,,ii #aaeth ,,congress #ast ,session ,s4 #bjbf ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,october #bf1 #bjag,mr4 ,nelson 7for himself1 ,mrs4 ,gillibrand1 ,mr4 ,blumenthal1 ,mr4 ,menendez1 and ,mr4 ,booker7 introduced the following bill2 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 programs1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,improving the ,treatment of the ,u4,s4 ,territories ,under ,federal ,health ,programs ,act of #bjag4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,,title ,i--,medicaid ,sec4 #aja4 ,elimination of general ,medicaid funding limitations 7cap7 for territories4 ,sec4 #ajb4 ,elimination of specific ,federal medical assistance percentage 7,,fmap7 limitation for territories4 ,sec4 #ajc4 ,application of ,medicaid waiver authority to all of the territories4 ,sec4 #ajd4 ,permitting ,medicaid ,,dsh allotments for territories4 ,,title ,,ii--,medicare ,subtitle ,a--,part ,a ,sec4 #bja4 ,calculation of ,medicare ,,dsh payments for ,,ipps hospitals in ,puerto ,rico4 ,sec4 #bjb4 ,rebasing ,target ,amount for ,hospitals in ,territories4 ,sec4 #bjc4 ,medicare ,,dsh ,target ,adjustment for ,hospitals in ,territories4 ,subtitle ,b--,part ,b ,sec4 #baa4 ,application of part ,b deemed enrollment process to residents of ,puerto ,rico2 special enrollment period and limit on late enrollment penalties4 ,subtitle ,c--,medicare ,advantage 7,part ,c7 ,sec4 #bba4 ,adjustment in benchmark for low base payment counties in ,puerto ,rico4 ,subtitle ,d--,part ,d ,sec4 #bca4 ,eliminating exclusion of part ,d eligible individuals residing in territories from eligibility for premium and cost-sharing subsidies4 ,sec4 #bcb4 ,report on treatment of territories under ,medicare part ,d4 ,,title ,,iii--,miscellaneous ,sec4 #cja4 ,report on exclusion of territories from ,exchanges4 ,sec4 #cjb4 ,medicaid and ,,chip territory transparency and information4 ,i ,medicaid #aja4 ,elimination of general ,medicaid funding limitations 7cap7 for territories 7a7 ,in general ,section #aajh of the ,social ,security ,act 7#db ,u4,s4,c4 #acjh7 is amended-- 7#a7 in subsection 7f71 in the matter before paragraph 7#a71 by striking subsection 7g7 and inserting subsections 7g7 and 7h72 7#b7 in subsection 7g77#b71 in the matter before subparagraph 7,a71 by inserting and subsection 7h7 after paragraphs 7#c7 and 7#e72 and 7#c7 by adding at the end the following new subsection3 7h7 ,sunset of ,medicaid funding limitations for ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa ,subsections 7f7 and 7g7 shall not apply to ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa beginning with fiscal year #bjah4 4 7b7 ,conforming amendments 7#a7 ,section #aijb7;j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7j77 is amended by striking 1 the limitation in section #aajh7;f714 7#b7 ,section #aijc7u7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7u77 is amended by striking paragraph 7#d74 7#c7 ,section #acbc7;c77#a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjdc7;c77#a77 is amended by striking #bjai and inserting #bjah4 7c7 ,effective date ,the amendments made by this section shall apply beginning with fiscal year #bjah4 #ajb4 ,elimination of specific ,federal medical assistance percentage 7,,fmap7 limitation for territories ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is amended-- 7#a7 in subsection 7b77#b71 by inserting for fiscal years before fiscal year #bjah after ,american ,samoa2 and 7#b7 in subsection 7y77#a71 in the matter preceding subparagraph 7,a7-- 7,a7 by inserting 1 for fiscal years before fiscal year #bjah1 before is one of the2 and 7,b7 by inserting and1 for fiscal year #bjah and subsequent fiscal years1 is one of the #ej ,states1 the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 or ,american ,samoa1 after the ,district of ,columbia4 #ajc4 ,application of ,medicaid waiver authority to all of the territories 7a7 ,in general ,section #aijb7;j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7j77 is amended-- 7#a7 by striking ,american ,samoa and the ,northern ,mariana ,islands and inserting ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa2 7#b7 by striking ,american ,samoa or the ,northern ,mariana ,islands and inserting ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 or ,american ,samoa2 7#c7 by striking 1 the limitation in section #aajh7;f712 7#d7 by inserting 7#a7 after 7j72 7#e7 by inserting except as otherwise provided in this subsection1 after ,notwithstanding any other requirement of this title2 and 7#f7 by adding at the end the following3 7#b7 ,the ,secretary may not waive under this subsection the requirement of subsection 7a77#aj77;,a77i77,,ix7 7relating to coverage of adults formerly under foster care7 with respect to any territory4 4 7b7 ,effective date ,the amendments made by this section shall apply beginning ,october #a1 #bjag4 #ajd4 ,permitting ,medicaid ,,dsh allotments for territories ,section #aibc7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif7 is amended-- 7#a7 in paragraph 7#f71 by adding at the end the following new subparagraph3 7,c7 ,territories 7i7 ,fiscal year #bjah ,for fiscal year #bjah1 with respect to the territories of ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa1 the ,,dsh allotment determined for each such territory shall bear the same ratio to #aej1jjj1jjj as the ratio of the number of individuals who are low-income or uninsured and residing in each such respective territory 7as estimated from time to time by the ,secretary7 bears to the sums of the number of such individuals residing in all of the territories4 7ii7 ,subsequent fiscal year ,for each subsequent fiscal year1 the ,,dsh allotment for each such territory is subject to an increase or reduction in accordance with paragraphs 7#c7 and 7#g74 2 7#b7 in paragraph 7#g77;,a71 by striking clause 7iv7 and redesignating clause 7v7 as clause 7iv72 and 7#c7 in paragraph 7#i71 by inserting before the period at the end the following3 1 and includes1 beginning with fiscal year #bjah1 ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa4 ,,ii ,medicare ,a ,part ,a #bja4 ,calculation of ,medicare ,,dsh payments for ,,ipps hospitals in ,puerto ,rico ,section #ahhf7;d77#i77;,d77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#i77;,d77iii77 is amended to read as follows3 7iii7 ,subparagraph 7,f7 7relating to disproportionate share payments71 including application of subsection 7r71 except that for this purpose-- 7,i7 the sum described in clause 7ii7 of this subparagraph shall be substituted for the sum referred to in paragraph 7#e77;,f77ii77,i72 and 7,,ii7 for discharges occurring on or after ,october #a1 #bjag1 subclause 7,i7 of paragraph 7#e77;,f77vi7 shall be applied by substituting for the numerator described in such subclause the number of subsection 7d7 ,puerto ,rico hospital's patient days for the cost reporting period involved which were made up of patients who 7for such days7 were entitled to benefits under part ,a of this title and were-- 7aa7 entitled to supplementary security income benefits 7excluding any ,state supplementation7 under title ,,xvi of this ,act2 7bb7 eligible for medical assistance under a ,state plan under title ,,xix2 or 7cc7 receiving aid or assistance under any plan of the ,state approved under title ,i1 ,x1 ,,xiv1 or ,,xvi4 4 #bjb4 ,rebasing ,target ,amount for ,hospitals in ,territories ,section #ahhf7;b77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77 is amended by adding at the end the following new subparagraph3 7,m7 7i7 ,for each cost reporting period beginning on or after ,october #a1 #bjag1 in the case of a hospital located in a territory of the ,united ,states1 there shall be substituted for the target amount otherwise determined under subparagraph 7,a7 the rebased target amount 7as defined in clause 7ii771 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 apply4 7ii7 ,for purposes of this subparagraph1 the term rebased target amount has the meaning given the term target amount in subparagraph 7,a71 except that-- 7,i7 there shall be substituted for the base cost reporting period the #ab-month cost reporting period beginning during fiscal year #bjae2 7,,ii7 any reference in subparagraph 7,a77i7 to the first such cost reporting period is deemed a reference to the first cost reporting period beginning on or after ,october #a1 #bjag2 and 7,,iii7 the applicable percentage increase shall only be applied under subparagraph 7,b77ii7 for cost reporting periods beginning on or after ,october #a1 #bjag4 7iii7 ,nothing in this subparagraph shall affect any rebasing request by a hospital for any cost reporting period beginning during a fiscal year before fiscal year #bjae4 4 #bjc4 ,medicare ,,dsh ,target ,adjustment for ,hospitals in ,territories ,section #ahhf7;b77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c771 as amended by section #bjb1 is further amended by adding at the end the following new subparagraph3 7,n7 7i7 ,for each cost reporting period beginning on or after ,october #a1 #bjag1 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 7d7 hospital if it were located in one of the #ej ,states1 the target amount shall be increased by-- 7,i7 in the case that such hospital has a disproportionate patient percentage of not less than #ae percent and not greater than #dj percent1 #aj percent2 and 7,,ii7 in the case that such hospital has a disproportionate patient percentage of greater than #dj percent1 #aj percent plus #fj percent of the number of percentage points by which such hospital's disproportionate patient percentage exceeds #dj percent4 7ii7 ,for purposes of this subparagraph1 the term disproportionate patient percentage has the meaning given such term in subsection 7d77#e77;,f77vi71 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-- 7,i7 eligible for medical assistance under a ,state plan under title ,,xix2 or 7,,ii7 receiving aid or assistance under any plan of the territory approved under title ,i1 ,x1 ,,xiv1 or ,,xvi4 4 ,b ,part ,b #baa4 ,application of part ,b deemed enrollment process to residents of ,puerto ,rico2 special enrollment period and limit on late enrollment penalties 7a7 ,application of part ,b deemed enrollment process to residents of ,puerto ,rico ,section #ahcg7;f77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciep7f77#c77 is amended by striking 1 exclusive of ,puerto ,rico4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply to individuals whose initial enrollment period under section #ahcg7;d7 of the ,social ,security ,act begins on or after the first day of the effective month1 specified by the ,secretary of ,health and ,human ,services under section #ahci7;j77#a77;,c7 of such ,act1 as added by subsection 7c77#b74 7c7 ,transition providing special enrollment period and limit on late enrollment penalties for certain ,medicare beneficiaries ,section #ahci of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7 is amended-- 7#a7 in the first sentence of subsection 7b71 by inserting subject to section #ahci7;j77#b71 after subsection 7i77#d7 or 7l7 of section #ahcg12 and 7#b7 by adding at the end the following new subsection3 7j7 ,special rules for certain residents of ,puerto ,rico 7#a7 ,special enrollment period1 coverage period for residents who are eligible but not enrolled 7,a7 ,in general ,in the case of a transition individual 7as defined in paragraph 7#c77 who is not enrolled under this part as of the day before the first day of the effective month 7as defined in subparagraph 7,c771 the ,secretary shall provide for a special enrollment period under section #ahcg of #g months beginning with such effective month during which the individual may be enrolled under this part4 7,b7 ,coverage period ,in the case of such an individual who enrolls during such special enrollment period1 the coverage period under section #ahch shall begin on the first day of the second month after the month in which the individual enrolls4 7,c7 ,effective month defined ,in this section1 the term effective month means a month1 not earlier than ,october #bjag and not later than ,january #bjah1 specified by the ,secretary4 7#b7 ,reduction in late enrollment penalties for current enrollees and individuals enrolling during transition 7,a7 ,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 7#a77;,a71 the amount of the late enrollment penalty imposed under section #ahci7;b7 shall be recalculated by reducing the penalty to #ae percent of the penalty otherwise established4 7,b7 ,application ,subparagraph 7,a7 shall be applied in the case of a transition individual who-- 7i7 is enrolled under this part as of the month before the effective month1 for premiums for months beginning with such effective month2 or 7ii7 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 7#a77;,a71 for premiums for months during the coverage period under this part which occur during or after the effective month4 7,c7 ,loss of reduction if individual terminates enrollment ,subparagraph 7,a7 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 7#a74 7#c7 ,transition individual defined ,in this section1 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 #ahcg7;f7 before the first day of the effective month but for the fact that the individual was a resident of ,puerto ,rico1 regardless of whether the individual is enrolled under this part as of such first day4 4 ,c ,medicare ,advantage 7,part ,c7 #bba4 ,adjustment in benchmark for low base payment counties in ,puerto ,rico ,section #ahec7n7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7n77 is amended-- 7#a7 in paragraph 7#a71 by striking and 7#e7 and inserting 1 7#e71 and 7#f72 7#b7 in paragraph 7#d71 by striking ,in no case and inserting ,subject to paragraph 7#f71 in no case2 and 7#c7 by adding at the end the following new paragraph3 7#f7 ,special rules for blended benchmark amount for territories 7,a7 ,in general ,subject to paragraph 7#b71 the blended benchmark amount for an area in a territory for a year 7beginning with #bjah7 shall not be less than #hj percent of the national average of the base payment amounts specified in subparagraph 7#b77;,e7 for such year for areas within the #ej ,states and the ,district of ,columbia4 7,b7 ,limitation ,in no case shall the blended benchmark amount for an area in a territory for a year under subparagraph 7,a7 exceed the lowest blended benchmark amount for any area within the #ej ,states and the ,district of ,columbia for such year4 4 ,d ,part ,d #bca4 ,eliminating exclusion of part ,d eligible individuals residing in territories from eligibility for premium and cost-sharing subsidies 7a7 ,in general ,section #ahfj;,d-#ad7;a77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77#c77 is amended-- 7#a7 in subparagraph 7,a71 in the matter preceding clause 7i71 by striking subject to subparagraph 7,f712 7#b7 in subparagraph 7,b77v71 in the matter preceding subclause 7,i71 by striking ,subject to subparagraph 7,f71 the ,secretary and inserting ,the ,secretary2 7#c7 in subparagraph 7,c71 by adding at the end the following new sentence3 ,in the case of an individual who is not a resident of the #ej ,states or the ,district of ,columbia1 the poverty line 7as such term is defined in clause 7ii77 that shall apply to such individual shall be the poverty line for the #dh contiguous ,states and the ,district of ,columbia42 and 7#d7 by striking subparagraph 7,f74 7b7 ,application of ,medicaid provisions ,section #aice of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7 is amended-- 7#a7 in subsection 7a71 by striking subject to subsection 7e7 in the matter preceding paragraph 7#a72 and 7#b7 by striking