Territories Health Equity Act of 2021
Bill: H.R.3434 | Sponsor: Del. Plaskett, Stacey E. (D-VI)
Policy area: Health

Summary:
Territories Health Equity Act of 2021
This bill alters provisions relating to the treatment of U.S. territories under Medicaid, Medicare, and Medicare Advantage.
For example, the bill
The bill also allows residents of U.S. territories who are unable to obtain health insurance through their employer or a health insurance exchange to instead obtain coverage that is at least as broad as the coverage available to Members of Congress and their staff through the District of Columbia exchange.

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 programs, and for other purposes.

    Be it enacted by the Senate and House of Representatives 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 2021''.
    (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 territories.
Sec. 102. Elimination of specific Federal medical assistance percentage 
                            (FMAP) limitation for territories.
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 program; 
                            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 available Exchange plans.

                           TITLE I--MEDICAID

SEC. 101. ELIMINATION OF GENERAL MEDICAID FUNDING LIMITATIONS (``CAP'') 
              FOR TERRITORIES.

    (a) In General.--Section 1108 of the Social Security Act (42 U.S.C. 
1308) is amended--
            (1) in subsection (f), in the matter preceding paragraph 
        (1), by striking ``subsections (g) and (h)'' and inserting 
        ``subsections (g), (h), and (i)'';
            (2) in subsection (g)(2), in the matter preceding 
        subparagraph (A), by inserting ``subsection (i) and'' after 
        ``subject to''; and
            (3) by adding at the end the following new subsection:
    ``(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.--
            (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 paragraph (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) LIMITATION FOR TERRITORIES.

    Section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is 
amended, in clause (2), by inserting ``for fiscal years before fiscal 
year 2022'' after ``American Samoa''.

SEC. 103. 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 2022.--For fiscal year 
                        2022, the DSH allotment for Puerto Rico, the 
                        Virgin Islands, Guam, the Northern Mariana 
                        Islands, and American Samoa shall bear the same 
                        ratio to $300,000,000 as the ratio of the 
                        number of individuals who are low-income or 
                        uninsured and residing in such respective 
                        territory (as estimated 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 paragraph (3).''; and
            (2) in paragraph (9), by inserting before the period at the 
        end the following: ``, and includes, beginning with fiscal year 
        2022, 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), 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, 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 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 
                                        supplementary security income 
                                        benefits (excluding any State 
                                        supplementation) under title 
                                        XVI;
                                            ``(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.''.

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 beginning 
                on or after October 1, 2021, 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 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 period 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 2015 (or, at the option of the 
                        hospital, beginning during fiscal year 2017);
                            ``(II) any reference in subparagraph (A)(i) 
                        to the `first such cost reporting period' is 
                        deemed a reference to the first cost reporting 
                        period following the 12-month cost reporting 
                        period beginning during fiscal year 2015 (or, 
                        at the option of the hospital, beginning during 
                        fiscal year 2017); 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 request by a hospital for a new target amount for 
                any cost reporting period beginning during a fiscal 
                year after fiscal year 2021.''.

SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOSPITALS IN TERRITORIES.

    Section 1886(b)(3) of the Social Security Act (42 U.S.C. 
1395ww(b)(3)), as amended by section 202, is further amended by adding 
at the end the following new subparagraph:
                    ``(N)(i) For each cost reporting period beginning 
                on or after October 1, 2021, 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 
                        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 disproportionate 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 
                subsection 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.''.

                           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 Security 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 becomes 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 2021'' before the period at the end of 
such sentence.
    (b) Application.--The amendment made by subsection (a) shall apply 
with respect to premiums paid for months beginning on or after the date 
of the enactment of this Act.

                Subtitle C--Medicare Advantage (Part C)

SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW-BASE PAYMENT COUNTIES IN 
              PUERTO RICO.

