Subtitle B—Additional Provisions 
SEC. 2201. 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— 
‘‘(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, 2018, subclause (I) of paragraph 
(5)(F)(vi) shall be applied by substituting for 
the numerator described in such subclause a 
factor determined appropriate by the Sec-
retary.’’. 
SEC. 2202. ADMINISTRATIVE FLEXIBILITY WITH RESPECT 
TO THE TERRITORIES. 
(a) IN GENERAL.—Section 1108 of the Social Secu-
rity Act (42 U.S.C. 1308) is amended by adding at the 
end the following: 
‘‘(h) ADMINISTRATIVE FLEXIBILITY WITH RESPECT 
TO THE TERRITORIES.—Notwithstanding any other provi-
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sion of this Act, with respect to the applicability to Puerto 
Rico, the United States Virgin Islands, Guam, the North-
ern Mariana Islands, and American Samoa of payment 
formulas under titles XVIII and XIX, the Secretary shall 
do the following: 
‘‘(1) Determine the availability of data for pay-
ment calculation factors required or authorized by 
respective payment formulas under such titles. 
‘‘(2) Determine the sufficiency, relevance and 
reliability of available data for payment calculation 
factors to adequately account for variations in stand-
ard benefits under programs established under this 
Act, variations in program penetration, and vari-
ations in the cost of delivering care that are unique 
to such territories. 
‘‘(3) Determine whether the inclusion of pay-
ment calculation factors or certain data sources 
thereunder, whether prescribed by the respective ti-
tles or ordinarily used by the Secretary, dispropor-
tionately impact the resulting payment calculation 
with respect to each such territory, either generally 
or relative to the States. 
‘‘(4) Insofar as the Secretary determines in ac-
cordance with paragraph (1), (2), or (3) that data 
are not available, that available data is insufficient 
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to reliably and adequately account for variations in 
standard benefits under programs established under 
this Act, variations in program penetration, and 
variations in the cost of delivering care that are 
unique to such territories, or to the extent that dis-
proportionate impact to such territories would other-
wise occur— 
‘‘(A) establish and apply a proxy for pay-
ment calculation factors or substitute data 
sources where data sources are determined un-
available, or as determined necessary to ade-
quately reflect variations in standard benefits 
under programs established under this Act and 
in the cost of delivering care that are unique to 
such territories; or 
‘‘(B) to the extent the inclusion of pay-
ment calculation factors or certain data sources 
thereunder disproportionately impacts the re-
sulting payment calculation with respect to each 
such territory, either generally or relative to the 
States, disregard the factor or data source or 
devise and apply an appropriate adjustment 
factor. 
‘‘(5) For purposes of extending the full benefits 
of payments to such territories intended under the 
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respective titles, ensure that the application of pay-
ment calculation factors with respect to such terri-
tories occurs in a manner that takes into account 
the geographic and demographic differences, abnor-
malities in the cost of delivering care in such terri-
tories, and the potential disproportionate impact to 
each such territory, either generally or relative to 
the States.’’. 
(b) IMPLEMENTATION.—The Secretary of Health and 
Human Services shall determine and apply the payment 
calculation adjustments authorized under section 1108(h) 
of the Social Security Act (42 U.S.C. 1308(h)), as added 
by subsection (a), as soon as practicable after the date 
of enactment of this Act in order to allow for the applica-
tion of appropriate payment calculation factors to Puerto 
Rico, the United States Virgin Islands, Guam, the North-
ern Mariana Islands, and American Samoa under titles 
XVIII and XIX of the Social Security Act (42 U.S.C. 
1395 et seq., 1396 et seq.) at the earliest feasible oppor-
tunity. 
SEC. 2203. SENSE OF CONGRESS REGARDING FEDERAL 
HEALTH PROGRAMS IN TERRITORIES OF THE 
UNITED STATES. 
It is the sense of Congress that— 
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(1) the territories of the United States should 
receive more equitable and sustainable treatment 
under Federal health policies and programs, includ-
ing the Medicare and Medicaid programs, in a fis-
cally responsible manner; and 
(2) the treatment of the territories of the 
United States under Federal health programs, with 
appropriate Federal oversight, should aim to— 
(A) 
improve 
patient 
outcomes 
and 
strengthen health care systems in the terri-
tories; 
(B) mitigate against migration from the 
territories to the States and the costs to the 
State and Federal governments which are asso-
ciated with such migration; and 
(C) stabilize and strengthen the fiscal con-
dition of the governments of the territories. 
TITLE III—SECURITY 
SEC. 
3101. 
CARIBBEAN 
BORDER 
COUNTERNARCOTICS 
STRATEGY. 
(a) 
CARIBBEAN
BORDER
COUNTERNARCOTICS 
STRATEGY.—Not later than 6 months after the date of 
enactment of this Act, and every 2 years thereafter, the 
Office of National Drug Control Policy shall develop a 
Caribbean Border Counternarcotics Strategy, that is made 
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available to the public, with emphasis on the borders of 
Puerto Rico and the Virgin Islands of the United States, 
on terms substantially equivalent to the existing South-
west Border Counternarcotics Strategy and the Northern 
Border Counternarcotics Strategy. 
(b) AMENDMENTS.—The Office of National Drug 
Control Policy Reauthorization Act of 1998 (21 U.S.C. 
1701 et seq.) is amended— 
(1) in section 702 (21 U.S.C. 1701)— 
(A) by redesignating paragraphs (10) 
through (13) as paragraphs (11) through (14), 
respectively; 
(B) by inserting after paragraph (9) the 
following new paragraph: 
‘‘(10) STATE.—The term ‘State’ means the sev-
eral States, the District of Columbia, Puerto Rico, 
the Virgin Islands of the United States, American 
Samoa, Guam, and the Commonwealth of the North-
ern Mariana Islands.’’; and 
(C) by adding at the end the following new 
paragraph: 
‘‘(15) UNITED
STATES.—The term ‘United 
States’ when used in the geographic sense, means 
the several States, the District of Columbia, Puerto 
Rico, the Virgin Islands of the United States, Amer-
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ican Samoa, Guam, the Commonwealth of the 
Northern Mariana Islands, and all other territories 
and possessions of the United States, and any 
waters within the jurisdiction of the United States.’’; 
and 
(2) in section 704(b)(13)(B) (21 U.S.C. 
1703(b)(13)(B)), by inserting ‘‘the borders of Puer-
to Rico and the Virgin Islands of the United States 
and’’ after ‘‘in particular’’. 
Æ 
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