II 

114TH CONGRESS 

1ST SESSION S. 1961 

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 SENATE OF THE UNITED STATES 

AUGUST 5, 2015 

Mr. SCHUMER (for himself, Mrs. GILLIBRAND, Mr. BLUMENTHAL, and Mr. 

MENENDEZ) introduced the following bill; which was read twice and referred to the Committee on Finance 

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 ‘‘Improving the Treatment of the U.S. Territories Under 

6 Federal Health Programs Act of 2015’’. 

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

8 this Act is as follows: 


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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. Application of 100 percent Federal poverty line (FPL) limitation to 

territories. 

Sec. 105. Permitting Medicaid DSH allotments for territories. 

TITLE II—MEDICARE 

Subtitle A—Part A 

Sec. 201. Modification of Medicare inpatient hospital payment rate for Puerto 

Rico hospitals. 

Sec. 202. Application of Medicare HITECH payments to hospitals in Puerto 

Rico. 

Sec. 203. Calculation of Medicare DSH payments for IPPS hospitals in Puerto 

Rico. 

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. 

Sec. 212. Puerto Rico practice expense GPCI improvement. 

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. Report on exclusion of territories from Exchanges. 

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— 


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1 (1) in subsection (f), in the matter before para2 graph (1), by striking ‘‘subsection (g)’’ and inserting 

3 ‘‘subsections (g) and (h)’’; 

4 (2) in subsection (g)(2), in the matter before 

5 subparagraph (A), by inserting ‘‘and subsection (h)’’ 

6 after ‘‘paragraphs (3) and (5)’’; and 

7 (3) by adding at the end the following new sub8 section: 

9 ‘‘(h) SUNSET OF MEDICAID FUNDING LIMITATIONS

10 FOR PUERTO RICO, THE VIRGIN ISLANDS OF THE

11 UNITED STATES, GUAM, THE NORTHERN MARIANA IS12 LANDS, AND AMERICAN SAMOA.—Subsections (f) and (g) 

13 shall not apply to Puerto Rico, the Virgin Islands of the 

14 United States, Guam, the Northern Mariana Islands, and 

15 American Samoa beginning with fiscal year 2017.’’. 

16 (b) CONFORMING AMENDMENTS.— 

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

18 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 

19 limitation in section 1108(f),’’. 

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

21 (42 U.S.C. 1396b(u)) is amended by striking para22 graph (4). 

23 (3) Section 1323(c)(1) of the Patient Protection 

24 and Affordable Care Act (42 U.S.C. 18043(c)(1)) is 

25 amended by striking ‘‘2019’’ and inserting ‘‘2016’’. 


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

2 this section shall apply beginning with fiscal year 2017. 

3 SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 

4 ASSISTANCE PERCENTAGE (FMAP) LIMITA5 TION FOR TERRITORIES. 

6 Section 1905 of the Social Security Act (42 U.S.C. 

7 1396d) is amended— 

8 (1) in subsection (b)(2), by inserting ‘‘for fiscal 

9 years before fiscal year 2017’’ after ‘‘American 

10 Samoa’’; and 

11 (2) in subsection (y)(1), in the matter preceding 

12 subparagraph (A)— 

13 (A) by inserting ‘‘, for fiscal years before 

14 fiscal year 2017,’’ before ‘‘is one of the’’; and 

15 (B) by inserting ‘‘and, for fiscal year 2017 

16 and subsequent fiscal years, is one of the 50 

17 States, the District of Columbia, Puerto Rico, 

18 the Virgin Islands of the United States, Guam, 

19 the Northern Mariana Islands, or American 

20 Samoa,’’ after ‘‘the District of Columbia’’. 

21 SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY 

22 TO ALL OF THE TERRITORIES. 

23 (a) IN GENERAL.—Section 1902(j) of the Social Se24 curity Act (42 U.S.C. 1396a(j)) is amended— 


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

2 Northern Mariana Islands’’ and inserting ‘‘Puerto 

3 Rico, the Virgin Islands of the United States, Guam, 

4 the Northern Mariana Islands, and American 

5 Samoa’’; 

6 (2) by striking ‘‘American Samoa or the North7 ern Mariana Islands’’ and inserting ‘‘Puerto Rico, 

8 the Virgin Islands of the United States, Guam, the 

9 Northern Mariana Islands, or American Samoa’’; 

10 (3) by inserting ‘‘(1)’’ after ‘‘(j)’’; 

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

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

13 other requirement of this title’’; and 

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

15 ‘‘(2) The Secretary may not waive under this sub16 section the requirement of subsection (a)(10)(A)(i)(IX) 

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

18 with respect to any territory.’’. 

