Territories Health Equity Act of 2021

I 117TH CONGRESS 1ST SESSION H. R. 3434 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 MAY 20, 2021 Ms. PLASKETT (for herself, Miss GONZA´LEZ-COLO´N, Mrs. RADEWAGEN, Mr. SABLAN, Mr. SAN NICOLAS, 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 2021’’. 5 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 3434 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 terri- tories. 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 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 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 3434 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 (i)’’; 3 (2) in subsection (g)(2), in the matter pre- 4 ceding subparagraph (A), by inserting ‘‘subsection 5 (i) and’’ after ‘‘subject to’’; and 6 (3) by adding at the end the following new sub- 7 section: 8 ‘‘(i) SUNSET OF MEDICAID FUNDING LIMITATIONS 9 FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE 10 NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 11 Subsections (f) and (g) shall not apply to Puerto Rico, 12 the Virgin Islands, Guam, the Northern Mariana Islands, 13 and American Samoa beginning with fiscal year 2022.’’. 14 (b) CONFORMING AMENDMENTS.— 15 (1) Section 1902(j) of the Social Security Act 16 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 17 limitation in section 1108(f),,’’. 18 (2) Section 1903(u) of the Social Security Act 19 (42 U.S.C. 1396b(u)) is amended by striking para- 20 graph (4). 21 (c) EFFECTIVE DATE.—The amendments made by 22 this section shall apply beginning with fiscal year 2022. 23 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 3434 IH SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 1 ASSISTANCE PERCENTAGE (FMAP) LIMITA- 2 TION FOR TERRITORIES. 3 Section 1905(b) of the Social Security Act (42 U.S.C. 4 1396d(b)) is amended, in clause (2), by inserting ‘‘for fis- 5 cal years before fiscal year 2022’’ after ‘‘American 6 Samoa’’. 7 SEC. 103. PERMITTING MEDICAID DSH ALLOTMENTS FOR 8 TERRITORIES. 9 Section 1923(f) of the Social Security Act (42 U.S.C. 10 1396r–4(f)) is amended— 11 (1) in paragraph (6), by adding at the end the 12 following new subparagraph: 13 ‘‘(C) TERRITORIES.— 14 ‘‘(i) FISCAL YEAR 2022.—For fiscal 15 year 2022, the DSH allotment for Puerto 16 Rico, the Virgin Islands, Guam, the North- 17 ern Mariana Islands, and American Samoa 18 shall bear the same ratio to $300,000,000 19 as the ratio of the number of individuals 20 who are low-income or uninsured and re- 21 siding in such respective territory (as esti- 22 mated from time to time by the Secretary) 23 bears to the sums of the number of such 24 individuals residing in all of the territories. 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 3434 IH ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 1 For each subsequent fiscal year, the DSH 2 allotment for each such territory is subject 3 to an increase in accordance with para- 4 graph (3).’’; and 5 (2) in paragraph (9), by inserting before the pe- 6 riod at the end the following: ‘‘, and includes, begin- 7 ning with fiscal year 2022, Puerto Rico, the Virgin 8 Islands, Guam, the Northern Mariana Islands, and 9 American Samoa’’. 10 TITLE II—MEDICARE 11 Subtitle A—Part A 12 SEC. 201. CALCULATION OF MEDICARE DSH PAYMENTS FOR 13 IPPS HOSPITALS IN PUERTO RICO. 14 Section 1886(d)(9)(D)(iii) of the Social Security Act 15 (42 U.S.C. 1395ww(d)(9)(D)(iii)) is amended to read as 16 follows: 17 ‘‘(iii) Subparagraph (F) (relating to 18 disproportionate share payments), includ- 19 ing application of subsection (r), except 20 that for this purpose— 21 ‘‘(I) the sum described in clause 22 (ii) of this subparagraph shall be sub- 23 stituted for the sum referred to in 24 paragraph (5)(F)(ii)(I); and 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 3434 IH ‘‘(II) for discharges occurring on 1 or after October 1, 2021, subclause 2 (I) of paragraph (5)(F)(vi) shall be 3 applied by substituting for the numer- 4 ator described in such subclause the 5 number of subsection (d) Puerto Rico 6 hospital’s patient days for the cost re- 7 porting period involved which were 8 made up of patients who (for such 9 days) were entitled to benefits under 10 part A of this title and were— 11 ‘‘(aa) entitled to supple- 12 mentary security income benefits 13 (excluding any State supplemen- 14 tation) under title XVI; 15 ‘‘(bb) eligible for medical as- 16 sistance under a State plan 17 under title XIX; or 18 ‘‘(cc) receiving aid or assist- 19 ance under any plan of the State 20 approved under title I, X, XIV, 21 or XVI.’’. 22 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 3434 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, 2021, 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) there shall be substituted for the 22 preceding 12-month cost reporting period 23 the 12-month cost reporting period begin- 24 ning during fiscal year 2015 (or, at the op- 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 8 •HR 3434 IH tion of the hospital, beginning during fiscal 1 year 2017); 2 ‘‘(II) any reference in subparagraph 3 (A)(i) to the ‘first such cost reporting pe- 4 riod’ is deemed a reference to the first cost 5 reporting period following the 12-month 6 cost reporting period beginning during fis- 7 cal year 2015 (or, at the option of the hos- 8 pital, beginning during fiscal year 2017); 9 and 10 ‘‘(III) the applicable percentage in- 11 crease shall only be applied under subpara- 12 graph (B)(ii) for cost reporting periods be- 13 ginning on or after October 1, 2021. 