II 

116TH CONGRESS 

1ST SESSION S. 1773 

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 

JUNE 11, 2019 

Mr. SANDERS (for himself, Mr. MERKLEY, Mrs. GILLIBRAND, Mr. 

BLUMENTHAL, Ms. HARRIS, Mr. BOOKER, Ms. WARREN, and Mr. MARKEY) 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 ‘‘Territories Health Equity Act of 2019’’. 

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

7 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; temporary increase in 

FMAP for Puerto Rico and the Virgin Islands to 100 percent. 

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. 

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 preceding 

2 paragraph (1), by striking ‘‘subsection (g)’’ and in3 serting ‘‘subsections (g) and (h)’’; 

4 (2) in subsection (g)(2), in the matter pre5 ceding subparagraph (A), by inserting ‘‘subsection 

6 (h)’’ after ‘‘subject to’’; 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, GUAM, THE

11 NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 

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

13 the Virgin Islands, Guam, the Northern Mariana Islands, 

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

15 (b) CONFORMING AMENDMENTS.— 

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

17 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 

18 limitation in section 1108(f),’’. 

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

20 (42 U.S.C. 1396b(u)) is amended by striking para21 graph (4). 

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

23 this section shall apply beginning with fiscal year 2020. 


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1 SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 

2 ASSISTANCE PERCENTAGE (FMAP) LIMITA3 TION FOR TERRITORIES; TEMPORARY IN4 CREASE IN FMAP FOR PUERTO RICO AND 

5 THE VIRGIN ISLANDS TO 100 PERCENT. 

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

7 1396d(b)) is amended— 

8 (1) in clause (2), by inserting ‘‘for fiscal years 

9 before fiscal year 2020’’ after ‘‘American Samoa’’; 

10 and 

11 (2) by adding at the end the following new sen12 tence: ‘‘Notwithstanding the first sentence of this 

13 subsection, for each of fiscal years 2020 and 2021, 

14 the Federal medical assistance percentage for Puerto 

15 Rico and the Virgin Islands shall be 100 percent.’’. 

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, Guam, the Northern Mar23 iana Islands, and American Samoa’’; 

24 (2) by striking ‘‘American Samoa or the North25 ern Mariana Islands’’ and inserting ‘‘Puerto Rico, 


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1 the Virgin Islands, Guam, the Northern Mariana Is2 lands, or American Samoa’’; 

3 (3) by inserting ‘‘(1)’’ before ‘‘Notwith4 standing’’; 

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

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

7 other requirement of this title’’; and 

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

9 ‘‘(2) The Secretary may not waive under this sub10 section— 

11 ‘‘(A) the requirement of subsection 

12 (a)(10)(A)(i)(IX) (relating to coverage of adults for13 merly under foster care) with respect to any terri14 tory; 

15 ‘‘(B) the requirement to provide medical assist16 ance for early and periodic screening, diagnostic, 

17 and treatment services (as defined in section 

18 1905(r)) for individuals who are eligible for assist19 ance under the program and who under the age of 

20 21; or 

21 ‘‘(C) the requirement to provide for payment 

22 for services described in section 1905(a)(2)(C) fur23 nished by a Federally-qualified health center and 

24 services described in section 1905(a)(2)(B) furnished 


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1 by a rural health clinic in accordance with the provi2 sions of subsection (bb).’’. 

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

4 this section shall apply beginning October 1, 2019. 

5 SEC. 104. PERMITTING MEDICAID DSH ALLOTMENTS FOR 

6 TERRITORIES. 

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

8 1396r–4(f)) is amended— 

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

10 following new subparagraph: 

11 ‘‘(C) TERRITORIES.— 

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

13 year 2020, the DSH allotment for Puerto 

14 Rico, the Virgin Islands, Guam, the North15 ern Mariana Islands, and American Samoa 

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

17 as the ratio of the number of individuals 

18 who are low-income or uninsured and re19 siding in such respective territory (as esti20 mated from time to time by the Secretary) 

21 bears to the sums of the number of such 

22 individuals residing in all of the territories. 

