S. 1506 — Medicare for All Act

This section directs the Secretary of Health and Human Services to develop policies, procedures, guidelines, and regulations for administering the Medicare for All Program, including on eligibility, enrollment, benefits, provider standards and qualifications, funding levels, provider payments, coverage appeals, capital and service delivery planning, health professional education funding, and State regional planning mechanisms, with regulations issued under 5 U.S.C. §553. It requires the Secretary to (1) establish uniform reporting standards and a national database on health practitioners, approved providers, costs, quality, outcomes, and health equity among population groups; (2) regularly analyze reported data and enable qualified access for research; (3) submit annual reports to Congress beginning January 1 of the second year after benefits first become available under section 106(a), covering implementation status, enrollment, benefits, expenditures, cost containment, quality assurance, utilization patterns, per capita costs, State health status differences by demographics, progress on quality measures, plans for medically underserved populations (as defined in 42 U.S.C. §254b(b)(3)), transition issues, and improvement opportunities; and (4) conduct statistical studies, test service delivery methods, and develop evidence-based policymaking standards. It further requires the Comptroller General to audit the Department of Health and Human Services every fifth fiscal year after benefits first become available under section 106(a) and report results to Congress.

This section requires the Secretary to consult with Federal agencies, Indian Tribes and urban Indian health organizations, and private entities (e.g., labor organizations representing health care workers, professional societies, national associations, medical schools, consumer groups, patient advocate groups, disability rights organizations, and labor business organizations) in formulating guidelines, regulations, policy initiatives, and information gathering for administering this Act. The section further authorizes the Secretary to adopt guidelines developed by such private entities if, in the Secretary's judgment, they are generally accepted as reasonable and prudent and consistent with the Act and section 203(c).

This section establishes regional Medicare for All offices, to be coordinated with Centers for Medicare & Medicaid Services (CMS) processes where possible, to promote enrollee access to tertiary care facilities, equipment, items, and services and to carry out specified duties. Each office is led by a regional director appointed by the Secretary—assisted by a deputy director for Indian and Alaska Native Tribes (if any) and a deputy director for home- and community-based services—who must (1) submit annual regional health care needs assessments after consultation with public health officials, clinicians, patients, and advocates; (2) recommend provider reimbursement or payment changes subject to title VI requirements; and (3) establish quality assurance mechanisms to minimize underutilization and overutilization of covered items and services and to ensure participating providers meet quality standards.

This section establishes a Beneficiary Ombudsman for the Medicare for All Program, to be appointed by the Secretary with expertise in health care, education, and assisting beneficiaries entitled to program benefits. The Ombudsman must (1) receive complaints, grievances, and information requests from such beneficiaries on any program aspect; (2) provide assistance in collecting information for appeals of regional office or Secretary decisions and in presenting cost-sharing information; and (3) submit annual reports to Congress and the Secretary describing activities and recommending administrative improvements. The Ombudsman may identify payment or coverage policy issues but must not advocate for payment increases or new coverage of items or services.

This section directs the Secretary of Health and Human Services, in performing functions related to health personnel education and training, health research, environmental health, disability insurance, vocational rehabilitation, food and drug regulation, and other health matters, to focus departmental activities on contributions to public health that complement this Act.

This section applies specified federal sanctions for fraud and abuse under Medicaid (title XIX) to the Medicare for All Program, including (1) exclusion of individuals and entities, (2) civil monetary penalties, (3) criminal penalties, (4) disclosure of ownership and related information, (5) disclosure of certain owners, and (6) limitations on physician self-referrals. (Thus, providers and entities participating in the Medicare for All Program are subject to the same anti-fraud measures as under Medicaid.)

