Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021
This bill alters certain funding and payment mechanisms, and establishes several requirements, for Puerto Rico's Medicaid program.
Among other changes, the bill increases the federal matching rate, also known as the Federal Medical Assistance Percentage (FMAP), from 55% to 83% through FY2031; beginning in FY2032, the FMAP must be calculated in the same manner as for states (i.e., based on per capita income). Puerto Rico must also expand its Medicaid program to include certain items, services, and populations that states are already required to cover; failure to do so results in a reduction of the applicable FMAP. Additionally, beginning in FY2027, the bill excludes Puerto Rico from a Medicaid funding cap that currently applies to U.S. territories.
To amend titles XI and XIX of the Social Security Act to stabilize the 
                    Medicaid program in Puerto Rico.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Puerto Rico Health Care Fairness, 
Accountability, and Beneficiary Access Act of 2021''.

SEC. 2. ADJUSTMENTS TO FMAP AND CAP FOR PUERTO RICO.

    (a) Adjustments to FMAP.--Section 1905 of the Social Security Act 
(42 U.S.C. 1396d) is amended--
            (1) in subsection (b) by inserting ``(except for Puerto 
        Rico, for calendar quarters in a fiscal year beginning with 
        fiscal year 2022, shall be the PR specified percent under 
        subsection (hh) for such fiscal year)'' after ``shall be 55 
        percent''; and
            (2) by adding at the end the following new subsection:
    ``(hh) PR Specified Percent.--
            ``(1) In general.--For purposes of subsection (b), the PR 
        specified percent under this subsection is--
                    ``(A) subject to paragraph (2), for each of fiscal 
                years 2022 through 2026, 83 percent;
                    ``(B) subject to paragraph (3)(D)(iii), for each of 
                fiscal years 2027 through 2031, 83 percent; and
                    ``(C) subject to paragraph (3)(D)(iii), for fiscal 
                year 2032 and each subsequent fiscal year, the Federal 
                medical assistance percentage calculated in accordance 
                with the first sentence of subsection (b), as such 
                sentence applies to the 50 States.
    ``(2) Program Enhancement Incentives.--
            ``(A) In general.--If Puerto Rico--
                    ``(i) for fiscal year 2023, is in compliance with 
                none of the program enhancement requirements described 
                in subparagraph (B), the PR specified percent specified 
                under paragraph (1) for such fiscal year shall be 
                reduced by 2 percent;
                    ``(ii) for fiscal year 2024, is in compliance with 
                fewer than two of the four program enhancement 
                requirements described in subparagraph (B), the PR 
                specified percent specified under paragraph (1) for 
                such fiscal year shall be reduced by 3 percent;
                    ``(iii) for fiscal year 2025, is in compliance with 
                fewer than three of the four program enhancement 
                requirements described in subparagraph (B), the PR 
                specified percent specified under paragraph (1) for 
                such fiscal year shall be reduced by 5 percent; and
                    ``(iv) for fiscal year 2026, is in compliance with 
                fewer than four of the program enhancement requirements 
                described in subparagraph (B), the PR specified percent 
                specified under paragraph (1) for such fiscal year 
                shall be reduced by 5 percent.
            ``(B) Program enhancement requirements.--For purposes of 
        this subsection, the program enhancement requirements described 
        in this subparagraph are each of the following:
                    ``(i) Rates of payment under the State plan under 
                this title for inpatient hospital services are not less 
                than the costs incurred for such services.
                    ``(ii) Rates of payment under the State plan under 
                this title for physicians' services are not less than 
                70 percent of the amount that is payable for such 
                services under section 1848.
                    ``(iii) The State plan provides for medical 
                assistance for Hepatitis C drugs, in accordance with 
                the requirements of section 1927 otherwise applicable 
                to the 50 States.
                    ``(iv) The State plan provides for medical 
                assistance for Medicare cost-sharing described in 
                subsection (p)(3)(A)(ii) for qualified Medicare 
                beneficiaries described in subsection (p)(1), in 
                accordance with the requirements under subsection (p) 
                otherwise applicable to the 50 States.
