79–006 

115TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 2d Session 115–734 

CHIP MENTAL HEALTH PARITY ACT 

JUNE 12, 2018.—Committed to the Committee of the Whole House on the State of 

the Union and ordered to be printed 

Mr. WALDEN, from the Committee on Energy and Commerce, 

submitted the following 

R E P O R T 

[To accompany H.R. 3192] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Energy and Commerce, to whom was referred 

the bill (H.R. 3192) to amend title XXI of the Social Security Act 

to ensure access to mental health services for children under the 

Children’s Health Insurance Program, and for other purposes, having considered the same, report favorably thereon with an amendment and recommend that the bill as amended do pass. 

CONTENTS 

Page 

Purpose and Summary ............................................................................................ 2 

Background and Need for Legislation .................................................................... 3 

Committee Action .................................................................................................... 5 

Committee Votes ...................................................................................................... 6 

Oversight Findings and Recommendations ........................................................... 6 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 6 

Congressional Budget Office Estimate ................................................................... 6 

Federal Mandates Statement ................................................................................. 28 

Statement of General Performance Goals and Objectives .................................... 28 

Duplication of Federal Programs ............................................................................ 28 

Committee Cost Estimate ....................................................................................... 28 

Earmark, Limited Tax Benefits, and Limited Tariff Benefits ............................. 29 

Disclosure of Directed Rule Makings ..................................................................... 29 

Advisory Committee Statement .............................................................................. 29 

Applicability to Legislative Branch ........................................................................ 29 

Section-by-Section Analysis of the Legislation ...................................................... 29 

Changes in Existing Law Made by the Bill, as Reported ..................................... 30 

The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

This Act may be cited as the ‘‘CHIP Mental Health Parity Act’’. 

2 

SEC. 2. ENSURING ACCESS TO MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 

FOR CHILDREN AND PREGNANT WOMEN UNDER THE CHILDREN’S HEALTH INSURANCE PROGRAM. 

(a) IN GENERAL.—Section 2103(c)(1) of the Social Security Act (42 U.S.C. 

1397cc(c)(1)) is amended by adding at the end the following new subparagraph: 

‘‘(E) Mental health and substance use disorder services (as defined in 

paragraph (5)).’’. 

(b) MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES.— (1) IN GENERAL.—Section 2103(c) of the Social Security Act (42 U.S.C. 

1397cc(c)) is amended— 

(A) by redesignating paragraphs (5), (6), (7), and (8) as paragraphs (6), 

(7), (8), and (9), respectively; and 

(B) by inserting after paragraph (4) the following new paragraph: 

‘‘(5) MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES.—In the case of 

a State that provides child health assistance for targeted low-income children 

or targeted low-income pregnant women (as defined in section 2112(d)) in the 

form of providing any health benefits coverage described in subsection (a), such 

child health assistance shall— 

‘‘(A) include coverage of mental health services (including behavioral 

health treatment) necessary to prevent, diagnose, and treat a broad range 

of mental health symptoms and disorders, including substance use disorders; and 

‘‘(B) be delivered in a culturally and linguistically appropriate manner.’’. 

(2) CONFORMING AMENDMENTS.— (A) Section 2103(a) of the Social Security Act (42 U.S.C. 1397cc(a)) is 

amended, in the matter before paragraph (1), by striking ‘‘paragraphs (5), 

(6), and (7)’’ and inserting ‘‘paragraphs (5), (6), (7), and (8)’’. 

(B) Section 2110(a) of the Social Security Act (42 U.S.C. 1397jj(a)) is 

amended— 

(i) in paragraph (18), by striking ‘‘substance abuse’’ each place it appears and inserting ‘‘substance use’’; and 

(ii) in paragraph (19), by striking ‘‘substance abuse’’ and inserting 

‘‘substance use’’. 

(C) Section 2110(b)(5)(A)(i) of the Social Security Act (42 U.S.C. 

1397jj(b)(5)(A)(i)) is amended by striking ‘‘subsection (c)(5)’’ and inserting 

‘‘subsection (c)(6)’’. 

(c) ASSURING ACCESS TO CARE.—Section 2102(a)(7)(B) of the Social Security Act 

(42 U.S.C. 1397bb(c)(2)) is amended by striking ‘‘section 2103(c)(5)’’ and inserting 

‘‘paragraphs (5) and (6) of section 2103(c)’’. 

(d) MENTAL HEALTH SERVICES PARITY.—Subparagraph (A) of paragraph (7) of section 2103(c) of the Social Security Act (42 U.S.C. 1397cc(c)) (as redesignated by subsection (b)(1)) is amended to read as follows: 

‘‘(A) IN GENERAL.—A State child health plan shall ensure that the financial requirements and treatment limitations applicable to mental health 

and substance use disorder services (as described in paragraph (5)) provided 

under such plan comply with the requirements of section 2726(a) of the 

Public Health Service Act in the same manner as such requirements or limitations apply to a group health plan under such section.’’. 

(e) EFFECTIVE DATE.— 

(1) IN GENERAL.—Subject to paragraph (2), the amendments made by this section shall take effect with respect to child health assistance provided on or after 

the date that is one year after the date of the enactment of this Act. 

(2) EXCEPTION FOR STATE LEGISLATION.—In the case of a State child health 

plan under title XXI of the Social Security Act (or a waiver of such plan), which 

the Secretary of Health and Human Services determines requires State legislation in order for the respective plan (or waiver) to meet any requirement imposed by the amendments made by this section, the respective plan (or waiver) 

shall not be regarded as failing to comply with the requirements of such title 

solely on the basis of its failure to meet such an additional requirement before 

the first day of the first calendar quarter beginning after the close of the first 

regular session of the State legislature that begins after the date of enactment 

of this section. For purposes of the previous sentence, in the case of a State that 

has a 2-year legislative session, each year of the session shall be considered to 

be a separate regular session of the State legislature. 

PURPOSE AND SUMMARY

H.R. 3192 was introduced on July 7, 2017, by Rep. Joseph Kennedy, III (D–MA). The bill requires comprehensive mental health 

3 

1 Centers for Disease Control and Prevention. ‘‘Drug Overdose Death Data.’’ December 19, 

2017. Available at https://www.cdc.gov/drugoverdose/data/statedeaths.html. 2Dowell, D., Arias E., Kochanek K. et al. ‘‘Contribution of Opioid-Involved Poisoning to the 

Change in Life Expectancy in the United States, 2000–2015.’’ JAMA, September 2017. Available 

at https://jamanetwork.com/journals/jama/fullarticle/2654372. 3 American Action Forum. ‘‘The Labor Force and Output Consequences of the Opioid Crisis.’’ 

March 27, 2018. Available at https://www.americanactionforum.org/research/labor-force-outputconsequences-opioid-crisis/. 4 American Enterprise Institute. ‘‘The Geographic Variation in the Cost of the Opioid Crisis’’. 

Available at https://www.aei.org/wp-content/uploads/2018/03/GeographiclVariationlinlCostl oflOpioidlCrisis.pdf. 5Kaiser Family Foundation, ‘‘A Look at How the Opioid Crisis Has Affected People with Employer Coverage,’’ April 2018. Available online at: https://www.kff.org/health-costs/press-release/ 

analysis-cost-of-treating-opioid-addiction-rose-rapidly-for-large-employers-as-the-number-of-prescriptions-has-declined/. 6Government Accountability Office, ‘‘Medicaid: States Fund Services for Adults in Institutions 

for Mental Disease Using a Variety of Strategies,’’ GAO–17–652, August 2017. Available at 

https://www.gao.gov/assets/690/686456.pdf. 7Medicaid and CHIP Payment and Access Commission, ‘‘Medicaid and the Opioid Epidemic,’’ 

Chapter 2 in June 2017 Report to Congress on Medicaid and CHIP. Available at: https:// 

www.macpac.gov/wp-content/uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf. 8Kaiser Family Foundation. ‘‘Medicaid’s Role in Addressing the Opioid Epidemic.’’ Available 

at https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/. 

and substance use disorder services as a mandatory benefit under 

the CHIP program for pregnant women and children. 

BACKGROUND AND NEED FOR LEGISLATION

Deaths due to overdoses of opioids and other drugs have ravaged 

American communities. According to the Centers for Disease Control and Prevention (CDC), on average, 1,000 people are treated for 

opioid misuse in emergency departments per day, an average of 

115 Americans die per day, and opioid-related overdoses have increased steadily since 1999.1

While the impacts to Americans’ health outcomes are staggering, 

the opioid crisis has negatively impacted society in numerous ways. 

The Centers for Disease Control and Prevention note that life expectancy dropped in 2015 and 2016 and that one of the reasons 

was an increase in unintentional injuries, a category that includes 

drug overdoses.2 The opioid crisis has also resulted in a contraction 

in the labor force by almost 1 million workers in the years between 

1999 and 2015, which resulted in a loss of $702 billion in real output.3 In 2015, the total economic burden of the opioid epidemic was estimated to be $504 billion.4 While all states were negatively impacted, there is geographic variation in the burden. West Virginia 

had the greatest loss per person ($4,378) and Nebraska had the 

lowest loss per person ($394).4 One recent analysis found that the 

annual cost for private sector employers for treating opioid addiction and overdoses has increased more than eight-fold since 2004, 

and more than one in five persons aged 55 to 64 had at least one 

opioid prescription in 2016.5

Medicaid is the largest source of federal funding for behavioral 

health services—mental health and substance use disorder services—with nearly $71 billion in projected 2017 spending.6 As the 

Medicaid and CHIP Payment and Access Commission (MACPAC) 

stated in 2017, ‘‘the opioid epidemic, which has reached most communities across the U.S., disproportionately affects Medicaid beneficiaries.’’ 7 Medicaid provides care to four in ten adults with opioid 

use disorder and compared to other insurance types, provides a significantly higher percentage of inpatient and outpatient substance 

use disorder treatment.8

4 

9Medicaid and CHIP Payment and Access Commission, ‘‘Medicaid and the Opioid Epidemic,’’ 

Chapter 2 in June 2017 Report to Congress on Medicaid and CHIP. Available at: https:// 

www.macpac.gov/wp-content/uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf. 10See SAMHSA website. Available at: https://www.samhsa.gov/medication-assisted-treatment. 

MACPAC found that ‘‘Medicaid beneficiaries are prescribed pain 

relievers at higher rates than those with other sources of insurance. They also have a higher risk of overdose and other negative 

outcomes, from both prescription opioids and illegal opioids such as 

heroin and illicitly manufactured fentanyl.’’ 9 Not only are the number of Medicaid beneficiaries with opioid misuse disproportionately 

high, so too are the number of overdoses. Studies from North Carolina and Washington indicate high rates of opioid-related deaths for 

the Medicaid population (33 percent and 45 percent, respectively). 

For treatment, Medicaid has several pharmacy and medical benefits for treating opioid use disorder that vary by state. A primary 

pharmaceutical treatment offered to patients with opioid abuse 

and/or substance use disorder is medication-assisted treatment 

(MAT). The Substance Abuse and Mental Health Services Administration (SAMHSA) describes MAT as ‘‘the use of FDA-approved 

medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders.’’ 10

Non-pharmaceutical treatment of opioid use disorder in Medicaid 

occurs in inpatient, outpatient, residential, and community-based 

settings. MACPAC’s 2017 analysis found that ‘‘Medicaid is responding to the opioid crisis by covering treatment, innovating in the delivery of care, and working with other state agencies to reduce misuse of prescription opioids.’’ State Medicaid programs adopt strategies and design their programs to meet the needs of their Medicaid 

beneficiaries resulting in variations in covered treatment services 

and settings. It is important state Medicaid programs provide a 

continuum of care to serve the needs of Medicaid beneficiaries. 

However, as MACPAC noted, ‘‘there are gaps in the continuum 

of care, and states vary in the extent to which they cover needed 

treatment.’’ One of the barriers to appropriate treatment consistently identified by Medicaid directors and health policy experts is 

a statutory prohibition on federal Medicaid matching funds for paying for care for certain Medicaid beneficiaries in Institutions for 

Mental Diseases (IMD). As MACPAC has explained, ‘‘the Medicaid 

IMD exclusion acts a barrier for individuals with an opioid use disorder to receive residential treatment, which, depending on an individual’s treatment plan, may be the most appropriate setting for 

care.’’ Given these and other findings, there continues to be an opportunity for Congress and state Medicaid programs to work to improve access to timely, high-quality treatment across the continuum of care. 

States may design their CHIP programs in three ways. They may 

cover eligible children under their Medicaid programs (i.e., CHIP 

Medicaid expansion), create a separate CHIP program, or adopt a 

combination approach where the state operates a CHIP Medicaid 

expansion and one or more separate CHIP programs concurrently. 

Regardless of the choice of benefit design, all states must cover 

emergency services, well-baby and well-child care, including ageappropriate immunizations, vision, and dental services under 

CHIP. All CHIP programs cover some level of outpatient and inpaVerDate Sep 11 2014 06:36 Jun 19, 2018 Jkt 079006 PO 00000 Frm 00004 Fmt 6659 Sfmt 6602 E:\HR\OC\HR734.XXX HR734
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11Kaiser Family Foundation, ‘‘The Impact of the Children’s Health Insurance Program 

(CHIP): What Does the Research Tell US?’’, July 17, 2014. Available at: https://www.kff.org/report-section/the-impact-of-the-childrens-health-insurance-program-chip-issue-brief/. 12 § 1937(b)(6)(B) of the Social Security Act (SSA); 42 C.F.R. § 440.395(c). 13Financial requirements refer to deductibles, copayments, coinsurance, or out of pocket maximums, while treatment limitations include limits on frequency of treatment, number of visits, 

days of coverage, or other similar limits on scope of coverage. 14SSA § 2103(c)(6)(A). 15Section 2103 of the Social Security Act. 16 Anita Cardwell, et al., National Academy for State Health Policy and Georgetown University Health Policy Institute, Center for Children and Families; Benefits and Cost Sharing in 

Separate CHIP Programs, May 2014. Available at http://ccf.georgetown.edu/wp-content/uploads/ 

2014/05/Benefits-and-Cost-Sharing-in-Separate-CHIP-Programs.pdf. 

tient mental health services, but not all cover substance use disorder treatment.11

In general, states with CHIP Medicaid expansion programs must 

provide CHIP-eligible children with the same benefits provided to 

children enrolled in the Medicaid program. Under Medicaid, states 

are required to provide Early and Periodic Screening, Diagnostic, 

and Treatment (EPSDT) services, which covers health screenings 

and services, including assessments of each child’s physical and 

mental health development. States are required to provide all federally allowed treatment to correct problems identified through 

screenings—including mental health, substance use disorder, and 

behavioral health treatment needs. EPSDT sets Medicaid benefit 

coverage for children (including CHIP children) apart from other 

sources of health insurance in that it permits coverage of all services listed in Medicaid statute (regardless of whether a given benefit is covered in the state plan). Coverage of EPSDT is deemed to 

be compliant with mental health parity, including the financial requirements and treatment limitations for individuals entitled to 

such benefits.12 13

States that offer separate CHIP programs have more latitude in 

designing benefit coverage, and benefits must be on par with an 

approved benchmark plan. Such states can determine which services to cover and may place limits on the services that they offer. 

