Because the House legislation is longer (120 pages) and somewhat more detailed than the Senate version (100 pages), the below analysis summarizes the House bill. Major differences between the House and Senate bills are summarized in italics.
Establishes a “national health insurance program to provide comprehensive protection against the costs of health care and health-related services.”
Makes “every individual who is a resident of the United States” eligible for benefits. Allows the secretary of Health and Human Services (HHS) to make “other individuals” eligible for benefits, “to ensure that every person in the United States has access to health care,” while preventing individuals from traveling “for the sole purpose of obtaining health care” services.
Allows any individual entitled to benefits to receive those benefits from “any institution, agency, or individual qualified to participate” in the program.
Prevents any individual from being denied benefits from, or the opportunity to participate in, the program based on “race, color, national origin, age, disability…or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy).” Requires the secretary to establish a procedure for investigating such complaints administratively, and allows aggrieved individuals to file claims in any federal district court.
Requires the secretary to provide a mechanism to enroll individuals in the program, and issue “Universal Medicare card[s]” for identification and claims processing. The cards shall not include beneficiaries’ Social Security numbers.
Makes benefits available two years after the date of enactment. Individuals younger than age 19 or older than age 55 one year after enactment may receive benefits at that time; however, they may continue in their existing coverage for a one-year transition period until the entire program takes effect (i.e., two years after enactment).
The Senate bill includes a four-year transition, rather than a two-year transition. Only individuals younger than age 19 would become eligible early, effective on January 1 of the first year after enactment. Other individuals could buy into the program, as outlined in Sections 1001 and 1002 of the Senate bill.
Beginning on the effective date, makes it unlawful for a private insurer to sell, or an employer to offer, coverage that “duplicates the benefits provided” under the act. Permits “the sale of health insurance coverage for any additional benefits not covered” by the act.
Makes individuals “entitled to have payment made…to an eligible provider for the following items and services if medically necessary”:
Requires the secretary to evaluate and update the list of services at least annually, and make recommendations to Congress. Also requires the secretary to consult with experts in “complementary and alternative medicine” about whether and how to include such practices in single payer.
Permits states to provide additional benefits for their residents, and provide benefits to individuals not eligible for benefits, at their own expense.
The Senate bill covers all the benefits outlined above, except long-term services and supports. With respect to these services, the Senate bill covers only home and community-based services as part of the federal program. State Medicaid programs would continue to provide institutional care, as outlined in Section 204 below.
Prohibits the imposition of any “cost-sharing, including deductibles, co-insurance, co-payments, or similar charges.” Also prohibits providers from charging enrolled individuals for services provided under the act.
The Senate bill permits cost-sharing for “prescription drugs and biological products” only, up to an annual maximum of $200 per person per year. The cost-sharing would not apply to preventive drugs, or to any individual with a household income less than 200% of the federal poverty level ($51,500 for a family of four in 2019).
Requires covered goods and services to meet regulations the secretary sets. Requires the secretary to make national coverage determinations regarding experimental treatments, and to create an appeals process for coverage decisions.
Allows HHS to establish national practice guidelines, in which case items and services provided under those guidelines shall be considered eligible for coverage. Allows individual providers to override such national standards, if using appropriate professional judgment in the best interest of the patient.
Creates an entitlement for coverage of long-term supports and services for any mental or physical condition that “causes a functional limitation in performing one or more activities of daily living,” such as eating, bathing, and dressing, or “requires a similar need of assistance in performing instrumental activities of daily living,” such as managing finances and conducting chores, “due to cognitive or other impairments.” Requires the secretary to develop a process for determining individuals’ eligibility and assessing their needed services.
Describes criteria for covered services, which shall include “a broad spectrum of long-term services and supports.” Prioritizes home and community-based services over institutionalization in nursing homes, and states that individuals will receive community-based services “unless an individual elects otherwise.” Requires the secretary to consult with an advisory commission when determining the covered services.