    ``(3) Territory Transition Plan.--
            ``(A) In general.--
                    ``(i) Submission of plan.--Not later than January 
                1, 2024, the Governor of Puerto Rico shall submit to 
                the Secretary a Territory Transition Plan, which shall 
                be developed with stakeholder input and with a public 
                comment period, that includes--
                            ``(I) a detailed description of which 
                        program enhancements described in subparagraph 
                        (C) Puerto Rico will include as medical 
                        assistance under the State plan under title 
                        XIX, the first plan year by which each such 
                        program enhancement will be so included in 
                        order to satisfy the requirements described in 
                        subparagraph (B), and a timeline for milestones 
                        for including such program enhancements; and
                            ``(II) a description of any challenges, 
                        including infrastructure challenges, provider 
                        shortages, and financing challenges, for so 
                        including such program enhancements and a plan 
                        to ameliorate any such challenges.
                    ``(ii) Notification of plan approval.--The plan 
                submitted under clause (i) shall be treated as approved 
                by the Secretary not later than 180 days after the date 
                of submission of the plan unless within such 180-day 
                period the Secretary disapproves such plan and notifies 
                Puerto Rico of such disapproval with the reason for 
                such disapproval. In the case of such a disapproval, 
                the Governor of Puerto Rico shall, within the 90-day 
                period following such notification, submit to the 
                Secretary a Territory Transition Plan that addresses 
                the reason specified in such notification for such 
                disapproval. Such resubmitted plan shall be treated as 
                approved by the Secretary under this clause unless the 
                Secretary notifies Puerto Rico within the 30-day period 
                following such submission of its disapproval with a 
                reason for such disapproval. The Governor of Puerto 
                Rico may develop and submit to the Secretary, in the 
                same manner and subject to the same conditions as apply 
                under clause (i) to the development and submission of 
                the Territory Transition Plan, modifications to the 
                plan and such modifications shall be treated as 
                approved by the Secretary and incorporated into the 
                plan in the same manner and subject to the same 
                conditions that apply under this clause to the approval 
                of the plan.
            ``(B) Requirements described.--For purposes of this 
        paragraph, the requirements described in this subparagraph, 
        with respect to Puerto Rico, are the following:
                    ``(i) For 2029, the State plan under title XIX 
                includes at least 2 of the program enhancements 
                described in subparagraph (C).
                    ``(ii) For 2031, the State plan includes at least 4 
                of such program enhancements.
                    ``(iii) For 2033, the State plan includes at least 
                6 of such program enhancements.
                    ``(iv) For 2035 and each subsequent year, the State 
                plan includes all of such program enhancements.
            ``(C) Program enhancements described.--For purposes of this 
        paragraph, the program enhancements described in this 
        subparagraph are the following:
                    ``(i) The State plan provides for medical 
                assistance to all individuals described in clause (i) 
                of section 1902(a)(10)(A)).
                    ``(ii) The State plan provides for inclusion as 
                medical assistance of home health services, in 
                accordance with section 1902(a)(10)(D).
                    ``(iii) The State plan provides for inclusion as 
                medical assistance of nonemergency transportation to 
                medically necessary services.
                    ``(iv) The State plan provides for inclusion as 
                medical assistance of services described in subsection 
                (a)(21) to all individuals described in clause (i) of 
                section 1902(a)(10)(A)).
                    ``(v) The State plan provides for inclusion as 
                medical assistance of services described in subsection 
                (a)(17) to all individuals described in such clause 
                (other than subclause (VIII) of such clause.
                    ``(vi) The State plan provides for inclusion as 
                medical assistance of nursing facility services, as 
                defined in subsection (a)(4)(A).
                    ``(vii) The State plan provides for inclusion as 
                medical assistance of early and periodic screening, 
                diagnosis, and treatment services under subsection 
                (a)(4)(B).
                    ``(viii) The State plan provides for inclusion as 
                medical assistance of freestanding birth center 
                services and other ambulatory services, as described in 
                subsection (a)(28).