States are not required to offer mental health services and substance use disorder services (including behavioral health treatment) under separate CHIP programs. However, if offered, such 

services must meet federal mental health parity requirements related to financial requirements and treatment limitations for such 

benefits.14 This benefit coverage must be benchmarked to one of 

the following: a federal employees health benefits program equivalent, state employee coverage, or coverage offered through a health 

maintenance organization.15 The benchmark can also be an existing comprehensive state-based program or one approved by the 

Secretary. Reviews of separate CHIP programs found that nearly 

all covered outpatient and inpatient substance use disorder services.16 In addition, the level of benefits offered varied greatly. 

COMMITTEE ACTION

On April 11 and 12, 2018, the Subcommittee on Health held a 

hearing on H.R. 3192. The Subcommittee received testimony from: 

• Kimberly Brandt, Principal Deputy Administrator for Operations, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services; 

6 

• Michael Botticelli, Executive Director, Grayken Center for 

Addiction, Boston Medical Center; 

• Toby Douglas, Senior Vice President, Medicaid Solutions, 

Centene Corporation; 

• David Guth, Chief Executive Officer, Centerstone; 

• John Kravitz, Chief Information Officer, Geisinger Health 

System; and, 

• Sam Srivastava, Chief Executive Officer, Magellan Health. 

On April 25, 2018, the Subcommittee on Health met in open 

markup session and forwarded H.R. 3192, without amendment, to 

the full Committee by a voice vote. On May 17, 2018, the full Committee on Energy and Commerce met in open markup session and 

ordered H.R. 3192, as amended, favorably reported to the House by 

a voice vote. 

COMMITTEE VOTES

Clause 3(b) of rule XIII requires the Committee to list the record 

votes on the motion to report legislation and amendments thereto. 

There were no record votes taken in connection with ordering H.R. 

3192 reported. 

OVERSIGHT FINDINGS AND RECOMMENDATIONS

Pursuant to clause 2(b)(1) of rule X and clause 3(c)(1) of rule 

XIII, the Committee held a hearing and made findings that are reflected in this report. 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

Pursuant to clause 3(c)(2) of rule XIII, the Committee finds that 

H.R. 3192 would result in no new or increased budget authority, 

entitlement authority, or tax expenditures or revenues. 

CONGRESSIONAL BUDGET OFFICE ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII, the following is the cost 

estimate provided by the Congressional Budget Office pursuant to 

section 402 of the Congressional Budget Act of 1974: 

U.S. CONGRESS, CONGRESSIONAL BUDGET OFFICE, Washington, DC, June 6, 2018. 

Hon. GREG WALDEN, 

Chairman, Committee on Energy and Commerce, 

House of Representatives, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed document with cost estimates for the opioid-related legislation ordered to be reported on May 9 and May 17, 

2018. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contacts are Tom Bradley and 

Chad Chirico. 

Sincerely, 

MARK P. HADLEY

(For Keith Hall, Director). 

7 

Enclosure. 

Opioid Legislation 

Summary: On May 9 and May 17, 2018, the House Committee 

on Energy and Commerce ordered 59 bills to be reported related to 

the nation’s response to the opioid epidemic. Generally, the bills 

would: 

• Provide grants to facilities and providers that treat people 

with substance use disorders, 

• Direct various agencies within the Department of Health 

and Human Services (HHS) to explore nonopioid approaches to 

treating pain and to educate providers about those alternatives, 

• Modify requirements under Medicaid and Medicare for 

prescribing controlled substances, 

• Expand Medicaid coverage for substance abuse treatment, 

and 

• Direct the Food and Drug Administration (FDA) to modify 

its oversight of opioid drugs and other medications that are 

used to manage pain. 

Because of the large number of related bills ordered reported by 

the Committee, CBO is publishing a single comprehensive document that includes estimates for each piece of legislation. 

CBO estimates that enacting 20 of the bills would affect direct 

spending, and 2 of the bills would affect revenues; therefore, payas-you-go procedures apply for those bills. 

CBO estimates that enacting H.R. 4998, the Health Insurance for 

Former Foster Youth Act, would increase net direct spending by 

more than $2.5 billion and on-budget deficits by more than $5 billion in at least one of the four consecutive 10-year periods beginning in 2029. None of the remaining 58 bills included in this estimate would increase net direct spending by more than $2.5 billion 

or on-budget deficits by more than $5 billion in any of the four consecutive 10-year periods beginning in 2029. 

One of the bills reviewed for this document, H.R. 5795, would impose both intergovernmental and private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). CBO estimates that the costs of those mandates on public and private entities would fall below the thresholds in UMRA ($80 million and 

$160 million, respectively, in 2018, adjusted annually for inflation). 

Five bills, H.R. 5228, H.R. 5333, H.R. 5554, H.R. 5687, and H.R. 

5811, would impose private-sector mandates as defined in UMRA. 

CBO estimates that the costs of the mandates in three of the bills 

(H.R. 5333, H.R. 5554, and H.R. 5811) would not exceed the UMRA 

threshold for private entities. Because CBO is uncertain how federal agencies would implement new authority granted in the other 

two bills, H.R. 5228 and H.R. 5687, CBO cannot determine whether 

the costs of those mandates would exceed the UMRA threshold. 

Estimated cost to the Federal Government: The estimates in this 

document do not include the effects of interactions among the bills. 

If all 59 bills were combined and enacted as one piece of legislation, 

the budgetary effects would be different from the sum of the estimates in this document, although CBO expects that any such differences would be small. The costs of this legislation fall within 

8 

budget functions 550 (health), 570 (Medicare), 750 (administration 

of justice), and 800 general government). 

Basis of estimate: For this estimate, CBO assumes that all of the 

legislation will be enacted late in 2018 and that authorized and estimated amounts will be appropriated each year. Outlays for discretionary programs are estimated based on historical spending patterns for similar programs. 

Uncertainty 

CBO aims to produce estimates that generally reflect the middle 

of a range of the most likely budgetary outcomes that would result 

if the legislation was enacted. Because data on the utilization of 

mental health and substance abuse treatment under Medicaid and 

Medicare is scarce, CBO cannot precisely predict how patients or 

providers would respond to some policy changes or what budgetary 

effects would result. In addition, several of the bills would give the 

Department of Health and Human Services (HHS) considerable 

latitude in designing and implementing policies. Budgetary effects 

could differ from those provided in CBO’s analyses depending on 

those decisions. 

Direct spending and revenues 

Table 1 lists the 22 bills of the 59 ordered to be reported that 

would affect direct spending or revenues. 

9 

TABLE 1.—ESTIMATED CHANGES IN MANDATORY SPENDING AND REVENUES 

By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2019– 2023 2019–2028 

INCREASES OR DECREASES (¥) IN DIRECT SPENDING 

Legislation Primarily Affecting Medicaid: 

H.R. 1925, At-Risk Youth Medicaid Protection Act of 2017 ................... 0 * 5 5 5 10 10 10 10 10 10 25 75 H.R. 4998, Health Insurance for Former Foster Youth Act ...................... 0 0 0 0 0 * 10 21 33 46 61 * 171 H.R. 5477, Rural Development of Opioid Capacity Services Act ............ 0 13 35 58 68 83 27 9 3 3 3 256 301 H.R. 5583, a bill to amend title XI of the Social Security Act to require 

States to annually report on certain adult health quality measures, and for other purposes ........................................................................ 0 * * * * * * * * * * * * 

H.R. 5797, IMD CARE Act ........................................................................ 0 38 158 251 265 279 0 0 0 0 0 991 991 H.R. 5799, Medicaid DRUG Improvement Act a ....................................... 0 * * 1 1 1 1 1 1 1 1 2 5 

H.R. 5801 Medicaid Providers Are Required To Note Experiences in 

Record Systems to Help In-Need Patients (PARTNERSHIP) Act a ........ 0 * * * * * * * * * * * * 

H.R. 5808, Medicaid Pharmaceutical Home Act of 2018 a ..................... 0 * ¥1 ¥1 ¥1 ¥1 ¥2 ¥2 ¥2 ¥2 ¥2 ¥4 ¥13 

H.R. 5810, Medicaid Health HOME Act .................................................... 0 94 58 62 56 52 48 43 38 32 25 323 509 

Legislation Primarily Affecting Medicare: 

H.R. 3528, Every Prescription Conveyed Securely Act ............................. 0 0 0 ¥24 ¥35 ¥33 ¥30 ¥33 ¥32 ¥31 ¥32 ¥92 ¥250 

H.R. 4841, Standardizing Electronic Prior Authorization for Safe Prescribing Act of 2018 ............................................................................ 0 0 0 * * * * * * * * * * H.R. 5603, Access to Telehealth Services for Opioid Use Disorders Act 0 2 * * * 1 1 1 2 2 2 3 11 H.R. 5605, Advancing High Quality Treatment for Opioid Use Disorders 

in Medicare Act .................................................................................... 0 0 0 15 26 24 23 23 10 1 * 65 122 

H.R. 5675, a bill to amend title XVIII of the Social Security Act to require prescription drug plan sponsors under the Medicare program 

to establish drug management programs for at-risk beneficiaries ... 0 0 0 ¥6 ¥7 ¥7 ¥7 ¥8 ¥9 ¥9 ¥11 ¥20 ¥64 

H.R. 5684, Protecting Seniors From Opioid Abuse Act ............................ 0 0 0 * * * * * * * * * * H.R. 5796, Responsible Education Achieves Care and Healthy Outcomes for Users’ Treatment Act of 2018 ............................................ 0 10 25 50 10 5 0 0 0 0 0 100 100 H.R. 5798, Opioid Screening and Chronic Pain Management Alternatives for Seniors Act ........................................................................ 0 0 * 1 1 1 1 1 1 1 1 2 5 H.R. 5804, Post-Surgical Injections as an Opioid Alternative Act a ....... 0 0 25 30 25 20 10 5 0 0 0 100 115 

H.R. 5809, Postoperative Opioid Prevention Act of 2018 ........................ 0 0 0 0 10 15 20 25 30 35 45 25 180 

Legislation Primarily Affecting the Food and Drug Administration: 

10 

TABLE 1.—ESTIMATED CHANGES IN MANDATORY SPENDING AND REVENUES—Continued 

By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2019– 2023 2019–2028 

H.R. 5333, Over-the-Counter Monograph Safety, Innovation, and Reform Act of 2018 a ............................................................................... 0 0 * * * * * * * * * * * 

INCREASES OR DECREASES (¥) IN REVENUES b

H.R. 5752, Stop Illicit Drug Importation Act of 2018 ............................. 0 * * * * * * * * * * * * 

Annual amounts may not sum to totals because of rounding. * = between ¥$500,000 and $500,000. Budget authority is equivalent to outlays. a This bill also would affect spending subject to appropriation. b One additional bill, H.R. 5228, the Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act, would have a negligible effect on revenues. 

11 

Legislation Primarily Affecting Medicaid. The following nine bills 

would affect direct spending for the Medicaid program. 

H.R. 1925, the At-Risk Youth Medicaid Protection Act of 2017, 

would require states to suspend, rather than terminate, Medicaid 

eligibility for juvenile enrollees (generally under 21 years of age) 

who become inmates of public correctional institutions. States also 

would have to redetermine those enrollees’ Medicaid eligibility before their release and restore their coverage upon release if they 

qualify for the program. States would be required to process Medicaid applications submitted by or on behalf of juveniles in public 

correctional institutions who were not enrolled in Medicaid before 

becoming inmates and ensure that Medicaid coverage is provided 

when they are released if they are found to be eligible. On the 

basis of an analysis of juvenile incarceration trends and of the per 

enrollee spending for Medicaid foster care children, who have a 

similar health profile to incarcerated juveniles, CBO estimates that 

implementing the bill would cost $75 million over the 2019–2028 

period. 

H.R. 4998, the Health Insurance for Former Foster Youth Act, 

would require states to provide Medicaid coverage to adults up to 

age 25 who had aged out of foster care in any state. Under current 

law, such coverage is mandatory only if the former foster care 

youth has aged out in the state in which the individual applies for 

coverage. The policy also would apply to former foster children who 

had been in foster care upon turning 14 years of age but subsequently left foster care to enter into a legal guardianship with a 

kinship caregiver. The provisions would take effect respect for foster youth who turn 18 on or after January 1, 2023. On the basis 

of spending for Medicaid foster care children and data from the 

Census Bureau regarding annual migration rates between states, 

CBO estimates that implementing the bill would cost $171 million 

over the 2019–2028 period. 

H.R. 5477, the Rural Development of Opioid Capacity Services 

Act, would direct the Secretary of HHS to conduct a five-year demonstration to increase the number and ability of providers participating in Medicaid to provide treatment for substance use disorders. On the basis of an analysis of federal and state spending 

for treatment of substance use disorders and the prevalence of such 

disorders, CBO estimates that enacting the bill would increase direct spending by $301 million over the 2019–2028 period. 

