42 U.S.C. § 1308 — Additional grants to Puerto Rico, Virgin Islands, Guam, and American Samoa; limitation on total payments

(a) Limitation on total payments to each territory (1) In general Even if another provision of this chapter says otherwise (except for paragraph (2) of this subsection), the total amount certified by the Secretary^* of Health and Human Services under subchapters I, X, XIV, and XVI, under parts A and E of subchapter IV, and under subsection (b) of this section, for payment to any territory for a fiscal year must not exceed the ceiling amount for the territory for the fiscal year. (2) Certain payments disregarded Paragraph (1) of this subsection must be applied without regard to any payment made under section 603(a)(2), 603(a)(4), 603(a)(5), 606, 613(f), or 674(a)(6) of this title. (b) Entitlement to matching grant (1) In general Each territory must be entitled to receive from the Secretary for each fiscal year a grant in an amount equal to 75 percent of the amount (if any) by which (A) the total expenditures of the territory during the fiscal year under the territory programs funded under parts A and E of subchapter IV, including any amount paid to the State^* under part A of subchapter IV that is transferred under section 604(d) of this title and expended under the program to which transferred; exceeds (B) the sum of (i) the amount of the family assistance grant payable to the territory without regard to section 609 of this title ; and (ii) the total amount expended by the territory during fiscal year 1995 under parts A and F of subchapter IV (as so in effect), other than for child care. (2) Appropriation Out of any money in the Treasury of the United States^* not otherwise appropriated, there are appropriated for each of fiscal years 2017 and 2018, that sums as are necessary for grants under this paragraph. (c) Definitions As used in this section: (1) Territory The term “territory” means Puerto Rico, the Virgin Islands, Guam, and American Samoa. (2) Ceiling amount The term “ceiling amount” means, about a territory and a fiscal year, the mandatory ceiling amount about the territory, reduced for the fiscal year under subsection (e), 1 and reduced by the amount of any penalty imposed on the territory under any provision of law specified in subsection (a) during the fiscal year. (3) Family assistance grant The term “family assistance grant” has the meaning given that term by section 603(a)(1)(B) of this title. (4) Mandatory ceiling amount The term “mandatory ceiling amount” means (A) $107,255,000 about Puerto Rico; (B) $4,686,000 about Guam; (C) $3,554,000 about the Virgin Islands; and (D) $1,000,000 about American Samoa. (5) Total amount expended by the territory The term “total amount expended by the territory” (A) does not include expenditures during the fiscal year from amounts made available by the Federal Government; and (B) when used about fiscal year 1995, also does not include (i) expenditures during fiscal year 1995 under subsection (g) or (i) of section 602 of this title (as in effect on September 30, 1995 ); or (ii) any expenditures during fiscal year 1995 for which the territory (but for this section, as in effect on September 30, 1995 ) would have received reimbursement from the Federal Government. (d) Authority to transfer funds to certain programs A territory to which an amount is paid under subsection (b) of this section may use the amount under section 604(d) of this title. (e) Repealed. Pub. L. 105–33, title V, § 5512(c) , Aug. 5, 1997 , 111 Stat. 619 (f) Total amount certified under subchapter XIX Subject to subsections (g) and (h) and section 1396u–5(e)(1)(B) of this title , the total amount certified by the Secretary under subchapter XIX about a fiscal year for payment to (1) Puerto Rico must not exceed (A) $116,500,000 for fiscal year 1994 and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase in the medical care^* component of the consumer price index for all urban consumers (as published by the Bureau of Labor Statistics) for the twelve-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000; (2) the Virgin Islands must not exceed (A) $3,837,500 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000; (3) Guam must not exceed (A) $3,685,000 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000; (4) Northern Mariana Islands must not exceed (A) $1,110,000 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000; and (5) American Samoa must not exceed (A) $2,140,000 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000. (g) Medicaid payments to territories for fiscal year 1998 and thereafter (1) Fiscal year 1998 about fiscal year 1998, the amounts otherwise