I 
116TH CONGRESS 
1ST SESSION H. R. 3371 
To amend titles XI and XIX of the Social Security Act to stabilize the 
Medicaid program in Puerto Rico. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 19, 2019 
Ms. VELA´ZQUEZ (for herself, Mr. SOTO, Mr. SERRANO, Mr. GRIJALVA, Mr. 
ESPAILLAT, Ms. OCASIO-CORTEZ, Mr. GARCI´A of Illinois, and Miss 
GONZA´LEZ-COLO´N of Puerto Rico) introduced the following bill; which 
was referred to the Committee on Energy and Commerce 
A BILL 
To amend titles XI and XIX of the Social Security Act 
to stabilize the Medicaid program in Puerto Rico. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Puerto Rico Health 
Care Fairness, Accountability, and Beneficiary Access Act 
of 2019’’. 
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SEC. 2. ADJUSTMENTS TO FMAP AND CAP FOR PUERTO 
RICO. 
(a) ADJUSTMENTS TO FMAP.—Section 1905 of the 
Social Security Act (42 U.S.C. 1396d) is amended— 
(1) in subsection (b)— 
(A) by striking ‘‘for Puerto Rico, the Vir-
gin Islands’’ and inserting ‘‘for the Virgin Is-
lands’’; and 
(B) by striking ‘‘and American Samoa 
shall be 55 percent,’’ and inserting ‘‘and Amer-
ica Samoa (and, for calendar quarters in a fis-
cal year before fiscal year 2020, Puerto Rico) 
shall be 55 percent, and for Puerto Rico, for 
calendar quarters in a fiscal year beginning 
with fiscal year 2020, shall be the PR specified 
percent under subsection (ff) for such fiscal 
year,’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(ff)(1) For purposes of subsection (b), the PR speci-
fied percent under this subsection is— 
‘‘(A) subject to paragraph (2), for each of fiscal 
years 2020 through 2024, 83 percent; 
‘‘(B) subject to paragraph (3)(D)(iii), for each 
of fiscal years 2025 through 2029, 83 percent; and 
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specified percent specified under paragraph (1) for 
such fiscal year shall be reduced by 5 percent. 
‘‘(B) For purposes of this subsection, the program 
enhancement requirements described in this subparagraph 
are each of the following: 
‘‘(i) Rates of payment under the State plan 
under this title for inpatient hospital services are not 
less than the costs incurred for such services. 
‘‘(ii) Rates of payment under the State plan 
under this title for physicians’ services are not less 
than 70 percent of the amount that is payable for 
such services under section 1848. 
‘‘(iii) The State plan provides for medical as-
sistance for Hepatitis C drugs, in accordance with 
the requirements of section 1927 otherwise applica-
ble to the 50 States. 
‘‘(iv) The State plan provides for medical as-
sistance for Medicare cost-sharing described in sub-
section (p)(3)(A)(ii) for qualified Medicare bene-
ficiaries described in subsection (p)(1), in accord-
ance with the requirements under subsection (p) oth-
erwise applicable to the 50 States. 
‘‘(3)(A)(i) Not later than January 1, 2022, the Gov-
ernor of Puerto Rico shall submit to the Secretary a Terri-
tory Transition Plan, which shall be developed with stake-
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holder input and with a public comment period, that in-
cludes— 
‘‘(I) a detailed description of which pro-
gram enhancements described in subparagraph 
(C) Puerto Rico will include as medical assist-
ance under the State plan under title XIX, the 
first plan year by which each such program en-
hancement will be so included in order to sat-
isfy the requirements described in subparagraph 
(B), and a timeline for milestones for including 
such program enhancements; and 
‘‘(II) a description of any challenges, in-
cluding 
infrastructure 
challenges, 
provider 
shortages, and financing challenges, for so in-
cluding such program enhancements and a plan 
to ameliorate any such challenges. 
‘‘(ii) The plan submitted under clause (i) shall be 
treated as approved by the Secretary not later than 180 
days after the date of submission of the plan unless within 
such 180-day period the Secretary disapproves such plan 
and notifies Puerto Rico of such disapproval with the rea-
son for such disapproval. In the case of such a disapproval, 
the Governor of Puerto Rico shall, within the 90-day pe-
riod following such notification, submit to the Secretary 
a Territory Transition Plan that addresses the reason 
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specified in such notification for such disapproval. Such 
resubmitted plan shall be treated as approved by the Sec-
retary under this clause unless the Secretary notifies 
Puerto Rico within the 30-day period following such sub-
mission of its disapproval with a reason for such dis-
approval. The Governor of Puerto Rico may develop and 
submit to the Secretary, in the same manner and subject 
to the same conditions as apply under clause (i) to the 
development and submission of the Territory Transition 
Plan, modifications to the plan and such modifications 
shall be treated as approved by the Secretary and incor-
porated into the plan in the same manner and subject to 
the same conditions that apply under this clause to the 
approval of the plan. 
