H. R. 3775

117

CONGRESS

ESSION

H. R. 3775

To amend title I of the Patient Protection and Affordable Care Act to

authorize the establishment of, and provide support for, State-based

universal health care systems that provide comprehensive health benefits

to State residents, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

UNE

8, 2021

Mr. K

HANNA

(for himself, Ms. P

INGREE

, Mr. R

ASKIN

, Mr. L

EVIN

of Michi-

gan, Mr. B

LUMENAUER

, Ms. L

of California, Ms. J

AYAPAL

, Mr. S

MITH

of Washington, Mr. P

OCAN

, Ms. O

MAR

, Ms. N

ORTON

, Mr. D

AZIO

, Mr.

EGUSE

, Ms. T

LAIB

, Ms. P

RESSLEY

, Mr. G

RIJALVA

, Mr. M

ICHAEL

OYLE

of Pennsylvania, Mr. H

UFFMAN

, Ms. B

ONAMICI

, Ms. S

CHA

KOWSKY

, Mrs. W

ATSON

OLEMAN

, Mr. B

OWMAN

, Mr. G

ARCI

of Illinois,

Mr. J

ONES

, and Mr. T

HOMPSON

of California) introduced the following

bill; which was referred to the Committee on Energy and Commerce, and

in addition to the Committees on Ways and Means, Armed Services,

Oversight and Reform, and Education and Labor, for a period to be sub-

sequently determined by the Speaker, in each case for consideration of

such provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend title I of the Patient Protection and Affordable

Care Act to authorize the establishment of, and provide

support for, State-based universal health care systems

that provide comprehensive health benefits to State resi-

dents, and for other purposes.

Be it enacted by the Senate and House of Representa-1

tives of the United States of America in Congress assembled, 2

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SECTION 1. SHORT TITLE; PURPOSE. 1

(a) S

HORT

ITLE

.—This Act may be cited as the 2

‘‘State-Based Universal Health Care Act of 2021’’. 3

(b) P

URPOSE

.—The purpose of this Act is to estab-4

lish a flexible framework under which States can provide 5

comprehensive universal health coverage to their residents. 6

SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 7

(a) I

ENERAL

.—Subtitle D of title I of the Patient 8

Protection and Affordable Care Act (42 U.S.C. 18021 et 9

seq.) is amended by inserting after section 1334 the fol-10

lowing new section: 11

‘‘SEC. 1335. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 12

‘‘(a) A

PPLICATION

.— 13

‘‘(1) I

N GENERAL

.—Subject to paragraph (6), a 14

State may apply to the Secretary (as defined in sub-15

section (i)(3)) for the waiver of so much of the re-16

quirements described in paragraph (2) with respect 17

to health benefits coverage within the State for plan 18

years beginning on or after January 1, 2022, as is 19

necessary to implement a comprehensive State uni-20

versal health care plan in the State under this sec-21

tion. Such application shall— 22

‘‘(A) be filed at such time and in such 23

manner as the Secretary may require; 24

‘‘(B) contain such information as the Sec-25

retary may require, including— 26

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‘‘(i) a comprehensive description of 1

the State legislation, or other State legal 2

authority as applicable, and program to 3

implement a plan meeting the require-4

ments for a waiver under this section; 5

‘‘(ii) a plan for how the State will 6

achieve in 5 years health coverage for at 7

least 95 percent of residents of the State; 8

and 9

‘‘(iii) a 10-fiscal-year budget plan for 10

such plan that is budget neutral for the 11

Federal Government; and 12

‘‘(C) provide an assurance that the State 13

has legal authority to implement such plan or 14

has enacted the law described in subsection 15

(b)(2). 16

‘‘(2) R

EQUIREMENTS

.—The requirements de-17

scribed in this paragraph with respect to health ben-18

efits coverage within the State for plan years begin-19

ning on or after January 1, 2022, are as follows: 20

‘‘(A) Sections 1301 through 1324. 21

‘‘(B) Section 1402. 22

‘‘(C) Sections 36B and 4980H of the In-23

ternal Revenue Code of 1986. 24

‘‘(D) Title XI of the Social Security Act. 25

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‘‘(E) Title XVIII of the Social Security 1