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

20 this section shall apply beginning October 1, 2016. 

21 SEC. 104. APPLICATION OF 100 PERCENT FEDERAL POV22 ERTY LINE (FPL) LIMITATION TO TERRI23 TORIES. 

24 (a) IN GENERAL.—Section 1902 of the Social Secu25 rity Act (42 U.S.C. 1396a) is amended— 


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1 (1) in subsection (a)(10)(A)(i)(VIII), by insert2 ing ‘‘(or, subject to subsection (j), 100 percent in 

3 the case of Puerto Rico, the Virgin Islands of the 

4 United States, Guam, the Northern Mariana Is5 lands, and American Samoa)’’ after ‘‘133 percent’’; 

6 and 

7 (2) in subsection (j), as amended by section 

8 103, by adding at the end the following new para9 graph: 

10 ‘‘(3)(A) Subject to subparagraph (B), Federal finan11 cial participation shall not be available to Puerto Rico, the 

12 Virgin Islands of the United States, Guam, the Northern 

13 Mariana Islands, or American Samoa for medical assist14 ance for an individual whose family income exceeds 100 

15 percent of the official poverty line for a family of the size 

16 involved, except in the case of individuals qualifying for 

17 medical assistance under subsection (a)(10)(A)(i)(IX). 

18 ‘‘(B) The Secretary may, under paragraph (1) or sec19 tion 1115, waive the limitation under subparagraph (A) 

20 in the case of a territory other than Puerto Rico. In car21 rying out this subparagraph, the Secretary shall take into 

22 account the eligibility levels established under the State 

23 plan of the territory involved before the date of the enact24 ment of this paragraph.’’. 


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1 (b) NOT APPLYING 5 PERCENT DISREGARD.—Sec2 tion 1902(e)(14)(I) of the Social Security Act (42 U.S.C. 

3 1396b(e)(14)(I)) is amended by adding at the end the fol4 lowing: 

5 ‘‘The previous sentence shall only apply to a 

6 State that is one of the 50 States or the Dis7 trict of Columbia.’’. 

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

9 this section shall apply with respect to eligibility deter10 minations made with respect to items and services fur11 nished on or after October 1, 2016. 

12 SEC. 105. PERMITTING MEDICAID DSH ALLOTMENTS FOR 

13 TERRITORIES. 

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

15 1396) is amended— 

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

17 following new subparagraph: 

18 ‘‘(C) TERRITORIES.— 

19 ‘‘(i) FISCAL YEAR 2017.—For fiscal 

20 year 2017, with respect to the territories of 

21 Puerto Rico, the Virgin Islands of the 

22 United States, Guam, the Northern Mar23 iana Islands, and American Samoa, the 

24 DSH allotment determined for each such 

25 territory shall bear the same ratio to 


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1 $150,000,000 as the ratio of the number 

2 of individuals who are low-income or unin3 sured and residing in each such respective 

4 territory (as estimated from time to time 

5 by the Secretary) bears to the sums of the 

6 number of such individuals residing in all 

7 of the territories. 

