Federal

Territories Health Equity Act of 2023

Source: Congress.gov · 5,010 words in original text

What This Bill Does

This bill makes changes to Medicare and Medicaid programs to improve how they treat five U.S. territories: Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. The bill removes certain funding limits on these territories, increases hospital payments, and helps low-income residents get health insurance subsidies. ##

Who It Affects

- Residents of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa - Hospitals in these territories - Low-income individuals in these territories receiving Medicare or Medicaid - The U.S. Department of Health and Human Services ##

Key Provisions

- The federal government will stop limiting Medicaid funding for these five territories starting in fiscal year 2024 (Sec. 101) - Hospitals in these territories can now receive Disproportionate Share Hospital payments, which are extra funds for hospitals serving many low-income patients (Sec. 103) - Starting October 1, 2023, hospital payment calculations for Puerto Rico will change to count more low-income patients (Sec. 201) - Starting in 2024, low-income residents of these territories who are enrolled in Medicaid will automatically be eligible for Medicare drug plan subsidies (Sec. 231) - The federal government must publish information online about Medicaid and CHIP (Children's Health Insurance Program) in these territories within 180 days of the law taking effect (Sec. 301) - The Secretary of Health and Human Services must report to Congress by February 1, 2024 about how these territories are excluded from health insurance exchanges (Sec. 302) ##

What Changes

**Medicaid Funding:** Starting in fiscal year 2024, these five territories no longer face caps on how much federal Medicaid money they can receive. **Medicare Payments to Hospitals:** Beginning October 1, 2023, hospitals in Puerto Rico will calculate their payments differently to count more patients who are low-income or receiving government assistance. Hospitals in other territories will get payment increases between 10 and 16 percent depending on how many low-income patients they serve. **Hospital Payment Bases:** Starting October 1, 2023, hospitals in these territories can use older cost data (from fiscal year 2015 or earlier) to calculate their baseline payments if that results in higher payments. **Late Enrollment Penalties:** Certain people moving to or living in Puerto Rico will not face Medicare Part B late enrollment penalties if they became eligible for Medicare while living in Puerto Rico. **Benchmark Amounts for Medicare Advantage Plans:** Starting in 2024, the payment amounts for Medicare Advantage plans in these territories cannot be less than 80 percent of the national average payment for the 50 states and Washington, D.C. **Drug Plan Subsidies:** Starting January 1, 2024, people in these territories who are enrolled in their territory's Medicaid program will automatically be considered eligible for help paying Medicare drug plan premiums and costs. **Public Information:** The government will now publish details online about how Medicaid and CHIP work in each territory, including income limits, enrollment numbers, federal spending, and any special approval documents. **Insurance Options:** The bill creates a process allowing territorial residents to buy health insurance through Washington, D.C.'s exchange system if no insurance plans are available in their territory. ##

Important Definitions

- **Territory:** Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa (Sec. 231(b)(2) and others) - **Medicaid:** The health insurance program for low-income individuals under title XIX of the Social Security Act (Sec. 301(b)(2)) - **CHIP:** The State Children's Health Insurance Program under title XXI of the Social Security Act (Sec. 301(b)(1)) - **Disproportionate Share Hospital (DSH) payments:** Extra Medicare and Medicaid payments for hospitals serving large numbers of low-income or uninsured patients (Sec. 103) - **Possession of the United States:** Includes Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa (Sec. 303) - **Mirror code tax system:** A territory's income tax system that bases tax on U.S. income tax laws (Sec. 303) - **Disproportionate patient percentage:** The share of a hospital's patients who are low-income or receiving government assistance (Sec. 203) ##

Effective Date

Most changes take effect starting in fiscal year 2024, which begins October 1, 2023 (Sec. 101(c), Sec. 201, Sec. 202). Some provisions take effect January 1, 2024 (Sec. 231). The requirement to publish Medicaid and CHIP information must be completed within 180 days of the bill becoming law (Sec. 301). The Secretary must submit a report to Congress by February 1, 2024 (Sec. 302).