Act. 2

‘‘(F) Title XIX of the Social Security Act. 3

‘‘(G) Title XXI of the Social Security Act. 4

‘‘(H) Chapter 89 of title 5, United States 5

Code. 6

‘‘(I) Chapter 55 of title 10, United States 7

Code, including coverage under the TRICARE 8

program. 9

‘‘(J) Section 514 of the Employee Retire-10

ment Income Security Act of 1974. 11

‘‘(3) P

ASSTHROUGH OF FUNDING

.—With re-12

spect to a State waiver under paragraph (1), under 13

which the State assumes responsibility for health 14

coverage under one or more of the specified Federal 15

health programs, including under each of the Fed-16

eral health care or subsidy programs specified in 17

subparagraphs (A), (B), (C), (E), (F), (G), (H), and 18

(I) of paragraph (2), the Secretary shall not spend 19

Federal health or related administrative funds that 20

would otherwise have been spent for such a pro-21

gram, as applicable, for the time periods covered 22

under the waiver and shall provide for an alternative 23

means by which the aggregate amount of such funds 24

(determined by the Secretary in coordination with 25

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the State), including caseload growth, adjusted for 1

inflation in health care costs within the State, shall 2

be paid to the State for purposes of implementing 3

the State plan under the waiver. Any savings in 4

health care spending, including administrative sav-5

ings, shall be available to the State for reinvestment 6

in health care services under the State plan. Such 7

amount shall be determined annually by the Sec-8

retary, taking into account the amount that would 9

otherwise have been spent under each such Federal 10

health program, including for administrative activi-11

ties and caseload growth, with respect to residents 12

of such State, for those time periods covered under 13

the waiver, adjusted for inflation in health care 14

costs, if such waiver did not apply. Such amount 15

shall include funds equal to the aggregate amount of 16

premium tax credits, cost-sharing reductions, or 17

small-business credits, to the extent applicable to an 18

approved waiver, under sections 36B and 45R of the 19

Internal Revenue Code of 1986 or under section 20

1402 that would have been available to individuals 21

and businesses in the State for those time periods 22

covered under the waiver, including caseload growth, 23

adjusted for inflation in health care costs, if such 24

waiver did not apply. 25

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‘‘(4) W

AIVER CONSIDERATION AND TRANS

-1

PARENCY

.— 2

‘‘(A) I

N GENERAL

.—An application for a 3

waiver under this section shall be considered by 4

the Secretary, after taking into account rec-5

ommendations of the Panel under subsection 6

(g), in accordance with the regulations de-7

scribed in subparagraph (B). 8

‘‘(B) R

EGULATIONS

.—Not later than 180 9

days after the date of the enactment of the 10

State-Based Universal Health Care Act of 11

2021, the Secretary shall promulgate regula-12

tions relating to waivers under this section that 13

provide— 14

‘‘(i) a process for public notice and 15

comment in accordance with the public no-16

tice and comment requirements applicable 17

under regulations used for Medicaid waiv-18

ers pursuant to section 1115 of the Social 19

Security Act; 20

‘‘(ii) a process for the submission of 21

an application that ensures the disclosure 22

of— 23

‘‘(I) the provisions of law that 24

the State involved seeks to waive; and 25

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‘‘(II) the specific plans of the 1

State to ensure that the waiver will be 2

in compliance with subsection (b); 3

‘‘(iii) a process for providing public 4

notice and comment after the application is 5

received by the Secretary that is sufficient 6

to ensure a meaningful level of public 7

input and that does not impose require-8

ments that are in addition to, or duplica-9

tive of, requirements imposed under chap-10

ter 5 of title 5, United States Code (com-11

monly referred to as the Administrative 12

Procedure Act), or requirements that are 13

unreasonable or unnecessarily burdensome 14

with respect to State compliance; 15

‘‘(iv) a process for the submission to 16

the Secretary of periodic reports by the 17

State concerning the implementation of the 18

program under the waiver; 19

‘‘(v) a process for the periodic evalua-20

tion by the Secretary with respect to waiv-21

ers granted under this section; and 22

‘‘(vi) a process for providing technical 23

assistance on— 24

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‘‘(I) how to develop an applica-1

