Title: Territories Health Equity Act of 2019
Policy area: Health

Summary:
Territories Health Equity Act of 2019
This bill alters provisions under Medicaid, Medicare, and Medicare Advantage relating to U.S. territories, and generally modifies and establishes programs to expand health insurance coverage for residents.
Among other things, the bill

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 1773 Introduced in Senate (IS)]

<DOC>






116th CONGRESS
  1st Session
                                S. 1773

   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.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 11, 2019

Mr. Sanders (for himself, Mr. Merkley, Mrs. Gillibrand, Mr. Blumenthal, 
  Ms. Harris, Mr. Booker, Ms. Warren, and Mr. Markey) introduced the 
 following bill; which was read twice and referred to the Committee on 
                                Finance

_______________________________________________________________________

                                 A BILL


 
   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 2019''.
    (b) Table of Contents.--The table of contents of 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; 
                            temporary increase in FMAP for Puerto Rico 
                            and the Virgin Islands to 100 percent.
Sec. 103. Application of Medicaid waiver authority to all of the 
                            territories.
Sec. 104. 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. Application of part B deemed enrollment process to residents 
                            of Puerto Rico; special enrollment period 
                            and limit on late enrollment penalties.
                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. Improved use of allocated prescription drug funds by 
                            territories.
Sec. 232. Report on treatment of territories under Medicare part D.
                        TITLE III--MISCELLANEOUS

Sec. 301. Modified treatment of territories with respect to application 
                            of ACA annual health insurance provider 
                            fees.
Sec. 302. Medicaid and CHIP territory transparency and information.
Sec. 303. Report on exclusion of territories from Exchanges.
Sec. 304. Access to coverage for individuals in certain areas without 
                            any available Exchange plans.
Sec. 305. Extension of family-to-family health information centers 
                            program to territories.

                           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 ``subsection (g)'' and inserting ``subsections 
        (g) and (h)'';
            (2) in subsection (g)(2), in the matter preceding 
        subparagraph (A), by inserting ``subsection (h)'' after 
        ``subject to''; and
            (3) by adding at the end the following new subsection:
    ``(h) 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 2020.''.
    (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 2020.

SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL ASSISTANCE PERCENTAGE 
              (FMAP) LIMITATION FOR TERRITORIES; TEMPORARY INCREASE IN 
              FMAP FOR PUERTO RICO AND THE VIRGIN ISLANDS TO 100 
              PERCENT.

    Section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is 
amended--
            (1) in clause (2), by inserting ``for fiscal years before 
        fiscal year 2020'' after ``American Samoa''; and
            (2) by adding at the end the following new sentence: 
        ``Notwithstanding the first sentence of this subsection, for 
        each of fiscal years 2020 and 2021, the Federal medical 
        assistance percentage for Puerto Rico and the Virgin Islands 
        shall be 100 percent.''.

SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY TO ALL OF THE 
              TERRITORIES.

    (a) In General.--Section 1902(j) of the Social Security Act (42 
U.S.C. 1396a(j)) is amended--
            (1) by striking ``American Samoa and the Northern Mariana 
        Islands'' and inserting ``Puerto Rico, the Virgin Islands, 
        Guam, the Northern Mariana Islands, and American Samoa'';
            (2) by striking ``American Samoa or the Northern Mariana 
        Islands'' and inserting ``Puerto Rico, the Virgin Islands, 
        Guam, the Northern Mariana Islands, or American Samoa'';
            (3) by inserting ``(1)'' before ``Notwithstanding'';
            (4) by inserting ``except as otherwise provided in this 
        subsection,'' after ``Notwithstanding any other requirement of 
        this title''; and
            (5) by adding at the end the following:
    ``(2) The Secretary may not waive under this subsection--
            ``(A) the requirement of subsection (a)(10)(A)(i)(IX) 
        (relating to coverage of adults formerly under foster care) 
        with respect to any territory;
            ``(B) the requirement to provide medical assistance for 
        early and periodic screening, diagnostic, and treatment 
        services (as defined in section 1905(r)) for individuals who 
        are eligible for assistance under the program and who under the 
        age of 21; or
            ``(C) the requirement to provide for payment for services 
        described in section 1905(a)(2)(C) furnished by a Federally-
        qualified health center and services described in section 
        1905(a)(2)(B) furnished by a rural health clinic in accordance 
        with the provisions of subsection (bb).''.
    (b) Effective Date.--The amendments made by this section shall 
apply beginning October 1, 2019.

SEC. 104. 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 2020.--For fiscal year 
                        2020, 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 
        2020, 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, 2019, 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 of this Act;
                            ``(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, 2019, 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, 2019.
                    ``(iii) Nothing in this subparagraph shall affect 
                any pending request by a hospital for a new target 
                amount for any cost reporting period beginning during a 
                fiscal year before fiscal year 2020.''.

