181 
(8) According to the Drexel University Center 
for labor markets and policy, the mean annual earn-
ings of underemployed immigrants were $32,000, or 
43 percent less than United States born college 
graduates employed in the college labor market. 
(9) According to Upwardly Global and the Wel-
come Back Initiative, with proper guidance and sup-
port, underemployed skilled immigrants typically in-
crease their income by 215 percent to 900 percent. 
(10) According to the Brookings Institution and 
the Partnership for a New American Economy, im-
migrants working in the health workforce are, on av-
erage, better educated than United States-born 
workers in the health workforce. 
(b) GRANTS TO ELIGIBLE ENTITIES.— 
(1) AUTHORITY
TO
PROVIDE
GRANTS.—The 
Secretary of Health and Human Services acting 
through the Bureau of Health Workforce within the 
Health Resources and Services Administration, the 
National Institute on Minority Health and Health 
Disparities, or the Office of Minority Health (in this 
section referred to as the ‘‘Secretary’’) may award 
grants to eligible entities to carry out activities de-
scribed in subsection (c). 
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(2) ELIGIBILITY.—To be eligible to receive a 
grant under this section, an entity shall— 
(A) be a clinical, public health, or health 
services organization, a community-based or 
nonprofit entity, an academic institution, a 
faith-based organization, a State, county, or 
local government, an Area Health Education 
Center, or another entity determined appro-
priate by the Secretary; and 
(B) submit to the Secretary an application 
at such time, in such manner, and containing 
such information as the Secretary may require. 
(c) AUTHORIZED ACTIVITIES.—A grant awarded 
under this section shall be used— 
(1) to provide services to assist unemployed and 
underemployed skilled immigrants, residing in the 
United States, who have legal, permanent work au-
thorization and who are internationally educated 
health professionals, enter into the American health 
workforce with employment matching their health 
professional skills and education, and advance in em-
ployment to positions that better match their health 
professional education and expertise; 
(2) to provide training opportunities to reduce 
barriers to entry and advancement in the health 
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workforce for skilled, internationally educated immi-
grants; 
(3) to educate employers regarding the abilities 
and capacities of internationally educated health 
professionals; 
(4) to assist in the evaluation of foreign creden-
tials; and 
(5) to facilitate access to contextualized and ac-
celerated courses on English as a second language. 
(d) DEFINITION.—In this section: 
(1) The term ‘‘health professional’’ means an 
individual trained for employment or intended em-
ployment in the field of public health, health man-
agement, dentistry, health administration, medicine, 
nursing, pharmacy, psychology, social work, psychi-
atry, other mental and behavioral health, allied 
health, community health or wellness work, including 
fitness and nutrition, or other fields as determined 
appropriate by the Secretary. 
(2) The term ‘‘underemployed’’ means being 
employed at less skilled tasks than an employee’s 
training or abilities would otherwise permit. 
(e) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated to carry out this section 
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such sums as may be necessary for each of fiscal years 
2017 through 2021. 
TITLE IV—IMPROVEMENT OF 
HEALTH CARE SERVICES 
Subtitle A—Health Empowerment 
Zones 
SEC. 401. SHORT TITLE. 
This subtitle may be cited as the ‘‘Health Empower-
ment Zone Act of 2016’’. 
SEC. 402. FINDINGS. 
The Congress finds the following: 
(1) Numerous studies and reports, including 
the 2012 National Healthcare Disparities Report of 
the Administration on Healthcare Research and 
Quality and the 2002 Unequal Treatment Report of 
the Institute of Medicine, document the extensive-
ness to which health disparities exist across the 
country. 
(2) These studies have found that, on average, 
racial and ethnic minorities are disproportionately 
afflicted with chronic and acute conditions—such as 
cancer, diabetes, musculoskeletal disease, obesity, 
and hypertension—and suffer worse health out-
comes, worse health status, and higher mortality 
rates than their White counterparts. 
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(3) Several recent studies also show that health 
disparities are a function of not only access to health 
care, but also the social determinants of health—in-
cluding the environment, the physical structure of 
communities, nutrition and food options, educational 
attainment, employment, race, ethnicity, geography, 
and language preference—that directly and indi-
rectly affect the health, health care, and wellness of 
individuals and communities. 