8 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 

9 For each subsequent fiscal year, the DSH 

10 allotment for each such territory is subject 

11 to an increase or reduction in accordance 

12 with paragraphs (3) and (7).’’; 

13 (2) in paragraph (7)(A), by striking clause (iv) 

14 and redesignating clause (v) as clause (iv); and 

15 (3) in paragraph (9), by inserting before the pe16 riod at the end the following: ‘‘, and includes, begin17 ning with fiscal year 2017, Puerto Rico, the Virgin 

18 Islands of the United States, Guam, the Northern 

19 Mariana Islands, and American Samoa’’. 


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1 TITLE II—MEDICARE 

2 Subtitle A—Part A 

3 SEC. 201. MODIFICATION OF MEDICARE INPATIENT HOS4 PITAL PAYMENT RATE FOR PUERTO RICO 

5 HOSPITALS. 

6 Section 1886(d)(9)(E) of the Social Security Act (42 

7 U.S.C. 1395ww(d)(9)(E)) is amended— 

8 (1) by striking ‘‘and’’ at the end of clause (iii); 

9 (2) in clause (iv)— 

10 (A) by inserting ‘‘and before October 1, 

11 2015,’’ after ‘‘2004,’’; and 

12 (B) by striking the period at the end and 

13 inserting ‘‘; and’’; and 

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

15 clause: 

16 ‘‘(v) on or after October 1, 2015, the applicable 

17 Puerto Rico percentage is 0 percent and the applica18 ble Federal percentage is 100 percent.’’. 

19 SEC. 202. APPLICATION OF MEDICARE HITECH PAYMENTS 

20 TO HOSPITALS IN PUERTO RICO. 

21 (a) IN GENERAL.—Subsection (n)(6)(B) of section 

22 1886 of the Social Security Act (42 U.S.C. 1395ww) is 

23 amended by striking ‘‘subsection (d) hospital’’ and insert24 ing ‘‘hospital that is a subsection (d) hospital or a sub25 section (d) Puerto Rico hospital’’. 


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1 (b) CONFORMING AMENDMENTS.— 

2 (1) Subsection (b)(3)(B)(ix) of section 1886 of 

3 the Social Security Act (42 U.S.C. 1395ww) is 

4 amended— 

5 (A) in subclause (I), by striking 

6 ‘‘(n)(6)(A)’’ and inserting ‘‘(n)(6)(B)’’; and 

7 (B) in subclause (II), by striking ‘‘a sub8 section (d) hospital’’ and inserting ‘‘an eligible 

9 hospital’’. 

10 (2) Paragraphs (2) and (4)(A) of section 

11 1853(m) of the Social Security Act (42 U.S.C. 

12 1395w–23(m)) are each amended by striking 

13 ‘‘1886(n)(6)(A)’’ and inserting ‘‘1886(n)(6)(B)’’. 

14 (c) IMPLEMENTATION.—Notwithstanding any other 

15 provision of law, the Secretary of Health and Human 

16 Services may implement the amendments made by this 

17 section by program instruction or otherwise. 

18 (d) EFFECTIVE DATE.—The amendments made by 

19 this section shall apply as if included in the enactment 

20 of the American Recovery and Reinvestment Act of 2009 

21 (Public Law 111–5), except that, in order to take into ac22 count delays in the implementation of this section, in ap23 plying subsections (b)(3)(B)(ix), (n)(2)(E)(ii), and 

24 (n)(2)(G)(i) of section 1886 of the Social Security Act, 

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1 sections to a particular year shall be treated with respect 

2 to a subsection (d) Puerto Rico hospital as a reference 

3 to the year that is 5 years after such particular year (or 

4 7 years after such particular year in the case of applying 

5 subsection (b)(3)(B)(ix) of such section). 

6 SEC. 203. CALCULATION OF MEDICARE DSH PAYMENTS FOR 

7 IPPS HOSPITALS IN PUERTO RICO. 

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

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

10 follows: 

11 ‘‘(iii) Subparagraph (F) (relating to dispropor12 tionate share payments), including application of 

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

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

15 subparagraph shall be substituted for the sum 

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

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

18 October 1, 2015, subclause (I) of paragraph 

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

20 the numerator described in such subclause the 

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

22 patient days for the cost reporting period in23 volved which were made up of patients who (for 

24 such days) were entitled to benefits under part 

25 A of this title and were— 


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1 ‘‘(aa) entitled to supplementary secu2 rity income benefits (excluding any State 