The Senate bill would maintain coverage of institutional long-term care services—such as nursing-home care and inpatient psychiatric care—through state Medicaid programs. State Medicaid programs would cover institutional long-term care only, and would no longer cover other services, such as home and community-based care or health-care services (e.g., doctor and hospital visits, etc.), which would be provided through the new federal program.
The Senate bill includes maintenance of effort provisions regarding state Medicaid coverage of institutional long-term care. States cannot reduce their eligibility standards below those in place as of January 1, 2019. States must also maintain their spending levels for Medicaid institutional long-term services, calculated based on spending levels in fiscal year 2018 and updated for inflation by an adjustment factor calculated by the secretary.
The Senate bill includes a Section 205, prohibiting state Medicaid programs from imposing liens against the estates of individuals who received nursing-home benefits, “except pursuant to the judgement of a court on account of benefits incorrectly paid.”
The Senate bill includes a Section 206, permitting states to set their own additional standards, “provided that such standards do not restrict eligibility or reduce access to services.”
Requires providers furnishing services covered under the act to file participation agreements. In the participation agreements, providers shall agree to provide services without discrimination and without cost-sharing to patients, not to employ “any individual or other provider that has had a participation agreement…terminated for cause,” provide proper documentation of services rendered, and comply with other requirements.
Providers must ensure “that no board member, executive, or administrator of [an institutional] provider receives compensation from, owns stock or has other financial investments in, or serves as a board member of any entity that contracts with or provides items or services, including pharmaceutical products and medical devices or equipment, to such provider.” The Senate bill does not include this provision.
States that “each health care provider…has a duty to advocate for and to act in the exclusive interest of each individual…such that no financial interest or relationship impairs any health care provider’s ability to furnish necessary and appropriate care.” Requires the secretary to pass reporting rules that will “prohibit participating providers, spouses, and immediate family members of participating providers, from accepting or entering into any arrangement for any bonus, incentive payment, profit-sharing, or compensation based on patient utilization or based on financial outcomes,” or from serving as board members for or receiving any compensation from a contractor to that provider. The Senate bill does not include these provisions.
Allows for termination of participation agreements, whether by the secretary, by the provider, or as a result of a conviction for fraudulent activity. Requires “notice and a reasonable opportunity to correct deficiencies before the secretary terminates an agreement,” unless “public safety or similar reasons” require a faster termination.
Prohibits the secretary from terminating the participation of, “or in any other way discriminat[ing] against,” a provider for bringing information to state or federal authorities regarding violations of the act, or “refusing to participate in, any activity, policy, practice, or assigned task that the provider or representative reasonably believes to be in violation of any provision” of the act, or any rule promulgated under the act.
Prohibits any person from “discharg[ing] or otherwise discriminat[ing]” against an employee for notifying the employer, or state or federal authorities, about alleged wrongdoing. Provides for a private right of action, subject to the statute of limitations laid out in the False Claims Act, for any individual alleging discrimination by an employer. The Senate bill does not include these provisions.
Provides that a health-care provider is qualified to furnish covered items and services if certified or licensed in compliance with state law, and any applicable federal requirements. States that “any provider qualified to provide health-care items and services through the Department of Veterans Affairs or Indian Health Service is a qualifying provider” for individuals who qualify for those services.
Requires the secretary to create national minimum standards under the act, which may include such elements as facility adequacy, training and competence, performance standards, and outcomes. The House bill, but not the Senate bill, includes an additional provision allowing for the creation of “mandatory minimum safe registered nurse to patient staffing ratios and optimal staffing levels for physicians and other health care practitioners.”
Prohibits participating providers from contracting privately for any covered service. Permits participating providers to contract privately for non-covered services, provided the patient signs a written contract not entered into “when the individual is facing an emergency health care situation,” and that the provider files an affidavit with the secretary stating that the provider will not submit a claim to the federal program for such services.
If the provider “knowingly and willfully” submits a claim for such services, “or receives any reimbursement or amount for any such item or service,” the contract is null and void, “no payment shall be made under this title for any item or service furnished by the provider” for a one-year period, and “any payment received…for any item or service furnished during such period shall be remitted.”
