who are low-income or uninsured and re-
siding in such respective territory (as esti-
mated from time to time by the Secretary) 
bears to the sums of the number of such 
individuals residing in all of the territories. 
‘‘(ii) SUBSEQUENT
FISCAL
YEAR.— 
For each subsequent fiscal year, the DSH 
allotment for each such territory is subject 
to an increase in accordance with para-
graph (3).’’; and 
(2) in paragraph (9), by inserting before the pe-
riod at the end the following: ‘‘, and includes, begin-
ning with fiscal year 2020, Puerto Rico, the Virgin 
Islands, Guam, the Northern Mariana Islands, and 
American Samoa’’. 
TITLE II—MEDICARE 
Subtitle A—Part A 
SEC. 201. CALCULATION OF MEDICARE DSH PAYMENTS FOR 
IPPS HOSPITALS IN PUERTO RICO. 
Section 1886(d)(9)(D)(iii) of the Social Security Act 
(42 U.S.C. 1395ww(d)(9)(D)(iii)) is amended to read as 
follows: 
‘‘(iii) Subparagraph (F) (relating to dispropor-
tionate share payments), including application of 
subsection (r), except that for this purpose— 
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‘‘(I) the sum described in clause (ii) of this 
subparagraph shall be substituted for the sum 
referred to in paragraph (5)(F)(ii)(I); and 
‘‘(II) for discharges occurring on or after 
October 1, 2019, subclause (I) of paragraph 
(5)(F)(vi) shall be applied by substituting for 
the numerator described in such subclause the 
number of subsection (d) Puerto Rico hospital’s 
patient days for the cost reporting period in-
volved which were made up of patients who (for 
such days) were entitled to benefits under part 
A of this title and were— 
‘‘(aa) entitled to supplementary secu-
rity income benefits (excluding any State 
supplementation) under title XVI of this 
Act; 
‘‘(bb) eligible for medical assistance 
under a State plan under title XIX; or 
‘‘(cc) receiving aid or assistance under 
any plan of the State approved under title 
I, X, XIV, or XVI.’’. 
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SEC. 202. REBASING TARGET AMOUNT FOR HOSPITALS IN 
TERRITORIES. 
Section 1886(b)(3) of the Social Security Act (42 
U.S.C. 1395ww(b)(3)) is amended by adding at the end 
the following new subparagraph: 
‘‘(M)(i) For each cost reporting period be-
ginning on or after October 1, 2019, in the case 
of a hospital located in a territory of the United 
States, there shall be substituted for the target 
amount otherwise determined under subpara-
graph (A) the rebased target amount (as de-
fined in clause (ii)), if such substitution results 
in an amount of payment under this section to 
the hospital for such period that is greater than 
the amount of payment that would be made 
under this section to the hospital for such pe-
riod if this subparagraph were not to apply. 
‘‘(ii) For purposes of this subparagraph, 
the term ‘rebased target amount’ has the mean-
ing given the term ‘target amount’ in subpara-
graph (A), except that— 
‘‘(I) there shall be substituted for the 
preceding 12-month cost reporting period 
the 12-month cost reporting period begin-
ning during fiscal year 2015 (or, at the op-
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tion of the hospital, beginning during fiscal 
year 2017); 
‘‘(II) any reference in subparagraph 
(A)(i) to the ‘first such cost reporting pe-
riod’ is deemed a reference to the first cost 
reporting period following the 12-month 
cost reporting period beginning during fis-
cal year 2015 (or, at the option of the hos-
pital, beginning during fiscal year 2017); 
and 
‘‘(III) the applicable percentage in-
crease shall only be applied under subpara-
graph (B)(ii) for cost reporting periods be-
ginning on or after October 1, 2019. 
‘‘(iii) Nothing in this subparagraph shall 
affect any pending request by a hospital for a 
new target amount for any cost reporting pe-
riod beginning during a fiscal year before fiscal 
year 2020.’’. 
SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOS-
PITALS IN TERRITORIES. 
