangements, that rates to ensure payment based on a fee schedule improve quality and reduce accuracy, efficiency, access determined by the Secretary, to care, and affordability; costs taking into account current subject to limit that overall fee schedule, Medicare payments should not exceed expertise of providers, what would have been spent information from national under current law payments data/tracking program and subject to annual review Secretary may use innovative mechanisms to payment determine payments for services covered under the public health insurance option to promote care that is integrated, efficient and affordable among other outcomes A ND OTHER COST CONTAINMENT MEASURES PRESCRIPTION DRUG PRICES Secretary negotiates drug No provision negotiate shall Secretary Secretary is authorized to Secretary negotiates drug Secretary negotiates drug is authorized to Secretary Secretary is authorized to Secretary negotiates prices Prescription Drug prices for Medicare negotiate drug prices for the drug prices for Medicare and with drug manufacturers fo prices for the public plan prices annually, and negotiate drug prices for - X and negotiate drug prices, by r Prices and Part E - striking the “non Medicare program and the - in plan current Medicare program taking into Medicare establishes a formulary for covered drugs the buy the Medicare for All public health insurance comparative clinical interference clause” in account current Medicare program, Part D sponsors would be program that discourages option, but is prohibited from effectiveness, budgetary with fall back to the lesser Title XVIII, for Medicare permitted to obta in ineffective, of prices paid by the VA impact, number of similar or the use of or and the buy - in plan requiring a particular discounts or price reductions formulary or price structure alternative treatments, total federal supply schedule if dangerous or excessively below the rate negotiated by negotiations are not costly medications when revenue from global sales for the Secretary better alternatives are such drug, and associated an successful in obtaining Medicare beneficiaries would  available and promotes use investment in research and appropriate price as be guaranteed at least three No authorization for the determined by the development of generic drugs. Off - Part D plans, including a Secretary to establish a Secretary formulary drugs covered national prescription drug formulary, and no change in If negotiations are not subject to rules established plan sponsored by the current law provisions that , the Secretary The Secretary determines successful by Secretary Secretary and at least two assure appropriate and which Part D drugs are shall authorize the use of any qualifying plans (one of which adequate access to drugs patents, data or exclusivity appropriate for negotiation must be a PD P) offered by at based on a number of granted by the federal least two different entities. government for the factors, such as spending Establishes a base premium manufacture of the drug, on a per beneficiary basis, Medicare - by - for - a ll and Public Plan Proposals : Introduced in the 116th Congress Side Comparison of 7 - Side

8 Side - Side Comparison of Medicare - for - a ll and Public Plan Proposals by - th 6 Congress Introduced in the 11 Single Payer Public Plan Option for Older Adults - Medicaid Buy In In - Buy Medicare (Federal/Medicare) ll) a - for - (Medicare Bennet and Luján Schatz/ ley/Richmond Higgins Stabenow Schakowsky/Whitehouse Sanders Jayapal Cardin Mer k Kaine/Delgado of $37 in 2021 for the national providing reasonable total spending on a given plan, indexed to growth in per compensation to drug, initial launch price capita Medicare drug manufacturer holding the and other criteria spending license Payments from qualified  Secretary is authorized to retiree health plans would p rocure drugs directly - count toward the true out - of pocke t limit (TrOOP) on During an interim period, the Medicare enrollee drug Program shall not pay more nforming , with co spending than the average of prices subsidy payments to from the manufacturer to any sponsors of qualified health wholesaler, retailer, provider, plans and others, including government entities in the 10  Requires drug manufacturers OECD countries that meet to provide rebates for drugs capita income GDP and per dispensed to Medicare threshold levels beneficiaries also covered ble) under Medicaid (dual eligi Drug manufacturers are and individuals eligible for prohibited from engaging in Part D low - income subsidies. competitive behaviors - anti Rebate amounts would be excluded from Medicaid best price determination and AMP determination. Changes definition of covered Part D drug to include only those drugs from a manufacturer that en ters into a rebate agreement vision No pro No provision No provision Permits states to establish No provision ly Secretary annual Allows for alternative  No