Participating providers may contract privately with any individuals not eligible for the single-payer program for any service. Non-participating providers may contract privately with eligible individuals, provided the patient signs a written contract not entered into “when the individual is facing an emergency health care situation,” and that the provider files an affidavit with the secretary stating that the provider “will not submit any claim…for any covered item or service” for two years.
If the provider “knowingly and willfully” submits a claim to the federal program for such services, “or receives any reimbursement or amount for any such item or service,” the contract is null and void, “no payment shall be made under this title for any item or service furnished by the provider” for a two-year period, and “any payment received…for any item or service furnished during such period shall be remitted.”
The Senate bill includes similar provisions, except that providers who contract privately cannot bill the new program for one year, whereas the House legislation would prohibit non-participating providers who contract privately with eligible individuals from billing the government program for two years.
Provides the general duties of the secretary in implementing the act, including related to eligibility; enrollment; benefits provided; provider participation criteria; levels of funding; determining payment methods; making coverage determinations; planning for capital expenditures; planning for workforce education funding; encouraging states to develop regional planning mechanisms; and “any other regulations necessary to carry out the purposes of this Act.” The House bill, but not the Senate bill, also gives the secretary “the obligation to ensure the timely and accessible provision of items and services that all eligible individuals are entitled to” under the act.
Requires the secretary to “ensure an adequate national database” relating to health services and costs, including patient outcomes. The House bill, but not the Senate bill, includes more specific language regarding the database, requiring participating providers to disclose all data presently required by government programs (e.g., the current Medicare and Medicaid programs), along with “annual financial data that includes information on employees (including the number of employees, hours worked, and wage information) by job title and by each patient care unit or department within each facility (including outpatient units or departments); the number of registered nurses per staffed bed by each such unit or department; information on the dollar value and annual spending (including purchases, upgrades, and maintenance) for health information technology; and risk-adjusted and raw patient outcome data (including data on medical, surgical, obstetric, and other procedures).”
Requires the secretary to analyze the data, and issue regulations permitting its release for research purposes (with patient identifying information removed). Requires the secretary to submit annual reports to Congress regarding the act, including implementation, enrollment, benefits, cost-containment measures, health disparities, and opportunities for improvement.
Permits the secretary to commission studies, and “develop and test methods…as the Secretary may consider necessary or promising for the evaluation, or for the improvement, of the operation of this Act.” Requires the Government Accountability Office to audit the program every five years.
Requires the secretary to consult with “federal agencies, Indian tribes and urban Indian health organizations, and private entities, such as labor organizations representing health care workers, professional societies, national associations, nationally recognized associations of health care experts, medical schools and academic health centers, consumer groups, and business organizations…to ensure the broadest and most informed input in the administration of this Act.”
Requires the secretary to establish regional offices to “promot[e] adequate access to, and efficient use of, tertiary care facilities, equipment, and services” by beneficiaries. Each regional office shall have a director appointed by the secretary, and a deputy director to represent Indian and Alaska Native tribes in the region, if any. Where possible, the regions should incorporate existing Centers for Medicare and Medicaid Services (CMS) regional offices. Each office shall prepare an annual needs assessment, recommend changes in provider reimbursement or payment, and establish quality assurance mechanisms in each region.
Requires the secretary to appoint a beneficiary ombudsman to receive complaints from, and provide assistance to, individuals dissatisfied with elements of the program, and submit annual reports to Congress and the secretary on beneficiary complaints. “The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies.”
With respect to other programs in the Department of Health and Human Services’ remit (e.g., disability insurance, health personnel education and research), requires the secretary to “direct the activities of the Department…toward contributions to the health of the people complementary to this Act.”
Extends a series of existing anti-fraud provisions that apply to the current Medicare and Medicaid programs to the new program, including provisions related to 1) the exclusion of individuals and entities (i.e., medical providers) from the program; 2) civil monetary penalties; 3) criminal penalties; 4) disclosure of ownership and related information; 5) disclosure of certain owners previously excluded from the programs for fraud-related offenses; and 6) physician self-referral.