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, 2019, 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. APPLICATION OF PART B DEEMED ENROLLMENT PROCESS TO RESIDENTS 
              OF PUERTO RICO; SPECIAL ENROLLMENT PERIOD AND LIMIT ON 
              LATE ENROLLMENT PENALTIES.

    (a) Application of Part B Deemed Enrollment Process to Residents of 
Puerto Rico.--Section 1837(f)(3) of the Social Security Act (42 U.S.C. 
1395p(f)(3)) is amended by striking ``, exclusive of Puerto Rico''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to individuals whose initial enrollment period under section 
1837(d) of the Social Security Act begins on or after the first day of 
the effective month, specified by the Secretary of Health and Human 
Services under section 1839(j)(1)(C) of such Act, as added by 
subsection (c)(2).
    (c) Transition Providing Special Enrollment Period and Limit on 
Late Enrollment Penalties for Certain Medicare Beneficiaries.--Section 
1839 of the Social Security Act (42 U.S.C. 1395r) is amended--
            (1) in the first sentence of subsection (b), by inserting 
        ``subject to section 1839(j)(2),'' after ``subsection (i)(4) or 
        (l) of section 1837,''; and
            (2) by adding at the end the following new subsection:
    ``(j) Special Rules for Certain Residents of Puerto Rico.--
            ``(1) Special enrollment period, coverage period for 
        residents who are eligible but not enrolled.--
                    ``(A) In general.--In the case of a transition 
                individual (as defined in paragraph (3)) who is not 
                enrolled under this part as of the day before the first 
                day of the effective month (as defined in subparagraph 
                (C)), the Secretary shall provide for a special 
                enrollment period under section 1837 of 7 months 
                beginning with such effective month during which the 
                individual may be enrolled under this part.
                    ``(B) Coverage period.--In the case of such an 
                individual who enrolls during such special enrollment 
                period, the coverage period under section 1838 shall 
                begin on the first day of the second month after the 
                month in which the individual enrolls.
                    ``(C) Effective month defined.--In this section, 
                the term `effective month' means a month, not earlier 
                than October 2020 and not later than January 2021, 
                specified by the Secretary.
            ``(2) Reduction in late enrollment penalties for current 
        enrollees and individuals enrolling during transition.--
                    ``(A) In general.--In the case of a transition 
                individual who is enrolled under this part as of the 
                day before the first day of the effective month or who 
                enrolls under this part on or after the date of the 
                enactment of this subsection but before the end of the 
                special enrollment period under paragraph (1)(A), the 
                amount of the late enrollment penalty imposed under 
                section 1839(b) shall be recalculated by reducing the 
                penalty to 15 percent of the penalty otherwise 
                established.
                    ``(B) Application.--Subparagraph (A) shall be 
                applied in the case of a transition individual who--
                            ``(i) is enrolled under this part as of the 
                        month before the effective month, for premiums 
                        for months beginning with such effective month; 
                        or
                            ``(ii) enrolls under this part on or after 
                        the date of the enactment of this Act and 
                        before the end of the special enrollment period 
                        under paragraph (1)(A), for premiums for months 
                        during the coverage period under this part 
                        which occur during or after the effective 
                        month.
                    ``(C) Loss of reduction if individual terminates 
                enrollment.--Subparagraph (A) shall not apply to a 
                transition individual if the individual terminates 
                enrollment under this part after the end of the special 
                enrollment period under paragraph (1).
            ``(3) Transition individual defined.--In this section, the 
        term `transition individual' means an individual who resides in 
        Puerto Rico and who would have been deemed enrolled under this 
        part pursuant to section 1837(f) before the first day of the 
        effective month but for the fact that the individual was a 
        resident of Puerto Rico, regardless of whether the individual 
        is enrolled under this part as of such first day.''.

                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 subparagraph (B), the 
                blended benchmark amount for an area in a territory for 
                a year (beginning with 2020) 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. IMPROVED USE OF ALLOCATED PRESCRIPTION DRUG FUNDS BY 
              TERRITORIES.

    Section 1935(e) of the Social Security Act (42 U.S.C. 1396u-5(e)) 
is amended by adding at the end the following new paragraph:
            ``(5) Improved use of funds for low-income part d eligible 
        individuals.--This subsection shall be applied beginning with 
        fiscal year 2020 as follows, notwithstanding any other 
        provision of this title:
                    ``(A) Clarifying state flexibility to cover non-
                dual-eligible individuals.--In this title, the term 
                `medical assistance' includes financial assistance 
                furnished by a State under this subsection to part D 
                eligible individuals who, if they were residing in one 
                of the 50 States or the District of Columbia, would 
                qualify as subsidy eligible individuals under section 
                1860D-14(a)(3), and without regard to whether such 
                individuals otherwise qualify for medical assistance 
                under this title.
                    ``(B) 100 percent fmap to reflect no state matching 
                required for part d low income subsidies.--The Federal 
                medical assistance percentage applicable to the 
                assistance furnished under this subsection is 100 
                percent.
                    ``(C) Limited funding for special rules.--
                Subparagraphs (A) and (B), and the provision of medical 
                assistance for covered part D drugs to low-income part 
                D eligible individuals for a State and period under 
                this subsection, is limited to the amount specified in 
                paragraph (3) for such State and period.''.