    Section 1853(n) of the Social Security Act (42 U.S.C. 1395w-23(n)) 
is amended--
            (1) in paragraph (1), by striking ``and (5)'' and inserting 
        ``(5), and (6)'';
            (2) in paragraph (4), by striking ``In no case'' and 
        inserting ``Subject to paragraph (6), in no case''; and
            (3) by adding at the end the following new paragraph:
            ``(6) Special rules for blended benchmark amount for 
        territories.--
                    ``(A) In general.--Subject to paragraph (2), the 
                blended benchmark amount for an area in a territory for 
                a year (beginning with 2022) shall not be less than 80 
                percent of the national average of the base payment 
                amounts specified in subparagraph (2)(E) for such year 
                for areas within the 50 States and the District of 
                Columbia.
                    ``(B) Limitation.--In no case shall the blended 
                benchmark amount for an area in a territory for a year 
                under subparagraph (A) exceed the lowest blended 
                benchmark amount for any area within the 50 States and 
                the District of Columbia for such year.''.

                           Subtitle D--Part D

SEC. 231. AUTOMATIC ELIGIBILITY OF CERTAIN LOW-INCOME TERRITORIAL 
              RESIDENTS FOR PREMIUM AND COST-SHARING SUBSIDIES UNDER 
              THE MEDICARE PROGRAM; SUNSET OF ENHANCED ALLOTMENT 
              PROGRAM.

    (a) Automatic Eligibility of Certain Low-Income Territorial 
Residents for Premium and Cost-Sharing Subsidies Under the Medicare 
Program.--
            (1) In general.--Section 1860D-14(a)(3) of the Social 
        Security Act (42 U.S.C. 1395w-114(a)(3)) is amended--
                    (A) in subparagraph (B)(v)--
                            (i) in subclause (I), by striking ``and'' 
                        at the end;
                            (ii) in subclause (II), by striking the 
                        period and inserting ``; and''; and
                            (iii) by inserting after subclause (II) the 
                        following new subclause:
                                    ``(III) with respect to plan years 
                                beginning on or after January 1, 2022, 
                                shall provide that any part D eligible 
                                individual who is enrolled for medical 
                                assistance under the State Medicaid 
                                plan of a territory (as defined in 
                                section 1935(f)) under title XIX (or a 
                                waiver of such a plan) shall be treated 
                                as a subsidy eligible individual 
                                described in paragraph (1).''; and
                    (B) in subparagraph (F), by adding at the end the 
                following new sentence: ``The previous sentence shall 
                not apply with respect to eligibility determinations 
                for premium and cost-sharing subsidies under this 
                section made on or after January 1, 2022.''.
            (2) Conforming amendment.--Section 1860D-31(j)(2)(D) of the 
        Social Security Act (42 U.S.C. 1395w-141(j)(2)(D)) is amended 
        by adding at the end the following new sentence: ``The previous 
        sentence shall not apply with respect to amounts made available 
        to a State under this paragraph on or after January 1, 2022.''.
    (b) Sunset of Enhanced Allotment Program.--
            (1) In general.--Section 1935(e) of the Social Security Act 
        (42 U.S.C. 1396u-5(e)) is amended--
                    (A) in paragraph (1)(A), by inserting after ``such 
                State'' the following: ``before January 1, 2022''; and
                    (B) in paragraph (3)--
                            (i) in subparagraph (A), in the matter 
                        preceding clause (i), by inserting after ``a 
                        year'' the following: ``(before 2022)''; and
                            (ii) in subparagraph (B)(iii), by striking 
                        ``a subsequent year'' and inserting ``each of 
                        fiscal years 2008 through 2021''.
            (2) Territory defined.--Section 1935 of the Social Security 
        Act (42 U.S.C. 1396u-5) is amended by adding at the end the 
        following new subsection:
    ``(f) Territory Defined.--In this section, the term `territory' 
means Puerto Rico, the Virgin Islands, Guam, the Northern Mariana 
Islands, and American Samoa.''.

                        TITLE III--MISCELLANEOUS

SEC. 301. MEDICAID AND CHIP TERRITORY TRANSPARENCY AND INFORMATION.