H.R. 5583, a bill to amend title XI of the Social Security Act to 

require States to annually report on certain adult health quality 

measures, and for other purposes, would require states to include 

behavioral health indicators in their annual reports on the quality 

of care under Medicaid. Although the bill would add a requirement 

for states, CBO estimates that its enactment would not have a significant budgetary effect because most states have systems in place 

for reporting such measures to the federal government. 

H.R. 5797, the IMD CARE Act, would expand Medicaid coverage 

for people with opioid use disorder who are in institutions for mental disease (IMDs) for up to 30 days per year. Under a current-law 

policy known as the IMD exclusion, the federal government generally does not make matching payments to state Medicaid programs for most services provided by IMDs to adults between the 

ages of 21 and 64. Recent administrative changes have made fedVerDate Sep 11 2014 06:36 Jun 19, 2018 Jkt 079006 PO 00000 Frm 00011 Fmt 6659 Sfmt 6602 E:\HR\OC\HR734.XXX HR734
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eral financing for IMDs available in limited circumstances, but the 

statutory prohibition remains in place. CBO analyzed several data 

sets, primarily those collected by the Substance Abuse and Mental 

Health Services Administration (SAMHSA), to estimate current 

federal spending under Medicaid for IMD services and to estimate 

spending under H.R. 5797. Using that analysis, CBO estimates 

that enacting H.R. 5797 would increase direct spending by $991 

million over the 2019–2028 period. 

H.R. 5799, the Medicaid DRUG Improvement Act, would require 

state Medicaid programs to implement additional reviews of opioid 

prescriptions, monitor concurrent prescribing of opioids and certain 

other drugs, and monitor use of antipsychotic drugs by children. 

CBO estimates that the bill would increase direct spending by $5 

million over 2019–2028 period to cover the administrative costs of 

complying with those requirements. On the basis of stakeholder 

feedback, CBO expects that the bill would not have a significant effect on Medicaid spending for prescription drugs because many of 

the bill’s requirements would duplicate current efforts to curb 

opioid and antipsychotic drug use. (If enacted, H.R. 5799 also 

would affect spending subject to appropriation; CBO has not completed an estimate of that amount.) 

H.R. 5801, the Medicaid Providers Are Required To Note Experiences in Record Systems to Help In-Need Patients (PARTNERSHIP) 

Act, would require providers who are permitted to prescribe controlled substances and who participate in Medicaid to query prescription drug monitoring programs (PDMPs) before prescribing 

controlled substances to Medicaid patients. PDMPs are statewide 

electronic databases that collect data on controlled substances dispensed in the state. The bill also would require PDMPs to comply 

with certain data and system criteria, and it would provide additional federal matching funds to certain states to help cover administrative costs. On the basis of a literature review and stakeholder 

feedback, CBO estimates that the net budgetary effect of enacting 

H.R. 5801 would be insignificant. Costs for states to come into compliance with the systems and administrative requirements would 

be roughly offset by savings from small reductions in the number 

of controlled substances paid for by Medicaid under the proposal. 

(If enacted, H.R. 5801 also would affect spending subject to appropriation; CBO has not completed an estimate of that amount.) 

H.R. 5808, the Medicaid Pharmaceutical Home Act of 2018, 

would require state Medicaid programs to operate pharmacy programs that would identify people at high risk of abusing controlled 

substances and require those patients to use a limited number of 

providers and pharmacies. Although nearly all state Medicaid programs currently meet such a requirement, a small number of highrisk Medicaid beneficiaries are not now monitored. Based on an 

analysis of information about similar state and federal programs, 

CBO estimates that net Medicaid spending under the bill would decrease by $13 million over the 2019–2028 period. That amount represents a small increase in administrative costs and a small reduction in the number of controlled substances paid for by Medicaid 

under the proposal. (If enacted, H.R. 5808 also would affect spending subject to appropriation; CBO has not completed an estimate 

of that amount.) 

13 

H.R. 5810, the Medicaid Health HOME Act, would allow states 

to receive six months of enhanced federal Medicaid funding for programs that coordinate care for people with substance use disorders. 

Based on enrollment and spending data from states that currently 

participate in Medicaid’s Health Homes program, CBO estimates 

that the expansion would cost approximately $469 million over the 

2019–2028 period. The bill also would require states to cover all 

FDA-approved drugs used in medication-assisted treatment for five 

years, although states could seek a waiver from that requirement. 

(Medication-assisted treatment combines behavioral therapy and 

pharmaceutical treatment for substance use disorders.) Under current law, states already cover most FDA-approved drugs used in 

such programs in some capacity, although a few exclude methadone 

dispensed by opioid treatment programs. CBO estimates that a 

small share of those states would begin to cover methadone if this 

bill was enacted at a federal cost of about $39 million over the 

2019–2028 period. In sum, CBO estimates that the enacting H.R. 

5810 would increase direct spending by $509 million over the 

2019–2028 period. 

Legislation Primarily Affecting Medicare. The following ten bills 

would affect direct spending for the Medicare program. 

H.R. 3528, the Every Prescription Conveyed Securely Act, would 

require prescriptions for controlled substances covered under Medicare Part D to be transmitted electronically, starting on January 

1, 2021. Based on CBO’s analysis of prescription drug spending, 

spending for controlled substances is a small share of total drug 

spending. CBO also assumes a small share of those prescriptions 

would not be filled because they are not converted to an electronic 

format. Therefore, CBO expects that enacting H.R. 3528 would reduce the number of prescriptions filled and estimates that Medicare spending be reduced by $250 million over the 2019–2028 period. 

H.R. 4841, the Standardizing Electronic Prior Authorization for 

Safe Prescribing Act of 2018, would require health care professionals to submit prior authorization requests electronically, starting on January 1, 2021, for drugs covered under Medicare Part D. 

Taking into account that many prescribers already use electronic 

methods to submit such requests, CBO estimates that enacting 

H.R. 4841 would not significantly affect direct spending for Part D. 

H.R. 5603, the Access to Telehealth Services for Opioid Use Disorders Act, would permit the Secretary of HHS to lift current geographic and other restrictions on coverage of telehealth services 

under Medicare for treatment of substance use disorders or co-occurring mental health disorders. Under the bill, the Secretary of 

HHS would be directed to encourage other payers to coordinate 

payments for opioid use disorder treatments and to evaluate the 

extent to which the demonstration reduces hospitalizations, increases the use of medication-assisted treatments, and improves 

the health outcomes of individuals with opioid use disorders during 

and after the demonstration. Based on current use of Medicare 

telehealth services for treatment of substance use disorders, CBO 

estimates that expanding that coverage would increase direct 

spending by $11 million over the 2019–2028 period. 

H.R. 5605, the Advancing High Quality Treatment for Opioid Use 

Disorders in Medicare Act, would establish a five-year demonstraVerDate Sep 11 2014 06:36 Jun 19, 2018 Jkt 079006 PO 00000 Frm 00013 Fmt 6659 Sfmt 6602 E:\HR\OC\HR734.XXX HR734
14 

tion program to increase access to treatment for opioid use disorder. The demonstration would provide incentive payments and 

funding for care management services based on criteria such as patient engagement, use of evidence-based treatments, and treatment 

length and intensity. Under the bill, the Secretary of HHS would 

be directed to encourage other payers to coordinate payments for 

opioid use disorder treatments and to evaluate the extent to which 

the demonstration reduces hospitalizations, increases the use of 

medication-assisted treatments, and improves the health outcomes 

of individuals with opioid use disorders during and after the demonstration. Based on historical utilization of opioid use disorder 

treatments and projected spending on incentive payments and care 

management fees, CBO estimates that increased use of treatment 

services and the demonstration’s incentive payments would increase direct spending by $122 million over the 2019–2028 period. 

H.R. 5675, a bill to amend title XVIII of the Social Security Act 

to require prescription drug plan sponsors under the Medicare program to establish drug management programs for at-risk beneficiaries, would require Part D prescription drug plans to provide 

drug management programs for Medicare beneficiaries who are at 

risk for prescription drug abuse. (Under current law, Part D plans 

are permitted but not required to establish such programs as of 

2019.) Based on an analysis of the number of plans currently providing those programs, CBO estimates that enacting H.R. 5675 

would lower federal spending by $64 million over the 2019–2028 

period by reducing the number of prescriptions filled and Medicare’s payments for controlled substances. 

H.R. 5684, the Protecting Seniors From Opioid Abuse Act, would 

expand medication therapy management programs under Medicare 

Part D to include beneficiaries who are at risk for prescription drug 

abuse. Because relatively few beneficiaries would be affected by 

this bill, CBO estimates that its enactment would not significantly 

affect direct spending for Part D. 

H.R. 5796, the Responsible Education Achieves Care and Healthy 

Outcomes for Users’ Treatment Act of 2018, would allow the Secretary of HHS to award grants to certain organizations that provide technical assistance and education to high-volume prescribers 

of opioids. The bill would appropriate $100 million for fiscal year 

2019. Based on historical spending patterns for similar activities, 

CBO estimates that implementing H.R. 5796 would cost $100 million over the 2019–2028 period. 

H.R. 5798, the Opioid Screening and Chronic Pain Management 

Alternatives for Seniors Act, would add an assessment of current 

opioid prescriptions and screening for opioid use disorder to the 

Welcome to Medicare Initial Preventive Physical Examination. 

Based on historical use of the examinations and pain management 

alternatives, CBO expects that enacting the bill would increase use 

of pain management services and estimates that direct spending 

would increase by $5 million over the 2019–2028 period. 

H.R. 5804, the Post-Surgical Injections as an Opioid Alternative 

Act, would freeze the Medicare payment rate for certain analgesic 

injections provided in ambulatory surgical centers (ASCs). (For injections identified by specific billing codes, Medicare would pay the 

2016 rate, which is higher than the current rate, during the 2020– 

2024 period.) Based on current utilization in the ASC setting, CBO 

15 

estimates that enacting the legislation would increase direct spending by about $115 million over the 2019–2028 period. (If enacted, 

H.R. 5804 also would affect spending subject to appropriation; see 

Table 3.) 

H.R. 5809, the Postoperative Opioid Prevention Act of 2018, 

would create an additional payment under Medicare for nonopioid 

analgesics. Under current law, certain new drugs and devices may 

receive an additional payment—separate from the bundled payment for a surgical procedure—in outpatient hospital departments 

and ambulatory surgical centers. The bill would allow nonopioid 

analgesics to qualify for a five-year period of additional payments. 

Based on its assessment of current spending for analgesics and on 

the probability of new nonopioid analgesics coming to market, CBO 

estimates that H.R. 5809 would increase direct spending by about 

$180 million over the 2019–2028 period. 

Legislation Primarily Affecting the Food and Drug Administration. One bill related to the FDA would affect direct spending. 

H.R. 5333, the Over-the-Counter Monograph Safety, Innovation, 

and Reform Act of 2018, would change the way that the FDA regulates the marketing of over-the-counter (OTC) medicines, and it 

would authorize that agency to grant 18 months of exclusive market protection for certain qualifying OTC drugs, thus delaying the 

entry of other versions of the same qualifying OTC product. Medicaid currently provides some coverage for OTC medicines, but only 

if a medicine is the least costly alternative in its drug class. On the 

basis of stakeholder feedback, CBO expects that delaying the availability of additional OTC versions of a drug would not significantly 

affect the average net price paid by Medicaid. As a result, CBO estimates that enacting H.R. 5333 would have a negligible effect on 

the federal budget. (If enacted, H.R. 5333 also would affect spending subject to appropriation; see Table 3.) 

Legislation with Revenue Effects. Two bills would affect revenues. However, CBO estimates that one bill, H.R. 5228, the Stop 

Counterfeit Drugs by Regulating and Enhancing Enforcement Now 

Act, would have only a negligible effect. 

H.R. 5752, the Stop Illicit Drug Importation Act of 2018, would 

amend the Federal, Food, Drug, and Cosmetic Act (FDCA) to 

strengthen the FDA’s seizure powers and enhance its authority to 

detain, refuse, seize, or destroy illegal products offered for import. 

The legislation would subject more people to debarment under the 

FDCA and thus increase the potential for violations, and subsequently, the assessment of civil penalties, which are recorded in 

the budget as revenues. CBO estimates that those collections would 

result in an insignificant increase in revenues. Because H.R. 5752 

would prohibit the importation of drugs that are in the process of 

being scheduled, it also could reduce amounts collected in customs 

duties. CBO anticipates that the result would be a negligible decrease in revenues. With those results taken together, CBO estimates, enacting H.R. 5752 would generate an insignificant net increase in revenues over the 2019–2028 period. 

Spending subject to appropriation 

For this document, CBO has grouped bills with spending that 

would be subject to appropriation into four general categories: 

• Bills that would have no budgetary effect, 

16 

• Bills with provisions that would authorize specified 

amounts to be appropriated (see Table 2), 

• Bills with provisions for which CBO has estimated an authorization of appropriations (see Table 3), and 

• Bills with provisions that would affect spending subject to 

appropriation for which CBO has not yet completed an estimate. 

No Budgetary Effect. CBO estimates that 6 of the 59 bills would 

have no effect on direct spending, revenues, or spending subject to 

appropriation. 

H.R. 3192, the CHIP Mental Health Parity Act, would require all 

Children’s Health Insurance Program (CHIP) plans to cover mental 

health and substance abuse treatment. In addition, states would 

not be allowed to impose financial or utilization limits on mental 

health treatment that are lower than limits placed on physical 

health treatment. Based on information from the Centers for Medicare and Medicaid Services, CBO estimates that enacting the bill 

would have no budgetary effect because all CHIP enrollees are already in plans that meet those requirements. 

H.R. 3331, a bill to amend title XI of the Social Security Act to 

promote testing of incentive payments for behavioral health providers for adoption and use of certified electronic health record technology, would give the Center for Medicare and Medicaid Innovation (CMMI) explicit authorization to test a program offering incentive payments to behavioral health providers that adopt and use 

certified electronic health record technology. Because it is already 

clear to CMMI that it has that authority, CBO estimates that enacting the legislation would not affect federal spending. 

