II 

Calendar No. 265 

118TH CONGRESS 

1ST SESSION S. 3430 

[Report No. 118–121] 

To amend titles XVIII and XIX of the Social Security Act to expand the 

mental health care workforce and services, reduce prescription drug costs, 

and extend certain expiring provisions under Medicare and Medicaid, 

and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

DECEMBER 7, 2023 

Mr. WYDEN, from the Committee on Finance, reported the following original 

bill; which was read twice and placed on the calendar 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to expand the mental health care workforce and services, 

reduce prescription drug costs, and extend certain expiring provisions under Medicare and Medicaid, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Better Mental Health Care, Lower-Cost Drugs, and Ex4 tenders Act of 2023’’. 

5 (b) TABLE OF CONTENTS.—The table of contents of 

6 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—EXPANDING MENTAL HEALTH CARE WORKFORCE AND 

SERVICES UNDER MEDICARE AND MEDICAID 

Sec. 101. Expanding eligibility for incentives under the Medicare health professional shortage area bonus program to practitioners furnishing 

mental health and substance use disorder services. 

Sec. 102. Improved access to mental health services under the Medicare program. 

Sec. 103. Clarifying coverage of occupational therapy under the Medicare program. 

Sec. 104. Medicare incentives for behavioral health integration with primary 

care. 

Sec. 105. Establishment of Medicare incident to modifier for mental health 

services furnished through telehealth. 

Sec. 106. Guidance on furnishing behavioral health services via telehealth to individuals with limited English proficiency under Medicare program. 

Sec. 107. Ensuring timely communication regarding telehealth and interstate licensure requirements. 

Sec. 108. Facilitating accessibility for behavioral health services furnished 

through telehealth. 

Sec. 109. Requiring Enhanced & Accurate Lists of (REAL) Health Providers 

Act. 

Sec. 110. Guidance to States on strategies under Medicaid and CHIP to increase mental health and substance use disorder care provider 

capacity. 

Sec. 111. Guidance to States on supporting mental health services and substance use disorder care for children and youth. 

Sec. 112. Recurring analysis and publication of Medicaid health care data related to mental health services. 

Sec. 113. Guidance to States on supporting mental health services or substance 

use disorder care integration with primary care in Medicaid 

and CHIP. 

Sec. 114. Medicaid State option relating to inmates with a substance use disorder pending disposition of charges. 

Sec. 115. Definition of Certified Community Behavioral Health Clinic Services 

under Medicaid. 

TITLE II—REDUCING PRESCRIPTION DRUG COSTS UNDER 

MEDICARE AND MEDICAID 

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Sec. 201. Assuring pharmacy access and choice for Medicare beneficiaries. 

Sec. 202. Ensuring accurate payments to pharmacies under Medicaid. 

Sec. 203. Protecting seniors from excessive cost-sharing for certain medicines. 

TITLE III—MEDICAID EXPIRING PROVISIONS 

Sec. 301. Delaying certain disproportionate share hospital payment reductions 

under the Medicaid program. 

Sec. 302. Extension of State option to provide medical assistance for certain individuals who are patients in certain institutions for mental 

diseases. 

TITLE IV—MEDICARE EXPIRING PROVISIONS AND PROVIDER 

PAYMENT CHANGES 

Sec. 401. Extension of funding for quality measure endorsement, input, and selection. 

Sec. 402. Extension of funding outreach and assistance for low-income programs. 

Sec. 403. Extension of the work geographic index floor under the Medicare program. 

Sec. 404. Extending incentive payments for participation in eligible alternative 

payment models. 

Sec. 405. Payment rates for durable medical equipment under the Medicare 

Program. 

Sec. 406. Extending the independence at home medical practice demonstration 

program under the Medicare program. 

Sec. 407. Increase in support for physicians and other professionals in adjusting to Medicare payment changes. 

Sec. 408. Revised phase-in of Medicare clinical laboratory test payment 

changes. 

Sec. 409. Extension of adjustment to calculation of hospice cap amount under 

Medicare. 

TITLE V—OFFSETS 

Sec. 501. Medicaid Improvement Fund. 

Sec. 502. Medicare Improvement Fund. 

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1 TITLE I—EXPANDING MENTAL 

2 HEALTH CARE WORKFORCE 

3 AND SERVICES UNDER MEDI4 CARE AND MEDICAID 

5 SEC. 101. EXPANDING ELIGIBILITY FOR INCENTIVES 

6 UNDER THE MEDICARE HEALTH PROFES7 SIONAL SHORTAGE AREA BONUS PROGRAM 

8 TO PRACTITIONERS FURNISHING MENTAL 

9 HEALTH AND SUBSTANCE USE DISORDER 

10 SERVICES. 

11 Section 1833(m) of the Social Security Act (42 

12 U.S.C. 1395l(m)) is amended— 

13 (1) by striking paragraph (1) and inserting the 

14 following new paragraph: 

15 ‘‘(1) In the case of— 

16 ‘‘(A) physicians’ services (other than specified 

17 health services that are eligible for the additional 

18 payment under subparagraph (B)) furnished in a 

19 year to an individual, who is covered under the in20 surance program established by this part and who 

21 incurs expenses for such services, in an area that is 

22 designated (under section 332(a)(1)(A) of the Public 

23 Health Service Act) as a health professional short24 age area as identified by the Secretary prior to the 

25 beginning of such year, in addition to the amount 

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1 otherwise paid under this part, there also shall be 

2 paid to the physician (or to an employer or facility 

3 in the cases described in clause (A) of section 

4 1842(b)(6)) (on a monthly or quarterly basis) from 

5 the Federal Supplementary Medical Insurance Trust 

6 Fund an amount equal to 10 percent of the payment 

7 amount for the service under this part; and 

8 ‘‘(B) specified health services (as defined in 

9 paragraph (5)) furnished in a year to an individual, 

10 who is covered under the insurance program estab11 lished by this part and who incurs expenses for such 

12 services, in an area that is designated (under such 

13 section 332(a)(1)(A)) as a mental health profes14 sional shortage area as identified by the Secretary 

15 prior to the beginning of such year, in addition to 

16 the amount otherwise paid under this part, there 

17 also shall be paid to the physician or applicable 

18 practitioner (as defined in paragraph (6)) (or to an 

19 employer or facility in the cases described in clause 

20 (A) of section 1842(b)(6)) (on a monthly or quar21 terly basis) from such Trust Fund an amount equal 

22 to 15 percent of the payment amount for the service 

23 under this part.’’; 

24 (2) in paragraph (2)— 

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1 (A) by striking ‘‘in paragraph (1)’’ and in2 serting ‘‘in subparagraph (A) or (B) of para3 graph (1)’’; 

4 (B) by inserting ‘‘or, in the case of speci5 fied health services, the physician or applicable 

6 practitioner’’ after ‘‘physician’’; 

7 (3) in paragraph (3), by striking ‘‘in paragraph 

8 (1)’’ and inserting ‘‘in subparagraph (A) or (B) of 

9 paragraph (1)’’; 

10 (4) in paragraph (4)— 

11 (A) in subparagraph (B), by inserting ‘‘or 

12 applicable practitioner’’ after ‘‘physician’’; and 

13 (B) in subparagraph (C), by inserting ‘‘or 

14 applicable practitioner’’ after ‘‘physician’’; and 

15 (5) by adding at the end the following new 

16 paragraphs: 

17 ‘‘(5) In this subsection, the term ‘specified health 

18 services’ means services otherwise covered under this part 

19 that are furnished on or after January 1, 2026, by a phy20 sician or an applicable practitioner to an individual— 

21 ‘‘(A) for purposes of diagnosis, evaluation, or 

22 treatment of a mental health disorder, as determined 

23 by the Secretary; or 

24 ‘‘(B) with a substance use disorder diagnosis 

25 for purposes of treatment of such disorder or co-ocVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 curring mental health disorder, as determined by the 

2 Secretary. 

3 ‘‘(6) In this subsection, the term ‘applicable practi4 tioner’ means the following: 

5 ‘‘(A) A physician assistant, nurse practitioner, 

6 or clinical nurse specialist (as defined in section 

7 1861(aa)(5)). 

8 ‘‘(B) A clinical social worker (as defined in sec9 tion 1861(hh)(1)). 

10 ‘‘(C) A clinical psychologist (as defined by the 

11 Secretary for purposes of section 1861(ii)). 

12 ‘‘(D) A marriage and family therapist (as de13 fined in section 1861(lll)(2)). 

14 ‘‘(E) A mental health counselor (as defined in 

15 section 1861(lll)(4)).’’. 

16 SEC. 102. IMPROVED ACCESS TO MENTAL HEALTH SERV17 ICES UNDER THE MEDICARE PROGRAM. 

18 (a) ACCESS TO CLINICAL SOCIAL WORKER SERVICES

19 PROVIDED TO RESIDENTS OF SKILLED NURSING FACILI20 TIES.— 

21 (1) EXCLUSION OF CLINICAL SOCIAL WORKER

22 SERVICES FROM THE SKILLED NURSING FACILITY

23 PROSPECTIVE PAYMENT SYSTEM.—Section 

24 1888(e)(2)(A)(iii) of the Social Security Act (42 

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1 U.S.C. 1395yy(e)(2)(A)(iii)) is amended by adding 

2 at the end the following new subclause: 

3 ‘‘(VII) Clinical social worker 

4 services (as defined in section 

5 1861(hh)(2)).’’. 

6 (2) CONFORMING AMENDMENT.—Section 

7 1861(hh)(2) of the Social Security Act (42 U.S.C. 

8 1395x(hh)(2)) is amended by striking ‘‘and other 

9 than services furnished to an inpatient of a skilled 

10 nursing facility which the facility is required to pro11 vide as a requirement for participation’’. 

12 (b) ACCESS TO THE COMPLETE SCOPE OF CLINICAL

13 SOCIAL WORKER SERVICES.—Section 1861(hh)(2) of the 

14 Social Security Act (42 U.S.C. 1395x(hh)(2)), as amended 

15 by subsection (a)(2), is amended by striking ‘‘for the diag16 nosis and treatment of mental illnesses (other than serv17 ices furnished to an inpatient of a hospital)’’ and inserting 

18 ‘‘, including services for the diagnosis and treatment of 

19 mental illnesses or services for health behavior assessment 

20 and intervention (identified as of January 1, 2023, by 

21 HCPCS codes 96160 and 96161 (and any succeeding 

22 codes)), but not including services furnished to an inpa23 tient of a hospital,’’. 

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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to items and services furnished on 

3 or after January 1, 2026. 

4 SEC. 103. CLARIFYING COVERAGE OF OCCUPATIONAL 

5 THERAPY UNDER THE MEDICARE PROGRAM. 

6 Not later than 1 year after the date of enactment 

7 of this Act, the Secretary of Health and Human Services 

8 shall use existing communication mechanisms to provide 

9 education and outreach to stakeholders about the Medi10 care Benefit Policy Manual with respect to occupational 

11 therapy services furnished to individuals under the Medi12 care program for the treatment of a substance use or men13 tal health disorder diagnosis using applicable Healthcare 

14 Common Procedure Coding System (HCPCS) codes. 

15 SEC. 104. MEDICARE INCENTIVES FOR BEHAVIORAL 

16 HEALTH INTEGRATION WITH PRIMARY CARE. 

17 (a) INCENTIVES.— 

18 (1) IN GENERAL.—Section 1848(b) of the So19 cial Security Act (42 U.S.C. 1395w–4(b)) is amend20 ed by adding at the end the following new para21 graph: 

22 ‘‘(13) INCENTIVES FOR BEHAVIORAL HEALTH

23 INTEGRATION.— 

24 ‘‘(A) IN GENERAL.—For services described 

25 in subparagraph (B) that are furnished during 

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1 2026, 2027, or 2028, instead of the payment 

2 amount that would otherwise be determined 

3 under this section for such year, the payment 

4 amount shall be equal to the applicable percent 

5 (as defined in subparagraph (C)) of such pay6 ment amount for such year. 

7 ‘‘(B) SERVICES DESCRIBED.—The services 

8 described in this subparagraph are services 

9 identified, as of January 1, 2023, by HCPCS 

10 codes 99484, 99492, 99493, 99494, and G2214 

11 (and any successor or similar codes as deter12 mined appropriate by the Secretary). 

13 ‘‘(C) APPLICABLE PERCENT.—In this 

14 paragraph, the term ‘applicable percent’ means, 

15 with respect to a service described in subpara16 graph (A), the following: 

17 ‘‘(i) For services furnished during 

18 2026 , 175 percent. 

19 ‘‘(ii) For services furnished during 

20 2027, 150 percent. 

21 ‘‘(iii) For services furnished during 

22 2028, 125 percent.’’. 

23 (2) WAIVER OF BUDGET NEUTRALITY.—Section 

24 1848(c)(2)(B)(iv) of such Act (42 U.S.C. 1395w– 

25 4(c)(2)(B)(iv)) is amended— 

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1 (A) in subclause (V), by striking ‘‘and’’ at 

2 the end; 

3 (B) in subclause (VI), by striking the pe4 riod at the end and inserting ‘‘; and’’ and 

5 (C) by adding at the end the following new 

6 subclause: 

7 ‘‘(VII) the increase in payment 

8 amounts as a result of the application 

9 of subsection (b)(13) shall not be 

10 taken into account in applying clause 

11 (ii)(II) for 2026, 2027, or 2028.’’. 

12 (b) TECHNICAL ASSISTANCE FOR THE ADOPTION OF

13 BEHAVIORAL HEALTH INTEGRATION.— 

14 (1) IN GENERAL.—Not later than January 1, 

15 2025, the Secretary of Health and Human Services 

16 (in this subsection referred to as the ‘‘Secretary’’) 

17 shall enter into contracts or agreements with appro18 priate entities to offer technical assistance to pri19 mary care practices that are seeking to adopt behav20 ioral health integration models in such practices. 

21 (2) BEHAVIORAL HEALTH INTEGRATION MOD22 ELS.—For purposes of paragraph (1), behavioral 

23 health integration models include the Collaborative 

24 Care Model (with services identified as of January 

25 1, 2023, by HCPCS codes 99492, 99493, 99494, 

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1 and G2214 (and any successor codes)), the Primary 

2 Care Behavioral Health model (with services identi3 fied as of January 1, 2023, by HCPCS code 99484 

4 (and any successor code)), and other models identi5 fied by the Secretary. 

6 (3) IMPLEMENTATION.—Notwithstanding any 

7 other provision of law, the Secretary may implement 

8 the provisions of this subsection by program instruc9 tion or otherwise. 

10 (4) FUNDING.—In addition to amounts other11 wise available, there is appropriated to the Secretary 

12 for fiscal year 2024, out of any money in the Treas13 ury not otherwise appropriated, $5,000,000, to re14 main available until expended, for purposes of car15 rying out this subsection. 

16 SEC. 105. ESTABLISHMENT OF MEDICARE INCIDENT TO 

17 MODIFIER FOR MENTAL HEALTH SERVICES 

18 FURNISHED THROUGH TELEHEALTH. 

19 Section 1834(m)(7) of the Social Security Act (42 

20 U.S.C. 1395m(m)(7)) is amended by adding at the end 

21 the following new subparagraph: 

22 ‘‘(C) ESTABLISHMENT OF INCIDENT TO

23 MODIFIER FOR MENTAL HEALTH SERVICES

24 FURNISHED THROUGH TELEHEALTH.—Not 

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1 ment of this subparagraph, the Secretary shall 

2 establish requirements to include a code or 

3 modifier, as determined appropriate by the Sec4 retary, on claims for mental health services fur5 nished through telehealth under this paragraph 

6 that are furnished by auxiliary personnel (as 

7 defined in section 410.26(a)(1) of title 42, Code 

8 of Federal Regulations, or any successor regula9 tion) and billed incident to a physician or prac10 titioner’s professional services.’’. 