tion to any State seeking to submit an 2

application for a waiver relating to de-3

veloping a program of providing 4

health care for all residents for such 5

State; and 6

‘‘(II) how to improve such a pro-7

gram for purposes of a State seeking 8

assistance pursuant to subsection 9

(e)(2). 10

‘‘(C) R

EPORT

.—The Secretary shall annu-11

ally report to Congress concerning actions 12

taken by the Secretary with respect to applica-13

tions for waivers under this section and pro-14

grams conducted pursuant to such waivers that 15

are approved. 16

‘‘(5) R

EGIONAL WAIVER REQUEST AND PLAN

.— 17

Nothing in this section shall be construed to prevent 18

two or more States in a region from submitting a 19

single application under this section for a waiver 20

that establishes a plan that is applicable to all of the 21

States included in such application. In the case of 22

such an application and plan, the requirements of 23

this section shall continue to be applicable with re-24

spect to each State included in such application. 25

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‘‘(6) C

OORDINATION WITH 1332 WAIVERS

.—A 1

State may not apply for a waiver under this section 2

with respect to a plan year if such State has in ef-3

fect, with respect to such plan year, a waiver under 4

section 1332. 5

‘‘(7) A

UTHORIZATION OF APPROPRIATIONS

.— 6

There is authorized to be appropriated such sums as 7

may be necessary for providing funds to States with 8

a waiver under this section for purposes of carrying 9

out activities described in subsection (b)(1)(E). 10

‘‘(b) G

RANTING OF

AIVERS

.— 11

‘‘(1) I

N GENERAL

.—The Secretary shall grant a 12

request for a waiver under subsection (a)(1) if the 13

Secretary determines that the State plan— 14

‘‘(A) will provide, in accordance with sub-15

paragraph (B), health benefits coverage to ap-16

plicable State residents that is at least as com-17

prehensive as the health benefits coverage that 18

such residents would have received under one or 19

more of the specified Federal health programs 20

(as defined in subsection (i)(4)), as applicable, 21

for which such residents would have been eligi-22

ble, absent such waiver; 23

‘‘(B) will provide, in the case of such a 24

waiver under subsection (a)(1) for the State to 25

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waive any of the requirements described in sub-1

section (a)(2)(F), as applicable, health benefits 2

coverage to applicable State residents who 3

would have otherwise received health benefits 4

coverage in the form of medical assistance 5

under the State Federal health program de-6

scribed in subsection (i)(4)(B) (regardless of 7

whether the State provides for such assistance 8

through a State Medicaid plan under title XIX 9

of the Social Security Act or a waiver of such 10

State Medicaid plan) that includes at least the 11

mandatory benefits under title XIX of the So-12

cial Security Act that are required of a State 13

without a waiver of a State Medicaid plan 14

under such title, including benefits for early 15

and periodic screening, diagnostic, and treat-16

ment, benefits for non-emergency transpor-17

tation, and retroactive coverage; 18

‘‘(C) will provide coverage and cost-sharing 19

protections against excessive out-of-pocket 20

spending to State residents that are at least as 21

affordable as the coverage and cost-sharing pro-22

tections under the specified Federal health pro-23

gram (as defined in subsection (i)(4)) for which 24

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such residents would have been eligible, absent 1

such waiver; 2

‘‘(D) will provide coverage to all residents 3

of the State, including those otherwise covered 4

under one or more of the Federal health care 5

or subsidy programs specified in subparagraphs 6

(B), (C), (E), (F), (G), and (H) of subsection 7

(a)(2), except individuals who are eligible for 8

benefits through the Indian Health Service or 9

for benefits and services under title 38, United 10

States Code; 11

‘‘(E) will provide for public education ac-12

tivities to raise awareness of the availability of 13

qualified health plans and the facilitation of en-14

rollment in such coverage in a manner similar 15

to an entity that serves as a navigator under a 16

grant under section 1311(i); 17

‘‘(F) will be publicly administered by an 18

agency or multiple agencies of the State, or an 19

independent public entity within the govern-20

ment of the State; 21

‘‘(G) will not preclude the purchase of in-22

surance that offers coverage for benefits that 23

are not offered under the State plan; and 24

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‘‘(H) will provide systems for complaints, 1