Requires CMS’s Center for Clinical Standards and Quality, in coordination with the Agency for Healthcare Research and Quality (AHRQ), to implement and evaluate all standards and quality measures. Requires the Center for Clinical Standards to review and evaluate all existing AHRQ research, and determine which standards are appropriate to incorporate as national practice guidelines. Requires the center to submit a report annually to the secretary about practice guidelines, which “may affect the Secretary’s determination of coverage of services.”
The House bill, but not the Senate bill, includes additional language prohibiting “the use of Quality-Adjusted Life Years, Disability-Adjusted Life Years, or other similar mechanisms that discriminate against people with disabilities…in any value or cost-effectiveness assessments.”
Requires the Center for Clinical Standards to evaluate the collection of data “on disparities in health care services and performance on the basis of race, ethnicity, gender, geography…or socioeconomic status.” Requires the center to regularly report to Congress and the secretary on ways to collect and evaluate data on health disparities, and requires the secretary to implement changes the reports identify.
Requires the secretary to submit a national health budget by September 1 each year. The budget would consist of eight components: 1) an operating budget; 2) a capital expenditures budget; 3) a special projects budget for health professional shortage areas; 4) quality assessment activities; 5) health professional education; 6) administrative costs; 7) a reserve fund to respond to emergencies (e.g., a pandemic); and 8) prevention and public health activities.
Allows the secretary to allocate the national health budget among the components, and directs the secretary to provide each regional office “with an allotment the Secretary determines appropriate” to carry out the act in each region.
For “up to five years” after the program’s enactment, allocates “at least one percent of the budget…to programs providing assistance to workers who perform functions in the administration of the health insurance system, or related functions within health care institutions or organizations… who may experience economic dislocation” as a result of the act’s implementation.
The Senate bill includes a slightly different description of the national health budget components, contains no specific provision for allocating the budget to various regions, and provides for “up to one percent” of the budget to be used for transitional worker assistance, as opposed to “at least one percent.”
Requires the secretary to provide quarterly lump-sum payments to institutional providers (including hospitals and nursing homes), which shall constitute payment in full for all inpatient and outpatient services rendered. Group physician practices and other related health-care providers can elect to join a facility’s global budget, provided those physicians are paid on a salaried basis.
The regional director will “negotiate” the amount of the payment with the provider, and review the adequacy of the payments quarterly, considering “additional funding necessary for unanticipated items and services,” changes in market conditions, and the need for any adjustments. The current Medicare prospective payment system shall serve as the initial baseline for the negotiations, except that the new system “shall not include…value-based payment adjustments” and adjustments for capital expenses (considered separately in the capital expenditures section below).
Global payment levels will consider historical volumes of services provided; actual expenditures at the facility compared to those of other facilities; projected changes in services; employee wages, including any needed to meet required staff-to-patient ratios; the provider’s maximum capacity; education and prevention; and “any other factor determined appropriate by the Secretary.” Payment amounts may not take into account capital expenditures, exceed the provider’s capacity to provide services, or compensate directors or executives with financial conflicts of interest.
Operating expenses will include wages and salaries for all staff, costs for all pharmaceuticals and medical devices dispensed within the facility, patient care and education, incidental services, and administrative costs. Providers may not pay any employees more than the compensation caps set in federal law. The Senate bill does not include this section, nor any provision regarding global budgets for hospitals and nursing homes.
Requires the secretary to establish a physician fee schedule one year after enactment, and update it annually. The fee schedule will take into account the existing physician fee schedule under the current Medicare program, and “the expertise of providers and value of items and services furnished by such providers.” Payment will apply to all doctors, except those group practices using the global payment method above, and will constitute payment in full, with additional charges to patients prohibited.
Requires each regional director to establish a physician practice review board “to assure quality, cost effectiveness, and fair reimbursements” for physician services. “The use of Quality Adjusted Life Years, Disability-Adjusted Life Years, or other similar mechanisms that discriminate against people with disabilities is prohibited for use in any value or cost-effectiveness assessments.”