3 supplementation) under title XVI of this 

4 Act; 

5 ‘‘(bb) eligible for medical assistance 

6 under a State plan under title XIX; or 

7 ‘‘(cc) receiving aid or assistance under 

8 any plan of the State approved under title 

9 I, X, XIV, or XVI.’’. 

10 Subtitle B—Part B 

11 SEC. 211. APPLICATION OF PART B DEEMED ENROLLMENT 

12 PROCESS TO RESIDENTS OF PUERTO RICO; 

13 SPECIAL ENROLLMENT PERIOD AND LIMIT 

14 ON LATE ENROLLMENT PENALTIES. 

15 (a) APPLICATION OF PART B DEEMED ENROLLMENT

16 PROCESS TO RESIDENTS OF PUERTO RICO.—Section 

17 1837(f)(3) of the Social Security Act (42 U.S.C. 

18 1395p(f)(3)) is amended by striking ‘‘, exclusive of Puerto 

19 Rico’’. 

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

21 subsection (a) shall apply to individuals whose initial en22 rollment period under section 1837(d) of the Social Secu23 rity Act begins on or after the first day of the effective 

24 month, specified by the Secretary of Health and Human 


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

2 by subsection (c)(2). 

3 (c) TRANSITION PROVIDING SPECIAL ENROLLMENT

4 PERIOD AND LIMIT ON LATE ENROLLMENT PENALTIES

5 FOR CERTAIN MEDICARE BENEFICIARIES.—Section 1839 

6 of the Social Security Act (42 U.S.C. 1395r) is amend7 ed— 

8 (1) in the first sentence of subsection (b), by in9 serting ‘‘subject to section 1839(j)(2),’’ after ‘‘sub10 section (i)(4) or (l) of section 1837,’’; and 

11 (2) by adding at the end the following new sub12 section: 

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

14 PUERTO RICO.— 

15 ‘‘(1) SPECIAL ENROLLMENT PERIOD, COVERAGE

16 PERIOD FOR RESIDENTS WHO ARE ELIGIBLE BUT

17 NOT ENROLLED.— 

18 ‘‘(A) IN GENERAL.—In the case of a tran19 sition individual (as defined in paragraph (3)) 

20 who is not enrolled under this part as of the 

21 day before the first day of the effective month 

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

23 shall provide for a special enrollment period 

24 under section 1837 of 7 months beginning with 


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1 such effective month during which the indi2 vidual may be enrolled under this part. 

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

4 such an individual who enrolls during such spe5 cial enrollment period, the coverage period 

6 under section 1838 shall begin on the first day 

7 of the second month after the month in which 

8 the individual enrolls. 

9 ‘‘(C) EFFECTIVE MONTH DEFINED.—In 

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

11 month, not earlier than October 2016 and not 

12 later than January 2017, specified by the Sec13 retary. 

14 ‘‘(2) REDUCTION IN LATE ENROLLMENT PEN15 ALTIES FOR CURRENT ENROLLEES AND INDIVID16 UALS ENROLLING DURING TRANSITION.— 

17 ‘‘(A) IN GENERAL.—In the case of a tran18 sition individual who is enrolled under this part 

19 as of the day before the first day of the effec20 tive month or who enrolls under this part on or 

21 after the date of the enactment of this sub22 section but before the end of the special enroll23 ment period under paragraph (1)(A), the 

24 amount of the late enrollment penalty imposed 

25 under section 1839(b) shall be recalculated by 


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1 reducing the penalty to 15 percent of the pen2 alty otherwise established. 

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

4 shall be applied in the case of a transition indi5 vidual who— 

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

7 the month before the effective month, for 

8 premiums for months beginning with such 

9 effective month; or 

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

11 after the date of the enactment of this Act 

12 and before the end of the special enroll13 ment period under paragraph (1)(A), for 

14 premiums for months during the coverage 

15 period under this part which occur during 

16 or after the effective month. 

17 ‘‘(C) LOSS OF REDUCTION IF INDIVIDUAL

18 TERMINATES ENROLLMENT.—Subparagraph 

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

20 the individual terminates enrollment under this 

21 part after the end of the special enrollment pe22 riod under paragraph (1). 