subsection 7e74 7c7 ,conforming amendment ,section #aajh7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acjh7;f77 is amended by striking and section #aice7;e77#a77;,b7 in the matter preceding clause 7i74 7d7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjah4 #bcb4 ,report on treatment of territories under ,medicare part ,d ,paragraph 7#d7 of section #aice7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;e77 is amended to read as follows3 7#d7 ,report on application of subsection 7,a7 ,in general ,not later than ,may #a1 #bjah1 the ,secretary shall submit to ,congress a report on the application of this subsection during the period beginning with fiscal year #bjjf and ending with ,december #ca1 #bjag4 7,b7 ,information to be included in report ,such report shall include-- 7i7 program guidance issued by the ,secretary to implement this subsection2 7ii7 for each of ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa1 information on the increased amount under paragraph 7#c7 and how the territory has applied such amount1 including the territory's program design1 expenditures1 and number of individuals 7and dual-eligible individuals7 assisted2 and 7iii7 a description of the differences between how such territories are treated under part ,d of title ,,xviii and under this title compared with the treatment of the #ej ,states and the ,district of ,columbia under such part and this title for different fiscal years within the period covered under the report4 7,c7 ,recommendations ,such report shall include recommendations for improving prescription drug coverage for low-income individuals in each territory identified in subparagraph 7,b77ii71 including recommendations regarding each of the following alternative approaches3 7i7 ,adjusting the aggregate amount specified in paragraph 7#c77;,b74 7ii7 ,allowing residents of the territories to be subsidy eligible individuals under section #ahfj;,d-#ad1 notwithstanding subsection 7a77#c77;,f7 of such section1 or providing substantially equivalent low-income prescription drug subsidies to such residents4 4 ,,iii ,miscellaneous #cja4 ,report on exclusion of territories from ,exchanges 7a7 ,in general ,not later than ,february #a1 #bjai1 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 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 businesses4 7b7 ,information in report ,the report shall include information on the following3 7#a7 ,an estimate of the total number of uninsured and underinsured individuals residing in each territory with respect to health insurance coverage4 7#b7 ,a description of the number of health insurance issuers in each territory and the health insurance plans these issuers offer4 7#c7 ,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 #ej ,states or in the ,district of ,columbia4 7#d7 ,an estimate of the amount of ,federal assistance described in paragraph 7#c7 that is not being made available to residents of each territory4 7#e7 ,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 7,,shop7 ,marketplace that would operate as part of an ,exchange if the employers were in one of the #ej ,states or in the ,district of ,columbia4 #cjb4 ,medicaid and ,,chip territory transparency and information 7a7 ,publication of ,information on ,federal ,expenditures ,under ,medicaid and ,,chip in the ,territories ,not later than #ahj days after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall publish1 and periodically update1 on the ,internet site of the ,centers for ,medicare ,medicaid ,services information on ,medicaid and ,,chip carried out in the territories of the ,united ,states4 ,such information shall include1 with respect to each such territory-- 7#a7 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 ,,chip2 7#b7 the number of individuals enrolled in ,medicaid and ,,chip in such territory2 7#c7 any ,state plan amendments in effect to carry out ,medicaid or ,,chip in such territory2 7#d7 any waiver of the requirements of title ,,xix or ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq41 #acig;aa et seq47 issued by the ,secretary to carry out ,medicaid or ,,chip in the territory1 including a waiver under section #aaae of the ,social ,security ,act 7#db ,u4,s4,c4 #acae71 any application for such a waiver1 and any documentation related to such application 7including correspondence72 7#e7 the amount of the ,federal and non-,federal share of expenditures under ,medicaid and ,,chip in such territory2 7#f7 the systems in place for the furnishing of health care items and services under ,medicaid and ,,chip in such territory2 7#g7 the design of ,,chip in such territory2 and 7#h7 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 of the #ej ,states and the ,district of ,columbia4 7b7 ,definitions ,in this section3 7#a7 ,,chip ,the term ,,chip means the ,state ,children's ,health ,insurance ,program established under title ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq474 7#b7 ,medicaid ,the term ,medicaid means the ,medicaid program established under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 7#c7 ,territory of the ,united ,states ,the term territory of the ,united ,states means ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa4