Medicare for All Act of 2019 Section by Section Summary

Transcript

1 Last updated /19 2/25 by - Section Medicare for All Act of 2019 Section - — TITLE I ; UNIVERSAL PROGRAM ESTABLISHMENT OF THE MEDICARE FOR ALL ENTITLEMENT; ENROLLMENT Universal coverage . Establishes the Medicare for All Program entitl ing all United States residents to benefits  for . health care services to determine criteria of HHS Secretary residen cy .  Authorizes the Freedom of choice. ny individual entitled to benefits to obtain services from any provider qualified to  Allows a participate under the Act. Non - discrimination. Program discrimination by providers or entities administering the s  on the basi P roh ibit s of race, color, national origin, age, disability, marital status, status, primary citizenship language use, genetic conditions, previous or existing medical conditions, re ligion, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy or related medical conditions (including termination of pregnancy).  Requires the HHS Secretary to establish a process for adjudicating claims of discrimination.  Establishes a private right of action to enforce the prohibition on discrimination. Enrollment. Requires t he Secretary provide a mechanism for automatic enrollment at birth, time of  to immigration into the US, or acquisition of qualified resident statu and to issue Medicare s for All Program cards. Effective date of benefits.  Establishes a two - year transition period for the Medicare for All Program and makes benefits available to all eligible individuals two years after the date of enactment. and 55 or older are eligible for benefits one year after Provide s that individuals under 19  the date of enactment. Prohibition against duplicating coverage. 10 1 of

2 2/25 Last updated /19 Prohibits the sale of health insurance coverage that duplicates the benefits available  . Program under the Prohibits employers from provid ing  benefits that duplicate the benefits under the Program . Medicare for All Allows  the sale of insurance and employer - sponsored benefits that provide supplemental coverage . TITLE II — COMPREHENSIVE BENEFITS, INCLUDING PR EVENTIVE BENEFITS AND BENEFITS FOR LONG - TERM CARE Comprehensive benefits.  Program benefits where such items or services are Authorizes payment to providers for their s determined by medically necessary or appropriate for the individual treating a or other licensed health care provider with the appropriate scope of practice. physician  Lists covered b enefits includ ing : day  Hospital services, including inpatient and outpatient hospital care, 24 - hour - a - emergency services and inpatient prescription drugs.  Ambu latory patient services.  Primary and preventive services, including chronic disease management. biological products, including outpatient and Prescription drugs, medical devices  prescription drugs, medical devices, and biological products. d substance abuse treatment services, including inpatient care.  Mental health an  Laboratory and diagnostic services. Comprehensive reproductive, maternity, and newborn care.   Pediatrics.  Dental , audiology, and vision services.  Rehabilitative and habilitative services and de vices.  Dietary and nutritional therapies approved by the Secretary.  Emergency services and transportation.  Early and periodic screening, dia gnostic, and treatment services.  T ransportation to receive health care services for persons with disabilities or l ow - income individuals.  Long - term care services and supports.  Secretary to evaluate benefits and give recommendations to Congress Authorizes the for improvements and adjustments to the benefits package. Requires the Secretary to consult with experts to ide  ntify complementary and integrative medicine practices that are appropriate to include in the benefits package .  Permits States to provide additional benefits and to provide benefits to individuals who may not be eligible for the Medicare for A ll Program . - sharing. No cost  Medicare for - sharing and balance billing for benefits provided through the Prohibits cost Program . All 10 2 of

3 2/25 Last updated /19 Exclusions and limitations. they are Provides that b  unless Program enefits are not available to the individual r appropriate. medically necessary o Authorizes the Secretary to include coverage of experimental items and services and  requires the Secretary to establish an s process . appeal  Allows health care professionals, who by their scope of practice and licensure can ent professional judgment, to override national practice guidelines if exercise independ ’ consistent with the professional s assessment of the individual, in the individual’s best interest, and consistent with the individual’s wishes. Coverage of long - term care services.  E ntitles Program enrollees to long - term services and supports where illness, injury, or age limit their ability to perform one or more activities of daily living or similar need of assistance to perform instrumental activities of daily living. term - term ser vices and supports include: nursing and medical services ,  - Long long rehabilitative and habilitative services , and services to support activities of daily living and instrumental activities of daily living whether provided in an institution, home, or commun ity - based setting .  Requires that such services be provided in the most integrative and least restrictive setting and that they maximize the recipient’s autonomy as well as their civic, social, and economic participation.  Requires that the Program presume that recipients of all ages and disabilities will receive - term services and supports through home and community - long based services unless the individual chooses otherwise. the Secretary develop regulations in consult ation with an advisory  Requires that ommission that includes c - term supports and services, their those who use long representatives and family caregivers ; provider s of such supports and services ; and disability rights , academic, and labor organizations — PROVIDER PARTICIPATION TITLE III Provide r participation and standards; whistleblower protections.  Describes provisions required in the participation agreement between providers and the Program .  Requires disclose to the Secretary any system or index of coding or classifying patient symptoms, dia gnoses, clinical interventions, episodes, or procedures that such provider utilizes for global budget negotiations .  rovider ethics for participating physicians and other health care Establishes a duty of p s and prohibits hospitals and other institu tional providers from limiting the ability provider of such professionals to advocat e for medically necessary and appropriate care.  Prohibits b onuses, incentive payment s , or compensation based on utilization of service s disclose or the financial resul ts of any health care p rovider and requires p roviders to to financial interests or relationships with other providers the Secretary. 10 3 of

