,i  #aaf? ,,congress  #a/ ,session  ,h4 
,r4 #ccga  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,june #ai1 #bjai,ms4  
,velzquez 7= h]self1 ,mr4 ,soto1 ,mr4   
,s]rano1 ,mr4 ,grijalva1 ,mr4           
,espaillat1 ,ms4 ,ocasio-,cortez1 ,mr4  
,g>ca ( ,ill9ois1 & ,miss ,gonzlez-,coln
 ( ,pu]to ,rico7 introduc$ ! foll[+     
bill2 :i* 0 ref]r$ to ! ,committee on   
,en]gy & ,comm]ce  ,a ,,bill  ,to am5d  
titles ,,xi & ,,xix ( ! ,social         
,security ,act to /abilize ! ,m$icaid   
program 9 ,pu]to ,rico4  #a4 ,%ort title
 ,?is ,act may be cit$ z ! ,pu]to ,rico 
,heal? ,c>e ,fairness1 ,acc\ntability1 &
 ,b5efici>y ,access ,act ( #bjai4  #b4  
,adju/m5ts to ,,fmap & cap = ,pu]to     
,rico  7a7 ,adju/m5ts to ,,fmap ,section
 #aije ( ! ,social ,security ,act 7#db  
,u4,s4,c4 #acif;d7 is am5d$--  7#a7 9   
subsection 7b7-- 7,a7 by /rik+ = ,pu]to 
,rico1 ! ,virg9 ,isl&s & ins]t+ = !     
,virg9 ,isl&s2 &  7,b7 by /rik+ &       
,am]ican ,samoa %all be #ee p]c5t1 &    
ins]t+ & ,am]ica ,samoa 7&1 = cal5d>    

qu>t]s 9 a fiscal ye> be=e fiscal ye>   
#bjbj1 ,pu]to ,rico7 %all be #ee p]c5t1 
& = ,pu]to ,rico1 = cal5d> qu>t]s 9 a   
fiscal ye> beg9n+ ) fiscal ye> #bjbj1   
%all be ! ,,pr specifi$ p]c5t "u        
subsection 7ff7 = su* fiscal ye>12 &    
7#b7 by add+ at ! end ! foll[+ new      
subsection3  7ff7 7#a7 ,= purposes (    
subsection 7b71 ! ,,pr specifi$ p]c5t "u
 ?is subsection is--  7,a7 subject to   
p>agraph 7#b71 = ea* ( fiscal ye>s #bjbj
 ?r\gh #bjbd1 #hc p]c5t2  7,b7 subject  
to p>agraph 7#c77;,d77iii71 = ea* (     
fiscal ye>s #bjbe ?r\gh #bjbi1 #hc      
p]c5t2 &  7,c7 subject to p>agraph      
7#c77;,d77iii71 = fiscal ye> #bjcj & ea*
 subsequ5t fiscal ye>1 ! ,f$]al m$ical  
assi/ance p]c5tage calculat$ 9          
accordance ) ! fir/ s5t5ce ( subsection 
7b71 z su* s5t5ce applies to ! #ej      
,/ates4  7#b7  7,a7 ,if ,pu]to ,rico--  
7i7 = fiscal ye> #bjba1 is 9 compliance 
) none ( ! program enhancem5t           
requirem5ts describ$ 9 subp>agraph 7,b71
 ! ,,pr specifi$ p]c5t specifi$ "u      

