Earned Benefits Equality and Family Reunification Act

Purpose and overall aim

• HR 9054, the Earned Benefits Equality and Family Reunification Act, proposes establishing a 10-year demonstration program under Medicare (Title XVIII) to allow eligible beneficiaries to obtain coverage for health care items, services, premiums, and other cost-sharing through health insurance systems in selected foreign countries.
• The program is designed to be a targeted pilot to evaluate international coverage options and their effect on beneficiary outcomes, federal costs, and US health care capacity.

Key provisions and changes

• Establishment of a new demonstration program (Section 1866H) for international coverage:
  • Implement a 10-year demonstration, to begin within one year of enactment.
  • Allow Applicable Beneficiaries to apply Medicare benefits to coverage in selected foreign health care systems.
  • The Secretary would make payments to or on behalf of Applicable Beneficiaries for costs paid in the selected countries.
• Program design and evaluation (subsection (b)):
  • Goals include improving quality of care for participants, reducing government health care costs, enabling family reunification, and alleviating strain on the U.S. medical infrastructure.
  • Open door forums and stakeholder input (e.g., State Department, clinical/analytical experts, beneficiaries, foreign health system experts) guiding program design.
  • Guidance on quality, affordability, and targeting low-income Americans as participants.
• Selected countries (Section (c)):
  • Initial list to include at least 11 countries or subdivisions, with examples such as Canada, Germany, India, Israel, Korea, the Philippines, Panama, Mexico (states), Dominican Republic, and Ghana.
• Applicable Beneficiaries (Section (d)):
  • Voluntary participation; beneficiaries may terminate at any time (Special Election Period under Medicare rules).
  • Participants must reside in a Selected Country during the period of receiving covered services abroad.
  • Beneficiaries retain access to U.S. covered services and are not required to relinquish US benefits as a condition of participating.
  • The Secretary may cap participants but not below 150,000.
• Provider qualifications (Section (e)):
  • Participating physicians must be in good standing with accreditation/licensing in the Selected Country.
• Payments and funding (Section (f)):
  • Payments for care, cost-sharing, and foreign premiums/insurance paid by beneficiaries can be made by the Secretary in the Selected Country.
  • Payments must be limited so total program costs do not exceed what the Secretary would pay for equivalent US services.
  • No duplicate payments; payments apply only in months the beneficiary resides in the Selected Country and incurs no other US health care costs.
• Role of Medicare Advantage (Section (g)):
  • The program may be administered in part or entirely through Medicare Advantage Organizations.
  • MA payments under the program are treated as if they were standard Medicare Part A/Part B benefits and link to standard prescription drug coverage (not as supplemental PDP coverage).
  • The Secretary can limit the number of MA organizations participating.
• Reporting and evaluation (Section (h)):
  • Annual intermediate and final evaluations to assess achievement of program goals and provide recommendations on expansion.
• Safeguards and accountability (Section (i)):
  • Mandatory fraud, waste, and abuse training for participating physicians within 90 days of implementation and annually thereafter.
  • A system for patients and providers to report WFI (waste, fraud, abuse).
• Definitions (Section (j)):
  • Applicable Beneficiary: criteria define eligibility (enrollment in Part A/B, potential Part C enrollment, residency status, relocation intent, or primary payor status in a Selected Country) and other criteria as Secretary determines.
  • Selected Country: nations or subdivisions with health systems meeting quality and cost criteria comparable to or better than US costs.
• Funding and waivers (Sections (k)-(l)):
  • Administrative funding from 1115A funds; program benefit payments from the Hospital Insurance and Supplementary Medical Insurance Trust Funds.
  • The Secretary may waive any provisions necessary to carry out the program.
• Limitations on review (Section (m)):
  • No administrative or judicial review of the selection of participants or the program’s design/parameters; rights to appeal remain for individuals on certain existing channels.
• Administration (Section (n)):
  • Provisions limiting applicability of Chapter 35 of Title 44 (Paperwork Reduction Act) for program activities.
  • Secretary may contract for program administration without competitive procurement requirements.

Who is affected

• Eligible Medicare beneficiaries who choose to participate (voluntarily) and relocate or reside temporarily in a Selected Country to receive care covered by the foreign health system.
• Physicians and health care providers in Selected Countries who participate and must meet credentialing standards.
• Medicare Advantage organizations, if the program is implemented in whole or part through MA plans.
• U.S. taxpayers and federal health care programs, due to funding and demonstrative nature of the program.

Procedural and timeline aspects

• Implementation timeline: program to be implemented not later than one year after enactment; it would run for 10 years as a demonstration.
• Evaluation: annual intermediate evaluation and a final evaluation to assess outcomes and inform potential expansion.
• Enrollment caps: at least 150,000 Applicable Beneficiaries, with the secretary having discretion on the upper limit based on program design.
• Administrative flexibility: waivers and contracting authorities provided to facilitate program design and operation, with limited standard administrative review.

Potential impact considerations

• Potential benefits: increased family reunification opportunities, exploration of lower-cost or higher-quality international care options, and possible reductions in certain U.S. health system burdens.
• Potential risks: cross-border care quality assurance, continuity of care with U.S. providers, medication and equipment standards, and ensuring beneficiary protections and cost controls in foreign systems.
• Fiscal implications: funding constrained to levels equivalent to US-appropriate costs; requires careful monitoring of international cost-sharing and federal outlays.

If you’d like, I can provide a side-by-side comparison with current Medicare rules and a plain-language FAQ for beneficiaries and providers.