I 

116TH CONGRESS 

1ST SESSION H. R. 1354 

To amend titles XVIII and XIX of the Social Security Act to make improvements to the treatment of the United States territories under the Medicare and Medicaid programs, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 25, 2019 

Ms. PLASKETT (for herself, Miss GONZA ́LEZ-COLO ́N of Puerto Rico, Mrs. 

RADEWAGEN, Mr. SAN NICOLAS, Mr. SERRANO, and Ms. VELA ́ZQUEZ) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and 

Means, 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 amend titles XVIII and XIX of the Social Security Act 

to make improvements to the treatment of the United 

States territories under the Medicare and Medicaid programs, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Territories Health Equity Act of 2019’’. 


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1 (b) TABLE OF CONTENTS.—The table of contents of 

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—MEDICAID 

Sec. 101. Elimination of general Medicaid funding limitations (‘‘cap’’) for territories. 

Sec. 102. Elimination of specific Federal medical assistance percentage 

(FMAP) limitation for territories. 

Sec. 103. Application of Medicaid waiver authority to all of the territories. 

Sec. 104. Permitting Medicaid DSH allotments for territories. 

TITLE II—MEDICARE 

Subtitle A—Part A 

Sec. 201. Calculation of Medicare DSH payments for IPPS hospitals in Puerto 

Rico. 

Sec. 202. Rebasing target amount for hospitals in territories. 

Sec. 203. Medicare DSH target adjustment for hospitals in territories. 

Subtitle B—Part B 

Sec. 211. Application of part B deemed enrollment process to residents of 

Puerto Rico; special enrollment period and limit on late enrollment penalties. 

Subtitle C—Medicare Advantage (Part C) 

Sec. 221. Adjustment in benchmark for low-base payment counties in Puerto 

Rico. 

Subtitle D—Part D 

Sec. 231. Improved use of allocated prescription drug funds by territories. 

Sec. 232. Report on treatment of territories under Medicare part D. 

TITLE III—MISCELLANEOUS 

Sec. 301. Modified treatment of territories with respect to application of ACA 

annual health insurance provider fees. 

Sec. 302. Medicaid and CHIP territory transparency and information. 

Sec. 303. Report on exclusion of territories from Exchanges. 

Sec. 304. Access to coverage for individuals in certain areas without any available Exchange plans. 

Sec. 305. Extension of family-to-family health information centers program to 

territories. 


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1 TITLE I—MEDICAID 

2 SEC. 101. ELIMINATION OF GENERAL MEDICAID FUNDING 

3 LIMITATIONS (‘‘CAP’’) FOR TERRITORIES. 

4 (a) IN GENERAL.—Section 1108 of the Social Secu5 rity Act (42 U.S.C. 1308) is amended— 

6 (1) in subsection (f), in the matter preceding 

7 paragraph (1), by striking ‘‘subsection (g)’’ and in8 serting ‘‘subsections (g) and (h)’’; 

9 (2) in subsection (g)(2), in the matter pre10 ceding subparagraph (A), by inserting ‘‘subsection 

11 (h)’’ after ‘‘subject to’’; and 

12 (3) by adding at the end the following new sub13 section: 

14 ‘‘(h) SUNSET OF MEDICAID FUNDING LIMITATIONS

15 FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE

16 NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 

17 Subsections (f) and (g) shall not apply to Puerto Rico, 

18 the Virgin Islands, Guam, the Northern Mariana Islands, 

19 and American Samoa beginning with fiscal year 2020.’’. 

20 (b) CONFORMING AMENDMENTS.— 

21 (1) Section 1902(j) of the Social Security Act 

22 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 

23 limitation in section 1108(f),’’. 


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1 (2) Section 1903(u) of the Social Security Act 

2 (42 U.S.C. 1396b(u)) is amended by striking para3 graph (4). 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply beginning with fiscal year 2020. 

