Territories Health Equity Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 1354 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 25, 2019 Ms. PLASKETT (for herself, Miss GONZA´LEZ-COLO´N of Puerto Rico, Mrs. RADEWAGEN, Mr. SAN NICOLAS, Mr. SERRANO, and Ms. VELA´ZQUEZ) in- troduced the following bill; which was referred to the Committee on En- ergy 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 jurisdic- tion 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 2019’’. 5 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 2 •HR 1354 IH (b) TABLE OF CONTENTS.—The table of contents of 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. 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 enroll- ment 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 avail- able Exchange plans. Sec. 305. Extension of family-to-family health information centers program to territories. VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6211 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 3 •HR 1354 IH TITLE I—MEDICAID 1 SEC. 101. ELIMINATION OF GENERAL MEDICAID FUNDING 2 LIMITATIONS (‘‘CAP’’) FOR TERRITORIES. 3 (a) IN GENERAL.—Section 1108 of the Social Secu- 4 rity Act (42 U.S.C. 1308) is amended— 5 (1) in subsection (f), in the matter preceding 6 paragraph (1), by striking ‘‘subsection (g)’’ and in- 7 serting ‘‘subsections (g) and (h)’’; 8 (2) in subsection (g)(2), in the matter pre- 9 ceding subparagraph (A), by inserting ‘‘subsection 10 (h)’’ after ‘‘subject to’’; and 11 (3) by adding at the end the following new sub- 12 section: 13 ‘‘(h) SUNSET OF MEDICAID FUNDING LIMITATIONS 14 FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE 15 NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 16 Subsections (f) and (g) shall not apply to Puerto Rico, 17 the Virgin Islands, Guam, the Northern Mariana Islands, 18 and American Samoa beginning with fiscal year 2020.’’. 19 (b) CONFORMING AMENDMENTS.— 20 (1) Section 1902(j) of the Social Security Act 21 (42 U.S.C. 1396a(j)) is amended by striking ‘‘, the 22 limitation in section 1108(f),’’. 23 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 4 •HR 1354 IH (2) Section 1903(u) of the Social Security Act 1 (42 U.S.C. 1396b(u)) is amended by striking para- 2 graph (4). 3 (c) EFFECTIVE DATE.—The amendments made by 4 this section shall apply beginning with fiscal year 2020. 5 SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL 6 ASSISTANCE PERCENTAGE (FMAP) LIMITA- 7 TION FOR TERRITORIES. 8 Section 1905(b) of the Social Security Act (42 U.S.C. 9 1396d(b)) is amended, in clause (2), by inserting ‘‘for fis- 10 cal years before fiscal year 2020’’ after ‘‘American 11 Samoa’’. 12 SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY 13 TO ALL OF THE TERRITORIES. 14 (a) IN GENERAL.—Section 1902(j) of the Social Se- 15 curity Act (42 U.S.C. 1396a(j)) is amended— 16 (1) by striking ‘‘American Samoa and the 17 Northern Mariana Islands’’ and inserting ‘‘Puerto 18 Rico, the Virgin Islands, Guam, the Northern Mar- 19 iana Islands, and American Samoa’’; 20 (2) by striking ‘‘American Samoa or the North- 21 ern Mariana Islands’’ and inserting ‘‘Puerto Rico, 22 the Virgin Islands, Guam, the Northern Mariana Is- 23 lands, or American Samoa’’; 24 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 5 •HR 1354 IH (3) by inserting ‘‘(1)’’ before ‘‘Notwith- 1 standing’’; 2 (4) by inserting ‘‘except as otherwise provided 3 in this subsection,’’ after ‘‘Notwithstanding any 4 other requirement of this title’’; and 5 (5) by adding at the end the following: 6 ‘‘(2) The Secretary may not waive under this sub- 7 section the requirement of subsection (a)(10)(A)(i)(IX) 8 (relating to coverage of adults formerly under foster care) 9 with respect to any territory.’’. 10 (b) EFFECTIVE DATE.—The amendments made by 11 this section shall apply beginning October 1, 2019. 12 SEC. 104. PERMITTING MEDICAID DSH ALLOTMENTS FOR 13 TERRITORIES. 14 Section 1923(f) of the Social Security Act (42 U.S.C. 15 1396r–4(f)) is amended— 16 (1) in paragraph (6), by adding at the end the 17 following new subparagraph: 18 ‘‘(C) TERRITORIES.— 19 ‘‘(i) FISCAL YEAR 2020.—For fiscal 20 year 2020, the DSH allotment for Puerto 21 Rico, the Virgin Islands, Guam, the North- 22 ern Mariana Islands, and American Samoa 23 shall bear the same ratio to $300,000,000 24 as the ratio of the number of individuals 25 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 6 •HR 1354 IH who are low-income or uninsured and re- 1 siding in such respective territory (as esti- 2 mated from time to time by the Secretary) 3 bears to the sums of the number of such 4 individuals residing in all of the territories. 