Territories Health Equity Act of 2025
This bill alters provisions relating to the treatment of U.S. territories under Medicaid, Medicare, and Medicare Advantage.
For example, the bill
The bill also allows residents of U.S. territories who are unable to obtain health insurance through their employer or a health insurance exchange to instead obtain coverage that is at least as broad as the coverage available to Members of Congress and their staff through the District of Columbia exchange.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6494 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 6494
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 HOUSE OF REPRESENTATIVES
December 5, 2025
Ms. Plaskett (for herself, Mrs. Radewagen, Mr. Hernandez, Mr. Moylan,
and Ms. King-Hinds) introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the
Committee on Ways and Means, for a period to be subsequently determined
by the Speaker, in each case for consideration of such provisions as
fall within the jurisdiction of the committee concerned
_______________________________________________________________________
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 ``Territories Health
Equity Act of 2025''.
(b) Table of Contents.--The table of contents for 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 Puerto Rico.
Sec. 103. Permitting Medicaid DSH allotments for territories.
TITLE II--MEDICARE
Subtitle A--Part A
Sec. 201. Calculation of Medicare DSH payments for IPPS hospitals in
Puerto Rico.
Sec. 202. Rebasing target amount for hospitals in territories.
Sec. 203. Medicare DSH target adjustment for hospitals in territories.
Subtitle B--Part B
Sec. 211. Eliminating late enrollment penalties under Part B of the
Medicare program for certain individuals
residing in Puerto Rico.
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. Automatic eligibility of certain low-income territorial
residents for premium and cost-sharing
subsidies under the Medicare program;
sunset of enhanced allotment program.
TITLE III--MISCELLANEOUS
Sec. 301. Medicaid and CHIP territory transparency and information.
Sec. 302. Report on exclusion of territories from exchanges.
Sec. 303. Access to coverage for individuals in certain areas without
any available exchange plans.
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 preceding paragraph
(1), by striking ``subsections (g) and (h)'' and inserting
``subsections (g), (h), and (j)'';
(2) in subsection (g)(2), in the matter preceding
subparagraph (A), by inserting ``subsection (j) and'' after
``subject to'';
(3) in subsection (i), by striking paragraph (4); and
(4) by adding at the end the following new subsection:
``(j) Sunset of Medicaid Funding Limitations for Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, and American
Samoa.--Subsections (f) and (g) shall not apply to Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa
beginning with fiscal year 2026.''.
(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).
(c) Effective Date.--The amendments made by this section shall
apply beginning with fiscal year 2026.
SEC. 102. ELIMINATION OF SPECIFIC FEDERAL MEDICAL ASSISTANCE PERCENTAGE
(FMAP) LIMITATION FOR PUERTO RICO.
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 2026'' after ``American Samoa''; and
(2) in subsection (ff)(2), by striking ``2027'' and
inserting ``2025''.
SEC. 103. PERMITTING MEDICAID DSH ALLOTMENTS FOR TERRITORIES.
Section 1923(f) of the Social Security Act (42 U.S.C. 1396r-4(f))
is amended--
(1) in paragraph (6), by adding at the end the following
new subparagraph:
``(C) Territories.--
``(i) Fiscal year 2026.--For fiscal year
2026, the DSH allotment for Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana
Islands, and American Samoa shall bear the same
ratio to $300,000,000 as the ratio of the
number of individuals who are low-income or
uninsured and residing in 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
in accordance with paragraph (3).''; and
(2) in paragraph (9), by inserting before the period at the
end the following: ``, and includes, beginning with fiscal year
2026, Puerto Rico, the Virgin Islands, Guam, the Northern
Mariana Islands, and American Samoa''.
TITLE II--MEDICARE
Subtitle A--Part A
SEC. 201. 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, 2025, 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;
``(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.''.
SEC. 202. REBASING TARGET AMOUNT FOR HOSPITALS IN TERRITORIES.
Section 1886(b)(3) of the Social Security Act (42 U.S.C.
1395ww(b)(3)) is amended by adding at the end the following new
subparagraph:
``(M)(i) For each cost reporting period beginning
on or after October 1, 2025, in the case of a hospital
located in a territory of the United States, there
shall be substituted for the target amount otherwise
determined under subparagraph (A) the rebased target
amount (as defined in clause (ii)), if such
substitution results in an amount of payment under this
section to the hospital for such period that is greater
than the amount of payment that would be made under
this section to the hospital for such period if this
subparagraph were not to apply.