H.R. 5202, the Ensuring Patient Access to Substance Use Disorder Treatments Act of 2018, would clarify permission for pharmacists to deliver controlled substances to providers under certain 

circumstances. Because this provision would codify current practice, CBO estimates that H.R. 5202 would not affect direct spending or revenues during the 2019–2028 period. 

H.R. 5685, the Medicare Opioid Safety Education Act of 2018, 

would require the Secretary of HHS to include information on 

opioid use, pain management, and nonopioid pain management 

treatments in future editions of Medicare & You, the program’s 

handbook for beneficiaries, starting on January 1, 2019. Because 

H.R. 5685 would add information to an existing administrative document, CBO estimates that enacting the bill would have no budgetary effect. 

H.R. 5686, the Medicare Clear Health Options in Care for Enrollees Act of 2018, would require prescription drug plans that provide 

coverage under Medicare Part D to furnish information to beneficiaries about the risks of opioid use and the availability of alternative treatments for pain. CBO estimates that enacting the bill 

would not affect direct spending because the required activities 

would not impose significant administrative costs. 

H.R. 5716, the Commit to Opioid Medical Prescriber Accountability and Safety for Seniors Act, would require the Secretary of 

HHS on an annual basis to identify high prescribers of opioids and 

furnish them with information about proper prescribing methods. 

Because HHS already has the capacity to meet those requirements, 

17 

CBO estimates that enacting that provision would not impose additional administrative costs on the agency. 

Specified Authorizations. Table 2 lists the ten bills that would 

authorize specified amounts to be appropriated over the 2019–2023 

period. Spending from those authorized amounts would be subject 

to appropriation. 

TABLE 2.—ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH SPECIFIED 

AUTHORIZATIONS 

By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2023 2019– 

2023 

INCREASES IN SPENDING SUBJECT TO APPROPRIATION 

H.R. 4684, Ensuring Access to Quality Sober Living Act: 

Authorization Level ........................................................... 0 3 0 0 0 0 3 

Estimated Outlays ............................................................ 0 1 2 * * * 3 

H.R. 5102, Substance Use Disorder Workforce Loan Repayment Act of 2018: 

Authorization Level ........................................................... 0 25 25 25 25 25 125 

Estimated Outlays ............................................................ 0 9 19 23 25 25 100 

H.R. 5176, Preventing Overdoses While in Emergency Rooms 

Act of 2018: 

Authorization Level ........................................................... 0 50 0 0 0 0 50 

Estimated Outlays ............................................................ 0 16 26 6 2 1 50 

H.R. 5197, Alternatives to Opioids (ALTO) in the Emergency 

Department Act: 

Authorization Level ........................................................... 0 10 10 10 0 0 30 

Estimated Outlays ............................................................ 0 3 8 10 7 2 30 

H.R. 5261, Treatment, Education, and Community Help to 

Combat Addiction Act of 2018: 

Authorization Level ........................................................... 0 4 4 4 4 4 20 

Estimated Outlays ............................................................ 0 1 3 4 4 4 16 

H.R. 5327, Comprehensive Opioid Recovery Centers Act of 

2018: 

Authorization Level ........................................................... 0 10 10 10 10 10 50 

Estimated Outlays ............................................................ 0 3 8 10 10 10 41 

H.R. 5329, Poison Center Network Enhancement Act of 2018: 

Authorization Level ........................................................... 0 30 30 30 30 30 151 

Estimated Outlays ............................................................ 0 12 25 29 29 29 125 

H.R. 5353, Eliminating Opioid-Related Infectious Diseases 

Act of 2018: 

Authorization Level ........................................................... 0 40 40 40 40 40 200 

Estimated Outlays ............................................................ 0 15 34 38 39 40 166 

H.R. 5580, Surveillance and Testing of Opioids to Prevent 

Fentanyl Deaths Act of 2018: 

Authorization Level ........................................................... 30 30 30 30 30 0 120 

Estimated Outlays ............................................................ 0 11 25 29 29 19 113 

H.R. 5587, Peer Support Communities of Recovery Act: 

Authorization Level ........................................................... 0 15 15 15 15 15 75 

Estimated Outlays ............................................................ 0 5 13 14 15 15 62 

Annual amounts may not sum to totals because of rounding. * = between zero and $500,000. 

H.R. 4684, the Ensuring Access to Quality Sober Living Act, 

would direct the Secretary of HHS to develop and disseminate best 

practices for organizations that operate housing designed for people 

recovering from substance use disorders. The bill would authorize 

a total of $3 million over the 2019–2021 period for that purpose. 

Based on historical spending patterns for similar activities, CBO 

estimates that implementing H.R. 4684 would cost $3 million over 

the 2019–2023 period. 

H.R. 5102, the Substance Use Disorder Workforce Loan Repayment Act of 2018, would establish a loan repayment program for 

18 

mental health professionals who practice in areas with few mental 

health providers or with high rates of death from overdose and 

would authorize $25 million per year over the 2019–2028 period for 

that purpose. Based on historical spending patterns for similar activities, CBO estimates that implementing H.R. 5102 would cost 

$100 million over the 2019–2023 period; the remaining amounts 

would be spent in years after 2023. 

H.R. 5176, the Preventing Overdoses While in Emergency Rooms 

Act of 2018, would require the Secretary of HHS to develop protocols and a grant program for health care providers to address the 

needs of people who survive a drug overdose, and it would authorize $50 million in 2019 for that purpose. Based on historical spending patterns for similar activities, CBO estimates that implementing H.R. 5176 would cost $50 million over the 2019–2023 period. 

H.R. 5197, the Alternatives to Opioids (ALTO) in the Emergency 

Department Act, would direct the Secretary of HHS to carry out a 

demonstration program for hospitals and emergency departments 

to develop alternative protocols for pain management that limit the 

use of opioids and would authorize $10 million annually in grants 

for fiscal years 2019 through 2021. Based on historical spending 

patterns for similar programs, CBO estimates that implementing 

H.R. 5197 would cost $30 million over the 2019–2023 period. 

H.R. 5261, the Treatment, Education, and Community Help to 

Combat Addiction Act of 2018, would direct the Secretary of HHS 

to designate regional centers of excellence to improve the training 

of health professionals who treat substance use disorders. The bill 

would authorize $4 million annually for grants to those programs 

over the 2019–2023 period. Based on historical spending patterns 

for similar activities, CBO estimates that implementing H.R. 5261 

would cost $16 million over the 2019–2023 period; the remaining 

amounts would be spent in years after 2023. 

H.R. 5327, the Comprehensive Opioid Recovery Centers Act of 

2018, would direct the Secretary of HHS to award grants to at 

least 10 providers that offer treatment services for people with 

opioid use disorder, and it would authorize $10 million per year 

over the 2019–2023 period for that purpose. Based on historical 

spending patterns for similar activities, CBO estimates that implementing H.R. 5327 would cost $41 million over the 2019–2023 period; the remaining amounts would be spent in years after 2023. 

H.R. 5329, the Poison Center Network Enhancement Act of 2018, 

would reauthorize the poison control center toll-free number, national media campaign, and grant program under the Public 

Health Service Act. Among other actions, H.R. 5329 would increase 

the share of poison control center funding that could be provided 

by federal grants. The bill would authorize a total of about $30 million per year over the 2019–2023 period. Based on historical spending patterns for similar activities, CBO estimates that implementing H.R. 5329 would cost $125 million over the 2019–2023 period; the remaining amounts would be spent in years after 2023. 

H.R. 5353, the Eliminating Opioid Related Infectious Diseases 

Act of 2018, would amend Public Health Service Act by broadening 

the focus of surveillance and education programs from preventing 

and treating hepatitis C virus to preventing and treating infections 

associated with injection drug use. It would authorize $40 million 

19 

per year over 2019–2023 period for that purpose. Based on historical spending patterns for similar activities, CBO estimates that 

implementing H.R. 5353 would cost $166 million over the 2019– 

2023 period; the remaining amounts would be spent in years after 

2023. 

H.R. 5580, the Surveillance and Testing of Opioids to Prevent 

Fentanyl Deaths Act of 2018, would establish a grant program for 

public health laboratories that conduct testing for fentanyl and 

other synthetic opioids. It also would direct the Centers for Disease 

Control and Prevention to expand its drug surveillance program, 

with a particular focus on collecting data on fentanyl. The bill 

would authorize a total of $30 million per year over the 2018–2022 

period for those activities. Based on historical spending patterns for 

similar activities, CBO estimates that implementing H.R. 5580 

would cost $113 million over the 2019–2023 period; the remaining 

amounts would be spent in years after 2023. 

H.R. 5587, Peer Support Communities of Recovery Act, would direct the Secretary of HHS to award grants to nonprofit organizations that support community-based, peer-delivered support, including technical support for the establishment of recovery community organizations, independent, nonprofit groups led by people in 

recovery and their families. The bill would authorize $15 million 

per year for the 2019–2023 period. Based on historical spending 

patterns for similar activities, CBO estimates that implementing 

H.R. 5587 would cost $62 million over the 2019–2023 period; the 

remaining amounts would be spent in years after 2023. 

Estimated Authorizations. Table 3 shows CBO’s estimates of the 

appropriations that would be necessary to implement 19 of the 

bills. Spending would be subject to appropriation of those amounts. 

H.R. 449, the Synthetic Drug Awareness Act of 2018, would require the Surgeon General to report to the Congress on the health 

effects of synthetic psychoactive drugs on children between the 

ages of 12 and 18. Based on spending patterns for similar activities, CBO estimates that implementing H.R. 449 would cost approximately $1 million over the 2019–2023 period. 

H.R. 4005, the Medicaid Reentry Act, would direct the Secretary 

of HHS to convene a group of stakeholders to develop and report 

to the Congress on best practices for addressing issues related to 

health care faced by those returning from incarceration to their 

communities. The bill also would require the Secretary to issue a 

letter to state Medicaid directors about relevant demonstration 

projects. Based on an analysis of anticipated workload, CBO estimates that implementing H.R. 4005 would cost less than $500,000 

over the 2018–2023 period. 

H.R. 4275, the Empowering Pharmacists in the Fight Against 

Opioid Abuse Act, would require the Secretary of HHS to develop 

and disseminate materials for training pharmacists, health care 

practitioners, and the public about the circumstances under which 

a pharmacist may decline to fill a prescription. Based on historical 

spending patterns for similar activities, CBO estimates that costs 

to the federal government for the development and distribution of 

those materials would not be significant. 

20 

TABLE 3.—ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH ESTIMATED 

AUTHORIZATIONS 

By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2023 2019– 

2023 

INCREASES IN SPENDING SUBJECT TO APPROPRIATION 

H.R. 449, Synthetic Drug Awareness Act of 2018: 

Estimated Authorization Level .............................................. 0 * * * 0 0 1 

Estimated Outlays ................................................................. 0 * * * 0 0 1 

H.R. 4005, Medicaid Reentry Act: 

Estimated Authorization Level .............................................. * * 0 0 0 0 * 

Estimated Outlays ................................................................. * * 0 0 0 0 * 

H.R. 4275, Empowering Pharmacists in the Fight Against Opioid 

Abuse Act: 

Estimated Authorization Level .............................................. 0 * * * * * * 

Estimated Outlays ................................................................. 0 * * * * * * 

H.R. 5009, Jessie’s Law: 

Estimated Authorization Level .............................................. 0 * * * * * * 

Estimated Outlays ................................................................. 0 * * * * * * 

H.R. 5041, Safe Disposal of Unused Medication Act: 0 * * * * * * 

Estimated Authorization Level .............................................. 0 * * * * * * 

Estimated Outlays ................................................................. 0 * * * * * * 

H.R. 5272, Reinforcing Evidence-Based Standards Under Law in 

Treating Substance Abuse Act of 2018: 

Estimated Authorization Level .............................................. 0 1 1 1 1 1 4 

Estimated Outlays ................................................................. 0 1 1 1 1 1 4 

H.R. 5333, Over-the-Counter Monograph Safety, Innovation, and 

Reform Act of 2018: a

Food and Drug Administration: 

Collections from fees: 

Estimated Authorization Level ............................ 0 ¥22 ¥22 ¥26 ¥35 ¥42 ¥147 

Estimated Outlays ............................................... 0 ¥22 ¥22 ¥26 ¥35 ¥42 ¥147 

Spending of fees: 

Estimated Authorization Level ............................ 0 22 22 26 35 42 147 

Estimated Outlays ............................................... 0 6 17 30 44 41 137 

Net effect on FDA: 

Estimated Authorization Level ............................ 0 0 0 0 0 0 0 

Estimated Outlays ............................................... 0 ¥17 ¥6 4 9 * ¥10 

Government Accountability Office: 

Estimated Authorization Level ..................................... 0 0 0 0 0 * * 

Estimated Outlays ........................................................ 0 0 0 0 0 * * 

Total, H.R. 5333: 

Estimated Authorization Level ..................................... 0 0 0 0 0 * * 

Estimated Outlays ........................................................ 0 ¥17 ¥6 4 9 * ¥10 

H.R. 5473, Better Pain Management Through Better Data Act of 

2018: 

Estimated Authorization Level .............................................. 0 * * * * 0 1 

Estimated Outlays ................................................................. 0 * * * * * 1 

H.R. 5483, Special Registration for Telemedicine Clarification 

Act of 2018: 

Estimated Authorization Level .............................................. 0 * * * * * * 

Estimated Outlays ................................................................. 0 * * * * * * 

H.R. 5554, Animal Drug and Animal Generic Drug User Fee 

Amendments of 2018: 

Collections from fees: 

Animal drug fees ......................................................... 0 ¥30 ¥31 ¥32 ¥33 ¥34 ¥159 

Generic animal drug fees ............................................ 0 ¥18 ¥19 ¥19 ¥20 ¥21 ¥97 

Total, Estimated Authorization Level .................. 0 ¥49 ¥50 ¥51 ¥53 ¥55 ¥257 

Total, Estimated Outlays ..................................... 0 ¥49 ¥50 ¥51 ¥53 ¥55 ¥257 

Spending of fees: 

Animal drug fees ......................................................... 0 30 31 32 33 34 159 

Generic animal drug fees ............................................ 0 18 19 19 20 21 97 