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

24 this section, the term ‘transition individual’ means 

25 an individual who resides in Puerto Rico and who 


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1 would have been deemed enrolled under this part 

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

3 the effective month but for the fact that the indi4 vidual was a resident of Puerto Rico, regardless of 

5 whether the individual is enrolled under this part as 

6 of such first day.’’. 

7 SEC. 212. PUERTO RICO PRACTICE EXPENSE GPCI IM8 PROVEMENT. 

9 Section 1848(e)(1) of the Social Security Act (42 

10 U.S.C. 1395w–4(e)(1)) is amended— 

11 (1) in subparagraph (A), by striking ‘‘and (I)’’ 

12 and inserting ‘‘(I), and (J)’’; and 

13 (2) by adding at the end the following new sub14 paragraph: 

15 ‘‘(J) FLOOR FOR PRACTICE EXPENSE

16 INDEX FOR SERVICES FURNISHED IN PUERTO

17 RICO.— 

18 ‘‘(i) IN GENERAL.—For purposes of 

19 payment for services furnished in Puerto 

20 Rico in a year (beginning with 2016), after 

21 calculating the practice expense index in 

22 subparagraph (A)(i) for Puerto Rico, if 

23 such index is below the reference index (as 

24 defined in clause (ii)) for the year, the Sec25 retary shall increase such index for Puerto 


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1 Rico to equal the value of the reference 

2 index for the year. The preceding sentence 

3 shall not be applied in a budget neutral 

4 manner. 

5 ‘‘(ii) REFERENCE INDEX DEFINED.— 

6 In this subparagraph, the term ‘reference 

7 index’ means, with respect to a year, 0.800 

8 or, if less, the lowest practice expense 

9 index value for the year for any area in the 

10 50 States or the District of Columbia.’’. 

11 Subtitle C—Medicare Advantage 

12 (Part C) 

13 SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW BASE 

14 PAYMENT COUNTIES IN PUERTO RICO. 

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

16 1395w–23(n)) is amended— 

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

18 inserting ‘‘, (5), and (6)’’; 

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

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

21 case’’; and 

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

23 paragraph: 

24 ‘‘(6) SPECIAL RULES FOR BLENDED BENCH25 MARK AMOUNT FOR TERRITORIES.— 


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

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

3 in a territory for a year (beginning with 2016) 

4 shall not be less than 80 percent of the national 

5 average of the base payment amounts specified 

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

7 within the 50 States and the District of Colum8 bia. 

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

10 blended benchmark amount for an area in a 

11 territory for a year under subparagraph (A) ex12 ceed the lowest blended benchmark amount for 

13 any area within the 50 States and the District 

14 of Columbia for such year.’’. 

15 Subtitle D—Part D 

16 SEC. 231. IMPROVED USE OF ALLOCATED PRESCRIPTION 

17 DRUG FUNDS BY TERRITORIES. 

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

19 1396u–5(e)) is amended by adding at the end the fol20 lowing new paragraph: 

21 ‘‘(5) IMPROVED USE OF FUNDS FOR LOW-IN22 COME PART D ELIGIBLE INDIVIDUALS.—This sub23 section shall be applied beginning on January 1, 

24 2016, as follows, notwithstanding any other provi25 sion of this title: 


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1 ‘‘(A) CLARIFYING STATE FLEXIBILITY TO

2 COVER NON-DUAL-ELIGIBLE INDIVIDUALS.— 

3 For purposes of this subsection, the term ‘med4 ical assistance’ includes financial assistance fur5 nished under this subsection by a State other 

6 than the 50 States or the District of Columbia 

7 to part D eligible individuals who, if they were 

8 residing in one of the 50 States or the District 

9 of Columbia, would qualify as subsidy eligible 

10 individuals under section 1860D–14(a)(3), 

11 without regard to whether such individuals oth12 erwise qualify for medical assistance under this 

13 title. 

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

15 STATE MATCHING REQUIRED FOR PART D LOW

16 INCOME SUBSIDIES.—The Federal medical as17 sistance percentage applicable to the assistance 

18 furnished under this subsection is 100 percent. 