(4) Integrally involving and fully supporting the 
communities most affected by health inequities in 
the assessment, planning, launch, and evaluation of 
health disparity elimination efforts are among the 
leading recommendations made to adequately ad-
dress and ultimately reduce health disparities. 
(5) Recommendations also include supporting 
the efforts of community stakeholders from a broad 
cross section—including, but not limited to local 
businesses, local departments of commerce, edu-
cation, labor, urban planning, and transportation, 
and community-based and other nonprofit organiza-
tions, including national and regional intermediaries 
with demonstrated capacity to serve low-income 
urban communities—to find areas of common 
ground around health disparity elimination and col-
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laborate to improve the overall health and wellness 
of a community and its residents. 
SEC. 
403. 
DESIGNATION 
OF 
HEALTH 
EMPOWERMENT 
ZONES. 
(a) IN GENERAL.—At the request of an eligible com-
munity partnership, the Secretary may designate an eligi-
ble area as a health empowerment zone. 
(b) ELIGIBILITY CRITERIA.— 
(1) ELIGIBLE
COMMUNITY
PARTNERSHIP.—A 
community partnership is eligible to submit a re-
quest under this section if the partnership— 
(A) demonstrates widespread public sup-
port from key individuals and entities in the eli-
gible area, including members of the target 
community, State and local governments, non-
profit organizations including national and re-
gional intermediaries with demonstrated capac-
ity to serve low-income urban communities, and 
community and industry leaders, for designa-
tion of the eligible area as a health empower-
ment zone; and 
(B) includes representatives of— 
(i) a broad cross section of stake-
holders and residents from communities in 
the eligible area experiencing dispropor-
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tionate disparities in health status and 
health care; and 
(ii) organizations, facilities, and insti-
tutions that have a history of working 
within and serving such communities. 
(2) ELIGIBLE AREA.—An area is eligible to be 
designated as a health empowerment zone under this 
section if one or more communities in the area expe-
rience disproportionate disparities in health status 
and health care. In determining whether a commu-
nity experiences such disparities, the Secretary shall 
consider the data collected by the Department of 
Health and Human Services focusing on the fol-
lowing areas: 
(A) Access to affordable, high-quality 
health services. 
(B) The prevalence of disproportionate 
rates of certain illnesses or diseases including 
the following: 
(i) Arthritis, osteoporosis, chronic 
back conditions, and other musculoskeletal 
diseases. 
(ii) Cancer. 
(iii) Chronic kidney disease. 
(iv) Diabetes. 
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(v) Injury (intentional and uninten-
tional). 
(vi) Violence (intimate and non-
intimate). 
(vii) Maternal and paternal illnesses 
and diseases. 
(viii) Infant mortality. 
(ix) Mental illness and other disabil-
ities. 
(x) Substance abuse treatment and 
prevention, including underage drinking. 
(xi) Nutrition, obesity, and overweight 
conditions. 
(xii) Heart disease. 
(xiii) Hypertension. 
(xiv) 
Cerebrovascular 
disease 
or 
stroke. 
(xv) Tuberculosis. 
(xvi) HIV/AIDS and other sexually 
transmitted infections. 
(xvii) Viral hepatitis. 
(xviii) Asthma. 
(xix) Tooth decay and other oral 
health issues. 
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(C) Within the target community, the his-
torical and persistent presence of conditions 
that have been found to contribute to health 
disparities including any such conditions re-
specting the following: 
(i) Poverty. 
(ii) Educational status and the quality 
of community schools. 
(iii) Income. 
(iv) Access to high-quality affordable 
health care. 
(v) Work and work environment. 
(vi) Environmental conditions in the 
community, including with respect to clean 
water, clean air, and the presence or ab-
sence of pollutants. 
(vii) Language and English pro-
ficiency. 
(viii) Access to affordable healthy 
food. 
(ix) Access to ethnically and culturally 
diverse health and human service providers 
and practitioners. 
(x) Access to culturally and linguis-
tically competent health and human serv-
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ices and health and human service pro-
viders. 
(xi) Health-supporting infrastructure. 
(xii) Health insurance that is ade-
quate and affordable. 
(xiii) Race, racism, and bigotry (con-
scious and unconscious). 
(xiv) Sexual orientation. 
(xv) Health literacy. 
(xvi) Place of residence (such as 
urban areas, rural areas, and tribal res-
ervations). 
(xvii) Stress. 
