I 
117TH CONGRESS 
1ST SESSION H. R. 2713 
To provide for equitable treatment for Puerto Rico, the Virgin Islands, Guam, 
the Northern Mariana Islands, and American Samoa. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 20, 2021 
Ms. VELA´ZQUEZ (for herself, Ms. OCASIO-CORTEZ, Mr. GRIJALVA, and Mr. 
TORRES of New York) introduced the following bill; which was referred 
to the Committee on Ways and Means, and in addition to the Committees 
on Energy and Commerce, Agriculture, Education and Labor, and Nat-
ural Resources, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To provide for equitable treatment for Puerto Rico, the Vir-
gin Islands, Guam, the Northern Mariana Islands, and 
American Samoa. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Territorial Equity Act of 2021’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
Sec. 1. Short title; table of contents. 
TITLE I—HEALTH EQUITY FOR THE TERRITORIES 
Subtitle A—Medicaid 
Sec. 101. Elimination of general Medicaid funding limitations (‘‘cap’’) for terri-
tories. 
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. 
Subtitle B—Medicare Part A 
Sec. 111. Calculation of Medicare DSH payments for IPPS hospitals in Puerto 
Rico. 
Sec. 112. Rebasing target amount for hospitals in territories. 
Sec. 113. Medicare DSH target adjustment for hospitals in territories. 
Subtitle C—Medicare Part B 
Sec. 121. Application of part B deemed enrollment process to residents of 
Puerto Rico; special enrollment period and limit on late enroll-
ment penalties. 
Subtitle D—Medicare Advantage (Part C) 
Sec. 131. Adjustment in benchmark for low-base payment counties in Puerto 
Rico. 
Subtitle E—Medicare Part D 
Sec. 141. Improved use of allocated prescription drug funds by territories. 
Sec. 142. Report on treatment of territories under Medicare part D. 
Subtitle F—Miscellaneous 
Sec. 151. Medicaid and CHIP territory transparency and information. 
Sec. 152. Report on exclusion of territories from Exchanges. 
Sec. 153. Access to coverage for individuals in certain areas without any avail-
able Exchange plans. 
TITLE II—INCLUSION OF THE TERRITORIES IN THE 
SUPPLEMENTAL NUTRITIONAL ASSISTANCE PROGRAM 
Sec. 201. Participation and transition of Puerto Rico, American Samoa, and 
the Northern Mariana Islands in supplemental nutrition assist-
ance program. 
TITLE III—EQUITABLE TREATMENT FOR PUERTO RICO AND THE 
VIRGIN ISLANDS WITH RESPECT TO TAX CREDITS 
Sec. 301. Equitable treatment for residents of Puerto Rico and the Virgin Is-
lands with respect to the earned income tax credit and the 
child tax credit. 
TITLE IV—LABOR EQUITY FOR PUERTO RICO 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6211
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
Sec. 401. Minimum wage for young employees in Puerto Rico. 
Sec. 402. Overtime hours protections for workers in Puerto Rico. 
TITLE V—EXTENSION OF SUPPLEMENTAL SECURITY INCOME 
(SSI) PROGRAM TO ALL TERRITORIES 
Sec. 501. Extension of SSI program to all territories. 
TITLE I—HEALTH EQUITY FOR 
THE TERRITORIES 
Subtitle A—Medicaid 
SEC. 101. ELIMINATION OF GENERAL MEDICAID FUNDING 
LIMITATIONS (‘‘CAP’’) FOR TERRITORIES. 
(a) IN GENERAL.—Section 1108 of the Social Secu-
rity Act (42 U.S.C. 1308) is amended— 
(1) in subsection (f), in the matter preceding 
paragraph (1), by striking ‘‘and (h)’’ and inserting 
‘‘(h), and (i)’’; 
(2) in subsection (g)(2), in the matter pre-
ceding subparagraph (A), by inserting ‘‘subsection 
(i),’’ after ‘‘subject to’’; and 
(3) by adding at the end the following new sub-
section: 
‘‘(i) SUNSET OF MEDICAID FUNDING LIMITATIONS 
FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE 
NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 
Subsections (f) and (g) shall not apply to Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Islands, 
and American Samoa beginning with fiscal year 2022.’’. 
(b) CONFORMING AMENDMENTS.— 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
(1) Section 1902(j) of the Social Security Act 
(42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 
limitation in section 1108(f),’’. 
(2) Section 1903(u) of the Social Security Act 
(42 U.S.C. 1396b(u)) is amended by striking para-
graph (4). 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply beginning with fiscal year 2022. 
SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 
ASSISTANCE PERCENTAGE (FMAP) LIMITA-
TION FOR TERRITORIES; TEMPORARY IN-
CREASE IN FMAP FOR PUERTO RICO AND 
THE VIRGIN ISLANDS TO 100 PERCENT. 
Section 1905(b) of the Social Security Act (42 U.S.C. 
1396d(b)) is amended— 
(1) in clause (2), by inserting ‘‘for fiscal years 
before fiscal year 2022’’ after ‘‘American Samoa’’; 
and 
(2) by adding at the end the following new sen-
tence: ‘‘Notwithstanding the first sentence of this 
subsection, for each of fiscal years 2022 and 2023, 
the Federal medical assistance percentage for Puerto 
Rico and the Virgin Islands shall be 100 percent.’’. 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY 
TO ALL OF THE TERRITORIES. 