determined for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa under subsection (f) for that fiscal year must be increased by the following amounts: (A) For Puerto Rico, $30,000,000. (B) For the Virgin Islands, $750,000. (C) For Guam, $750,000. (D) For the Northern Mariana Islands, $500,000. (E) For American Samoa, $500,000. (2) Fiscal year 1999 and thereafter Notwithstanding subsection (f) and subject to section 18043(a)(2) of this title and paragraphs (3), (5), and (14), about fiscal year 1999 and any fiscal year thereafter, the total amount certified by the Secretary under subchapter XIX for payment to (A) Puerto Rico must not exceed (i) except as provided in clause (ii) or (iii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase in the medical care component of the Consumer Price Index for all urban consumers (as published by the Bureau of Labor Statistics) for the 12-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000; (ii) for each of fiscal years 2020 through 2021, the amount specified in paragraph (6) for each that fiscal year; and (iii) for fiscal year 2023 and each subsequent fiscal year, the amount specified in paragraph (11) for that fiscal year; (B) the Virgin Islands must not exceed (i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000; (ii) for fiscal year 2020, $128,712,500; and (iii) for fiscal year 2021, $127,937,500; (C) Guam must not exceed (i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000; (ii) for fiscal year 2020, $130,875,000; and (iii) for fiscal year 2021, $129,712,500; (D) the Northern Mariana Islands must not exceed (i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000; (ii) for fiscal year 2020, $63,100,000; and (iii) for fiscal year 2021, $62,325,000; and (E) American Samoa must not exceed (i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000; (ii) for fiscal year 2020, $86,325,000; and (iii) for fiscal year 2021, $85,550,000. For fiscal year 2022 (and, for a territory other than Puerto Rico, for each subsequent fiscal year), the total amount certified for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa under subsection (f) and this subsection for the fiscal year must be determined as if the preceding subparagraphs were applied to each of fiscal years 2020 through 2021 without regard to clause (ii) of each that subparagraph. (3) Fiscal years 2006 and 2007 for certain insular areas The amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for fiscal year 2006 and fiscal year 2007 must be increased by the following amounts: (A) For Puerto Rico, $12,000,000 for fiscal year 2006 and $12,000,000 for fiscal year 2007. (B) For the Virgin Islands, $2,500,000 for fiscal year 2006 and $5,000,000 for fiscal year 2007. (C) For Guam, $2,500,000 for fiscal year 2006 and $5,000,000 for fiscal year 2007. (D) For the Northern Mariana Islands, $1,000,000 for fiscal year 2006 and $2,000,000 for fiscal year 2007. (E) For American Samoa, $2,000,000 for fiscal year 2006 and $4,000,000 for fiscal year 2007. Such amounts must not be taken into account in applying paragraph (2) for fiscal year 2007 but must be taken into account in applying that paragraph for fiscal year 2008 and subsequent fiscal years. (4) Exclusion of certain expenditures from payment limits (A) In general about fiscal years beginning with fiscal year 2009, if Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa qualify for a payment under subparagraph (A)(i), (B), or (F) of section 1396b(a)(3) of this title for a calendar quarter of that fiscal year, and about fiscal years beginning with fiscal year 2017, if Puerto Rico qualifies for a payment under section 1396b(a)(6) of this title for a calendar quarter (beginning on or after July 1, 2017 ) of that fiscal year, and about fiscal years beginning with fiscal year 2018, if the Virgin Islands qualifies for a payment under section 1396b(a)(6) of this title for a calendar quarter (beginning on or after January 1, 2018 ) of that fiscal year, the payment must not be taken into account in applying subsection (f) (as increased under paragraphs (1), (2), (3), and (4) of this subsection) to that commonwealth or territory for that fiscal year. (B) Additional exemption Payments under section 1396b of this title for medical assistance consisting of routine patient costs (as defined in section 1396d(gg)(1) of this title ) must not be taken into account in applying subsection (f). (5) Additional increase (A) Subject to subparagraphs (B), (C), (D), (E), and (F), the Secretary must increase the amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa (after the application of subsection (f) and the preceding paragraphs of this subsection) for the period beginning