Total, Estimated Authorization Level .................. 0 49 50 51 53 55 257 

Total, Estimated Outlays ..................................... 0 39 47 51 52 54 243 

21 

TABLE 3.—ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH ESTIMATED 

AUTHORIZATIONS—Continued 

By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2023 2019– 

2023 

Net changes in fees: 

Estimated Authorization Level ..................................... 0 0 0 0 0 0 0 

Estimated Outlays ........................................................ 0 ¥10 ¥3 * * * ¥14 

Other effects: 

Estimated Authorization Level ..................................... 0 3 1 1 1 1 6 

Estimated Outlays ........................................................ 0 2 1 1 1 1 6 

Total, H.R. 5554: 

Estimated Authorization Level ..................................... 0 3 1 1 1 1 6 

Estimated Outlays ........................................................ 0 ¥8 ¥2 1 * * ¥8 

H.R. 5582, Abuse Deterrent Access Act of 2018: 

Estimated Authorization Level .............................................. 0 0 * 0 0 0 * 

Estimated Outlays ................................................................. 0 0 * 0 0 0 * 

H.R. 5590, Opioid Addiction Action Plan Act: 

Estimated Authorization Level .............................................. * * * * * * 2 

Estimated Outlays ................................................................. * * * * * * 2 

H.R. 5687, Securing Opioids and Unused Narcotics with Deliberate Disposal and Packaging Act of 2018: 

Estimated Authorization Level .............................................. 0 * * * * * * 

Estimated Outlays ................................................................. 0 * * * * * * 

H.R. 5715, Strengthening Partnerships to Prevent Opioid Abuse 

Act: 

Estimated Authorization Level .............................................. 0 2 2 2 2 2 9 

Estimated Outlays ................................................................. 0 2 2 2 2 2 9 

H.R. 5789, a bill to require the Secretary of Health and Human 

Services to issue guidance to improve care for infants with 

neonatal abstinence syndrome and their mothers, and to require the Comptroller General of the United States to conduct 

a study on gaps in Medicaid coverage for pregnant and 

postpartum women with substance use disorder: 

Estimated Authorization Level .............................................. 0 2 0 0 0 0 2 

Estimated Outlays ................................................................. 0 2 0 0 0 0 2 

H.R. 5795, Overdose Prevention and Patient Safety Act: 

Estimated Authorization Level .............................................. 0 1 0 0 0 0 1 

Estimated Outlays ................................................................. 0 1 0 0 0 0 1 

H.R. 5800, Medicaid IMD ADDITIONAL INFO Act: 

Estimated Authorization Level .............................................. 0 1 0 0 0 0 1 

Estimated Outlays ................................................................. 0 * * 0 0 0 1 

H.R. 5804, Post-Surgical Injections as an Opioid Alternative 

Act: a

Estimated Authorization Level .............................................. 0 0 0 0 1 1 1 

Estimated Outlays ................................................................. 0 0 0 0 1 1 1 

H.R. 5811, a bill to amend the Federal Food, Drug, and Cosmetic Act with respect to postapproval study requirements 

for certain controlled substances, and for other purposes: 

Estimated Authorization Level .............................................. 0 * * * * * * 

Estimated Outlays ................................................................. 0 * * * * * * 

Annual amounts may not sum to totals because of rounding. * = between ¥$500,000 and $500,000. a This bill also would affect mandatory spending (see Table 1). 

H.R. 5009, Jessie’s Law, would require HHS, in collaboration 

with outside experts, to develop best practices for displaying information about opioid use disorder in a patient’s medical record. 

HHS also would be required to develop and disseminate written 

materials annually to health care providers about what disclosures 

could be made while still complying with federal laws that govern 

health care privacy. Based on spending patterns for similar activities, CBO estimates that implementing H.R. 5009 would have an 

insignificant effect on spending over the 2019–2023 period. 

22 

H.R. 5041, the Safe Disposal of Unused Medication Act, would require hospice programs to have written policies and procedures for 

the disposal of controlled substances after a patient’s death. Certain licensed employees of hospice programs would be permitted to 

assist in the disposal of controlled substances that were lawfully 

dispensed. Using information from the Department of Justice 

(DOJ), CBO estimates that implementing the bill would cost less 

than $500,000 over the 2019–2023 period. 

H.R. 5272, the Reinforcing Evidence-Based Standards Under Law 

in Treating Substance Abuse Act of 2018, would require the newly 

established National Mental Health and Substance Use Policy Laboratory to issue guidance to applicants for SAMHSA grants that 

support evidence-based practices. Using information from HHS 

about the historical cost of similar activities, CBO estimates that 

enacting this bill would cost approximately $4 million over the 

2019–2023 period. 

H.R. 5333, the Over-the-Counter Monograph Safety, Innovation, 

and Reform Act of 2018, would change the FDA’s oversight of the 

commercial marketing of OTC medicines and authorize the collection and spending of fees through 2023 to cover the costs of expediting the FDA’s administrative procedures for certain regulatory 

activities relating to OTC products. Under H.R. 5333, CBO estimates, the FDA would assess about $147 million in fees over the 

2019–2023 period that could be collected and made available for obligation only to the extent and in the amounts provided in advance 

in appropriation acts. Because the FDA could spend those fees, 

CBO estimates that the estimated budget authority for collections 

and spending would offset each other exactly in each year, although CBO expects that spending initially would lag behind collections. Assuming appropriation action consistent with the bill, 

CBO estimates that implementing H.R. 5333 would reduce net discretionary outlays by $10 million over the 2019–2023 period, primarily because of that lag. The bill also would require the Government Accountability Office to study exclusive market protections 

for certain qualifying OTC drugs authorized by the bill—a provision that CBO estimates would cost less than $500,000. (If enacted, 

H.R. 5333 also would affect mandatory spending; see Table 1.) 

H.R. 5473, the Better Pain Management Through Better Data Act 

of 2018, would require that the FDA conduct a public meeting and 

issue guidance to industry addressing data collection and labeling 

for medical products that reduce pain while enabling the reduction, 

replacement, or avoidance of oral opioids. Using information from 

the agency, CBO estimates that implementing H.R. 5473 would 

cost about $1 million over the 2019–2023 period. 

H.R. 5483, the Special Registration for Telemedicine Clarification 

Act of 2018, would direct DOJ, within one year of the bill’s enactment, to issue regulations concerning the practice of telemedicine 

(for remote diagnosis and treatment of patients). Using information 

from DOJ, CBO estimates that implementing the bill would cost 

less than $500,000 over the 2019–2023 period. 

H.R. 5554, the Animal Drug and Animal Generic Drug User Fee 

Amendments of 2018, would authorize the FDA to collect and spend 

fees to cover the cost of expedited approval for the development and 

marketing of certain drugs for use in animals. The legislation 

would extend through fiscal year 2023, and make several changes 

23 

to, the FDA’s existing approval processes and fee programs for 

brand-name and generic veterinary drugs, which expire at the end 

of fiscal year 2018. CBO estimates that implementing H.R. 5554 

would reduce net discretionary outlays by $8 million over the 

2019–2023 period, primarily because the spending of fees lags 

somewhat behind their collection. 

Fees authorized under the bill would supplement funds appropriated to cover the FDA’s cost of reviewing certain applications 

and investigational submissions for brand-name and generic drugs 

for use in animals. Those fees could be collected and made available for obligation only to the extent and in the amounts provided 

in advance in appropriation acts. Under H.R. 5554, CBO estimates, 

the FDA would assess about $257 million in fees over the 2019– 

2023 period. Because the FDA could spend those funds, CBO estimates that budget authority for collections and spending would offset each other exactly in each year. CBO estimates that the delay 

between collecting and spending fees under the reauthorized programs would reduce net discretionary outlays by $14 million over 

the 2019–2023 period, assuming appropriation actions consistent 

with the bill. 

Enacting H.R. 5554 would increase the FDA’s workload because 

the legislation would expand eligibility for conditional approval for 

certain drugs. The agency’s administrative costs also would increase because of regulatory activities required by a provision concerning petitions for additives intended for use in animal food. H.R. 

5554 also would require the FDA to publish guidance or produce 

regulations on a range of topics, transmit a report to the Congress, 

and hold public meetings. CBO expects that the costs associated 

with those activities would not be covered by fees, and it estimates 

that implementing such provisions would cost $6 million over the 

2019–2023 period. 

H.R. 5582, the Abuse Deterrent Access Act of 2018, would require 

the Secretary of HHS to report to the Congress on existing barriers 

to access to ‘‘abuse-deterrent opioid formulations’’ by Medicare Part 

C and D beneficiaries. Such formulations make the drugs more difficult to dissolve for injection, for example, and thus can impede 

their abuse. Assuming the availability of appropriated funds and 

based on historical spending patterns for similar activities, CBO estimates that implementing the legislation would cost less than 

$500,000 over the 2019–2023 period. 

H.R. 5590, the Opioid Addiction Action Plan Act, would require 

the Secretary of HHS to develop an action plan by January 1, 2019, 

for increasing access to medication-assisted treatment among Medicare and Medicaid enrollees. The bill also would require HHS to 

convene a stakeholder meeting and issue a request for information 

within three months of enactment, and to submit a report to the 

Congress by June 1, 2019. Based on historical spending patterns 

for similar activities, CBO estimates that implementing H.R. 5590 

would cost approximately $2 million over the 2019–2023 period. 

H.R. 5687, the Securing Opioids and Unused Narcotics with Deliberate Disposal and Packaging Act of 2018, would permit the FDA 

to require certain packaging and disposal technologies, controls, or 

measures to mitigate the risk of abuse and misuse of drugs. Based 

on information from the FDA, CBO estimates that implementing 

H.R. 5687 would not significantly affect spending over the 2019– 

24 

2023 period. This bill would also require that the GAO study the 

effectiveness and use of packaging technologies for controlled substances—a provision that CBO estimates would cost less than 

$500,000. 

H.R. 5715, the Strengthening Partnerships to Prevent Opioid 

Abuse Act, would require the Secretary of HHS to establish a secure Internet portal to allow HHS, Medicare Advantage plans, and 

Medicare Part D plans to exchange information about fraud, waste, 

and abuse among providers and suppliers no later than two years 

after enactment. H.R. 5715 also would require organizations with 

Medicare Advantage contracts to submit information on investigations related to providers suspected of prescribing large volumes of 

opioids through a process established by the Secretary no later 

than January 2021. Based on historical spending patterns for similar activities, CBO estimates that implementing H.R. 5715 would 

cost approximately $9 million over the 2019–2023 period. 

H.R. 5789, a bill to require the Secretary of Health and Human 

Services to issue guidance to improve care for infants with neonatal 

abstinence syndrome and their mothers, and to require the Comptroller General of the United States to conduct a study on gaps in 

Medicaid coverage for pregnant and postpartum women with substance use disorder, would direct the Secretary of HHS to issue 

guidance to states on best practices under Medicaid and CHIP for 

treating infants with neonatal abstinence syndrome. H.R. 5789 also 

would direct the Government Accountability Office to study Medicaid coverage for pregnant and postpartum women with substance 

use disorders. Based on information from HHS and historical 

spending patterns for similar activities, CBO estimates that enacting H.R. 5789 would cost approximately $2 million over the 2019– 

2023 period. 

H.R. 5795, the Overdose Prevention and Patient Safety Act, would 

amend the Public Health Service Act so that requirements pertaining to the confidentiality and disclosure of medical records relating to substance use disorders align with the provisions of the 

Health Insurance Portability and Accountability Act of 1996. The 

bill would require the Office of the Secretary of HHS to issue regulations prohibiting discrimination based on data disclosed from 

such medical records, to issue regulations requiring covered entities 

to provide written notice of privacy practices, and to develop model 

training programs and materials for health care providers and patients and their families. Based on spending patterns for similar 

activities, CBO estimates that implementing H.R. 5795 would cost 

approximately $1 million over the 2019–2023 period. 

H.R. 5800, Medicaid IMD ADDITIONAL INFO Act, would direct 

the Medicaid and CHIP Payment and Access Commission to study 

institutions for mental diseases in a representative sample of 

states. Based on information from the commission about the cost 

of similar work, CBO estimates that implementing H.R. 5800 

would cost about $1 million over the 2019–2023 period. 

H.R. 5804, the Post-Surgical Injections as an Opioid Alternative 

Act, would freeze the Medicare payment rate for certain analgesic 

injections provided in ambulatory surgical centers. The bill also 

would mandate two studies of Medicare coding and payments arising from enactment of this legislation. Based on the cost of similar 

activities, CBO estimates that those reports would cost $1 million 

25 

over the 2019–2023 period. (If enacted, H.R. 5804 also would affect 

mandatory spending; see Table 1.) 

H.R. 5811, a bill to amend the Federal Food, Drug, and Cosmetic 

Act with respect to postapproval study requirements for certain controlled substances, and for other purposes, would allow the FDA to 

require that pharmaceutical manufacturers study certain drugs 

after they are approved to assess any potential reduction in those 

drugs’ effectiveness for the conditions of use prescribed, recommended, or suggested in labeling. CBO anticipates that implementing H.R. 5811 would not significantly affect the FDA’s costs 

over the 2019–2023 period. 

Other Authorizations. The following nine bills would increase authorization levels, but CBO has not completed estimates of 

amounts. All authorizations would be subject to future appropriation action. • H.R. 4284, Indexing Narcotics, Fentanyl, and Opioids Act 

of 2017 • H.R. 5002, Advancing Cutting Edge Research Act • H.R. 5228, Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act (see Table 1 for an estimate of 

the revenue effects of H.R. 5228) • H.R. 5752, Stop Illicit Drug Importation Act of 2018 (see 

Table 1 for an estimate of the revenue effects of H.R. 5752) • H.R. 5799, Medicaid DRUG Improvement Act (see Table 1 

for an estimate of the direct spending effects of H.R. 5799) • H.R. 5801, Medicaid Providers and Pharmacists Are Required to Note Experiences in Record Systems to Help In-Need 

Patients (PARTNERSHIP) Act (see Table 1 for an estimate of 

the direct spending effects of H.R. 5801) • H.R. 5806, 21st Century Tools for Pain and Addiction 

Treatments Act • H.R. 5808, Medicaid Pharmaceutical Home Act of 2018 

(see Table 1 for an estimate of the direct spending effects of 

H.R. 5808) 

• H.R. 5812, Creating Opportunities that Necessitate New 

and Enhanced Connections That Improve Opioid Navigation 

Strategies Act (CONNECTIONS) Act 

Pay-As-You-Go considerations: The Statutory Pay-As-You-Go Act 

of 2010 establishes budget-reporting and enforcement procedures 

for legislation affecting direct spending or revenues. Twenty-two of 

the bills discussed in this document contain direct spending or revenues and are subject to pay-as-you-go procedures. Details about 

the amount of direct spending and revenues in those bills can be 

found in Table 1. 

