[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 1961 Introduced in Senate (IS)]
114th CONGRESS
1st Session
S. 1961
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 programs, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
August 5, 2015
Mr. Schumer (for himself, Mrs. Gillibrand, Mr. Blumenthal, and Mr.
Menendez) introduced the following bill; 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 programs, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Improving the
Treatment of the U.S. Territories Under Federal Health Programs Act of
2015''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICAID
Sec. 101. Elimination of general Medicaid funding limitations (``cap'')
for territories.
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. Application of 100 percent Federal poverty line (FPL)
limitation to territories.
Sec. 105. Permitting Medicaid DSH allotments for territories.
TITLE II--MEDICARE
Subtitle A--Part A
Sec. 201. Modification of Medicare inpatient hospital payment rate for
Puerto Rico hospitals.
Sec. 202. Application of Medicare HITECH payments to hospitals in
Puerto Rico.
Sec. 203. Calculation of Medicare DSH payments for IPPS hospitals in
Puerto Rico.
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 enrollment penalties.
Sec. 212. Puerto Rico practice expense GPCI improvement.
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. Report on exclusion of territories from Exchanges.
TITLE I--MEDICAID
SEC. 101. ELIMINATION OF GENERAL MEDICAID FUNDING LIMITATIONS (``CAP'')
FOR TERRITORIES.
(a) In General.--Section 1108 of the Social Security Act (42 U.S.C.
1308) is amended--
(1) in subsection (f), in the matter before paragraph (1),
by striking ``subsection (g)'' and inserting ``subsections (g)
and (h)'';
(2) in subsection (g)(2), in the matter before subparagraph
(A), by inserting ``and subsection (h)'' after ``paragraphs (3)
and (5)''; and
(3) by adding at the end the following new subsection:
``(h) Sunset of Medicaid Funding Limitations for Puerto Rico, the
Virgin Islands of the United States, Guam, the Northern Mariana
Islands, and American Samoa.--Subsections (f) and (g) shall not apply
to Puerto Rico, the Virgin Islands of the United States, Guam, the
Northern Mariana Islands, and American Samoa beginning with fiscal year
2017.''.
(b) Conforming Amendments.--
(1) Section 1902(j) of the Social Security Act (42 U.S.C.
1396a(j)) is amended by striking ``, the limitation in section
1108(f),''.
(2) Section 1903(u) of the Social Security Act (42 U.S.C.
1396b(u)) is amended by striking paragraph (4).
(3) Section 1323(c)(1) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18043(c)(1)) is amended by
striking ``2019'' and inserting ``2016''.
(c) Effective Date.--The amendments made by this section shall
apply beginning with fiscal year 2017.
SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL ASSISTANCE PERCENTAGE
(FMAP) LIMITATION FOR TERRITORIES.
Section 1905 of the Social Security Act (42 U.S.C. 1396d) is
amended--
(1) in subsection (b)(2), by inserting ``for fiscal years
before fiscal year 2017'' after ``American Samoa''; and
(2) in subsection (y)(1), in the matter preceding
subparagraph (A)--
(A) by inserting ``, for fiscal years before fiscal
year 2017,'' before ``is one of the''; and
(B) by inserting ``and, for fiscal year 2017 and
subsequent fiscal years, is one of the 50 States, the
District of Columbia, Puerto Rico, the Virgin Islands
of the United States, Guam, the Northern Mariana
Islands, or American Samoa,'' after ``the District of
Columbia''.
SEC. 103. APPLICATION OF MEDICAID WAIVER AUTHORITY TO ALL OF THE
TERRITORIES.