SEC. 232. REPORT ON TREATMENT OF TERRITORIES UNDER MEDICARE PART D.

    Paragraph (4) of section 1935(e) of the Social Security Act (42 
U.S.C. 1396u-5(e)) is amended to read as follows:
            ``(4) Report on application of subsection.--
                    ``(A) In general.--Not later than February 1, 2021, 
                the Secretary shall submit to Congress a report on the 
                application of this subsection during the period 
                beginning fiscal year 2006 and ending fiscal year 2020.
                    ``(B) Information to be included in report.--Such 
                report shall include--
                            ``(i) program guidance issued by the 
                        Secretary to implement this subsection;
                            ``(ii) for each territory, information on 
                        the increased amount under paragraph (3) and 
                        how the territory has applied such amount, 
                        including the territory's program design, 
                        expenditures, and number of individuals (and 
                        dual-eligible individuals) assisted; and
                            ``(iii) differences between how such 
                        territories are treated under part D of title 
                        XVIII and under this title compared with the 
                        treatment of the 50 States and the District of 
                        Columbia under such part and this title for 
                        different fiscal years within the period 
                        covered under the report.
                    ``(C) Recommendations.--Such report shall include 
                recommendations for improving prescription drug 
                coverage for low-income individuals in each territory, 
                including recommendations regarding each of the 
                following alternative approaches:
                            ``(i) Adjusting the aggregate amount 
                        specified in paragraph (3)(B).
                            ``(ii) Allowing residents of the 
                        territories to be subsidy eligible individuals 
                        under section 1860D-14, notwithstanding 
                        subsection (a)(3)(F) of such section, or 
                        providing substantially equivalent low-income 
                        prescription drug subsidies to such 
                        residents.''.

                        TITLE III--MISCELLANEOUS

SEC. 301. MODIFIED TREATMENT OF TERRITORIES WITH RESPECT TO APPLICATION 
              OF ACA ANNUAL HEALTH INSURANCE PROVIDER FEES.

    Section 9010 of the Patient Protection and Affordable Care Act (26 
U.S.C. 4001 note prec.) is amended--
            (1) in subsection (b)(1), by inserting ``subject to 
        subsection (k)(1),'' after ``With respect to each covered 
        entity,''; and
            (2) by adding at the end the following:
    ``(k) Special Rules for Treatment of Territories.--
            ``(1) In general.--In applying this section with respect to 
        United States health risks located outside of the 50 States or 
        the District of Columbia for years beginning with 2020--
                    ``(A) the amount of the fee under subsection (b) 
                shall be 50 percent of the amount of the fee otherwise 
                determined;
                    ``(B) the Secretary shall deposit the amount of 
                such fees collected for each territory into a separate 
                account; and
                    ``(C) amounts in such an account for a territory 
                for a year are appropriated and shall be available to 
                the territory in accordance with paragraph (2).
            ``(2) Availability of funds.--Amounts made available to a 
        territory under paragraph (1)(C) with respect to a territory 
        for a year shall be made available to the territory, upon 
        application of the territory to the Secretary of Health and 
        Human Services, only for the following purposes, as elected by 
        the territory in such application:
                    ``(A) Increased prescription drug assistance for 
                low-income part d eligible individuals.--For increasing 
                the amount of funds made available to the territory 
                under section 1935(e)(3) of the Social Security Act (42 
                U.S.C. 1396u-5(e)(3)) for assistance for low-income 
                part D eligible individuals in obtaining part D covered 
                drugs.
                    ``(B) Satisfying state medicaid matching 
                requirement.--For the territory to meet non-Federal 
                matching requirements imposed with respect to obtaining 
                Federal financial participation under title XIX of the 
                Social Security Act.''.

SEC. 302. 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. 303. REPORT ON EXCLUSION OF TERRITORIES FROM EXCHANGES.

    (a) In General.--Not later than February 1, 2020, 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 or III 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 individuals residing 
        in each territory with health insurance coverage, and the total 
        number of individuals in each territory without health 
        insurance coverage.
            (2) The number of health insurance issuers in each 
        territory and the health insurance coverage each such issuer 
        offers.
            (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. 304. 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).''.

SEC. 305. EXTENSION OF FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS 
              PROGRAM TO TERRITORIES.

    Section 501(c)(3)(C) of the Social Security Act (42 U.S.C. 701(c)) 
is amended by striking ``years 2018 and 2019'' and inserting ``year 
2018 and each fiscal year thereafter''.
                                 <all>