23 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 

24 For each subsequent fiscal year, the DSH 

25 allotment for each such territory is subject 


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1 to an increase in accordance with para2 graph (3).’’; and 

3 (2) in paragraph (9), by inserting before the pe4 riod at the end the following: ‘‘, and includes, begin5 ning with fiscal year 2020, Puerto Rico, the Virgin 

6 Islands, Guam, the Northern Mariana Islands, and 

7 American Samoa’’. 

8 TITLE II—MEDICARE 

9 Subtitle A—Part A 

10 SEC. 201. CALCULATION OF MEDICARE DSH PAYMENTS FOR 

11 IPPS HOSPITALS IN PUERTO RICO. 

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

13 (42 U.S.C. 1395ww(d)(9)(D)(iii)) is amended to read as 

14 follows: 

15 ‘‘(iii) Subparagraph (F) (relating to dispropor16 tionate share payments), including application of 

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

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

19 subparagraph shall be substituted for the sum 

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

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

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

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

24 the numerator described in such subclause the 

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


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1 patient days for the cost reporting period in2 volved which were made up of patients who (for 

3 such days) were entitled to benefits under part 

4 A of this title and were— 

5 ‘‘(aa) entitled to supplementary secu6 rity income benefits (excluding any State 

7 supplementation) under title XVI of this 

8 Act; 

9 ‘‘(bb) eligible for medical assistance 

10 under a State plan under title XIX; or 

11 ‘‘(cc) receiving aid or assistance under 

12 any plan of the State approved under title 

13 I, X, XIV, or XVI.’’. 

14 SEC. 202. REBASING TARGET AMOUNT FOR HOSPITALS IN 

15 TERRITORIES. 

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

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

18 the following new subparagraph: 

19 ‘‘(M)(i) For each cost reporting period be20 ginning on or after October 1, 2019, in the case 

21 of a hospital located in a territory of the United 

22 States, there shall be substituted for the target 

23 amount otherwise determined under subpara24 graph (A) the rebased target amount (as de25 fined in clause (ii)), if such substitution results 


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1 in an amount of payment under this section to 

2 the hospital for such period that is greater than 

3 the amount of payment that would be made 

4 under this section to the hospital for such pe5 riod if this subparagraph were not to apply. 

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

7 the term ‘rebased target amount’ has the mean8 ing given the term ‘target amount’ in subpara9 graph (A), except that— 

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

11 preceding 12-month cost reporting period 

12 the 12-month cost reporting period begin13 ning during fiscal year 2015 (or, at the op14 tion of the hospital, beginning during fiscal 

15 year 2017); 

16 ‘‘(II) any reference in subparagraph 

17 (A)(i) to the ‘first such cost reporting pe18 riod’ is deemed a reference to the first cost 

19 reporting period following the 12-month 

20 cost reporting period beginning during fis21 cal year 2015 (or, at the option of the hos22 pital, beginning during fiscal year 2017); 

23 and 

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1 graph (B)(ii) for cost reporting periods be2 ginning on or after October 1, 2019. 

3 ‘‘(iii) Nothing in this subparagraph shall 

4 affect any pending request by a hospital for a 

5 new target amount for any cost reporting pe6 riod beginning during a fiscal year before fiscal 

7 year 2020.’’. 

8 SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOS9 PITALS IN TERRITORIES. 

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

11 U.S.C. 1395ww(b)(3)), as amended by section 202, is fur12 ther amended by adding at the end the following new sub13 paragraph: 

14 ‘‘(N)(i) For each cost reporting period be15 ginning on or after October 1, 2019, in the case 

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

17 United States other than Puerto Rico and that 

18 would be a subsection (d) hospital if it were lo19 cated in one of the 50 States, the target 

20 amount shall be increased by— 

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

22 a disproportionate patient percentage of 

23 not less than 15 percent and not greater 

24 than 40 percent, 10 percent; and 


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

2 has a disproportionate patient percentage 

3 of greater than 40 percent, 10 percent plus 

4 60 percent of the number of percentage 

5 points by which such hospital’s dispropor6 tionate patient percentage exceeds 40 per7 cent. 

