[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3911 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 3911
To provide for the establishment of Medicare part E public health
plans, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 11, 2025
Mr. Gomez (for himself, Mr. Beyer, Mr. Huffman, Mrs. McIver, and Ms.
Norton) introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committees on
Ways and Means, and Education and Workforce, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To provide for the establishment of Medicare part E public health
plans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Choose Medicare Act''.
SEC. 2. PUBLIC HEALTH PLAN.
(a) In General.--The Social Security Act is amended by adding at
the end the following:
``title xxii--medicare part e public health plans
``Sec. 2201. Public Health Plans.--
``(a) Establishment.--The Secretary shall establish public health
plans (to be known as `Medicare part E plans') that are available in
the individual market, small group market, and large group market.
``(b) Benefits.--
``(1) In general.--Each Medicare part E plan, regardless of
whether the plan is offered in the individual market, small
group market, or large group market, shall be a qualified
health plan within the meaning of section 1301(a) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18021(a))
that--
``(A) meets all requirements applicable to
qualified health plans under subtitle D of title I of
the Patient Protection and Affordable Care Act (42
U.S.C. 18021 et seq.) (other than the requirement under
section 1301(a)(1)(C)(ii) of such Act) and title XXVII
of the Public Health Service Act (42 U.S.C. 300gg et
seq.);
``(B) provides coverage of--
``(i) the essential health benefits
described in section 1302(b) of the Patient
Protection and Affordable Care Act (42 U.S.C.
18022(b)); and
``(ii) all items and services for which
benefits are available under title XVIII;
``(C) provides gold-level coverage described in
section 1302(d)(1)(C) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18022(d)(1)(C)); and
``(D) provides coverage of abortions and all other
reproductive services.
``(2) Preemption.--Notwithstanding section 1303(a)(1) of
the Patient Protection and Affordable Care Act (42 U.S.C.
18023(a)(1))--
``(A) a State may not prohibit a Medicare part E
plan from offering the coverage described in paragraph
(1)(D); and
``(B) no provision of State law that would prohibit
such a plan from offering such coverage shall apply to
such plan.
``(c) Eligibility; Enrollment.--
``(1) Availability on the exchanges.--The Medicare part E
plans offered in the individual and small group markets shall
be offered through the Federal and State Exchanges, including
the Small Business Health Options Program Exchanges (commonly
referred to as the `SHOP Exchanges').
``(2) Eligibility.--
``(A) In general.--Any individual who is a resident
of the United States, as determined by the Secretary
under subparagraph (C), and who is not an individual
described in subparagraph (B), is eligible to enroll in
a Medicare part E plan.
``(B) Exclusions.--An individual described in this
subparagraph is any individual who is--
``(i) entitled to, or enrolled for,
benefits under title XVIII;
``(ii) eligible for medical assistance
under a State plan under title XIX; or
``(iii) enrolled for child health
assistance or pregnancy-related assistance
under a State plan under title XXI.
``(C) Regulations.--The Secretary shall promulgate
a rule for determining residency for purposes of
subparagraph (A).
``(3) Employer-sponsored plans.--
``(A) Employer enrollment.--Effective with respect
to the first plan year that begins 1 year after the
date of enactment of the Choose Medicare Act and each
plan year thereafter, the Secretary shall provide
options for Medicare part E plans in the small group
market and large group market that are voluntary, and
available to all employers.
``(B) Group health plans.--The Secretary, acting
through the Administrator for the Centers for Medicare
& Medicaid Services, at the request of a plan sponsor,
shall serve as a third party administrator of a group
health plan that is a Medicare part E plan offered by
such sponsor.
``(C) Portability for employer-sponsored plans.--
The Secretary shall develop a process for allowing
individuals enrolled in a Medicare part E plan offered
in the small group market or large group market to
maintain health insurance coverage through a Medicare
part E plan if the individual subsequently loses
eligibility for enrollment in such a plan based on
termination of the employment relationship. The ability
to maintain such coverage shall exist regardless of
whether the individual has the option to enroll in
other health insurance coverage, including coverage
offered in the individual market or through a
subsequent employer.
``(d) Premiums.--The Secretary shall establish premium rates for
the Medicare part E plans that--
``(1) are adjusted based on--
``(A) whether the plan is offered in the individual
market, small group market, or large group market; and
``(B) the applicable rating area;
``(2) are at a level sufficient to fully finance--
``(A) the costs of health benefits provided by such
plans; and
``(B) administrative costs related to operating the
plans; and
``(3) comply with the requirements under section 2701 of
the Public Health Service Act (42 U.S.C. 300gg), including for
such plans that are offered in the large group market.