This section directs the Secretary to establish, by September 1 each year beginning the year before benefits commence under section 106(a), a national health budget for total expenditures under the Medicare for All Program, divided into at least the following components: (1) operating budget for payments to institutional providers (sec. 611) and individual providers (sec. 612); (2) capital expenditures budget for health care facility construction or renovation (excluding congregate or segregated long-term care facilities for individuals with disabilities) and major equipment; (3) special projects budget for new facilities, major equipment, and staffing in rural areas or areas described in section 330(b)(3) of the Public Health Service Act (42 U.S.C. 254b(b)(3)) (i.e., migratory and seasonal agricultural workers, homeless, and public housing residents), health professional shortage areas, and to address health disparities; (4) quality assessment activities under title V; (5) health professional education expenditures; (6) administrative costs including regional office operations; (7) reserve fund for epidemics, pandemics, disasters, or patient volume shifts; and (8) prevention and public health activities. The Secretary must allocate funds to ensure the operating budget meets patient needs, special projects address specified areas timely, quality activities receive fair shares, and education funding suffices for program needs; annually allot funds to regional offices; and require all construction, including under capital and special projects budgets, to comply fully with the Americans with Disabilities Act of 1990 new construction standards. This section defines capital expenditures (i.e., for purchase, lease, construction, or renovation of facilities and major equipment) and health professional education expenditures (i.e., for teaching, research, workforce recruitment, retention, and diversity in hospitals and facilities).

This section requires allocation of at least 1% of the national health budget for up to five years following the date benefits are first available under section 106(a) to programs assisting workers performing administrative functions in the health insurance system or related functions in health care institutions or organizations who experience economic dislocation from this Act's implementation. Such assistance includes wage replacement, retirement benefits, job training and placement, preferential hiring, and education benefits.

This section establishes quarterly lump-sum global budget payments by the Secretary to institutional providers—including hospitals, skilled nursing facilities, and independent dialysis facilities—as full payment for all operating expenses related to items and services furnished under the Medicare for All Program, whether inpatient or outpatient. Such payments are subject to quarterly review by the regional director for compliance with participation agreements and negotiated budgets, with potential adjustments for unanticipated needs of complex patients, market shifts in volume, or prior adjustments; institutional providers may also petition for interim adjustments due to factors such as natural disasters, public health emergencies, unexpected repairs or price increases, changes in law, or labor cost increases (1) Payments are negotiated annually between the provider and regional director based on factors including (A) historical volume over the prior three years; (B) recent Medicare cost reports compared to peers and normative rates; (C) projected volume and type changes; (D) employee wages, including for mandatory minimum registered nurse-to-patient ratios; (E) maximum capacity; (F) education and prevention programs; (G) permissible operating budget adjustments for increased access, disparity reduction in underserved or rural areas (including those under 42 U.S.C. 254b(b)(3)), epidemics, complex patients, or innovative programs; (H) high social vulnerability or minority-serving status; and (I) other Secretary-determined factors; and (2) negotiated amounts exclude capital expenditures and non-direct care costs. Certain group practices and providers may elect salaried payments equivalent to the institutional provider's professionals through its global budget in lieu of fee-for-service under section 612, subject to the same reporting requirements.

This section establishes a national fee schedule for Medicare for All Program payments on a fee-for-service basis to individual providers, non-salaried group practice providers, home- and community-based services providers, and other providers not covered under section 611. The Secretary must establish the schedule not later than one year after enactment of this Act, in consultation with providers and regional office directors, and annually update it to reflect amounts payable under Medicare (title XVIII of the Social Security Act) and other federal health programs, as well as provider expertise and service value. The section requires the fee schedule to leverage Medicare payment processes (e.g., documentation, transparency, public comment, and provisions of section 613); establishes a uniform national electronic billing system; and authorizes application of certain planned or implemented Medicare payment reforms (e.g., demonstrations, waivers) during transition, subject to a transparent public review process. It further directs each regional office director, in consultation with regional physicians, to establish a physician practice review board to ensure quality, cost-effectiveness, and fair reimbursements for physician services, prohibiting disability-discriminatory mechanisms in value or cost-effectiveness assessments.