``(ii) For purposes of this subparagraph, the term
`rebased target amount' has the meaning given the term
`target amount' in subparagraph (A), except that--
``(I) for a cost reporting period beginning
on or after October 1, 2025, and before
September 30, 2030, there shall be substituted
for the preceding 12-month cost reporting
period the 12-month cost reporting period
beginning during fiscal year 2017;
``(II) for a cost reporting period
beginning on or after October 1, 2030, there
shall be substituted for the preceding 12-month
cost reporting period the cost reporting period
for which the target amount determined under
subparagraph (A) is the highest among the 5
cost reporting periods for which the Secretary
has the most recent settled cost reports;
``(III) any reference in subparagraph
(A)(i) to the `first such cost reporting
period' is deemed a reference to the first cost
reporting period following the 12-month cost
reporting period beginning during fiscal year
2017; and
``(IV) the applicable percentage increase
shall only be applied under subparagraph
(B)(ii) for cost reporting periods beginning on
or after October 1, 2025.''.
SEC. 203. MEDICARE DSH TARGET ADJUSTMENT FOR HOSPITALS IN TERRITORIES.
Section 1886(b)(3) of the Social Security Act (42 U.S.C.
1395ww(b)(3)), as amended by section 202, is further amended by adding
at the end the following new subparagraph:
``(N)(i) For each cost reporting period beginning
on or after October 1, 2025, in the case of a hospital
that is located in a territory of the United States
other than Puerto Rico and that would be a subsection
(d) hospital if it were located in one of the 50
States, the target amount shall be increased by--
``(I) in the case that such hospital has a
disproportionate patient percentage of not less
than 15 percent and not greater than 40
percent, 10 percent; and
``(II) in the case that such hospital has a
disproportionate patient percentage of greater
than 40 percent, 10 percent plus 60 percent of
the number of percentage points by which such
hospital's disproportionate patient percentage
exceeds 40 percent.
``(ii) For purposes of this subparagraph, the term
`disproportionate patient percentage' has the meaning
given such term in subsection (d)(5)(F)(vi), except
that in applying such meaning any reference under such
subsection to individuals entitled to supplementary
security income under title XVI shall be deemed for
purposes of this subparagraph to include individuals--
``(I) eligible for medical assistance under
a State plan under title XIX; or
``(II) receiving aid or assistance under
any plan of the territory approved under title
I, X, XIV, or XVI.''.
Subtitle B--Part B
SEC. 211. ELIMINATING LATE ENROLLMENT PENALTIES UNDER PART B OF THE
MEDICARE PROGRAM FOR CERTAIN INDIVIDUALS RESIDING IN
PUERTO RICO.
(a) In General.--Section 1839(b) of the Social Security Act (42
U.S.C. 1395r(b)) is amended in the second sentence by inserting ``or
months occurring in the 5-year period beginning on the date on which
the individual becomes entitled to benefits under part A if such
individual was residing in Puerto Rico as of such date and such date is
after the date that is 4 years before the date of the enactment of the
Territories Health Equity Act of 2025'' before the period at the end of
such sentence.
(b) Application.--The amendment made by subsection (a) shall apply
with respect to premiums paid for months beginning on or after the date
of the enactment of this Act.
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 2026) 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. AUTOMATIC ELIGIBILITY OF CERTAIN LOW-INCOME TERRITORIAL
RESIDENTS FOR PREMIUM AND COST-SHARING SUBSIDIES UNDER
THE MEDICARE PROGRAM; SUNSET OF ENHANCED ALLOTMENT
PROGRAM.