(c) PROCEDURE.— 
(1) REQUEST.—A request under subsection (a) 
shall— 
(A) describe the bounds of the area to be 
designated as a health empowerment zone and 
the process used to select those bounds; 
(B) demonstrate that the partnership sub-
mitting the request is an eligible community 
partnership described in subsection (b)(1); 
(C) demonstrate that the area is an eligible 
area described in subsection (b)(2); 
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(D) include a comprehensive assessment of 
disparities in health status and health care ex-
perience by one or more communities in the 
area; 
(E) set forth— 
(i) a vision and a set of values for the 
area; and 
(ii) a comprehensive and holistic set of 
goals to be achieved in the area through 
designation as a health empowerment zone; 
and 
(F) include a strategic plan and an action 
plan for achieving the goals described in sub-
paragraph (E)(ii). 
(2) APPROVAL.—Not later than 60 days after 
the receipt of a request for designation of an area 
as a health empowerment zone under this section, 
the Secretary shall approve or disapprove the re-
quest. 
(d) MINIMUM NUMBER.—The Secretary— 
(1) shall designate not more than 110 health 
empowerment zones under this section; and 
(2) shall designate at least one health empower-
ment zone in each of the several States, the District 
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of Columbia, and each territory or possession of the 
United States. 
SEC. 404. ASSISTANCE TO THOSE SEEKING DESIGNATION. 
At the request of any organization or entity seeking 
to submit a request under section 403(a), the Secretary 
shall provide technical assistance, and may award a grant, 
to assist such organization or entity— 
(1) to form an eligible community partnership 
described in section 403(b)(1); 
(2) to complete a health assessment, including 
an assessment of health disparities under section 
403(c)(1)(D); or 
(3) to prepare and submit a request, including 
a strategic plan, in accordance with section 403. 
SEC. 405. BENEFITS OF DESIGNATION. 
(a) PRIORITY.—In awarding any competitive grant, 
a Federal official shall give priority to any applicant 
that— 
(1) meets the eligibility criteria for the grant; 
(2) proposes to use the grant for activities in a 
health empowerment zone; and 
(3) demonstrates that such activities will di-
rectly and significantly further the goals of the stra-
tegic plan approved for such zone under section 403. 
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(b) GRANTS
FOR INITIAL IMPLEMENTATION
OF 
STRATEGIC PLAN.— 
(1) IN GENERAL.—Upon designating an eligible 
area as a health empowerment zone at the request 
of an eligible community partnership, the Secretary 
shall, subject to the availability of appropriations, 
make a grant to the community partnership for im-
plementation of the strategic plan for such zone. 
(2) GRANT PERIOD.—A grant under paragraph 
(1) for a health empowerment zone shall be for a pe-
riod of 2 years and may be renewed, except that the 
total period of grants under paragraph (1) for such 
zone may not exceed 10 years. 
(3) LIMITATION.—In awarding grants under 
this subsection, the Secretary shall not give less pri-
ority to an applicant or reduce the amount of a 
grant because the Secretary rendered technical as-
sistance or made a grant to the same applicant 
under section 404. 
(4) REPORTING.—The Secretary shall require 
each recipient of a grant under this subsection to re-
port to the Secretary not less than every 6 months 
on the progress in implementing the strategic plan 
for the health empowerment zone. 
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SEC. 406. DEFINITION. 
In this subtitle, the term ‘‘Secretary’’ means the Sec-
retary of Health and Human Services, acting through the 
Administrator of the Health Resources and Services Ad-
ministration and the Deputy Assistant Secretary for Mi-
nority Health, and in cooperation with the Director of the 
Office of Community Services and the Director of the Na-
tional Institute for Minority Health and Health Dispari-
ties. 
SEC. 407. AUTHORIZATION OF APPROPRIATIONS. 
To carry out this subtitle, there is authorized to be 
appropriated $100,000,000 for fiscal year 2017. 
Subtitle B—Other Improvements of 
Health Care Services 
CHAPTER 1—EXPANSION OF COVERAGE 
SEC. 411. AMENDMENT TO THE PUBLIC HEALTH SERVICE 
ACT. 