p>agraph 7#a7 = su* fiscal ye> %all be  
r$uc$ by #b p]c5t2  7ii7 = fiscal ye>   
#bjbb1 is 9 compliance ) few] ?an two ( 
! f\r program enhancem5t requirem5ts    
describ$ 9 subp>agraph 7,b71 ! ,,pr     
specifi$ p]c5t specifi$ "u p>agraph 7#a7
 = su* fiscal ye> %all be r$uc$ by #c   
p]c5t2  7iii7 = fiscal ye> #bjbc1 is 9  
compliance ) few] ?an ?ree ( ! f\r      
program enhancem5t requirem5ts describ$ 
9 subp>agraph 7,b71 ! ,,pr specifi$     
p]c5t specifi$ "u p>agraph 7#a7 = su*   
fiscal ye> %all be r$uc$ by #e p]c5t2 & 
7iv7 = fiscal ye> #bjbd1 is 9 compliance
 ) few] ?an f\r ( ! program enhancem5t  
requirem5ts describ$ 9 subp>agraph 7,b71
 ! ,,pr specifi$ p]c5t specifi$ "u      
p>agraph 7#a7 = su* fiscal ye> %all be  
r$uc$ by #e p]c5t4  7,b7 ,= purposes (  
?is subsection1 ! program enhancem5t    
requirem5ts describ$ 9 ?is subp>agraph  
are ea* ( ! foll[+3  7i7 ,rates ( paym5t
 "u ! ,/ate plan "u ?is title = inpati5t
 hospital s]vices are n less ?an ! co/s 
incurr$ = su* s]vices4  7ii7 ,rates (   

paym5t "u ! ,/ate plan "u ?is title =   
physicians' s]vices are n less ?an #gj  
p]c5t ( ! am\nt t is payable = su*      
s]vices "u section #ahdh4  7iii7 ,!     
,/ate plan provides = m$ical assi/ance =
 ,hepatitis ,c drugs1 9 accordance ) !  
requirem5ts ( section #aibg o!rwise     
applicable to ! #ej ,/ates4  7iv7 ,!    
,/ate plan provides = m$ical assi/ance =
 ,m$ic>e co/-%>+ describ$ 9 subsection  
7p77#c77;,a77ii7 = qualifi$ ,m$ic>e     
b5efici>ies describ$ 9 subsection       
7p77#a71 9 accordance ) ! requirem5ts "u
 subsection 7p7 o!rwise applicable to ! 
#ej ,/ates4  7#c7  7,a7  7i7 ,n lat] ?an
 ,janu>y #a1 #bjbb1 ! ,gov]nor ( ,pu]to 
,rico %all submit to ! ,secret>y a      
,t]ritory ,transition ,plan1 :i* %all be
 develop$ ) /akehold] input & ) a public
 comm5t p]iod1 t includes--  7,i7 a     
detail$ description ( :i* program       
enhancem5ts describ$ 9 subp>agraph 7,c7 
,pu]to ,rico w include z m$ical         
assi/ance "u ! ,/ate plan "u title      
,,xix1 ! fir/ plan ye> by :i* ea* su*   

program enhancem5t w be s includ$ 9 ord]
 to satisfy ! requirem5ts describ$ 9    
subp>agraph 7,b71 & a timel9e =         
mile/ones = includ+ su* program         
enhancem5ts2 &  7,,ii7 a description (  
any *all5ges1 includ+ infra/ructure     
*all5ges1 provid] %ortages1 & f9anc+    
*all5ges1 = s includ+ su* program       
enhancem5ts & a plan to ameliorate any  
su* *all5ges4  7ii7 ,! plan submitt$ "u 
clause 7i7 %all be treat$ z approv$ by !
 ,secret>y n lat] ?an #ahj days aft] !  
date ( submission ( ! plan unless )9 su*
 #ahj-;day p]iod ! ,secret>y disapproves
 su* plan & notifies ,pu]to ,rico ( su* 
disapproval ) ! reason = su*            
disapproval4 ,9 ! case ( su* a          
disapproval1 ! ,gov]nor ( ,pu]to ,rico  
%all1 )9 ! #ij-;day p]iod foll[+ su*    
notification1 submit to ! ,secret>y a   
,t]ritory ,transition ,plan t addresses 
! reason specifi$ 9 su* notification =  
su* disapproval4 ,su* resubmitt$ plan   
%all be treat$ z approv$ by ! ,secret>y 
"u ?is clause unless ! ,secret>y        