19 ‘‘(C) LIMITED FUNDING FOR SPECIAL

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

21 provision of medical assistance for covered part 

22 D drugs to low-income part D eligible individ23 uals for a State and year under this subsection, 

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1 gard to the application of subsection (f) or (g) 

2 of section 1108.’’. 

3 SEC. 232. REPORT ON TREATMENT OF TERRITORIES 

4 UNDER MEDICARE PART D. 

5 Paragraph (4) of section 1935(e) of the Social Secu6 rity Act (42 U.S.C. 1396u–5(e)) is amended to read as 

7 follows: 

8 ‘‘(4) REPORT ON APPLICATION OF SUB9 SECTION.— 

10 ‘‘(A) IN GENERAL.—Not later than May 1, 

11 2018, the Secretary shall submit to Congress a 

12 report on the application of this subsection dur13 ing the period beginning with fiscal year 2006 

14 and ending with December 31, 2017. 

15 ‘‘(B) INFORMATION TO BE INCLUDED IN

16 REPORT.—Such report shall include— 

17 ‘‘(i) program guidance issued by the 

18 Secretary to implement this subsection; 

19 ‘‘(ii) for each of Puerto Rico, the Vir20 gin Islands of the United States, Guam, 

21 the Northern Mariana Islands, and Amer22 ican Samoa, information on the increased 

23 amount under paragraph (3) and how the 

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1 itures, and number of individuals (and 

2 dual-eligible individuals) assisted; and 

3 ‘‘(iii) a description of the differences 

4 between how such territories are treated 

5 under part D of title XVIII and under this 

6 title compared with the treatment of the 

7 50 States and the District of Columbia 

8 under such part and this title for different 

9 fiscal years within the period covered 

10 under the report. 

11 ‘‘(C) RECOMMENDATIONS.—Such report 

12 shall include recommendations for improving 

13 prescription drug coverage for low-income indi14 viduals in each territory identified in subpara15 graph (B)(ii), including recommendations re16 garding each of the following alternative ap17 proaches: 

18 ‘‘(i) Adjusting the aggregate amount 

19 specified in paragraph (3)(B). 

20 ‘‘(ii) Allowing residents of the terri21 tories to be subsidy eligible individuals 

22 under section 1860D–14, notwithstanding 

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

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1 come prescription drug subsidies to such 

2 residents.’’. 

3 TITLE III—MISCELLANEOUS 

4 SEC. 301. REPORT ON EXCLUSION OF TERRITORIES FROM 

5 EXCHANGES. 

6 (a) IN GENERAL.—Not later than February 1, 2018, 

7 the Secretary of Health and Human Services shall submit 

8 to Congress a report that details the adverse impacts in 

9 each territory from the practical exclusion of the terri10 tories from the provisions of part II of subtitle D of title 

11 I of the Patient Protection and Affordable Care Act inso12 far as such provisions provide for the establishment of an 

13 American Health Benefit Exchange or the administration 

14 of a federally facilitated Exchange in each State and in 

15 the District of Columbia for the purpose of making health 

16 insurance more affordable and accessible for individuals 

17 and small businesses. 

18 (b) INFORMATION IN REPORT.—The report shall in19 clude information on the following: 

20 (1) An estimate of the total number of unin21 sured and underinsured individuals residing in each 

22 territory with respect to health insurance coverage. 

23 (2) A description of the number of health insur24 ance issuers in each territory and the health insur25 ance plans these issuers offer. 


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23 

•S 1961 IS

1 (3) An estimate of the number of individuals re2 siding in each territory who are denied premium and 

3 cost-sharing assistance that would otherwise be 

4 available to them for obtaining health insurance cov5 erage through an Exchange if they resided in one of 

6 the 50 States or in the District of Columbia. 

7 (4) An estimate of the amount of Federal as8 sistance described in paragraph (3) that is not being 

9 made available to residents of each territory. 

10 (5) An estimate of the number of small employ11 ers in each territory that would be eligible to pur12 chase health insurance coverage through a Small 

13 Business Health Options Program (SHOP) Market14 place that would operate as part of an Exchange if 

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

16 District of Columbia. 

Æ 


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