11 SEC. 106. GUIDANCE ON FURNISHING BEHAVIORAL 

12 HEALTH SERVICES VIA TELEHEALTH TO IN13 DIVIDUALS WITH LIMITED ENGLISH PRO14 FICIENCY UNDER MEDICARE PROGRAM. 

15 Not later than 1 year after the date of the enactment 

16 of this section, the Secretary of Health and Human Serv17 ices shall issue and disseminate, or update and revise as 

18 applicable, guidance on the following: 

19 (1) Best practices for providers to work with in20 terpreters to furnish behavioral health services via 

21 video-based and audio-only telehealth, when video22 based telehealth is not an option. 

23 (2) Best practices on integrating the use of 

24 video platforms that enable multi-person video calls 

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1 into behavioral health services furnished via tele2 health. 

3 (3) Best practices on teaching patients, espe4 cially those with limited English proficiency, to use 

5 video-based telehealth platforms. 

6 (4) Best practices for providing patient mate7 rials, communications, and instructions in multiple 

8 languages, including text message appointment re9 minders and prescription information. 

10 SEC. 107. ENSURING TIMELY COMMUNICATION REGARDING 

11 TELEHEALTH AND INTERSTATE LICENSURE 

12 REQUIREMENTS. 

13 The Secretary of Health and Human Services shall 

14 provide information— 

15 (1) on licensure requirements for furnishing 

16 telehealth services under titles XVIII and XIX of 

17 the Social Security Act (42 U.S.C. 1395 et seq.; 

18 1396 et seq.); and 

19 (2) clarifying the extent to which licenses 

20 through an interstate license compact pathway can 

21 qualify as valid and full licenses for the purposes of 

22 meeting Federal licensure requirements under such 

23 titles. 

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1 SEC. 108. FACILITATING ACCESSIBILITY FOR BEHAVIORAL 

2 HEALTH SERVICES FURNISHED THROUGH 

3 TELEHEALTH. 

4 The Secretary of Health and Human Services shall 

5 provide regular updates to guidance to facilitate the acces6 sibility of behavioral health services furnished through 

7 telehealth for the visually and hearing impaired. 

8 SEC. 109. REQUIRING ENHANCED & ACCURATE LISTS OF 

9 (REAL) HEALTH PROVIDERS ACT. 

10 (a) IN GENERAL.—Section 1852(c) of the Social Se11 curity Act (42 U.S.C. 1395w–22(c)) is amended— 

12 (1) in paragraph (1)(C)— 

13 (A) by striking ‘‘plan, and any’’ and insert14 ing ‘‘plan, any’’; and 

15 (B) by inserting the following before the 

16 period: ‘‘, and, in the case of a network-based 

17 plan (as defined in paragraph (3)(C)), for plan 

18 year 2026 and subsequent plan years, the infor19 mation described in paragraph (3)(B)’’; and 

20 (2) by adding at the end the following new 

21 paragraph: 

22 ‘‘(3) PROVIDER DIRECTORY ACCURACY.— 

23 ‘‘(A) IN GENERAL.—For plan year 2026 

24 and subsequent plan years, each MA organiza25 tion offering a network-based plan (as defined 

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1 in subparagraph (C)) shall, for each network2 based plan offered by the organization— 

3 ‘‘(i) maintain, on a publicly available 

4 internet website, an accurate provider di5 rectory that includes the information de6 scribed in subparagraph (B); 

7 ‘‘(ii) not less frequently than once 

8 every 90 days (or, in the case of a hospital 

9 or any other facility determined appro10 priate by the Secretary, at a lesser fre11 quency specified by the Secretary but in no 

12 case less frequently than once every 12 

13 months), verify the provider directory in14 formation of each provider listed in such 

15 directory and, if applicable, update such 

16 provider directory information; 

17 ‘‘(iii) if the organization is unable to 

18 verify such information with respect to a 

19 provider, include in such directory an indi20 cation that the information of such pro21 vider may not be up to date; 

22 ‘‘(iv) remove a provider from such di23 rectory within 5 business days if the orga24 nization determines that the provider is no 

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1 longer a provider participating in the net2 work of such plan; and 

3 ‘‘(v) meet such other requirements as 

4 the Secretary may specify. 

5 ‘‘(B) PROVIDER DIRECTORY INFORMA6 TION.—The information described in this sub7 paragraph is information enrollees may need to 

8 access covered benefits from a provider with 

9 which such organization offering such plan has 

10 an agreement for furnishing items and services 

11 covered under such plan such as name, spe12 cialty, contact information, primary office or fa13 cility address, whether the provider is accepting 

14 new patients, accommodations for people with 

15 disabilities, cultural and linguistic capabilities, 

16 and telehealth capabilities. 

17 ‘‘(C) NETWORK-BASED PLAN.—In this 

18 paragraph, the term ‘network-based plan’ has 

19 the meaning given that term in subsection 

20 (d)(5)(C), except such term includes a Medicare 

21 Advantage private fee-for-service plan, as deter22 mined appropriate by the Secretary.’’. 

23 (b) ACCOUNTABILITY FOR PROVIDER DIRECTORY

24 ACCURACY.— 

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1 (1) COST SHARING FOR SERVICES FURNISHED

2 BASED ON RELIANCE ON INCORRECT PROVIDER DI3 RECTORY INFORMATION.—Section 1852(d) of the 

4 Social Security Act (42 U.S.C. 1395w–22(d)) is 

5 amended— 

6 (A) in paragraph (1)(C)— 

7 (i) in clause (ii), by striking ‘‘or’’ at 

8 the end; 

9 (ii) in clause (iii), by striking the 

10 semicolon at the end and inserting ‘‘, or’’; 

11 and 

12 (iii) by adding at the end the fol13 lowing new clause: 

14 ‘‘(iv) the services are furnished by a 

15 provider that is not participating in the 

16 network of a network-based plan (as de17 fined in subsection (c)(3)(C)) but is listed 

18 in the provider directory of such plan on 

19 the date on which the appointment is 

20 made, as described in paragraph (7)(A);’’; 

21 and 

22 (B) by adding at the end the following new 

23 paragraph: 

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1 ‘‘(7) COST SHARING FOR SERVICES FURNISHED

2 BASED ON RELIANCE ON INCORRECT PROVIDER DI3 RECTORY INFORMATION.— 

4 ‘‘(A) IN GENERAL.—For plan year 2026 

5 and subsequent plan years, if an enrollee is fur6 nished an item or service by a provider that is 

7 not participating in the network of a network8 based plan (as defined in subsection (c)(3)(C)) 

9 but is listed in the provider directory of such 

10 plan (as required to be provided to an enrollee 

11 pursuant to subsection (c)(1)(C)) on the date 

12 on which the appointment is made, and if such 

13 item or service would otherwise be covered 

14 under such plan if furnished by a provider that 

15 is participating in the network of such plan, the 

16 MA organization offering such plan shall ensure 

17 that the enrollee is only responsible for the 

18 amount of cost sharing that would apply if such 

19 provider had been participating in the network 

20 of such plan. 

21 ‘‘(B) NOTIFICATION REQUIREMENT.—For 

22 plan year 2026 and subsequent plan years, each 

23 MA organization that offers a network-based 

24 plan shall— 

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1 ‘‘(i) notify enrollees of their cost-shar2 ing protections under this paragraph and 

3 make such notifications, to the extent 

4 practicable, by not later than the first day 

5 of an annual, coordinated election period 

6 under section 1851(e)(3) with respect to a 

7 year; 

8 ‘‘(ii) include information regarding 

9 such cost-sharing protections in the pro10 vider directory of each network-based plan 

11 offered by the MA organization.; and 

12 ‘‘(iii) notify enrollees of their cost13 sharing protections under this paragraph 

14 in an explanation of benefits.’’. 

15 (2) REQUIRED PROVIDER DIRECTORY ACCU16 RACY ANALYSIS AND REPORTS.— 

17 (A) IN GENERAL.—Section 1857(e) of the 

18 Social Security Act (42 U.S.C. 1395w–27(e)) is 

19 amended by adding at the end the following 

20 new paragraph: 

21 ‘‘(6) PROVIDER DIRECTORY ACCURACY ANAL22 YSIS AND REPORTS.— 

23 ‘‘(A) IN GENERAL.—Beginning with plan 

24 years beginning on or after January 1, 2026, 

25 subject to subparagraph (C), a contract under 

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1 this section with an MA organization shall re2 quire the organization, for each network-based 

3 plan (as defined in section 1852(c)(3)(C)) of4 fered by the organization, to annually— 

5 ‘‘(i) conduct an analysis estimating 

6 the accuracy of the provider directory of 

7 such plan using a sample of providers in8 cluded in such provider directory (includ9 ing provider specialties with high inaccu10 racy rates of provider directory informa11 tion, such as providers specializing in men12 tal health or substance use disorder treat13 ment, as determined by the Secretary); and 

14 ‘‘(ii) submit a report to the Secretary 

15 containing the results of such analysis, in16 cluding an accuracy score for such provider 

17 directory (as determined using a method18 ology specified by the Secretary under sub19 paragraph (B)(i)), and other information 

20 required by the Secretary. 

21 ‘‘(B) DETERMINATION OF ACCURACY

22 SCORE.— 

23 ‘‘(i) IN GENERAL.—The Secretary 

24 shall specify methodologies for MA plans 

25 to use in estimating the accuracy of the 

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1 provider directory information of such 

2 plans and determining the accuracy score 

3 for the plan’s provider directory. 

4 ‘‘(ii) CONSIDERATIONS.—In carrying 

5 out clause (i), the Secretary shall take into 

6 consideration— 

7 ‘‘(I) data sources maintained by 

8 MA organizations; 

9 ‘‘(II) publicly available data sets; 

10 ‘‘(III) the administrative burden 

11 on plans and providers; and 

12 ‘‘(IV) the relative importance of 

13 certain provider directory information 

14 on enrollee ability to access care. 

15 ‘‘(C) EXCEPTION.—The Secretary may 

16 waive the requirements of this paragraph in the 

17 case of a network-based plan with low enroll18 ment (as defined by the Secretary). 

19 ‘‘(D) TRANSPARENCY.—Beginning with 

20 plan years beginning on or after January 1, 

21 2027, the Secretary shall post accuracy scores 

22 (as reported under subparagraph (A)(ii)), in a 

23 machine readable file, on the internet website of 

24 the Centers for Medicare & Medicaid Services. 

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1 ‘‘(E) IMPLEMENTATION.—The Secretary 

2 shall implement this paragraph through notice 

3 and comment rulemaking.’’. 

4 (B) PROVISION OF INFORMATION TO

5 BENEFICIARIES.—Section 1851(d)(4) of the So6 cial Security Act (42 U.S.C. 1395w–21(d)(4)) 

7 is amended by adding at the end the following 

8 new subparagraph: 

9 ‘‘(F) PROVIDER DIRECTORY.—Beginning 

10 with plan years beginning on or after January 

11 1, 2027, the accuracy score of the plan’s pro12 vider directory (as reported under section 

13 1857(e)(6)(A)(ii)) on the plan’s provider direc14 tory.’’. 

15 (C) FUNDING.—In addition to amounts 

16 otherwise available, there is appropriated to the 

17 Centers for Medicare & Medicaid Services Pro18 gram Management Account, out of any money 

19 in the Treasury not otherwise appropriated, 

20 $1,000,000 for fiscal year 2025, to remain 

21 available until expended, to carry out the 

22 amendments made by this paragraph. 

23 (3) GAO STUDY AND REPORT.— 

24 (A) ANALYSIS.—The Comptroller General 

25 of the United States (in this paragraph referred 

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1 to as the ‘‘Comptroller General’’) shall conduct 

2 study of the implementation of the amendments 

3 made by paragraphs (1) and (2). To the extent 

4 data are available and reliable, such study shall 

5 include an analysis of— 

6 (i) the use of protections required 

7 under section 1852(d)(7) of the Social Se8 curity Act, as added by paragraph (1); 

9 (ii) the provider directory accuracy 

10 scores trends under section 

11 1857(e)(6)(A)(ii) of the Social Security 

12 Act (as added by paragraph (2)(A)), both 

13 overall and among providers specializing in 

14 mental health or substance disorder treat15 ment; 

16 (iii) provider response rates by plan 

17 verification methods; and 

18 (iv) other items determined appro19 priate by the Comptroller General. 

20 (B) REPORT.—Not later than January 15, 

21 2031, the Comptroller General shall submit to 

22 Congress a report containing the results of the 

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1 tion and administrative action as the Comp2 troller General determines appropriate. 

3 (c) GUIDANCE ON MAINTAINING ACCURATE PRO4 VIDER DIRECTORIES.— 

5 (1) STAKEHOLDER MEETING.— 

6 (A) IN GENERAL.—Not later than 3 

7 months after the date of enactment of this Act, 

8 the Secretary of Health and Human Services 

9 (referred to in this subsection as the ‘‘Sec10 retary’’) shall hold a public stakeholder meeting 

11 to receive input on approaches for maintaining 

12 accurate provider directories for Medicare Ad13 vantage plans under part C of title XVIII of the 

14 Social Security Act (42 U.S.C. 1395w–21 et 

15 seq.), including input on approaches for reduc16 ing administrative burden such as data stand17 ardization and best practices to maintain pro18 vider directory information. 

19 (B) PARTICIPANTS.—Participants of the 

20 meeting under subparagraph (A) shall include 

21 representatives from the Centers for Medicare & 

22 Medicaid Services and the Office of the Na23 tional Coordinator for Health Information 

24 Technology, health care providers, companies 

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1 that specialize in relevant technologies, health 

2 insurers, and patient advocates. 

3 (2) GUIDANCE TO MEDICARE ADVANTAGE OR4 GANIZATIONS.—Not later than 12 months after the 

5 date of enactment of this Act, the Secretary shall 

6 issue guidance to Medicare Advantage organizations 

7 offering Medicare Advantage plans under part C of 

8 title XVIII of the Social Security Act (42 U.S.C. 

9 1395w–21 et seq.) on maintaining accurate provider 

10 directories for such plans, taking into consideration 

11 input received during the stakeholder meeting under 

12 paragraph (1). Such guidance may include the fol13 lowing, as determined appropriate by the Secretary: 

14 (A) Best practices for Medicare Advantage 

15 organizations on how to work with providers to 

16 maintain the accuracy of provider directories 

17 and reduce provider and Medicare Advantage 

18 organization burden with respect to maintaining 

19 the accuracy of provider directories . 

20 (B) Information on data sets and data 

21 sources with information that could be used by 

22 Medicare Advantage organizations to maintain 

23 accurate provider directories. 

24 (C) Approaches for utilizing data sources 

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1 tions and publicly available data sets to main2 tain accurate provider directories. 

3 (D) Information to be included in the pro4 vider directory that may be useful for Medicare 

5 beneficiaries to assess plan networks when se6 lecting a plan and accessing providers partici7 pating in plan networks during the plan year. 

8 (3) GUIDANCE TO PART B PROVIDERS.—Not 

9 later than 12 months after the date of enactment of 

10 this Act, the Secretary shall issue guidance to pro11 viders of services and suppliers who furnish items or 

12 services for which benefits are available under part 

13 B of title XVIII of the Social Security Act (42 

14 U.S.C. 1395j et seq.) on when to update the Na15 tional Plan and Provider Enumeration System re16 garding any information changes. 

