Title: Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2019
Policy area: Health

Summary:
Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2019
This bill alters certain funding and payment mechanisms, and establishes several requirements, for Puerto Rico's Medicaid program.
Among other changes, the bill increases the Federal Medical Assistance Percentage (FMAP) from 55% to 83% through FY2029; beginning in FY2030, the FMAP must be calculated in the same manner as for states (i.e., based on per capita income). Puerto Rico must also expand its Medicaid program to include certain items, services, and populations that states are already required to cover; failure to do so results in a reduction of the applicable FMAP. Additionally, beginning in FY2025, the bill excludes Puerto Rico from a Medicaid funding cap that currently applies to U.S. territories.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3371 Introduced in House (IH)]

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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. Velazquez (for herself, Mr. Soto, Mr. Serrano, Mr. Grijalva, Mr. 
    Espaillat, Ms. Ocasio-Cortez, Mr. Garcia of Illinois, and Miss 
Gonzalez-Colon 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 Representatives 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''.

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 Virgin 
                Islands'' and inserting ``for the Virgin Islands''; and
                    (B) by striking ``and American Samoa shall be 55 
                percent,'' and inserting ``and America Samoa (and, for 
                calendar quarters in a fiscal 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 subsection:
    ``(ff)(1) For purposes of subsection (b), the PR specified 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
            ``(C) subject to paragraph (3)(D)(iii), for fiscal year 
        2030 and each subsequent fiscal year, the Federal medical 
        assistance percentage calculated in accordance with the first 
        sentence of subsection (b), as such sentence applies to the 50 
        States.
    ``(2)(A) If Puerto Rico--
            ``(i) for fiscal year 2021, is in compliance with none of 
        the program enhancement requirements described in subparagraph 
        (B), the PR specified percent specified under paragraph (1) for 
        such fiscal year shall be reduced by 2 percent;
            ``(ii) for fiscal year 2022, is in compliance with fewer 
        than two of the four program enhancement requirements described 
        in subparagraph (B), the PR specified percent specified under 
        paragraph (1) for such fiscal year shall be reduced by 3 
        percent;
            ``(iii) for fiscal year 2023, is in compliance with fewer 
        than three of the four program enhancement requirements 
        described in subparagraph (B), the PR specified percent 
        specified under paragraph (1) for such fiscal year shall be 
        reduced by 5 percent; and
            ``(iv) for fiscal year 2024, is in compliance with fewer 
        than four of the program enhancement requirements described in 
        subparagraph (B), the PR 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 assistance for 
        Hepatitis C drugs, in accordance with the requirements of 
        section 1927 otherwise applicable to the 50 States.
            ``(iv) The State plan provides for medical assistance for 
        Medicare cost-sharing described in subsection (p)(3)(A)(ii) for 
        qualified Medicare beneficiaries described in subsection 
        (p)(1), in accordance with the requirements under subsection 
        (p) otherwise applicable to the 50 States.
    ``(3)(A)(i) Not later than January 1, 2022, the Governor of Puerto 
Rico shall submit to the Secretary a Territory Transition Plan, which 
shall be developed with stakeholder input and with a public comment 
period, that includes--
                    ``(I) a detailed description of which program 
                enhancements described in subparagraph (C) Puerto Rico 
                will include as medical assistance under the State plan 
                under title XIX, the first plan year by which each such 
                program enhancement will be so included in order to 
                satisfy the requirements described in subparagraph (B), 
                and a timeline for milestones for including such 
                program enhancements; and
                    ``(II) a description of any challenges, including 
                infrastructure challenges, provider shortages, and 
                financing challenges, for so including 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 reason for such disapproval. In the case of such a disapproval, the 
Governor of Puerto Rico shall, within the 90-day period following such 
notification, submit to the Secretary a Territory Transition Plan that 
addresses the reason specified in such notification for such 
disapproval. Such resubmitted plan shall be treated as approved by the 
Secretary under this clause unless the Secretary notifies Puerto Rico 
within the 30-day period following such submission of its disapproval 
with a reason for such disapproval. 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 incorporated 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 requirements 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 described 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.
            ``(iv) For 2033 and each subsequent year, the State plan 
        includes all of such program enhancements.
    ``(C) For purposes of this paragraph, the program enhancements 
described in this subparagraph are the following:
            ``(i) The State plan provides for medical assistance to all 
        individuals described in clause (i) of section 1902(a)(10)(A)).
            ``(ii) The State plan provides for inclusion as medical 
        assistance of home health services, in accordance 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.
            ``(vi) The State plan provides for inclusion as medical 
        assistance of nursing facility services, as defined 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 services and other 
        ambulatory services, as described in subsection (a)(28).
    ``(D)(i) For fiscal year 2022 and each subsequent fiscal 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 
        subparagraph (A) and, beginning with fiscal year 2027, whether 
        Puerto Rico is in compliance with the applicable 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 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 
requirement 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 Secretary determines that Puerto Rico has not fulfilled the terms 
of such corrective action plan, the PR specified percent specified 
under paragraph (1) for the fiscal year involved shall be reduced by 5 
percent for the period beginning with the month beginning after such 
determination and ending with the first month beginning after the 
Secretary determines Puerto Rico has fulfilled the terms of the 
corrective action plan.''.
    (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 Affordable 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 
                        inserting ``$100,000; and''; and
                            (iii) by adding at the end the following 
                        new clause:
                            ``(ii) in the case of fiscal year 2020 and 
                        each subsequent fiscal year (before fiscal year 
                        2025), the amount specified in paragraph (6) 
                        for such fiscal year;''; and
            (2) by adding at the end the following new paragraphs:
            ``(6) Application to puerto rico for fiscal years 2020 
        through 2024.--For purposes of paragraph (2)(A)(ii), the amount 
        specified in this paragraph is--
                    ``(A) for fiscal year 2020, $2,823,188,000;
                    ``(B) for fiscal year 2021, $2,919,072,000;
                    ``(C) for fiscal year 2022, $3,012,610,000;
                    ``(D) for fiscal year 2023, $3,114,331,000; and
                    ``(E) for fiscal year 2024, $3,225,627,000.
            ``(7) Puerto rico exclusion from payment limitation 
        beginning fiscal year 2025.--Beginning with fiscal year 2025, 
        there shall be no limitation applied under this subsection (f) 
        or this subsection on the total amount certified by the 
        Secretary under title XIX for payment to Puerto Rico.''.
    (c) Temporary Increase in Federal Match for State Plan 
Administrative Costs.--Section 1903(a)(7) of the Social Security Act 
(42 U.S.C. 1396b(a)(7)) is amended by inserting ``(or, in the case of 
Puerto Rico for each of fiscal years 2020 through 2033, 100 percent)'' 
after ``50 per centum''.
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