appeals, independent review, and other proce-2

dures for accessing and maintaining benefits 3

that are at least as accessible to applicable 4

State residents as those of one or more of the 5

specified Federal health programs (as defined 6

in subsection (i)(4)) for which such residents 7

would have otherwise been eligible without ap-8

plication of such waiver under subsection 9

(a)(1). 10

Subparagraph (D) shall not be construed as limiting 11

a State from contracting with one or more private 12

entities to administer the State plan. 13

‘‘(2) R

EQUIREMENT TO ENACT A LAW

.— 14

‘‘(A) I

N GENERAL

.—A law described in 15

this paragraph is a State law (including an ex-16

ecutive order by a State governor) that provides 17

for State actions under a waiver under this sec-18

tion, including the implementation of the State 19

plan under subsection (a)(1)(B). 20

‘‘(B) T

ERMINATION OF OPT OUT

.—A State 21

may repeal a law described in subparagraph (A) 22

and terminate the authority provided under the 23

waiver with respect to the State. 24

‘‘(c) S

COPE OF

AIVER

.— 25

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‘‘(1) I

N GENERAL

.—The Secretary shall deter-1

mine the scope of a waiver of a requirement de-2

scribed in subsection (a)(2) granted to a State under 3

subsection (a)(1). 4

‘‘(2) L

IMITATION

.—Under this section, the Sec-5

retary may not waive any Federal law or require-6

ment that is not listed in subsection (a)(2). 7

‘‘(d) D

ETERMINATIONS BY

ECRETARY

.— 8

‘‘(1) T

IME FOR DETERMINATION

.—The Sec-9

retary shall, with respect to an application from a 10

State under this section and after taking into ac-11

count recommendations of the Panel under sub-12

section (g) for such application, make a determina-13

tion under subsection (a)(1) not later than 90 days 14

after the receipt of such recommendations. 15

‘‘(2) E

FFECT OF DETERMINATION

.— 16

‘‘(A) G

RANTING OF WAIVERS

.—If the Sec-17

retary determines to grant a waiver under sub-18

section (a)(1), the Secretary shall notify the 19

State involved of such determination and the 20

terms and effectiveness of such waiver. 21

‘‘(B) D

ENIAL OF WAIVER

.—If the Sec-22

retary determines a waiver should not be grant-23

ed under subsection (a)(1), the Secretary shall 24

notify the State involved and the appropriate 25

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committees of Congress of such determination 1

and the reasons therefor. 2

‘‘(e) R

EQUIRED

EPORTS

; 5-Y

EAR

EVIEW

.— 3

‘‘(1) I

N GENERAL

.—As a condition of receipt of 4

a waiver under this section, after each 5-year period 5

of such waiver, a State shall submit to the Secretary 6

a report that is carried out by an independent, non- 7

partisan entity, with respect to such 5-year period 8

and after a process for public notice and comment 9

at the State level, including public hearings, suffi-10

cient to ensure a meaningful level of public input, on 11

the following: 12

‘‘(A) How waiver funds have been spent by 13

the State. 14

‘‘(B) The number of residents of the State 15

without health insurance and a description of 16

how the State plans to provide health insurance 17

coverage within the subsequent 5 years to resi-18

dents of the State without health insurance. 19

‘‘(C) How affordability in the State for 20

health care has changed over the period. 21

‘‘(D) Whether the State has achieved 22

health coverage for at least 95 percent of the 23

residents of the State. 24

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‘‘(E) Measurable changes in quality and 1

