S.Amdt. 4875

SA 4875. Mr. SCHUMER submitted an amendment intended to be proposed
by him to the bill S. 2328, to reauthorize and amend the National Sea
Grant College Program Act, and for other purposes; which was ordered to
lie on the table; as follows:

On page 157, after line 19, add the following:
TITLE VIII--IMPROVING THE TREATMENT OF THE U.S. TERRITORIES UNDER
FEDERAL HEALTH PROGRAMS

SEC. 800. EFFECTIVE DATE.

Section 2 of this Act shall apply to this title and the
amendments made by this title unless otherwise specified in
this title.
Subtitle A--Medicaid

SEC. 801. 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)--
(A) by striking ``subject to and'' and inserting ``subject
to''; and
(B) by striking ``paragraphs (3) and (5)'' and inserting
``, and paragraphs (3) and (5) of this subsection and
subsection (h)''; 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. 802. 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. 803. 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. 804. 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 803, 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. 805. 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''.

[[Page S4654]]

Subtitle B--Medicare
PART I--PART A

SEC. 811. 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,
2016, 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.''.
PART II--PART B

SEC. 821. 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. 822. 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.''.
PART III--MEDICARE ADVANTAGE (PART C)

SEC. 831. 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.''.
PART IV--PART D

SEC. 841. 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. 842. 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

[[Page S4655]]

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.''.
Subtitle C--Miscellaneous

SEC. 851. 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.
______