provision  Secretary annually  Other Cost advisory councils to make establishes a global budget establishes a global budget payment models to Containment recommendations to for all health expenditures, achieve savings and/or all health expenditures for , Secretary on various policies consisting of 8 components: consisting of 7 components promote quality to promote cost containment, program operations; capital including operations,  Secretary shall implement native payment including alter expenditures; capital capital expenditures, quality delivery system and expenditures for based models and value - assessment activities, payment reforms found to insurance rural/underserved areas; health professional reduce costs on as large a quality assessment activities; education, administrative geographic scale as health professions education; costs, innovation, and practical and economical reserve administrative costs ; prevention and public fund for disasters, epidemics; health activities; Secretary Secretary shall establish  and prevention/public health shall also establish a processes and, when activities reserve fund for epidemics, appropriate, collaborate pandemics, natural with other agencies to disasters, and other health integrate medical care with emergencies other social services and income assistance, and to Allows for continuation of se telehealth, if it will u payment and delivery reduce spending without system reforms hurting quality or improve - ll and Public Plan Proposals : Introduced in the 116th Congress for a 8 - Medicare Side Comparison of - by - Side

9 Side Side Comparison of Medicare - for - a ll and Public Plan Proposals - - by th Congress Introduced in the 11 6 Single Payer Public Plan Option Medicare Buy - In for Older Adults Medicaid Buy - In a - (Federal/Medicare) for - ll) (Medicare Stabenow Schakowsky/Whitehouse Bennet and ley/Richmond k Mer Luján Schatz/ Higgins Sanders Jayapal Cardin Kaine/Delgado quality without raising spending  Authorizes funding for new grant program to permit experimentation with accountable communities for health models that integrate social needs in he delivery of health care t CONSUMER ASSISTANCE sion No provi No provision thorizes such sums as Au Appropriates $500 million Establishes Office of No provision Appropriates $500 million Establishes Office of Secretary shall establish  Consumer Assistance to address Beneficiary Ombudsman to necessary per calendar year 2019 Beneficiary Ombudsman to per calendar year 2019 O ffice of the Ombudsman for receive complaints, capacity limitations of through 2021 for enrollment receive complaints, through 2021 for the public health insurance in eligible grievances, provide help grievances, provide help filing navigator programs r buy assistance fo - enrollment assistance for option. Duties simi lar to buy - in eligible individuals. individuals appeals, submit filing appeals, submit Office of Medicare Requires employers that recommendations on recommendations on Grants can also be used Ombudsman do not offer health benefits Grants can also be used to improvements to improvements to to help individuals apply help individuals apply for tax meeting ACA standards for administration of program for tax credits and CSR administration of program cre affordability and minimum dits and CSR through the ce through the marketpla marketplace value to refer employees Buy - in enrollees also to navigators in enrollees also have - Buy have access to the access to the Medicare Medicare Beneficiary Beneficiary Ombudsman Ombudsman T O OTHER COVERAGE (MEDICARE, MEDIGAP, MARKETPLACE CHANGES MEDICAID A ND V A / IHS ) , No provision Secretary shall negotiate Authorizes Secretary to No provision Secretary negotiates drug Replaces current Medicare Medicare   Authorizes Secretary to Authorizes Secretary to Replaces current  Changes to Current for Medicare, drug prices prices for Medicare Part D negotiate drug prices for am. No benefits progr negotiate drug prices for program negotiate drug prices for Medicare P rogram Establishes a separate with no authorization to Medicare program ; if negotiations furnished under current Medicare Medicare account in Treasury for public Before full implementation are not successful in establish a formulary. Part D Medicare program two years in plan - plan option The Medicare buy Medicare X will not affect - of Universal Medicare, adds  Establishes a national ermitted to obtain plans p obtaining an appropriate after the date of enactment, will not affect benefits sharing benefits under the current annual OOP cost - prescription drug plan under price, The Secretary shall discounts below negotiated with provisions for under the current limit to Medicare Parts A Medicare program, or Medicare Part D establish a price that is the continuation of benefits for price Medicare program or and B ($1,500), eliminates impact the Medicare trust persons receiving inpatient lessor of the price paid