‘‘(B) For purposes of this paragraph, the require-
ments described in this subparagraph, with respect to 
Puerto Rico, are the following: 
‘‘(i) For 2027, the State plan under title XIX 
includes at least 2 of the program enhancements de-
scribed in subparagraph (C). 
‘‘(ii) For 2029, the State plan includes at least 
4 of such program enhancements. 
‘‘(iii) For 2031, the State plan includes at least 
6 of such program enhancements. 
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‘‘(iv) For 2033 and each subsequent year, the 
State plan includes all of such program enhance-
ments. 
‘‘(C) For purposes of this paragraph, the program 
enhancements described in this subparagraph are the fol-
lowing: 
‘‘(i) The State plan provides for medical assist-
ance to all individuals described in clause (i) of sec-
tion 1902(a)(10)(A)). 
‘‘(ii) The State plan provides for inclusion as 
medical assistance of home health services, in ac-
cordance with section 1902(a)(10)(D). 
‘‘(iii) The State plan provides for inclusion as 
medical assistance of nonemergency transportation 
to medically necessary services. 
‘‘(iv) The State plan provides for inclusion as 
medical assistance of services described in subsection 
(a)(21) to all individuals described in clause (i) of 
section 1902(a)(10)(A)). 
‘‘(v) The State plan provides for inclusion as 
medical assistance of services described in subsection 
(a)(17) to all individuals described in such clause 
(other than subclause (VIII) of such clause. 
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‘‘(vi) The State plan provides for inclusion as 
medical assistance of nursing facility services, as de-
fined in subsection (a)(4)(A). 
‘‘(vii) The State plan provides for inclusion as 
medical assistance of early and periodic screening, 
diagnosis, and treatment services under subsection 
(a)(4)(B). 
‘‘(viii) The State plan provides for inclusion as 
medical assistance of freestanding birth center serv-
ices and other ambulatory services, as described in 
subsection (a)(28). 
‘‘(D)(i) For fiscal year 2022 and each subsequent fis-
cal year through fiscal year 2033— 
‘‘(I) the Comptroller General of the United 
States shall review, and submit to the Secretary and 
Congress a report on, whether or not Puerto Rico is 
in compliance with the timeline and achieving the 
milestones described in the Territory Transition plan 
(as modified, if applicable) approved under subpara-
graph (A) and, beginning with fiscal year 2027, 
whether Puerto Rico is in compliance with the appli-
cable requirements described in subparagraph (B); 
and 
‘‘(II) Puerto Rico shall submit to the Secretary 
a report on the extent to which Puerto Rico has met 
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the timelines and milestones included in such plan 
(as modified, if applicable). 
‘‘(ii) If, for a fiscal year described in clause (i) after 
fiscal year 2024, the Comptroller General submits a report 
with a finding that Puerto Rico is not in compliance with 
the timeline or with achieving milestones as described in 
subclause (I) (or, with respect to a fiscal year after fiscal 
year 2026, not in compliance with the applicable require-
ment under subparagraph (B)), not later than 90 days 
after the date of such finding, Puerto Rico shall submit 
to the Secretary for approval a corrective action plan to 
remedy such noncompliance. 
‘‘(iii) If, by not later than a period specified by the 
Secretary after the date of the submission (and approval) 
of a corrective action plan under clause (ii), with respect 
to a fiscal year after fiscal year 2024 for which a finding 
of non-compliance was made under clause (i), the Sec-
retary determines that Puerto Rico has not fulfilled the 
terms of such corrective action plan, the PR specified per-
cent specified under paragraph (1) for the fiscal year in-
volved shall be reduced by 5 percent for the period begin-
ning with the month beginning after such determination 
and ending with the first month beginning after the Sec-
retary determines Puerto Rico has fulfilled the terms of 
the corrective action plan.’’. 
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(b) TREATMENT OF CAP.—Section 1108(g) of the 
Social Security Act (42 U.S.C. 1308(g)) is amended— 
(1) in paragraph (2)— 
(A) in the matter preceding subparagraph 
(A), by striking ‘‘subject to and section 
1323(a)(2) of the Patient Protection and Af-
fordable Care Act paragraphs (3) and (5)’’ and 
inserting ‘‘subject to section 1323(a)(2) of the 
Patient Protection and Affordable Care Act and 
paragraphs (3), (5), and (7)’’; and 
(B) in subparagraph (A)— 
(i) by striking ‘‘Puerto Rico shall not 
exceed the sum of’’ and inserting ‘‘Puerto 
Rico shall not exceed— 
‘‘(i) in the case of a fiscal year before 
fiscal year 2020, the sum of’’; 
(ii) by striking ‘‘$100,000;’’ and in-
serting ‘‘$100,000; and’’; and 
(iii) by adding at the end the fol-
lowing new clause: 
‘‘(ii) in the case of fiscal year 2020 
and each subsequent fiscal year (before fis-
cal year 2025), the amount specified in 
paragraph (6) for such fiscal year;’’; and 
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