``(e) Providers and Reimbursement Rates.--
``(1) In general.--The Secretary shall establish a rate
schedule for reimbursing types of health care providers
furnishing items and services under the Medicare part E plans
at rates that are consistent with the negotiations described in
paragraph (2) and are necessary to maintain network adequacy.
``(2) Manner of negotiation.--The Secretary shall negotiate
the rates described in paragraph (1) in a manner that results
in payment rates that are not lower, in the aggregate, than
rates under title XVIII, and not higher, in the aggregate, than
the average rates paid by other health insurance issuers
offering health insurance coverage through an Exchange.
``(3) Participating providers.--
``(A) In general.--A health care provider that is a
participating provider of services or supplier under
the Medicare program under title XVIII on the date of
enactment of the Choose Medicare Act shall be a
participating provider for Medicare part E plans.
``(B) Additional providers.--The Secretary shall
establish a process to allow health care providers not
described in subparagraph (A) to become participating
providers for Medicare part E plans.
``(4) Limitations on balance billing.--The limitations on
balance billing pursuant to the provisions of section
1866(a)(1)(A) shall apply to participating providers for
Medicare part E plans in the same manner as such provisions
apply to participating providers under the Medicare program.
``(f) Encouraging Use of Alternative Payment Models.--The Secretary
shall, as applicable, utilize alternative payment models, including
those described in section 1833(z)(3)(C), in making payments for items
and services (including prescription drugs) furnished under Medicare
part E plans. The payment rates under such alternative payment models
shall comply with the requirement for negotiated rates under subsection
(e)(2).
``(g) Prescription Drugs.--The Secretary shall apply the provisions
of part E of title XI to prescription drugs under Medicare part E plans
in the same manner as such provisions apply with respect to selected
drugs under part E of title XI.
``(h) Appropriations.--
``(1) Start up funding.--For purposes of establishing the
Medicare part E plans, there is appropriated to the Secretary,
out of any funds in the Treasury not otherwise obligated,
$2,000,000,000, for fiscal year 2026.
``(2) Initial reserves.--There is appropriated to the
Secretary, out of any funds in the Treasury not otherwise
obligated, such sums as may be necessary, based on projected
enrollment in the Medicare part E plans in the first plan year
in which such plans are offered, to provide reserves for the
purpose of paying claims filed during the initial 90-day period
of such plan year.
``(3) Clarification.--Any provision of law restricting the
use of Federal funds with respect to any reproductive health
service shall not apply to funds appropriated under paragraph
(1) or (2).
``(i) Health Insurance Issuer.--With respect to any Medicare part E
plan, the Secretary shall be considered a health insurance issuer,
within the meaning of section 2791(b) of the Public Health Service Act
(42 U.S.C. 300gg-91(b)).''.
(b) Application of Excise Tax for Noncompliance With Negotiation
Requirements.--Section 5000D(e)(1) of the Internal Revenue Code of 1986
is amended by adding at the end the following new sentence: ``Such term
shall apply to any drug treated in the same manner as a drug described
in the preceding sentence by reason of section 2201(g) of the Social
Security Act.''.
SEC. 3. NOTICE AND NAVIGATOR REFERRAL FOR EMPLOYEES UNDER THE FAIR
LABOR STANDARDS ACT OF 1938.
(a) In General.--Section 18B of the Fair Labor Standards Act of
1938 (29 U.S.C. 218b) is amended--
(1) in the heading, by striking ``to'' and inserting ``and
navigator referral for'';
(2) by redesignating subsection (b) as subsection (c);
(3) by inserting after subsection (a) the following:
``(b) Navigator Referral.--
``(1) In general.--An employer described in paragraph (3)
shall refer each employee who is a full-time employee (as
defined in section 4980H(c) of the Internal Revenue Code of
1986) to--
``(A) an entity that serves as a navigator under
section 1311(i) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18031(i)) for the
Exchange operating in the State of the employer; or
``(B) if the Exchange operating in the State of the
employer does not have an entity serving as such a
navigator, another entity that shall carry out
equivalent activities as such a navigator.
``(2) Referral.--The referral described in paragraph (1)
shall occur--
``(A) at the time the employer hires the employee;
or
``(B) on the effective date described in subsection
(c)(2) with respect to an employee who is currently
employed by the employer on such date.