Section 1886(b)(3) of the Social Security Act (42 
U.S.C. 1395ww(b)(3)), as amended by section 202, is fur-
ther amended by adding at the end the following new sub-
paragraph: 
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‘‘(N)(i) For each cost reporting period be-
ginning on or after October 1, 2019, in the case 
of a hospital that is located in a territory of the 
United States other than Puerto Rico and that 
would be a subsection (d) hospital if it were lo-
cated in one of the 50 States, the target 
amount shall be increased by— 
‘‘(I) in the case that such hospital has 
a disproportionate patient percentage of 
not less than 15 percent and not greater 
than 40 percent, 10 percent; and 
‘‘(II) in the case that such hospital 
has a disproportionate patient percentage 
of greater than 40 percent, 10 percent plus 
60 percent of the number of percentage 
points by which such hospital’s dispropor-
tionate patient percentage exceeds 40 per-
cent. 
‘‘(ii) For purposes of this subparagraph, 
the term ‘disproportionate patient percentage’ 
has the meaning given such term in subsection 
(d)(5)(F)(vi), except that in applying such 
meaning any reference under such subsection to 
individuals entitled to supplementary security 
income under title XVI shall be deemed for pur-
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poses of this subparagraph to include individ-
uals— 
‘‘(I) eligible for medical assistance 
under a State plan under title XIX; or 
‘‘(II) receiving aid or assistance under 
any plan of the territory approved under 
title I, X, XIV, or XVI.’’. 
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. 
(a) APPLICATION OF PART B DEEMED ENROLLMENT 
PROCESS
TO RESIDENTS
OF PUERTO RICO.—Section 
1837(f)(3) of the Social Security Act (42 U.S.C. 
1395p(f)(3)) is amended by striking ‘‘, exclusive of Puerto 
Rico’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to individuals whose initial en-
rollment period under section 1837(d) of the Social Secu-
rity Act begins on or after the first day of the effective 
month, specified by the Secretary of Health and Human 
Services under section 1839(j)(1)(C) of such Act, as added 
by subsection (c)(2). 
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(c) TRANSITION PROVIDING SPECIAL ENROLLMENT 
PERIOD AND LIMIT ON LATE ENROLLMENT PENALTIES 
FOR CERTAIN MEDICARE BENEFICIARIES.—Section 1839 
of the Social Security Act (42 U.S.C. 1395r) is amend-
ed— 
(1) in the first sentence of subsection (b), by in-
serting ‘‘subject to section 1839(j)(2),’’ after ‘‘sub-
section (i)(4) or (l) of section 1837,’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(j) SPECIAL RULES FOR CERTAIN RESIDENTS OF 
PUERTO RICO.— 
‘‘(1) SPECIAL ENROLLMENT PERIOD, COVERAGE 
PERIOD FOR RESIDENTS WHO ARE ELIGIBLE BUT 
NOT ENROLLED.— 
‘‘(A) IN GENERAL.—In the case of a tran-
sition individual (as defined in paragraph (3)) 
who is not enrolled under this part as of the 
day before the first day of the effective month 
(as defined in subparagraph (C)), the Secretary 
shall provide for a special enrollment period 
under section 1837 of 7 months beginning with 
such effective month during which the indi-
vidual may be enrolled under this part. 
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‘‘(B) COVERAGE PERIOD.—In the case of 
such an individual who enrolls during such spe-
cial enrollment period, the coverage period 
under section 1838 shall begin on the first day 
of the second month after the month in which 
the individual enrolls. 
‘‘(C) EFFECTIVE
MONTH
DEFINED.—In 
this section, the term ‘effective month’ means a 
month, not earlier than October 2020 and not 
later than January 2021, specified by the Sec-
retary. 
‘‘(2) REDUCTION IN LATE ENROLLMENT PEN-
ALTIES
FOR
CURRENT
ENROLLEES
AND
INDIVID-
UALS ENROLLING DURING TRANSITION.— 
‘‘(A) IN GENERAL.—In the case of a tran-
sition individual who is enrolled under this part 
as of the day before the first day of the effec-
tive month or who enrolls under this part on or 
after the date of the enactment of this sub-
section but before the end of the special enroll-
ment period under paragraph (1)(A), the 
amount of the late enrollment penalty imposed 
under section 1839(b) shall be recalculated by 
reducing the penalty to 15 percent of the pen-
alty otherwise established. 
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‘‘(B) APPLICATION.—Subparagraph (A) 
shall be applied in the case of a transition indi-
vidual who— 
‘‘(i) is enrolled under this part as of 
the month before the effective month, for 
premiums for months beginning with such 
effective month; or 
‘‘(ii) enrolls under this part on or 
after the date of the enactment of this Act 
and before the end of the special enroll-
ment period under paragraph (1)(A), for 
premiums for months during the coverage 
period under this part which occur during 
or after the effective month. 
‘‘(C) LOSS OF REDUCTION IF INDIVIDUAL 
TERMINATES
ENROLLMENT.—Subparagraph 
(A) shall not apply to a transition individual if 
the individual terminates enrollment under this 
part after the end of the special enrollment pe-
riod under paragraph (1). 
‘‘(3) TRANSITION
INDIVIDUAL
DEFINED.—In 
this section, the term ‘transition individual’ means 
an individual who resides in Puerto Rico and who 
would have been deemed enrolled under this part 
pursuant to section 1837(f) before the first day of 
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the effective month but for the fact that the indi-
vidual was a resident of Puerto Rico, regardless of 
whether the individual is enrolled under this part as 
of such first day.’’. 
Subtitle C—Medicare Advantage 
(Part C) 
SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW-BASE 
PAYMENT COUNTIES IN PUERTO RICO. 
Section 1853(n) of the Social Security Act (42 U.S.C. 
1395w–23(n)) is amended— 
(1) in paragraph (1), by striking ‘‘and (5)’’ and 
inserting ‘‘(5), and (6)’’; 
(2) in paragraph (4), by striking ‘‘In no case’’ 
and inserting ‘‘Subject to paragraph (6), in no 
case’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(6) SPECIAL
RULES
FOR
BLENDED
BENCH-
MARK AMOUNT FOR TERRITORIES.— 
‘‘(A) IN GENERAL.—Subject to paragraph 
(2), the blended benchmark amount for an area 
in a territory for a year (beginning with 2020) 
shall not be less than 80 percent of the national 
average of the base payment amounts specified 
in subparagraph (2)(E) for such year for areas 
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within the 50 States and the District of Colum-
bia. 
‘‘(B) LIMITATION.—In no case shall the 
blended benchmark amount for an area in a 
territory for a year under subparagraph (A) ex-
ceed the lowest blended benchmark amount for 
any area within the 50 States and the District 
of Columbia for such year.’’. 
Subtitle D—Part D 
SEC. 231. IMPROVED USE OF ALLOCATED PRESCRIPTION 
DRUG FUNDS BY TERRITORIES. 
Section 1935(e) of the Social Security Act (42 U.S.C. 
1396u–5(e)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(5) IMPROVED USE OF FUNDS FOR LOW-IN-
COME PART D ELIGIBLE INDIVIDUALS.—This sub-
section shall be applied beginning with fiscal year 
2020 as follows, notwithstanding any other provision 
of this title: 
‘‘(A) CLARIFYING STATE FLEXIBILITY TO 
COVER
NON-DUAL-ELIGIBLE
INDIVIDUALS.—In 
this title, the term ‘medical assistance’ includes 
financial assistance furnished by a State under 
this subsection to part D eligible individuals 
who, if they were residing in one of the 50 
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States or the District of Columbia, would qual-
ify as subsidy eligible individuals under section 
1860D–14(a)(3), and without regard to wheth-
er such individuals otherwise qualify for medical 
assistance under this title. 
‘‘(B) 100 PERCENT FMAP TO REFLECT NO 
STATE MATCHING REQUIRED FOR PART D LOW 
INCOME SUBSIDIES.—The Federal medical as-
sistance percentage applicable to the assistance 
furnished under this subsection is 100 percent. 
‘‘(C) LIMITED
FUNDING
FOR
SPECIAL 
RULES.—Subparagraphs (A) and (B), and the 
provision of medical assistance for covered part 
D drugs to low-income part D eligible individ-
uals for a State and period under this sub-
section, is limited to the amount specified in 
paragraph (3) for such State and period.’’. 
SEC. 232. REPORT ON TREATMENT OF TERRITORIES 
UNDER MEDICARE PART D. 