This section revises the process for reviewing and adjusting relative values of physicians' services under the Medicare physician fee schedule (MPFS), which determines Medicare payments to physicians and other practitioners based on work, practice expense, and malpractice relative value units (RVUs). Specifically, it (1) requires the Secretary of Health and Human Services (HHS), not later than one year after enactment, to establish, document, and publicly post a standardized process—in consultation with the Office of Primary Health Care—for such reviews, including minimum criteria for identifying and prioritizing services, reviewing stakeholder input, and using additional resources; (2) requires the Secretary, for each fiscal year beginning after enactment, to submit to Congress a plan for using specified MPFS funds to collect and apply data on physicians' services; (3) directs the Secretary, not later than one year after enactment, to propose to Congress a plan and timeline for an internal tracking system (e.g., database) covering service identification, review timing and resources, value adjustments, and decision rationales; (4) changes the review frequency for targeted RVUs to every four years (from five) and for potentially misvalued services to annually (from periodically); (5) requires HHS consultation and coordination with the Medicare Payment Advisory Commission (MedPAC) on these reviews and adds conforming duties for MedPAC to systematically review RVUs and propose adjustments; and (6) mandates periodic audits of the review process by the Comptroller General, who receives unrestricted, timely access to related records and data.

This section directs the Secretary to negotiate annually the prices paid for pharmaceutical products, medical supplies, and medically necessary assistive equipment covered under the Medicare for All Program. The section further requires the Secretary to establish a prescription drug formulary system—pursuant to section 202—that (1) encourages best prescribing practices and discourages ineffective, dangerous, or excessively costly medications when alternatives exist; (2) promotes generic medications to the greatest extent possible; (3) provides for frequent updates and allows clinicians and patients to petition for additions or removals; and (4) includes rules for off-formulary access that protect the formulary while allowing patient needs.

This section prohibits payments to participating providers under the Medicare for All Program from funding or being used for (1) provider marketing, (2) provider profit or net revenue (or increasing it), (3) agreements or arrangements with labor relations consultants to persuade employees on union organizing rights or supply information on employee or labor organization activities during labor disputes (i.e., under 29 U.S.C. 433(a)(4)), or (4) political contributions prohibited under the Federal Election Campaign Act (52 U.S.C. 30119(a)(1)). This section directs the Secretary to pay providers for capital expenditures from specified funds upon application, prioritizing projects serving medically underserved populations and areas (i.e., under 42 U.S.C. 254b(b)(3)) or addressing health disparities (including by race, ethnicity, national origin, primary language, age, disability, sex including gender identity and sexual orientation, geography, or socioeconomic status); bars such payments for projects diverting non-program funds in ways that reduce patient care (e.g., nursing staffing or emergency/primary care services); and restricts operating funds from being used for capital assets not funded by the program without regional director approval. This section prohibits providers from co-mingling operating and capital funds. This section directs the Secretary to allocate specified funds for special projects (e.g., construction, renovation, or staffing of facilities) to regional directors for distribution to providers in underserved, rural, or health professional shortage areas and to address specified health disparities, subject to the director submitting a distribution budget to the Secretary. This section prohibits the Secretary from using quality metrics or standards to establish provider payment methodologies, programs, modifiers, or adjustments.

This section establishes an Office of Health Equity in the Office of the Secretary of Health and Human Services, headed by a Director, to coordinate and collaborate across department programs and activities to ensure health equity. The office must (1) monitor, track, and publicly report disaggregated data on disproportionate disease and death burdens among people of color; barriers to health and health care access (e.g., lack of trust, transportation, facilities, and staffing); and disparities in care quality and utilization, enabling cross-sectional analysis by factors including race, ethnicity, Tribal affiliation, immigration status, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status; (2) develop and promote policies to enhance health equity, including recommendations on cultural competence training, health workforce diversity, sufficient professionals and facilities, and adequate local and state public health funding; (3) consult with Indian Tribes and urban Indian organizations; (4) publish an annual report on collected statistics, evidence-based solutions to inequities, and health care staffing and facility access; and (5) create and maintain a centralized public electronic repository of relevant federal data. The section prohibits disclosure or use of personally identifiable information collected under the office for law enforcement or immigration purposes.

