Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021

To amend titles XI and XIX of the Social Security Act to stabilize the Medicaid program in Puerto Rico. 1. Short title This Act may be cited as the Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021 2. Adjustments to FMAP and cap for Puerto Rico (a) Adjustments to FMAP Section 1905 of the Social Security Act ( 42 U.S.C. 1396d (1) in subsection (b) by inserting (except for Puerto Rico, for calendar quarters in a fiscal year beginning with fiscal year 2022, shall be the PR specified percent under subsection (hh) for such fiscal year) shall be 55 percent (2) by adding at the end the following new subsection: (hh) PR specified percent (1) In general For purposes of subsection (b), the PR specified percent under this subsection is— (A) subject to paragraph (2), for each of fiscal years 2022 through 2026, 83 percent; (B) subject to paragraph (3)(D)(iii), for each of fiscal years 2027 through 2031, 83 percent; and (C) subject to paragraph (3)(D)(iii), for fiscal year 2032 and each subsequent fiscal year, the Federal medical assistance percentage calculated in accordance with the first sentence of subsection (b), as such sentence applies to the 50 States. (2) Program enhancement incentives (A) In general If Puerto Rico— (i) for fiscal year 2023, is in compliance with none of the program enhancement requirements described in subparagraph (B), the PR specified percent specified under paragraph (1) for such fiscal year shall be reduced by 2 percent; (ii) for fiscal year 2024, is in compliance with fewer than two of the four program enhancement requirements described in subparagraph (B), the PR specified percent specified under paragraph (1) for such fiscal year shall be reduced by 3 percent; (iii) for fiscal year 2025, is in compliance with fewer than three of the four program enhancement requirements described in subparagraph (B), the PR specified percent specified under paragraph (1) for such fiscal year shall be reduced by 5 percent; and (iv) for fiscal year 2026, is in compliance with fewer than four of the program enhancement requirements described in subparagraph (B), the PR specified percent specified under paragraph (1) for such fiscal year shall be reduced by 5 percent. (B) Program enhancement requirements For purposes of this subsection, the program enhancement requirements described in this subparagraph are each of the following: (i) Rates of payment under the State plan under this title for inpatient hospital services are not less than the costs incurred for such services. (ii) Rates of payment under the State plan under this title for physicians’ services are not less than 70 percent of the amount that is payable for such services under section 1848. (iii) The State plan provides for medical assistance for Hepatitis C drugs, in accordance with the requirements of section 1927 otherwise applicable to the 50 States. (iv) The State plan provides for medical assistance for Medicare cost-sharing described in subsection (p)(3)(A)(ii) for qualified Medicare beneficiaries described in subsection (p)(1), in accordance with the requirements under subsection (p) otherwise applicable to the 50 States. (3) Territory transition plan (A) In general (i) Submission of plan Not later than January 1, 2024, the Governor of Puerto Rico shall submit to the Secretary a Territory Transition Plan, which shall be developed with stakeholder input and with a public comment period, that includes— (I) a detailed description of which program enhancements described in subparagraph (C) Puerto Rico will include as medical assistance under the State plan under title XIX, the first plan year by which each such program enhancement will be so included in order to satisfy the requirements described in subparagraph (B), and a timeline for milestones for including such program enhancements; and (II) a description of any challenges, including infrastructure challenges, provider shortages, and financing challenges, for so including such program enhancements and a plan to ameliorate any such challenges. (ii) Notification of plan approval The plan submitted under clause (i) shall be treated as approved by the Secretary not later than 180 days after the date of submission of the plan unless within such 180-day period the Secretary disapproves such plan and notifies Puerto Rico of such disapproval with the reason for such disapproval. In the case of such a disapproval, the Governor of Puerto Rico shall, within the 90-day period following such notification, submit to the Secretary a Territory Transition Plan that addresses the reason specified in such notification for such disapproval. Such resubmitted plan shall be treated as approved by the Secretary under this clause unless the Secretary notifies Puerto Rico within the 30-day period following such submission of its disapproval with a reason for such disapproval. The Governor of Puerto Rico may develop and submit to the Secretary, in the same manner and subject to the same conditions as apply under clause (i) to the development and submission of the Territory Transition Plan, modifications to the plan and such modifications shall be treated as approved by the Secretary and incorporated into the plan in the same manner and subject to the same conditions that apply under this clause to the approval of the plan. (B) Requirements described For purposes of this paragraph, the requirements described in this subparagraph, with respect to Puerto Rico, are the following: (i) For 2029, the State plan under title XIX includes at least 2 of the program enhancements described in subparagraph (C). (ii) For 2031, the State plan includes at least 4 of such program enhancements. (iii) For 2033, the State plan includes at least 6 of such program enhancements. (iv) For 2035 and each subsequent year, the State plan includes all of such program enhancements. (C) Program