(a) In General.--Section 1902(j) of the Social Security Act (42
U.S.C. 1396a(j)) is amended--
(1) by striking ``American Samoa and the Northern Mariana
Islands'' and inserting ``Puerto Rico, the Virgin Islands of
the United States, Guam, the Northern Mariana Islands, and
American Samoa'';
(2) by striking ``American Samoa or the Northern Mariana
Islands'' and inserting ``Puerto Rico, the Virgin Islands of
the United States, Guam, the Northern Mariana Islands, or
American Samoa'';
(3) by inserting ``(1)'' after ``(j)'';
(4) by inserting ``except as otherwise provided in this
subsection,'' after ``Notwithstanding any other requirement of
this title''; and
(5) by adding at the end the following:
``(2) The Secretary may not waive under this subsection the
requirement of subsection (a)(10)(A)(i)(IX) (relating to coverage of
adults formerly under foster care) with respect to any territory.''.
(b) Effective Date.--The amendments made by this section shall
apply beginning October 1, 2016.
SEC. 104. APPLICATION OF 100 PERCENT FEDERAL POVERTY LINE (FPL)
LIMITATION TO TERRITORIES.
(a) In General.--Section 1902 of the Social Security Act (42 U.S.C.
1396a) is amended--
(1) in subsection (a)(10)(A)(i)(VIII), by inserting ``(or,
subject to subsection (j), 100 percent in the case of Puerto
Rico, the Virgin Islands of the United States, Guam, the
Northern Mariana Islands, and American Samoa)'' after ``133
percent''; and
(2) in subsection (j), as amended by section 103, by adding
at the end the following new paragraph:
``(3)(A) Subject to subparagraph (B), Federal financial
participation shall not be available to Puerto Rico, the Virgin Islands
of the United States, Guam, the Northern Mariana Islands, or American
Samoa for medical assistance for an individual whose family income
exceeds 100 percent of the official poverty line for a family of the
size involved, except in the case of individuals qualifying for medical
assistance under subsection (a)(10)(A)(i)(IX).
``(B) The Secretary may, under paragraph (1) or section 1115, waive
the limitation under subparagraph (A) in the case of a territory other
than Puerto Rico. In carrying out this subparagraph, the Secretary
shall take into account the eligibility levels established under the
State plan of the territory involved before the date of the enactment
of this paragraph.''.
(b) Not Applying 5 Percent Disregard.--Section 1902(e)(14)(I) of
the Social Security Act (42 U.S.C. 1396b(e)(14)(I)) is amended by
adding at the end the following:
``The previous sentence shall only apply to a State
that is one of the 50 States or the District of
Columbia.''.
(c) Effective Date.--The amendments made by this section shall
apply with respect to eligibility determinations made with respect to
items and services furnished on or after October 1, 2016.
SEC. 105. PERMITTING MEDICAID DSH ALLOTMENTS FOR TERRITORIES.
Section 1923(f) of the Social Security Act (42 U.S.C. 1396) is
amended--
(1) in paragraph (6), by adding at the end the following
new subparagraph:
``(C) Territories.--
``(i) Fiscal year 2017.--For fiscal year
2017, with respect to the territories of Puerto
Rico, the Virgin Islands of the United States,
Guam, the Northern Mariana Islands, and
American Samoa, the DSH allotment determined
for each such territory shall bear the same
ratio to $150,000,000 as the ratio of the
number of individuals who are low-income or
uninsured and residing in each such respective
territory (as estimated from time to time by
the Secretary) bears to the sums of the number
of such individuals residing in all of the
territories.
``(ii) Subsequent fiscal year.--For each
subsequent fiscal year, the DSH allotment for
each such territory is subject to an increase
or reduction in accordance with paragraphs (3)
and (7).'';
(2) in paragraph (7)(A), by striking clause (iv) and
redesignating clause (v) as clause (iv); and
(3) in paragraph (9), by inserting before the period at the
end the following: ``, and includes, beginning with fiscal year
2017, Puerto Rico, the Virgin Islands of the United States,
Guam, the Northern Mariana Islands, and American Samoa''.
TITLE II--MEDICARE
Subtitle A--Part A
SEC. 201. MODIFICATION OF MEDICARE INPATIENT HOSPITAL PAYMENT RATE FOR
PUERTO RICO HOSPITALS.
Section 1886(d)(9)(E) of the Social Security Act (42 U.S.C.