Title XXXIV of the Public Health Service Act, as 
amended by titles I, II, III, and IX of this Act, is further 
amended by inserting after subtitle C the following: 
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‘‘Subtitle 
D—Reconstruction 
and 
Improvement Grants for Public 
Health Care Facilities Serving 
Pacific Islanders and the Insu-
lar Areas 
‘‘SEC. 3451. GRANT SUPPORT FOR QUALITY IMPROVEMENT 
INITIATIVES. 
‘‘(a) IN GENERAL.—The Secretary, in collaboration 
with the Administrator of the Health Resources and Serv-
ices Administration, the Director of the Agency for 
Healthcare Research and Quality, and the Administrator 
of the Centers for Medicare & Medicaid Services, shall 
award grants to eligible entities for the conduct of dem-
onstration projects to improve the quality of and access 
to health care. 
‘‘(b) ELIGIBILITY.—To be eligible to receive a grant 
under subsection (a), an entity shall— 
‘‘(1) be a health center, hospital, health plan, 
health system, community clinic. or other health en-
tity determined appropriate by the Secretary— 
‘‘(A) that, by legal mandate or explicitly 
adopted mission, provides patients with access 
to services regardless of their ability to pay; 
‘‘(B) that provides care or treatment for a 
substantial number of patients who are unin-
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sured, are receiving assistance under a State 
program under title XIX of the Social Security 
Act, or are members of vulnerable populations, 
as determined by the Secretary; and 
‘‘(C)(i) with respect to which, not less than 
50 percent of the entity’s patient population is 
made up of racial and ethnic minorities; or 
‘‘(ii) that— 
‘‘(I) serves a disproportionate percent-
age of local, minority racial and ethnic pa-
tients, or that has a patient population, at 
least 50 percent of which is limited- 
English-proficient; and 
‘‘(II) provides an assurance that 
amounts received under the grant will be 
used only to support quality improvement 
activities in the racial and ethnic popu-
lation served; and 
‘‘(2) prepare and submit to the Secretary an 
application at such time, in such manner, and con-
taining such information as the Secretary may re-
quire. 
‘‘(c) PRIORITY.—In awarding grants under sub-
section (a), the Secretary shall give priority to applicants 
under subsection (b)(2) that— 
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‘‘(1) demonstrate an intent to operate as part 
of a health care partnership, network, collaborative, 
coalition, or alliance where each member entity con-
tributes to the design, implementation, and evalua-
tion of the proposed intervention; or 
‘‘(2) intend to use funds to carry out system-
wide changes with respect to health care quality im-
provement, including— 
‘‘(A) improved systems for data collection 
and reporting; 
‘‘(B) innovative collaborative or similar 
processes; 
‘‘(C) group programs with behavioral or 
self-management interventions; 
‘‘(D) case management services; 
‘‘(E) physician or patient reminder sys-
tems; 
‘‘(F) educational interventions; or 
‘‘(G) other activities determined appro-
priate by the Secretary. 
‘‘(d) USE OF FUNDS.—An entity shall use amounts 
received under a grant under subsection (a) to support 
the implementation and evaluation of health care quality 
improvement activities or minority health and health care 
disparity reduction activities that include— 
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‘‘(1) with respect to health care systems, activi-
ties relating to improving— 
‘‘(A) patient safety; 
‘‘(B) timeliness of care; 
‘‘(C) effectiveness of care; 
‘‘(D) efficiency of care; 
‘‘(E) patient centeredness; and 
‘‘(F) health information technology; and 
‘‘(2) with respect to patients, activities relating 
to— 
‘‘(A) staying healthy; 
‘‘(B) getting well, mentally and physically; 
‘‘(C) living effectively with illness or dis-
ability; and 
‘‘(D) coping with end-of-life issues. 
‘‘(e) COMMON DATA SYSTEMS.—The Secretary shall 
provide financial and other technical assistance to grant-
ees under this section for the development of common data 
systems. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section 
such sums as may be necessary for each of fiscal years 
2017 through 2022. 
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‘‘SEC. 3452. CENTERS OF EXCELLENCE. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Administrator of the Health Resources and Services 
Administration, shall designate centers of excellence at 
public hospitals, and other health systems serving large 
numbers of minority patients, that— 
‘‘(1) 
meet 
the 
requirements 
of 
section 
3451(b)(1); 
‘‘(2) demonstrate excellence in providing care to 
minority populations; and 
‘‘(3) demonstrate excellence in reducing dispari-
ties in health and health care. 
