I 
118TH CONGRESS 
1ST SESSION H. R. 1029 
To amend titles XVIII and XIX of the Social Security Act to make improve-
ments to the treatment of the United States territories under the Medi-
care and Medicaid programs, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 14, 2023 
Ms. PLASKETT (for herself, Mrs. GONZA´LEZ-COLO´N, Mr. MOYLAN, Mrs. 
RADEWAGEN, Mr. SABLAN, Ms. CLARKE of New York, Mr. GRIJALVA, 
Ms. PRESSLEY, Mr. SOTO, Mr. TORRES
of New York, and Ms. 
VELA´ZQUEZ) 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 pro-
grams, and for other purposes. 
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 
‘‘Territories Health Equity Act of 2023’’. 
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(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—MEDICAID 
Sec. 101. Elimination of general Medicaid funding limitations (‘‘CAP’’) for ter-
ritories. 
Sec. 102. Elimination of specific Federal medical assistance percentage 
(FMAP) limitation for Puerto Rico. 
Sec. 103. 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. Eliminating late enrollment penalties under Part B of the medicare 
program for certain individuals residing in Puerto Rico. 
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. Automatic eligibility of certain low-income territorial residents for 
premium and cost-sharing subsidies under the medicare pro-
gram; sunset of enhanced allotment program. 
TITLE III—MISCELLANEOUS 
Sec. 301. Medicaid and CHIP territory transparency and information. 
Sec. 302. Report on exclusion of territories from exchanges. 
Sec. 303. Access to coverage for individuals in certain areas without any avail-
able exchange plans. 
TITLE I—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— 
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(1) in subsection (f), in the matter preceding 
paragraph (1), by striking ‘‘subsections (g) and (h)’’ 
and inserting ‘‘subsections (g), (h), and (j)’’; 
(2) in subsection (g)(2), in the matter pre-
ceding subparagraph (A), by inserting ‘‘subsection 
(j) and’’ after ‘‘subject to’’; 
(3) in subsection (i), by striking paragraph (4); 
and 
(4) by adding at the end the following new sub-
section: 
‘‘(j) 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 2024.’’. 
(b) CONFORMING AMENDMENTS.— 
(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 2024. 
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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 2024, 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 
disproportionate share payments), includ-
ing application of subsection (r), except 
that for this purpose— 
‘‘(I) the sum described in clause 
(ii) of this subparagraph shall be sub-
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stituted for the sum referred to in 
paragraph (5)(F)(ii)(I); and 
‘‘(II) for discharges occurring on 
or after October 1, 2023, subclause 
(I) of paragraph (5)(F)(vi) shall be 
applied by substituting for the numer-
ator described in such subclause the 
number of subsection (d) Puerto Rico 
hospital’s patient days for the cost re-
porting period involved 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 supple-
mentary security income benefits 
(excluding any State supplemen-
tation) under title XVI; 
‘‘(bb) eligible for medical as-
sistance under a State plan 
under title XIX; or 
‘‘(cc) receiving aid or assist-
ance 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, 2023, 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) for a cost reporting period begin-
ning on or after October 1, 2023, and be-
fore September 30, 2028, there shall be 
substituted for the preceding 12-month 
cost reporting period the 12-month cost re-
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porting period beginning during fiscal year 
2015; 
‘‘(II) for a cost reporting period be-
ginning on or after October 1, 2028, there 
shall be substituted for the preceding 12- 
month cost reporting period the cost re-
porting period for which the target amount 
determined under subparagraph (A) is the 
highest among the 5 cost reporting periods 
for which the Secretary has the most re-
cent settled cost reports; 
‘‘(III) 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; and 
‘‘(IV) 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, 2023.’’. 
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-
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ther amended by adding at the end the following new sub-
paragraph: 
‘‘(N)(i) For each cost reporting period be-
ginning on or after October 1, 2023, 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 
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individuals entitled to supplementary security 
income under title XVI shall be deemed for pur-
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. ELIMINATING LATE ENROLLMENT PENALTIES 
UNDER PART B OF THE MEDICARE PROGRAM 
FOR CERTAIN INDIVIDUALS RESIDING IN 
PUERTO RICO. 
(a) IN GENERAL.—Section 1839(b) of the Social Se-
curity Act (42 U.S.C. 1395r(b)) is amended in the second 
sentence by inserting ‘‘or months occurring in the 5-year 
period beginning on the date on which the individual be-
comes entitled to benefits under part A if such individual 
was residing in Puerto Rico as of such date and such date 
is after the date that is 4 years before the date of the 
enactment of the Territories Health Equity Act of 2023’’ 
before the period at the end of such sentence. 
(b) APPLICATION.—The amendment made by sub-
section (a) shall apply with respect to premiums paid for 
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