6 SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 

7 ASSISTANCE PERCENTAGE (FMAP) LIMITA8 TION FOR TERRITORIES. 

9 Section 1905(b) of the Social Security Act (42 U.S.C. 

10 1396d(b)) is amended, in clause (2), by inserting ‘‘for fis11 cal years before fiscal year 2020’’ after ‘‘American 

12 Samoa’’. 

13 SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY 

14 TO ALL OF THE TERRITORIES. 

15 (a) IN GENERAL.—Section 1902(j) of the Social Se16 curity Act (42 U.S.C. 1396a(j)) is amended— 

17 (1) by striking ‘‘American Samoa and the 

18 Northern Mariana Islands’’ and inserting ‘‘Puerto 

19 Rico, the Virgin Islands, Guam, the Northern Mar20 iana Islands, and American Samoa’’; 

21 (2) by striking ‘‘American Samoa or the North22 ern Mariana Islands’’ and inserting ‘‘Puerto Rico, 

23 the Virgin Islands, Guam, the Northern Mariana Is24 lands, or American Samoa’’; 


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1 (3) by inserting ‘‘(1)’’ before ‘‘Notwith2 standing’’; 

3 (4) by inserting ‘‘except as otherwise provided 

4 in this subsection,’’ after ‘‘Notwithstanding any 

5 other requirement of this title’’; and 

6 (5) by adding at the end the following: 

7 ‘‘(2) The Secretary may not waive under this sub8 section the requirement of subsection (a)(10)(A)(i)(IX) 

9 (relating to coverage of adults formerly under foster care) 

10 with respect to any territory.’’. 

11 (b) EFFECTIVE DATE.—The amendments made by 

12 this section shall apply beginning October 1, 2019. 

13 SEC. 104. PERMITTING MEDICAID DSH ALLOTMENTS FOR 

14 TERRITORIES. 

15 Section 1923(f) of the Social Security Act (42 U.S.C. 

16 1396r–4(f)) is amended— 

17 (1) in paragraph (6), by adding at the end the 

18 following new subparagraph: 

19 ‘‘(C) TERRITORIES.— 

20 ‘‘(i) FISCAL YEAR 2020.—For fiscal 

21 year 2020, the DSH allotment for Puerto 

22 Rico, the Virgin Islands, Guam, the North23 ern Mariana Islands, and American Samoa 

24 shall bear the same ratio to $300,000,000 

25 as the ratio of the number of individuals 


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1 who are low-income or uninsured and re2 siding in such respective territory (as esti3 mated from time to time by the Secretary) 

4 bears to the sums of the number of such 

5 individuals residing in all of the territories. 

6 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 

7 For each subsequent fiscal year, the DSH 

8 allotment for each such territory is subject 

9 to an increase in accordance with para10 graph (3).’’; and 

11 (2) in paragraph (9), by inserting before the pe12 riod at the end the following: ‘‘, and includes, begin13 ning with fiscal year 2020, Puerto Rico, the Virgin 

14 Islands, Guam, the Northern Mariana Islands, and 

15 American Samoa’’. 

16 TITLE II—MEDICARE 

17 Subtitle A—Part A 

18 SEC. 201. CALCULATION OF MEDICARE DSH PAYMENTS FOR 

19 IPPS HOSPITALS IN PUERTO RICO. 

20 Section 1886(d)(9)(D)(iii) of the Social Security Act 

21 (42 U.S.C. 1395ww(d)(9)(D)(iii)) is amended to read as 

22 follows: 

23 ‘‘(iii) Subparagraph (F) (relating to dispropor24 tionate share payments), including application of 

25 subsection (r), except that for this purpose— 


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1 ‘‘(I) the sum described in clause (ii) of this 

2 subparagraph shall be substituted for the sum 

3 referred to in paragraph (5)(F)(ii)(I); and 

4 ‘‘(II) for discharges occurring on or after 

5 October 1, 2019, subclause (I) of paragraph 

6 (5)(F)(vi) shall be applied by substituting for 

7 the numerator described in such subclause the 

8 number of subsection (d) Puerto Rico hospital’s 

9 patient days for the cost reporting period in10 volved which were made up of patients who (for 

11 such days) were entitled to benefits under part 

12 A of this title and were— 

13 ‘‘(aa) entitled to supplementary secu14 rity income benefits (excluding any State 

15 supplementation) under title XVI of this 

16 Act; 

17 ‘‘(bb) eligible for medical assistance 

18 under a State plan under title XIX; or 

19 ‘‘(cc) receiving aid or assistance under 

20 any plan of the State approved under title 

21 I, X, XIV, or XVI.’’. 


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1 SEC. 202. REBASING TARGET AMOUNT FOR HOSPITALS IN 

2 TERRITORIES. 

3 Section 1886(b)(3) of the Social Security Act (42 

4 U.S.C. 1395ww(b)(3)) is amended by adding at the end 

5 the following new subparagraph: 

6 ‘‘(M)(i) For each cost reporting period be7 ginning on or after October 1, 2019, in the case 

8 of a hospital located in a territory of the United 

9 States, there shall be substituted for the target 

10 amount otherwise determined under subpara11 graph (A) the rebased target amount (as de12 fined in clause (ii)), if such substitution results 

13 in an amount of payment under this section to 

14 the hospital for such period that is greater than 

15 the amount of payment that would be made 

16 under this section to the hospital for such pe17 riod if this subparagraph were not to apply. 