14 ‘‘(iii) Nothing in this subparagraph shall 15 affect any request by a hospital for a new tar- 16 get amount for any cost reporting period begin- 17 ning during a fiscal year after fiscal year 18 2021.’’. 19 SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOS- 20 PITALS IN TERRITORIES. 21 Section 1886(b)(3) of the Social Security Act (42 22 U.S.C. 1395ww(b)(3)), as amended by section 202, is fur- 23 ther amended by adding at the end the following new sub- 24 paragraph: 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 9 •HR 3434 IH ‘‘(N)(i) For each cost reporting period be- 1 ginning on or after October 1, 2021, in the case 2 of a hospital that is located in a territory of the 3 United States other than Puerto Rico and that 4 would be a subsection (d) hospital if it were lo- 5 cated in one of the 50 States, the target 6 amount shall be increased by— 7 ‘‘(I) in the case that such hospital has 8 a disproportionate patient percentage of 9 not less than 15 percent and not greater 10 than 40 percent, 10 percent; and 11 ‘‘(II) in the case that such hospital 12 has a disproportionate patient percentage 13 of greater than 40 percent, 10 percent plus 14 60 percent of the number of percentage 15 points by which such hospital’s dispropor- 16 tionate patient percentage exceeds 40 per- 17 cent. 18 ‘‘(ii) For purposes of this subparagraph, 19 the term ‘disproportionate patient percentage’ 20 has the meaning given such term in subsection 21 (d)(5)(F)(vi), except that in applying such 22 meaning any reference under such subsection to 23 individuals entitled to supplementary security 24 income under title XVI shall be deemed for pur- 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 10 •HR 3434 IH poses of this subparagraph to include individ- 1 uals— 2 ‘‘(I) eligible for medical assistance 3 under a State plan under title XIX; or 4 ‘‘(II) receiving aid or assistance under 5 any plan of the territory approved under 6 title I, X, XIV, or XVI.’’. 7 Subtitle B—Part B 8 SEC. 211. ELIMINATING LATE ENROLLMENT PENALTIES 9 UNDER PART B OF THE MEDICARE PROGRAM 10 FOR CERTAIN INDIVIDUALS RESIDING IN 11 PUERTO RICO. 12 (a) IN GENERAL.—Section 1839(b) of the Social Se- 13 curity Act (42 U.S.C. 1395r(b)) is amended in the second 14 sentence by inserting ‘‘or months occurring in the 5-year 15 period beginning on the date on which the individual be- 16 comes entitled to benefits under part A if such individual 17 was residing in Puerto Rico as of such date and such date 18 is after the date that is 4 years before the date of the 19 enactment of the Territories Health Equity Act of 2021’’ 20 before the period at the end of such sentence. 21 (b) APPLICATION.—The amendment made by sub- 22 section (a) shall apply with respect to premiums paid for 23 months beginning on or after the date of the enactment 24 of this Act. 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 11 •HR 3434 IH Subtitle C—Medicare Advantage 1 (Part C) 2 SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW-BASE 3 PAYMENT COUNTIES IN PUERTO RICO. 4 Section 1853(n) of the Social Security Act (42 U.S.C. 5 1395w–23(n)) is amended— 6 (1) in paragraph (1), by striking ‘‘and (5)’’ and 7 inserting ‘‘(5), and (6)’’; 8 (2) in paragraph (4), by striking ‘‘In no case’’ 9 and inserting ‘‘Subject to paragraph (6), in no 10 case’’; and 11 (3) by adding at the end the following new 12 paragraph: 13 ‘‘(6) SPECIAL RULES FOR BLENDED BENCH- 14 MARK AMOUNT FOR TERRITORIES.— 15 ‘‘(A) IN GENERAL.—Subject to paragraph 16 (2), the blended benchmark amount for an area 17 in a territory for a year (beginning with 2022) 18 shall not be less than 80 percent of the national 19 average of the base payment amounts specified 20 in subparagraph (2)(E) for such year for areas 21 within the 50 States and the District of Colum- 22 bia. 23 ‘‘(B) LIMITATION.—In no case shall the 24 blended benchmark amount for an area in a 25 VerDate Sep 11 2014 05:29 Jun 22, 2021 Jkt 019200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3434.IH H3434 kjohnson on DSK79L0C42PROD with BILLS 12 •HR 3434 IH territory for a year under subparagraph (A) ex- 1 ceed the lowest blended benchmark amount for 2 any area within the 50 States and the District 3 of Columbia for such year.’’. 4 Subtitle D—Part D 5 SEC. 231. AUTOMATIC ELIGIBILITY OF CERTAIN LOW-IN- 6 COME TERRITORIAL RESIDENTS FOR PRE- 7 MIUM AND COST-SHARING SUBSIDIES UNDER 8 THE MEDICARE PROGRAM; SUNSET OF EN- 9 HANCED ALLOTMENT PROGRAM. 10 (a) AUTOMATIC ELIGIBILITY OF CERTAIN LOW-IN- 11 COME TERRITORIAL RESIDENTS FOR PREMIUM AND 12 COST-SHARING SUBSIDIES UNDER THE MEDICARE PRO- 13 GRAM.— 14 (1) IN GENERAL.—Section 1860D–14(a)(3) of 15 the Social Security Act (42 U.S.C. 1395w– 16 114(a)(3)) is amended— 17 (A) in subparagraph (B)(v)— 18 (i) in subclause (I), by striking ‘‘and’’ 19 at the end; 20 (ii) in subclause (II), by striking the 21 period and inserting [Text truncated for display. Full text available on Congress.gov.]