access. 2

‘‘(F) Any additional information specified 3

by the Secretary for purposes of determining 4

the successes and challenges of the waiver. 5

‘‘(2) 5-

YEAR REVIEW

.—In the case a State, 6

based on the report submitted under paragraph (1) 7

for a 5-year period— 8

‘‘(A) has been determined by the Secretary 9

to have not achieved health coverage for at least 10

95 percent of the residents of the State— 11

‘‘(i) the State shall have access to 12

technical assistance described in subsection 13

(a)(4)(B)(vii) to improve the health insur-14

ance program of the State implemented 15

through the waiver under this section; 16

‘‘(ii) the State shall have a grace pe-17

riod of 12 months after such determination 18

to achieve health coverage for at least 95 19

percent of residents of the State; and 20

‘‘(iii) if after such 12 months, the 21

State has not achieved such health cov-22

erage, the waiver under this section may be 23

terminated at the discretion of the Sec-24

retary; and 25

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‘‘(B) has been determined by the Secretary 1

to have achieved health coverage for at least 95 2

percent of residents of the State, the State, as 3

a condition of continuing such waiver, shall sub-4

mit to the Secretary a plan for achieving health 5

coverage for the remainder of the residents of 6

the State. 7

‘‘(f) A

SSURING

OORDINATION

.— 8

‘‘(1) I

N GENERAL

.—Not later than 180 days 9

after the date of the enactment of the State-Based 10

Universal Health Care Act of 2021, the Secretary of 11

Health and Human Services, the Secretary of the 12

Treasury, the Secretary of Defense, the Secretary of 13

Labor, and the Director of the Office of Personnel 14

Management, shall, through the execution of an 15

interagency memorandum of understanding among 16

such Secretaries and Director— 17

‘‘(A) develop a process for coordinating 18

and consolidating the State waiver processes 19

applicable under the provisions of this section, 20

and the existing waiver processes applicable 21

under— 22

‘‘(i) titles XI, XVIII, XIX, and XXI 23

of the Social Security Act; and 24

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‘‘(ii) any other Federal law relating to 1

the provision of health care items or serv-2

ices; and 3

‘‘(B) ensure that— 4

‘‘(i) regulations (including regulations 5

required under subsection (a)(4)(B)), rul-6

ings, and interpretations issued by such 7

Secretaries and Director relating to the 8

same matter over which two or more such 9

Secretaries or Director have responsibility 10

under this section are administered so as 11

to have the same effect at all times; and 12

‘‘(ii) coordination of policies relating 13

to the granting, implementation, and con-14

tinuation of waivers through such Secre-15

taries and Director in order to have a co-16

ordinated strategy that avoids duplication 17

of effort by the States or Secretaries and 18

Director and ensures clarity about waiver 19

application status and approval. 20

‘‘(2) S

INGLE APPLICATION

.—The process under 21

paragraph (1)(A) shall permit a State to submit a 22

single application for a waiver under all of the provi-23

sions of this section and the provisions of law listed 24

under clauses (i) and (ii) of such paragraph. 25

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‘‘(3) S

UBMISSION OF CONFORMING AMEND

-1

MENTS

.—The Secretary of Health and Human Serv-2

ices, in coordination with the other Secretaries listed 3

in paragraph (1) (including the Director of the Of-4

fice of Personnel Management), shall submit to Con-5

gress such recommendations for such technical and 6

conforming amendments to law as may be appro-7

priate to assist in the implementation of this section. 8

‘‘(g) I

NDEPENDENT

SSESSMENT

ANEL FOR

-9

PREHENSIVE

EALTH

ARE

.— 10

‘‘(1) E

STABLISHMENT

.—There is established a 11

committee to be known as the ‘Independent Assess-12

ment Panel for Comprehensive Health Care’ (in this 13

section referred to as the ‘Panel’). 14

‘‘(2) C

ONSIDERATION OF SUBMISSIONS

.—The 15

Secretary shall forward a copy of each waiver appli-16

cation submitted under this section to the Panel for 17

consideration under this subsection. 18

‘‘(3) D

UTIES

.—The Panel shall— 19

‘‘(A) review any waiver application by a 20

State forwarded under paragraph (2) and any 21

report submitted under paragraph (1) of sub-22

section (e) for purposes of the review under 23

paragraph (2) of such subsection; 24

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‘‘(B) not later than 90 days after submis-1