notifies ,pu]to ,rico )9 ! #cj-;day     
p]iod foll[+ su* submission ( its       
disapproval ) a reason = su*            
disapproval4 ,! ,gov]nor ( ,pu]to ,rico 
may develop & submit to ! ,secret>y1 9 !
 same mann] & subject to ! same         
conditions z apply "u clause 7i7 to !   
developm5t & submission ( ! ,t]ritory   
,transition ,plan1 modifications to !   
plan & su* modifications %all be treat$ 
z approv$ by ! ,secret>y & incorporat$  
into ! plan 9 ! same mann] & subject to 
! same conditions t apply "u ?is clause 
to ! approval ( ! plan4  7,b7 ,=        
purposes ( ?is p>agraph1 ! requirem5ts  
describ$ 9 ?is subp>agraph1 ) respect to
 ,pu]to ,rico1 are ! foll[+3  7i7 ,=    
#bjbg1 ! ,/ate plan "u title ,,xix      
includes at lea/ #b ( ! program         
enhancem5ts describ$ 9 subp>agraph 7,c74
  7ii7 ,= #bjbi1 ! ,/ate plan includes  
at lea/ #d ( su* program enhancem5ts4   
7iii7 ,= #bjca1 ! ,/ate plan includes at
 lea/ #f ( su* program enhancem5ts4     
7iv7 ,= #bjcc & ea* subsequ5t ye>1 !    

,/ate plan includes all ( su* program   
enhancem5ts4  7,c7 ,= purposes ( ?is    
p>agraph1 ! program enhancem5ts describ$
 9 ?is subp>agraph are ! foll[+3  7i7 ,!
 ,/ate plan provides = m$ical assi/ance 
to all individuals describ$ 9 clause 7i7
 ( section #aijb7;a77#aj77;,a774  7ii7  
,! ,/ate plan provides = inclusion z    
m$ical assi/ance ( home heal? s]vices1 9
 accordance ) section                   
#aijb7;a77#aj77;,d74  7iii7 ,! ,/ate    
plan provides = inclusion z m$ical      
assi/ance ( nonem]g5cy transportation to
 m$ically necess>y s]vices4  7iv7 ,!    
,/ate plan provides = inclusion z m$ical
 assi/ance ( s]vices describ$ 9         
subsection 7a77#ba7 to all individuals  
describ$ 9 clause 7i7 ( section         
#aijb7;a77#aj77;,a774  7v7 ,! ,/ate plan
 provides = inclusion z m$ical assi/ance
 ( s]vices describ$ 9 subsection        
7a77#ag7 to all individuals describ$ 9  
su* clause 7o!r ?an subclause 7,,viii7 (
 su* clause4  7vi7 ,! ,/ate plan        
provides = inclusion z m$ical assi/ance 

( nurs+ facility s]vices1 z def9$ 9     
subsection 7a77#d77;,a74  7vii7 ,! ,/ate
 plan provides = inclusion z m$ical     
assi/ance ( e>ly & p]iodic scre5+1      
diagnosis1 & treatm5t s]vices "u        
subsection 7a77#d77;,b74  7viii7 ,!     
,/ate plan provides = inclusion z m$ical
 assi/ance ( free/&+ bir? c5t] s]vices &
 o!r ambulatory s]vices1 z describ$ 9   
subsection 7a77#bh74  7,d7  7i7 ,=      
fiscal ye> #bjbb & ea* subsequ5t fiscal 
ye> ?r\gh fiscal ye> #bjcc-- 7,i7 !     
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all review1 & submit to ! ,secret>y &  
,congress a report on1 :e!r or n ,pu]to 
,rico is 9 compliance ) ! timel9e &     
a*iev+ ! mile/ones describ$ 9 !         
,t]ritory ,transition plan 7z modifi$1  
if applicable7 approv$ "u subp>agraph   
7,a7 &1 beg9n+ ) fiscal ye> #bjbg1 :e!r 
,pu]to ,rico is 9 compliance ) !        
applicable requirem5ts describ$ 9       
subp>agraph 7,b72 &  7,,ii7 ,pu]to ,rico
 %all submit to ! ,secret>y a report on 
! ext5t to :i* ,pu]to ,rico has met !   