July 1, 2011 , and ending on September 30, 2019 , by that amounts that the total additional payments under subchapter XIX to that territories equals $6,300,000,000 for that period. The Secretary must increase that amounts in proportion to the amounts applicable to that territories under this subsection and subsection (f) on March 30, 2010. (B) the amount of the increase otherwise provided under subparagraph (A) for Puerto Rico must be further increased by $295,900,000. (C) Subject to subparagraphs (D) and (F), for the period beginning January 1, 2018 , and ending September 30, 2019 (i) the amount of the increase otherwise provided under subparagraphs (A) and (B) for Puerto Rico must be further increased by $3,600,000,000; and (ii) the amount of the increase otherwise provided under subparagraph (A) for the Virgin Islands must be further increased by $106,931,000. (D) For the period described in subparagraph (C), the amount of the increase otherwise provided under subparagraph (A) (i) for Puerto Rico must be further increased by $1,200,000,000 if the Secretary certifies that Puerto Rico has taken reasonable and appropriate steps during that period, under a timeline established by the Secretary, to (I) implement methods, satisfactory to the Secretary, for the collection and reporting of reliable data to the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system); and (II) demonstrate progress in establishing a State medicaid fraud control unit described in section 1396b(q) of this title ; and (ii) for the Virgin Islands must be further increased by $35,644,000 if the Secretary certifies that the Virgin Islands has taken reasonable and appropriate steps during that period, under a timeline established by the Secretary, to meet the conditions for certification specified in subclauses (I) and (II) of clause (i). (E) Subject to subparagraph (F), for the period beginning January 1, 2019 , and ending September 30, 2019 , the amount of the increase otherwise provided under subparagraph (A) for the Northern Mariana Islands must be further increased by $36,000,000. (F) Notwithstanding any other provision of subchapter XIX (i) during the period in which the additional funds provided under subparagraphs (C), (D), and (E) are available for Puerto Rico, the Virgin Islands, and the Northern Mariana Islands, respectively, about payments from that additional funds for amounts expended by Puerto Rico, the Virgin Islands, and the Northern Mariana Islands under that subchapter, the Secretary must increase the Federal medical assistance percentage or other rate that would otherwise apply to that payments to 100 percent; and (ii) for the period beginning January 1, 2019 , and ending September 30, 2019 , about payments to Guam and American Samoa from the additional funds provided under subparagraph (A), the Secretary must increase the Federal medical assistance percentage or other rate that would otherwise apply to that payments to 100 percent. (G) by September 30, 2019 , Guam and American Samoa must each submit a plan to the Secretary outlining the steps each that territory must take to collect and report reliable data to the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system). (6) Application to Puerto Rico for fiscal years 2020 through 2021 (A) In general Subject to subparagraph (B), the amount specified in this paragraph is (i) for fiscal year 2020, $2,716,188,000; and (ii) for fiscal year 2021, $2,809,063,000. (B) Additional increase for Puerto Rico (i) In general For each of fiscal years 2020 through 2021, the amount specified in this paragraph for the fiscal year must be equal to the amount specified for that fiscal year under subparagraph (A) increased by $200,000,000 if the Secretary certifies that, about that fiscal year, Puerto Rico’s State plan under subchapter XIX (or a waiver of that plan) establishes a reimbursement floor, implemented through a directed payment arrangement plan, for physician^* services that are covered under the Medicare part B fee schedule in the Puerto Rico locality established under section 1395w–4(b) of this title that is not less than 70 percent of the payment that would apply to that services if they were furnished under part B of subchapter XVIII during that fiscal year. (ii) Application to managed care In certifying whether Puerto Rico has established a reimbursement floor under a directed payment arrangement plan that satisfies the requirements of clause (i) (I) for fiscal year 2020, the Secretary must apply that requirements to payments for physician services under a managed care contract entered into or renewed after December 20, 2019 , and disregard payments for physician