I 

116TH CONGRESS 

1ST SESSION H. R. 3371 

To amend titles XI and XIX of the Social Security Act to stabilize the 

Medicaid program in Puerto Rico. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 19, 2019 

Ms. VELA ́ZQUEZ (for herself, Mr. SOTO, Mr. SERRANO, Mr. GRIJALVA, Mr. 

ESPAILLAT, Ms. OCASIO-CORTEZ, Mr. GARCI ́A of Illinois, and Miss 

GONZA ́LEZ-COLO ́N of Puerto Rico) introduced the following bill; which 

was referred to the Committee on Energy and Commerce 

A BILL 

To amend titles XI and XIX of the Social Security Act 

to stabilize the Medicaid program in Puerto Rico. 

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. 

4 This Act may be cited as the ‘‘Puerto Rico Health 

5 Care Fairness, Accountability, and Beneficiary Access Act 

6 of 2019’’. 


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1 SEC. 2. ADJUSTMENTS TO FMAP AND CAP FOR PUERTO 

2 RICO. 

3 (a) ADJUSTMENTS TO FMAP.—Section 1905 of the 

4 Social Security Act (42 U.S.C. 1396d) is amended— 

5 (1) in subsection (b)— 

6 (A) by striking ‘‘for Puerto Rico, the Vir7 gin Islands’’ and inserting ‘‘for the Virgin Is8 lands’’; and 

9 (B) by striking ‘‘and American Samoa 

10 shall be 55 percent,’’ and inserting ‘‘and Amer11 ica Samoa (and, for calendar quarters in a fis12 cal year before fiscal year 2020, Puerto Rico) 

13 shall be 55 percent, and for Puerto Rico, for 

14 calendar quarters in a fiscal year beginning 

15 with fiscal year 2020, shall be the PR specified 

16 percent under subsection (ff) for such fiscal 

17 year,’’; and 

18 (2) by adding at the end the following new sub19 section: 

20 ‘‘(ff)(1) For purposes of subsection (b), the PR speci21 fied percent under this subsection is— 

22 ‘‘(A) subject to paragraph (2), for each of fiscal 

23 years 2020 through 2024, 83 percent; 

24 ‘‘(B) subject to paragraph (3)(D)(iii), for each 

25 of fiscal years 2025 through 2029, 83 percent; and 


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1 ‘‘(C) subject to paragraph (3)(D)(iii), for fiscal 

2 year 2030 and each subsequent fiscal year, the Fed3 eral medical assistance percentage calculated in ac4 cordance with the first sentence of subsection (b), as 

5 such sentence applies to the 50 States. 

6 ‘‘(2)(A) If Puerto Rico— 

7 ‘‘(i) for fiscal year 2021, is in compliance with 

8 none of the program enhancement requirements de9 scribed in subparagraph (B), the PR specified per10 cent specified under paragraph (1) for such fiscal 

11 year shall be reduced by 2 percent; 

12 ‘‘(ii) for fiscal year 2022, is in compliance with 

13 fewer than two of the four program enhancement re14 quirements described in subparagraph (B), the PR 

15 specified percent specified under paragraph (1) for 

16 such fiscal year shall be reduced by 3 percent; 

17 ‘‘(iii) for fiscal year 2023, is in compliance with 

18 fewer than three of the four program enhancement 

19 requirements described in subparagraph (B), the PR 

20 specified percent specified under paragraph (1) for 

21 such fiscal year shall be reduced by 5 percent; and 

22 ‘‘(iv) for fiscal year 2024, is in compliance with 

23 fewer than four of the program enhancement re24 quirements described in subparagraph (B), the PR 


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1 specified percent specified under paragraph (1) for 

2 such fiscal year shall be reduced by 5 percent. 

3 ‘‘(B) For purposes of this subsection, the program 

4 enhancement requirements described in this subparagraph 

5 are each of the following: 

6 ‘‘(i) Rates of payment under the State plan 

7 under this title for inpatient hospital services are not 

8 less than the costs incurred for such services. 

9 ‘‘(ii) Rates of payment under the State plan 

10 under this title for physicians’ services are not less 

11 than 70 percent of the amount that is payable for 

12 such services under section 1848. 

13 ‘‘(iii) The State plan provides for medical as14 sistance for Hepatitis C drugs, in accordance with 

15 the requirements of section 1927 otherwise applica16 ble to the 50 States. 

17 ‘‘(iv) The State plan provides for medical as18 sistance for Medicare cost-sharing described in sub19 section (p)(3)(A)(ii) for qualified Medicare bene20 ficiaries described in subsection (p)(1), in accord21 ance with the requirements under subsection (p) oth22 erwise applicable to the 50 States. 

23 ‘‘(3)(A)(i) Not later than January 1, 2022, the Gov24 ernor of Puerto Rico shall submit to the Secretary a Terri25 tory Transition Plan, which shall be developed with stakeVerDate Sep 11 2014 22:42 Jun 24, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H3371.IH H3371

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1 holder input and with a public comment period, that in2 cludes— 

3 ‘‘(I) a detailed description of which pro4 gram enhancements described in subparagraph 

5 (C) Puerto Rico will include as medical assist6 ance under the State plan under title XIX, the 

7 first plan year by which each such program en8 hancement will be so included in order to sat9 isfy the requirements described in subparagraph 

10 (B), and a timeline for milestones for including 

11 such program enhancements; and 

12 ‘‘(II) a description of any challenges, in13 cluding infrastructure challenges, provider 

14 shortages, and financing challenges, for so in15 cluding such program enhancements and a plan 

16 to ameliorate any such challenges. 

17 ‘‘(ii) The plan submitted under clause (i) shall be 

18 treated as approved by the Secretary not later than 180 

19 days after the date of submission of the plan unless within 

20 such 180-day period the Secretary disapproves such plan 

21 and notifies Puerto Rico of such disapproval with the rea22 son for such disapproval. In the case of such a disapproval, 

23 the Governor of Puerto Rico shall, within the 90-day pe24 riod following such notification, submit to the Secretary 

25 a Territory Transition Plan that addresses the reason 


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1 specified in such notification for such disapproval. Such 

2 resubmitted plan shall be treated as approved by the Sec3 retary under this clause unless the Secretary notifies 

4 Puerto Rico within the 30-day period following such sub5 mission of its disapproval with a reason for such dis6 approval. The Governor of Puerto Rico may develop and 

7 submit to the Secretary, in the same manner and subject 

8 to the same conditions as apply under clause (i) to the 

9 development and submission of the Territory Transition 

10 Plan, modifications to the plan and such modifications 

11 shall be treated as approved by the Secretary and incor12 porated into the plan in the same manner and subject to 

13 the same conditions that apply under this clause to the 

14 approval of the plan. 

15 ‘‘(B) For purposes of this paragraph, the require16 ments described in this subparagraph, with respect to 

17 Puerto Rico, are the following: 

18 ‘‘(i) For 2027, the State plan under title XIX 

19 includes at least 2 of the program enhancements de20 scribed in subparagraph (C). 

21 ‘‘(ii) For 2029, the State plan includes at least 

22 4 of such program enhancements. 

23 ‘‘(iii) For 2031, the State plan includes at least 

24 6 of such program enhancements. 


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1 ‘‘(iv) For 2033 and each subsequent year, the 

2 State plan includes all of such program enhance3 ments. 

4 ‘‘(C) For purposes of this paragraph, the program 

5 enhancements described in this subparagraph are the fol6 lowing: 

7 ‘‘(i) The State plan provides for medical assist8 ance to all individuals described in clause (i) of sec9 tion 1902(a)(10)(A)). 

10 ‘‘(ii) The State plan provides for inclusion as 

11 medical assistance of home health services, in ac12 cordance with section 1902(a)(10)(D). 

13 ‘‘(iii) The State plan provides for inclusion as 

14 medical assistance of nonemergency transportation 

15 to medically necessary services. 

16 ‘‘(iv) The State plan provides for inclusion as 

17 medical assistance of services described in subsection 

18 (a)(21) to all individuals described in clause (i) of 

19 section 1902(a)(10)(A)). 

20 ‘‘(v) The State plan provides for inclusion as 

21 medical assistance of services described in subsection 

22 (a)(17) to all individuals described in such clause 

23 (other than subclause (VIII) of such clause. 


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1 ‘‘(vi) The State plan provides for inclusion as 

2 medical assistance of nursing facility services, as de3 fined in subsection (a)(4)(A). 

4 ‘‘(vii) The State plan provides for inclusion as 

5 medical assistance of early and periodic screening, 

6 diagnosis, and treatment services under subsection 

7 (a)(4)(B). 

8 ‘‘(viii) The State plan provides for inclusion as 

9 medical assistance of freestanding birth center serv10 ices and other ambulatory services, as described in 

11 subsection (a)(28). 