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

9 the term ‘disproportionate patient percentage’ 

10 has the meaning given such term in subsection 

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

12 meaning any reference under such subsection to 

13 individuals entitled to supplementary security 

14 income under title XVI shall be deemed for pur15 poses of this subparagraph to include individ16 uals— 

17 ‘‘(I) eligible for medical assistance 

18 under a State plan under title XIX; or 

19 ‘‘(II) receiving aid or assistance under 

20 any plan of the territory approved under 

21 title 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 2020 and not 


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1 later than January 2021, 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.’’. 


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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–23(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 subpara17 graph (B), the blended benchmark amount for 

18 an area in a territory for a year (beginning with 

19 2020) shall not be less than 80 percent of the 

20 national average of the base payment amounts 

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

22 for areas within the 50 States and the District 

23 of Columbia. 

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 2020 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.’’. 

15 SEC. 232. REPORT ON TREATMENT OF TERRITORIES 

16 UNDER MEDICARE PART D. 

17 Paragraph (4) of section 1935(e) of the Social Secu18 rity Act (42 U.S.C. 1396u–5(e)) is amended to read as 

19 follows: 

20 ‘‘(4) REPORT ON APPLICATION OF SUB21 SECTION.— 

22 ‘‘(A) IN GENERAL.—Not later than Feb23 ruary 1, 2021, the Secretary shall submit to 

24 Congress a report on the application of this 


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1 subsection during the period beginning fiscal 

2 year 2006 and ending fiscal year 2020. 

3 ‘‘(B) INFORMATION TO BE INCLUDED IN

4 REPORT.—Such report shall include— 

5 ‘‘(i) program guidance issued by the 

6 Secretary to implement this subsection; 

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

8 the increased amount under paragraph (3) 

9 and how the territory has applied such 

10 amount, including the territory’s program 

11 design, expenditures, and number of indi12 viduals (and dual-eligible individuals) as13 sisted; and 

14 ‘‘(iii) differences between how such 

15 territories are treated under part D of title 

16 XVIII and under this title compared with 

17 the treatment of the 50 States and the 

18 District of Columbia under such part and 

19 this title for different fiscal years within 

20 the period covered under the report. 

21 ‘‘(C) RECOMMENDATIONS.—Such report 

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

20 covered entity,’’; and 

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

22 ‘‘(k) SPECIAL RULES FOR TREATMENT OF TERRI23 TORIES.— 

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

25 with respect to United States health risks located 


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1 outside of the 50 States or the District of Columbia 

2 for years beginning with 2020— 

3 ‘‘(A) the amount of the fee under sub4 section (b) shall be 50 percent of the amount 

5 of the fee otherwise determined; 

6 ‘‘(B) the Secretary shall deposit the 

7 amount of such fees collected for each territory 

8 into a separate account; and 

9 ‘‘(C) amounts in such an account for a ter10 ritory for a year are appropriated and shall be 

11 available to the territory in accordance with 

12 paragraph (2). 

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

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

15 respect to a territory for a year shall be made avail16 able to the territory, upon application of the terri17 tory to the Secretary of Health and Human Serv18 ices, only for the following purposes, as elected by 

19 the territory in such application: 

20 ‘‘(A) INCREASED PRESCRIPTION DRUG AS21 SISTANCE FOR LOW-INCOME PART D ELIGIBLE

22 INDIVIDUALS.—For increasing the amount of 

23 funds made available to the territory under sec24 tion 1935(e)(3) of the Social Security Act (42 

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1 come part D eligible individuals in obtaining 

2 part D covered drugs. 