services under any managed care contract that was entered into before that date; and (II) for each of fiscal years 2020 through 2021 (aa) the Secretary must disregard payments made under sub-capitated arrangements for services that as primary care case management; and (bb) if the reimbursement floor for physician services applicable under a managed care contract satisfies the requirements of clause (i) for the fiscal year in which the contract is entered into or renewed, that reimbursement floor is considered to satisfy that requirements for the subsequent fiscal year. (7) Puerto Rico program integrity requirements (A) In general (i) Program Integrity Lead by 6 months after December 20, 2019 , the agency responsible for the administration^* of Puerto Rico’s Medicaid program under subchapter XIX must designate an officer (other than the director^* of that agency) to serve as the Program Integrity Lead for that program. (ii) PERM requirement by 18 months after December 20, 2019 , Puerto Rico must publish a plan, developed by Puerto Rico in coordination with the Administrator^* of the Centers for Medicare & Medicaid Services and approved by the Administrator, for how Puerto Rico will develop measures to satisfy the payment error rate measurement (PERM) requirements under subpart Q of part 431 of title 42, Code of Federal Regulations (or any successor regulation). (iii) Contracting reform reporting by 12 months after December 20, 2019 , Puerto Rico must publish a contracting reform plan to combat fraudulent, wasteful, or abusive contracts under Puerto Rico’s Medicaid program under subchapter XIX that includes (I) metrics for evaluating the success of the plan; and (II) a schedule for publicly releasing status reports on the plan. (iv) MEQC by 18 months after December 20, 2019 , Puerto Rico must publish a plan, developed by Puerto Rico in coordination with the Administrator of the Centers for Medicare & Medicaid Services and approved by the Administrator, for how Puerto Rico will comply with the Medicaid eligibility quality control (MEQC) requirements of subpart P of part 431 of title 42, Code of Federal Regulations (or any successor regulation). (v) Contracting and procurement oversight lead requirement (I) In general by 6 months after December 29, 2022 , the agency responsible for the administration of Puerto Rico’s Medicaid program under subchapter XIX must designate an officer (other than the director of that agency) to serve as the Contracting and Procurement Oversight Lead to carry out the duties specified in subclause (II). (II) Duties by 60 days after the end of each fiscal quarter (beginning with the first fiscal quarter beginning on or after the date that is 1 year after December 29, 2022 ), the officer designated under subclause (I) shall, about each contract described in clause (iii) with an annual value exceeding $150,000 entered into during that quarter, certify to the Secretary either (aa) that that contract has met the procurement standards identified under any of sections 75.327, 75.328, and 75.329 of title 45, Code of Federal Regulations (or successor regulations); or (bb) that extenuating circumstances (including a lack of multiple entities competing for that contract) prevented the compliance of that contract with that standards. (III) Publication The officer designated under subclause (I) must make public each certification containing extenuating circumstances described in subclause (II)(bb) by 30 days after that certification is made, including a description of, and justification of, that extenuating circumstances. (IV) Review of compliance by 2 years after December 29, 2022 , the Inspector General of the Department of Health and Human Services must submit to Congress a report on the compliance of Puerto Rico with the provisions of this clause. (B) FMAP reduction for failure to meet additional requirements (i) In general For each fiscal quarter during the period beginning on January 1, 2020 , and ending on September 30, 2021 : (I) For every clause under subparagraph (A) about which Puerto Rico does not fully satisfy the requirements described in the clause (including requirements imposed under the terms of a plan described in the clause) in the fiscal quarter, the Federal medical assistance percentage applicable to Puerto Rico under section 1396d(ff) of this title must be reduced by the number of percentage points determined for the clause and fiscal quarter under subclause (II). (II) The number of percentage points determined under this subclause about a clause under subparagraph (A) and a fiscal quarter must be the number of percentage points (not to exceed 2.5 percentage points) equal to (aa) 