18 ‘‘(ii) For purposes of this subparagraph, 

19 the term ‘rebased target amount’ has the mean20 ing given the term ‘target amount’ in subpara21 graph (A), except that— 

22 ‘‘(I) there shall be substituted for the 

23 preceding 12-month cost reporting period 

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1 tion of the hospital, beginning during fiscal 

2 year 2017); 

3 ‘‘(II) any reference in subparagraph 

4 (A)(i) to the ‘first such cost reporting pe5 riod’ is deemed a reference to the first cost 

6 reporting period following the 12-month 

7 cost reporting period beginning during fis8 cal year 2015 (or, at the option of the hos9 pital, beginning during fiscal year 2017); 

10 and 

11 ‘‘(III) the applicable percentage in12 crease shall only be applied under subpara13 graph (B)(ii) for cost reporting periods be14 ginning on or after October 1, 2019. 

15 ‘‘(iii) Nothing in this subparagraph shall 

16 affect any pending request by a hospital for a 

17 new target amount for any cost reporting pe18 riod beginning during a fiscal year before fiscal 

19 year 2020.’’. 

20 SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOS21 PITALS IN TERRITORIES. 

22 Section 1886(b)(3) of the Social Security Act (42 

23 U.S.C. 1395ww(b)(3)), as amended by section 202, is fur24 ther amended by adding at the end the following new sub25 paragraph: 


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1 ‘‘(N)(i) For each cost reporting period be2 ginning on or after October 1, 2019, in the case 

3 of a hospital that is located in a territory of the 

4 United States other than Puerto Rico and that 

5 would be a subsection (d) hospital if it were lo6 cated in one of the 50 States, the target 

7 amount shall be increased by— 

8 ‘‘(I) in the case that such hospital has 

9 a disproportionate patient percentage of 

10 not less than 15 percent and not greater 

11 than 40 percent, 10 percent; and 

12 ‘‘(II) in the case that such hospital 

13 has a disproportionate patient percentage 

14 of greater than 40 percent, 10 percent plus 

15 60 percent of the number of percentage 

16 points by which such hospital’s dispropor17 tionate patient percentage exceeds 40 per18 cent. 

19 ‘‘(ii) For purposes of this subparagraph, 

20 the term ‘disproportionate patient percentage’ 

21 has the meaning given such term in subsection 

22 (d)(5)(F)(vi), except that in applying such 

23 meaning any reference under such subsection to 

24 individuals entitled to supplementary security 

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1 poses of this subparagraph to include individ2 uals— 

3 ‘‘(I) eligible for medical assistance 

4 under a State plan under title XIX; or 

5 ‘‘(II) receiving aid or assistance under 

6 any plan of the territory approved under 

7 title I, X, XIV, or XVI.’’. 

8 Subtitle B—Part B 

9 SEC. 211. APPLICATION OF PART B DEEMED ENROLLMENT 

10 PROCESS TO RESIDENTS OF PUERTO RICO; 

11 SPECIAL ENROLLMENT PERIOD AND LIMIT 

12 ON LATE ENROLLMENT PENALTIES. 

13 (a) APPLICATION OF PART B DEEMED ENROLLMENT

14 PROCESS TO RESIDENTS OF PUERTO RICO.—Section 

15 1837(f)(3) of the Social Security Act (42 U.S.C. 

16 1395p(f)(3)) is amended by striking ‘‘, exclusive of Puerto 

17 Rico’’. 

18 (b) EFFECTIVE DATE.—The amendment made by 

19 subsection (a) shall apply to individuals whose initial en20 rollment period under section 1837(d) of the Social Secu21 rity Act begins on or after the first day of the effective 

22 month, specified by the Secretary of Health and Human 

23 Services under section 1839(j)(1)(C) of such Act, as added 

24 by subsection (c)(2). 