‘‘(b) REQUIREMENTS.—A hospital or health system 
that serves as a center of excellence under subsection (a) 
shall— 
‘‘(1) design, implement, and evaluate programs 
and policies relating to the delivery of care in ra-
cially, ethnically, and linguistically diverse popu-
lations; 
‘‘(2) provide training and technical assistance 
to other hospitals and health systems relating to the 
provision of quality health care to minority popu-
lations; and 
‘‘(3) develop activities for graduate or con-
tinuing medical education that institutionalize a 
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focus on cultural competence training for health care 
providers. 
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section, 
such sums as may be necessary for each of fiscal years 
2017 through 2022. 
‘‘SEC. 3453. RECONSTRUCTION AND IMPROVEMENT GRANTS 
FOR PUBLIC HEALTH CARE FACILITIES SERV-
ING PACIFIC ISLANDERS AND THE INSULAR 
AREAS. 
‘‘(a) IN GENERAL.—The Secretary shall provide di-
rect financial assistance to designated health care pro-
viders and community health centers in American Samoa, 
Guam, the Commonwealth of the Northern Mariana Is-
lands, the United States Virgin Islands, Puerto Rico, and 
Hawaii for the purposes of reconstructing and improving 
health care facilities and services in a culturally competent 
and sustainable manner. 
‘‘(b) ELIGIBILITY.—To be eligible to receive direct fi-
nancial assistance under subsection (a), an entity shall be 
a public health facility or community health center located 
in American Samoa, Guam, the Commonwealth of the 
Northern Mariana Islands, the United States Virgin Is-
lands, Puerto Rico, or Hawaii that— 
‘‘(1) is owned or operated by— 
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‘‘(A) the Government of American Samoa, 
Guam, the Commonwealth of the Northern 
Mariana Islands, the United States Virgin Is-
lands, Puerto Rico, or Hawaii or a unit of local 
government; or 
‘‘(B) a nonprofit organization; and 
‘‘(2)(A) provides care or treatment for a sub-
stantial number of patients who are uninsured, re-
ceiving assistance under a State program under a 
title XVIII of the Social Security Act, or a State 
program under title XIX of such Act, or who are 
members of a vulnerable population, as determined 
by the Secretary; or 
‘‘(B) serves a disproportionate percentage of 
local, minority racial and ethnic patients. 
‘‘(c) REPORT.—Not later than 180 days after the 
date of enactment of this title and annually thereafter, the 
Secretary shall submit to the Congress and the President 
a report that includes an assessment of health resources 
and facilities serving populations in American Samoa, 
Guam, the Commonwealth of the Northern Mariana Is-
lands, the United States Virgin Islands, Puerto Rico, and 
Hawaii. In preparing such report, the Secretary shall— 
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‘‘(1) consult with and obtain information on all 
health care facilities needs from the entities de-
scribed in subsection (b); 
‘‘(2) include all amounts of Federal assistance 
received by each entity in the preceding fiscal year; 
‘‘(3) review the total unmet needs of each juris-
diction for health care facilities, including needs for 
renovation and expansion of existing facilities; 
‘‘(4) include a strategic plan for addressing the 
needs of each jurisdiction identified in the report; 
and 
‘‘(5) evaluate the effectiveness of the care pro-
vided by measuring patient outcomes and cost meas-
ures. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as necessary 
to carry out this section.’’. 
SEC. 412. REMOVING CITIZENSHIP AND IMMIGRATION BAR-
RIERS TO ACCESS TO AFFORDABLE HEALTH 
CARE UNDER THE ACA. 
(a) IN GENERAL.— 
(1) PREMIUM TAX CREDITS.—Section 36B of 
the Internal Revenue Code of 1986 is amended— 
(A) in subsection (c)(1)(B)— 
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(i) by amending the subparagraph 
heading to read as follows: ‘‘SPECIAL RULE 
FOR
CERTAIN
INDIVIDUALS
INELIGIBLE 
FOR MEDICAID DUE TO STATUS’’, and 
(ii) in clause (ii), by striking ‘‘lawfully 
present in the United States, but’’ and in-
serting ‘‘who’’, and 
(B) by striking subsection (e). 
(2) COST-SHARING REDUCTIONS.—Section 1402 
of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18071) is amended by striking sub-
section (e). 