``(3) Employer.--An employer described in this paragraph is
any employer that--
``(A) does not provide an eligible employer-
sponsored plan as defined in section 5000A(f)(2) of the
Internal Revenue Code of 1986; or
``(B) provides such an eligible employer-sponsored
plan, but the plan is determined--
``(i) to be unaffordable to the employee
under clause (i) of section 36B(c)(2)(C) of
such Code; or
``(ii) to not provide the required minimum
value under clause (ii) of such section.''; and
(4) in subsection (c), as so redesignated--
(A) in the heading, by striking ``Effective Date''
and inserting ``Effective Dates'';
(B) by striking ``Subsection (a)'' and inserting
the following:
``(1) Notice.--Subsection (a)''; and
(C) by adding at the end the following:
``(2) Navigator referral.--Subsection (b) shall take effect
with respect to employers in a State beginning on the date that
is 2 years after the date of enactment of the Choose Medicare
Act.''.
(b) Study.--Not later than January 1, 2030, the Comptroller General
of the United States shall conduct a study on the impact of the
requirements under section 18B of the Fair Labor Standards Act of 1938
(29 U.S.C. 218b), including the amendments made by subsection (a), on
the rate of individuals without minimum essential coverage as defined
in section 5000A(f) of the Internal Revenue Code of 1986 in the United
States and in each State.
(c) Funding for Navigator Program.--Section 1311(i)(6) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18031(i)(6)) is
amended--
(1) by striking ``Grants'' and inserting the following:
``(A) In general.--Grants''; and
(2) by adding at the end the following:
``(B) Authorization of appropriations.--There is
authorized to be appropriated such sums as may be
necessary to address capacity limitations of entities
serving as navigators through a grant under this
subsection.''.
SEC. 4. PROTECTING AGAINST HIGH OUT-OF-POCKET EXPENDITURES FOR MEDICARE
FEE-FOR-SERVICE BENEFITS.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is
amended by adding at the end the following new section:
``protection against high out-of-pocket expenditures
``Sec. 1899C. (a) In General.--Notwithstanding any other provision
of this title, in the case of an individual entitled to, or enrolled
for, benefits under part A or enrolled in part B, if the amount of the
out-of-pocket cost-sharing of such individual for a year (beginning
with 2027) equals or exceeds the annual out-of-pocket limit under
subsection (b) for that year, the individual shall not be responsible
for additional out-of-pocket cost-sharing incurred during that year.
``(b) Annual Out-of-Pocket Limit.--
``(1) In general.--The amount of the annual out-of-pocket
limit under this subsection shall be--
``(A) for 2027, $6,700; or
``(B) for a subsequent year, the amount specified
in this subsection for the preceding year increased or
decreased by the percentage change in the medical care
component of the Consumer Price Index for All Urban
Consumers for the 12-month period ending with June of
such preceding year.
``(2) Rounding.--If any amount determined under paragraph
(1)(B) is not a multiple of $5, such amount shall be rounded to
the nearest multiple of $5.
``(c) Out-of-Pocket Cost-Sharing Defined.--
``(1) In general.--Subject to paragraphs (2) and (3), in
this section, the term `out-of-pocket cost-sharing' means, with
respect to an individual, the amount of the expenses incurred
by the individual that are attributable to--
``(A) deductibles, coinsurance, and copayments
applicable under part A or B; or
``(B) for items and services that would have
otherwise been covered under part A or B but for the
exhaustion of those benefits.
``(2) Certain costs not included.--
``(A) Non-covered items and services.--Expenses
incurred for items and services which are not covered
under part A or B shall not be considered incurred
expenses for purposes of determining out-of-pocket
cost-sharing under paragraph (1).
``(B) Items and services not furnished on an
assignment-related basis.--If an item or service is
furnished to an individual under this title and is not
furnished on an assignment-related basis, any
additional expenses the individual incurs above the
amount the individual would have incurred if the item
or service was furnished on an assignment-related basis
shall not be considered incurred expenses for purposes
of determining out-of-pocket cost-sharing under
paragraph (1).
``(3) Source of payment.--For purposes of paragraph (1),
the Secretary shall consider expenses to be incurred by the
individual without regard to whether the individual or another
person, including a State program, an employer, a medicare
supplemental policy, or other third-party coverage, has paid
for such expenses.
``(d) Announcement of the Annual Out-of-Pocket Limit.--The
Secretary shall (beginning in 2026) announce (in a manner intended to
provide notice to all interested parties) the annual out-of-pocket
limit under this section that will be applicable for the succeeding
year.''.
SEC. 5. ENHANCEMENT OF PREMIUM ASS