by Applies Medicaid drug  negatively affect the Nothing in this proposal funds Parts A and B deductibles, the VA or under the and other services rebates for dual eligible and would adversely affect Federal HI and SMI Trust of - and reduces Part D out - Federal supp ly schedule. income Medicare Part D low - eligibility or benefits for the liminates 24 E - month waiting Funds pocket threshold and recipients subsidy current Medicare program, period for Medicare coverage Adds annual OOP limit on eliminates cost sharing or the Medicare HI Trust cost sharing for benefits ividuals with disabilities for ind under Me dicare Part D  under Parts A (see below) and B at Fund. The Secretary may above the threshold. Also - adjust premiums for the buy $6,700 in 2021 and adds vision, hearing aids indexed thereafter in population so th at and exams, and dental expenditures under benefits to Medicare Part B. In calculating the OOP Medicare do not rise due to month Eliminates the 24 - limit, the Secretary will in option the new buy - waiting period for Medicare consider expenses to be for people receiving SSDI A new voluntary public incurred by the individual payments without regard to whether Medigap option is the established for beneficiaries individual or another Prohibits Medigap insurers in current Medicare program person, a state program, from denying a policy, o r by Side Comparison of Medicare - 9 for - a ll and Public Plan Proposals : Introduced in the 116th Congress - Side -

10 Side - Side Comparison of Medicare - for - a ll and Public Plan Proposals by - th 6 Congress Introduced in the 11 Single Payer Public Plan Option In - Medicaid Buy for Older Adults In - Medicare Buy (Federal/Medicare) ll) a - for - (Medicare Luján Schatz/ Sanders Higgins Jayapal Cardin Mer k ley/Richmond Bennet and Stabenow Schakowsky/Whitehouse Kaine/Delgado in - (and new Medicare buy employer, Medigap policy, discriminating in the pricing of a policy to an individual program), to be or a third party payer has administered by the based on pre - existing paid the expenses Secretary conditions o (see Changes t Medigap and Supplemental During transition, premiums Insurance) paid for Medicare buy - in (see Transitional Coverage Program) would be deposited into the Medicare Hospital Insurance and Medical Supplementary Insurance Trust Funds. The Secretary would implement these provisions in a manner to have no effect on benefits for beneficiaries covered under the current Medicare program, and no negative effect on the Trust Funds pplicable Not a No provision No provision No restrictions on the sale of No restrictions on the sale No provision ndividuals can buy Eligible i ligible individuals can E Not applicable Changes to Medigap Medigap on a guaranteed of health insurance for any buy Medigap on a - health insurance for any non and Supplemental covered benefits guaranteed issue basis issue basis each time they covered benefits non - Insurance each time they enroll in enroll in the Medicare buy in - Before full implementation plan in plan - the Medicare buy of Universal Medicare, prohibits Medigap issuers A new public Medigap option is established for from denying policies, or Medicare buy - discriminating in the pricing in enrollees of policies, to individuals and for current Medicare beneficiaries covered by Medicare due to existing conditions - pre Current Medicare beneficiaries would have a one - time initial enrollment period; individuals who subsequently become eligible for Medicare would have an individual enrollment period during their first 6 months of Medicare eligibility Enrollment in the public Medigap plan would be permitted at other times, subject to a late enrollment premium penalty . Penalty does not apply to p eriods of time cove red under a retiree health benefit plan, a Side 10 - by Introduced in the 116th Congress : ll and Public Plan Proposals a - for - Medicare - Side Comparison of

11 Side - Side Comparison of Medicare - for - a ll and Public Plan Proposals by - th 6 Congress Introduced in the 11 Single Payer Public Plan Option - - Medicaid Buy for Older Adults In In Buy Medicare (Federal/Medicare) ll) a - for - (Medicare Luján Schatz/ Higgins Stabenow Sanders Jayapal Cardin Mer k ley/Richmond Bennet and Schakowsky/Whitehouse Kaine/Delgado Medicare Advantage plan, or a PACE program Benefits shall not be medically underwritten or existing - subject to pre condition exclusion period Premiums for the public Medigap option will be set to cover costs, an d community rated (not adjusted by age, geography or any other factor, other than a late enrollment penalty, if applicable) provision No No provision Expands premium Authorizes Secretary to sharing - Enhances cost subsidy No provision private insurance No provision Replaces  Replaces private insurance Other Changes to eligibility to 600% FPL establish a reinsurance subsidies for marketplace (marketplace, employer, (marketplace, employer, Marketplace