Paragraph (4) of section 1935(e) of the Social Secu-
rity Act (42 U.S.C. 1396u–5(e)) is amended to read as 
follows: 
‘‘(4) REPORT
ON
APPLICATION
OF
SUB-
SECTION.— 
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‘‘(A) IN GENERAL.—Not later than Feb-
ruary 1, 2020, the Secretary shall submit to 
Congress a report on the application of this 
subsection during the period beginning fiscal 
year 2006 and ending fiscal year 2019. 
‘‘(B) INFORMATION TO BE INCLUDED IN 
REPORT.—Such report shall include— 
‘‘(i) program guidance issued by the 
Secretary to implement this subsection; 
‘‘(ii) for each territory, information on 
the increased amount under paragraph (3) 
and how the territory has applied such 
amount, including the territory’s program 
design, expenditures, and number of indi-
viduals (and dual-eligible individuals) as-
sisted; and 
‘‘(iii) differences between how such 
territories are treated under part D of title 
XVIII and under this title compared with 
the treatment of the 50 States and the 
District of Columbia under such part and 
this title for different fiscal years within 
the period covered under the report. 
‘‘(C) RECOMMENDATIONS.—Such report 
shall include recommendations for improving 
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prescription drug coverage for low-income indi-
viduals 
in 
each 
territory, 
including 
rec-
ommendations regarding each of the following 
alternative approaches: 
‘‘(i) Adjusting the aggregate amount 
specified in paragraph (3)(B). 
‘‘(ii) Allowing residents of the terri-
tories to be subsidy eligible individuals 
under section 1860D–14, notwithstanding 
subsection (a)(3)(F) of such section, or 
providing substantially equivalent low-in-
come prescription drug subsidies to such 
residents.’’. 
TITLE III—MISCELLANEOUS 
SEC. 301. MODIFIED TREATMENT OF TERRITORIES WITH 
RESPECT TO APPLICATION OF ACA ANNUAL 
HEALTH INSURANCE PROVIDER FEES. 
Section 9010 of the Patient Protection and Afford-
able Care Act (26 U.S.C. 4001 note prec.) is amended— 
(1) in subsection (b)(1), by inserting ‘‘subject 
to subsection (k)(1),’’ after ‘‘With respect to each 
covered entity,’’; and 
(2) by adding at the end the following: 
‘‘(k) SPECIAL RULES FOR TREATMENT OF TERRI-
TORIES.— 
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‘‘(1) IN
GENERAL.—In applying this section 
with respect to United States health risks located 
outside of the 50 States or the District of Columbia 
for years beginning with 2020— 
‘‘(A) the amount of the fee under sub-
section (b) shall be 50 percent of the amount 
of the fee otherwise determined; 
‘‘(B) the Secretary shall deposit the 
amount of such fees collected for each territory 
into a separate account; and 
‘‘(C) amounts in such an account for a ter-
ritory for a year are appropriated and shall be 
available to the territory in accordance with 
paragraph (2). 
‘‘(2) AVAILABILITY OF FUNDS.—Amounts made 
available to a territory under paragraph (1)(C) with 
respect to a territory for a year shall be made avail-
able to the territory, upon application of the terri-
tory to the Secretary of Health and Human Serv-
ices, only for the following purposes, as elected by 
the territory in such application: 
‘‘(A) INCREASED PRESCRIPTION DRUG AS-
SISTANCE FOR LOW-INCOME PART D ELIGIBLE 
INDIVIDUALS.—For increasing the amount of 
funds made available to the territory under sec-
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tion 1935(e)(3) of the Social Security Act (42 
U.S.C. 1396u–5(e)(3)) for assistance for low-in-
come part D eligible individuals in obtaining 
part D covered drugs. 
‘‘(B) 
SATISFYING
STATE
MEDICAID 
MATCHING REQUIREMENT.—For the territory to 
meet non-Federal matching requirements im-
posed with respect to obtaining Federal finan-
cial participation under title XIX of the Social 
Security Act.’’. 
SEC. 302. MEDICAID AND CHIP TERRITORY TRANSPARENCY 
AND INFORMATION. 