17 SEC. 110. GUIDANCE TO STATES ON STRATEGIES UNDER 

18 MEDICAID AND CHIP TO INCREASE MENTAL 

19 HEALTH AND SUBSTANCE USE DISORDER 

20 CARE PROVIDER CAPACITY. 

21 Not later than 12 months after the date of enactment 

22 of this Act, the Secretary of Health and Human Services 

23 shall issue guidance to States on strategies under Med24 icaid and the Children’s Health Insurance Program 

25 (CHIP) to increase access to mental health and substance 

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1 use disorder care providers that participate in Medicaid 

2 or CHIP, which may include education, training, recruit3 ment, and retention of such providers, with a focus on im4 proving the capacity of the mental health and substance 

5 use disorder care workforce in rural and underserved areas 

6 by increasing the number, type, and capacity of providers. 

7 Such guidance shall include, but not be limited to— 

8 (1) best practices from States that have used 

9 Medicaid or CHIP waivers and authorities under ti10 tles XI, XIX, and XXI of such Act (42 U.S.C. 1301 

11 et seq., 1396 et seq., 1397aa et seq.) for such pur12 poses; 

13 (2) best practices related to expanding the 

14 availability of community-based mental health and 

15 substance use disorder services under Medicaid and 

16 CHIP, including through the participation of para17 professionals with behavioral health expertise, and 

18 review of State practices for leveraging paraprofes19 sionals within State scope of practice requirements 

20 as well as State supervision requirements, such as 

21 peer support specialists and clinicians with bacca22 laureate degrees; and 

23 (3) best practices related to financing, sup24 porting, and expanding the education and training of 

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1 order services to increase the workforce of such pro2 viders who participate in Medicaid and CHIP, in3 cluding by supporting on-site training in the clinical 

4 setting and innovative public-private partnerships. 

5 SEC. 111. GUIDANCE TO STATES ON SUPPORTING MENTAL 

6 HEALTH SERVICES AND SUBSTANCE USE DIS7 ORDER CARE FOR CHILDREN AND YOUTH. 

8 (a) GUIDANCE ON INCREASING THE AVAILABILITY

9 AND PROVISION OF MENTAL HEALTH SERVICES AND

10 SUBSTANCE USE DISORDER CARE UNDER MEDICAID AND

11 CHIP.—Not later than 12 months after the date of enact12 ment of this Act, the Secretary shall issue guidance to 

13 States regarding opportunities to improve the availability 

14 and provision of mental health services and substance use 

15 disorder care through Medicaid and CHIP for children 

16 and youth. Such guidance shall address the following: 

17 (1) The design and implementation of a con18 tinuum of benefits for children and youth with sig19 nificant mental health conditions and substance use 

20 disorders covered by Medicaid and CHIP, including 

21 the role of EPSDT, how EPSDT requires States to 

22 make available a continuum of care across settings, 

23 and what is required of States to ensure compliance 

24 with EPSDT. 

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1 (2) Strategies to facilitate access to mental 

2 health services and substance use disorder care 

3 under Medicaid and CHIP that are delivered in the 

4 home or in community-based settings for children 

5 and youth. Such guidance shall outline strategies 

6 employed by States to expand the availability of 

7 such settings and include specific interventions and 

8 financing arrangements that could be replicated. 

9 (3) Strategies to facilitate access to mental 

10 health services and substance use disorder care 

11 under Medicaid and CHIP for children and youth 

12 who— 

13 (A) are at risk for having a significant 

14 mental health condition or substance use dis15 order; 

16 (B) have a significant mental health condi17 tion or substance use disorder; or 

18 (C) have an intellectual or developmental 

19 disability. 

20 (4) Strategies to promote screening for mental 

21 health and substance use disorder needs of children 

22 and youth, including children and youth provided, or 

23 at risk for needing, child welfare services, in coordi24 nation with providers, managed care organizations 

25 (as defined by the Secretary), prepaid inpatient 

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1 health plans (as defined by the Secretary), prepaid 

2 ambulatory health plans (as defined by the Sec3 retary), and schools (as defined by the Secretary). 

4 (5) Strategies for supporting the provision of 

5 culturally competent, developmentally appropriate, 

6 and trauma-informed mental health services and 

7 substance use disorder care to children and youth. 

8 (6) Strategies for providing early prevention, 

9 intervention, and screening services, including for 

10 children and youth at higher risk for having mental 

11 health or substance use disorder needs, children and 

12 youth who do not have a mental health or substance 

13 use disorder diagnosis, children and youth provided, 

14 or at risk for needing, child welfare services, and 

15 children at risk of first episode psychosis. 

16 (7) Best practices from State Medicaid and 

17 CHIP programs in expanding access to mental 

18 health services and substance use disorder care for 

19 children and youth, including children and youth 

20 that are part of underserved communities and chil21 dren and youth with co-occurring intellectual dis22 ability or autism spectrum disorder, and former fos23 ter youth. 

24 (8) Strategies to coordinate services and fund25 ing provided under parts B and E of title IV of the 

32 

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1 Social Security Act (42 U.S.C. 621 et seq., 670 et 

2 seq.), and other funding sources at the discretion of 

3 the Secretary, with services for which Federal finan4 cial participation is available under Medicaid or 

5 CHIP, to support improved access to comprehensive 

6 mental health services and substance use disorder 

7 care for children and youth provided, or at risk for 

8 needing, child welfare services. 

9 (b) CONSULTATION.—The Secretary shall consult 

10 with the Administrator of the Centers for Medicare & 

11 Medicaid Services, the Assistant Secretary for the Admin12 istration for Children and Families, the Assistant Sec13 retary for Mental Health and Substance Use, and the Di14 rector of the Office of National Drug Control Policy with 

15 respect to the guidance issued under subsection (a). 

16 (c) DEFINITIONS.—In this section: 

17 (1) EPSDT.—The term ‘‘EPSDT’’ means early 

18 and periodic screening, diagnostic, and treatment 

19 services under Medicaid in accordance with sections 

20 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the So21 cial Security Act (42 U.S.C. 1396a(a)(43), 

22 1396d(a)(4)(B), 1396d(r)). 

23 (2) SECRETARY.—The term ‘‘Secretary’’ means 

24 the Secretary of Health and Human Services. 

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1 (3) STATE.—The term ‘‘State’’ has the mean2 ing given that term in section 1101(a)(1) of the So3 cial Security Act (42 U.S.C. 1301(a)(1)) for pur4 poses of titles XIX and XXI of such Act. 

5 SEC. 112. RECURRING ANALYSIS AND PUBLICATION OF 

6 MEDICAID HEALTH CARE DATA RELATED TO 

7 MENTAL HEALTH SERVICES. 

8 (a) IN GENERAL.—The Secretary, on a biennial 

9 basis, shall link, analyze, and publish on a publicly avail10 able website Medicaid data reported by States through the 

11 Transformed Medicaid Statistical Information System (T– 

12 MSIS) (or a successor system) relating to mental health 

13 services provided to individuals enrolled in Medicaid, in14 cluding an analysis by age. Such enrollee information shall 

15 be de-identified of any personally identifying information, 

16 shall adhere to privacy standards established by the De17 partment of Health and Human Services, and shall be ag18 gregated to protect the privacy of enrollees, as necessary. 

19 Each publication of such analysis shall include for each 

20 State available data for the following measures: 

21 (1) The number and percentage of individuals 

22 by age enrolled in the State Medicaid plan or waiver 

23 of such plan in each of the major enrollment cat24 egories (as defined in a letter, to be made publicly 

25 available on the website of the Medicaid and CHIP 

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1 Payment and Access Commission, from the Medicaid 

2 and CHIP Payment and Access Commission to the 

3 Secretary) who have been diagnosed with a mental 

4 health condition and whether such individuals are 

5 enrolled under the State Medicaid plan or waiver of 

6 such plan, including the specific waiver authority 

7 under which they are enrolled, to the extent avail8 able. 

9 (2) A list of the mental health treatment serv10 ices, including specifying adult and pediatric serv11 ices, by each major type of service, such as coun12 seling, intensive home-based services, intensive care 

13 coordination, crisis services tailored to children and 

14 youth, youth peer support services, family-to-family 

15 support, inpatient hospitalization, and other appro16 priate services as identified by the Secretary, for 

17 which beneficiaries in each State received at least 1 

18 service under the State Medicaid plan or a waiver of 

19 such plan. 

20 (3) The number and percentage of individuals 

21 by age with a substance use disorder diagnosis en22 rolled in the State Medicaid plan or waiver of such 

23 plan who received services for a mental health condi24 tion under such plan or waiver by each major type 

25 of service specified under paragraph (2) within each 

35 

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1 major setting type, such as outpatient, inpatient, 

2 residential, and other home-based and community3 based settings. 

4 (4) The number of services provided under the 

5 State Medicaid plan or waiver of such plan per indi6 vidual with a mental health diagnosis, including by 

7 age, enrolled in such plan or waiver for each major 

8 type of service specified under paragraph (2). 

9 (5) The number and percentage of individuals 

10 by age enrolled in the State Medicaid plan or waiver 

11 by major enrollment category, who received mental 

12 health services through— 

13 (A) a Medicaid managed care entity (as 

14 defined in section 1932(a)(1)(B) of the Social 

15 Security Act (42 U.S.C. 1396u–2(a)(1)(B))), 

16 including the number of such individuals who 

17 received such assistance through a prepaid in18 patient health plan (as defined by the Sec19 retary) or a prepaid ambulatory health plan (as 

20 defined by the Secretary); 

21 (B) a fee-for-service payment model; or 

22 (C) an alternative payment model, to the 

23 extent available. 

24 (6) The number and percentage of individuals 

25 by age with a mental health diagnosis who received 

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1 mental health services in an outpatient or home2 based and community-based setting after receiving 

3 services in an inpatient or residential setting and the 

4 number of services received by such individuals in 

5 the outpatient or home-based and community-based 

6 setting. 

7 (7) The number and percentage of inpatient ad8 missions by age in which services for a mental 

9 health condition were provided to an individual en10 rolled in the State Medicaid plan or a waiver of such 

11 plan that occurred within 30 days after discharge 

12 from a hospital or inpatient facility in which services 

13 for a mental health condition previously were pro14 vided to such individual, disaggregated by type of fa15 cility, to the extent such information is available. 

16 (8) The number of emergency department visits 

17 by an individual by age enrolled in the State Med18 icaid plan or a waiver of such plan for treatment of 

19 a mental health condition within 7 days of such indi20 vidual being discharged from a hospital inpatient fa21 cility in which services for a mental health condition 

22 were provided, or from a mental health facility, an 

23 independent psychiatric wing of acute care hospital, 

24 or an intermediate care facility for individuals with 

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1 intellectual disabilities, disaggregated by type of fa2 cility, to the extent such information is available. 

3 (9) The number and percentage of individuals 

4 by age enrolled in the State Medicaid plan or a waiv5 er of such plan— 

6 (A) who received an assessment to diag7 nose a mental health condition; and 

8 (B) the number of mental health services 

9 provided to individuals described in subpara10 graph (A) in the 30 days post-assessment. 

11 (10) Prescription National Drug Code codes, 

12 fill dates, and number of days supply of any covered 

13 outpatient drug (as defined in section 1927(k)(2) of 

14 the Social Security Act (42 U.S.C. 1396r-8(k)(2)) to 

15 treat a mental health condition that were dispensed 

16 to an individual by age enrolled in the State Med17 icaid plan or waiver with an episode described in 

18 paragraph (7) or (8) during any period that occurs 

19 after the individual’s discharge date defined in para20 graph (7) or (8) (as applicable), and before the ad21 mission date applicable under paragraph (7) or the 

22 date of the emergency department visit applicable 

23 under paragraph (8). 

24 (b) PUBLICATION.— 

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1 (1) IN GENERAL.—Not later than 18 months 

2 after the date of enactment of this Act, the Sec3 retary shall make publicly available the first analysis 

4 required by subsection (a). 

5 (2) USE OF T–MSIS DATA.—The report required 

6 under paragraph (1) and updates required under 

7 paragraph (3) shall— 

8 (A) use data and definitions from the 

9 Transformed Medicaid Statistical Information 

10 System (‘‘T–MSIS’’) (or a successor system) 

11 data set that is no more than 12 months old on 

12 the date that the report or update is published; 

13 and 

14 (B) as appropriate, include a description 

15 with respect to each State of the quality and 

16 completeness of the data and caveats describing 

17 the limitations of the data reported to the Sec18 retary by the State that is sufficient to commu19 nicate the appropriate uses for the information. 

20 (3) REVISED PUBLICATION.—Not later than 3 

21 years after the date of enactment of this Act, the 

22 Secretary shall publish a revised publication of the 

23 analysis required by subsection (a) that allows for a 

24 research-ready and publicly accessible interface of 

25 the publication that is developed after consultation 

39 

•S 3430 RS

1 with stakeholders on the usability of the data con2 tained in the publication. 

3 (c) MAKING PERMANENT THE REQUIREMENT TO AN4 NUALLY UPDATE THE SUD DATA BOOK.—Section 1015 

5 of the SUPPORT for Patients and Communities Act 

6 (Public Law 115–271) is amended— 

7 (1) in subsection (a)(3), by striking ‘‘through 

8 2024’’; and 

9 (2) in subsection (b), by adding at the end the 

10 following new paragraph: 

11 ‘‘(4) PUBLICATION OF DATA.— 

12 ‘‘(A) IN GENERAL.—The Secretary shall 

13 publish in the Federal Register a system of 

14 records notice that modifies the system of 

15 records notice required under paragraph (1) to 

16 provide that— 

17 ‘‘(i) the data specified in paragraph 

18 (2) shall be published on a publicly avail19 able website; and 

20 ‘‘(ii) such data shall be de-identified 

21 of any personally identifying information, 

22 shall adhere to privacy standards estab23 lished by the Department of Health and 

24 Human Services, and shall be aggregated 

40 

•S 3430 RS

1 to protect the privacy of enrollees, as nec2 essary. 

3 ‘‘(B) INITIATION OF MODIFIED DATA4 SHARING ACTIVITIES.—Not later than January 

5 1, 2025, the Secretary shall initiate the data 

6 sharing activities outlined in the notice required 

7 under paragraph (1), as modified pursuant to 

8 this paragraph.’’. 

9 (d) DEFINITIONS.—In this section: 

10 (1) SECRETARY.—The term ‘‘Secretary’’ means 

11 the Secretary of Health and Human Services. 

12 (2) STATE.—The term ‘‘State’’ has the mean13 ing given that term in section 1101(a)(1) of the So14 cial Security Act (42 U.S.C. 1301(a)(1)) for pur15 poses of title XIX of such Act. 

16 SEC. 113. GUIDANCE TO STATES ON SUPPORTING MENTAL 

17 HEALTH SERVICES OR SUBSTANCE USE DIS18 ORDER CARE INTEGRATION WITH PRIMARY 

19 CARE IN MEDICAID AND CHIP. 

20 (a) ANALYSIS REGARDING CARE INTEGRATION.— 

21 Not later than 18 months after the date of enactment of 

22 this Act, the Secretary shall conduct an analysis of Med23 icaid and CHIP regarding clinical outcomes among dif24 ferent models of integration of mental health services or 

41 

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1 substance use disorder care within the primary care set2 ting. Such analysis shall— 

3 (1) consider different models for how mental 

4 health services or substance use disorder care is de5 livered and integrated within the primary care set6 ting, including when providers operating in an inte7 grated model are physically located in the same 

8 practice or building, when at least 1 provider in an 

9 integrated care model is available via telehealth, and 

10 when primary care, mental health, or substance use 

11 disorder care providers seek education and consulta12 tion from other providers through electronic modali13 ties; and 

14 (2) evaluate— 

15 (A) the use of different payment meth16 odologies, such as bundled payments and value17 based payment arrangements; and 

18 (B) the use and quality of services to co19 ordinate care, including but not limited to case 

20 management, care coordination, enhanced care 

21 coordination, and enhanced care management, 

22 for mental health services and for substance use 

23 disorder care. 