1395ww(d)(9)(E)) is amended--
(1) by striking ``and'' at the end of clause (iii);
(2) in clause (iv)--
(A) by inserting ``and before October 1, 2015,''
after ``2004,''; and
(B) by striking the period at the end and inserting
``; and''; and
(3) by adding at the end the following new clause:
``(v) on or after October 1, 2015, the applicable Puerto
Rico percentage is 0 percent and the applicable Federal
percentage is 100 percent.''.
SEC. 202. APPLICATION OF MEDICARE HITECH PAYMENTS TO HOSPITALS IN
PUERTO RICO.
(a) In General.--Subsection (n)(6)(B) of section 1886 of the Social
Security Act (42 U.S.C. 1395ww) is amended by striking ``subsection (d)
hospital'' and inserting ``hospital that is a subsection (d) hospital
or a subsection (d) Puerto Rico hospital''.
(b) Conforming Amendments.--
(1) Subsection (b)(3)(B)(ix) of section 1886 of the Social
Security Act (42 U.S.C. 1395ww) is amended--
(A) in subclause (I), by striking ``(n)(6)(A)'' and
inserting ``(n)(6)(B)''; and
(B) in subclause (II), by striking ``a subsection
(d) hospital'' and inserting ``an eligible hospital''.
(2) Paragraphs (2) and (4)(A) of section 1853(m) of the
Social Security Act (42 U.S.C. 1395w-23(m)) are each amended by
striking ``1886(n)(6)(A)'' and inserting ``1886(n)(6)(B)''.
(c) Implementation.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services may implement the amendments
made by this section by program instruction or otherwise.
(d) Effective Date.--The amendments made by this section shall
apply as if included in the enactment of the American Recovery and
Reinvestment Act of 2009 (Public Law 111-5), except that, in order to
take into account delays in the implementation of this section, in
applying subsections (b)(3)(B)(ix), (n)(2)(E)(ii), and (n)(2)(G)(i) of
section 1886 of the Social Security Act, as amended by this section,
any reference in such subsections to a particular year shall be treated
with respect to a subsection (d) Puerto Rico hospital as a reference to
the year that is 5 years after such particular year (or 7 years after
such particular year in the case of applying subsection (b)(3)(B)(ix)
of such section).
SEC. 203. CALCULATION OF MEDICARE DSH PAYMENTS FOR IPPS HOSPITALS IN
PUERTO RICO.
Section 1886(d)(9)(D)(iii) of the Social Security Act (42 U.S.C.
1395ww(d)(9)(D)(iii)) is amended to read as follows:
``(iii) Subparagraph (F) (relating to disproportionate
share payments), including application of subsection (r),
except that for this purpose--
``(I) the sum described in clause (ii) of this
subparagraph shall be substituted for the sum referred
to in paragraph (5)(F)(ii)(I); and
``(II) for discharges occurring on or after October
1, 2015, subclause (I) of paragraph (5)(F)(vi) shall be
applied by substituting for the numerator described in
such subclause the number of subsection (d) Puerto Rico
hospital's patient days for the cost reporting period
involved which were made up of patients who (for such
days) were entitled to benefits under part A of this
title and were--
``(aa) entitled to supplementary security
income benefits (excluding any State
supplementation) under title XVI of this Act;
``(bb) eligible for medical assistance
under a State plan under title XIX; or
``(cc) receiving aid or assistance under
any plan of the State approved under title I,
X, XIV, or XVI.''.
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 ENROLLMENT PENALTIES.
(a) Application of Part B Deemed Enrollment Process to Residents of
Puerto Rico.--Section 1837(f)(3) of the Social Security Act (42 U.S.C.
1395p(f)(3)) is amended by striking ``, exclusive of Puerto Rico''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to individuals whose initial enrollment period under section
1837(d) of the Social Security Act begins on or after the first day of
the effective month, specified by the Secretary of Health and Human
Services under section 1839(j)(1)(C) of such Act, as added by
subsection (c)(2).