enhancements described For purposes of this paragraph, the program enhancements described in this subparagraph are the following: (i) The State plan provides for medical assistance to all individuals described in clause (i) of section 1902(a)(10)(A)). (ii) The State plan provides for inclusion as medical assistance of home health services, in accordance with section 1902(a)(10)(D). (iii) The State plan provides for inclusion as medical assistance of nonemergency transportation to medically necessary services. (iv) The State plan provides for inclusion as medical assistance of services described in subsection (a)(21) to all individuals described in clause (i) of section 1902(a)(10)(A)). (v) The State plan provides for inclusion as medical assistance of services described in subsection (a)(17) to all individuals described in such clause (other than subclause (VIII) of such clause. (vi) The State plan provides for inclusion as medical assistance of nursing facility services, as defined in subsection (a)(4)(A). (vii) The State plan provides for inclusion as medical assistance of early and periodic screening, diagnosis, and treatment services under subsection (a)(4)(B). (viii) The State plan provides for inclusion as medical assistance of freestanding birth center services and other ambulatory services, as described in subsection (a)(28). (D) Reports (i) For fiscal year 2024 and each subsequent fiscal year through fiscal year 2035— (I) the Comptroller General of the United States shall review, and submit to the Secretary and Congress a report on, whether or not Puerto Rico is in compliance with the timeline and achieving the milestones described in the Territory Transition plan (as modified, if applicable) approved under subparagraph (A) and, beginning with fiscal year 2029, whether Puerto Rico is in compliance with the applicable requirements described in subparagraph (B); and (II) Puerto Rico shall submit to the Secretary a report on the extent to which Puerto Rico has met the timelines and milestones included in such plan (as modified, if applicable). (ii) If, for a fiscal year described in clause (i) after fiscal year 2026, the Comptroller General submits a report with a finding that Puerto Rico is not in compliance with the timeline or with achieving milestones as described in subclause (I) (or, with respect to a fiscal year after fiscal year 2028, not in compliance with the applicable requirement under subparagraph (B)), not later than 90 days after the date of such finding, Puerto Rico shall submit to the Secretary for approval a corrective action plan to remedy such noncompliance. (iii) If, by not later than a period specified by the Secretary after the date of the submission (and approval) of a corrective action plan under clause (ii), with respect to a fiscal year after fiscal year 2026 for which a finding of non-compliance was made under clause (i), the Secretary determines that Puerto Rico has not fulfilled the terms of such corrective action plan, the PR specified percent specified under paragraph (1) for the fiscal year involved shall be reduced by 5 percent for the period beginning with the month beginning after such determination and ending with the first month beginning after the Secretary determines Puerto Rico has fulfilled the terms of the corrective action plan. . (b) Treatment of cap Section 1108(g) of the Social Security Act ( 42 U.S.C. 1308(g) (1) in paragraph (2)— (A) in the matter preceding subparagraph (A), by striking subject to and section 1323(a)(2) of the Patient Protection and Affordable Care Act paragraphs (3) and (5) subject to section 1323(a)(2) of the Patient Protection and Affordable Care Act and paragraphs (3), (5), and (7) (B) in subparagraph (A)— (i) by striking Puerto Rico shall not exceed the sum of Puerto Rico shall not exceed— (i) in the case of a fiscal year before fiscal year 2022, the sum of ; (ii) by striking $100,000; $100,000; and (iii) by adding at the end the following new clause: (ii) in the case of fiscal year 2022 and each subsequent fiscal year (before fiscal year 2027), the amount specified in paragraph (6) for such fiscal year; ; and (2) by adding at the end the following new paragraphs: (6) Application to Puerto Rico for fiscal years 2022 through 2026 For purposes of paragraph (2)(A)(ii), the amount specified in this paragraph is— (A) for fiscal year 2022, $3,012,610,000; (B) for fiscal year 2023, $3,114,331,000; (C) for fiscal year 2024, $3,225,627,000; (D) for fiscal year 2025, $3,336,627,000; and (E) for fiscal year 2026, $3,447,627,000. (7) Puerto Rico exclusion from payment limitation beginning fiscal year 2027 Beginning with fiscal year 2027, there shall be no limitation applied under this subsection (f) or this subsection on the total amount certified by the Secretary under title XIX for payment to Puerto Rico. . (c) Temporary increase in Federal match for State plan administrative costs Section 1903(a)(7) of the Social Security Act ( 42 U.S.C. 1396b(a)(7) (or, in the case of Puerto Rico for each of fiscal years 2022 through 2035, 100 percent) 50 per centum

Summary: Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021 This bill alters certain funding and payment mechanisms, and establishes several requirements, for Puerto Rico's Medicaid program. Among other changes, the bill increases the federal matching rate, also known as the Federal Medical Assistance Percentage (FMAP), from 55% to 83% through FY2031; beginning in FY2032, the FMAP must be calculated in the same manner as for states (i.e., based on per capita income). Puerto Rico must also expand its Medicaid program to include certain items, services, and populations that states are already required to cover; failure to do so results in a reduction of the applicable FMAP. Additionally, beginning in FY2027, the bill excludes Puerto Rico from a Medicaid funding cap that currently applies to U.S. territories.