24 (b) GUIDANCE.—Not later than 12 months after the 

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1 section (a), the Secretary shall issue guidance to States 

2 on supporting integration of mental health services or sub3 stance use disorder care with primary care under Medicaid 

4 and CHIP. Such guidance shall be informed by the anal5 ysis required under subsection (a) and, at minimum, shall 

6 do the following: 

7 (1) Provide an overview of State options for 

8 adopting and expanding value-based payment ar9 rangements and alternative payment models, includ10 ing accountable care organizations and other shared 

11 savings programs, that integrate mental health serv12 ices or substance use disorder care with primary 

13 care. 

14 (2) Describe opportunities for States to use and 

15 align existing authorities and resources to finance 

16 integration of mental health services or substance 

17 use disorder care with primary care, including with 

18 respect to the use of electronic health records in 

19 mental health care settings and in substance use dis20 order care settings. 

21 (3) Describe strategies to support integration of 

22 mental health services or substance use disorder care 

23 with primary care through the use of non-clinical 

24 professionals and paraprofessionals, including 

25 trained peer support specialists. 

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1 (4) Provide examples of specific strategies and 

2 models designed to support integration of mental 

3 health services or substance use disorder care with 

4 primary care for differing age groups, including chil5 dren and youth, and individuals over the age of 65. 

6 (5) Describe options for assessing the clinical 

7 outcomes of differing models and strategies for inte8 gration of mental health services or substance use 

9 disorder care with primary care. 

10 (c) INTEGRATION OF MENTAL HEALTH SERVICES OR

11 SUBSTANCE USE DISORDER CARE WITH PRIMARY

12 CARE.—For purposes of subsections (a) and (b), integra13 tion of mental health services or substance use disorder 

14 care with primary care may include (and shall not be lim15 ited to, including when furnished via telehealth, when ap16 propriate)— 

17 (1) adherence to the collaborative care model or 

18 primary care behavioral health model for behavioral 

19 health integration; 

20 (2) use of behavioral health integration models 

21 primarily intended for pediatric populations with 

22 non-severe mental health needs that are focused on 

23 prevention and early detection and intervention 

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1 mary care, to include same-day access to family-fo2 cused mental health treatment services; 

3 (3) having mental health providers or substance 

4 use disorder providers physically co-located in a pri5 mary care setting with same-day visit availability; 

6 (4) implementing or maintaining enhanced care 

7 coordination or targeted case management which in8 cludes regular interactions between and within care 

9 teams; 

10 (5) providing mental health or substance use 

11 disorder screening and follow-up assessments, inter12 ventions, or services within the same practice or fa13 cility as a primary care or physical service setting; 

14 (6) the use of assertive community treatment 

15 that is integrated with or facilitated by a primary 

16 care practice; and 

17 (7) delivery of integrated primary care and 

18 mental health services or substance use disorder care 

19 in the home or in community-based settings for indi20 viduals who choose and are able to receive care in 

21 such settings, as authorized under subsections (b), 

22 (c), (i), (j), and (k) of section 1915 of the Social Se23 curity Act (42 U.S.C. 1396n), under a waiver under 

24 section 1115 of such Act (42 U.S.C. 1315), or under 

45 

•S 3430 RS

1 section 1937, 1945, or 1945A of such Act (42 

2 U.S.C. 1396u–7, 1396w–4, 1396w–4a). 

3 (d) DEFINITIONS.—In this section: 

4 (1) SECRETARY.—The term ‘‘Secretary’’ means 

5 the Secretary of Health and Human Services. 

6 (2) STATE.—The term ‘‘State’’ has the mean7 ing given that term in section 1101(a)(1) of the So8 cial Security Act (42 U.S.C. 1301(a)(1)) for pur9 poses of titles XIX and XXI of such Act. 

10 SEC. 114. MEDICAID STATE OPTION RELATING TO INMATES 

11 WITH A SUBSTANCE USE DISORDER PENDING 

12 DISPOSITION OF CHARGES. 

13 (a) STATE OPTION.— 

14 (1) IN GENERAL.—Section 1905 of the Social 

15 Security Act (42 U.S.C. 1396d) is amended— 

16 (A) in the subdivision (A) following the 

17 last numbered paragraph of subsection (a), by 

18 inserting ‘‘subject to subsection (jj),’’ before 

19 ‘‘any such payments’’; and 

20 (B) by adding at the end the following new 

21 subsection: 

22 ‘‘(jj) STATE OPTION TO PROVIDE MEDICAL ASSIST23 ANCE TO CERTAIN INMATES WITH A SUBSTANCE USE

24 DISORDER PENDING DISPOSITION OF CHARGES.— 

46 

•S 3430 RS

1 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

2 State may elect to provide, and, notwithstanding the 

3 subdivision (A) following the last numbered para4 graph of subsection (a), receive Federal financial 

5 participation for, medical assistance for an indi6 vidual who— 

7 ‘‘(A) is an inmate of a public institution 

8 (as defined in section 1902(nn)(3)) pending dis9 position of charges; and 

10 ‘‘(B) has been diagnosed with a substance 

11 use disorder. 

12 ‘‘(2) LIMITATION; CONDITIONS.— 

13 ‘‘(A) LIMITATION.—A State may only re14 ceive Federal financial participation for medical 

15 assistance provided to an individual described in 

16 paragraph (1) during the 7-day period that be17 gins on the first day that the individual is an 

18 inmate of a public institution. 

19 ‘‘(B) CONDITIONS.—A State may only re20 ceive Federal financial participation for medical 

21 assistance provided to an individual described in 

22 paragraph (1) if— 

23 ‘‘(i) the State has elected to not ter24 minate eligibility for medical assistance 

25 under the State plan for individuals on the 

47 

•S 3430 RS

1 basis that they are inmates of public insti2 tutions (but may suspend coverage during 

3 the period an individual is such an in4 mate); and 

5 ‘‘(ii) the diagnosis that the covered in6 dividual has a substance use disorder is 

7 made while the individual is an inmate of 

8 the public institution by a licensed medical 

9 professional using a standardized screening 

10 and assessment model approved by the 

11 Secretary.’’. 

12 (2) EFFECTIVE DATE.—The amendments made 

13 by this subsection shall take effect on January 1, 

14 2026. 

15 (b) TECHNICAL CORRECTION AND CONFORMING

16 AMENDMENTS.— 

17 (1) TECHNICAL CORRECTION.—Section 

18 5122(a)(1) of the Consolidated Appropriations Act, 

19 2023 (Public Law 117–328) is amended by striking 

20 ‘‘after’’ and all that follows through the period at 

21 the end and inserting ‘‘after ‘or in the case of an eli22 gible juvenile described in section 1902(a)(84)(D) 

23 with respect to the screenings, diagnostic services, 

24 referrals, and targeted case management services re25 quired under such section’.’’. 

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1 (2) OTHER CONFORMING AMENDMENTS.— 

2 (A) Section 1902(nn)(3) of the Social Se3 curity Act (42 U.S.C. 1396a(nn)(3)), is amend4 ed by striking ‘‘following’’ and all that follows 

5 through ‘‘section 1905(a)’’ and inserting ‘‘fol6 lowing the last numbered paragraph of section 

7 1905(a)’’. 

8 (B) The fifth sentence of section 1905(a) 

9 of the Social Security Act (42 U.S.C. 1396d(a)) 

10 is amended by striking ‘‘paragraph (30)’’ and 

11 inserting ‘‘the last numbered paragraph’’. 

12 SEC. 115. DEFINITION OF CERTIFIED COMMUNITY BEHAV13 IORAL HEALTH CLINIC SERVICES UNDER 

14 MEDICAID. 

15 (a) DEFINITION OF MEDICAL ASSISTANCE.—Section 

16 1905 of the Social Security Act (42 U.S.C. 1396d) is 

17 amended— 

18 (1) in subsection (a)— 

19 (A) in paragraph (30), by striking ‘‘; and’’ 

20 and inserting a semicolon; 

21 (B) by redesignating paragraph (31) as 

22 paragraph (32); and 

23 (C) by inserting after paragraph (30) the 

24 following new paragraph: 

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•S 3430 RS

1 ‘‘(31) certified community behavioral health 

2 clinic services, as defined in subsection (jj); and’’; 

3 and 

4 (2) by adding at the end the following new sub5 section: 

6 ‘‘(jj) CERTIFIED COMMUNITY BEHAVIORAL HEALTH

7 CLINIC SERVICES.— 

8 ‘‘(1) IN GENERAL.—The term ‘certified commu9 nity behavioral health services’ means any of the fol10 lowing when furnished to an individual as a patient 

11 of a certified community behavioral health clinic (as 

12 defined in paragraph (2)), in a manner reflecting 

13 person-centered care and which, if not available di14 rectly through a certified community behavioral 

15 health clinic, may be provided or referred through 

16 formal relationships with other providers: 

17 ‘‘(A) Crisis mental health services, includ18 ing 24-hour mobile crisis teams, emergency cri19 sis intervention services, and crisis stabilization. 

20 ‘‘(B) Screening, assessment, and diagnosis, 

21 including risk assessment. 

22 ‘‘(C) Patient-centered treatment planning 

23 or similar processes, including risk assessment 

24 and crisis planning. 

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1 ‘‘(D) Outpatient mental health and sub2 stance use services. 

3 ‘‘(E) Outpatient clinic primary care screen4 ing and monitoring of key health indicators and 

5 health risk. 

6 ‘‘(F) Intensive case management. 

7 ‘‘(G) Psychiatric rehabilitation services. 

8 ‘‘(H) Peer support and counselor services 

9 and family supports. 

10 ‘‘(I) Intensive, community-based mental 

11 health care for members of the armed forces 

12 and veterans, particularly those members and 

13 veterans located in rural areas, provided the 

14 care is consistent with minimum clinical mental 

15 health guidelines promulgated by the Veterans 

16 Health Administration, including clinical guide17 lines contained in the Uniform Mental Health 

18 Services Handbook of such Administration. 

19 ‘‘(2) CERTIFIED COMMUNITY BEHAVIORAL

20 HEALTH CLINIC.—The term ‘certified community be21 havioral health clinic’ means an organization that— 

22 ‘‘(A) is engaged in furnishing to patients 

23 all of the services described in paragraph (1); 

24 ‘‘(B) is legally authorized to furnish such 

25 services under State law; 

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1 ‘‘(C) agrees, as a condition of the certifi2 cation described in subparagraph (D), to fur3 nish to the State or Secretary any data re4 quired as part of ongoing monitoring of the or5 ganization’s provision of services, including en6 counter data, clinical outcomes data, quality 

7 data, and such other data as the State or Sec8 retary may require; and 

9 ‘‘(D) has been certified by a State as meet10 ing the criteria established by the Secretary 

11 pursuant to subsection (a) of section 223 of the 

12 Protecting Access to Medicare Act as of Janu13 ary 1, 2024, and any subsequent updates to 

14 such criteria, regardless of whether the State is 

15 carrying out a demonstration program under 

16 this title under subsection (d) of such section.’’. 

17 (b) EFFECTIVE DATE.—The amendments made by 

18 this section shall apply with respect to medical assistance 

19 furnished on or after January 1, 2024. 

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1 TITLE II—REDUCING PRESCRIP2 TION DRUG COSTS UNDER 

3 MEDICARE AND MEDICAID 

4 SEC. 201. ASSURING PHARMACY ACCESS AND CHOICE FOR 

5 MEDICARE BENEFICIARIES. 

6 (a) IN GENERAL.—Section 1860D–4(b)(1) of the So7 cial Security Act (42 U.S.C. 1395w–104(b)(1)) is amend8 ed by striking subparagraph (A) and inserting the fol9 lowing: 

10 ‘‘(A) IN GENERAL.— 

11 ‘‘(i) PARTICIPATION OF ANY WILLING

12 PHARMACY.—A PDP sponsor offering a 

13 prescription drug plan shall permit any 

14 pharmacy that meets the standard contract 

15 terms and conditions under such plan to 

16 participate as a network pharmacy of such 

17 plan. 

18 ‘‘(ii) CONTRACT TERMS AND CONDI19 TIONS.— 

20 ‘‘(I) IN GENERAL.—For plan 

21 years beginning on or after January 

22 1, 2028, in accordance with clause (i), 

23 contract terms and conditions offered 

24 by such PDP sponsor shall be reason25 able and relevant according to standVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00052 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 ards established by the Secretary 

2 under subclause (II). 

3 ‘‘(II) STANDARDS.—Not later 

4 than the first Monday in April of 

5 2027, the Secretary shall establish 

6 standards for reasonable and relevant 

7 contract terms and conditions for pur8 poses of this clause. 

9 ‘‘(III) REQUEST FOR INFORMA10 TION.—Not later than January 1, 

11 2025, for purposes of establishing the 

12 standards under subclause (II), the 

13 Secretary shall issue a request for in14 formation to seek input on trends in 

15 prescription drug plan and network 

16 pharmacy contract terms and condi17 tions, current prescription drug plan 

18 and network pharmacy contracting 

19 practices, whether pharmacy reim20 bursement and dispensing fees under 

21 this part cover pharmacy ingredient 

22 and operational costs, areas in current 

23 regulations or program guidance re24 lated to contracting between prescrip25 tion drug plans and network pharVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 macies requiring clarification or addi2 tional specificity, factors for consider3 ation in determining the reasonable4 ness and relevance of contract terms 

5 and conditions between prescription 

6 drug plans and network pharmacies, 

7 and other issues determined appro8 priate by the Secretary.’’. 

9 (b) TREATMENT OF ESSENTIAL RETAIL PHAR10 MACIES.—Section 1860D–4(b)(1)(C) of the Social Secu11 rity Act (42 U.S.C. 1395w–104(b)(1)(C)) is amended by 

12 adding at the end the following new clause: 

13 ‘‘(v) ESSENTIAL RETAIL PHAR14 MACIES.— 

15 ‘‘(I) IN GENERAL.—For plan 

16 years beginning on or after January 

17 1, 2028, a PDP sponsor of a prescrip18 tion drug plan that has preferred 

19 pharmacies in its network shall con20 tract with, as preferred pharmacies in 

21 such plan’s network, at least— 

22 ‘‘(aa) 80 percent of essential 

23 retail pharmacies (as defined in 

24 subclause (III)) in such plan’s 

25 service area that are independent 

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1 community pharmacies (as de2 fined in subclause (V)(bb)); and 

3 ‘‘(bb) 50 percent of essential 

4 retail pharmacies in such plan’s 

5 service area not described in item 

6 (aa). 