I 118TH CONGRESS 1ST SESSION H. R. 1029 To amend titles XVIII and XIX of the Social Security Act to make improve- ments to the treatment of the United States territories under the Medi- care and Medicaid programs, and for other purposes. IN THE HOUSE OF REPRESENTATIVES FEBRUARY 14, 2023 Ms. PLASKETT (for herself, Mrs. GONZA´LEZ-COLO´N, Mr. MOYLAN, Mrs. RADEWAGEN, Mr. SABLAN, Ms. CLARKE of New York, Mr. GRIJALVA, Ms. PRESSLEY, Mr. SOTO, Mr. TORRES of New York, and Ms. VELA´ZQUEZ) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 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 pro- grams, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Territories Health Equity Act of 2023’’. 5 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 1029 IH (b) TABLE OF CONTENTS.—The table of contents for 1 this Act is as follows: 2 Sec. 1. Short title; table of contents. TITLE I—MEDICAID Sec. 101. Elimination of general Medicaid funding limitations (‘‘CAP’’) for ter- ritories. Sec. 102. Elimination of specific Federal medical assistance percentage (FMAP) limitation for Puerto Rico. 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 pro- gram; 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 avail- able exchange plans. TITLE I—MEDICAID 3 SEC. 101. ELIMINATION OF GENERAL MEDICAID FUNDING 4 LIMITATIONS (‘‘CAP’’) FOR TERRITORIES. 5 (a) IN GENERAL.—Section 1108 of the Social Secu- 6 rity Act (42 U.S.C. 1308) is amended— 7 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 1029 IH (1) in subsection (f), in the matter preceding 1 paragraph (1), by striking ‘‘subsections (g) and (h)’’ 2 and inserting ‘‘subsections (g), (h), and (j)’’; 3 (2) in subsection (g)(2), in the matter pre- 4 ceding subparagraph (A), by inserting ‘‘subsection 5 (j) and’’ after ‘‘subject to’’; 6 (3) in subsection (i), by striking paragraph (4); 7 and 8 (4) by adding at the end the following new sub- 9 section: 10 ‘‘(j) SUNSET OF MEDICAID FUNDING LIMITATIONS 11 FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE 12 NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 13 Subsections (f) and (g) shall not apply to Puerto Rico, 14 the Virgin Islands, Guam, the Northern Mariana Islands, 15 and American Samoa beginning with fiscal year 2024.’’. 16 (b) CONFORMING AMENDMENTS.— 17 (1) Section 1902(j) of the Social Security Act 18 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 19 limitation in section 1108(f),,’’. 20 (2) Section 1903(u) of the Social Security Act 21 (42 U.S.C. 1396b(u)) is amended by striking para- 22 graph (4). 23 (c) EFFECTIVE DATE.—The amendments made by 24 this section shall apply beginning with fiscal year 2024. 25 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 1029 IH SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 1 ASSISTANCE PERCENTAGE (FMAP) LIMITA- 2 TION FOR PUERTO RICO. 3 Section 1905 of the Social Security Act (42 U.S.C. 4 1396d) is amended— 5 (1) in subsection (b)(2), by inserting ‘‘for fiscal 6 years before fiscal year 2024’’ after ‘‘American 7 Samoa’’; and 8 (2) in subsection (ff)(2), by striking ‘‘2027’’ 9 and inserting ‘‘2023’’. 10 SEC. 103. PERMITTING MEDICAID DSH ALLOTMENTS FOR 11 TERRITORIES. 12 Section 1923(f) of the Social Security Act (42 U.S.C. 13 1396r–4(f)) is amended— 14 (1) in paragraph (6), by adding at the end the 15 following new subparagraph: 16 ‘‘(C) TERRITORIES.— 17 ‘‘(i) FISCAL YEAR 2024.—For fiscal 18 year 2024, the DSH allotment for Puerto 19 Rico, the Virgin Islands, Guam, the North- 20 ern Mariana Islands, and American Samoa 21 shall bear the same ratio to $300,000,000 22 as the ratio of the number of individuals 23 who are low-income or uninsured and re- 24 siding in such respective territory (as esti- 25 mated from time to time by the Secretary) 26 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 1029 IH bears to the sums of the number of such 1 individuals residing in all of the territories. 2 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 3 For each subsequent fiscal year, the DSH 4 allotment for each such territory is subject 5 to an increase in accordance with para- 6 graph (3).’’; and 7 (2) in paragraph (9), by inserting before the pe- 8 riod at the end the following: ‘‘, and includes, begin- 9 ning with fiscal year 2024, Puerto Rico, the Virgin 10 Islands, Guam, the Northern Mariana Islands, and 11 American Samoa’’. 