4 2/25 Last updated /19 Establishes the process for terminating a participation agreement.  lowe Establishes prot ctions for participating providers and b e r protecti o ns for  whistle individuals that report potential violations of the Act.  Prohibits providers or their board members from serving on the board of or receiving compensation, stock, or other financial investments in any other entity that furnishes items an d services (including pharmaceuticals and medical devices) to the provider. Qualifications for providers.  roviders are qualified to participate in the Program if they have the Establishes that p requisite license from the state in which they practice and m eet minimum provider standards including adequate facilities, safe staffing, and patient access . Use of private contracts.  Prohibits participating providers from entering into private contracts for covered services Program be nefits and establishes penalties for violating th is with individuals eligible for prohibition.  Permits participating providers to enter into private contracts with individuals ineligible for benefits under the Program and with eligible individuals for noncovered services , and establish es conditions for these contracts. private  Establishes conditions under which nonparticipating providers may enter into a contract with individuals eligible for benefits under the . Program  overed services bars the Entering into a private contract with an eligible individual for c provider from participating in the Program for one calendar year. — ADMINISTRATION TITLE IV Administration.  Outlines the duties of the Secretary to includ e develop ing policies, procedures, and guidelines to ensure the timely and a ccessible provision of benefits under the Act. ing and data the provider  Lists the types of information that providers must report includ is required to report to any State or local agency annual financial data. and Requires the Secretary to report on the  to Congress and regular audits by the Program Comptroller General. Consultation.  Requires the Secretary to consult with other federal agencies, Indian tribes, labor organizations representing health care workers, health care experts, etc. in the administ ration of the Act. Regional administration.  Requires the Secretary to establish regional offices and appoint r egional d irectors, incorporating the existing offices of the Centers for Medicare & Medicaid Services (CMS) ic r an where possible . Also requires appoin tment of deputy directors to represent Am e Indian and Alaska Native tribes in each region. 10 4 of

5 2/25 Last updated /19 Details the duties of regional directors includ health care needs  ing performing , changes in provider reimbursement or payment, and s assessment recommending ablishing quality assurance mechanisms in their respective regions. est Beneficiary ombudsman. Establishes a beneficiary ombudsman  receive complaints and grievances and to to provide assistance to individuals entitled to benefits under the Act. Conduct of r elated health program s. s to program related  Requires the Secretary to direct activities of other health - to the health of the people. complement this Act and contribute Subtitle B — Control Over Fraud and Abuse Application of f ederal sanctions to all fraud and abuse under the Medicare for All Program .  Incorporates the fraud and abuse sanctions as well as limitations on referrals that already exist under Medicare or Medicaid. TITLE V — QUALITY ASSESSMENT Quality standards. be and quality measures implemented and  Requires that a ll Program standards the CMS Center for Clinical Standards and Quality in coordination with the evaluated by Agency for Healthcare Research and Quality and other HHS offices.  Center ’s duties to include review ing and eval uat ing Establishes the practice guidelines, and performance measures ; creating methodology quality standards, to monitor and evaluate patterns of practice for appropriate utilization ; develop ing competenc y criteria to qualify independent organizations to conduct quality r eviews at the regional level; and reporting findings to the Secretary . Addressing health care disparities. Requires CMS’s Center for Clinical Standards and Quality  evaluate data collection to methods to ensure accurate reporting of health care disparities on the basis of race, ethnicity, gender, geography, and socioeconomic status and report the results to Congress and the Secretary. implement  Requires the Secretary to effective approaches for data collection . — HEALTH BUDGET; PAYMENTS; COST CONTAI NMENT MEASURES TITLE VI Subtitle A — Budgeting National health budget. the following:  Requires the Secretary to establish a national health budget covering operating , capital expenditures, special projects for rural or medically expenditures 10 5 of

