I 

114TH CONGRESS 

1ST SESSION H. R. 2635 

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 

JUNE 3, 2015 

Mr. PIERLUISI (for himself, Ms. BORDALLO, Mr. SABLAN, and Ms. 

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

6 Federal Health Programs Act of 2015’’. 


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

2 this Act are 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. 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. 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. 


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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 before para7 graph (1), by striking ‘‘subsection (g)’’ and inserting 

8 ‘‘subsections (g) and (h)’’; 

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

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

11 after ‘‘paragraphs (3) and (5)’’; 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 OF THE

16 UNITED STATES, GUAM, THE NORTHERN MARIANA IS17 LANDS, AND AMERICAN SAMOA.—Subsections (f) and (g) 

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

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

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

21 (b) CONFORMING AMENDMENTS.— 

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

23 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 

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

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

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

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

8 this section shall apply beginning with fiscal year 2017. 

9 SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 

10 ASSISTANCE PERCENTAGE (FMAP) LIMITA11 TION FOR TERRITORIES. 

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

13 1396d(b)) is amended, in clause (2), by inserting ‘‘for fis14 cal years before fiscal year 2017’’ after ‘‘American 

15 Samoa’’. 

16 SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY 

17 TO ALL OF THE TERRITORIES. 

18 (a) IN GENERAL.—Section 1902(j) of the Social Se19 curity Act (42 U.S.C. 1396a(j)) is amended— 

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

21 Northern Mariana Islands’’ and inserting ‘‘Puerto 

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

23 the Northern Mariana Islands, and American 

24 Samoa’’; 


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1 (2) by striking ‘‘American Samoa or the North2 ern Mariana Islands’’ and inserting ‘‘Puerto Rico, 

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

4 Northern Mariana Islands, or American Samoa’’; 

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

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

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

8 other requirement of this title’’; and 

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

10 ‘‘(2) The Secretary may not waive under this sub11 section the requirement of subsection (a)(10)(A)(i)(IX) 

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

13 with respect to any territory.’’. 

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

15 this section shall apply beginning October 1, 2016. 

16 SEC. 104. APPLICATION OF 100 PERCENT FEDERAL POV17 ERTY LINE (FPL) LIMITATION TO TERRI18 TORIES. 

19 (a) IN GENERAL.—Section 1902(a)(10)(A)(i)(VIII) 

20 of the Social Security Act (42 U.S.C. 

21 1396a(a)(10)(A)(i)(VIII)) is amended— 

22 (1) by inserting ‘‘(or, subject to subsection (j), 

23 100 percent in the case of Puerto Rico, the Virgin 

24 Islands of the United States, Guam, the Northern 


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1 Mariana Islands, and American Samoa)’’ after ‘‘133 

2 percent’’; and 

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

4 103, by adding at the end the following new para5 graph: 

6 ‘‘(3)(A) Notwithstanding any other provision of law, 

7 Federal financial participation shall not be available to a 

8 territory for medical assistance for an individual whose 

9 family income exceeds 100 percent of the official poverty 

10 line for a family of the size involved, except in the case 

11 of individuals qualifying for medical assistance under sub12 section (a)(10)(A)(i)(IX) and except as authorized under 

13 a waiver under this subsection or section 1115. 

14 ‘‘(B) The Secretary may, under paragraph (1) or sec15 tion 1115, waive the limitation under subparagraph (A) 

16 but only in the case of a territory other than Puerto Rico. 

17 In carrying out this subparagraph, the Secretary shall 

18 take into account the eligibility levels established under 

19 the State plan of the territory involved before the date 

20 of the enactment of this paragraph.’’. 

21 (b) NOT APPLYING 5 PERCENT DISREGARD.—Sub22 paragraph (I) of section 1902(a)(14) of the Social Secu23 rity Act (42 U.S.C. 1396b(a)(14)) is amended by adding 

24 at the end the following: 


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1 ‘‘The previous sentence shall only apply to a 

2 State that is one of the 50 States or the Dis3 trict of Columbia.’’. 

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

5 this section shall apply with respect to eligibility deter6 minations made with respect to items and services fur7 nished on or after October 1, 2016. 

8 SEC. 105. PERMITTING MEDICAID DSH ALLOTMENTS FOR 

9 TERRITORIES. 

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

11 1396) is amended— 

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

13 following new subparagraph: 

14 ‘‘(C) TERRITORIES.— 

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

16 year 2017, the DSH allotment for Puerto 

17 Rico, the Virgin Islands of the United 

18 States, Guam, the Northern Mariana Is19 lands, and American Samoa shall bear the 

20 same ratio to $150,000,000 as the ratio of 

21 the number of individuals who are low-in22 come or uninsured and residing in such re23 spective territory (as estimated from time 

24 to time by the Secretary) bears to the 


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1 sums of the number of such individuals re2 siding in all of the territories. 