The Senate bill includes a Section 611 providing for fee schedules for both hospitals and physicians “consistent with the process for determining payments for items and services” under the current Medicare program. The section also applies existing Medicare payment demonstration projects to the new single-payer program. The section does not contain language included in the House bill prohibiting the use of Quality Adjusted Life Years and related metrics.
Effective one year after enactment, requires a “standardized process for reviewing the relative values of physicians’ services.” Requires the secretary to submit to Congress a plan for tracking relative values, such as via a database. Requires a review of “potentially misvalued” codes every year, and a full review of all codes every four years (as opposed to five under current law).
Also requires the secretary to consult with the Medicare Payment Advisory Commission on adjustments to billing codes. Requires the Government Accountability Office to audit the secretary’s process for adjusting billing codes “periodically.” The Senate bill includes this section as Section 612.
Includes “Sense of Congress” language stating that “tens of millions of people in the United States do not receive health care services while billions of dollars that could be spent on providing health care are diverted to profit. There is a moral imperative to correct the massive deficiencies in our current health system and to eliminate profit from the provision of health care.”
Prohibits payments to providers from taking into account, or being used by a provider for 1) marketing; 2) profit or net revenue; 3) “incentive payments, bonuses, or other compensation based on patient utilization of items and services…including any value-based payment or employment-based compensation;” 4) payments to labor relations consultants to educate employees about whether to join a union; and 5) prohibited political campaign contributions.
Instructs the secretary to pay from the capital expenditure budget “such sums determined appropriate by the Secretary,” with priority going to funds improving service in medically underserved areas or to address health-care disparities. Prohibits any funding of capital projects “that results in care reductions to patients, including reductions in registered nursing staffing patterns and changes in emergency room or primary care services or availability.”
Prohibits institutional providers from using “operating expenses and funds…for a capital project funded by charitable donations” without the approval of the relevant regional director or directors. Prohibits providers from using funds designated for operating expenses for capital expenses or profit, or using funds for capital expenses for operating costs.
Requires the secretary to grant to each regional director “such sums determined appropriate” for special projects, including for facilities in underserved or health professional shortage areas. Prohibits the secretary from “utiliz[ing] any quality metrics or standards” when determining provider payment methodologies. The Senate bill does not include this section or any of its provisions.
Establishes this office within the Agency for Healthcare Research and Quality, to coordinate health education goals, promote training for primary care practitioners, and consult on the special projects component of the national health budget. Within one year of enactment, requires the office to “set forth national goals to increase access to high quality primary health care.” The Senate bill includes this section as Section 613.
Requires the secretary to “negotiate” prices for drugs and medical devices. The secretary must consider “the comparative clinical effectiveness and cost effectiveness,” budgetary impact, similarly effective or alternative therapies, a manufacturer’s total revenues, and “associated investment in research and development of such drug.”
Provides that “in the case that the Secretary is unable to successfully negotiate an appropriate price” for a drug, the secretary “shall authorize the use of any patent…or other exclusivity granted by the federal government with respect to such drug as the Secretary determines appropriate for purposes of manufacturing such drug for sale.” Provides that other entities using a competitive license shall provide to the original manufacturer “reasonable compensation, as determined by the Secretary” based on 1) any federal subsidies used to develop the drug, 2) the value of investment made by the manufacturer to develop the drug, 3) “the impact of the price…on meeting the medical need of all patients at a reasonable cost,” 4) “the relationship between the price of such drug” and its health benefits, and 5) any other factors considered by the secretary. Manufacturers “may seek recovery against the United States” in the Court of Federal Claims.
If the secretary decides to license competitors to a branded drug, the price for its first year shall consist of the average price in the ten largest Organization for Economic Cooperation and Development (OECD) countries, as determined by gross domestic product.