7 ‘‘(II) TOTAL REIMBURSEMENT

8 FOR ESSENTIAL RETAIL PHARMACIES

9 THAT ARE INDEPENDENT COMMUNITY

10 PHARMACIES.—For plan years begin11 ning on or after January 1, 2028, 

12 total reimbursement (as defined in 

13 subclause (V)(dd)) paid by a PDP 

14 sponsor to an essential retail phar15 macy that is an independent commu16 nity pharmacy for a covered part D 

17 drug shall not be lower than— 

18 ‘‘(aa) in the case where Na19 tional Average Drug Acquisition 

20 Cost information for such drug 

21 for retail community pharmacies 

22 or applicable non-retail commu23 nity pharmacies has been avail24 able under section 1927(f) for at 

25 least one full plan year— 

56 

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1 ‘‘(AA) if such informa2 tion is available for such 

3 drug for retail community 

4 pharmacies, the average Na5 tional Average Drug Acqui6 sition Cost for such drug for 

7 retail community pharmacies 

8 for the most recent plan 

9 year for which such informa10 tion is available; 

11 ‘‘(BB) in the case 

12 where such information for 

13 retail community pharmacies 

14 is not available, the average 

15 National Average Drug Ac16 quisition Cost for such drug 

17 for applicable non-retail 

18 pharmacies for the most re19 cent plan year for which 

20 such information is avail21 able; 

22 ‘‘(bb) in the case where Na23 tional Average Drug Acquisition 

24 Cost information for such drug 

25 under section 1927(f) is not 

57 

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1 available for retail community 

2 pharmacies or applicable non-re3 tail pharmacies, the wholesale ac4 quisition cost (as defined in sec5 tion 1847A(c)(6)(B)) for such 

6 drug; and 

7 ‘‘(cc) in the case where Na8 tional Average Drug Acquisition 

9 Cost information under section 

10 1927(f) is available for such drug 

11 and ending on the date such sur12 vey information has been avail13 able for such drug but has not 

14 been available for a full plan 

15 year— 

16 ‘‘(AA) the most recent 

17 National Average Drug Ac18 quisition Cost for such drug 

19 for retail community phar20 macies, if available; or 

21 ‘‘(BB) if the informa22 tion specified in subitem 

23 (AA) is not available, the 

24 most recent National Aver25 age Drug Acquisition Cost 

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1 for such drug for applicable 

2 non-retail pharmacies. 

3 ‘‘(III) DEFINITION OF ESSEN4 TIAL RETAIL PHARMACY.—In this 

5 clause, the term ‘essential retail phar6 macy’ means, with respect to a plan 

7 year, a retail pharmacy that— 

8 ‘‘(aa) is not an affiliate of a 

9 pharmacy benefit manager or 

10 PDP sponsor; 

11 ‘‘(bb) is located in a medi12 cally underserved area (as des13 ignated pursuant to section 

14 330(b)(3)(A) of the Public 

15 Health Service Act); and 

16 ‘‘(cc) is designated as an es17 sential retail pharmacy by the 

18 Secretary for such plan year 

19 under subclause (IV). 

20 ‘‘(IV) DESIGNATION OF ESSEN21 TIAL RETAIL PHARMACIES.— 

22 ‘‘(aa) IN GENERAL.—For 

23 each plan year (beginning with 

24 plan year 2028), the Secretary 

25 shall designate pharmacies that 

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1 meet the requirements specified 

2 in items (aa) and (bb) of sub3 clause (III) as essential retail 

4 pharmacies, in accordance with 

5 this subclause. 

6 ‘‘(bb) REQUIRED SUBMIS7 SIONS FROM PDP SPONSORS.— 

8 For each plan year beginning 

9 with plan year 2028, each PDP 

10 sponsor offering a prescription 

11 drug plan shall submit to the 

12 Secretary, for the purposes of de13 termining retail pharmacies that 

14 do not meet the requirement 

15 specified in item (aa) of sub16 clause (III), a list of any retail 

17 pharmacy that is an affiliate of 

18 such sponsor, subject to time, 

19 manner, and form requirements 

20 established by the Secretary. 

21 ‘‘(cc) PUBLICATION.—Not 

22 later than one month prior to the 

23 start of each plan year (begin24 ning with plan year 2028), the 

25 Secretary shall list, on a publicly 

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1 available website of the Centers 

2 for Medicare & Medicaid Serv3 ices, all pharmacies designated as 

4 essential retail pharmacies for 

5 such plan year. 

6 ‘‘(dd) REVOCATION OF DES7 IGNATION.—In the case where, 

8 during a plan year, the Secretary 

9 determines that a pharmacy no 

10 longer meets the requirements 

11 for designation as an essential re12 tail pharmacy, the Secretary may 

13 revoke such designation for such 

14 pharmacy, as determined appro15 priate by the Secretary. 

16 ‘‘(V) OTHER DEFINITIONS.—In 

17 this clause: 

18 ‘‘(aa) AFFILIATE.—The 

19 term ‘affiliate’ means any entity 

20 that is owned by, controlled by, 

21 or related under a common own22 ership structure with a pharmacy 

23 benefit manager or PDP sponsor 

24 or that acts as a contractor or 

25 agent to such pharmacy benefit 

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1 manager or PDP sponsor, if such 

2 contractor or agent performs any 

3 of the functions described in item 

4 (cc). 

5 ‘‘(bb) INDEPENDENT COM6 MUNITY PHARMACY.—The term 

7 ‘independent community phar8 macy’ means a retail pharmacy, 

9 including a pharmacy that is as10 sociated with a franchise or a 

11 pharmacy services administrative 

12 organization, that has fewer than 

13 4 locations and is not affiliated 

14 with any person or entity other 

15 than its owners. 

16 ‘‘(cc) PHARMACY BENEFIT

17 MANAGER.—The term ‘pharmacy 

18 benefit manager’ means any per19 son or entity that, either directly 

20 or through an intermediary, acts 

21 as a price negotiator or group 

22 purchaser on behalf of a PDP 

23 sponsor or prescription drug 

24 plan, or manages the prescription 

25 drug benefits provided by such 

62 

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1 sponsor or plan, including the 

2 processing and payment of claims 

3 for prescription drugs, the per4 formance of drug utilization re5 view, the processing of drug prior 

6 authorization requests, the adju7 dication of appeals or grievances 

8 related to the prescription drug 

9 benefit, contracting with network 

10 pharmacies, controlling the cost 

11 of covered part D drugs, or the 

12 provision of related services. 

13 Such term includes any person or 

14 entity that carries out one or 

15 more of the activities described in 

16 the preceding sentence, irrespec17 tive of whether such person or 

18 entity identifies itself as a ‘phar19 macy benefit manager’. 

20 ‘‘(dd) TOTAL REIMBURSE21 MENT.—The term ‘total reim22 bursement’ means, with respect 

23 to a covered part D drug, the ne24 gotiated price (as defined in sec25 tion 1860D–2(d)(1)(B)) plus any 

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1 incentive payments paid by the 

2 PDP sponsor to such essential 

3 retail pharmacy that is an inde4 pendent community pharmacy 

5 net of any fees, pharmacy price 

6 concessions, discounts, or any 

7 other forms of remuneration paid 

8 by such pharmacy and furnished 

9 by such PDP sponsor under sec10 tion 1860D–2(f)(4).’’. 

11 (c) ENFORCEMENT.— 

12 (1) IN GENERAL.—Section 1860D–4(b)(1) of 

13 the Social Security Act (42 U.S.C. 1395w– 

14 104(b)(1)) is amended by adding at the end the fol15 lowing new subparagraph: 

16 ‘‘(F) ENFORCEMENT OF STANDARDS FOR

17 REASONABLE AND RELEVANT CONTRACT TERMS

18 AND CONDITIONS AND ESSENTIAL RETAIL

19 PHARMACY PROTECTIONS.— 

20 ‘‘(i) ALLEGATION SUBMISSION PROC21 ESS.— 

22 ‘‘(I) IN GENERAL.—Not later 

23 than January 1, 2028, the Secretary 

24 shall establish a process through 

25 which a pharmacy may submit an alVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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•S 3430 RS

1 legation of a violation by a PDP spon2 sor offering a prescription drug plan 

3 of— 

4 ‘‘(aa) the standards for rea5 sonable and relevant contract 

6 terms and conditions under sub7 paragraph (A)(ii); or 

8 ‘‘(bb) the requirements for 

9 total reimbursement for essential 

10 retail pharmacies that are inde11 pendent community pharmacies 

12 under subparagraph (C)(v)(II). 

13 ‘‘(II) FREQUENCY OF SUBMIS14 SION.— 

15 ‘‘(aa) VIOLATIONS OF REA16 SONABLE AND RELEVANT CON17 TRACT TERMS AND CONDI18 TIONS.— 

19 ‘‘(AA) IN GENERAL.— 

20 Except as provided in 

21 subitem (BB), the allegation 

22 submission process under 

23 this clause shall allow phar24 macies to submit any allega25 tions of violations described 

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1 in item (aa) of subclause (I) 

2 not more frequently than 

3 once per plan year per con4 tract between a pharmacy 

5 and a PDP sponsor. 

6 ‘‘(BB) ALLEGATIONS

7 RELATING TO CONTRACT

8 CHANGES.—In the case 

9 where a contract is amended 

10 or otherwise updated fol11 lowing the submission of al12 legations by a pharmacy 

13 with respect to such contract 

14 and plan year, the allegation 

15 submission process under 

16 this clause shall allow such 

17 pharmacy to submit an addi18 tional allegation related to 

19 those changes with respect 

20 to such contract and plan 

21 year. 

22 ‘‘(CC) SUBMISSIONS.— 

23 Submissions of any allega24 tions under this item shall 

25 be separate from any subVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
66 

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1 missions under item (bb) 

2 and may include multiple al3 legations of such violations. 

4 ‘‘(bb) VIOLATIONS OF ES5 SENTIAL RETAIL PHARMACY PRO6 TECTIONS.— 

7 ‘‘(AA) IN GENERAL.— 

8 The allegation submission 

9 process under this clause 

10 shall allow essential retail 

11 pharmacies that are inde12 pendent community phar13 macies to submit any allega14 tions of violations described 

15 in item (bb) of subclause (I) 

16 once per calendar quarter. 

17 ‘‘(BB) SUBMISSIONS.— 

18 Submissions of any allega19 tions under this item shall 

20 be separate from any sub21 missions under item (aa) 

22 and may include multiple al23 legations of such violations. 

24 ‘‘(III) ACCESS TO RELEVANT

25 DOCUMENTS AND MATERIALS.—A 

67 

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1 PDP sponsor subject to an allegation 

2 under this clause— 

3 ‘‘(aa) shall provide docu4 ments or materials, as specified 

5 by the Secretary, including con6 tract offers made by such spon7 sor to such pharmacy or cor8 respondence related to such of9 fers, to the Secretary at a time 

10 and in a form and manner speci11 fied by the Secretary; and 

12 ‘‘(bb) shall not prohibit or 

13 otherwise limit the ability of a 

14 pharmacy to submit such docu15 ments or materials to the Sec16 retary for the purpose of submit17 ting an allegation or providing 

18 evidence for such an allegation 

19 under this clause. 

20 ‘‘(IV) STANDARDIZED TEM21 PLATE.—The Secretary shall establish 

22 separate standardized templates for 

23 pharmacies to use for the submission 

24 of allegations described in items (aa) 

25 and (bb) of subclause (I). Each such 

68 

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1 template shall require that the sub2 mission include a certification by the 

3 pharmacy that the information in4 cluded is accurate, complete, and true 

5 to the best of the knowledge, informa6 tion, and belief of such pharmacy. 

7 ‘‘(V) PREVENTING FRIVOLOUS

8 ALLEGATIONS.—In the case where the 

9 Secretary determines that a pharmacy 

10 has submitted frivolous allegations 

11 under this clause on a routine basis, 

12 the Secretary may temporarily pro13 hibit such pharmacy from using the 

14 allegation submission process under 

15 this clause, as determined appropriate 

16 by the Secretary. 

17 ‘‘(VI) EXEMPTION FROM FREE18 DOM OF INFORMATION ACT.—Allega19 tions submitted under this clause shall 

20 be exempt from disclosure under sec21 tion 552 of title 5, United States 

22 Code. 

23 ‘‘(ii) INVESTIGATION.—The Secretary 

24 shall investigate, as determined approVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00068 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 priate by the Secretary, allegations sub2 mitted pursuant to clause (i). 

3 ‘‘(iii) ENFORCEMENT.— 

4 ‘‘(I) REASONABLE AND REL5 EVANT CONTRACT TERMS AND CONDI6 TIONS.—In the case where the Sec7 retary determines that a PDP sponsor 

8 offering a prescription drug plan has 

9 violated the standards for reasonable 

10 and relevant contract terms and con11 ditions under subparagraph (A)(ii), 

12 the Secretary shall use existing au13 thorities under sections 1857(g) and 

14 1860D–12(b)(3)(E) to impose civil 

15 monetary penalties or take other en16 forcement actions. 

17 ‘‘(II) ESSENTIAL RETAIL PHAR18 MACY PROTECTIONS.—In the case 

19 where the Secretary determines that a 

20 PDP sponsor offering a prescription 

21 drug plan has violated the require22 ments for total reimbursement for es23 sential retail pharmacies that are 

24 independent community pharmacies 

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1 under subparagraph (C)(v)(II), the 

2 Secretary shall— 

3 ‘‘(aa) if the amount of total 

4 reimbursement paid by the spon5 sor to an essential retail phar6 macy that is an independent 

7 community pharmacy for a cov8 ered part D drug was less than 

9 the amount of total reimburse10 ment required to be paid to the 

11 pharmacy under subparagraph 

12 (C)(v)(II) for such drug, require 

13 the PDP sponsor to pay to the 

14 pharmacy an amount equal to 

15 the difference between such 

16 amounts; and 

17 ‘‘(bb) use existing authori18 ties under section 1857(g) and 

19 1860D–12(b)(3)(E) to impose 

20 civil monetary penalties or take 

21 other enforcement actions. 

22 ‘‘(III) APPLICATION OF CIVIL

23 MONETARY PENALTIES.—The provi24 sions of section 1128A (other than 

25 subsections (a) and (b)) shall apply to 

71 

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1 a civil monetary penalty under this 

2 clause in the same manner as such 

3 provisions apply to a penalty or pro4 ceeding under section 1128A(a). 

5 ‘‘(iv) DEFINITIONS.—In this subpara6 graph, the terms ‘essential retail phar7 macy’, ‘independent community pharmacy’, 

8 and ‘total reimbursement’ have the mean9 ing given those terms in subparagraph 

10 (C)(v).’’. 

11 (2) CONFORMING AMENDMENT.—Section 

12 1857(g)(1) of the Social Security Act (42 U.S.C. 

13 1395w–27(g)(1)) is amended— 

14 (A) in subparagraph (J), by striking ‘‘or’’ 

15 after the semicolon; 

16 (B) by redesignating subparagraph (K) as 

17 subparagraph (L); 

18 (C) by inserting after subparagraph (J), 

19 the following new subparagraph: 

20 ‘‘(K) fails to comply with— 

21 ‘‘(i) the standards for reasonable and 

22 relevant contract terms and conditions 

23 under subparagraph (A)(ii) of section 

24 1860D–4(b)(1); or 

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1 ‘‘(ii) the requirements for total reim2 bursement for essential retail pharmacies 

3 that are independent community phar4 macies under subparagraph (C)(v)(II) of 

5 such section; or’’; 

6 (D) in subparagraph (L), as redesignated 

7 by subparagraph (B), by striking ‘‘through (J)’’ 

8 and inserting ‘‘through (K)’’; and 

9 (E) in the flush matter following subpara10 graph (L), as so redesignated, by striking ‘‘sub11 paragraphs (A) through (K)’’ and inserting 

12 ‘‘subparagraphs (A) through (L)’’. 