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1 (c) TRANSITION PROVIDING SPECIAL ENROLLMENT

2 PERIOD AND LIMIT ON LATE ENROLLMENT PENALTIES

3 FOR CERTAIN MEDICARE BENEFICIARIES.—Section 1839 

4 of the Social Security Act (42 U.S.C. 1395r) is amend5 ed— 

6 (1) in the first sentence of subsection (b), by in7 serting ‘‘subject to section 1839(j)(2),’’ after ‘‘sub8 section (i)(4) or (l) of section 1837,’’; and 

9 (2) by adding at the end the following new sub10 section: 

11 ‘‘(j) SPECIAL RULES FOR CERTAIN RESIDENTS OF

12 PUERTO RICO.— 

13 ‘‘(1) SPECIAL ENROLLMENT PERIOD, COVERAGE

14 PERIOD FOR RESIDENTS WHO ARE ELIGIBLE BUT

15 NOT ENROLLED.— 

16 ‘‘(A) IN GENERAL.—In the case of a tran17 sition individual (as defined in paragraph (3)) 

18 who is not enrolled under this part as of the 

19 day before the first day of the effective month 

20 (as defined in subparagraph (C)), the Secretary 

21 shall provide for a special enrollment period 

22 under section 1837 of 7 months beginning with 

23 such effective month during which the indi24 vidual may be enrolled under this part. 


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1 ‘‘(B) COVERAGE PERIOD.—In the case of 

2 such an individual who enrolls during such spe3 cial enrollment period, the coverage period 

4 under section 1838 shall begin on the first day 

5 of the second month after the month in which 

6 the individual enrolls. 

7 ‘‘(C) EFFECTIVE MONTH DEFINED.—In 

8 this section, the term ‘effective month’ means a 

9 month, not earlier than October 2020 and not 

10 later than January 2021, specified by the Sec11 retary. 

12 ‘‘(2) REDUCTION IN LATE ENROLLMENT PEN13 ALTIES FOR CURRENT ENROLLEES AND INDIVID14 UALS ENROLLING DURING TRANSITION.— 

15 ‘‘(A) IN GENERAL.—In the case of a tran16 sition individual who is enrolled under this part 

17 as of the day before the first day of the effec18 tive month or who enrolls under this part on or 

19 after the date of the enactment of this sub20 section but before the end of the special enroll21 ment period under paragraph (1)(A), the 

22 amount of the late enrollment penalty imposed 

23 under section 1839(b) shall be recalculated by 

24 reducing the penalty to 15 percent of the pen25 alty otherwise established. 


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1 ‘‘(B) APPLICATION.—Subparagraph (A) 

2 shall be applied in the case of a transition indi3 vidual who— 

4 ‘‘(i) is enrolled under this part as of 

5 the month before the effective month, for 

6 premiums for months beginning with such 

7 effective month; or 

8 ‘‘(ii) enrolls under this part on or 

9 after the date of the enactment of this Act 

10 and before the end of the special enroll11 ment period under paragraph (1)(A), for 

12 premiums for months during the coverage 

13 period under this part which occur during 

14 or after the effective month. 

15 ‘‘(C) LOSS OF REDUCTION IF INDIVIDUAL

16 TERMINATES ENROLLMENT.—Subparagraph 

17 (A) shall not apply to a transition individual if 

18 the individual terminates enrollment under this 

19 part after the end of the special enrollment pe20 riod under paragraph (1). 

21 ‘‘(3) TRANSITION INDIVIDUAL DEFINED.—In 

22 this section, the term ‘transition individual’ means 

23 an individual who resides in Puerto Rico and who 

24 would have been deemed enrolled under this part 

25 pursuant to section 1837(f) before the first day of 


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1 the effective month but for the fact that the indi2 vidual was a resident of Puerto Rico, regardless of 

3 whether the individual is enrolled under this part as 

4 of such first day.’’. 

5 Subtitle C—Medicare Advantage 

6 (Part C) 

7 SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW-BASE 

8 PAYMENT COUNTIES IN PUERTO RICO. 

9 Section 1853(n) of the Social Security Act (42 U.S.C. 

10 1395w–23(n)) is amended— 

11 (1) in paragraph (1), by striking ‘‘and (5)’’ and 

12 inserting ‘‘(5), and (6)’’; 

13 (2) in paragraph (4), by striking ‘‘In no case’’ 

14 and inserting ‘‘Subject to paragraph (6), in no 

15 case’’; and 

16 (3) by adding at the end the following new 

17 paragraph: 

18 ‘‘(6) SPECIAL RULES FOR BLENDED BENCH19 MARK AMOUNT FOR TERRITORIES.— 

20 ‘‘(A) IN GENERAL.—Subject to paragraph 

21 (2), the blended benchmark amount for an area 

22 in a territory for a year (beginning with 2020) 

23 shall not be less than 80 percent of the national 

24 average of the base payment amounts specified 

25 in subparagraph (2)(E) for such year for areas 


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1 within the 50 States and the District of Colum2 bia. 