12 TITLE II—MEDICARE 13 Subtitle A—Part A 14 SEC. 201. CALCULATION OF MEDICARE DSH PAYMENTS FOR 15 IPPS HOSPITALS IN PUERTO RICO. 16 Section 1886(d)(9)(D)(iii) of the Social Security Act 17 (42 U.S.C. 1395ww(d)(9)(D)(iii)) is amended to read as 18 follows: 19 ‘‘(iii) Subparagraph (F) (relating to 20 disproportionate share payments), includ- 21 ing application of subsection (r), except 22 that for this purpose— 23 ‘‘(I) the sum described in clause 24 (ii) of this subparagraph shall be sub- 25 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 1029 IH stituted for the sum referred to in 1 paragraph (5)(F)(ii)(I); and 2 ‘‘(II) for discharges occurring on 3 or after October 1, 2023, subclause 4 (I) of paragraph (5)(F)(vi) shall be 5 applied by substituting for the numer- 6 ator described in such subclause the 7 number of subsection (d) Puerto Rico 8 hospital’s patient days for the cost re- 9 porting period involved which were 10 made up of patients who (for such 11 days) were entitled to benefits under 12 part A of this title and were— 13 ‘‘(aa) entitled to supple- 14 mentary security income benefits 15 (excluding any State supplemen- 16 tation) under title XVI; 17 ‘‘(bb) eligible for medical as- 18 sistance under a State plan 19 under title XIX; or 20 ‘‘(cc) receiving aid or assist- 21 ance under any plan of the State 22 approved under title I, X, XIV, 23 or XVI.’’. 24 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 1029 IH SEC. 202. REBASING TARGET AMOUNT FOR HOSPITALS IN 1 TERRITORIES. 2 Section 1886(b)(3) of the Social Security Act (42 3 U.S.C. 1395ww(b)(3)) is amended by adding at the end 4 the following new subparagraph: 5 ‘‘(M)(i) For each cost reporting period be- 6 ginning on or after October 1, 2023, in the case 7 of a hospital located in a territory of the United 8 States, there shall be substituted for the target 9 amount otherwise determined under subpara- 10 graph (A) the rebased target amount (as de- 11 fined in clause (ii)), if such substitution results 12 in an amount of payment under this section to 13 the hospital for such period that is greater than 14 the amount of payment that would be made 15 under this section to the hospital for such pe- 16 riod if this subparagraph were not to apply. 17 ‘‘(ii) For purposes of this subparagraph, 18 the term ‘rebased target amount’ has the mean- 19 ing given the term ‘target amount’ in subpara- 20 graph (A), except that— 21 ‘‘(I) for a cost reporting period begin- 22 ning on or after October 1, 2023, and be- 23 fore September 30, 2028, there shall be 24 substituted for the preceding 12-month 25 cost reporting period the 12-month cost re- 26 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 8 •HR 1029 IH porting period beginning during fiscal year 1 2015; 2 ‘‘(II) for a cost reporting period be- 3 ginning on or after October 1, 2028, there 4 shall be substituted for the preceding 12- 5 month cost reporting period the cost re- 6 porting period for which the target amount 7 determined under subparagraph (A) is the 8 highest among the 5 cost reporting periods 9 for which the Secretary has the most re- 10 cent settled cost reports; 11 ‘‘(III) any reference in subparagraph 12 (A)(i) to the ‘first such cost reporting pe- 13 riod’ is deemed a reference to the first cost 14 reporting period following the 12-month 15 cost reporting period beginning during fis- 16 cal year 2015; and 17 ‘‘(IV) the applicable percentage in- 18 crease shall only be applied under subpara- 19 graph (B)(ii) for cost reporting periods be- 20 ginning on or after October 1, 2023.’’. 21 SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOS- 22 PITALS IN TERRITORIES. 