3 ‘‘(B) SATISFYING STATE MEDICAID

4 MATCHING REQUIREMENT.—For the territory to 

5 meet non-Federal matching requirements im6 posed with respect to obtaining Federal finan7 cial participation under title XIX of the Social 

8 Security Act.’’. 

9 SEC. 302. MEDICAID AND CHIP TERRITORY TRANSPARENCY 

10 AND INFORMATION. 

11 (a) PUBLICATION OF INFORMATION ON FEDERAL

12 EXPENDITURES UNDER MEDICAID AND CHIP IN THE

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

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

15 Human Services shall publish, and periodically update, on 

16 the Internet site of the Centers for Medicare & Medicaid 

17 Services information on Medicaid and CHIP carried out 

18 in the territories of the United States. Such information 

19 shall include, with respect to each such territory— 

20 (1) the income levels established by the terri21 tory for purposes of eligibility of an individual to re22 ceive medical assistance under Medicaid or child 

23 health assistance under CHIP; 

24 (2) the number of individuals enrolled in Med25 icaid and CHIP in such territory; 


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1 (3) any State plan amendments in effect to 

2 carry out Medicaid or CHIP in such territory; 

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

4 or title XXI issued by the Secretary to carry out 

5 Medicaid or CHIP in the territory, including a waiv6 er under section 1115 of the Social Security Act (42 

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

8 any documentation related to such application (in9 cluding correspondence); 

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

11 share of expenditures under Medicaid and CHIP in 

12 such territory; 

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

14 health care items and services under Medicaid and 

15 CHIP in such territory; 

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

17 (8) other information regarding the carrying 

18 out of Medicaid and CHIP in the territory that is 

19 published on such Internet site with respect to car20 rying out Medicaid and CHIP in each State and the 

21 District of Columbia. 

22 (b) DEFINITIONS.—In this section: 

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

24 State Children’s Health Insurance Program under 

25 title XXI of the Social Security Act. 


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

2 the Medicaid program under title XIX of the Social 

3 Security Act. 

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

5 United States’’ includes Puerto Rico, the Virgin Is6 lands of the United States, Guam, the Northern 

7 Mariana Islands, and American Samoa. 

8 SEC. 303. REPORT ON EXCLUSION OF TERRITORIES FROM 

9 EXCHANGES. 

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

11 the Secretary of Health and Human Services shall submit 

12 to Congress a report that details the adverse impacts in 

13 each territory from the practical exclusion of the terri14 tories from the provisions of part II or III of subtitle D 

15 of title I of the Patient Protection and Affordable Care 

16 Act insofar as such provisions provide for the establish17 ment of an American Health Benefit Exchange or the ad18 ministration of a federally facilitated Exchange in each 

19 State and in the District of Columbia for the purpose of 

20 making health insurance more affordable and accessible 

21 for individuals and small businesses. 

22 (b) INFORMATION IN REPORT.—The report shall in23 clude information on the following: 

24 (1) An estimate of the total number of individ25 uals residing in each territory with health insurance 


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1 coverage, and the total number of individuals in each 

2 territory without health insurance coverage. 

3 (2) The number of health insurance issuers in 

4 each territory and the health insurance coverage 

5 each such issuer offers. 

6 (3) An estimate of the number of individuals re7 siding in each territory who are denied premium and 

8 cost-sharing assistance that would otherwise be 

9 available to them for obtaining health insurance cov10 erage through an Exchange if they resided in one of 

11 the 50 States or in the District of Columbia. 

12 (4) An estimate of the amount of Federal as13 sistance described in paragraph (3) that is not being 

14 made available to residents of each territory. 

15 (5) An estimate of the number of small employ16 ers in each territory that would be eligible to pur17 chase health insurance coverage through a Small 

18 Business Health Options Program (SHOP) Market19 place that would operate as part of an Exchange if 

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

21 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 EXCHANGE.— 

12 Not later than 3 months after the date of enactment 

13 of this section, the Secretary, in consultation with 

14 the Secretary of the Treasury and the Director of 

15 the Office of Personnel Management, shall establish 

16 a mechanism to ensure that, for any plan year be17 ginning on or after the date described in subsection 

18 (c), any individual described in paragraph (2) has 

19 access to health insurance coverage which is at least 

20 as broad as the coverage available to Members of 

21 Congress and congressional staff (as defined in sec22 tion 1312(d)(3)(D)) through the Exchange operating 

23 in the District of Columbia. Such individuals shall 

24 be eligible for any premium tax credit under section 

25 36B of the Internal Revenue Code of 1986, reduced 

26 cost sharing under section 1402, and advance deterVerDate Sep 11 2014 00:20 Jun 14, 2019 Jkt 089200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\S1773.IS S1773

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1 mination and payment of such credits or such reduc2 tions under section 1412 to be administered by the 

3 Secretary, in consultation with the Secretary of the 

4 Treasury and the Director of the Office of Personnel 

5 Management. The District of Columbia, its resi6 dents, and small businesses shall be held harmless 

7 from any increased costs resulting from the enact8 ment of this section. 