(a) PUBLICATION OF INFORMATION ON FEDERAL 
EXPENDITURES UNDER MEDICAID AND CHIP IN THE 
TERRITORIES.—Not later than 180 days after the date 
of the enactment of this Act, the Secretary of Health and 
Human Services shall publish, and periodically update, on 
the Internet site of the Centers for Medicare & Medicaid 
Services information on Medicaid and CHIP carried out 
in the territories of the United States. Such information 
shall include, with respect to each such territory— 
(1) the income levels established by the terri-
tory for purposes of eligibility of an individual to re-
ceive medical assistance under Medicaid or child 
health assistance under CHIP; 
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(2) the number of individuals enrolled in Med-
icaid and CHIP in such territory; 
(3) any State plan amendments in effect to 
carry out Medicaid or CHIP in such territory; 
(4) any waiver of the requirements of title XIX 
or title XXI issued by the Secretary to carry out 
Medicaid or CHIP in the territory, including a waiv-
er under section 1115 of the Social Security Act (42 
U.S.C. 1315), any application for such a waiver, and 
any documentation related to such application (in-
cluding correspondence); 
(5) the amount of the Federal and non-Federal 
share of expenditures under Medicaid and CHIP in 
such territory; 
(6) the systems in place for the furnishing of 
health care items and services under Medicaid and 
CHIP in such territory; 
(7) the design of CHIP in such territory; and 
(8) other information regarding the carrying 
out of Medicaid and CHIP in the territory that is 
published on such Internet site with respect to car-
rying out Medicaid and CHIP in each State and the 
District of Columbia. 
(b) DEFINITIONS.—In this section: 
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(1) CHIP.—The term ‘‘CHIP’’ means the 
State Children’s Health Insurance Program under 
title XXI of the Social Security Act. 
(2) MEDICAID.—The term ‘‘Medicaid’’ means 
the Medicaid program under title XIX of the Social 
Security Act. 
(3) TERRITORY.—The term ‘‘territory of the 
United States’’ includes Puerto Rico, the Virgin Is-
lands of the United States, Guam, the Northern 
Mariana Islands, and American Samoa. 
SEC. 303. REPORT ON EXCLUSION OF TERRITORIES FROM 
EXCHANGES. 
(a) IN GENERAL.—Not later than February 1, 2020, 
the Secretary of Health and Human Services shall submit 
to Congress a report that details the adverse impacts in 
each territory from the practical exclusion of the terri-
tories from the provisions of part II of subtitle D of title 
I of the Patient Protection and Affordable Care Act inso-
far as such provisions provide for the establishment of an 
American Health Benefit Exchange or the administration 
of a federally facilitated Exchange in each State and in 
the District of Columbia for the purpose of making health 
insurance more affordable and accessible for individuals 
and small businesses. 
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SEC. 304. ACCESS TO COVERAGE FOR INDIVIDUALS IN CER-
TAIN AREAS WITHOUT ANY AVAILABLE EX-
CHANGE PLANS. 
Part 2 of subtitle D of title I of the Patient Protec-
tion and Affordable Care Act (42 U.S.C. 18031 et seq.) 
is amended by adding at the end the following: 
‘‘SEC. 1314. ACCESS TO COVERAGE FOR INDIVIDUALS IN 
CERTAIN AREAS WITHOUT ANY AVAILABLE 
EXCHANGE PLANS. 
‘‘(a) IN GENERAL.— 
‘‘(1) COVERAGE
THROUGH
DC
SHOP
EX-
CHANGE.—Not later than 3 months after the date of 
enactment of this section, the Secretary, in consulta-
tion with the Secretary of the Treasury and the Di-
rector of the Office of Personnel Management, shall 
establish a mechanism to ensure that, for any plan 
year beginning on or after the date described in sub-
section (d), any individual described in paragraph 
(2) may enroll in health insurance coverage in the 
small group market through the Exchange operating 
in the District of Columbia, including the health in-
surance coverage that is available to Members of 
Congress and congressional staff (as defined in sec-
tion 1312(d)(3)(D)). 