sion of such application (or report) by the 2

State, provide to the State and to the Secretary 3

the recommendations of the Panel regarding 4

the approval or disapproval of such waiver ap-5

plication (or regarding the status of the waiver 6

for continuation pursuant to subsection (e)(2)) 7

and, if applicable, possible improvements to 8

such application (or for purposes of subsection 9

(e)(2)); and 10

‘‘(C) submit to Congress an annual report 11

on waiver applications (and waiver reports 12

under subsection (e)) reviewed by the Panel 13

during the applicable year, including the num-14

ber of applications (and reports) received and 15

the number of applications recommended for 16

approval (and of reports with respect to which 17

recommendations for continuation were pro-18

vided). 19

‘‘(4) M

EMBERSHIP

.— 20

‘‘(A) N

UMBER AND APPOINTMENT

.—The 21

Panel shall consist of 11 members appointed by 22

the Secretary of Health and Human Services, 23

of whom— 24

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‘‘(i) one shall be appointed on the rec-1

ommendation of the Speaker of the House 2

of Representatives; 3

‘‘(ii) one shall be appointed on the 4

recommendation of the minority leader of 5

the House of Representatives; 6

‘‘(iii) one shall be appointed on the 7

recommendation of the majority leader of 8

the Senate; 9

‘‘(iv) one shall be appointed on the 10

recommendation of the minority leader of 11

the Senate; 12

‘‘(v) one shall be appointed on the rec-13

ommendation of the Republican Governors 14

Association; 15

‘‘(vi) one shall be appointed on the 16

recommendation of the Democratic Gov-17

ernors Association; 18

‘‘(vii) one shall be a representative 19

from the patient advocacy community; 20

‘‘(viii) two shall be representatives of 21

a labor organization representing health 22

care professionals who provide direct pa-23

tient care, including at least one labor or-24

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ganization that primarily represents reg-1

istered nurses; 2

‘‘(ix) one shall be a representative of 3

primary care physicians; and 4

‘‘(x) one shall be a representative of 5

health care professionals practicing in 6

rural or underserved areas. 7

‘‘(B) T

ERM OF SERVICE

.— 8

‘‘(i) I

N GENERAL

.—Each member of 9

the Panel shall serve a three-year term. A 10

member may serve after the expiration of 11

that member’s term until a successor has 12

been appointed pursuant to subparagraph 13

(A). 14

‘‘(ii) V

ACANCY

.—Any member ap-15

pointed to fill a vacancy occurring before 16

the expiration of the term for which the 17

member’s predecessor was appointed shall 18

be appointed only for the remainder of that 19

term. A vacancy in the Commission shall 20

be filled in the manner in which the origi-21

nal appointment was made. 22

‘‘(C) P

.—Members of the Panel shall 23

serve without pay. 24

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‘‘(D) C

HAIRPERSON

;