3 ‘‘(B) LIMITATION.—In no case shall the 

4 blended benchmark amount for an area in a 

5 territory for a year under subparagraph (A) ex6 ceed the lowest blended benchmark amount for 

7 any area within the 50 States and the District 

8 of Columbia for such year.’’. 

9 Subtitle D—Part D 

10 SEC. 231. IMPROVED USE OF ALLOCATED PRESCRIPTION 

11 DRUG FUNDS BY TERRITORIES. 

12 Section 1935(e) of the Social Security Act (42 U.S.C. 

13 1396u–5(e)) is amended by adding at the end the fol14 lowing new paragraph: 

15 ‘‘(5) IMPROVED USE OF FUNDS FOR LOW-IN16 COME PART D ELIGIBLE INDIVIDUALS.—This sub17 section shall be applied beginning with fiscal year 

18 2020 as follows, notwithstanding any other provision 

19 of this title: 

20 ‘‘(A) CLARIFYING STATE FLEXIBILITY TO

21 COVER NON-DUAL-ELIGIBLE INDIVIDUALS.—In 

22 this title, the term ‘medical assistance’ includes 

23 financial assistance furnished by a State under 

24 this subsection to part D eligible individuals 

25 who, if they were residing in one of the 50 


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1 States or the District of Columbia, would qual2 ify as subsidy eligible individuals under section 

3 1860D–14(a)(3), and without regard to wheth4 er such individuals otherwise qualify for medical 

5 assistance under this title. 

6 ‘‘(B) 100 PERCENT FMAP TO REFLECT NO

7 STATE MATCHING REQUIRED FOR PART D LOW

8 INCOME SUBSIDIES.—The Federal medical as9 sistance percentage applicable to the assistance 

10 furnished under this subsection is 100 percent. 

11 ‘‘(C) LIMITED FUNDING FOR SPECIAL

12 RULES.—Subparagraphs (A) and (B), and the 

13 provision of medical assistance for covered part 

14 D drugs to low-income part D eligible individ15 uals for a State and period under this sub16 section, is limited to the amount specified in 

17 paragraph (3) for such State and period.’’. 

18 SEC. 232. REPORT ON TREATMENT OF TERRITORIES 

19 UNDER MEDICARE PART D. 

20 Paragraph (4) of section 1935(e) of the Social Secu21 rity Act (42 U.S.C. 1396u–5(e)) is amended to read as 

22 follows: 

23 ‘‘(4) REPORT ON APPLICATION OF SUB24 SECTION.— 


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1 ‘‘(A) IN GENERAL.—Not later than Feb2 ruary 1, 2020, the Secretary shall submit to 

3 Congress a report on the application of this 

4 subsection during the period beginning fiscal 

5 year 2006 and ending fiscal year 2019. 

6 ‘‘(B) INFORMATION TO BE INCLUDED IN

7 REPORT.—Such report shall include— 

8 ‘‘(i) program guidance issued by the 

9 Secretary to implement this subsection; 

10 ‘‘(ii) for each territory, information on 

11 the increased amount under paragraph (3) 

12 and how the territory has applied such 

13 amount, including the territory’s program 

14 design, expenditures, and number of indi15 viduals (and dual-eligible individuals) as16 sisted; and 

17 ‘‘(iii) differences between how such 

18 territories are treated under part D of title 

19 XVIII and under this title compared with 

20 the treatment of the 50 States and the 

21 District of Columbia under such part and 

22 this title for different fiscal years within 

23 the period covered under the report. 

24 ‘‘(C) RECOMMENDATIONS.—Such report 

25 shall include recommendations for improving 


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1 prescription drug coverage for low-income indi2 viduals in each territory, including rec3 ommendations regarding each of the following 

4 alternative approaches: 

5 ‘‘(i) Adjusting the aggregate amount 

6 specified in paragraph (3)(B). 