(c) Transition Providing Special Enrollment Period and Limit on
Late Enrollment Penalties for Certain Medicare Beneficiaries.--Section
1839 of the Social Security Act (42 U.S.C. 1395r) is amended--
(1) in the first sentence of subsection (b), by inserting
``subject to section 1839(j)(2),'' after ``subsection (i)(4) or
(l) of section 1837,''; and
(2) by adding at the end the following new subsection:
``(j) Special Rules for Certain Residents of Puerto Rico.--
``(1) Special enrollment period, coverage period for
residents who are eligible but not enrolled.--
``(A) In general.--In the case of a transition
individual (as defined in paragraph (3)) who is not
enrolled under this part as of the day before the first
day of the effective month (as defined in subparagraph
(C)), the Secretary shall provide for a special
enrollment period under section 1837 of 7 months
beginning with such effective month during which the
individual may be enrolled under this part.
``(B) Coverage period.--In the case of such an
individual who enrolls during such special enrollment
period, the coverage period under section 1838 shall
begin on the first day of the second month after the
month in which the individual enrolls.
``(C) Effective month defined.--In this section,
the term `effective month' means a month, not earlier
than October 2016 and not later than January 2017,
specified by the Secretary.
``(2) Reduction in late enrollment penalties for current
enrollees and individuals enrolling during transition.--
``(A) 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 (1)(A), the
amount of the late enrollment penalty imposed under
section 1839(b) shall be recalculated by reducing the
penalty to 15 percent of the penalty otherwise
established.
``(B) Application.--Subparagraph (A) shall be
applied in the case of a transition individual who--
``(i) is enrolled under this part as of the
month before the effective month, for premiums
for months beginning with such effective month;
or
``(ii) 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 (1)(A), for premiums for months
during the coverage period under this part
which occur during or after the effective
month.
``(C) Loss of reduction if individual terminates
enrollment.--Subparagraph (A) 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 (1).
``(3) Transition individual defined.--In this section, 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 1837(f) before the first day of the
effective month but for the fact that the individual was a
resident of Puerto Rico, regardless of whether the individual
is enrolled under this part as of such first day.''.
SEC. 212. PUERTO RICO PRACTICE EXPENSE GPCI IMPROVEMENT.
Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)) is amended--
(1) in subparagraph (A), by striking ``and (I)'' and
inserting ``(I), and (J)''; and
(2) by adding at the end the following new subparagraph:
``(J) Floor for practice expense index for services
furnished in puerto rico.--
``(i) In general.--For purposes of payment
for services furnished in Puerto Rico in a year
(beginning with 2016), after calculating the
practice expense index in subparagraph (A)(i)
for Puerto Rico, if such index is below the
reference index (as defined in clause (ii)) for
the year, the Secretary shall increase such
index for Puerto Rico to equal the value of the
reference index for the year. The preceding
sentence shall not be applied in a budget
neutral manner.
``(ii) Reference index defined.--In this
subparagraph, the term `reference index' means,
with respect to a year, 0.800 or, if less, the
lowest practice expense index value for the
year for any area in the 50 States or the
District of Columbia.''.
Subtitle C--Medicare Advantage (Part C)
SEC. 221. ADJUSTMENT IN BENCHMARK FOR LOW BASE PAYMENT COUNTIES IN
PUERTO RICO.
Section 1853(n) of the Social Security Act (42 U.S.C. 1395w-23(n))
is amended--
(1) in paragraph (1), by striking ``and (5)'' and inserting
``, (5), and (6)'';
(2) in paragraph (4), by striking ``In no case'' and
inserting ``Subject to paragraph (6), in no case''; and
(3) by adding at the end the following new paragraph:
``(6) Special rules for blended benchmark amount for
territories.--
``(A) In general.--Subject to paragraph (2), the
blended benchmark amount for an area in a territory for
a year (beginning with 2016) shall not be less than 80
percent of the national average of the base payment
amounts specified in subparagraph (2)(E) for such year
for areas within the 50 States and the District of
Columbia.