Increase in long-term direct spending and deficits: CBO estimates that enacting H.R. 4998, the Health Insurance for Former 

Foster Youth Act, would increase net direct spending by more than 

$2.5 billion and on-budget deficits by more than $5 billion in at 

least one of the four consecutive 10-year periods beginning in 2029. 

CBO estimates that none of the remaining 58 bills included in 

this estimate would increase net direct spending by more than $2.5 

billion or on-budget deficits by more than $5 billion in any of the 

four consecutive 10-year periods beginning in 2029. 

Mandates: One of the 59 bills included in this document, H.R. 

5795, would impose both intergovernmental and private-sector 

26 

mandates as defined in UMRA. CBO estimates that the costs of 

that bill’s mandates on public and private entities would fall below 

UMRA’s thresholds ($80 million and $160 million, respectively, for 

public- and private-sector entities in 2018, adjusted annually for inflation). 

In addition, five bills would impose private-sector mandates as 

defined in UMRA. CBO estimates that the costs of the mandates 

in three of those bills (H.R. 5333, H.R. 5554, and H.R. 5811) would 

fall below the UMRA threshold. Because CBO does not know how 

federal agencies would implement new authority granted in the 

other two of those five bills, H.R. 5228 and 5687, CBO cannot determine whether the costs of their mandates would exceed the 

threshold. 

For large entitlement grant programs, including Medicaid and 

CHIP, UMRA defines an increase in the stringency of conditions on 

states or localities as an intergovernmental mandate if the affected 

governments lack authority to offset those costs while continuing to 

provide required services. Because states possess significant flexibility to alter their responsibilities within Medicaid and CHIP, the 

requirements imposed by various bills in the markup on state administration of those programs would not constitute mandates as 

defined in UMRA. 

Mandates Affecting Public and Private Entities 

H.R. 5795, the Overdose Prevention and Patient Safety Act, would 

impose intergovernmental and private-sector mandates by requiring entities that provide treatment for substance use disorders to 

notify patients of their privacy rights and also to notify patients in 

the event that the confidentiality of their records is breached. In 

certain circumstances, H.R. 5795 also would prohibit public and 

private entities from denying entry to treatment on the basis of information in patient health records. Those requirements would either supplant or narrowly expand responsibilities under existing 

law, and compliance with them would not impose significant additional costs. CBO estimates that the costs of the mandates would 

fall below the annual thresholds established in UMRA. 

Mandates Affecting Private Entities 

Five bills included in this document would impose private-sector 

mandates: 

H.R. 5228, the Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act, would require drug distributors to 

cease distributing any drug that the Secretary of HHS determines 

might present an imminent or substantial hazard to public health. 

CBO cannot determine what drugs could be subject to such an 

order nor can it determine how private entities would respond. 

Consequently, CBO cannot determine whether the aggregate cost 

of the mandate would exceed the annual threshold for private-sector mandates. 

H.R. 5333, the Over-the-Counter Monograph Safety, Innovation, 

and Reform Act of 2018, would require developers and manufacturers of OTC drugs to pay certain fees to the FDA. CBO estimates 

that about $30 million would be collected each year, on average, for 

a total of $147 million over the 2019–2023 period. Those amounts 

27 

would not exceed the annual threshold for private-sector mandates 

in any year during that period. 

H.R. 5554, the Animal Drug and Animal Generic Drug User Fee 

Amendments of 2018, would require developers and manufacturers 

of brand-name and generic veterinary drugs to pay application, 

product, establishment, and sponsor fees to the FDA. CBO estimates that about $51 million would be collected annually, on average, for a total of $257 million over the 2019–2023 period. Those 

amounts would not exceed the annual threshold for private-sector 

mandates in any year during that period. 

H.R. 5687, the Securing Opioids and Unused Narcotics with Deliberate Disposal and Packaging Act of 2018, would permit the Secretary of HHS to require drug developers and manufacturers to implement new packaging and disposal technology for certain drugs. 

Based on information from the agency, CBO expects that the Secretary would use the new regulatory authority provided in the bill; 

however, it is uncertain how or when those requirements would be 

implemented. Consequently, CBO cannot determine whether the 

aggregate cost of the mandate would exceed the annual threshold 

for private entities. 

H.R. 5811, a bill to amend the Federal Food, Drug, and Cosmetic 

Act with respect to postapproval study requirements for certain controlled substances, and for other purposes, would expand an existing mandate that requires drug developers to conduct postapproval 

studies or clinical trials for certain drugs. Under current law, in 

certain instances, the FDA can require studies or clinical trials 

after a drug has been approved. H.R. 5811 would permit the FDA 

to use that authority if the reduction in a drug’s effectiveness 

meant that its benefits no longer outweighed its costs. CBO estimates that the incremental cost of the mandate would fall below 

the annual threshold established in UMRA because of the small 

number of drugs affected and the narrow expansion of the authority that exists under current law. 

None of the remaining 53 bills included in this document would 

impose an intergovernmental or private-sector mandate. 

Previous CBO estimate: On June 6, 2018, CBO issued an estimate for seven opioid-related bills ordered reported by the House 

Committee on Ways and Means on May 16, 2018. Two of those bills 

contain provisions that are identical or similar to the legislation ordered reported by the Committee on Energy and Commerce, and 

for those provisions, CBO’s estimates are the same. 

In particular, five bills listed in this estimate contain provisions 

that are identical or similar to those in several sections of H.R. 

5773, the Preventing Addiction for Susceptible Seniors Act of 2018: 

• H.R. 5675, which would require prescription drug plans to 

implement drug management programs, is identical to section 2 of 

H.R. 5773. 

• H.R. 4841, regarding electronic prior authorization for prescriptions under Medicare’s Part D, is similar to section 3 of H.R. 

5773. 

• H.R. 5715, which would mandate the creation of a new Internet portal to allow various stakeholders to exchange information, 

is identical to section 4 of H.R. 5773. 

• H.R. 5684, which would expand medication therapy management, is the same as section 5 of H.R. 5773. 

28 

• H.R. 5716, regarding prescriber notification, is identical to 

section 6 of H.R. 5773. 

In addition, in this estimate, a provision related to Medicare beneficiary education in H.R. 5686, the Medicare Clear Health Options 

in Care for Enrollees Act of 2018, is the same as a provision in section 2 of H.R. 5775, the Providing Reliable Options for Patients and 

Educational Resources Act of 2018, in CBO’s estimate for the Committee on Ways and Means. 

Estimate prepared by: Federal Costs: Rebecca Yip (Centers for 

Disease Control and Prevention), Mark Grabowicz (Drug Enforcement Agency), Julia Christensen, Ellen Werble (Food and Drug Administration), Emily King, Andrea Noda, Lisa Ramirez-Branum, 

Robert Stewart (Medicaid and Children’s Health Insurance Program), Philippa Haven, Lara Robillard, Colin Yee, Rebecca Yip 

(Medicare), Philippa Haven (National Institutes of Health), Alice 

Burns, Andrea Noda (Office of the Secretary of the Department of 

Health and Human Services), Philippa Haven, Lori Housman, 

Emily King (Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration); Federal 

Revenues: Jacob Fabian, Peter Huether, and Cecilia Pastrone; Fact 

Checking: Zachary Byrum and Kate Kelly; Mandates: Andrew 

Laughlin. 

Estimate reviewed by: Tom Bradley, Chief Health Systems and 

Medicare Cost Estimates Unit; Chad M. Chirico, Chief Low-Income 

Health Programs and Prescription Drugs Cost Estimates Unit; 

Sarah Masi, Special Assistant for Health; Susan Willie, Chief, 

Mandates Unit; Leo Lex, Deputy Assistant Director for Budget 

Analysis; Theresa A. Gullo, Assistant Director for Budget Analysis. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates prepared by the Director of the Congressional Budget Office 

pursuant to section 423 of the Unfunded Mandates Reform Act. 

STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

Pursuant to clause 3(c)(4) of rule XIII, the general performance 

goal or objective of this legislation is to require comprehensive 

mental health and substance use disorder services as a mandatory 

benefit under the CHIP program for pregnant women and children. 

DUPLICATION OF FEDERAL PROGRAMS

Pursuant to clause 3(c)(5) of rule XIII, no provision of H.R. 3192 

is known to be duplicative of another Federal program, including 

any program that was included in a report to Congress pursuant 

to section 21 of Public Law 111–139 or the most recent Catalog of 

Federal Domestic Assistance. 

COMMITTEE COST ESTIMATE

Pursuant to clause 3(d)(1) of rule XIII, the Committee adopts as 

its own the cost estimate prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional 

Budget Act of 1974. 

29 

EARMARK, LIMITED TAX BENEFITS, AND LIMITED TARIFF BENEFITS

Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the Committee 

finds that H.R. 3192 contains no earmarks, limited tax benefits, or 

limited tariff benefits. 

DISCLOSURE OF DIRECTED RULE MAKINGS

Pursuant to section 3(i) of H. Res. 5, the Committee finds that 

H.R. 3192 contains no directed rule makings. 

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act were created by this legislation. 

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that the legislation does not relate to the 

terms and conditions of employment or access to public services or 

accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Short title 

Section 1 provides that the Act may be cited as the ‘‘CHIP Mental Health Parity Act.’’ 

Section 2. Ensuring access to mental health services for children 

under the Children’s Health Insurance Program 

Section 2 amends Section 2103(c)(1) of the Social Security Act to 

add mental health services and substance use disorder services (including behavioral health treatment) to the list of services that 

must be covered under separate CHIP programs. The provision 

would require mental health services to be delivered in a culturally 

and linguistically appropriate manner and to include services necessary to prevent, diagnose, and treat a broad range of mental 

health symptoms and disorders, including substance use disorders. 

Section 2 also requires state child health plans to include a description of the methods used to monitor access to mental health 

services and substance use disorder services (including behavioral 

health treatment) under separate CHIP programs. 

Section 2 requires separate CHIP programs to ensure the financial requirements and treatment limitations applicable to mental 

health services and substance use disorder services (including behavioral health treatment) comply with mental health parity requirements in the same manner as group health plans. 

If, under a state child health plan (or waiver of such plan) for 

a separate CHIP program, state legislation would be needed in 

order for the state to meet a specific statutory requirement under 

H.R. 3192, then the requirement would be deemed to take effect on 

the first day of the first calendar quarter beginning after the close 

of the first regular session of the state legislature beginning after 

enactment. 

30 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

and existing law in which no change is proposed is shown in 

roman): 

SOCIAL SECURITY ACT 

* * * * * * * 

TITLE XXI—STATE CHILDREN’S HEALTH INSURANCE 

PROGRAM 

* * * * * * * 

SEC. 2102. GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; OUTREACH. 

(a) GENERAL BACKGROUND AND DESCRIPTION.—A State child 

health plan shall include a description, consistent with the requirements of this title, of— 

(1) the extent to which, and manner in which, children in the 

State, including targeted low-income children and other classes 

of children classified by income and other relevant factors, currently have creditable health coverage (as defined in section 

2110(c)(2)); 

(2) current State efforts to provide or obtain creditable 

health coverage for uncovered children, including the steps the 

State is taking to identify and enroll all uncovered children 

who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships; 

(3) how the plan is designed to be coordinated with such efforts to increase coverage of children under creditable health 

coverage; 

(4) the child health assistance provided under the plan for 

targeted low-income children, including the proposed methods 

of delivery, and utilization control systems; 

(5) eligibility standards consistent with subsection (b); 

(6) outreach activities consistent with subsection (c); and 

(7) methods (including monitoring) used— 

(A) to assure the quality and appropriateness of care, 

particularly with respect to well-baby care, well-child care, 

and immunizations provided under the plan; 

(B) to assure access to covered services, including emergency services and services described in øsection 

2103(c)(5)¿ paragraphs (5) and (6) of section 2103(c); and 

(C) to ensure that the State agency involved is in compliance with subparagraphs (A), (B), and (C) of section 

1128K(b)(2). 

(b) GENERAL DESCRIPTION OF ELIGIBILITY STANDARDS AND METHODOLOGY.— 

(1) ELIGIBILITY STANDARDS.— 

(A) IN GENERAL.—The plan shall include a description of 

the standards used to determine the eligibility of targeted 

31 

low-income children for child health assistance under the 

plan. Such standards may include (to the extent consistent 

with this title) those relating to the geographic areas to be 

served by the plan, age, income and resources (including 

any standards relating to spenddowns and disposition of 

resources), residency, disability status (so long as any 

standard relating to such status does not restrict eligibility), access to or coverage under other health coverage, 

and duration of eligibility. Such standards may not discriminate on the basis of diagnosis. 

(B) LIMITATIONS ON ELIGIBILITY STANDARDS.—Such eligibility standards— 

(i) shall, within any defined group of covered targeted low-income children, not cover such children 

with higher family income without covering children 

with a lower family income; 

(ii) may not deny eligibility based on a child having 

a preexisting medical condition; 

(iii) may not apply a waiting period (including a 

waiting period to carry out paragraph (3)(C)) in the 

case of a targeted low-income pregnant woman provided pregnancy-related assistance under section 2112; 

(iv) at State option, may not apply a waiting period 

in the case of a child provided dental-only supplemental coverage under section 2110(b)(5); and 

(v) shall, beginning January 1, 2014, use modified 

adjusted gross income and household income (as defined in section 36B(d)(2) of the Internal Revenue 

Code of 1986) to determine eligibility for child health 

assistance under the State child health plan or under 

any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required, including with respect 

to the imposition of premiums and cost-sharing, consistent with section 1902(e)(14). 