ACA “level playing field” plans mechanism to pool costs FEHBP, TRICARE) FEHB, TRICARE) Plans/Private P lans requirement applies to public Enhances premium tax of highest cost patients on , ies Insurers may not sell polic plan (must follow market rules - Establishes reinsurance credits by tying to Gold Insurers may not sell  a nationwide basis level benchmark plan and employers may not ividual program for entire ind applicable to other qualified policies, and employers Authorizes funding of $10 health plans) market provide benefits that may not provide benefits Eliminates failsafe billion per year for each of duplicate covered benefits that duplicate covered The temporary ACA risk provisions of ACA that fiscal years 2021, 2022, benefits require reduction of corridor program is For first 5 years, 1% of global and 2023 premium tax credits if reestablished for calendar budget amount set aside to For first 5 years, up to 1% - spending exceeds a offset economic dislocation of 2021 years 2019 of global budget amount set threshold rs in private health worke aside to offset economic insurance system dislocation of workers in - sharing Enhances cost private health insurance subsidies for other system marketplace plans Applies ACA rating rules to large group market Appropriates $30 billion to blish and administer esta reinsurance and affordability fund for the individual market for 3 fiscal years (2020 - 2022) Fund enables states to provide reinsurance to insurers to reduce individual market premiums or to provide other assistance to individuals in t he - marketplace to reduce out of - pocket costs Introduced in the 116th Congress : ll and Public Plan Proposals a - - Medicare Side Comparison of - 11 Side by - for

12 a Side Side Comparison of Medicare - for - - ll and Public Plan Proposals by - th Introduced in the 11 Congress 6 Single Payer Public Plan Option Medicaid Buy for Older Adults In In - Medicare - Buy (Federal/Medicare) ll) a - for (Medicare - Jayapal Sanders Cardin Mer k ley/Richmond Bennet and Luján Schatz/ Schakowsky/Whitehouse Stabenow Higgins Kaine/Delgado No provision Replaces Medicaid o provision No provision No provision No provision Replaces Medicaid for most No provision New state option to offer N Changes to Medicaid in Medicaid buy - services. Retains Medicaid Bill specifies this will not No state maintenance of coverage institutional for affect benefits or eligibility of Requires states to pay at effort specified LTSS, and any other individuals otherwise entitled least Medicare rates to benefits furnished by a primary care providers to Medicaid state Medicaid program as of January 1, 2019 that are Requires the Universal not covered by - development of state Medicare, with a state level metrics of access to maintenance of effort and satisfaction with requirement for these Medicaid providers and services appropriates $200 million to support state Increases the resource limit implementation of the ty for for eligibili metrics Supplemental Security Income (SSI), which Extends 100% federal expands eligibility for full funds for three matching Medicaid during the years to any state newly transition period as well as adopting the Medicaid eligibility for Medicaid expansion institutional LTSS under Universal Medicare Adds comprehensive reproductive health services, including abortion services, as a mandatory Medicaid benefit No provision No provision No provision No provision No provision No provision No provision Retains VA and the IHS Retains VA and the IHS Changes to VA and Indian Health Service COVERAGE DURING TRANSITION Not applicable licable Not app No provision No provision Not applicable Not applicable For the year beginning one Not applicable During implementation  overage C Transitional year after the date of phase in, establishes rogram P enactment, a transitional several transitional - Medicare buy in plan will be programs: offered through the  19 have Children under marketplaces option of enrolling in Covered benefits will be the Universal Medicare same benefits available beginning January 1 of year all; cost - for - under Medicare following date of enactment benefits sharing for covered or can remain in current will be set to achieve an coverage actuarial value of 90% Option to buy into Medicare (similar to P latinum (or enroll in Medicare marketplace plan) Advantage) established for Secretary will determine a certain adults not otherwise premium for the transitional eligible for Medicare on a program; can vary by age, phased in basis (age 55 Introduced in the 116th Congress 12 : ll and Public Plan Proposals a - for - Medicare Side Comparison of - by - Side