VICE CHAIR

-1

PERSON

.— 2

‘‘(i) C

HAIRPERSON

.—The Secretary of 3

Health and Human Services, or a designee 4

of the Secretary, shall serve on the Panel 5

as the Chairperson of the Panel. 6

‘‘(ii) V

ICE CHAIRPERSON

.—The Ad-7

ministrator of the Federal Emergency 8

Management Agency, or a designee of the 9

Administrator, shall serve on the Panel as 10

the Vice Chairperson of the Panel. 11

‘‘(5) S

TAFF

EXPERTS

AND CONSULTANTS

.— 12

The Panel may— 13

‘‘(A) appoint such staff as the Panel con-14

siders to be appropriate, without regard to the 15

provisions of title 5, United States Code, gov-16

erning appointments in the competitive service; 17

‘‘(B) fix the pay of such staff, without re-18

gard to the provisions of chapter 51 and sub-19

chapter III of chapter 53 of such title relating 20

to classification and General Schedule pay 21

rates; and 22

‘‘(C) procure the services of experts and 23

consultants in accordance with the provisions of 24

section 3109(b) of such title. 25

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‘‘(6) D

ETAIL OF FEDERAL PERSONNEL

.—Upon 1

request of the Panel, the head of any Federal agency 2

may detail, on a reimbursable basis, any of the per-3

sonnel of the agency to the Panel to assist it in car-4

rying out the duties under paragraph (3). 5

‘‘(7) F

EDERAL ADVISORY COMMITTEE ACT

.— 6

The Federal Advisory Committee Act (5 U.S.C. 7

App.) shall apply to the Panel. 8

‘‘(8) A

UTHORIZATION OF APPROPRIATIONS

.— 9

There is authorized to be appropriated such sums as 10

may be necessary to the Panel for carrying out the 11

duties of the panel for each of fiscal years 2022 12

through 2027. 13

‘‘(h) G

UIDANCE

ELATING TO

MERICAN

NDIANS

AND

LASKA

ATIVES

.— 15

‘‘(1) I

N GENERAL

.—The Secretary shall issue 16

guidance with respect to applying the provisions of 17

this section in a manner consistent with the fol-18

lowing: 19

‘‘(A) To further the goal that Federal 20

health services to maintain and improve the 21

health of Indians are consonant with and re-22

quired by the Federal Government’s historical 23

and unique legal relationship with, and result-24

ing responsibility to, Indians. 25

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‘‘(B) No enrollment fee, premium, or simi-1

lar charge, and no deduction, copayment, cost 2

sharing, or similar charge, is to be imposed 3

against an Indian who is furnished an item or 4

service through a waiver under this section. All 5

costs incurred in waiving such charges shall be 6

borne by the Federal Government in fulfillment 7

of the trust responsibility. 8

‘‘(C) A State may not require the enroll-9

ment of an individual who is an Indian in 10

health insurance offered through a waiver under 11

this section. 12

‘‘(D) Health insurance issuers offering cov-13

erage pursuant to a waiver under this section 14

must make good faith efforts to contract with 15

Indian health care providers operating within 16

the area served by the issuers. 17

‘‘(E) Health insurance issuers offering cov-18

erage pursuant to a waiver under this section 19

shall pay Indian health care providers, whether 20

such providers are participating or nonpartici-21

pating providers with respect to the coverage, 22

for covered services provided to those Indian 23

enrollees who are eligible to receive services 24

from such providers at a rate equal to the rate 25

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negotiated between such entity and the provider 1

involved or, if such a rate has not been nego-2

tiated, at a rate that is not less than the level 3

and amount of payment which the entity would 4

make for the services if the services were fur-5

nished by a participating provider which is not 6

an Indian health care provider. 7

‘‘(F) Health insurance issuers offering cov-8

erage pursuant to a waiver under this section 9

will include a standard contract addendum 10

when contracting with Indian health care pro-11

viders. The contract addendum will be devel-12

oped in consultation with Tribes and in con-13

ference with urban Indian health programs op-14

erating within the service area of the State. 15

‘‘(G) The treatment of Indians under this 16

section does not constitute invidious racial dis-17

crimination in violation of the due process 18

clause of the Fifth or Fourteenth Amendments, 19

but is reasonable and rationally designed to fur-20

ther the health of Indians. 21

‘‘(H) In the case of any State in which 1 22

or more Indian health care programs furnishes 23

health care services, the State will provide for 24

a process under which the State seeks advice on 25

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a regular, ongoing basis from designees of such 1