(2) METHODOLOGY.—The plan shall include a description of 

methods of establishing and continuing eligibility and enrollment. 

(3) ELIGIBILITY SCREENING; COORDINATION WITH OTHER

HEALTH COVERAGE PROGRAMS.—The plan shall include a description of procedures to be used to ensure— 

(A) through both intake and followup screening, that 

only targeted low-income children are furnished child 

health assistance under the State child health plan; 

(B) that children found through the screening to be eligible for medical assistance under the State medicaid plan 

under title XIX are enrolled for such assistance under such 

plan; 

(C) that the insurance provided under the State child 

health plan does not substitute for coverage under group 

health plans; 

(D) the provision of child health assistance to targeted 

low-income children in the State who are Indians (as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)); and 

32 

(E) coordination with other public and private programs 

providing creditable coverage for low-income children. 

(4) REDUCTION OF ADMINISTRATIVE BARRIERS TO ENROLLMENT.— 

(A) IN GENERAL.—Subject to subparagraph (B), the plan 

shall include a description of the procedures used to reduce 

administrative barriers to the enrollment of children and 

pregnant women who are eligible for medical assistance 

under title XIX or for child health assistance or health 

benefits coverage under this title. Such procedures shall be 

established and revised as often as the State determines 

appropriate to take into account the most recent information available to the State identifying such barriers. 

(B) DEEMED COMPLIANCE IF JOINT APPLICATION AND RENEWAL PROCESS THAT PERMITS APPLICATION OTHER THAN IN

PERSON.—A State shall be deemed to comply with subparagraph (A) if the State’s application and renewal forms and 

supplemental forms (if any) and information verification 

process is the same for purposes of establishing and renewing eligibility for children and pregnant women for 

medical assistance under title XIX and child health assistance under this title, and such process does not require an 

application to be made in person or a face-to-face interview. 

(5) NONENTITLEMENT.—Nothing in this title shall be construed as providing an individual with an entitlement to child 

health assistance under a State child health plan. 

(c) OUTREACH AND COORDINATION.—A State child health plan 

shall include a description of the procedures to be used by the 

State to accomplish the following: 

(1) OUTREACH.—Outreach (through community health workers and others) to families of children likely to be eligible for 

child health assistance under the plan or under other public or 

private health coverage programs to inform these families of 

the availability of, and to assist them in enrolling their children in, such a program. 

(2) COORDINATION WITH OTHER HEALTH INSURANCE PROGRAMS.—Coordination of the administration of the State program under this title with other public and private health insurance programs. 

(3) PREMIUM ASSISTANCE SUBSIDIES.—In the case of a State 

that provides for premium assistance subsidies under the State 

child health plan in accordance with paragraph (2)(B), (3), or 

(10) of section 2105(c), or a waiver approved under section 

1115, outreach, education, and enrollment assistance for families of children likely to be eligible for such subsidies, to inform 

such families of the availability of, and to assist them in enrolling their children in, such subsidies, and for employers likely 

to provide coverage that is eligible for such subsidies, including 

the specific, significant resources the State intends to apply to 

educate employers about the availability of premium assistance 

subsidies under the State child health plan. 

33 

SEC. 2103. COVERAGE REQUIREMENTS FOR CHILDREN’S HEALTH INSURANCE. 

(a) REQUIRED SCOPE OF HEALTH INSURANCE COVERAGE.—The 

child health assistance provided to a targeted low-income child 

under the plan in the form described in paragraph (1) of section 

2101(a) shall consist, consistent with øparagraphs (5), (6), and (7)¿ 

paragraphs (5), (6), (7), and (8) of subsection (c), of any of the following: 

(1) BENCHMARK COVERAGE.—Health benefits coverage that is 

at least equivalent to the benefits coverage in a benchmark 

benefit package described in subsection (b). 

(2) BENCHMARK-EQUIVALENT COVERAGE.—Health benefits 

coverage that meets the following requirements: 

(A) INCLUSION OF BASIC SERVICES.—The coverage includes benefits for items and services within each of the 

categories of basic services described in subsection (c)(1). 

(B) AGGREGATE ACTUARIAL VALUE EQUIVALENT TO

BENCHMARK PACKAGE.—The coverage has an aggregate actuarial value that is at least actuarially equivalent to one 

of the benchmark benefit packages. 

(C) SUBSTANTIAL ACTUARIAL VALUE FOR ADDITIONAL

SERVICES INCLUDED IN BENCHMARK PACKAGE.—With respect to each of the categories of additional services described in subsection (c)(2) for which coverage is provided 

under the benchmark benefit package used under subparagraph (B), the coverage has an actuarial value that is 

equal to at least 75 percent of the actuarial value of the 

coverage of that category of services in such package. 

(3) EXISTING COMPREHENSIVE STATE-BASED COVERAGE.— 

Health benefits coverage under an existing comprehensive 

State-based program, described in subsection (d)(1). 

(4) SECRETARY-APPROVED COVERAGE.—Any other health benefits coverage that the Secretary determines, upon application 

by a State, provides appropriate coverage for the population of 

targeted low-income children proposed to be provided such coverage. 

(b) BENCHMARK BENEFIT PACKAGES.—The benchmark benefit 

packages are as follows: 

(1) FEHBP-EQUIVALENT CHILDREN’S HEALTH INSURANCE COVERAGE.—The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered 

under section 8903(1) of title 5, United States Code. 

(2) STATE EMPLOYEE COVERAGE.—A health benefits coverage 

plan that is offered and generally available to State employees 

in the State involved. 

(3) COVERAGE OFFERED THROUGH HMO.—The health insurance coverage plan that— 

(A) is offered by a health maintenance organization (as 

defined in section 2791(b)(3) of the Public Health Service 

Act), and 

(B) has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by 

such a health maintenance organization in the State involved. 

34 

(c) CATEGORIES OF SERVICES; DETERMINATION OF ACTUARIAL

VALUE OF COVERAGE.— (1) CATEGORIES OF BASIC SERVICES.—For purposes of this 

section, the categories of basic services described in this paragraph are as follows: 

(A) Inpatient and outpatient hospital services. 

(B) Physicians’ surgical and medical services. 

(C) Laboratory and x-ray services. 

(D) Well-baby and well-child care, including age-appropriate immunizations. 

(E) Mental health and substance use disorder services (as 

defined in paragraph (5)). 

(2) CATEGORIES OF ADDITIONAL SERVICES.—For purposes of 

this section, the categories of additional services described in 

this paragraph are as follows: 

(A) Coverage of prescription drugs. 

(B) Vision services. 

(C) Hearing services. 

(3) TREATMENT OF OTHER CATEGORIES.—Nothing in this subsection shall be construed as preventing a State child health 

plan from providing coverage of benefits that are not within a 

category of services described in paragraph (1) or (2). 

(4) DETERMINATION OF ACTUARIAL VALUE.—The actuarial 

value of coverage of benchmark benefit packages, coverage offered under the State child health plan, and coverage of any 

categories of additional services under benchmark benefit 

packages and under coverage offered by such a plan, shall be 

set forth in an actuarial opinion in an actuarial report that has 

been prepared— 

(A) by an individual who is a member of the American 

Academy of Actuaries; 

(B) using generally accepted actuarial principles and 

methodologies; 

(C) using a standardized set of utilization and price factors; 

(D) using a standardized population that is representative of privately insured children of the age of children 

who are expected to be covered under the State child 

health plan; 

(E) applying the same principles and factors in comparing the value of different coverage (or categories of 

services); 

(F) without taking into account any differences in coverage based on the method of delivery or means of cost 

control or utilization used; and 

(G) taking into account the ability of a State to reduce 

benefits by taking into account the increase in actuarial 

value of benefits coverage offered under the State child 

health plan that results from the limitations on cost sharing under such coverage. 

The actuary preparing the opinion shall select and specify in 

the memorandum the standardized set and population to be 

used under subparagraphs (C) and (D). 

(5) MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES.—In the case of a State that provides child health assistVerDate Sep 11 2014 06:36 Jun 19, 2018 Jkt 079006 PO 00000 Frm 00034 Fmt 6659 Sfmt 6603 E:\HR\OC\HR734.XXX HR734
35 

ance for targeted low-income children or targeted low-income 

pregnant women (as defined in section 2112(d)) in the form of 

providing any health benefits coverage described in subsection 

(a), such child health assistance shall— 

(A) include coverage of mental health services (including 

behavioral health treatment) necessary to prevent, diagnose, 

and treat a broad range of mental health symptoms and 

disorders, including substance use disorders; and 

(B) be delivered in a culturally and linguistically appropriate manner. 

ø(5)¿ (6) DENTAL BENEFITS.— (A) IN GENERAL.—The child health assistance provided 

to a targeted low-income child shall include coverage of 

dental services necessary to prevent disease and promote 

oral health, restore oral structures to health and function, 

and treat emergency conditions. 

(B) PERMITTING USE OF DENTAL BENCHMARK PLANS BY

CERTAIN STATES.—A State may elect to meet the requirement of subparagraph (A) through dental coverage that is 

equivalent to a benchmark dental benefit package described in subparagraph (C). 

(C) BENCHMARK DENTAL BENEFIT PACKAGES.—The benchmark dental benefit packages are as follows: 

(i) FEHBP CHILDREN’S DENTAL COVERAGE.—A dental 

benefits plan under chapter 89A of title 5, United 

States Code, that has been selected most frequently by 

employees seeking dependent coverage, among such 

plans that provide such dependent coverage, in either 

of the previous 2 plan years. 

(ii) STATE EMPLOYEE DEPENDENT DENTAL COV- ERAGE.—A dental benefits plan that is offered and 

generally available to State employees in the State involved and that has been selected most frequently by 

employees seeking dependent coverage, among such 

plans that provide such dependent coverage, in either 

of the previous 2 plan years. 

(iii) COVERAGE OFFERED THROUGH COMMERCIAL DEN- TAL PLAN.—A dental benefits plan that has the largest 

insured commercial, non-medicaid enrollment of dependent covered lives of such plans that is offered in 

the State involved. 

ø(6)¿ (7) MENTAL HEALTH SERVICES PARITY.— 

ø(A) IN GENERAL.—In the case of a State child health 

plan that provides both medical and surgical benefits and 

mental health or substance use disorder benefits, such 

plan shall ensure that the financial requirements and 

treatment limitations applicable to such mental health or 

substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act 

in the same manner as such requirements apply to a group 

health plan.¿ 

(A) IN GENERAL.—A State child health plan shall ensure 

that the financial requirements and treatment limitations 

applicable to mental health and substance use disorder 

services (as described in paragraph (5)) provided under 

36 

such plan comply with the requirements of section 2726(a) 

of the Public Health Service Act in the same manner as 

such requirements or limitations apply to a group health 

plan under such section. 

(B) DEEMED COMPLIANCE.—To the extent that a State 

child health plan includes coverage with respect to an individual described in section 1905(a)(4)(B) and covered under 

the State plan under section 1902(a)(10)(A) of the services 

described in section 1905(a)(4)(B) (relating to early and 

periodic screening, diagnostic, and treatment services defined in section 1905(r)) and provided in accordance with 

section 1902(a)(43), such plan shall be deemed to satisfy 

the requirements of subparagraph (A). 

ø(7)¿ (8) CONSTRUCTION ON PROHIBITED COVERAGE.—Nothing 

in this section shall be construed as requiring any health benefits coverage offered under the plan to provide coverage for 

items or services for which payment is prohibited under this 

title, notwithstanding that any benchmark benefit package includes coverage for such an item or service. 

ø(8)¿ (9) AVAILABILITY OF COVERAGE FOR ITEMS AND SERVICES

FURNISHED THROUGH SCHOOL-BASED HEALTH CENTERS.—Nothing in this title shall be construed as limiting a State’s ability 

to provide child health assistance for covered items and services that are furnished through school-based health centers (as 

defined in section 2110(c)(9)). 

(d) DESCRIPTION OF EXISTING COMPREHENSIVE STATE-BASED COV- ERAGE.— 

(1) IN GENERAL.—A program described in this paragraph is 

a child health coverage program that— 

(A) includes coverage of a range of benefits; 

(B) is administered or overseen by the State and receives 

funds from the State; 

(C) is offered in New York, Florida, or Pennsylvania; and 

(D) was offered as of the date of the enactment of this 

title. 

(2) MODIFICATIONS.—A State may modify a program described in paragraph (1) from time to time so long as it continues to meet the requirement of subparagraph (A) and does 

not reduce the actuarial value of the coverage under the program below the lower of— 

(A) the actuarial value of the coverage under the program as of the date of the enactment of this title, or 

(B) the actuarial value described in subsection (a)(2)(B), 

evaluated as of the time of the modification. 

(e) COST-SHARING.— 

(1) DESCRIPTION; GENERAL CONDITIONS.— 

(A) DESCRIPTION.—A State child health plan shall include a description, consistent with this subsection, of the 

amount (if any) of premiums, deductibles, coinsurance, and 

other cost sharing imposed. Any such charges shall be imposed pursuant to a public schedule. 

(B) PROTECTION FOR LOWER INCOME CHILDREN.—The 

State child health plan may only vary premiums, 

deductibles, coinsurance, and other cost sharing based on 

the family income of targeted low-income children in a 

37 

manner that does not favor children from families with 

higher income over children from families with lower income. 

(2) NO COST SHARING ON BENEFITS FOR PREVENTIVE SERVICES

OR PREGNANCY-RELATED ASSISTANCE.—The State child health 

plan may not impose deductibles, coinsurance, or other cost 

sharing with respect to benefits for services within the category of services described in subsection (c)(1)(D) or for pregnancy-related assistance. 