``(B) Limitation.--In no case shall the blended
benchmark amount for an area in a territory for a year
under subparagraph (A) exceed the lowest blended
benchmark amount for any area within the 50 States and
the District of Columbia for such year.''.
Subtitle D--Part D
SEC. 231. IMPROVED USE OF ALLOCATED PRESCRIPTION DRUG FUNDS BY
TERRITORIES.
Section 1935(e) of the Social Security Act (42 U.S.C. 1396u-5(e))
is amended by adding at the end the following new paragraph:
``(5) Improved use of funds for low-income part d eligible
individuals.--This subsection shall be applied beginning on
January 1, 2016, as follows, notwithstanding any other
provision of this title:
``(A) Clarifying state flexibility to cover non-
dual-eligible individuals.--For purposes of this
subsection, the term `medical assistance' includes
financial assistance furnished under this subsection by
a State other than the 50 States or the District of
Columbia to part D eligible individuals who, if they
were residing in one of the 50 States or the District
of Columbia, would qualify as subsidy eligible
individuals under section 1860D-14(a)(3), without
regard to whether such individuals otherwise qualify
for medical assistance under this title.
``(B) 100 percent fmap to reflect no state matching
required for part d low income subsidies.--The Federal
medical assistance percentage applicable to the
assistance furnished under this subsection is 100
percent.
``(C) Limited funding for special rules.--
Subparagraphs (A) and (B), and the provision of medical
assistance for covered part D drugs to low-income part
D eligible individuals for a State and year under this
subsection, are limited to the amount specified in
paragraph (3) for such State and year, without regard
to the application of subsection (f) or (g) of section
1108.''.
SEC. 232. REPORT ON TREATMENT OF TERRITORIES UNDER MEDICARE PART D.
Paragraph (4) of section 1935(e) of the Social Security Act (42
U.S.C. 1396u-5(e)) is amended to read as follows:
``(4) Report on application of subsection.--
``(A) In general.--Not later than May 1, 2018, the
Secretary shall submit to Congress a report on the
application of this subsection during the period
beginning with fiscal year 2006 and ending with
December 31, 2017.
``(B) Information to be included in report.--Such
report shall include--
``(i) program guidance issued by the
Secretary to implement this subsection;
``(ii) for each of Puerto Rico, the Virgin
Islands of the United States, Guam, the
Northern Mariana Islands, and American Samoa,
information on the increased amount under
paragraph (3) and how the territory has applied
such amount, including the territory's program
design, expenditures, and number of individuals
(and dual-eligible individuals) assisted; and
``(iii) 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 50 States
and the District of Columbia under such part
and this title for different fiscal years
within the period covered under the report.
``(C) Recommendations.--Such report shall include
recommendations for improving prescription drug
coverage for low-income individuals in each territory
identified in subparagraph (B)(ii), including
recommendations regarding each of the following
alternative approaches:
``(i) Adjusting the aggregate amount
specified in paragraph (3)(B).
``(ii) Allowing residents of the
territories to be subsidy eligible individuals
under section 1860D-14, notwithstanding
subsection (a)(3)(F) of such section, or
providing substantially equivalent low-income
prescription drug subsidies to such
residents.''.
TITLE III--MISCELLANEOUS
SEC. 301. REPORT ON EXCLUSION OF TERRITORIES FROM EXCHANGES.
(a) In General.--Not later than February 1, 2018, 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 businesses.
(b) Information in Report.--The report shall include information on
the following:
(1) An estimate of the total number of uninsured and
underinsured individuals residing in each territory with
respect to health insurance coverage.
(2) A description of the number of health insurance issuers
in each territory and the health insurance plans these issuers
offer.
(3) 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 50 States or in the District of Columbia.
(4) An estimate of the amount of Federal assistance
described in paragraph (3) that is not being made available to
residents of each territory.
(5) 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 (SHOP)
Marketplace that would operate as part of an Exchange if the
employers were in one of the 50 States or in the District of
Columbia.
<all>