13 (d) ACCOUNTABILITY OF PHARMACY BENEFIT MAN14 AGERS FOR VIOLATIONS OF REASONABLE AND RELEVANT

15 CONTRACT TERMS AND CONDITIONS AND ESSENTIAL RE16 TAIL PHARMACY PROTECTIONS.— 

17 (1) IN GENERAL.—Section 1860D–12(b) of the 

18 Social Security Act (42 U.S.C. 1395w–112) is 

19 amended by adding at the end the following new 

20 paragraph: 

21 ‘‘(9) ACCOUNTABILITY OF PHARMACY BENEFIT

22 MANAGERS FOR VIOLATIONS OF REASONABLE AND

23 RELEVANT CONTRACT TERMS AND CONDITIONS AND

24 ESSENTIAL RETAIL PHARMACY PROTECTIONS.—For 

25 plan years beginning on or after January 1, 2028, 

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1 each contract entered into with a PDP sponsor 

2 under this part with respect to a prescription drug 

3 plan offered by such sponsor shall provide that any 

4 pharmacy benefit manager acting on behalf of such 

5 sponsor has a written agreement with the PDP 

6 sponsor under which the pharmacy benefit manager 

7 agrees to reimburse the PDP sponsor for any 

8 amounts paid by such sponsor under subclause (I) 

9 or (II) of section 1860D–4(b)(1)(F)(iii) as a result 

10 of a violation described in such subclause (I) or (II) 

11 if such violation is related to a responsibility dele12 gated to the pharmacy benefit manager by such 

13 PDP sponsor.’’. 

14 (2) MA–PD PLANS.—Section 1857(f)(3) of the 

15 Social Security Act (42 U.S.C. 1395w–27(f)(3)) is 

16 amended by adding at the end the following new 

17 subparagraph: 

18 ‘‘(F) ACCOUNTABILITY OF PHARMACY

19 BENEFIT MANAGERS FOR VIOLATIONS OF REA20 SONABLE AND RELEVANT CONTRACT TERMS

21 AND CONDITIONS AND ESSENTIAL RETAIL

22 PHARMACY PROTECTIONS.—For plan years be23 ginning on or after January 1, 2028, section 

24 1860D–12(b)(9).’’. 

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1 (e) Section 1860D–42 of the Social Security Act (42 

2 U.S.C. 1395w–152) is amended by adding at the end the 

3 following new subsection: 

4 ‘‘(e) BRIEFING AND REPORTING REQUIREMENTS RE5 LATED TO PHARMACY PRICE CONCESSIONS UNDER THIS

6 PART.— 

7 ‘‘(1) BRIEFING REQUIREMENTS.—The Sec8 retary shall provide periodic briefings to the Com9 mittee on Finance of the Senate, the Committee on 

10 Ways and Means of the House of Representatives, 

11 and the Committee on Energy and Commerce of the 

12 House of Representatives, beginning not later than 

13 90 days after the date of enactment of this sub14 section, on implementation, oversight, data collec15 tion, and enforcement activities related to the ad16 ministration of the ‘Pharmacy Price Concessions to 

17 Drug Prices at the Point of Sale’ provisions codified 

18 under sections 423.100 and 423.2305 of title 42, 

19 Code of Federal Regulations (or any successor regu20 lations), as published in the Federal Register on 

21 May 9, 2022, in the final rule entitled ‘Medicare 

22 Program; Contract Year 2023 Policy and Technical 

23 Changes to the Medicare Advantage and Medicare 

24 Prescription Drug Benefit Programs; Policy and 

25 Regulatory Revisions in Response to the COVID–19 

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1 Public Health Emergency; Additional Policy and 

2 Regulatory Revisions in Response to the COVID–19 

3 Public Health Emergency’. 

4 ‘‘(2) REPORTING REQUIREMENTS.—Beginning 

5 not later than 90 days after the date of enactment 

6 of this subsection, and at least once every plan year 

7 beginning thereafter (through plan year 2027), the 

8 Secretary shall develop and submit to Congress re9 ports on the activities specified in paragraph (1). 

10 ‘‘(3) CONTENTS FOR BRIEFINGS AND RE11 PORTS.—The briefings required under paragraph (1) 

12 and reports required under paragraph (2) shall in13 clude information on— 

14 ‘‘(A) implementation, oversight, data col15 lection, and enforcement activities related to 

16 contract terms and conditions among PDP 

17 sponsors, MA organizations, and pharmacies for 

18 the purpose of establishing or maintaining 

19 pharmacy network participation or preferred 

20 pharmacy network participation; 

21 ‘‘(B) patterns and trends in such terms 

22 and conditions, to the extent applicable; 

23 ‘‘(C) implementation, oversight, and en24 forcement activities and developments related to 

25 assuring pharmacy access under section 

76 

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1 1860D–4(b)(1), along with applicable regula2 tions and program instruction or guidance; 

3 ‘‘(D) plans, strategies, initiatives, or pro4 grammatic changes undertaken by the Sec5 retary to prevent, mitigate, or otherwise address 

6 stakeholder feedback and concerns related to 

7 convenient pharmacy access for beneficiaries 

8 under this part; and 

9 ‘‘(E) other issues determined appropriate 

10 by the Secretary.’’. 

11 (f) FUNDING.—In addition to amounts otherwise 

12 available, there is appropriated to the Centers for Medi13 care & Medicaid Services Program Management Account, 

14 out of any money in the Treasury not otherwise appro15 priated, $250,000,000 for fiscal year 2024, to remain 

16 available until expended, to carry out the amendment 

17 made by this section. 

18 SEC. 202. ENSURING ACCURATE PAYMENTS TO PHAR19 MACIES UNDER MEDICAID. 

20 (a) IN GENERAL.—Section 1927(f) of the Social Se21 curity Act (42 U.S.C. 1396r–8(f)) is amended— 

22 (1) in paragraph (1)(A)— 

23 (A) by redesignating clause (ii) as clause 

24 (iii); and 

77 

•S 3430 RS

1 (B) by striking ‘‘and’’ after the semicolon 

2 at the end of clause (i) and all that precedes it 

3 through ‘‘(1)’’ and inserting the following: 

4 ‘‘(1) DETERMINING PHARMACY ACTUAL ACQUI5 SITION COSTS.—The Secretary shall conduct a sur6 vey of retail community pharmacy drug prices and 

7 applicable non-retail pharmacy drug prices to deter8 mine national average drug acquisition cost bench9 marks as follows: 

10 ‘‘(A) USE OF VENDOR.—The Secretary 

11 may contract services for— 

12 ‘‘(i) with respect to retail community 

13 pharmacies, the determination of retail 

14 survey prices of the national average drug 

15 acquisition cost for covered outpatient 

16 drugs that represent a nationwide average 

17 of consumer purchase prices for such 

18 drugs, net of all discounts and rebates (to 

19 the extent any information with respect to 

20 such discounts and rebates is available) 

21 based on a monthly survey of such phar22 macies; 

23 ‘‘(ii) with respect to applicable non-re24 tail pharmacies— 

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1 ‘‘(I) the determination of survey 

2 prices, separate from the survey prices 

3 described in clause (i), of the non-re4 tail national average drug acquisition 

5 cost for covered outpatient drugs that 

6 represent a nationwide average of con7 sumer purchase prices for such drugs, 

8 net of all discounts and rebates (to 

9 the extent any information with re10 spect to such discounts and rebates is 

11 available) based on a monthly survey 

12 of such pharmacies; and 

13 ‘‘(II) at the discretion of the Sec14 retary, for each type of applicable 

15 non-retail pharmacy (as identified 

16 pursuant to the type indicators estab17 lished by the Secretary under sub18 section (k)(12)(B)(ii)), the determina19 tion of survey prices, separate from 

20 the survey prices described in clause 

21 (i) or subclause (I) of this clause, of 

22 the national average drug acquisition 

23 cost for such type of pharmacy for 

24 covered outpatient drugs that rep25 resent a nationwide average of conVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00078 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 sumer purchase prices for such drugs, 

2 net of all discounts and rebates (to 

3 the extent any information with re4 spect to such discounts and rebates is 

5 available) based on a monthly survey 

6 of such pharmacies; and’’; 

7 (2) in subparagraph (D) of paragraph (1), by 

8 striking clauses (ii) and (iii) and inserting the fol9 lowing: 

10 ‘‘(ii) The vendor must update the Sec11 retary no less often than monthly on the 

12 survey prices for covered outpatient drugs. 

13 ‘‘(iii) The vendor must differentiate, 

14 in collecting and reporting survey data, the 

15 relevant pharmacy type indicator for all 

16 cost information collected, including wheth17 er a pharmacy is owned by, operated by, or 

18 otherwise affiliated with a pharmacy ben19 efit manager and whether a pharmacy is a 

20 retail community pharmacy or an applica21 ble non-retail pharmacy, and, in the case 

22 of an applicable non-retail pharmacy, 

23 which type of applicable non-retail phar24 macy (as identified pursuant to the type 

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1 indicators established by the Secretary 

2 under subsection (k)(12)(B)(ii)) it is.’’; 

3 (3) by adding at the end of paragraph (1) the 

4 following: 

5 ‘‘(F) SURVEY REPORTING.—In order to 

6 meet the requirement of section 1902(a)(54), a 

7 State shall require that any retail community 

8 pharmacy or applicable non-retail pharmacy in 

9 the State that receives any payment, reimburse10 ment, administrative fee, discount, or rebate re11 lated to the dispensing of covered outpatient 

12 drugs to individuals receiving benefits under 

13 this title, regardless of whether such payment, 

14 reimbursement, administrative fee, discount, or 

15 rebate is received from the State or a managed 

16 care entity or other specified entity (as such 

17 terms are defined in section 1903(m)(9)(D)) di18 rectly or from a pharmacy benefit manager or 

19 another entity that has a contract with the 

20 State or a managed care entity or other speci21 fied entity (as so defined), shall respond to sur22 veys conducted under this paragraph. 

23 ‘‘(G) SURVEY INFORMATION.—Information 

24 on national drug acquisition prices obtained 

25 under this paragraph shall be made publicly 

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1 available and shall include at least the fol2 lowing: 

3 ‘‘(i) The monthly response rate to the 

4 survey including a list of pharmacies not in 

5 compliance with subparagraph (F). 

6 ‘‘(ii) The sampling frame and number 

7 of pharmacies sampled monthly. 

8 ‘‘(iii) Information on price concessions 

9 to the pharmacy, including discounts, re10 bates, and other price concessions, to the 

11 extent that such information may be pub12 licly released and has been collected by the 

13 Secretary as part of the survey. 

14 ‘‘(H) PENALTIES.—The Secretary, in con15 sultation with the Office of the Inspector Gen16 eral of the Department of Health and Human 

17 Services, shall enforce the provisions of this 

18 paragraph with respect to a pharmacy through 

19 the establishment of appropriate civil monetary 

20 penalties, which may be assessed with respect 

21 to each violation or survey non-response, and 

22 with respect to each non-compliant pharmacy 

23 (including a pharmacy that is part of a chain), 

24 until compliance with this paragraph has been 

25 completed. The provisions of section 1128A 

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1 (other than subsections (a) and (b)) shall apply 

2 to a civil money penalty under the preceding 

3 sentence in the same manner as such provisions 

4 apply to a civil money penalty or proceeding 

5 under section 1128A(a). 

6 ‘‘(I) LIMITATION ON USE OF APPLICABLE

7 NON-RETAIL PHARMACY PRICING INFORMA8 TION.—No State shall use pricing information 

9 reported by applicable non-retail pharmacies 

10 under paragraph (1)(A)(ii) to develop or inform 

11 reimbursement rates for retail community phar12 macies.’’; 

13 (4) in paragraph (2)— 

14 (A) in subparagraph (A), by inserting ‘‘, 

15 including payment rates under managed care 

16 entities or other specified entities (as such 

17 terms are defined in section 1903(m)(9)(D)),’’ 

18 after ‘‘under this title’’; and 

19 (B) in subparagraph (B), by inserting 

20 ‘‘and the basis for such dispensing fees’’ before 

21 the semicolon; 

22 (5) by redesignating paragraph (4) as para23 graph (5); 

24 (6) by inserting after paragraph (3) the fol25 lowing new paragraph: 

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1 ‘‘(4) OVERSIGHT.— 

2 ‘‘(A) IN GENERAL.—The Inspector General 

3 of the Department of Health and Human Serv4 ices shall conduct periodic studies of the survey 

5 data reported under this subsection, as appro6 priate, including with respect to substantial 

7 variations in acquisition costs or other applica8 ble costs, as well as with respect to how internal 

9 transfer prices and related party transactions 

10 may influence the costs reported by pharmacies 

11 affiliated with pharmacy benefit managers, 

12 wholesalers, distributors, and other entities that 

13 acquire covered outpatient drugs relative to 

14 costs reported by pharmacies not affiliated with 

15 such entities. The Inspector General shall pro16 vide periodic updates to Congress on the results 

17 of such studies, as appropriate, in a manner 

18 that does not disclose trade secrets or other 

19 proprietary information. 

20 ‘‘(B) APPROPRIATION.—There is appro21 priated to the Inspector General of the Depart22 ment of Health and Human Services, out of 

23 any money in the Treasury not otherwise ap24 propriated, $5,000,000 for fiscal year 2024, to 

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1 remain available until expended, to carry out 

2 this paragraph.’’; and 

3 (7) in paragraph (5), as so redesignated, by in4 serting ‘‘, and $9,000,000 for fiscal year 2024 and 

5 each fiscal year thereafter,’’ after ‘‘2010’’. 

6 (b) DEFINITIONS.—Section 1927(k) of the Social Se7 curity Act (42 U.S.C. 1396r–8(k)) is amended by adding 

8 the following— 

9 ‘‘(12) APPLICABLE NON-RETAIL PHARMACY.— 

10 ‘‘(A) IN GENERAL.—The term ‘applicable 

11 non-retail pharmacy’ means a pharmacy that is 

12 licensed as a pharmacy by the State and that 

13 is not a retail community pharmacy, including 

14 a pharmacy that dispenses prescription medica15 tions to patients primarily through mail and 

16 specialty pharmacies. Such term does not in17 clude nursing home pharmacies, long-term care 

18 facility pharmacies, hospital pharmacies, clinics, 

19 charitable or not-for-profit pharmacies, govern20 ment pharmacies, or low dispensing pharmacies 

21 (as defined by the Secretary). 

22 ‘‘(B) IDENTIFICATION OF APPLICABLE

23 NON-RETAIL PHARMACIES.— 

24 ‘‘(i) IN GENERAL.—For purposes of 

25 subsection (f), the Secretary shall, not 

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1 later than January 1, 2025, in consulta2 tion with stakeholders as appropriate, issue 

3 guidance specifying pharmacies that meet 

4 the definition of applicable non-retail phar5 macies and that will be subject to the sur6 vey requirements under subsection (f)(1). 

7 ‘‘(ii) INCLUSION OF PHARMACY TYPE

8 INDICATORS.—The guidance promulgated 

9 under clause (i) shall include pharmacy 

10 type indicators to distinguish between dif11 ferent types of applicable non-retail phar12 macies, such as pharmacies that dispense 

13 prescriptions primarily through the mail 

14 and pharmacies that dispense prescriptions 

15 that require special handling or distribu16 tion. An applicable non-retail pharmacy 

17 may be identified through multiple phar18 macy type indicators. 

19 ‘‘(13) PHARMACY BENEFIT MANAGER.—The 

20 term ‘pharmacy benefit manager’ means any person 

21 or entity that, either directly or through an inter22 mediary, acts as a price negotiator or group pur23 chaser on behalf of a State, managed care entity or 

24 other specified entity (as such terms are defined in 

25 section 1903(m)(9)(D)), or manages the prescription 

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1 drug benefits provided by such State, managed care 

2 entity, or other specified entity, including the proc3 essing and payment of claims for prescription drugs, 

4 the performance of drug utilization review, the proc5 essing of drug prior authorization requests, the man6 aging of appeals or grievances related to the pre7 scription drug benefits, contracting with pharmacies, 

8 controlling the cost of covered outpatient drugs, or 

9 the provision of services related thereto. Such term 

10 includes any person or entity that carries out 1 or 

11 more of the activities described in the preceding sen12 tence, irrespective of whether such person or entity 

13 calls itself a ‘pharmacy benefit manager’.’’. 

14 (c) EFFECTIVE DATE.—The amendments made by 

15 this section take effect on the first day of the first quarter 

16 that begins on or after the date that is 18 months after 

17 the date of enactment of this Act. 

18 SEC. 203. PROTECTING SENIORS FROM EXCESSIVE COST19 SHARING FOR CERTAIN MEDICINES. 

20 Section 1860D–2 of the Social Security Act (42 

21 U.S.C. 1395w–102) is amended— 

22 (1) in subsection (b)— 

23 (A) in paragraph (2)(A), in the matter 

24 preceding clause (i), by striking ‘‘and (9)’’ and 

25 inserting ‘‘, (9), (10), and (11)’’; and 

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1 (B) by adding at the end the following new 

2 paragraphs: 

3 ‘‘(10) TYING COST-SHARING TO NET PRICE FOR

4 CERTAIN MEDICATIONS.— 

5 ‘‘(A) IN GENERAL.—For plan years begin6 ning on or after January 1, 2028, for costs 

7 above the annual deductible specified in para8 graph (1) and below the annual out-of-pocket 

9 threshold specified in paragraph (4), any coin10 surance amount for a discount-eligible drug 

11 that is included on the plan’s formulary and 

12 subject to coinsurance rather than a copayment 

13 shall be calculated based on the net price of 

14 such discount-eligible drug. 

15 ‘‘(B) REPORTING TO THE SECRETARY.— 

16 For plan years beginning on or after January 

17 1, 2028, a PDP sponsor of a prescription drug 

18 plan and an MA organization offering an MA– 

19 PD plan shall annually submit to the Secretary, 

20 in a form and manner determined appropriate 

21 by the Secretary— 

22 ‘‘(i) approximate price concessions 

23 and net prices for each discount-eligible 

24 drug; and 

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1 ‘‘(ii) a written explanation of the 

2 methodology used to calculate such approx3 imate price concessions and net prices. 

4 ‘‘(C) REQUIREMENTS FOR APPROXIMATE

5 PRICE CONCESSIONS.— 

6 ‘‘(i) IN GENERAL.—Approximate price 

7 concessions submitted under subparagraph 

8 (B) shall comply with— 

9 ‘‘(I) the drug-specific threshold 

10 under clause (ii) for the applicable 

11 plan year; and 

12 ‘‘(II) the aggregate threshold 

13 under clause (iii) for the applicable 

14 plan year. 

15 ‘‘(ii) THRESHOLDS.— 

16 ‘‘(I) PLAN YEARS 2028 THROUGH

17 2032.—For plan years 2028 through 

18 2032— 

19 ‘‘(aa) the drug-specific 

20 threshold is 20 percent; and 

21 ‘‘(bb) the aggregate thresh22 old is 15 percent. 

23 ‘‘(II) SUBSEQUENT PLAN

24 YEARS.— 

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1 ‘‘(aa) IN GENERAL.—For 

2 plan years beginning with 2033, 

3 the Secretary may, as determined 

4 appropriate by the Secretary, ad5 just the drug-specific and aggre6 gate thresholds under this clause. 

7 ‘‘(bb) CONSIDERATIONS.—In 

8 making any such adjustments, 

9 the Secretary may consider his10 torical variations in expected and 

11 actual manufacturer price conces12 sions for covered part D drugs, 

13 factors that may result in manu14 facturer price concession uncer15 tainty or variation in a given 

16 plan year, PDP sponsor and MA 

17 organization behavioral re18 sponses, effects of precise manu19 facturer price concession disclo20 sures, beneficiary out-of-pocket 

21 costs, expenditures under this 

22 part, and other factors deter23 mined appropriate by the Sec24 retary. 

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1 ‘‘(cc) REQUIREMENTS.—In 

2 making any such adjustments, 

3 the Secretary shall ensure that 

4 the aggregate threshold for an 

5 applicable plan year is lower than 

6 the drug-specific threshold for 

7 such applicable plan year. 

8 ‘‘(dd) PUBLICATION.—The 

9 Secretary shall publish any ad10 justments to the drug-specific 

11 and aggregate thresholds under 

12 this clause no later than the first 

13 Monday of April of the year be14 fore the start of the plan year for 

15 which such adjusted thresholds 

16 are applicable. 

17 ‘‘(D) PUBLICATION OF DISCOUNT-ELIGI18 BLE DRUGS.—Not later than 15 months before 

19 the start of each plan year (beginning with plan 

20 year 2028), the Secretary shall publish on a 

21 publicly available website a list of the discount22 eligible drugs that apply with respect to such 

23 plan year (as determined by the Secretary 

24 under subparagraph (F)(iv)). 

25 ‘‘(E) ENFORCEMENT.— 

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1 ‘‘(i) MONITORING COMPLIANCE.—The 

2 Secretary, in consultation with the Office 

3 of the Inspector General, shall conduct 

4 periodic audits of prescription drug plans 

5 and MA–PD plans to monitor compliance 

6 with the requirements under this para7 graph. All information reported by a PDP 

8 sponsor or MA organization under this 

9 paragraph may be subject to audit by the 

10 Secretary and the Office of the Inspector 

11 General. 

12 ‘‘(ii) PENALTIES.— 

13 ‘‘(I) IN GENERAL.—A PDP spon14 sor or an MA organization that vio15 lates the requirements under this 

16 paragraph may be subject to civil 

17 monetary penalties, consistent with 

18 sections 1857(g) and 1860D– 

19 12(b)(3)(E), as determined appro20 priate by the Secretary. 

21 ‘‘(II) APPLICATION.—The provi22 sions of section 1128A (other than 

23 subsections (a) and (b)) shall apply to 

24 a civil monetary penalty under this 

25 clause in the same manner as such 

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1 provisions apply to a penalty or pro2 ceeding under section 1128A(a). 

3 ‘‘(F) DEFINITIONS.—In this paragraph: 

4 ‘‘(i) ACTUAL PRICE CONCESSIONS.— 

5 The term ‘actual price concessions’ means, 

6 with respect to a covered part D drug, the 

7 amount of manufacturer price concessions 

8 that the PDP sponsor or MA organization 

9 reports for such drug in the Detailed DIR 

10 Report (or successor report) for the appli11 cable plan year. 

12 ‘‘(ii) AGGREGATE THRESHOLD.—The 

13 term ‘aggregate threshold’ means the max14 imum percentage by which the total ap15 proximate price concessions for all dis16 count-eligible drugs may vary from the 

17 total actual manufacturer price concessions 

18 for all such discount-eligible drugs as re19 ported in the Detailed DIR Report (or suc20 cessor report) for the applicable plan year. 

21 ‘‘(iii) APPROXIMATE PRICE CONCES22 SIONS.—The term ‘approximate price con23 cessions’ means, with respect to a covered 

24 part D drug, the amount of price conces25 sions from manufacturers that the PDP 

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1 sponsor or MA organization estimates it 

2 will receive with respect to an applicable 

3 plan year, subject to the thresholds estab4 lished under subparagraph (C)(ii), and re5 flected in the net price. 

6 ‘‘(iv) DISCOUNT-ELIGIBLE DRUG.— 

7 ‘‘(I) IN GENERAL.—The term 

8 ‘discount-eligible drug’ means a cov9 ered part D drug (other than a cov10 ered part D drug described in para11 graph (8) or (9))— 

12 ‘‘(aa) that is in an applica13 ble category or class described in 

14 subclause (II); and 

15 ‘‘(bb) for which the aggre16 gate manufacturer price conces17 sions received by PDP sponsors 

18 and MA organizations (or phar19 macy benefit managers acting on 

20 behalf of such sponsors or orga21 nizations) for such drug are 

22 equal to or exceed 50 percent of 

23 aggregate gross covered prescrip24 tion drug costs for such drug in 

25 the most recent plan year for 

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1 which data is available, as deter2 mined by the Secretary based on 

3 previous submissions of Detailed 

4 DIR Reports (or successor re5 ports) or other relevant reporting 

6 from PDP sponsors or MA orga7 nizations. 

8 ‘‘(II) APPLICABLE CATEGORY OR

9 CLASS.—The applicable categories and 

10 classes described in this subclause are 

11 the following, as specified by the 

12 United States Pharmacopeia: 

13 ‘‘(aa) Anti-inflammatories 

14 (Inhaled Corticosteroids). 

15 ‘‘(bb) Bronchodilators, Anti16 cholinergic. 

17 ‘‘(cc) Bronchodilators, 

18 Sympathomimetic. 

19 ‘‘(dd) Respiratory tract 

20 agents. 

21 ‘‘(ee) Anticoagulants. 

22 ‘‘(ff) Cardiovascular agents. 

23 ‘‘(v) DRUG-SPECIFIC THRESHOLD.— 

24 The term ‘drug-specific threshold’ means 

25 the maximum percentage by which approxVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00094 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
95 

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1 imate price concessions with respect to a 

2 discount-eligible drug may vary from the 

3 actual manufacturer price concessions for 

4 such drug, as reported in the Detailed DIR 

5 Report (or successor report) for the appli6 cable plan year. 

7 ‘‘(vi) NET PRICE.—The term ‘net 

8 price’ means, with respect to a covered 

9 part D drug, the negotiated price of such 

10 drug, net of all approximate price conces11 sions (estimated on an average per-unit 

12 basis, as needed) not already reflected in 

13 the negotiated price for the applicable plan 

14 year. 

15 ‘‘(vii) MANUFACTURER PRICE CON16 CESSIONS.—The term ‘manufacturer price 

17 concessions’ means, with respect to a cov18 ered part D drug, rebates that the PDP 

19 sponsor or MA organization receives from 

20 manufacturers. 

21 ‘‘(G) NONAPPLICATION OF PAPERWORK

22 REDUCTION ACT.—Chapter 35 of title 44, 

23 United States Code, shall not apply to any data 

24 collection undertaken by the Secretary under 

25 this paragraph. 

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1 ‘‘(11) LIMITING COST-SHARING TO NET

2 PRICE.— 

3 ‘‘(A) IN GENERAL.—For plan years begin4 ning on or after January 1, 2028, the cost5 sharing (for costs above the annual deductible 

6 specified in paragraph (1)) for a covered part D 

7 drug (other than a covered part D drug de8 scribed in paragraph (8) or (9)) shall not ex9 ceed the negotiated price for such covered part 

10 D drug net of all price concessions (as defined 

11 in paragraph (10)(F)(v)), as reported in the 

12 Detailed DIR Report (or successor report) for 

13 the applicable plan year. 

14 ‘‘(B) ENFORCEMENT.— 

15 ‘‘(i) MONITORING COMPLIANCE.—The 

16 Secretary shall monitor compliance with 

17 the requirements under subparagraph (A) 

18 on an ongoing basis, including through 

19 periodic audits. 

20 ‘‘(ii) RETROACTIVE PENALTIES.— 

21 ‘‘(I) IN GENERAL.—A PDP spon22 sor or an MA organization that vio23 lates the requirements under subpara24 graph (A) may be subject to civil 

25 monetary penalties, consistent with 

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1 sections 1857(g) and 1860D– 

2 12(b)(3)(E), as determined appro3 priate by the Secretary. The Secretary 

4 may impose such penalties retro5 actively upon review of the Detailed 

6 DIR Report (or any successor report) 

7 with respect to a given plan year. 

8 ‘‘(II) APPLICATION.—The provi9 sions of section 1128A (other than 

10 subsections (a) and (b)) shall apply to 

11 a civil monetary penalty under this 

12 clause in the same manner as such 

13 provisions apply to a penalty or pro14 ceeding under section 1128A(a). 

15 ‘‘(12) GAO STUDY AND REPORT ON IMPLEMEN16 TATION AND EFFECTS OF COST-SHARING RELIEF

17 PROVISIONS.— 

18 ‘‘(A) STUDY.—The Comptroller General of 

19 the United States (in this paragraph referred to 

20 as the ‘Comptroller General’) shall conduct a 

21 study on certain effects of the implementation 

22 of the requirements specified under the provi23 sions of paragraphs (10) and (11). 

24 ‘‘(B) REPORT.—Once the data and infor25 mation needed to conduct the study described 

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1 in subparagraph (A) has become available and 

2 the Comptroller General has had sufficient op3 portunity to review and analyze such data and 

4 information, the Comptroller General shall de5 velop and publish a report on the findings of 

6 such study, including with respect to the fol7 lowing: 

8 ‘‘(i) Effects on enrollee cost-sharing, 

9 utilization and adherence, formulary cov10 erage and placement, and utilization man11 agement with respect to affected covered 

12 part D drugs (discount-eligible drugs and 

13 covered part D drugs for which, prior to 

14 implementation of such provisions, cost15 sharing exceeded net price for some bene16 ficiaries). 

17 ‘‘(ii) Changes to pharmacy reimburse18 ment methodologies and levels, if any, with 

19 respect to discount-eligible drugs. 

20 ‘‘(iii) Changes in manufacturer rebat21 ing levels (relative to gross costs) for dis22 count-eligible drugs. 

23 ‘‘(iv) Other behavioral responses by 

24 PDP sponsors, enrollees, manufacturers, 

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1 pharmacies, or other entities related to the 

2 implementation of such provisions. 

3 ‘‘(v) Effects of such provisions on en4 rollee premiums and Federal outlays. 

5 ‘‘(vi) Other issues determined appro6 priate by the Comptroller General. 

7 ‘‘(C) SUBSEQUENT REPORTS.—The Comp8 troller General may, as determined appropriate, 

9 conduct subsequent studies and produce subse10 quent reports with respect to the ongoing imple11 mentation and effects of the provisions of para12 graphs (10) and (11).’’; and 

13 (2) in subsection (c), by adding at the end the 

14 following new paragraphs: 

15 ‘‘(7) TYING COST-SHARING TO NET PRICE FOR

16 CERTAIN DRUGS.—The coverage is provided in ac17 cordance with subsection (b)(10). 

18 ‘‘(8) LIMITING COST-SHARING TO NET PRICE.— 

19 The coverage is provided in accordance with sub20 section (b)(11).’’. 

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1 TITLE III—MEDICAID EXPIRING 

2 PROVISIONS 

3 SEC. 301. DELAYING CERTAIN DISPROPORTIONATE SHARE 

4 HOSPITAL PAYMENT REDUCTIONS UNDER 

5 THE MEDICAID PROGRAM. 

6 Section 1923(f)(7)(A) of the Social Security Act (42 

7 U.S.C. 1396r–4(f)(7)(A)), as amended by section 2341 of 

8 title III of division B of the Continuing Appropriations 

9 Act, 2024 and Other Extensions Act (Public Law 118– 

10 15), is further amended— 

11 (1) in clause (i)— 

12 (A) in the matter preceding subclause (I), 

13 by striking ‘‘For the period beginning’’ and all 

14 that follows through ‘‘2027’’ and inserting ‘‘For 

15 each of fiscal years 2026 and 2027’’; and 

16 (B) in subclauses (I) and (II), by striking 

17 ‘‘or period’’ each place it appears; and 

18 (2) in clause (ii), by striking ‘‘for the period be19 ginning’’ and all that follows through ‘‘2027’’ and 

20 inserting ‘‘for each of fiscal years 2026 and 2027’’. 

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1 SEC. 302. EXTENSION OF STATE OPTION TO PROVIDE MED2 ICAL ASSISTANCE FOR CERTAIN INDIVID3 UALS WHO ARE PATIENTS IN CERTAIN INSTI4 TUTIONS FOR MENTAL DISEASES. 

5 (a) MAKING PERMANENT STATE PLAN AMENDMENT

6 OPTION TO PROVIDE MEDICAL ASSISTANCE FOR CER7 TAIN INDIVIDUALS WHO ARE PATIENTS IN CERTAIN IN8 STITUTIONS FOR MENTAL DISEASES.—Section 1915(l)(1) 

9 of the Social Security Act (42 U.S.C. 1396n(l)(1)) is 

10 amended by striking ‘‘With respect to calendar quarters 

11 beginning during the period beginning October 1, 2019, 

12 and ending September 30, 2023,’’ and inserting ‘‘With re13 spect to calendar quarters beginning on or after October 

14 1, 2019,’’. 