timel9es & mile/ones includ$ 9 su* plan 
7z modifi$1 if applicable74  7ii7 ,if1 =
 a fiscal ye> describ$ 9 clause 7i7 aft]
 fiscal ye> #bjbd1 ! ,comptroll] ,g5]al 
submits a report ) a f9d+ t ,pu]to ,rico
 is n 9 compliance ) ! timel9e or )     
a*iev+ mile/ones z describ$ 9 subclause 
7,i7 7or1 ) respect to a fiscal ye> aft]
 fiscal ye> #bjbf1 n 9 compliance ) !   
applicable requirem5t "u subp>agraph    
7,b771 n lat] ?an #ij days aft] ! date (
 su* f9d+1 ,pu]to ,rico %all submit to !
 ,secret>y = approval a corrective      
action plan to rem$y su* noncompliance4 
7iii7 ,if1 by n lat] ?an a p]iod        
specifi$ by ! ,secret>y aft] ! date ( ! 
submission 7& approval7 ( a corrective  
action plan "u clause 7ii71 ) respect to
 a fiscal ye> aft] fiscal ye> #bjbd =   
:i* a f9d+ ( non-compliance 0 made "u   
clause 7i71 ! ,secret>y det]m9es t      
,pu]to ,rico has n fulfill$ ! t]ms ( su*
 corrective action plan1 ! ,,pr specifi$
 p]c5t specifi$ "u p>agraph 7#a7 = !    
fiscal ye> involv$ %all be r$uc$ by #e  

p]c5t = ! p]iod beg9n+ ) ! mon? beg9n+  
aft] su* det]m9ation & end+ ) ! fir/    
mon? beg9n+ aft] ! ,secret>y det]m9es   
,pu]to ,rico has fulfill$ ! t]ms ( !    
corrective action plan4  4  7b7         
,treatm5t ( cap ,section #aajh7;g7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acjh7;g77 is am5d$-- 7#a7 9 p>agraph   
7#b7--  7,a7 9 ! matt] prec$+           
subp>agraph 7,a71 by /rik+ subject to & 
section #acbc7;a77#b7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act       
p>agraphs 7#c7 & 7#e7 & ins]t+ subject  
to section #acbc7;a77#b7 ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act &     
p>agraphs 7#c71 7#e71 & 7#g72 &  7,b7 9 
subp>agraph 7,a7-- 7i7 by /rik+ ,pu]to  
,rico %all n exce$ ! sum ( & ins]t+     
,pu]to ,rico %all n exce$-- 7i7 9 ! case
 ( a fiscal ye> be=e fiscal ye> #bjbj1 !
 sum (  2  7ii7 by /rik+ #ajj1jjj2 &    
ins]t+ #ajj1jjj2 &2 &  7iii7 by add+ at 
! end ! foll[+ new clause3  7ii7 9 !    
case ( fiscal ye> #bjbj & ea* subsequ5t 
fiscal ye> 7be=e fiscal ye> #bjbe71 !   

am\nt specifi$ 9 p>agraph 7#f7 = su*    
fiscal ye>2  2 &  7#b7 by add+ at ! end 
! foll[+ new p>agraphs3  7#f7           
,application to ,pu]to ,rico = fiscal   
ye>s #bjbj ?r\gh #bjbd ,= purposes (    
p>agraph 7#b77;,a77ii71 ! am\nt specifi$
 9 ?is p>agraph is--  7,a7 = fiscal ye> 
#bjbj1 #b1hbc1ahh1jjj2  7,b7 = fiscal   
ye> #bjba1 #b1iai1jgb1jjj2  7,c7 =      
fiscal ye> #bjbb1 #c1jab1faj1jjj2  7,d7 
= fiscal ye> #bjbc1 #c1aad1cca1jjj2 &   
7,e7 = fiscal ye> #bjbd1 #c1bbe1fbg1jjj4
  7#g7 ,pu]to ,rico exclusion f paym5t  
limitation beg9n+ fiscal ye> #bjbe      
,beg9n+ ) fiscal ye> #bjbe1 !re %all be 
no limitation appli$ "u ?is subsection  
7f7 or ?is subsection on ! total am\nt  
c]tifi$ by ! ,secret>y "u title ,,xix = 
paym5t to ,pu]to ,rico4  4  7c7         
,tempor>y increase 9 ,f$]al mat* = ,/ate
 plan adm9i/rative co/s ,section        
#aijc7;a77#g7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acif;b7a77#g77 is am5d$
 by ins]t+ 7or1 9 ! case ( ,pu]to ,rico 
= ea* ( fiscal ye>s #bjbj ?r\gh #bjcc1  

#ajj p]c5t7 aft] #ej p] c5tum4