3 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 

4 For each subsequent fiscal year, the DSH 

5 allotment for each such territory is subject 

6 to an increase in accordance with para7 graph (2).’’; and 

8 (2) in paragraph (9), by inserting before the pe9 riod at the end the following: ‘‘, and includes, begin10 ning with fiscal year 2017, Puerto Rico, the Virgin 

11 Islands of the United States, Guam, the Northern 

12 Mariana Islands, and American Samoa’’. 

13 TITLE II—MEDICARE 

14 Subtitle A—Part A 

15 SEC. 201. MODIFICATION OF MEDICARE INPATIENT HOS16 PITAL PAYMENT RATE FOR PUERTO RICO 

17 HOSPITALS. 

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

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

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

21 (2) in clause (iv)— 

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

23 2015,’’ after ‘‘2004,’’; and 

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

25 inserting ‘‘; and’’; and 


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

2 clause: 

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

4 Puerto Rico percentage is 0 percent and the applica5 ble Federal percentage is 100 percent.’’. 

6 SEC. 202. APPLICATION OF MEDICARE HITECH PAYMENTS 

7 TO HOSPITALS IN PUERTO RICO. 

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

9 1886 of the Social Security Act (42 U.S.C. 1395ww) is 

10 amended by striking ‘‘subsection (d) hospital’’ and insert11 ing ‘‘hospital that is a subsection (d) hospital or a sub12 section (d) Puerto Rico hospital’’. 

13 (b) CONFORMING AMENDMENTS.— 

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

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

16 amended— 

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

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

19 (B) in subclause (II), by striking ‘‘a sub20 section (d) hospital’’ and inserting ‘‘an eligible 

21 hospital’’. 

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

23 1853(m) of the Social Security Act (42 U.S.C. 

24 1395w–23(m)) are each amended by striking 

25 ‘‘1886(n)(6)(A)’’ and inserting ‘‘1886(n)(6)(B)’’. 


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1 (c) IMPLEMENTATION.—Notwithstanding any other 

2 provision of law, the Secretary of Health and Human 

3 Services may implement the amendments made by this 

4 section by program instruction or otherwise. 

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

6 this section shall apply as if included in the enactment 

7 of the American Recovery and Reinvestment Act of 2009 

8 (Public Law 111–5), except that, in order to take into ac9 count delays in the implementation of this section, in ap10 plying subsections (b)(3)(B)(ix), (n)(2)(E)(ii), and 

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

12 as amended by this section, any reference in such sub13 sections to a particular year shall be treated with respect 

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

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

16 7 years after such particular year in the case of applying 

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

18 SEC. 203. 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, 2015, 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 Subtitle B—Part B 

2 SEC. 211. APPLICATION OF PART B DEEMED ENROLLMENT 

3 PROCESS TO RESIDENTS OF PUERTO RICO; 

4 SPECIAL ENROLLMENT PERIOD AND LIMIT 

5 ON LATE ENROLLMENT PENALTIES. 

6 (a) APPLICATION OF PART B DEEMED ENROLLMENT

7 PROCESS TO RESIDENTS OF PUERTO RICO.—Section 

8 1837(f)(3) of the Social Security Act (42 U.S.C. 

9 1395p(f)(3)) is amended by striking ‘‘, exclusive of Puerto 

10 Rico’’. 

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

12 subsection (a) shall apply to individuals whose initial en13 rollment period under section 1837(d) of the Social Secu14 rity Act begins on or after the first day of the effective 

15 month, specified by the Secretary of Health and Human 

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

17 by subsection (c)(2). 

18 (c) TRANSITION PROVIDING SPECIAL ENROLLMENT

19 PERIOD AND LIMIT ON LATE ENROLLMENT PENALTIES

20 FOR CERTAIN MEDICARE BENEFICIARIES.—Section 1839 

21 of the Social Security Act (42 U.S.C. 1395r) is amend22 ed— 

23 (1) in the first sentence of subsection (b), by in24 serting ‘‘subject to section 1839(j)(2),’’ after ‘‘sub25 section (i)(4) or (l) of section 1837,’’; and 


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1 (2) by adding at the end the following new sub2 section: 

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

4 PUERTO RICO.— 

5 ‘‘(1) SPECIAL ENROLLMENT PERIOD, COVERAGE

6 PERIOD FOR RESIDENTS WHO ARE ELIGIBLE BUT

7 NOT ENROLLED.— 

8 ‘‘(A) IN GENERAL.—In the case of a tran9 sition individual (as defined in paragraph (3)) 

10 who is not enrolled under this part as of the 

11 day before the first day of the effective month 

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

13 shall provide for a special enrollment period 

14 under section 1837 of 7 months beginning with 

15 such effective month during which the indi16 vidual may be enrolled under this part. 

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

18 such an individual who enrolls during such spe19 cial enrollment period, the coverage period 

20 under section 1838 shall begin on the first day 

21 of the second month after the month in which 

22 the individual enrolls. 

23 ‘‘(C) EFFECTIVE MONTH DEFINED.—In 

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

25 month, not earlier than October 2016 and not 


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1 later than January 2017, specified by the Sec2 retary. 

3 ‘‘(2) REDUCTION IN LATE ENROLLMENT PEN4 ALTIES FOR CURRENT ENROLLEES AND INDIVID5 UALS ENROLLING DURING TRANSITION.— 

6 ‘‘(A) IN GENERAL.—In the case of a tran7 sition individual who is enrolled under this part 

8 as of the day before the first day of the effec9 tive month or who enrolls under this part on or 

10 after the date of the enactment of this sub11 section but before the end of the special enroll12 ment period under paragraph (1)(A), the 

13 amount of the late enrollment penalty imposed 

14 under section 1839(b) shall be recalculated by 

15 reducing the penalty to 15 percent of the pen16 alty otherwise established. 

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

18 shall be applied in the case of a transition indi19 vidual who— 

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

21 the month before the effective month, for 

22 premiums for months beginning with such 

23 effective month; or 

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

25 after the date of the enactment of this Act 


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1 and before the end of the special enroll2 ment period under paragraph (1)(A), for 

3 premiums for months during the coverage 

4 period under this part which occur during 

5 or after the effective month. 

6 ‘‘(C) LOSS OF REDUCTION IF INDIVIDUAL

7 TERMINATES ENROLLMENT.—Subparagraph 

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

9 the individual terminates enrollment under this 

10 part after the end of the special enrollment pe11 riod under paragraph (1). 

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

13 this section, the term ‘transition individual’ means 

14 an individual who resides in Puerto Rico and who 

15 would have been deemed enrolled under this part 

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

17 the effective month but for the fact that the indi18 vidual was a resident of Puerto Rico, regardless of 

19 whether the individual is enrolled under this part as 

20 of such first day.’’. 

21 SEC. 212. PUERTO RICO PRACTICE EXPENSE GPCI IM22 PROVEMENT. 

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

24 U.S.C. 1395w–4(e)(1)) is amended— 


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

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

3 (2) by adding at the end the following new sub4 paragraph: 

5 ‘‘(J) FLOOR FOR PRACTICE EXPENSE

6 INDEX FOR SERVICES FURNISHED IN PUERTO

7 RICO.— 

8 ‘‘(i) IN GENERAL.—For purposes of 

9 payment for services furnished in Puerto 

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

11 calculating the practice expense index in 

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

13 such index is below the reference index (as 

14 defined in clause (ii)) for the year, the Sec15 retary shall increase such index for Puerto 

16 Rico to equal the value of the reference 

17 index for the year. The preceding sentence 

18 shall not be applied in a budget neutral 

19 manner. 

20 ‘‘(ii) REFERENCE INDEX DEFINED.— 

21 In this subparagraph, the term ‘reference 

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

23 or, if less, the lowest practice expense 

24 index value for the year for any area in the 

25 50 States or the District of Columbia.’’. 


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1 Subtitle C—Medicare Advantage 

2 (Part C) 

3 SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW BASE 

4 PAYMENT COUNTIES IN PUERTO RICO. 

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

6 1395w–103(n)) is amended— 

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

8 inserting ‘‘, (5), and (6)’’; 

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

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

11 case’’; and 

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

13 paragraph: 

14 ‘‘(6) SPECIAL RULES FOR BLENDED BENCH15 MARK AMOUNT FOR TERRITORIES.— 

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

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

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

19 shall not be less than 80 percent of the national 

20 average of the base payment amounts specified 

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

22 within the 50 States and the District of Colum23 bia. 

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

25 blended benchmark amount for an area in a 


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1 territory for a year under subparagraph (A) ex2 ceed the lowest blended benchmark amount for 

3 any area within the 50 States and the District 

4 of Columbia for such year.’’. 