‘‘(2) INDIVIDUAL
DESCRIBED.—An individual 
described in this paragraph is any individual who— 
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‘‘(A) is not eligible to enroll in an em-
ployer-sponsored health plan (excluding such a 
plan that would not be considered minimum es-
sential coverage due to the application of sub-
paragraph (C) of section 36B(c)(2) of the In-
ternal Revenue Code of 1986 if such subpara-
graph applied to such plan); and 
‘‘(B) is a bona fide resident of any posses-
sion of the United States (as determined under 
section 937(a) of such Code) in which the Sec-
retary certifies that no qualified health plan is 
offered through an Exchange established under 
this title. 
‘‘(3) POSSESSION OF THE UNITED STATES.— 
For purposes of this section, the term ‘possession of 
the United States’ shall include such possessions as 
are specified in section 937(a)(1) of the Internal 
Revenue Code of 1986. 
‘‘(b) PREMIUM
ASSISTANCE
TAX
CREDITS
AND 
COST-SHARING.—Any individual described in subsection 
(a)(2) who enrolls in health insurance coverage through 
the Exchange operating in the District of Columbia pursu-
ant to subsection (a)(1) shall be eligible for any premium 
tax credit under section 36B of the Internal Revenue Code 
of 1986, reduced cost-sharing under section 1402, and ad-
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vance determination and payment of such credits or such 
reductions under section 1412, that the individual would 
otherwise be eligible for if enrolling as a resident of the 
District of Columbia in health insurance coverage in the 
individual market through the Exchange operating in the 
District of Columbia. 
‘‘(c) TREATMENT OF POSSESSIONS.— 
‘‘(1) PAYMENTS TO POSSESSIONS.— 
‘‘(A) MIRROR
CODE
POSSESSION.—The 
Secretary of the Treasury shall periodically (but 
not less frequently than annually) pay to each 
possession of the United States with a mirror 
code tax system amounts equal to the loss to 
that possession by reason of the application of 
this section (determined without regard to para-
graph (2)) with respect to taxable years begin-
ning after the date described in subsection (d). 
Such amounts shall be determined by the Sec-
retary of the Treasury based on information 
provided by the government of the respective 
possession. 
‘‘(B) OTHER
POSSESSIONS.—The Sec-
retary of the Treasury shall periodically (but 
not less frequently than annually) pay to each 
possession of the United States which does not 
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have a mirror code tax system amounts esti-
mated by the Secretary of the Treasury as 
being equal to the aggregate benefits that would 
have been provided to residents of such posses-
sion by reason of the application of this section 
for any taxable years beginning after the date 
described in subsection (d) if a mirror code tax 
system had been in effect in such possession. 
The preceding sentence shall not apply with re-
spect to any possession of the United States un-
less such possession has a plan, which has been 
approved by the Secretary of the Treasury, 
under which such possession will promptly dis-
tribute such payments to the residents of such 
possession. 
‘‘(2) COORDINATION
WITH
CREDIT
ALLOWED 
AGAINST UNITED STATES INCOME TAXES.—No cred-
it shall be allowed against United States income 
taxes for any taxable year under section 36B of the 
Internal Revenue Code of 1986 to any person— 
‘‘(A) to whom a credit is allowed against 
taxes imposed by the possession by reason of 
this section (determined without regard to this 
paragraph) for such taxable year, or 
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‘‘(B) who is eligible for a payment under 
a plan described in paragraph (1)(B) with re-
spect to such taxable year. 
‘‘(3) MIRROR
CODE
TAX
SYSTEM.—For pur-
poses of this subsection, the term ‘mirror code tax 
system’ means, with respect to any possession of the 
United States, the income tax system of such posses-
sion if the income tax liability of the residents of 
such possession under such system is determined by 
reference to the income tax laws of the United 
States as if such possession were the United States. 
‘‘(4) TREATMENT
OF
PAYMENTS.—For pur-
poses of section 1324(b)(2) of title 31, United 
States Code, or any similar rule of law, the pay-
ments under this subsection shall be treated in the 
same manner as a refund due from the credit al-
lowed under section 36B of the Internal Revenue 
Code of 1986. 
‘‘(d) DATE DESCRIBED.—The date described in this 
subsection is the date on which the Secretary establishes 
the mechanism described in subsection (a)(1).’’. 
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