7 ‘‘(ii) Allowing residents of the terri8 tories to be subsidy eligible individuals 

9 under section 1860D–14, notwithstanding 

10 subsection (a)(3)(F) of such section, or 

11 providing substantially equivalent low-in12 come prescription drug subsidies to such 

13 residents.’’. 

14 TITLE III—MISCELLANEOUS 

15 SEC. 301. MODIFIED TREATMENT OF TERRITORIES WITH 

16 RESPECT TO APPLICATION OF ACA ANNUAL 

17 HEALTH INSURANCE PROVIDER FEES. 

18 Section 9010 of the Patient Protection and Afford19 able Care Act (26 U.S.C. 4001 note prec.) is amended— 

20 (1) in subsection (b)(1), by inserting ‘‘subject 

21 to subsection (k)(1),’’ after ‘‘With respect to each 

22 covered entity,’’; and 

23 (2) by adding at the end the following: 

24 ‘‘(k) SPECIAL RULES FOR TREATMENT OF TERRI25 TORIES.— 


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1 ‘‘(1) IN GENERAL.—In applying this section 

2 with respect to United States health risks located 

3 outside of the 50 States or the District of Columbia 

4 for years beginning with 2020— 

5 ‘‘(A) the amount of the fee under sub6 section (b) shall be 50 percent of the amount 

7 of the fee otherwise determined; 

8 ‘‘(B) the Secretary shall deposit the 

9 amount of such fees collected for each territory 

10 into a separate account; and 

11 ‘‘(C) amounts in such an account for a ter12 ritory for a year are appropriated and shall be 

13 available to the territory in accordance with 

14 paragraph (2). 

15 ‘‘(2) AVAILABILITY OF FUNDS.—Amounts made 

16 available to a territory under paragraph (1)(C) with 

17 respect to a territory for a year shall be made avail18 able to the territory, upon application of the terri19 tory to the Secretary of Health and Human Serv20 ices, only for the following purposes, as elected by 

21 the territory in such application: 

22 ‘‘(A) INCREASED PRESCRIPTION DRUG AS23 SISTANCE FOR LOW-INCOME PART D ELIGIBLE

24 INDIVIDUALS.—For increasing the amount of 

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1 tion 1935(e)(3) of the Social Security Act (42 

2 U.S.C. 1396u–5(e)(3)) for assistance for low-in3 come part D eligible individuals in obtaining 

4 part D covered drugs. 

5 ‘‘(B) SATISFYING STATE MEDICAID

6 MATCHING REQUIREMENT.—For the territory to 

7 meet non-Federal matching requirements im8 posed with respect to obtaining Federal finan9 cial participation under title XIX of the Social 

10 Security Act.’’. 

11 SEC. 302. MEDICAID AND CHIP TERRITORY TRANSPARENCY 

12 AND INFORMATION. 

13 (a) PUBLICATION OF INFORMATION ON FEDERAL

14 EXPENDITURES UNDER MEDICAID AND CHIP IN THE

15 TERRITORIES.—Not later than 180 days after the date 

16 of the enactment of this Act, the Secretary of Health and 

17 Human Services shall publish, and periodically update, on 

18 the Internet site of the Centers for Medicare & Medicaid 

19 Services information on Medicaid and CHIP carried out 

20 in the territories of the United States. Such information 

21 shall include, with respect to each such territory— 

22 (1) the income levels established by the terri23 tory for purposes of eligibility of an individual to re24 ceive medical assistance under Medicaid or child 

25 health assistance under CHIP; 


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1 (2) the number of individuals enrolled in Med2 icaid and CHIP in such territory; 

3 (3) any State plan amendments in effect to 

4 carry out Medicaid or CHIP in such territory; 

5 (4) any waiver of the requirements of title XIX 

6 or title XXI issued by the Secretary to carry out 

7 Medicaid or CHIP in the territory, including a waiv8 er under section 1115 of the Social Security Act (42 

9 U.S.C. 1315), any application for such a waiver, and 

10 any documentation related to such application (in11 cluding correspondence); 

12 (5) the amount of the Federal and non-Federal 

13 share of expenditures under Medicaid and CHIP in 

14 such territory; 

15 (6) the systems in place for the furnishing of 

16 health care items and services under Medicaid and 

17 CHIP in such territory; 

18 (7) the design of CHIP in such territory; and 

19 (8) other information regarding the carrying 

20 out of Medicaid and CHIP in the territory that is 

21 published on such Internet site with respect to car22 rying out Medicaid and CHIP in each State and the 

23 District of Columbia. 

24 (b) DEFINITIONS.—In this section: 


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1 (1) CHIP.—The term ‘‘CHIP’’ means the 

2 State Children’s Health Insurance Program under 

3 title XXI of the Social Security Act. 