This section establishes an Office of Primary Health Care, headed by a Director, within the Office of Health Equity to coordinate and collaborate across Department of Health and Human Services (HHS) programs and activities to increase access to high-quality primary health care, particularly in underserved areas and for underserved populations. Not later than one year after enactment, the Director must publish national goals to increase such access and address health disparities, including with respect to race, ethnicity, national origin, primary language, English proficiency, immigration status, length of stay in the United States, age, disability, sex (including gender identity and sexual orientation), incarceration, homelessness, geography, and socioeconomic status. The Director must also (1) coordinate health professional education policies; (2) monitor primary health care workforce numbers and specialties; (3) promote policies to expand primary care practitioners, including medical, dental, behavioral health providers, registered nurses, and advanced practice clinicians; (4) recommend workforce training, technical assistance, and patient protections; (5) recommend programs and resources for federally qualified health centers, community health centers, rural health centers, behavioral health clinics, and other community-based organizations; (6) recommend patient referrals to additional resources and collaboration with non-health sectors; and (7) consult on allocating the special projects budget under section 601(a)(2)(C) of the Medicare for All Act. This section includes a rule of construction clarifying that it does not preempt state laws on health professional practice standards or licensing or require states to impose additional educational standards.

This section (1) establishes a $1,500 annual cap on out-of-pocket cost-sharing (i.e., coinsurance, copayments under Parts A or B, and costs for otherwise covered items and services after benefit exhaustion, excluding non-covered services and balance billing above assignment-related basis) for Medicare Parts A and B enrollees, effective the year beginning January 1 following enactment; (2) sets the Part A inpatient hospital deductible to $0 (from the current annually adjusted amount, currently approximately $1,632) for each year beginning January 1 following enactment; and (3) sets the Part B annual deductible to $0 (from the current annually adjusted amount, currently $240) for each year after the enactment year. (Thus, these changes limit total annual beneficiary cost-sharing under Medicare fee-for-service to no more than $1,500, regardless of utilization.)

This section reduces the Medicare Part D annual out-of-pocket threshold to $300 (notwithstanding current statutory amounts) for plan years beginning on or after January 1 following the date of enactment of the Medicare for All Act and before January 1 of the year that is four years after such date of enactment. (Medicare Part D provides optional outpatient prescription drug coverage to Medicare enrollees; the threshold is the amount enrollees pay for deductibles, copays, and coinsurance before entering unlimited catastrophic coverage.) It further authorizes the Secretary to exempt from this reduced threshold costs incurred for a covered Part D drug that is an applicable drug under SSA section 1860D–14A(g)(2) (i.e., certain drugs subject to Medicare drug price negotiation and inflation rebates) if the Secretary determines a generic version is available.

This section expands Medicare Part B coverage, effective January 1 following enactment, by (1) removing the statutory exclusion for dental services (previously under section 1862(a)(12)), adding dental services to covered medical and other health services under section 1861(s)(2), and establishing payment equal to 80 percent of the lesser of the actual charge or the physician fee schedule amount under section 1848(b); (2) similarly removing the statutory exclusion for vision services, adding vision services to covered medical and other health services, and establishing the same payment methodology; and (3) removing the statutory exclusion for hearing aids and examinations therefor (previously under section 1862(a)(7)).

This section eliminates the 24-month waiting period for Medicare Part A (Hospital Insurance) coverage for individuals under age 65 entitled to Social Security Disability Insurance benefits or equivalent railroad retirement disability annuities (i.e., changes eligibility from the 25th month of entitlement to the month following the month of entitlement). It makes conforming amendments to related statutory provisions and applies to items and services furnished in months beginning after December 1 following the date of enactment and before January 1 of the year that is four years after such date.