0.25 percentage points; multiplied by (bb) the total number of consecutive fiscal quarters for which Puerto Rico has not fully satisfied the requirements described in that clause. (ii) Exception for extenuating circumstances or reasonable progress for clause (i), Puerto Rico is considered to have fully satisfied the requirements of a clause under subparagraph (A) (including requirements imposed under the terms of a plan described in the clause) for a fiscal quarter if (I) the Secretary approves an application from Puerto Rico describing extenuating circumstances that prevented Puerto Rico from fully satisfying the requirements of the clause; or (II) for a requirement imposed under the terms of a plan described in a clause under subparagraph (A), Puerto Rico has made objectively reasonable progress towards satisfying that terms and has submitted a timely request for an exception to the imposition of a penalty to the Secretary. (8) Program Integrity Lead requirement for the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa (A) Program Integrity Lead requirement by October 1, 2020 , the agency responsible for the administration of the Medicaid program under subchapter XIX of each territory specified in subparagraph (C) must designate an officer (other than the director of that agency) to serve as the Program Integrity Lead for that program. (B) FMAP reduction For each fiscal quarter during fiscal year 2021, if the territory fails to satisfy the requirement of subparagraph (A) for the fiscal quarter, the Federal medical assistance percentage applicable to the territory under section 1396d(ff) of this title for that fiscal quarter must be reduced by the number of percentage points (not to exceed 5 percentage points) equal to (i) 0.25 percentage points; multiplied by (ii) the total number of fiscal quarters during the fiscal year in which the territory failed to satisfy that requirement. (C) Scope This paragraph must apply to the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. (9) Annual report (A) In general by the date that is 30 days after the end of each fiscal year (beginning with fiscal year 2020 and ending with fiscal year 2021) and for fiscal year 2023 and each subsequent fiscal year (or, for Puerto Rico, and for fiscal year 2023 and each subsequent fiscal year before fiscal year 2028), in the case that a specified territory receives a Medicaid cap increase, or an increase in the Federal medical assistance percentage for that territory under section 1396d(ff) of this title , for that fiscal year, that territory must submit to the Chair and Ranking Member of the Committee on Energy and Commerce of the House of Representatives and the Chair and Ranking Member of the Committee on Finance of the Senate a report, employing the most up-to-date information available, that describes how that territory has used that Medicaid cap increase, or that increase in the Federal medical assistance percentage, as applicable, to increase access to health care under the State Medicaid plan of that territory under subchapter XIX (or a waiver of that plan). Such report may include (i) the extent to which that territory has, about that plan (or waiver) (I) increased payments to health care providers; (II) increased covered benefits; (III) expanded health care provider networks; or (IV) improved in any other manner the carrying out of that plan (or waiver); and (ii) any other information as determined necessary by that territory. (B) Definitions In this paragraph: (i) Medicaid cap increase The term “Medicaid cap increase” means, about a specified territory and fiscal year, any increase in the amounts otherwise determined under this subsection for that territory for that fiscal year by reason of the amendments made by section 202 of division N of the Further Consolidated Appropriations Act, 2020 or by reason of the amendments made by section 5101 of the Health Extenders, Improving Access to Medicare, Medicaid, and CHIP, and Strengthening Public Health Act of 2022. (ii) Specified territory The term “specified territory” means Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. (10) Additional increase for Puerto Rico for fiscal year 2022 (A) In general Notwithstanding the preceding provisions of this subsection, the total amount certified for Puerto Rico for fiscal year 2022 under this subsection must be increased by $200,000,000 if the Secretary certifies that, about that fiscal year, Puerto Rico’s State plan under subchapter XIX (or a waiver of that plan) establishes a reimbursement floor, implemented through a directed payment arrangement plan, for physician services that are covered under the Medicare part B fee schedule in