4 (2) MEDICAID.—The term ‘‘Medicaid’’ means 

5 the Medicaid program under title XIX of the Social 

6 Security Act. 

7 (3) TERRITORY.—The term ‘‘territory of the 

8 United States’’ includes Puerto Rico, the Virgin Is9 lands of the United States, Guam, the Northern 

10 Mariana Islands, and American Samoa. 

11 SEC. 303. REPORT ON EXCLUSION OF TERRITORIES FROM 

12 EXCHANGES. 

13 (a) IN GENERAL.—Not later than February 1, 2020, 

14 the Secretary of Health and Human Services shall submit 

15 to Congress a report that details the adverse impacts in 

16 each territory from the practical exclusion of the terri17 tories from the provisions of part II of subtitle D of title 

18 I of the Patient Protection and Affordable Care Act inso19 far as such provisions provide for the establishment of an 

20 American Health Benefit Exchange or the administration 

21 of a federally facilitated Exchange in each State and in 

22 the District of Columbia for the purpose of making health 

23 insurance more affordable and accessible for individuals 

24 and small businesses. 


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1 (b) INFORMATION IN REPORT.—The report shall in2 clude information on the following: 

3 (1) An estimate of the total number of unin4 sured and underinsured individuals residing in each 

5 territory with respect to health insurance coverage. 

6 (2) A description of the number of health insur7 ance issuers in each territory and the health insur8 ance plans these issuers offer. 

9 (3) An estimate of the number of individuals re10 siding in each territory who are denied premium and 

11 cost-sharing assistance that would otherwise be 

12 available to them for obtaining health insurance cov13 erage through an Exchange if they resided in one of 

14 the 50 States or in the District of Columbia. 

15 (4) An estimate of the amount of Federal as16 sistance described in paragraph (3) that is not being 

17 made available to residents of each territory. 

18 (5) An estimate of the number of small employ19 ers in each territory that would be eligible to pur20 chase health insurance coverage through a Small 

21 Business Health Options Program (SHOP) Market22 place that would operate as part of an Exchange if 

23 the employers were in one of the 50 States or in the 

24 District of Columbia. 


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1 SEC. 304. ACCESS TO COVERAGE FOR INDIVIDUALS IN CER2 TAIN AREAS WITHOUT ANY AVAILABLE EX3 CHANGE PLANS. 

4 Part 2 of subtitle D of title I of the Patient Protec5 tion and Affordable Care Act (42 U.S.C. 18031 et seq.) 

6 is amended by adding at the end the following: 

7 ‘‘SEC. 1314. ACCESS TO COVERAGE FOR INDIVIDUALS IN 

8 CERTAIN AREAS WITHOUT ANY AVAILABLE 

9 EXCHANGE PLANS. 

10 ‘‘(a) IN GENERAL.— 

11 ‘‘(1) COVERAGE THROUGH DC SHOP EX12 CHANGE.—Not later than 3 months after the date of 

13 enactment of this section, the Secretary, in consulta14 tion with the Secretary of the Treasury and the Di15 rector of the Office of Personnel Management, shall 

16 establish a mechanism to ensure that, for any plan 

17 year beginning on or after the date described in sub18 section (d), any individual described in paragraph 

19 (2) may enroll in health insurance coverage in the 

20 small group market through the Exchange operating 

21 in the District of Columbia, including the health in22 surance coverage that is available to Members of 

23 Congress and congressional staff (as defined in sec24 tion 1312(d)(3)(D)). 

25 ‘‘(2) INDIVIDUAL DESCRIBED.—An individual 

26 described in this paragraph is any individual who— 


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1 ‘‘(A) is not eligible to enroll in an em2 ployer-sponsored health plan (excluding such a 

3 plan that would not be considered minimum es4 sential coverage due to the application of sub5 paragraph (C) of section 36B(c)(2) of the In6 ternal Revenue Code of 1986 if such subpara7 graph applied to such plan); and 

8 ‘‘(B) is a bona fide resident of any posses9 sion of the United States (as determined under 

10 section 937(a) of such Code) in which the Sec11 retary certifies that no qualified health plan is 

12 offered through an Exchange established under 

13 this title. 