(a) Automatic Eligibility of Certain Low-Income Territorial
Residents for Premium and Cost-Sharing Subsidies Under the Medicare
Program.--
(1) In general.--Section 1860D-14(a)(3) of the Social
Security Act (42 U.S.C. 1395w-114(a)(3)) is amended--
(A) in subparagraph (B)(v)--
(i) in subclause (I), by striking ``and''
at the end;
(ii) in subclause (II), by striking the
period and inserting ``; and''; and
(iii) by inserting after subclause (II) the
following new subclause:
``(III) with respect to plan years
beginning on or after January 1, 2026,
shall provide that any part D eligible
individual who is enrolled for medical
assistance under the State Medicaid
plan of a territory (as defined in
section 1935(f)) under title XIX (or a
waiver of such a plan) shall be treated
as a subsidy eligible individual
described in paragraph (1).''; and
(B) in subparagraph (F), by adding at the end the
following new sentence: ``The previous sentence shall
not apply with respect to eligibility determinations
for premium and cost-sharing subsidies under this
section made on or after January 1, 2026.''.
(2) Conforming amendment.--Section 1860D-31(j)(2)(D) of the
Social Security Act (42 U.S.C. 1395w-141(j)(2)(D)) is amended
by adding at the end the following new sentence: ``The previous
sentence shall not apply with respect to amounts made available
to a State under this paragraph on or after January 1, 2026.''.
(b) Sunset of Enhanced Allotment Program.--
(1) In general.--Section 1935(e) of the Social Security Act
(42 U.S.C. 1396u-5(e)) is amended--
(A) in paragraph (1)(A), by inserting after ``such
State'' the following: ``before January 1, 2026''; and
(B) in paragraph (3)--
(i) in subparagraph (A), in the matter
preceding clause (i), by inserting after ``a
year'' the following: ``(before 2026)''; and
(ii) in subparagraph (B)(iii), by striking
``a subsequent year'' and inserting ``each of
fiscal years 2010 through 2025''.
(2) Territory defined.--Section 1935 of the Social Security
Act (42 U.S.C. 1396u-5) is amended by adding at the end the
following new subsection:
``(f) Territory Defined.--In this section, the term `territory'
means Puerto Rico, the Virgin Islands, Guam, the Northern Mariana
Islands, and American Samoa.''.
TITLE III--MISCELLANEOUS
SEC. 301. MEDICAID AND CHIP TERRITORY TRANSPARENCY AND INFORMATION.
(a) Publication of Information on Federal Expenditures Under
Medicaid and CHIP in the Territories.--Not later than 180 days after
the date of the enactment of this Act, the Secretary of Health and
Human Services shall publish, and periodically update, on the internet
site of the Centers for Medicare & Medicaid Services information on
Medicaid and CHIP carried out in the territories of the United States.
Such information shall include, with respect to each such territory--
(1) the income levels established by the territory for
purposes of eligibility of an individual to receive medical
assistance under Medicaid or child health assistance under
CHIP;
(2) the number of individuals enrolled in Medicaid and CHIP
in such territory;
(3) any State plan amendments in effect to carry out
Medicaid or CHIP in such territory;
(4) any waiver of the requirements of title XIX or title
XXI issued by the Secretary to carry out Medicaid or CHIP in
the territory, including a waiver under section 1115 of the
Social Security Act (42 U.S.C. 1315), any application for such
a waiver, and any documentation related to such application
(including correspondence);
(5) the amount of the Federal and non-Federal share of
expenditures under Medicaid and CHIP in such territory;
(6) the systems in place for the furnishing of health care
items and services under Medicaid and CHIP in such territory;
(7) the design of CHIP in such territory; and
(8) other information regarding the carrying out of
Medicaid and CHIP in the territory that is published on such
internet site with respect to carrying out Medicaid and CHIP in
each State and the District of Columbia.
(b) Definitions.--In this section:
(1) CHIP.--The term ``CHIP'' means the State Children's
Health Insurance Program under title XXI of the Social Security
Act.
(2) Medicaid.--The term ``Medicaid'' means the Medicaid
program under title XIX of the Social Security Act.
(3) Territory.--The term ``territory of the United States''
includes Puerto Rico, the Virgin Islands of the United States,
Guam, the Northern Mariana Islands, and American Samoa.
SEC. 302. REPORT ON EXCLUSION OF TERRITORIES FROM EXCHANGES.
(a) In General.--Not later than February 1, 2026, 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.
SEC. 303. ACCESS TO COVERAGE FOR INDIVIDUALS IN CERTAIN AREAS WITHOUT
ANY AVAILABLE EXCHANGE PLANS.