    (a) Publication of Information on Federal Expenditures Under 
Medicaid and CHIP in the Territories.--Not later than 180 days after 
the date of the enactment of this Act, the Secretary of Health and 
Human Services shall publish, and periodically update, on the internet 
site of the Centers for Medicare & Medicaid Services information on 
Medicaid and CHIP carried out in the territories of the United States. 
Such information shall include, with respect to each such territory--
            (1) the income levels established by the territory for 
        purposes of eligibility of an individual to receive medical 
        assistance under Medicaid or child health assistance under 
        CHIP;
            (2) the number of individuals enrolled in Medicaid and CHIP 
        in such territory;
            (3) any State plan amendments in effect to carry out 
        Medicaid or CHIP in such territory;
            (4) any waiver of the requirements of title XIX or title 
        XXI issued by the Secretary to carry out Medicaid or CHIP in 
        the territory, including a waiver under section 1115 of the 
        Social Security Act (42 U.S.C. 1315), any application for such 
        a waiver, and any documentation related to such application 
        (including correspondence);
            (5) the amount of the Federal and non-Federal share of 
        expenditures under Medicaid and CHIP in such territory;
            (6) the systems in place for the furnishing of health care 
        items and services under Medicaid and CHIP in such territory;
            (7) the design of CHIP in such territory; and
            (8) other information regarding the carrying out of 
        Medicaid and CHIP in the territory that is published on such 
        internet site with respect to carrying out Medicaid and CHIP in 
        each State and the District of Columbia.
    (b) Definitions.--In this section:
            (1) CHIP.--The term ``CHIP'' means the State Children's 
        Health Insurance Program under title XXI of the Social Security 
        Act.
            (2) Medicaid.--The term ``Medicaid'' means the Medicaid 
        program under title XIX of the Social Security Act.
            (3) Territory.--The term ``territory of the United States'' 
        includes Puerto Rico, the Virgin Islands of the United States, 
        Guam, the Northern Mariana Islands, and American Samoa.

SEC. 302. REPORT ON EXCLUSION OF TERRITORIES FROM EXCHANGES.

    (a) In General.--Not later than February 1, 2022, the Secretary of 
Health and Human Services shall submit to Congress a report that 
details the adverse impacts in each territory from the practical 
exclusion of the territories from the provisions of part II of subtitle 
D of title I of the Patient Protection and Affordable Care Act insofar 
as such provisions provide for the establishment of an American Health 
Benefit Exchange or the administration of a federally facilitated 
Exchange in each State and in the District of Columbia for the purpose 
of making health insurance more affordable and accessible for 
individuals and small businesses.
    (b) Information in Report.--The report shall include information on 
the following:
            (1) An estimate of the total number of uninsured and 
        underinsured individuals residing in each territory with 
        respect to health insurance coverage.
            (2) A description of the number of health insurance issuers 
        in each territory and the health insurance plans these issuers 
        offer.
            (3) An estimate of the number of individuals residing in 
        each territory who are denied premium and cost-sharing 
        assistance that would otherwise be available to them for 
        obtaining health insurance coverage through an Exchange if they 
        resided in one of the 50 States or in the District of Columbia.
            (4) An estimate of the amount of Federal assistance 
        described in paragraph (3) that is not being made available to 
        residents of each territory.
            (5) An estimate of the number of small employers in each 
        territory that would be eligible to purchase health insurance 
        coverage through a Small Business Health Options Program (SHOP) 
        Marketplace that would operate as part of an Exchange if the 
        employers were in one of the 50 States or in the District of 
        Columbia.

SEC. 303. ACCESS TO COVERAGE FOR INDIVIDUALS IN CERTAIN AREAS WITHOUT 
              ANY AVAILABLE EXCHANGE PLANS.

    Part 2 of subtitle D of title I of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18031 et seq.) is amended by adding at 
the end the following:

``SEC. 1314. ACCESS TO COVERAGE FOR INDIVIDUALS IN CERTAIN AREAS 
              WITHOUT ANY AVAILABLE EXCHANGE PLANS.