Indian health care programs and urban Indian 2

organizations on matters relating to the appli-3

cation of a waiver under this section that are 4

likely to have a direct effect on such Indian 5

health programs and that— 6

‘‘(i) shall include solicitation of advice 7

prior to submission of any plan amend-8

ments, waiver requests, and proposals for 9

demonstration projects likely to have a di-10

rect effect on Indians or Indian health care 11

programs; and 12

‘‘(ii) may include appointment of an 13

advisory committee and of a designee of 14

such Indian health care programs to the 15

medical care advisory committee advising 16

the State on its waiver under this section. 17

‘‘(2) D

EFINITIONS

.—For purposes of this sub-18

section: 19

‘‘(A) The term ‘Indian’ has the meaning 20

given such term in section 447.50 of title 42, 21

Code of Federal Regulations (as in effect on 22

July 1, 2010). 23

‘‘(B) The term ‘Indian health care pro-24

vider’ has the meaning given such term in sec-25

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tion 438.14(a) of title 42, Code of Federal Reg-1

ulations. 2

‘‘(i) D

EFINITIONS

.—In this section: 3

‘‘(1) H

EALTH BENEFITS COVERAGE

.—The term 4

‘health benefits coverage’— 5

‘‘(A) means— 6

‘‘(i) health insurance coverage, as 7

such term is defined in section 2791(b) of 8

the Public Health Service Act (42 U.S.C. 9

300gg–(b)); and 10

‘‘(ii) coverage under a group health 11

plan, as such term is defined in section 12

2791(a) of the Public Health Service Act 13

(42 U.S.C. 300gg–(a)); and 14

‘‘(B) includes any medical coverage or 15

health benefits provided under one or more of 16

the specified Federal health program described 17

in subparagraphs (A) through (E) of paragraph 18

(4), as applicable to a waiver under subsection 19

(a)(1). 20

‘‘(2) R

ESIDENT

.—With respect to a State, the 21

term ‘resident’ means an individual— 22

‘‘(A) who is— 23

‘‘(i) a citizen or national of the United 24

States; or 25

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‘‘(ii) an alien lawfully residing in the 1

State (including an alien who is granted 2

deferred action or who is otherwise author-3

ized to remain in the United States); and 4

‘‘(B) whose primary residence (as defined 5

by the State) is located in the State. 6

‘‘(3) S

ECRETARY

.—The term ‘Secretary’ 7

means— 8

‘‘(A) the Secretary of Health and Human 9

Services with respect to waivers relating to the 10

provisions described in subparagraphs (A), (B), 11

and (D) through (G) of paragraph (2) of sub-12

section (a); 13

‘‘(B) the Secretary of the Treasury with 14

respect to waivers relating to the provisions de-15

scribed in subparagraph (C) of such paragraph; 16

‘‘(C) the Director of the Office of Per-17

sonnel Management with respect to waivers re-18

lating to the provisions described in subpara-19

graph (H) of such paragraph; 20

‘‘(D) the Secretary of Defense with respect 21

to waivers relating to the provisions described 22

in subparagraph (I) of such paragraph; and 23

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‘‘(E) the Secretary of Labor with respect 1

to waivers relating to the provisions described 2

in subparagraph (J) of such paragraph. 3

‘‘(4) S

PECIFIED FEDERAL HEALTH PROGRAM

.— 4

The term ‘specified Federal health program’ means 5

one or more of the following programs, as applicable 6

to a waiver under subsection (a)(1): 7

‘‘(A) The Medicare program under title 8

XVIII of the Social Security Act. 9

‘‘(B) The Medicaid program under title 10

XIX of the Social Security Act. 11

‘‘(C) The Children’s Health Insurance Pro-12

gram under title XXI of the Social Security 13

Act. 14

‘‘(D) The Federal Employees Health Bene-15

fits Plan under chapter 89 of title 5, United 16

States Code. 17

‘‘(E) Medical coverage under chapter 55 of 18

title 10, United States Code, including coverage 19

under the TRICARE program. 20

‘‘(F) An Exchange established under this 21

subtitle. 22

‘‘(G) Subsidies under section 1402. 23

‘‘(H) Tax credits under sections 36B and 24

45R of the Internal Revenue Code of 1986.’’. 25

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(b) C

LERICAL

MENDMENT

.—The table of contents 1

in section 1(b) of the Patient Protection and Affordable 2

Care Act (42 U.S.C. 18001 note) is amended by inserting 3

after the item relating to section 1334 the following new 4

item: 5

‘‘1335. Waiver for State universal health care.’’.

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