12 ‘‘(D)(i) For fiscal year 2022 and each subsequent fis13 cal year through fiscal year 2033— 

14 ‘‘(I) the Comptroller General of the United 

15 States shall review, and submit to the Secretary and 

16 Congress a report on, whether or not Puerto Rico is 

17 in compliance with the timeline and achieving the 

18 milestones described in the Territory Transition plan 

19 (as modified, if applicable) approved under subpara20 graph (A) and, beginning with fiscal year 2027, 

21 whether Puerto Rico is in compliance with the appli22 cable requirements described in subparagraph (B); 

23 and 

24 ‘‘(II) Puerto Rico shall submit to the Secretary 

25 a report on the extent to which Puerto Rico has met 


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1 the timelines and milestones included in such plan 

2 (as modified, if applicable). 

3 ‘‘(ii) If, for a fiscal year described in clause (i) after 

4 fiscal year 2024, the Comptroller General submits a report 

5 with a finding that Puerto Rico is not in compliance with 

6 the timeline or with achieving milestones as described in 

7 subclause (I) (or, with respect to a fiscal year after fiscal 

8 year 2026, not in compliance with the applicable require9 ment under subparagraph (B)), not later than 90 days 

10 after the date of such finding, Puerto Rico shall submit 

11 to the Secretary for approval a corrective action plan to 

12 remedy such noncompliance. 

13 ‘‘(iii) If, by not later than a period specified by the 

14 Secretary after the date of the submission (and approval) 

15 of a corrective action plan under clause (ii), with respect 

16 to a fiscal year after fiscal year 2024 for which a finding 

17 of non-compliance was made under clause (i), the Sec18 retary determines that Puerto Rico has not fulfilled the 

19 terms of such corrective action plan, the PR specified per20 cent specified under paragraph (1) for the fiscal year in21 volved shall be reduced by 5 percent for the period begin22 ning with the month beginning after such determination 

23 and ending with the first month beginning after the Sec24 retary determines Puerto Rico has fulfilled the terms of 

25 the corrective action plan.’’. 


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1 (b) TREATMENT OF CAP.—Section 1108(g) of the 

2 Social Security Act (42 U.S.C. 1308(g)) is amended— 

3 (1) in paragraph (2)— 

4 (A) in the matter preceding subparagraph 

5 (A), by striking ‘‘subject to and section 

6 1323(a)(2) of the Patient Protection and Af7 fordable Care Act paragraphs (3) and (5)’’ and 

8 inserting ‘‘subject to section 1323(a)(2) of the 

9 Patient Protection and Affordable Care Act and 

10 paragraphs (3), (5), and (7)’’; and 

11 (B) in subparagraph (A)— 

12 (i) by striking ‘‘Puerto Rico shall not 

13 exceed the sum of’’ and inserting ‘‘Puerto 

14 Rico shall not exceed— 

15 ‘‘(i) in the case of a fiscal year before 

16 fiscal year 2020, the sum of’’; 

17 (ii) by striking ‘‘$100,000;’’ and in18 serting ‘‘$100,000; and’’; and 

19 (iii) by adding at the end the fol20 lowing new clause: 

21 ‘‘(ii) in the case of fiscal year 2020 

22 and each subsequent fiscal year (before fis23 cal year 2025), the amount specified in 

24 paragraph (6) for such fiscal year;’’; and 


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1 (2) by adding at the end the following new 

2 paragraphs: 

3 ‘‘(6) APPLICATION TO PUERTO RICO FOR FIS4 CAL YEARS 2020 THROUGH 2024.—For purposes of 

5 paragraph (2)(A)(ii), the amount specified in this 

6 paragraph is— 

7 ‘‘(A) for fiscal year 2020, $2,823,188,000; 

8 ‘‘(B) for fiscal year 2021, $2,919,072,000; 

9 ‘‘(C) for fiscal year 2022, $3,012,610,000; 

10 ‘‘(D) for fiscal year 2023, $3,114,331,000; 

11 and 

12 ‘‘(E) for fiscal year 2024, $3,225,627,000. 

13 ‘‘(7) PUERTO RICO EXCLUSION FROM PAYMENT

14 LIMITATION BEGINNING FISCAL YEAR 2025.—Begin15 ning with fiscal year 2025, there shall be no limita16 tion applied under this subsection (f) or this sub17 section on the total amount certified by the Sec18 retary under title XIX for payment to Puerto 

19 Rico.’’. 

20 (c) TEMPORARY INCREASE IN FEDERAL MATCH FOR

21 STATE PLAN ADMINISTRATIVE COSTS.—Section 

22 1903(a)(7) of the Social Security Act (42 U.S.C. 

23 1396b(a)(7)) is amended by inserting ‘‘(or, in the case of 


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1 Puerto Rico for each of fiscal years 2020 through 2033, 

2 100 percent)’’ after ‘‘50 per centum’’. 

Æ 


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