This section establishes guaranteed issue of Medicare supplemental policies (Medigap) for all individuals entitled to Medicare Part A benefits and enrolled in Part B, prohibiting issuers from denying or conditioning issuance or effectiveness of such a policy or discriminating in pricing based on health status, claims experience, receipt of health care, or medical condition, effective on or after the date of enactment. (As background, Medigap policies help cover Medicare cost-sharing such as deductibles and copays; previously, guaranteed issue protections applied only in limited circumstances such as during initial enrollment periods or loss of other coverage.)

This section establishes a temporary Medicare buy-in program under new SSA §1899D for U.S. citizens, nationals, or lawful permanent residents aged 55-64 in the first year after enactment (expanding to 45-64 in year two and 35-64 in year three), who are not otherwise entitled to or eligible for Medicare Parts A or B. Enrollees receive the same Part A hospital, Part B physician/other outpatient, and Part D prescription drug benefits (including Medicare Advantage and other private plan options) as standard beneficiaries; pay monthly premiums equal to one-twelfth of the estimated average annual per capita costs for Parts A, B, and D benefits and administration (with premium deposits allocated to the Medicare trust funds in proportion determined by the Secretary and no negative impact on trust fund solvency or existing beneficiaries); and are ineligible for Medicaid Medicare cost-sharing assistance. For ACA purposes, the coverage (1) qualifies as minimum essential coverage under IRC §5000A; (2) is treated as a qualified health plan enrolled through an Exchange for premium tax credit eligibility under IRC §36B (with the Secretary determining the applicable second-lowest-cost silver plan premium and excluding it from counting as other minimum essential coverage that would disqualify credits); and (3) is treated as silver-level coverage for cost-sharing reduction subsidies under ACA §1402 (42 U.S.C. 18071).

This section establishes a Medicare Transition plan, offered through the Exchanges and administered by the CMS Administrator, for plan years beginning after enactment until benefits are first available under section 106(a). The plan provides coverage for benefits required under title II with an actuarial value equivalent to 90% of full actuarial value; reimburses providers at Medicare fee-for-service rates under parts A and B of Medicare (or Administrator-set rates consistent with those for non-Medicare-covered items and services); and automatically deems Medicare or Medicaid participating providers as participating, with a process for other providers to join. For prescription drugs, the Administrator negotiates reimbursement rates with manufacturers or, absent agreement, sets rates at the lesser of (1) the VA procurement price under 38 U.S.C. 8126 (i.e., no more than 76% of non-federal average manufacturer price), (2) the DoD procurement price, or (3) the Medicaid best price. Premiums vary by family or individual coverage, age, and tobacco status but not by rating area and account for available premium tax credits and cost-sharing reductions; eligibility extends to any U.S. resident and qualified employers offering it to employees; and the plan complies with ACA requirements applicable to qualified health plans. The section terminates upon availability of section 106(a) benefits and amends IRC §36B to allow premium tax credits for Medicare Transition plan enrollees (or their spouses/dependents) at or above 44% of the federal poverty level in non-expansion states.

This section directs the Secretary to ensure that individuals enrolled in or seeking to enroll in a group health plan, health insurance coverage offered by a health insurance issuer, or the plan established under section 1012 are protected from disruptions in care during the transition period of this Act.

This section directs the Secretary to consult with communities and advocacy organizations for individuals living with disabilities and other patient advocacy organizations to ensure the transition described in section 1021 accounts for the safety and continuity of care for individuals with disabilities, complex medical needs, or chronic conditions.

This section defines, for purposes of this subtitle, the terms "health insurance coverage," "health insurance issuer," and "group health plan" by reference to section 2791 of the Public Health Service Act (42 U.S.C. 300gg-91).