14 ‘‘(3) POSSESSION OF THE UNITED STATES.— 

15 For purposes of this section, the term ‘possession of 

16 the United States’ shall include such possessions as 

17 are specified in section 937(a)(1) of the Internal 

18 Revenue Code of 1986. 

19 ‘‘(b) PREMIUM ASSISTANCE TAX CREDITS AND

20 COST-SHARING.—Any individual described in subsection 

21 (a)(2) who enrolls in health insurance coverage through 

22 the Exchange operating in the District of Columbia pursu23 ant to subsection (a)(1) shall be eligible for any premium 

24 tax credit under section 36B of the Internal Revenue Code 

25 of 1986, reduced cost-sharing under section 1402, and adVerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354

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1 vance determination and payment of such credits or such 

2 reductions under section 1412, that the individual would 

3 otherwise be eligible for if enrolling as a resident of the 

4 District of Columbia in health insurance coverage in the 

5 individual market through the Exchange operating in the 

6 District of Columbia. 

7 ‘‘(c) TREATMENT OF POSSESSIONS.— 

8 ‘‘(1) PAYMENTS TO POSSESSIONS.— 

9 ‘‘(A) MIRROR CODE POSSESSION.—The 

10 Secretary of the Treasury shall periodically (but 

11 not less frequently than annually) pay to each 

12 possession of the United States with a mirror 

13 code tax system amounts equal to the loss to 

14 that possession by reason of the application of 

15 this section (determined without regard to para16 graph (2)) with respect to taxable years begin17 ning after the date described in subsection (d). 

18 Such amounts shall be determined by the Sec19 retary of the Treasury based on information 

20 provided by the government of the respective 

21 possession. 

22 ‘‘(B) OTHER POSSESSIONS.—The Sec23 retary of the Treasury shall periodically (but 

24 not less frequently than annually) pay to each 

25 possession of the United States which does not 


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1 have a mirror code tax system amounts esti2 mated by the Secretary of the Treasury as 

3 being equal to the aggregate benefits that would 

4 have been provided to residents of such posses5 sion by reason of the application of this section 

6 for any taxable years beginning after the date 

7 described in subsection (d) if a mirror code tax 

8 system had been in effect in such possession. 

9 The preceding sentence shall not apply with re10 spect to any possession of the United States un11 less such possession has a plan, which has been 

12 approved by the Secretary of the Treasury, 

13 under which such possession will promptly dis14 tribute such payments to the residents of such 

15 possession. 

16 ‘‘(2) COORDINATION WITH CREDIT ALLOWED

17 AGAINST UNITED STATES INCOME TAXES.—No cred18 it shall be allowed against United States income 

19 taxes for any taxable year under section 36B of the 

20 Internal Revenue Code of 1986 to any person— 

21 ‘‘(A) to whom a credit is allowed against 

22 taxes imposed by the possession by reason of 

23 this section (determined without regard to this 

24 paragraph) for such taxable year, or 


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1 ‘‘(B) who is eligible for a payment under 

2 a plan described in paragraph (1)(B) with re3 spect to such taxable year. 

4 ‘‘(3) MIRROR CODE TAX SYSTEM.—For pur5 poses of this subsection, the term ‘mirror code tax 

6 system’ means, with respect to any possession of the 

7 United States, the income tax system of such posses8 sion if the income tax liability of the residents of 

9 such possession under such system is determined by 

10 reference to the income tax laws of the United 

11 States as if such possession were the United States. 

12 ‘‘(4) TREATMENT OF PAYMENTS.—For pur13 poses of section 1324(b)(2) of title 31, United 

14 States Code, or any similar rule of law, the pay15 ments under this subsection shall be treated in the 

16 same manner as a refund due from the credit al17 lowed under section 36B of the Internal Revenue 

18 Code of 1986. 

19 ‘‘(d) DATE DESCRIBED.—The date described in this 

20 subsection is the date on which the Secretary establishes 

21 the mechanism described in subsection (a)(1).’’. 


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1 SEC. 305. EXTENSION OF FAMILY-TO-FAMILY HEALTH IN2 FORMATION CENTERS PROGRAM TO TERRI3 TORIES. 

4 Section 501(c)(3)(C) of the Social Security Act (42 

5 U.S.C. 701(c)) is amended by striking ‘‘years 2018 and 

6 2019’’ and inserting ‘‘year 2018 and each fiscal year 

7 thereafter’’. 

Æ 


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