6 Last updated /19 2/25 qual underserved areas, ity assessments, health professional education, administrative costs, and prevention and public health activities. cate funds he Secretary to allo Requires to each regional office to carry out the Program  t in such region. Allocates at least 1 percent of t he budget for the first five years to worker assistance  s for those displaced or affected by the implementation of the Act. Assistance program program s shall include wage replacement, retirement benefits, job training, and education benefits. Requires the S ecretary to establish a reserve fund to cover the costs of treating  s, and for market - shift epidemics, natural disasters, and other health emergencie adjustments necessary due to patient volume. Payments to Providers Subtitle B — Payments to institutional p roviders based on global budgets. Establishes that institutional providers — including hospitals, skilled nursing facilities,  federally qualified health centers, home health agencies, and independent dialysis — be paid facilities dget on a quarterly basis to provide a lump sum global operating bu covered items and services. performance institutional provider  Requires regional directors to review on a quarterly s’ basis and determine whether adjustments to the budget are needed . providers institutional with  Requires regional directors to neg otiate the g lobal budget each fiscal year including: and establishes factors addressed in the negotiations The historical volume of services in the previous 3 - year period and provider  capacity. Actual expenditures most recent Medicare cost report of t based on the  he provider and compared to other providers within the region and to the normative payment rates established under a national comparative rate system.  Projected changes in volume and type of items and services to be f urnished. safe registered  Employee wages, including staffing increases necessary for nurse patient staffing ratios and optimal staffing of physicians and other health - to - care professionals. Education and prevention program s.  And other relevant factors a nd adjustments.   Requires regional directors to review institutional providers’ performance on a quarterly basis and determine whether adjustments to the budget are needed, including for additional funding needed for unanticipated care for individuals with complex medical needs or market - shift adjustments.  Establishes that the operating expenses in the global budget must not include capital expenditures, and that funding from an institution’s global budget cannot be used for capital expenditures. system be established to enable cost comparisons among institutional  Requires that a . providers 10 6 of

7 2/25 Last updated /19 - - service. Payment to individual providers through fee for  Requires that individual providers, including individuals in medical group practices, be fee - for - ser vice basis. paid on a  Requires t he Secretary to establish a national fee schedule that takes into account the prevailing rates under Medicare , provider expertise, and the value of the items and services furnished .  physician consultation review board to review quality, cost effectiveness, Establishes a of se physician and fair reimbursement s . rvices and items delivered by Requires a periodic audit by the Comptroller General.  Ensuring accurate valuation of services under the Medicare physician fee schedule.  Amends the Social Security Act to include a standardized documentation and review process of the relative values of physician services to determine appropriate fee payments . Payment prohibitions; capital expenditures; special projects. for Program from the Medicare for All marketing  Prohibits providers from using payments expenses, increasing profit or revenue, incentive payments or bonuses based on patient utilization, or for political activity. compensation for labor relations consultants,  Requires providers seeking capital expenditure funds to present an application to fund such capital project for review egional d irectors and prohibits comingling of by r operations funding with capital expenditures.  Requires regional d irectors seeking funding for special pro jects for construction, renovation, or staffing of health care facilities in rural, underserved, or shortage areas to present a budget for review to the Secretary. Office of primary health care. Establishes an Office of Primary Health Care, which develop  s and coordinates national goals related to education of health care professionals and expanding the number of primary care practitioners. Payments for prescription drugs and approved devices and equipment. Requires t he Secretary to  pharmaceuticals, medical supplies, and negotiate prices for medically necessary equipment based on factors including comparative clinical and cost effectiveness, budget impact of providing coverage, number of similarly effective drugs, and total revenues from global sales obta ined by the manufacturer for such drug.  Requires the Secretary, in the case of an unsuccessful negotiation at an appropriate price and price period, to authorize the use of any patent, clinical trial data, or other exclusivity with respect to such drug as the Secretary determines appropriate for purposes of manufacturing such drug for sale under the Medicare for All Program .  Prohibits anticompetitive behavior by manufacturers that may interfere with issuance and implementation of a competitive license. UNIVERSAL MEDICARE TRUST FUND — TIT LE VII 10 7 of