    ``(a) In General.--
            ``(1) Coverage through dc exchange.--Not later than 3 
        months after the date of enactment of this section, the 
        Secretary, in consultation with the Secretary of the Treasury 
        and the Director of the Office of Personnel Management, shall 
        establish a mechanism to ensure that, for any plan year 
        beginning on or after the date described in subsection (c), any 
        individual described in paragraph (2) has access to health 
        insurance coverage which is at least as broad as the coverage 
        available to Members of Congress and congressional staff (as 
        defined in section 1312(d)(3)(D)) through the Exchange 
        operating in the District of Columbia. Such individuals shall 
        be eligible for any premium tax credit under section 36B of the 
        Internal Revenue Code of 1986, reduced cost sharing under 
        section 1402, and advance determination and payment of such 
        credits or such reductions under section 1412 to be 
        administered by the Secretary, in consultation with the 
        Secretary of the Treasury and the Director of the Office of 
        Personnel Management. The District of Columbia, its residents, 
        and small businesses shall be held harmless from any increased 
        costs resulting from the enactment of this section.
            ``(2) Individual described.--An individual described in 
        this paragraph is any individual who--
                    ``(A) is not eligible to enroll in an employer-
                sponsored health plan (excluding such a plan that would 
                not be considered minimum essential coverage due to the 
                application of subparagraph (C) of section 36B(c)(2) of 
                the Internal Revenue Code of 1986 if such subparagraph 
                applied to such plan); and
                    ``(B) is a bona fide resident of any possession of 
                the United States (as determined under section 937(a) 
                of such Code) in which the Secretary certifies that no 
                qualified health plan is offered through an Exchange 
                established under this title.
            ``(3) Possession of the united states.--For purposes of 
        this section, the term `possession of the United States' shall 
        include such possessions as are specified in section 937(a)(1) 
        of the Internal Revenue Code of 1986.
    ``(b) Treatment of Possessions.--
            ``(1) Payments to possessions.--
                    ``(A) Mirror code possession.--The Secretary of the 
                Treasury shall periodically (but not less frequently 
                than annually) pay to each possession of the United 
                States with a mirror code tax system amounts equal to 
                the loss to that possession by reason of the 
                application of this section (determined without regard 
                to paragraph (2)) with respect to taxable years 
                beginning after the date described in subsection (c). 
                Such amounts shall be determined by the Secretary of 
                the Treasury based on information provided by the 
                government of the respective possession.
                    ``(B) Other possessions.--The Secretary of the 
                Treasury shall periodically (but not less frequently 
                than annually) pay to each possession of the United 
                States which does not have a mirror code tax system 
                amounts estimated by the Secretary of the Treasury as 
                being equal to the aggregate benefits that would have 
                been provided to residents of such possession by reason 
                of the application of this section for any taxable 
                years beginning after the date described in subsection 
                (c) if a mirror code tax system had been in effect in 
                such possession. The preceding sentence shall not apply 
                with respect to any possession of the United States 
                unless such possession has a plan, which has been 
                approved by the Secretary of the Treasury, under which 
                such possession will promptly distribute such payments 
                to the residents of such possession.
            ``(2) Coordination with credit allowed against united 
        states income taxes.--No credit shall be allowed against United 
        States income taxes for any taxable year under section 36B of 
        the Internal Revenue Code of 1986 to any person--
                    ``(A) to whom a credit is allowed against taxes 
                imposed by the possession by reason of this section 
                (determined without regard to this paragraph) for such 
                taxable year, or
                    ``(B) who is eligible for a payment under a plan 
                described in paragraph (1)(B) with respect to such 
                taxable year.
            ``(3) Mirror code tax system.--For purposes of this 
        subsection, the term `mirror code tax system' means, with 
        respect to any possession of the United States, the income tax 
        system of such possession if the income tax liability of the 
        residents of such possession under such system is determined by 
        reference to the income tax laws of the United States as if 
        such possession were the United States.
            ``(4) Treatment of payments.--For purposes of section 
        1324(b)(2) of title 31, United States Code, or any similar rule 
        of law, the payments under this subsection shall be treated in 
        the same manner as a refund due from the credit allowed under 
        section 36B of the Internal Revenue Code of 1986.
    ``(c) Date Described.--The date described in this subsection is the 
date on which the Secretary establishes the mechanism described in 
subsection (a)(1).''.
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