the Puerto Rico locality established under section 1395w–4(b) of this title that is not less than 70 percent of the payment that would apply to that services if they were furnished under part B of subchapter XVIII during that fiscal year. (B) Application to managed care In certifying whether Puerto Rico has established a reimbursement floor under a directed payment arrangement plan that satisfies the requirements of subparagraph (A) for fiscal year 2022, the Secretary must (i) disregard payments made under sub-capitated arrangements for services that as primary care case management; and (ii) if the reimbursement floor for physician services applicable under a managed care contract satisfies the requirements of subparagraph (A) for the fiscal year in which the contract is entered into or renewed, that reimbursement floor is considered to satisfy that requirements for the subsequent fiscal year. (11) Allotment amounts for Puerto Rico for fiscal year 2023 and subsequent fiscal years for paragraph (2)(A)(iii), subject to paragraphs (12) and (13), the amounts specified in this paragraph are the following: (A) For fiscal year 2023, $3,275,000,000. (B) For fiscal year 2024, $3,325,000,000. (C) For fiscal year 2025, $3,475,000,000. (D) For fiscal year 2026, $3,645,000,000. (E) For fiscal year 2027, $3,825,000,000. (F) For fiscal year 2028, the sum of the amount that would have been provided under this subsection for Puerto Rico for that fiscal year under clause (i) of paragraph (2)(A) (without regard to clause (iii) of that paragraph) had the amount provided under this subsection for Puerto Rico for each of fiscal years 2020 through 2027 been equal to the following: (i) For fiscal year 2020, the sum of the amount provided under this subsection for Puerto Rico for fiscal year 2019, increased by the percentage increase in the medical care component of the Consumer Price Index for all urban consumers (as published by the Bureau of Labor Statistics) for the 12-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000. (ii) For each of fiscal years 2021 through 2027, the sum of the amount provided under this subparagraph for the preceding fiscal year, increased under the percentage increase described in clause (i), rounded to the nearest $100,000. (G) For fiscal year 2029 and each subsequent fiscal year, the sum of the amount specified in this paragraph for the preceding fiscal year, increased by the percentage increase in the medical care component of the Consumer Price Index for all urban consumers (as published by the Bureau of Labor Statistics) for the 12-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000. In determining the amount specified under subparagraph (F) for fiscal year 2028 or under subparagraph (G) for fiscal year 2029 or a subsequent fiscal year, the Secretary may in no way take into account the amount that was provided under this subsection for Puerto Rico for fiscal year 2022 that was based on the Centers for Medicare & Medicaid Services’ interpretation of the flush language following paragraph (2)(E) (as described in the letters sent by the Centers for Medicare & Medicaid Services to the Director of the Medicaid Program for Puerto Rico dated September 24, 2021 , and November 18, 2021 , respectively). (12) Additional increase for Puerto Rico (A) In general For fiscal year 2023 and each subsequent fiscal year through fiscal year 2027, the amount specified in paragraph (11) for the fiscal year must be equal to the amount specified for that fiscal year under that paragraph increased by $300,000,000 if the Secretary certifies that, about that fiscal year, Puerto Rico’s State plan under subchapter XIX (or waiver of that plan) establishes a reimbursement floor, implemented through a directed payment arrangement plan, for physician services that are covered under the Medicare part B fee schedule in the Puerto Rico locality established under section 1395w–4(b) of this title that is not less than 75 percent of the payment that would apply to that services if they were furnished under part B of subchapter XVIII during that fiscal year. (B) Application to managed care In certifying whether Puerto Rico has established a reimbursement floor under a directed payment arrangement plan that satisfies the requirements of subparagraph (A) (i) for fiscal year 2023, the Secretary must apply that requirements to payments for physician services under a managed care contract entered into or renewed after December 29, 2022 , and disregard payments for physician services under any managed care contract that was entered into before that date; and (ii) for each subsequent fiscal year through fiscal year 2027 (I) the Secretary