Prioritizes Food and Drug Administration (FDA) review of any entity the secretary grants a license to produce prescription drugs. Prohibits drug manufacturers from “anti-competitive behavior” that “interfere[s] with the issuance and implementation of a competitive license or run[s] contrary to public policy.” Grants the secretary the authority to require drug manufacturers “to disclose… such information that the Secretary determines necessary” to carry out the licensing provisions.
The Senate bill includes this section as Section 614 of the bill. The Senate bill directs the secretary to negotiate drug and device prices annually, and establish a formulary that will promote the use of generics “to the greatest extent possible.” In addition, the formulary “shall encourage best practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.” The Senate bill does not include any provision allowing the secretary to license off pharmaceutical patents.
Creates the new trust fund in the Treasury, which shall consist of “such gifts and bequests as may be made and such amounts as many be deposited in, or appropriated to,” the fund.
Appropriates money into the fund every year equal to the tax revenue generated from 1) the prohibition on employer coverage of health benefits (which employers can currently provide on a pre-tax basis) under the new program and 2) repeal of the exchange (i.e., Obamacare) premium subsidies.
For the program’s first year of operations, appropriates dollars into the fund equal to current federal spending on 1) Medicare, 2) Medicaid, 3) the Federal Employee Health Benefits Program, 4) Tricare, 5) “programs providing general hospital or medical assistance,” and 6) “any other federal program identified by the Secretary.”
For future years, appropriates dollars “equal to the amount appropriated to the Trust Fund for the previous year, adjusted for reductions in costs resulting from the implementation of this Act, changes in the consumer price index for all urban consumers for the fiscal year involved, and other factors determined appropriate by the Secretary.” The Senate bill does not include this provision.
States that “any other provision of law in effect on the date of enactment…restricting the use of federal funds for any reproductive health service shall not apply” to dollars in the trust fund.
Amends ERISA to prohibit employer coverage of benefits covered by the new health program. Requires workers’ compensation carriers liable for services furnished to reimburse the program for such services.
Amends ERISA to state that continuation coverage requirements only apply to employer health plans that do not duplicate payments for items or services covered under the new program. The Senate bill would repeal this requirement entirely.
Makes the amendments effective on the effective date of the new program.
Sunsets benefits provided under Medicare, Medicaid, the Federal Employee Health Benefits Program, and Tricare two years after enactment (i.e., the effective date of the new program). States that school health programs and centers currently funded by Medicaid “shall be continued and covered” by the new program. Provides that “nothing in this act shall affect the eligibility of veterans” for services provided by the Department of Veterans Affairs, or of Indians for services provided by the Indian Health Service.
The Senate bill ends these programs when the new program takes effect, four years after the date of enactment. The Senate bill preserves the Medicaid program only to provide institutional long-term care services, and any services not covered by the new program. The Senate bill includes maintenance of effort provisions for states regarding these services, as outlined in Section 204 above.
Ends provisions related to the state exchanges, and the subsidies provided through them, two years after enactment (i.e., the effective date of the new program). The Senate bill would end these programs when the new program takes effect, four years after the date of enactment.
Eliminates a series of provider pay-for-performance programs established under Obamacare and other laws two years after enactment (i.e., the effective date of the new program). The Senate bill does not contain this section.
Amends the Social Security Act to allow individuals under age 18, over age 55, or currently enrolled in Medicare to enroll in the new program one year after enactment.
The Senate bill includes similar provisions, which allow individuals to purchase a plan consisting of Medicare Part A (hospital services), Part B (physician services), and Part D (prescription drug) benefits, or a Medicare Advantage plan. Eligibility would extend to individuals over age 55 as of January 1 the year after enactment, individuals over age 45 as of January 1 the second year after enactment, and individuals over age 35 as of January 1 the third year after enactment.
Premiums would consist of the average per beneficiary cost to provide benefits to eligible individuals (i.e., the buy-in population). Individuals will not be eligible for Medicare cost-sharing assistance, but would be eligible for Obamacare premium and cost-sharing subsidies, if they otherwise qualify (i.e., they meet income limits and do not have an offer of “affordable” employer coverage). The buy-in plan would also satisfy Obamacare’s individual mandate.