(3) BASIC
HEALTH
PROGRAM
ELIGIBILITY.— 
Section 1331(e)(1)(B) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18051(e)(1)(B)) is 
amended by striking ‘‘lawfully present in the United 
States’’. 
(4) RESTRICTIONS ON FEDERAL PAYMENTS.— 
Section 1412 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18082) is amended by 
striking subsection (d). 
(5) REQUIREMENT TO MAINTAIN MINIMUM ES-
SENTIAL
COVERAGE.—Subsection (d) of section 
5000A of the Internal Revenue Code of 1986 is 
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amended by striking paragraph (3) and by redesig-
nating paragraph (4) as paragraph (3). 
(b) CONFORMING AMENDMENT.— 
(1) Section 1411(a) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18081(a)) is 
amended by striking paragraph (1) and redesig-
nating paragraphs (2), (3), and (4) as paragraphs 
(1), (2), and (3), respectively. 
(2) Section 1312(f) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18032(f)) is 
amended— 
(A) in the subsection heading, by striking 
‘‘access limited to citizens and lawful resi-
dents’’; and 
(B) by striking paragraph (3). 
SEC. 413. STUDY ON THE UNINSURED. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall— 
(1) conduct a study, in accordance with the 
standards under section 3101 of the Public Health 
Service Act (42 U.S.C. 300kk), on the demographic 
characteristics of the population of individuals who 
do not have health insurance coverage; and 
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(2) predict, based on such study, the demo-
graphic characteristics of the population of individ-
uals who would remain without health insurance cov-
erage after the end of open enrollment or any special 
enrollment period. 
(b) REPORTING REQUIREMENTS.— 
(1) IN GENERAL.—Not later than 12 months 
after the date of the enactment of this Act, the Sec-
retary shall submit to the Congress the results of 
the study under subsection (a)(1) and the prediction 
made under subsection (a)(2). 
(2) REPORTING OF DEMOGRAPHIC CHARACTER-
ISTICS.—The Secretary shall report the demographic 
characteristics under paragraphs (1) and (2) of sub-
section (a) on the basis of racial and ethnic group, 
and shall stratify the reporting on each racial and 
ethnic group by other demographic characteristics 
that can impact access to health insurance coverage, 
such as sexual orientation, gender identity, primary 
language, disability status, sex, socioeconomic sta-
tus, age group, and citizenship and immigration sta-
tus, in a manner consistent with title I of this Act. 
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SEC. 414. MEDICAID PAYMENT PARITY FOR THE TERRI-
TORIES. 
(a) ELIMINATION OF FUNDING LIMITATIONS FOR 
PUERTO RICO, THE UNITED STATES VIRGIN ISLANDS, 
GUAM, THE COMMONWEALTH OF THE NORTHERN MAR-
IANA ISLANDS, AND AMERICAN SAMOA.— 
(1) IN GENERAL.—Section 1108 of the Social 
Security Act (42 U.S.C. 1308) is amended— 
(A) in subsection (f), in the matter pre-
ceding paragraph (1), by striking ‘‘subsection 
(g)’’ and inserting ‘‘subsections (g) and (h)’’; 
(B) in subsection (g)(2), in the matter pre-
ceding subparagraph (A)— 
(i) by striking ‘‘Notwithstanding sub-
section (f) and subject to and’’ and insert-
ing ‘‘Notwithstanding subsection (f) and 
subject to’’; and 
(ii) by striking ‘‘paragraphs (3) and 
(5)’’ and inserting ‘‘, paragraphs (3) and 
(5) of this subsection, and subsection (h)’’; 
and 
(C) by adding at the end the following new 
subsection: 
‘‘(h) SUNSET OF FUNDING LIMITATIONS FOR PUER-
TO RICO, THE UNITED STATES VIRGIN ISLANDS, GUAM, 
THE COMMONWEALTH OF THE NORTHERN MARIANA IS-
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LANDS, AND AMERICAN SAMOA.—Subsections (f) and (g) 
shall not apply to Puerto Rico, the United States Virgin 
Islands, Guam, the Commonwealth of the Northern Mar-
iana Islands, and American Samoa for any fiscal year 
after fiscal year 2017.’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1903(u) of the Social Security Act (42 U.S.C. 
1396c(u)) is amended by striking paragraph (4). 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply beginning with fiscal 
year 2018. 