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

10 described in this paragraph is any individual who— 

11 ‘‘(A) is not eligible to enroll in an em12 ployer-sponsored health plan (excluding such a 

13 plan that would not be considered minimum es14 sential coverage due to the application of sub15 paragraph (C) of section 36B(c)(2) of the In16 ternal Revenue Code of 1986 if such subpara17 graph applied to such plan); and 

18 ‘‘(B) is a bona fide resident of any posses19 sion of the United States (as determined under 

20 section 937(a) of such Code) in which the Sec21 retary certifies that no qualified health plan is 

22 offered through an Exchange established under 

23 this title. 

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

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


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1 the United States’ shall include such possessions as 

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

3 Revenue Code of 1986. 

4 ‘‘(b) TREATMENT OF POSSESSIONS.— 

5 ‘‘(1) PAYMENTS TO POSSESSIONS.— 

6 ‘‘(A) MIRROR CODE POSSESSION.—The 

7 Secretary of the Treasury shall periodically (but 

8 not less frequently than annually) pay to each 

9 possession of the United States with a mirror 

10 code tax system amounts equal to the loss to 

11 that possession by reason of the application of 

12 this section (determined without regard to para13 graph (2)) with respect to taxable years begin14 ning after the date described in subsection (c). 

15 Such amounts shall be determined by the Sec16 retary of the Treasury based on information 

17 provided by the government of the respective 

18 possession. 

19 ‘‘(B) OTHER POSSESSIONS.—The Sec20 retary of the Treasury shall periodically (but 

21 not less frequently than annually) pay to each 

22 possession of the United States which does not 

23 have a mirror code tax system amounts esti24 mated by the Secretary of the Treasury as 

25 being equal to the aggregate benefits that would 


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1 have been provided to residents of such posses2 sion by reason of the application of this section 

3 for any taxable years beginning after the date 

4 described in subsection (c) if a mirror code tax 

5 system had been in effect in such possession. 

6 The preceding sentence shall not apply with re7 spect to any possession of the United States un8 less such possession has a plan, which has been 

9 approved by the Secretary of the Treasury, 

10 under which such possession will promptly dis11 tribute such payments to the residents of such 

12 possession. 

13 ‘‘(2) COORDINATION WITH CREDIT ALLOWED

14 AGAINST UNITED STATES INCOME TAXES.—No cred15 it shall be allowed against United States income 

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

17 Internal Revenue Code of 1986 to any person— 

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

19 taxes imposed by the possession by reason of 

20 this section (determined without regard to this 

21 paragraph) for such taxable year, or 

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

23 a plan described in paragraph (1)(B) with re24 spect to such taxable year. 


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1 ‘‘(3) MIRROR CODE TAX SYSTEM.—For pur2 poses of this subsection, the term ‘mirror code tax 

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

4 United States, the income tax system of such posses5 sion if the income tax liability of the residents of 

6 such possession under such system is determined by 

7 reference to the income tax laws of the United 

8 States as if such possession were the United States. 

9 ‘‘(4) TREATMENT OF PAYMENTS.—For pur10 poses of section 1324(b)(2) of title 31, United 

11 States Code, or any similar rule of law, the pay12 ments under this subsection shall be treated in the 

13 same manner as a refund due from the credit al14 lowed under section 36B of the Internal Revenue 

15 Code of 1986. 

16 ‘‘(c) DATE DESCRIBED.—The date described in this 

17 subsection is the date on which the Secretary establishes 

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

19 SEC. 305. EXTENSION OF FAMILY-TO-FAMILY HEALTH IN20 FORMATION CENTERS PROGRAM TO TERRI21 TORIES. 

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

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


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1 2019’’ and inserting ‘‘year 2018 and each fiscal year 

2 thereafter’’. 

Æ 


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