(3) LIMITATIONS ON PREMIUMS AND COST-SHARING.— 

(A) CHILDREN IN FAMILIES WITH INCOME BELOW 150 PERCENT OF POVERTY LINE.—In the case of a targeted low-income child whose family income is at or below 150 percent 

of the poverty line, the State child health plan may not impose— 

(i) an enrollment fee, premium, or similar charge 

that exceeds the maximum monthly charge permitted 

consistent with standards established to carry out section 1916(b)(1) (with respect to individuals described 

in such section); and 

(ii) a deductible, cost sharing, or similar charge that 

exceeds an amount that is nominal (as determined 

consistent with regulations referred to in section 

1916(a)(3), with such appropriate adjustment for inflation or other reasons as the Secretary determines to be 

reasonable). 

(B) OTHER CHILDREN.—For children not described in 

subparagraph (A), subject to paragraphs (1)(B) and (2), 

any premiums, deductibles, cost sharing or similar charges 

imposed under the State child health plan may be imposed 

on a sliding scale related to income, except that the total 

annual aggregate cost-sharing with respect to all targeted 

low-income children in a family under this title may not 

exceed 5 percent of such family’s income for the year involved. 

(C) PREMIUM GRACE PERIOD.—The State child health 

plan— 

(i) shall afford individuals enrolled under the plan a 

grace period of at least 30 days from the beginning of 

a new coverage period to make premium payments before the individual’s coverage under the plan may be 

terminated; and 

(ii) shall provide to such an individual, not later 

than 7 days after the first day of such grace period, 

notice— 

(I) that failure to make a premium payment 

within the grace period will result in termination 

of coverage under the State child health plan; and 

(II) of the individual’s right to challenge the proposed termination pursuant to the applicable Federal regulations. 

For purposes of clause (i), the term ‘‘new coverage period’’ 

means the month immediately following the last month for 

which the premium has been paid. 

38 

(4) RELATION TO MEDICAID REQUIREMENTS.—Nothing in this 

subsection shall be construed as affecting the rules relating to 

the use of enrollment fees, premiums, deductions, cost sharing, 

and similar charges in the case of targeted low-income children 

who are provided child health assistance in the form of coverage under a medicaid program under section 2101(a)(2). 

(f) APPLICATION OF CERTAIN REQUIREMENTS.— (1) RESTRICTION ON APPLICATION OF PREEXISTING CONDITION

EXCLUSIONS.— (A) IN GENERAL.—Subject to subparagraph (B), the State 

child health plan shall not permit the imposition of any 

preexisting condition exclusion for covered benefits under 

the plan. 

(B) GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE

COVERAGE.—If the State child health plan provides for 

benefits through payment for, or a contract with, a group 

health plan or group health insurance coverage, the plan 

may permit the imposition of a preexisting condition exclusion but only insofar as it is permitted under the applicable provisions of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 and title 

XXVII of the Public Health Service Act. 

(2) COMPLIANCE WITH OTHER REQUIREMENTS.—Coverage offered under this section shall comply with the requirements of 

subpart 2 of part A of title XXVII of the Public Health Service 

Act insofar as such requirements apply with respect to a 

health insurance issuer that offers group health insurance coverage. 

(3) COMPLIANCE WITH MANAGED CARE REQUIREMENTS.—The 

State child health plan shall provide for the application of subsections (a)(4), (a)(5), (b), (c), (d), and (e) of section 1932 (relating to requirements for managed care) to coverage, State agencies, enrollment brokers, managed care entities, and managed 

care organizations under this title in the same manner as such 

subsections apply to coverage and such entities and organizations under title XIX. 

* * * * * * * 

SEC. 2110. DEFINITIONS. 

(a) CHILD HEALTH ASSISTANCE.—For purposes of this title, the 

term ‘‘child health assistance’’ means payment for part or all of the 

cost of health benefits coverage for targeted low-income children 

that includes any of the following (and includes, in the case described in section 2105(a)(1)(D)(i), payment for part or all of the 

cost of providing any of the following), as specified under the State 

plan: 

(1) Inpatient hospital services. 

(2) Outpatient hospital services. 

(3) Physician services. 

(4) Surgical services. 

(5) Clinic services (including health center services) and 

other ambulatory health care services. 

(6) Prescription drugs and biologicals and the administration 

of such drugs and biologicals, only if such drugs and biologicals 

are not furnished for the purpose of causing, or assisting in 

39 

causing, the death, suicide, euthanasia, or mercy killing of a 

person. 

(7) Over-the-counter medications. 

(8) Laboratory and radiological services. 

(9) Prenatal care and prepregnancy family planning services 

and supplies. 

(10) Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a 

State-operated mental hospital and including residential or 

other 24-hour therapeutically planned structured services. 

(11) Outpatient mental health services, other than services 

described in paragraph (19) but including services furnished in 

a State-operated mental hospital and including communitybased services. 

(12) Durable medical equipment and other medically-related 

or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 

(13) Disposable medical supplies. 

(14) Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with 

activities of daily living, chore services, day care services, respite care services, training for family members, and minor 

modifications to the home). 

(15) Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, 

private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 

(16) Abortion only if necessary to save the life of the mother 

or if the pregnancy is the result of an act of rape or incest. 

(17) Dental services. 

(18) Inpatient øsubstance abuse¿ substance use treatment 

services and residential øsubstance abuse¿ substance use treatment services. 

(19) Outpatient øsubstance abuse¿ substance use treatment 

services. 

(20) Case management services. 

(21) Care coordination services. 

(22) Physical therapy, occupational therapy, and services for 

individuals with speech, hearing, and language disorders. 

(23) Hospice care (concurrent, in the case of an individual 

who is a child, with care related to the treatment of the child’s 

condition with respect to which a diagnosis of terminal illness 

has been made. 

(24) Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services 

(whether in a facility, home, school, or other setting) if recognized by State law and only if the service is— 

(A) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, 

(B) performed under the general supervision or at the direction of a physician, or 

40 

(C) furnished by a health care facility that is operated 

by a State or local government or is licensed under State 

law and operating within the scope of the license. 

(25) Premiums for private health care insurance coverage. 

(26) Medical transportation. 

(27) Enabling services (such as transportation, translation, 

and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. 

(28) Any other health care services or items specified by the 

Secretary and not excluded under this section. 

(b) TARGETED LOW-INCOME CHILD DEFINED.—For purposes of 

this title— 

(1) IN GENERAL.—Subject to paragraph (2), the term ‘‘targeted low-income child’’ means a child— 

(A) who has been determined eligible by the State for 

child health assistance under the State plan; 

(B)(i) who is a low-income child, or 

(ii) is a child— 

(I) whose family income (as determined under the 

State child health plan) exceeds the medicaid applicable income level (as defined in paragraph (4)), but does 

not exceed 50 percentage points above the medicaid 

applicable income level; 

(II) whose family income (as so determined) does not 

exceed the medicaid applicable income level (as defined in paragraph (4) but determined as if ‘‘June 1, 

1997’’ were substituted for ‘‘March 31, 1997’’); or 

(III) who resides in a State that does not have a 

medicaid applicable income level (as defined in paragraph (4)); and 

(C) who is not found to be eligible for medical assistance 

under title XIX or, subject to paragraph (5), covered under 

a group health plan or under health insurance coverage 

(as such terms are defined in section 2791 of the Public 

Health Service Act). 

(2) CHILDREN EXCLUDED.—Such term does not include— 

(A) a child who is an inmate of a public institution or a 

patient in an institution for mental diseases; or 

(B) except as provided in paragraph (6), a child who is 

a member of a family that is eligible for health benefits 

coverage under a State health benefits plan on the basis 

of a family member’s employment with a public agency in 

the State. 

(3) SPECIAL RULE.—A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is 

covered under a health insurance coverage program that has 

been in operation since before July 1, 1997, and that is offered 

by a State which receives no Federal funds for the program’s 

operation. 

(4) MEDICAID APPLICABLE INCOME LEVEL.—The term ‘‘medicaid applicable income level’’ means, with respect to a child, 

the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under 

title XIX (including under a waiver authorized by the Secretary 

41 

or under section 1902(r)(2)), as of March 31, 1997, for the child 

to be eligible for medical assistance under section 1902(l)(2) or 

1905(n)(2) (as selected by a State) for the age of such child. 

(5) OPTION FOR STATES WITH A SEPARATE CHIP PROGRAM TO

PROVIDE DENTAL-ONLY SUPPLEMENTAL COVERAGE.— 

(A) IN GENERAL.—Subject to subparagraphs (B) and (C), 

in the case of any child who is enrolled in a group health 

plan or health insurance coverage offered through an employer who would, but for the application of paragraph 

(1)(C), satisfy the requirements for being a targeted low-income child under a State child health plan that is implemented under this title, a State may waive the application 

of such paragraph to the child in order to provide— 

(i) dental coverage consistent with the requirements 

of øsubsection (c)(5)¿ subsection (c)(6) of section 2103; 

or 

(ii) cost-sharing protection for dental coverage consistent with such requirements and the requirements 

of subsection (e)(3)(B) of such section. 

(B) LIMITATION.—A State may limit the application of a 

waiver of paragraph (1)(C) to children whose family income does not exceed a level specified by the State, so long 

as the level so specified does not exceed the maximum income level otherwise established for other children under 

the State child health plan. 

(C) CONDITIONS.—A State may not offer dental-only supplemental coverage under this paragraph unless the State 

satisfies the following conditions: 

(i) INCOME ELIGIBILITY.—The State child health plan 

under this title— 

(I) has the highest income eligibility standard 

permitted under this title (or a waiver) as of January 1, 2009; 

(II) does not limit the acceptance of applications 

for children or impose any numerical limitation, 

waiting list, or similar limitation on the eligibility 

of such children for child health assistance under 

such State plan; and 

(III) provides benefits to all children in the 

State who apply for and meet eligibility standards. 

(ii) NO MORE FAVORABLE TREATMENT.—The State 

child health plan may not provide more favorable dental coverage or cost-sharing protection for dental coverage to children provided dental-only supplemental 

coverage under this paragraph than the dental coverage and cost-sharing protection for dental coverage 

provided to targeted low-income children who are eligible for the full range of child health assistance provided under the State child health plan. 

(6) EXCEPTIONS TO EXCLUSION OF CHILDREN OF EMPLOYEES

OF A PUBLIC AGENCY IN THE STATE.— 

(A) IN GENERAL.—A child shall not be considered to be 

described in paragraph (2)(B) if— 

42 

(i) the public agency that employs a member of the 

child’s family to which such paragraph applies satisfies subparagraph (B); or 

(ii) subparagraph (C) applies to such child. 

(B) MAINTENANCE OF EFFORT WITH RESPECT TO AGENCY

CONTRIBUTION FOR FAMILY COVERAGE.—For purposes of 

subparagraph (A)(i), a public agency satisfies this subparagraph if the amount of annual agency expenditures made 

on behalf of employees enrolled in health coverage paid for 

by the agency that includes dependent coverage for the 

most recent State fiscal year is not less than the amount 

of such expenditures made by the agency for the 1997 

State fiscal year, increased by the percentage increase in 

the medical care expenditure category of the Consumer 

Price Index for All-Urban Consumers (all items: U.S. City 

Average) for such preceding fiscal year. 

(C) HARDSHIP EXCEPTION.—For purposes of subparagraph (A)(ii), this subparagraph applies to a child if the 

State determines that the annual aggregate amount of premiums and cost-sharing imposed for coverage of the family 

of the child would exceed 5 percent of such family’s income 

for the year involved. 

(c) ADDITIONAL DEFINITIONS.—For purposes of this title: 

(1) CHILD.—The term ‘‘child’’ means an individual under 19 

years of age. 

(2) CREDITABLE HEALTH COVERAGE.—The term ‘‘creditable 

health coverage’’ has the meaning given the term ‘‘creditable 

coverage’’ under section 2701(c) of the Public Health Service 

Act (42 U.S.C. 300gg(c)) and includes coverage that meets the 

requirements of section 2103 provided to a targeted low-income 

child under this title or under a waiver approved under section 

2105(c)(2)(B) (relating to a direct service waiver). 

(3) GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; 

ETC.—The terms ‘‘group health plan’’, ‘‘group health insurance 

coverage’’, and ‘‘health insurance coverage’’ have the meanings 

given such terms in section 2791 of the Public Health Service 

Act. 

(4) LOW-INCOME.—The term ‘‘low-income child’’ means a 

child whose family income is at or below 200 percent of the 

poverty line for a family of the size involved. 

(5) POVERTY LINE DEFINED.—The term ‘‘poverty line’’ has the 

meaning given such term in section 673(2) of the Community 

Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 

(6) PREEXISTING CONDITION EXCLUSION.—The term ‘‘preexisting condition exclusion’’ has the meaning given such term 

in section 2701(b)(1)(A) of the Public Health Service Act (42 

U.S.C. 300gg(b)(1)(A)). 

(7) STATE CHILD HEALTH PLAN; PLAN.—Unless the context 

otherwise requires, the terms ‘‘State child health plan’’ and 

‘‘plan’’ mean a State child health plan approved under section 

2106. 

(8) UNCOVERED CHILD.—The term ‘‘uncovered child’’ means a 

child that does not have creditable health coverage. 

(9) SCHOOL-BASED HEALTH CENTER.— 

43 

(A) IN GENERAL.—The term ‘‘school-based health center’’ 

means a health clinic that— 

(i) is located in or near a school facility of a school 

district or board or of an Indian tribe or tribal organization; 

(ii) is organized through school, community, and 

health provider relationships; 

(iii) is administered by a sponsoring facility; 

(iv) provides through health professionals primary 

health services to children in accordance with State 

and local law, including laws relating to licensure and 

certification; and 

(v) satisfies such other requirements as a State may 

establish for the operation of such a clinic. 

(B) SPONSORING FACILITY.—For purposes of subparagraph (A)(iii), the term ‘‘sponsoring facility’’ includes any of 

the following: 

(i) A hospital. 

(ii) A public health department. 

(iii) A community health center. 

(iv) A nonprofit health care agency. 

(v) A local educational agency (as defined under section 8101 of the Elementaryand Secondary Education 

Act of 1965. 

(vi) A program administered by the Indian Health 

Service or the Bureau of Indian Affairs or operated by 

an Indian tribe or a tribal organization. 

* * * * * * * 

Æ