5 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 6 For each subsequent fiscal year, the DSH 7 allotment for each such territory is subject 8 to an increase in accordance with para- 9 graph (3).’’; and 10 (2) in paragraph (9), by inserting before the pe- 11 riod at the end the following: ‘‘, and includes, begin- 12 ning with fiscal year 2020, Puerto Rico, the Virgin 13 Islands, Guam, the Northern Mariana Islands, and 14 American Samoa’’. 15 TITLE II—MEDICARE 16 Subtitle A—Part A 17 SEC. 201. CALCULATION OF MEDICARE DSH PAYMENTS FOR 18 IPPS HOSPITALS IN PUERTO RICO. 19 Section 1886(d)(9)(D)(iii) of the Social Security Act 20 (42 U.S.C. 1395ww(d)(9)(D)(iii)) is amended to read as 21 follows: 22 ‘‘(iii) Subparagraph (F) (relating to dispropor- 23 tionate share payments), including application of 24 subsection (r), except that for this purpose— 25 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 7 •HR 1354 IH ‘‘(I) the sum described in clause (ii) of this 1 subparagraph shall be substituted for the sum 2 referred to in paragraph (5)(F)(ii)(I); and 3 ‘‘(II) for discharges occurring on or after 4 October 1, 2019, subclause (I) of paragraph 5 (5)(F)(vi) shall be applied by substituting for 6 the numerator described in such subclause the 7 number of subsection (d) Puerto Rico hospital’s 8 patient days for the cost reporting period in- 9 volved which were made up of patients who (for 10 such days) were entitled to benefits under part 11 A of this title and were— 12 ‘‘(aa) entitled to supplementary secu- 13 rity income benefits (excluding any State 14 supplementation) under title XVI of this 15 Act; 16 ‘‘(bb) eligible for medical assistance 17 under a State plan under title XIX; or 18 ‘‘(cc) receiving aid or assistance under 19 any plan of the State approved under title 20 I, X, XIV, or XVI.’’. 21 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 8 •HR 1354 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, 2019, 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 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 9 •HR 1354 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, 2019. 14 ‘‘(iii) Nothing in this subparagraph shall 15 affect any pending request by a hospital for a 16 new target amount for any cost reporting pe- 17 riod beginning during a fiscal year before fiscal 18 year 2020.’’. 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 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 10 •HR 1354 IH ‘‘(N)(i) For each cost reporting period be- 1 ginning on or after October 1, 2019, 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 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 11 •HR 1354 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. APPLICATION OF PART B DEEMED ENROLLMENT 9 PROCESS TO RESIDENTS OF PUERTO RICO; 10 SPECIAL ENROLLMENT PERIOD AND LIMIT 11 ON LATE ENROLLMENT PENALTIES. 12 (a) APPLICATION OF PART B DEEMED ENROLLMENT 13 PROCESS TO RESIDENTS OF PUERTO RICO.—Section 14 1837(f)(3) of the Social Security Act (42 U.S.C. 15 1395p(f)(3)) is amended by striking ‘‘, exclusive of Puerto 16 Rico’’. 17 (b) EFFECTIVE DATE.—The amendment made by 18 subsection (a) shall apply to individuals whose initial en- 19 rollment period under section 1837(d) of the Social Secu- 20 rity Act begins on or after the first day of the effective 21 month, specified by the Secretary of Health and Human 22 Services under section 1839(j)(1)(C) of such Act, as added 23 by subsection (c)(2). 24 VerDate Sep 11 2014 00:00 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H1354.IH H1354 pbinns on DSK79D2C42PROD with BILLS 12 •HR 1354 IH (c) TRANSITION PROVIDING SPECIAL ENROLLMENT 1 PERIOD AND LIMIT ON LATE ENROLLMENT PENALTIES 2 FOR CERTAIN MEDICARE BENEFICIARIES.—Section 1839 3 of the Social Security Act (42 U.S.C. 1395r) is amend- 4 ed— 5 (1) in the first sentence of subsection (b), by in- 6 serting ‘‘subject to section 1839(j)(2),’’ after ‘‘sub- 7 section (i)(4) or (l) of section 1837,’’; and 8 (2) by adding at the end the following new sub- 9 section: 10 ‘‘(j) SPECIAL RULES FOR CERTAIN RESIDENTS OF 11 PUERTO RICO.— 12 ‘‘(1) SPECIAL ENROLLMENT PERIOD, COVERAGE 13 PERIOD FOR RESIDENTS WHO ARE ELIGIBLE BUT 14 NOT ENROLLED.— 15 ‘‘(A) IN GENERAL.—In th [Text truncated for display. 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