Requires the secretary to establish, effective one year after enactment and lasting through the effective date, a Medicare transition buy-in on the exchanges. The plan shall be available only on the exchanges, be open to “any United States resident,” cover all the services available under the new program, and have an actuarial value (percentage of average health expenses covered by insurance) of 90%.
All participating providers in the current Medicare or Medicaid programs shall participate in the buy-in program, but will be reimbursed as provided for in the new program. The plan will have premiums that vary by family size, age, and tobacco status, as provided for under current federal law (i.e., Obamacare).
Makes the transition buy-in plan eligible for current (i.e., Obamacare) premium and cost-sharing subsidies, which will be available to all individuals regardless of income. (Current law limits eligibility to households with incomes between 100-400% of the federal poverty level, or up to $103,000 for a family of four in 2019.) Provides subsidies on a sliding scale, such that households with incomes more than 150% of poverty—$18,735 for an individual, and $38,625 for a family of four, in 2019—will pay no more than 5% of their income in premiums.
The Senate bill includes an additional Section 1011, which sets a maximum out-of-pocket spending limit for current Medicare beneficiaries of $1,500, effective on January 1 of the year following enactment. That spending limit would apply to all covered services under Medicare Part A (hospital coverage) and Part B (physician coverage). In addition, this section would eliminate the current Medicare Part A and Part B deductibles, beginning on January 1 of the year following enactment.
The Senate bill includes an additional Section 1012, which would reduce the maximum out-of-pocket spending limit for current Medicare beneficiaries’ Part D drug costs to $305 per year. This change would take effect beginning on January 1 of the year following enactment.
The Senate bill includes an additional Section 1013, which would make dental services, vision services, and hearing aids and examinations for hearing aids covered services under the current Medicare program. These changes would take effect beginning on January 1 of the year following enactment.
Strikes current language that requires individuals who qualify for Social Security disability benefits to wait 24 months before becoming eligible for the current Medicare program. The changes take effect on December 1 after the date of enactment, and expire on the effective date for the new program.
The Senate bill includes this provision as Section 1014. The Senate bill also includes a Section 1015, which would prohibit issuers of Medigap supplemental insurance policies from denying the issuance of a policy, or discriminating in the pricing of that policy, “because of health status, claims experience, receipt of health care, or medical condition.”
Requires the secretary to keep all individuals, particularly those with disabilities or chronic conditions, from disruptions in care during the transition period, including in their provider teams. Prohibits employer plans and health insurers from ending coverage for enrollees “except as expressly agreed upon by the plan,” or ending coverage or imposing conditions on individuals with disabilities or chronic conditions, “until all ages are eligible to enroll” in the new program. The Senate bill includes similar provisions as Section 1021, except that the Senate bill does not explicitly prohibit employer plans and health insurers from ending coverage for individuals during the transition period.
Defines terms used in the bill: Group practice; Individual provider; Institutional provider; Medically necessary or appropriate; Provider; Secretary; State; and United States.
Section 1101 of the Senate bill would increase the asset limits for Supplemental Security Income (SSI) assistance. Under current law, individuals eligible for SSI cannot have outside resources of more than $2,000 for an individual and $3,000 for a couple. (The term “resources” excludes the value of a primary home, one car, personal household effects, life insurance policies, burial plots, and certain other assets.) The bill would raise these levels to $4,100 for an individual and $6,200 for a family, and index them to inflation in years after 2019.
The Senate bill includes its definitions as Section 1102.
Allows states to set additional standards or apply state or local laws, but only if they “provide equal or greater” eligibility and access to benefits, “do not reduce access to benefits,” “allow for the effective exercise” of physicians’ professional judgement, and remain consistent with the act.
Explicitly retains state licensure of health-care providers. Indicates that the act shall not diminish employers’ or employees’ rights under existing law or collective bargaining agreements. Indicates that states may not prohibit providers from participating in the program “for reasons other than the ability” of that entity to provide services.
The Senate bill does not include this section, but includes similar provisions in Section 206 of the bill.