Part 2 of subtitle D of title I of the Patient Protection and
Affordable Care Act (42 U.S.C. 18031 et seq.) is amended by adding at
the end the following:
``SEC. 1314. ACCESS TO COVERAGE FOR INDIVIDUALS IN CERTAIN AREAS
WITHOUT ANY AVAILABLE EXCHANGE PLANS.
``(a) In General.--
``(1) Coverage through dc exchange.--Not later than 3
months after the date of enactment of this section, the
Secretary, in consultation with the Secretary of the Treasury
and the Director of the Office of Personnel Management, shall
establish a mechanism to ensure that, for any plan year
beginning on or after the date described in subsection (c), any
individual described in paragraph (2) has access to health
insurance coverage which is at least as broad as the coverage
available to Members of Congress and congressional staff (as
defined in section 1312(d)(3)(D)) through the Exchange
operating in the District of Columbia. Such individuals shall
be eligible for any premium tax credit under section 36B of the
Internal Revenue Code of 1986, reduced cost sharing under
section 1402, and advance determination and payment of such
credits or such reductions under section 1412 to be
administered by the Secretary, in consultation with the
Secretary of the Treasury and the Director of the Office of
Personnel Management. The District of Columbia, its residents,
and small businesses shall be held harmless from any increased
costs resulting from the enactment of this section.
``(2) Individual described.--An individual described in
this paragraph is any individual who--
``(A) is not eligible to enroll in an employer-
sponsored health plan (excluding such a plan that would
not be considered minimum essential coverage due to the
application of subparagraph (C) of section 36B(c)(2) of
the Internal Revenue Code of 1986 if such subparagraph
applied to such plan); and
``(B) is a bona fide resident of any possession of
the United States (as determined under section 937(a)
of such Code) in which the Secretary certifies that no
qualified health plan is offered through an Exchange
established under this title.
``(3) Possession of the united states.--For purposes of
this section, the term `possession of the United States' shall
include such possessions as are specified in section 937(a)(1)
of the Internal Revenue Code of 1986.
``(b) Treatment of Possessions.--
``(1) Payments to possessions.--
``(A) Mirror code possession.--The Secretary of the
Treasury shall periodically (but not less frequently
than annually) pay to each possession of the United
States with a mirror code tax system amounts equal to
the loss to that possession by reason of the
application of this section (determined without regard
to paragraph (2)) with respect to taxable years
beginning after the date described in subsection (c).
Such amounts shall be determined by the Secretary of
the Treasury based on information provided by the
government of the respective possession.
``(B) Other possessions.--The Secretary of the
Treasury shall periodically (but not less frequently
than annually) pay to each possession of the United
States which does not have a mirror code tax system
amounts estimated by the Secretary of the Treasury as
being equal to the aggregate benefits that would have
been provided to residents of such possession by reason
of the application of this section for any taxable
years beginning after the date described in subsection
(c) if a mirror code tax system had been in effect in
such possession. The preceding sentence shall not apply
with respect to any possession of the United States
unless such possession has a plan, which has been
approved by the Secretary of the Treasury, under which
such possession will promptly distribute such payments
to the residents of such possession.
``(2) Coordination with credit allowed against united
states income taxes.--No credit shall be allowed against United
States income taxes for any taxable year under section 36B of
the Internal Revenue Code of 1986 to any person--
``(A) to whom a credit is allowed against taxes
imposed by the possession by reason of this section
(determined without regard to this paragraph) for such
taxable year, or
``(B) who is eligible for a payment under a plan
described in paragraph (1)(B) with respect to such
taxable year.
``(3) Mirror code tax system.--For purposes of this
subsection, the term `mirror code tax system' means, with
respect to any possession of the United States, the income tax
system of such possession if the income tax liability of the
residents of such possession under such system is determined by
reference to the income tax laws of the United States as if
such possession were the United States.
``(4) Treatment of payments.--For purposes of section
1324(b)(2) of title 31, United States Code, or any similar rule
of law, the payments under this subsection shall be treated in
the same manner as a refund due from the credit allowed under
section 36B of the Internal Revenue Code of 1986.
``(c) Date Described.--The date described in this subsection is the
date on which the Secretary establishes the mechanism described in
subsection (a)(1).''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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