(b) PARITY IN FMAP.— 
(1) IN GENERAL.—Section 1905(b) of the So-
cial Security Act (42 U.S.C. 1396d(b)) is amended 
by inserting after ‘‘and American Samoa shall be 55 
percent,’’ the following: ‘‘(except that, beginning 
with fiscal year 2020, the Federal medical assistance 
percentage for Puerto Rico, the United States Virgin 
Islands, Guam, the Commonwealth of the Northern 
Mariana Islands, and American Samoa shall be the 
Federal medical assistance percentage determined by 
the Secretary in consultation (for the United States 
Virgin Islands, Guam, the Commonwealth of the 
Northern Mariana Islands, and American Samoa) 
with the Secretary of the Interior)’’. 
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‘‘(1) 101 percent of the reasonable costs of pro-
viding such services, without regard to the amount 
of the customary or other charge, or 
‘‘(2) the amount of payment provided for under 
the prospective payment system for inpatient hos-
pital services under section 1886(d).’’. 
(2) OUTPATIENT SERVICES.—Section 1834 of 
such Act (42 U.S.C. 1395m) is amended by adding 
at the end the following new subsection: 
‘‘(p) PAYMENT FOR OUTPATIENT SERVICES FUR-
NISHED
IN
RURAL
COMMUNITY
HOSPITALS.—The 
amount of payment under this part for outpatient services 
furnished in a rural community hospital is, at the election 
of the hospital in the application referred to in section 
1861(jjj)(1)(E)— 
‘‘(1) 101 percent of the reasonable costs of pro-
viding such services, without regard to the amount 
of the customary or other charge and any limitation 
under section 1861(v)(1)(U), or 
‘‘(2) the amount of payment provided for under 
the prospective payment system for covered OPD 
services under section 1833(t).’’. 
(3) EXEMPTION FROM 30-PERCENT REDUCTION 
IN
REIMBURSEMENT
FOR
BAD
DEBT.—Section 
1861(v)(1)(T) 
of 
such 
Act 
(42 
U.S.C. 
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1395x(v)(1)(T)) is amended by inserting ‘‘(other 
than for a rural community hospital)’’ after ‘‘In de-
termining such reasonable costs for hospitals’’. 
(c) BENEFICIARY COST-SHARING FOR OUTPATIENT 
SERVICES.—Section 1834(p) of such Act (as added by 
subsection (b)(2)) is amended— 
(1) by redesignating paragraphs (1) and (2) as 
subparagraphs (A) and (B), respectively; 
(2) by inserting ‘‘(1)’’ after ‘‘(p)’’; and 
(3) by adding at the end the following: 
‘‘(2) The amounts of beneficiary cost-sharing for out-
patient services furnished in a rural community hospital 
under this part shall be as follows: 
‘‘(A) For items and services that would have 
been paid under section 1833(t) if provided by a 
hospital, the amount of cost-sharing determined 
under paragraph (8) of such section. 
‘‘(B) For items and services that would have 
been paid under section 1833(h) if furnished by a 
provider or supplier, no cost-sharing shall apply. 
‘‘(C) For all other items and services, the 
amount of cost-sharing that would apply to the item 
or service under the methodology that would be used 
to determine payment for such item or service if pro-
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vided by a physician, provider, or supplier, as the 
case may be.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) PART
A
PAYMENT.—Section 1814(b) of 
such Act (42 U.S.C. 1395f(b)) is amended in the 
matter preceding paragraph (1) by inserting ‘‘other 
than inpatient hospital services furnished by a rural 
community hospital,’’ after ‘‘critical access hospital 
services,’’. 
(2) PART
B
PAYMENT.—Section 1833(a) of 
such Act (42 U.S.C. 1395l(a)), as amended by sec-
tion 205(b)(3), is amended— 
(A) in paragraph (2), in the matter before 
subparagraph (A), by striking ‘‘and (I)’’ and in-
serting ‘‘(I), and (K)’’; 
(B) by striking ‘‘and’’ at the end of para-
graph (9); 
(C) by striking the period at the end of 
paragraph (10) and inserting ‘‘; and’’; and 
(D) by adding at the end the following: 
‘‘(11) in the case of outpatient services fur-
nished by a rural community hospital, the amounts 
described in section 1834(p).’’. 
(3) TECHNICAL AMENDMENTS.— 
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