Improving the Treatment of the U.S. Territories Under Federal Health Programs Act of 2015

Improving the Treatment of the U.S. Territories Under Federal Health Programs Act of 2015

This bill amends title XIX (Medicaid) the Social Security Act (SSAct) to terminate the limitations on general Medicaid funding, as well as the specific federal medical assistance percentage (FMAP, or matching rate), beginning FY2017 for Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa (territories).

The authority to waive or modify Medicaid requirements (except certain requirements for coverage of adults formerly under foster care) in American Samoa and the Northern Mariana Islands shall now extend as well to Puerto Rico, the U.S. Virgin Islands, and Guam.

Federal financial participation shall not be available to a territory, however, for medical assistance (with certain exceptions) for an individual whose family income exceeds 100% percent of the official poverty line for a family of the size involved.

A formula is prescribed for Medicaid disproportionate share hospital (DSH) payments to the territories beginning FY2017.

This bill also amends SSAct title XVIII (Medicare) to revise the formula for the Medicare inpatient hospital services payment rate for hospitals in Puerto Rico to: (1) reduce the applicable Puerto Rico percentage from 25% to zero, and (2) increase the applicable federal percentage from 75% to 100%.

Medicare HITECH (Health Information Technology for Economic and Clinical Health Act) payments shall now apply to subsection (d) hospitals in Puerto Rico to allow them to qualify for incentives for adoption and meaningful use of certified electronic health record technology.

(Generally, a subsection [d] hospital is an acute care hospital, particularly one that receives payments under Medicare's inpatient prospective payment system when providing covered inpatient services to eligible beneficiaries.)

A formula element is revised for calculating Medicare DSH payments under the inpatient prospective payment system for subsection (d) hospitals in Puerto Rico.

The exclusion of residents of Puerto Rico from deemed enrollment under part B (Supplementary Medical Insurance Benefits) is repealed and they may now be deemed to be so enrolled. The Department of Health and Human Services (HHS) shall provide a special seven-month enrollment period for such residents. The late enrollment penalty shall be recalculated to 15% of the usual penalty for residents of Puerto Rico who are current enrollees or who enroll during a specified transition period.

HHS shall increase the geographic adjustment practice expense index for Puerto Rico to equal 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) for the year.

The blended benchmark component of payments to Medicare + Choice organizations for an area in a territory under SSAct title XVIII part C (Medicare+Choice) shall be, beginning with 2016, at least 80% of the national average of specified base payment amounts for the year (but never more than the lowest blended benchmark amount) for any area within the 50 States and the District of Columbia.

HHS shall treat as medical assistance under the Medicaid program, with a 100% FMAP, any financial assistance a territory furnishes to individuals eligible for prescription drugs under SSAct title XVIII part D (Voluntary Prescription Drug Benefit Program) who, if they were residing in one of the 50 States or the District of Columbia, would qualify as low-income subsidy eligible individuals, without regard to whether they otherwise qualify for Medicaid.

HHS shall report to Congress on the treatment of territories under Medicare part D.

This bill amends the Patient Protection and Affordable Care Act (PPACA) to reduce by 50% the annual fee imposed on health insurance providers for U.S. health risks in the territories. Funds from such fees shall be available to a territory only to assist low-income part D eligible individuals to obtain part D-covered drugs.

HHS shall publish and update periodically, on the Internet site of the Centers for Medicare and Medicaid Services, information on the programs under SSAct titles XIX (Medicaid) and XXI (Children's Health Insurance Program, or CHIP) that are carried out in the U.S. territories.

HHS shall report to Congress on the adverse impacts in each territory from their practical exclusion under PPACA from the establishment of American Health Benefit Exchanges or the administration of a federally facilitated Exchange.

Written by the nonpartisan Congressional Research Service. All summary versions on Congress.gov