13 ll and Public Plan Proposals a - by - Side Comparison of Medicare - for - Side th Introduced in the 11 6 Congress Single Payer Public Plan Option Buy Medicare In - Medicaid Buy for Older Adults In - - for - a ll) (Federal/Medicare) (Medicare ley/Richmond Bennet and Cardin Schakowsky/Whitehouse Stabenow k Higgins Schatz/ Luján Sanders Jayapal Mer Kaine/Delgado and older, 1 year after date family status, and toba cco of enactment; age 45, 2 use but not geographically years after date of During transition, enactment; age 35, 3 years marketplace premium and after date of enactment) cost sharing subsidies available for transitional buy Premium for Medicare  - Medicare buy in plan; - in plan established to cover premium tax credits for costs of benefits and transitional buy - in plan would administrative costs for be m ore generous than Medicare Parts A, B and D in the applied otherwise benefits; marketplace marketplace and available to subsidies can be applied. individuals with income Individuals would not be above 400% FPL and to - eligible for Medicare cost those with income below sharing assistance provided 100% FPL in states that have under Medicaid not expanded Medicaid  Also during transition, a public plan option (the Medicare Transition Plan) will be established and offered in marketplace. National premium established to cover costs; essential health benefits covered with platinum plan level cost sharing. e Enhanced marketplac premium and cost sharing subsidies apply to the Medicare Transition plan, including for poor individuals in states that do not expand Medicaid. Current Medicare providers and payment rates will be used by Medicare Transition plan During transitional peri od,  Secretary shall ensure that individuals enrolled in private coverage are protected from disruptions in their care NANCING I F Premium for public plan set to Appropriates current federal Premium for the Premiums for public health Appropriates to new Premium for Medicare Premium for the Medicare - X Premiums for Medicare Program costs partially Financing cover benefit and in plan set - Medicare buy in plan set to cover buy - health spending offsets set to cover benefit and financed through Universal Medicare Trust insurance option set to cover Part E plan set to cover (e.g., for marketplace to cover benefit and administrative costs administrative costs Fund current federal health premiums benefit and administrative spending offsets (e.g., for costs, and deposited into a administrative costs, and subsidies, tax exclusion for ll and Public Plan Proposals 13 Introduced in the 116th Congress : a - for - Medicare Side Comparison of Side - by -

14 - - ll and Public Plan Proposals a for Side - by - Side Comparison of Medicare th 6 Congress Introduced in the 11 Public Plan Option Single Payer Medicaid Buy In for Older Adults - - Buy In Medicare - a ll) (Medicare - (Federal/Medicare) for Bennet and Schakowsky/Whitehouse Stabenow Higgins Schatz/ Luján Sanders Jayapal Cardin Mer k ley/Richmond Kaine/Delgado benefit and administrative - The public option is self new, separate, Medicare sponsored health Appropriates $1 billion in - employer Medicare, Medicaid, FEHB, benefit and administrative he deposited into t Costs for the Medicaid buy TRICARE, ACA marketplace in not covered by initial claims reserves and financed and cannot contract Medicare Buy - In Trust - coverage, Medicaid costs Buy - costs In Trust Fund for the premiums would be Fund with outside entities to sole purpose of financing matching payments for authorizes such sums as ubsidies, other federal s Appropriates $2 billion in Appropriates $2 billion in acute care services and financed with federal - in efits for the buy ben health programs), with ish a transfer insurance risk necessary to establ - up funds and such up costs, to be repaid start start - No provision for other amounts indexed to inflation population Medicare) to the Universal matching payments in the Data and Technology sums necessary to financing sources over 10 years Authorizes such sums as in future years Fund same way as the current Medicare Trust Fund establish initial reserves No provision for other necessary to pay for startup Medicaid program No provision for other The public option is self - Separate White Paper financing sources No provision for other day claims - costs and initial 90 financing sources Hyde restrictions do not Any excess revenues repaid reserve; startup funds financing sources describes other financing financed and cannot apply to this funding contract with outside would be shared with options to the Treasury over 10 years entities to transfer federal government at No provision for other Authorizes such sums as 50% matching rate insurance risk, except in financing sources necessary to pay for case of certain innovative Administrative costs for contracting costs for third payment models party to handle administrative in - the Medicaid buy No provision for other functions receive 90% federal matching payments financing sources No provision for other financing sources Side 14 Introduced in the 116th Congress : ll and Public Plan Proposals a - for - Medicare Side Comparison of - by -

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