(a) IN GENERAL.—Section 1902(j) of the Social Se-
curity Act (42 U.S.C. 1396a(j)) is amended— 
(1) by striking ‘‘American Samoa and the 
Northern Mariana Islands’’ and inserting ‘‘Puerto 
Rico, the Virgin Islands, Guam, the Northern Mar-
iana Islands, and American Samoa’’; 
(2) by striking ‘‘American Samoa or the North-
ern Mariana Islands’’ and inserting ‘‘Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Is-
lands, or American Samoa’’; 
(3) by inserting ‘‘(1)’’ before ‘‘Notwith-
standing’’; 
(4) by inserting ‘‘except as otherwise provided 
in this subsection,’’ after ‘‘Notwithstanding any 
other requirement of this title’’; and 
(5) by adding at the end the following: 
‘‘(2) The Secretary may not waive under this sub-
section— 
‘‘(A) 
the 
requirement 
of 
subsection 
(a)(10)(A)(i)(IX) (relating to coverage of adults for-
merly under foster care) with respect to any terri-
tory; 
‘‘(B) the requirement to provide medical assist-
ance for early and periodic screening, diagnostic, 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
and treatment services (as defined in section 
1905(r)) for individuals who are eligible for assist-
ance under the program and who are under the age 
of 21; or 
‘‘(C) the requirement to provide for payment 
for services described in section 1905(a)(2)(C) fur-
nished by a Federally-qualified health center and 
services described in section 1905(a)(2)(B) furnished 
by a rural health clinic in accordance with the provi-
sions of subsection (bb).’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply beginning October 1, 2021. 
SEC. 104. PERMITTING MEDICAID DSH ALLOTMENTS FOR 
TERRITORIES. 
Section 1923(f) of the Social Security Act (42 U.S.C. 
1396r–4(f)) is amended— 
(1) in paragraph (6), by adding at the end the 
following new subparagraph: 
‘‘(C) TERRITORIES.— 
‘‘(i) FISCAL
YEAR
2021.—For fiscal 
year 2022, the DSH allotment for Puerto 
Rico, the Virgin Islands, Guam, the North-
ern Mariana Islands, and American Samoa 
shall bear the same ratio to $300,000,000 
as the ratio of the number of individuals 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
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 2022, Puerto Rico, the Virgin 
Islands, Guam, the Northern Mariana Islands, and 
American Samoa’’. 
Subtitle B—Medicare Part A 
SEC. 111. 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— 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(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, 2021, 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.’’. 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
SEC. 112. 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 beginning on 
or after October 1, 2021, in the case of a hospital located 
in a territory of the United States, there shall be sub-
stituted for the target amount otherwise determined under 
subparagraph (A) the rebased target amount (as defined 
in clause (ii)), if such substitution results in an amount 
of payment under this section to the hospital for such pe-
riod that is greater than the amount of payment that 
would be made under this section to the hospital for such 
period if this subparagraph were not to apply. 
‘‘(ii) For purposes of this subparagraph, the term 
‘rebased target amount’ has the meaning given the term 
‘target amount’ in subparagraph (A), except that— 
‘‘(I) there shall be substituted for the preceding 
12-month cost reporting period the 12-month cost 
reporting period beginning during fiscal year 2017 
(or, at the option of the hospital, beginning during 
fiscal year 2019); 
‘‘(II) any reference in subparagraph (A)(i) to 
the ‘first such cost reporting period’ is deemed a ref-
erence to the first cost reporting period following the 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
12-month cost reporting period beginning during fis-
cal year 2017 (or, at the option of the hospital, be-
ginning during fiscal year 2019); and 
‘‘(III) the applicable percentage increase shall 
only be applied under subparagraph (B)(ii) for cost 
reporting periods beginning on or after October 1, 
2021. 
‘‘(iii) Nothing in this subparagraph shall affect any 
pending request by a hospital for a new target amount 
for any cost reporting period beginning during a fiscal 
year before fiscal year 2022.’’. 
SEC. 113. 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 112, is fur-
ther amended by adding at the end the following new sub-
paragraph: 
‘‘(N)(i) For each cost reporting period beginning on 
or after October 1, 2020, 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 located in one of the 50 States, the target 
amount shall be increased by— 
‘‘(I) in the case that such hospital has a dis-
proportionate patient percentage of not less than 15 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
percent and not greater than 40 percent, 10 percent; 
and 
‘‘(II) in the case that such hospital has a dis-
proportionate patient percentage of greater than 40 
percent, 10 percent plus 60 percent of the number 
of percentage points by which such hospital’s dis-
proportionate patient percentage exceeds 40 percent. 
‘‘(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 sub-
section to individuals entitled to supplementary security 
income under title XVI shall be deemed for purposes of 
this subparagraph to include individuals— 
‘‘(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.’’. 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
Subtitle C—Medicare Part B 
SEC. 121. 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(k)(1)(C) of such Act, as 
added by subsection (c)(2). 
(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 subsection (k)(2) of this section,’’ 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
after ‘‘subsection (i)(4), (l), or (l) of section 1837,’’; 
and 
(2) by adding at the end the following new sub-
section: 
‘‘(k) 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. 
‘‘(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. 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(C) EFFECTIVE
MONTH
DEFINED.—In 
this section, the term ‘effective month’ means a 
month, not earlier than October 2022 and not 
later than January 2023, 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. 
‘‘(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 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS
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 
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.’’. 
VerDate Sep 11 2014 
23:20 Jun 10, 2021
Jkt 019200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H2713.IH
H2713
pbinns on DSKJLVW7X2PROD with BILLS