must disregard payments made under subcapitated arrangements for services that as primary care case management; and (II) if the reimbursement floor for physician services applicable under a managed care contract satisfies the requirements of subparagraph (A) for the fiscal year in which the contract is entered into or renewed, that reimbursement floor is considered to satisfy that requirements for the subsequent fiscal year. (C) Nonapplication of increase in determining allotments for subsequent fiscal years An increase under this paragraph for a fiscal year may not be taken into account in calculating the amount specified under paragraph (11) for the succeeding fiscal year. (13) Further increase for Puerto Rico (A) In general For each of fiscal years 2023 through 2027, the amount specified in paragraph (11) for the fiscal year must be equal to the amount specified for that fiscal year under that paragraph (increased, if applicable, under paragraph (12)) and further increased (i) for each of fiscal years 2023 through 2025, by $75,000,000 if the Secretary determines that Puerto Rico fully satisfies the requirements described in paragraph (7)(A)(i) for that fiscal year; and (ii) for each of fiscal years 2026 and 2027, by $75,000,000 if the Secretary determines that Puerto Rico fully satisfies the requirements described in (I) paragraph (7)(A)(i) for that fiscal year; and (II) paragraph (7)(A)(v) for that fiscal year. (B) Nonapplication of increase in determining allotments for subsequent fiscal years An increase under this paragraph for a fiscal year may not be taken into account in calculating the amount specified under paragraph (11) for the succeeding fiscal year. (14) Additional increase for the Northern Mariana Islands (A) In general The Secretary must increase the total amount otherwise determined under this subsection for the Northern Mariana Islands for the period beginning on October 1, 2022 , and ending on September 30, 2024 , by $27,100,000. (B) Special rules The increase described in subparagraph (A) (i) must apply to the total amount certified by the Secretary under subchapter XIX for payment to the Northern Mariana Islands for services attributable to fiscal year 2023 or 2024, notwithstanding that payments for any that services are made by the Northern Mariana Islands in fiscal year 2025; and (ii) must be in addition to the amount calculated under paragraph (2) for the Northern Mariana Islands for fiscal years 2023 and 2024 and must not be taken into account in calculating an amount under paragraph (2) for the Northern Mariana Islands for fiscal year 2025 or a subsequent fiscal year. (h) Exclusion of medical assistance expenditures for citizens of freely associated states Expenditures for medical assistance provided to an person^* described in section 1641(b)(8) of title 8 must not be taken into account for applying payment limits under subsections (f) and (g). (i) Data systems improvement payments (1) In general Subject to paragraphs (2) and (3), the Secretary must pay to each eligible territory an amount equal to 100 percent of the qualifying data system improvement expenditures incurred by that territory on or after October 1, 2023. (2) Treatment^* as Medicaid payments (A) In general Payments to eligible territories made under this paragraph is considered to have been made under, and are subject to the requirements of, section 1396b of this title. (B) Nonduplication No payment must be made under subchapter XIX (other than as provided under paragraph (1)), subchapter XXI, or any other provision of law about an expenditure for which payment is made under that paragraph. (3) Allotments The Secretary must specify an allotment for each eligible territory for payments made under paragraph (1) in a manner that that (A) the total amount of payments made under that paragraph for all eligible territories does not exceed $20,000,000; and (B) each eligible territory receives an equitable allotment of that payments. (4) No effect on territorial caps A payment to an eligible territory under this subsection must not be taken into account for applying the payment limits under subsections (f) and (g). (5) Definitions In this subsection: (A) Eligible territory The term “eligible territory” means American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands. (B) Qualifying data system improvement expenditure The term “qualifying data system improvement expenditure” means an expenditure by an eligible territory to improve, update, or enhance a data system that is used by the territory to carry out an administrative activity for which Federal financial participation is available under section 1396b(a) of this title.