23 Section 1886(b)(3) of the Social Security Act (42 24 U.S.C. 1395ww(b)(3)), as amended by section 202, is fur- 25 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 9 •HR 1029 IH ther amended by adding at the end the following new sub- 1 paragraph: 2 ‘‘(N)(i) For each cost reporting period be- 3 ginning on or after October 1, 2023, in the case 4 of a hospital that is located in a territory of the 5 United States other than Puerto Rico and that 6 would be a subsection (d) hospital if it were lo- 7 cated in one of the 50 States, the target 8 amount shall be increased by— 9 ‘‘(I) in the case that such hospital has 10 a disproportionate patient percentage of 11 not less than 15 percent and not greater 12 than 40 percent, 10 percent; and 13 ‘‘(II) in the case that such hospital 14 has a disproportionate patient percentage 15 of greater than 40 percent, 10 percent plus 16 60 percent of the number of percentage 17 points by which such hospital’s dispropor- 18 tionate patient percentage exceeds 40 per- 19 cent. 20 ‘‘(ii) For purposes of this subparagraph, 21 the term ‘disproportionate patient percentage’ 22 has the meaning given such term in subsection 23 (d)(5)(F)(vi), except that in applying such 24 meaning any reference under such subsection to 25 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 10 •HR 1029 IH individuals entitled to supplementary security 1 income under title XVI shall be deemed for pur- 2 poses of this subparagraph to include individ- 3 uals— 4 ‘‘(I) eligible for medical assistance 5 under a State plan under title XIX; or 6 ‘‘(II) receiving aid or assistance under 7 any plan of the territory approved under 8 title I, X, XIV, or XVI.’’. 9 Subtitle B—Part B 10 SEC. 211. ELIMINATING LATE ENROLLMENT PENALTIES 11 UNDER PART B OF THE MEDICARE PROGRAM 12 FOR CERTAIN INDIVIDUALS RESIDING IN 13 PUERTO RICO. 14 (a) IN GENERAL.—Section 1839(b) of the Social Se- 15 curity Act (42 U.S.C. 1395r(b)) is amended in the second 16 sentence by inserting ‘‘or months occurring in the 5-year 17 period beginning on the date on which the individual be- 18 comes entitled to benefits under part A if such individual 19 was residing in Puerto Rico as of such date and such date 20 is after the date that is 4 years before the date of the 21 enactment of the Territories Health Equity Act of 2023’’ 22 before the period at the end of such sentence. 23 (b) APPLICATION.—The amendment made by sub- 24 section (a) shall apply with respect to premiums paid for 25 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 11 •HR 1029 IH months beginning on or after the date of the enactment 1 of this Act. 2 Subtitle C—Medicare Advantage 3 (Part C) 4 SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW-BASE 5 PAYMENT COUNTIES IN PUERTO RICO. 6 Section 1853(n) of the Social Security Act (42 U.S.C. 7 1395w–23(n)) is amended— 8 (1) in paragraph (1), by striking ‘‘and (5)’’ and 9 inserting ‘‘(5), and (6)’’; 10 (2) in paragraph (4), by striking ‘‘In no case’’ 11 and inserting ‘‘Subject to paragraph (6), in no 12 case’’; and 13 (3) by adding at the end the following new 14 paragraph: 15 ‘‘(6) SPECIAL RULES FOR BLENDED BENCH- 16 MARK AMOUNT FOR TERRITORIES.— 17 ‘‘(A) IN GENERAL.—Subject to paragraph 18 (2), the blended benchmark amount for an area 19 in a territory for a year (beginning with 2024) 20 shall not be less than 80 percent of the national 21 average of the base payment amounts specified 22 in subparagraph (2)(E) for such year for areas 23 within the 50 States and the District of Colum- 24 bia. 25 VerDate Sep 11 2014 07:20 Mar 07, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H1029.IH H1029 kjohnson on DSK79L0C42PROD with BILLS 12 •HR 1029 IH ‘‘(B) LIMITATION.—In no case shall the 1 blended benchmark amount for an area in a 2 territory for a year under subparagraph (A) ex- 3 ceed the lowest blended benchmark amount for 4 any area within the 50 States and the District 5 of Columbia for such year.’’. 6 Subtitle D—Part D 7 SEC. 231. AUTOMATIC ELIGIBILITY OF CERTAIN LOW-IN- 8 COME TERRITORIAL RESIDENTS FOR PRE- 9 MIUM AND COST-SHARING SUBSIDIES UNDER 10 THE MEDICARE PROGRAM; SUNSET OF EN- 11 HANCED ALLOTMENT PROGRAM. 12 (a) AUTOMATIC ELIGIBILITY OF CERTAIN LOW-IN- 13 COME TERRITORIAL RESIDENTS FOR PREMIUM AND 14 COST-SHARING SUBSIDIES UNDER THE MEDICARE PRO- 15 [Text truncated for display. Full text available on Congress.gov.]

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