            ``(D) Reports.--
                    ``(i) For fiscal year 2024 and each subsequent 
                fiscal year through fiscal year 2035--
                            ``(I) the Comptroller General of the United 
                        States shall review, and submit to the 
                        Secretary and Congress a report on, whether or 
                        not Puerto Rico is in compliance with the 
                        timeline and achieving the milestones described 
                        in the Territory Transition plan (as modified, 
                        if applicable) approved under subparagraph (A) 
                        and, beginning with fiscal year 2029, whether 
                        Puerto Rico is in compliance with the 
                        applicable requirements described in 
                        subparagraph (B); and
                            ``(II) Puerto Rico shall submit to the 
                        Secretary a report on the extent to which 
                        Puerto Rico has met the timelines and 
                        milestones included in such plan (as modified, 
                        if applicable).
                    ``(ii) If, for a fiscal year described in clause 
                (i) after fiscal year 2026, the Comptroller General 
                submits a report with a finding that Puerto Rico is not 
                in compliance with the timeline or with achieving 
                milestones as described in subclause (I) (or, with 
                respect to a fiscal year after fiscal year 2028, not in 
                compliance with the applicable requirement under 
                subparagraph (B)), not later than 90 days after the 
                date of such finding, Puerto Rico shall submit to the 
                Secretary for approval a corrective action plan to 
                remedy such noncompliance.
                    ``(iii) If, by not later than a period specified by 
                the Secretary after the date of the submission (and 
                approval) of a corrective action plan under clause 
                (ii), with respect to a fiscal year after fiscal year 
                2026 for which a finding of non-compliance was made 
                under clause (i), the Secretary determines that Puerto 
                Rico has not fulfilled the terms of such corrective 
                action plan, the PR specified percent specified under 
                paragraph (1) for the fiscal year involved shall be 
                reduced by 5 percent for the period beginning with the 
                month beginning after such determination and ending 
                with the first month beginning after the Secretary 
                determines Puerto Rico has fulfilled the terms of the 
                corrective action plan.''.
    (b) Treatment of Cap.--Section 1108(g) of the Social Security Act 
(42 U.S.C. 1308(g)) is amended--
            (1) in paragraph (2)--
                    (A) in the matter preceding subparagraph (A), by 
                striking ``subject to and section 1323(a)(2) of the 
                Patient Protection and Affordable Care Act paragraphs 
                (3) and (5)'' and inserting ``subject to section 
                1323(a)(2) of the Patient Protection and Affordable 
                Care Act and paragraphs (3), (5), and (7)''; and
                    (B) in subparagraph (A)--
                            (i) by striking ``Puerto Rico shall not 
                        exceed the sum of'' and inserting ``Puerto Rico 
                        shall not exceed--
                            ``(i) in the case of a fiscal year before 
                        fiscal year 2022, the sum of'';
                            (ii) by striking ``$100,000;'' and 
                        inserting ``$100,000; and''; and
                            (iii) by adding at the end the following 
                        new clause:
                            ``(ii) in the case of fiscal year 2022 and 
                        each subsequent fiscal year (before fiscal year 
                        2027), the amount specified in paragraph (6) 
                        for such fiscal year;''; and
            (2) by adding at the end the following new paragraphs:
            ``(6) Application to puerto rico for fiscal years 2022 
        through 2026.--For purposes of paragraph (2)(A)(ii), the amount 
        specified in this paragraph is--
                    ``(A) for fiscal year 2022, $3,012,610,000;
                    ``(B) for fiscal year 2023, $3,114,331,000;
                    ``(C) for fiscal year 2024, $3,225,627,000;
                    ``(D) for fiscal year 2025, $3,336,627,000; and
                    ``(E) for fiscal year 2026, $3,447,627,000.
            ``(7) Puerto rico exclusion from payment limitation 
        beginning fiscal year 2027.--Beginning with fiscal year 2027, 
        there shall be no limitation applied under this subsection (f) 
        or this subsection on the total amount certified by the 
        Secretary under title XIX for payment to Puerto Rico.''.
    (c) Temporary Increase in Federal Match for State Plan 
Administrative Costs.--Section 1903(a)(7) of the Social Security Act 
(42 U.S.C. 1396b(a)(7)) is amended by inserting ``(or, in the case of 
Puerto Rico for each of fiscal years 2022 through 2035, 100 percent)'' 
after ``50 per centum''.
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Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021
To amend titles XI and XIX of the Social Security Act to stabilize the Medicaid program in Puerto Rico.
Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021
Rep. Velazquez, Nydia M.