5 Subtitle D—Part D 

6 SEC. 231. IMPROVED USE OF ALLOCATED PRESCRIPTION 

7 DRUG FUNDS BY TERRITORIES. 

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

9 1396u–5(e)) is amended by adding at the end the fol10 lowing new paragraph: 

11 ‘‘(5) IMPROVED USE OF FUNDS FOR LOW-IN12 COME PART D ELIGIBLE INDIVIDUALS.—This sub13 section shall be applied beginning with fiscal year 

14 2016 as follows, notwithstanding any other provision 

15 of this title: 

16 ‘‘(A) CLARIFYING STATE FLEXIBILITY TO

17 COVER NON-DUAL-ELIGIBLE INDIVIDUALS.—In 

18 this title, the term ‘medical assistance’ includes 

19 financial assistance furnished by a State under 

20 this subsection to part D eligible individuals 

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

22 States or the District of Columbia, would qual23 ify as subsidy eligible individuals under section 

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1 er such individuals otherwise qualify for medical 

2 assistance under this title. 

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

4 STATE MATCHING REQUIRED FOR PART D LOW

5 INCOME SUBSIDIES.—The Federal medical as6 sistance percentage applicable to the assistance 

7 furnished under this subsection is 100 percent. 

8 ‘‘(C) LIMITED FUNDING FOR SPECIAL

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

10 provision of medical assistance for covered part 

11 D drugs to low-income part D eligible individ12 uals for a State and period under this sub13 section, is limited to the amount specified in 

14 paragraph (3) for such State and period, with15 out regard to the application of subsection (f) 

16 or (g) of section 1108.’’. 

17 SEC. 232. REPORT ON TREATMENT OF TERRITORIES 

18 UNDER MEDICARE PART D. 

19 Paragraph (4) of section 1935(e) of the Social Secu20 rity Act (42 U.S.C. 1396u–5(e)) is amended to read as 

21 follows: 

22 ‘‘(4) REPORT ON APPLICATION OF SUB23 SECTION.— 

24 ‘‘(A) IN GENERAL.—Not later than Feb25 ruary 1, 2018, the Secretary shall submit to 


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1 Congress a report on the application of this 

2 subsection during the period beginning fiscal 

3 year 2006 and ending fiscal year 2017. 

4 ‘‘(B) INFORMATION TO BE INCLUDED IN

5 REPORT.—Such report shall include— 

6 ‘‘(i) program guidance issued by the 

7 Secretary to implement this subsection; 

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

9 the increased amount under paragraph (3) 

10 and how the territory has applied such 

11 amount, including the territory’s program 

12 design, expenditures, and number of indi13 viduals (and dual-eligible individuals) as14 sisted; and 

15 ‘‘(iii) differences between how such 

16 territories are treated under part D of title 

17 XVIII and under this title compared with 

18 the treatment of the 50 States and the 

19 District of Columbia under such part and 

20 this title for different fiscal years within 

21 the period covered under the report. 

22 ‘‘(C) RECOMMENDATIONS.—Such report 

23 shall include recommendations for improving 

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1 ommendations regarding each of the following 

2 alternative approaches: 

3 ‘‘(i) Adjusting the aggregate amount 

4 specified in paragraph (3)(B). 

5 ‘‘(ii) Allowing residents of the terri6 tories to be subsidy eligible individuals 

7 under section 1860D–14, notwithstanding 

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

9 providing substantially equivalent low-in10 come prescription drug subsidies to such 

11 residents.’’. 

12 TITLE III—MISCELLANEOUS 

13 SEC. 301. MODIFIED TREATMENT OF TERRITORIES WITH 

14 RESPECT TO APPLICATION OF ACA ANNUAL 

15 HEALTH INSURANCE PROVIDER FEES. 

16 Section 9010 of the Patient Protection and Afford17 able Care Act (26 U.S.C. 4001 note prec.) is amended— 

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

19 to subsection (j)(1),’’ after ‘‘With respect to each 

20 covered entity,’’; and 

21 (2) by striking subsection (j) and inserting the 

22 following: 

23 ‘‘(j) SPECIAL RULES FOR TREATMENT OF TERRI24 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 2016— 

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 

25 funds made available to the territory under secVerDate Sep 11 2014 02:16 Jun 05, 2015 Jkt 049200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\H2635.IH H2635

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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 purposes of 

7 the territory meeting non-Federal matching re8 quirements imposed with respect to obtaining 

9 Federal financial participation under title XIX 

10 of the Social 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, 2018, 

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. 

Æ 


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