8 2/25 Last updated /19 Universal Medicare Trust Fund.  Establishes a Universal Medicare Trust Fund in the Treasury . Requires that, during the first fiscal year benefits are available under the Medicare for All  , amounts equal to those appropriated the preceding year to Medicare, Program . f program Medicaid, and other be deposited in the Fund ederal health Thereafter, f unds s equal to the previous year (adjusted for cost savings resulting from implementation of the Medicare for All Program and for changes in the consumer price index) shall be deposited . related to reproductive health services. on the Fund  Prohibits restrictions TITLE VIII — CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 Prohibition of employee benefits duplicative of benefits under the Medicare for All Program ; coordination in case of workers’ compensation.  Adds new sections to ERISA including a prohibition on employee benefits plans that duplicate payment for items or services that are benefits under t he Medicare for All requirement that workers’ compensation carriers reimburse the Medicare and a Program for All Program for costs of services furnished. Application of continuation coverage requirements under ERISA and certain other g to group health plans. requirements relatin  Amends ERISA ’s continuation of coverage requirements to apply only to plans that do not duplicate payment for items and services that are benefits under the Medicare for All Program . Effective date of title.  The effective date of Title 8 is the date o n which benefits are available under the Medicare for All Program . TITLE IX ADDITIONAL CONFORMING AMENDMENTS — program s. Relationship to existing Federal health  Maintains existing medical benefits or services under the Department of Veteran Affairs and the Indian Health Service.  the Secretary Requires to provide for continuation of benefits for people who are receiving inpatient hospital services and extended care services under Medicare, Medicaid, or the Children’s Health Insurance Program during the transition to the Medicare for All Program . Program .  Continues school related health program s under the Medicare for All Sunset of provisions related to the State Exchanges. 10 8 of

9 2/25 Last updated /19 Sunsets the Federal and State Exchanges years after the enactment of the  two Medicare for All Act of 2019. Sunset of provisions related to pay for performance program s. Sunsets federal  s related to pay for performance payments and value - based program purchasing for medical benefits or services. TITLE X TRANSIT ION — Subtitle A — Medicare for All Transition Over Two Years on and Transitional Buy - In Option Medicare for All transition over two years. and amends Program  Establishes a transition period of two years for the Medicare for All the Social Security Act to entitle individuals age 55 or older, age 18 or younger, or who are currently enrolled in Medicare to enroll and obtain benefits under the Medicare for All Program .  Establishes that enrollment in the Medicare for All Program satisfies the individual manda for health care coverage requirements under the Internal Revenue Code. te  Requires the Secretary to consult with beneficiary representatives, health care providers, employers, and insurance companies during the transition. in plan. - buy Establishment of the Medicare  - in plan during the two - year transition period Establishes a Medicare Transition buy that The will be offered through the Federal and State Exchanges. same benefits will be the benefits available under the Medicare for All Program .  Allows t hos e who are ineligible to enroll in Medicare for All during the two year transition, to enroll in the Medicare Transition buy - in plan. in  Authorizes the CMS Administrator to set premiums for the Medicare Transition buy - plan .  Requires that tax credits, prem ium assistance, and cost - sharing subsidies currently available under the Patient Protection and Affordable Care Act apply to Medicare Transition buy - in enrollees and makes them available to Medicare Transition buy - in - enrollees who live in a Medicaid non ex pansion state. — Transitional Medicare Reforms Subtitle B Eliminating the 24 - month waiting period for Medicare coverage for individuals with disabilities. month waiting period for Medicare coverage for individuals with  Strikes the 24 - disabilities. Ensur ing continuity of care. 10 9 of

10 2/25 Last updated /19  Requires that the Secretary ensure continuity of care during the Medicare for All transition period for individuals enrolled in health insurance plans. health  Prohibits re for All insurers from ending coverage of enrollees during the Medica transition period except for reasons expressly agreed upon under the terms of a plan.  P rotects people with disabilities, complex medical needs, or chronic conditions from disruptions in their care from health g plan or insurers ending coverage or imposin . during the transition period coverage exclusions MISCELLANEOUS — TITLE XI Definitions. Rules of Construction. Permits States and local government to expand benefits or eligibility and to set additional  state provider standards if there is no r eduction of benefits or access and does not limit the professional judgment of providers.  Prohibits States from barring providers of reproductive services from participating in the Program for reasons other than the provider’s ability to provide such serv ices.  Establishes that this shall not be construed to preempt state licensing, practice, or education laws, unless expressly preempted under the Act.  Establishes that no other workplace rights under Federal or State law or collective is diminished or altered by the Act bargaining agreement 10 10 of

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