15 (b) MAINTENANCE OF EFFORT REVISION.—Section 

16 1915(l)(3) of the Social Security Act (42 U.S.C. 

17 1396n(l)(3)) is amended— 

18 (1) in subparagraph (A)— 

19 (A) in the matter preceding clause (i), by 

20 striking ‘‘other than under this title’’; and 

21 (B) in clause (i), by striking ‘‘or, if high22 er,’’ and all that follows through ‘‘in accordance 

23 with this subsection’’; and 

24 (2) by adding at the end the following new sub25 paragraph: 

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1 ‘‘(D) APPLICATION OF MAINTENANCE OF

2 EFFORT REQUIREMENTS TO CERTAIN

3 STATES.—In the case of a State with a State 

4 plan amendment in effect as of September 30, 

5 2023, for the 1-year period beginning on the 

6 date of enactment of this subparagraph, the 

7 provisions of subparagraph (A) shall be applied 

8 as if the amendments to that subparagraph 

9 made by the Better Mental Health Care, 

10 Lower-Cost Drugs, and Extenders Act of 2023 

11 had never been made.’’. 

12 (c) ADDITIONAL REQUIREMENTS.— 

13 (1) IN GENERAL.—Section 1915(l)(4) of the 

14 Social Security Act (42 U.S.C. 1396n(l)(4)) is 

15 amended— 

16 (A) in subparagraph (A), by striking 

17 ‘‘through (D)’’ and inserting ‘‘through (F)’’; 

18 (B) in subparagraph (D), by adding at and 

19 below clause (ii)(II), the following flush sen20 tence: 

21 ‘‘With respect to calendar quarters beginning 

22 on or after October 1, 2025, the State shall 

23 have in place evidence-based, substance use dis24 order-specific individual placement criteria and 

25 utilization management approaches to ensure 

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1 placement of an eligible individual in an appro2 priate level of care and, prior to the approval of 

3 a State plan amendment for which approval is 

4 sought on or after such date, shall notify the 

5 Secretary of how the State will ensure that the 

6 requirements of clauses (i) and (ii) will be 

7 met.’’; and 

8 (C) by adding at the end the following new 

9 subparagraph: 

10 ‘‘(E) REVIEW PROCESS.—With respect to 

11 calendar quarters beginning on or after October 

12 1, 2025, the State shall have in place a process 

13 to review the compliance of eligible institutions 

14 for mental diseases with nationally recognized, 

15 evidence-based, substance use disorder-specific 

16 program standards specified by the State.’’. 

17 (2) ONE-TIME ASSESSMENT.—Section 

18 1915(l)(4) of the Social Security Act (42 U.S.C. 

19 1396n(l)(4)), as amended by paragraph (1), is fur20 ther amended by adding at the end the following 

21 new subparagraph: 

22 ‘‘(F) ASSESSMENT.— 

23 ‘‘(i) IN GENERAL.—The State shall, 

24 not later than 12 months after the ap25 proval of a State plan amendment deVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00103 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 scribed in this subsection (or, in the case 

2 such State has such an amendment ap3 proved as of September 30, 2023, not later 

4 than 12 months after the date of enact5 ment of this subparagraph), commence an 

6 assessment of— 

7 ‘‘(I) the availability for individ8 uals enrolled under a State plan under 

9 this title (or waiver of such plan) of 

10 treatment in— 

11 ‘‘(aa) each level of care de12 scribed in clause (i) of subpara13 graph (C); and 

14 ‘‘(bb) each level of care de15 scribed in clause (ii) of subpara16 graph (C) at which the State pro17 vides medical assistance; and 

18 ‘‘(II) the availability of medica19 tion-assisted treatment and medically 

20 supervised withdrawal management 

21 services for such individuals. 

22 ‘‘(ii) REQUIRED COMPLETION.—The 

23 State shall complete the assessment de24 scribed in clause (i) not later than 12 

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1 months after the date the State com2 mences such assessment.’’. 

3 (3) CLARIFICATION OF LEVELS OF CARE.—Sec4 tion 1915(l)(7)(A) of the Social Security Act (42 

5 U.S.C. 1396n(l)(7)(A)) is amended by inserting ‘‘(or 

6 any successor publication)’’ before the period. 

7 TITLE IV—MEDICARE EXPIRING 

8 PROVISIONS AND PROVIDER 

9 PAYMENT CHANGES 

10 SEC. 401. EXTENSION OF FUNDING FOR QUALITY MEASURE 

11 ENDORSEMENT, INPUT, AND SELECTION. 

12 Section 1890(d)(2) of the Social Security Act (42 

13 U.S.C. 1395aaa(d)(2)) is amended— 

14 (1) in the first sentence— 

15 (A) by striking ‘‘and $20,000,000’’ and in16 serting ‘‘$20,000,000’’; and 

17 (B) by inserting the following before the 

18 period at the end: ‘‘, and $20,000,000 for fiscal 

19 year 2024’’; and 

20 (2) in the third sentence, by striking ‘‘and 

21 2023’’ and inserting ‘‘2023, and 2024’’. 

22 SEC. 402. EXTENSION OF FUNDING OUTREACH AND ASSIST23 ANCE FOR LOW-INCOME PROGRAMS. 

24 (a) STATE HEALTH INSURANCE ASSISTANCE PRO25 GRAMS.—Subsection (a)(1)(B) of section 119 of the MediVerDate Sep 11 2014 00:25 Dec 08, 2023 Jkt 049200 PO 00000 Frm 00105 Fmt 6652 Sfmt 6201 E:\BILLS\S3430.RS S3430
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1 care Improvements for Patients and Providers Act of 2008 

2 (42 U.S.C. 1395b–3 note), as amended by section 3306 

3 of the Patient Protection and Affordable Care Act (Public 

4 Law 111–148), section 610 of the American Taxpayer Re5 lief Act of 2012 (Public Law 112–240), section 1110 of 

6 the Pathway for SGR Reform Act of 2013 (Public Law 

7 113–67), section 110 of the Protecting Access to Medicare 

8 Act of 2014 (Public Law 113–93), section 208 of the 

9 Medicare Access and CHIP Reauthorization Act of 2015 

10 (Public Law 114–10), section 50207 of division E of the 

11 Bipartisan Budget Act of 2018 (Public Law 115–123), 

12 section 1402 of division B of the Continuing Appropria13 tions Act, 2020, and Health Extenders Act of 2019 (Pub14 lic Law 116–59), section 1402 of division B of the Further 

15 Continuing Appropriations Act, 2020, and Further Health 

16 Extenders Act of 2019 (Public Law 116–69), section 103 

17 of division N of the Further Consolidated Appropriations 

18 Act, 2020 (Public Law 116–94), section 3803 of the 

19 CARES Act (Public Law 116–136), section 2203 of the 

20 Continuing Appropriations Act, 2021 and Other Exten21 sions Act (Public Law 116–159), section 1102 of the Fur22 ther Continuing Appropriations Act, 2021, and Other Ex23 tensions Act (Public Law 116–215), and section 103 of 

24 division CC of the Consolidated Appropriations Act, 2021 

25 (Public Law 116–260), is amended— 

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1 (1) in the matter preceding clause (i), by strik2 ing ‘‘Centers for Medicare & Medicaid Services Pro3 gram Management Account’’ and inserting ‘‘Admin4 istration for Community Living’’; 

5 (2) in clause (xii), by striking ‘‘and’’ at the end; 

6 (3) in clause (xiii), by striking the period at the 

7 end and inserting ‘‘; and’’; and 

8 (4) by inserting after clause (xiii) the following 

9 new clause: 

10 ‘‘(xiv) for fiscal year 2024, 

11 $15,000,000.’’. 

12 (b) AREA AGENCIES ON AGING.—Subsection 

13 (b)(1)(B) of such section 119, as so amended, is amend14 ed— 

15 (1) in clause (xii), by striking ‘‘and’’ at the end; 

16 (2) in clause (xiii), by striking the period at the 

17 end and inserting ‘‘; and’’; and 

18 (3) by inserting after clause (xiii) the following 

19 new clause: 

20 ‘‘(xiv) for fiscal year 2024, 

21 $15,000,000.’’. 

22 (c) AGING AND DISABILITY RESOURCE CENTERS.— 

23 Subsection (c)(1)(B) of such section 119, as so amended, 

24 is amended— 

25 (1) in clause (xii), by striking ‘‘and’’ at the end; 

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1 (2) in clause (xiii), by striking the comma at 

2 the end and inserting ‘‘; and’’; and 

3 (3) by inserting after clause (xiii) the following 

4 new clause: 

5 ‘‘(xiv) for fiscal year 2024, 

6 $5,000,000.’’. 

7 (d) COORDINATION OF EFFORTS TO INFORM OLDER

8 AMERICANS ABOUT BENEFITS AVAILABLE UNDER FED9 ERAL AND STATE PROGRAMS.—Subsection (d)(2) of such 

10 section 119, as so amended, is amended— 

11 (1) in clause (xii), by striking ‘‘and’’ at the end; 

12 (2) in clause (xiii), by striking the period at the 

13 end and inserting ‘‘; and’’; and 

14 (3) by inserting after clause (xiii) the following 

15 new clause: 

16 ‘‘(xiv) for fiscal year 2024, 

17 $15,000,000.’’. 

18 SEC. 403. EXTENSION OF THE WORK GEOGRAPHIC INDEX 

19 FLOOR UNDER THE MEDICARE PROGRAM. 

20 Section 1848(e)(1)(E) of the Social Security Act (42 

21 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘Janu22 ary 1, 2024’’ and inserting ‘‘January 1, 2025’’. 

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1 SEC. 404. EXTENDING INCENTIVE PAYMENTS FOR PARTICI2 PATION IN ELIGIBLE ALTERNATIVE PAYMENT 

3 MODELS. 

4 (a) IN GENERAL.—Section 1833(z) of the Social Se5 curity Act (42 U.S.C. 1395l(z)) is amended— 

6 (1) in paragraph (1)(A)— 

7 (A) by striking ‘‘with 2025’’ and inserting 

8 ‘‘with 2026’’; and 

9 (B) by inserting ‘‘, or, with respect to 

10 2026, 1.75 percent’’ after ‘‘3.5 percent’’. 

11 (2) in paragraph (2)— 

12 (A) in subparagraph (B)— 

13 (i) in the header, by striking ‘‘2025’’ 

14 and inserting ‘‘2026’’; and 

15 (ii) in the matter preceding clause (i), 

16 by striking ‘‘2025’’ and inserting ‘‘2026’’; 

17 (B) in subparagraph (C)— 

18 (i) in the header, by striking ‘‘2026’’ 

19 and inserting ‘‘2027’’; and 

20 (ii) in the matter preceding clause (i), 

21 by striking ‘‘2026’’ and inserting ‘‘2027’’; 

22 and 

23 (C) in subparagraph (D), by striking ‘‘and 

24 2025’’ and inserting ‘‘2025, and 2026’’; and 

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1 (3) in paragraph (4)(B), by inserting ‘‘, or, 

2 with respect to 2026, 1.75 percent’’ after ‘‘3.5 per3 cent’’. 

4 (b) CONFORMING AMENDMENTS.—Section 

5 1848(q)(1)(C)(iii) of the Social Security Act (42 U.S.C. 

6 1395w–4(q)(1)(C)(iii)) is amended— 

7 (1) in subclause (II), by striking ‘‘2025’’ and 

8 inserting ‘‘2026’’; and 

9 (2) in subclause (III), by striking ‘‘2026’’ and 

10 inserting ‘‘2027’’. 

11 SEC. 405. PAYMENT RATES FOR DURABLE MEDICAL EQUIP12 MENT UNDER THE MEDICARE PROGRAM. 

13 (a) AREAS OTHER THAN RURAL AND NONCONTIG14 UOUS AREAS.—The Secretary shall implement section 

15 414.210(g)(9)(v) of title 42, Code of Federal Regulations 

16 (or any successor regulation), to apply the transition rule 

17 described in the first sentence of such section to all appli18 cable items and services furnished in areas other than 

19 rural or noncontiguous areas (as such terms are defined 

20 for purposes of such section) through December 31, 2024. 

21 (b) ALL AREAS.—The Secretary shall not implement 

22 section 414.210(g)(9)(vi) of title 42, Code of Federal Reg23 ulations (or any successor regulation) until January 1, 

24 2025. 

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1 (c) IMPLEMENTATION.—Notwithstanding any other 

2 provision of law, the Secretary may implement the provi3 sions of this section by program instruction or otherwise. 

4 SEC. 406. EXTENDING THE INDEPENDENCE AT HOME MED5 ICAL PRACTICE DEMONSTRATION PROGRAM 

6 UNDER THE MEDICARE PROGRAM. 

7 (a) IN GENERAL.—Section 1866E of the Social Secu8 rity Act (42 U.S.C. 1395cc–5) is amended— 

9 (1) in subsection (e)— 

10 (A) in paragraph (1), by striking ‘‘10- 

11 year’’ and inserting ‘‘12-year’’; and 

12 (B) in paragraph (5)— 

13 (i) in the second sentence, by striking 

14 ‘‘tenth’’ and inserting ‘‘twelfth’’; and 

15 (ii) in the third sentence, by striking 

16 ‘‘tenth’’ and inserting ‘‘twelfth’’; and 

17 (2) in subsection (h), by striking ‘‘and 

18 $9,000,000 for fiscal year 2021’’ and inserting ‘‘, 

19 $9,000,000 for fiscal year 2021, and $3,000,000 for 

20 fiscal year 2024’’. 

21 (b) EFFECTIVE DATE.—The amendments made by 

22 subsection (a) shall take effect as if included in the enact23 ment of Public Law 111–148. 

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1 SEC. 407. INCREASE IN SUPPORT FOR PHYSICIANS AND 

2 OTHER PROFESSIONALS IN ADJUSTING TO 

3 MEDICARE PAYMENT CHANGES. 

4 Section 1848(t)(1)(D) of the Social Security Act (42 

5 U.S.C. 1395w–4(t)(1)(D)) is amended by striking ‘‘1.25 

6 percent’’ and inserting ‘‘2.5 percent’’. 

7 SEC. 408. REVISED PHASE-IN OF MEDICARE CLINICAL LAB8 ORATORY TEST PAYMENT CHANGES. 

9 (a) REVISED PHASE-IN OF REDUCTIONS FROM PRI10 VATE PAYOR RATE IMPLEMENTATION.—Section 

11 1834A(b)(3) of the Social Security Act (42 U.S.C. 

12 1395m–1(b)(3)) is amended— 

13 (1) in subparagraph (A), by striking ‘‘through 

14 2026’’ and inserting ‘‘through 2027’’; and 

15 (2) in subparagraph (B)— 

16 (A) in clause (ii), by striking ‘‘through 

17 2023’’ and inserting ‘‘through 2024’’; and 

18 (B) in clause (iii), by striking ‘‘2024 

19 through 2026’’ and inserting ‘‘2025 through 

20 2027’’. 

21 (b) REVISED REPORTING PERIOD FOR REPORTING

22 OF PRIVATE SECTOR PAYMENT RATES FOR ESTABLISH23 MENT OF MEDICARE PAYMENT RATES.—Section 

24 1834A(a)(1)(B) of the Social Security Act (42 U.S.C. 

25 1395m–1(a)(1)(B)) is amended— 

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1 (1) in clause (i), by striking ‘‘December 31, 

2 2023’’ and inserting ‘‘December 31, 2024’’; and 

3 (2) in clause (ii)— 

4 (A) by striking ‘‘January 1, 2024’’ and in5 serting ‘‘January 1, 2025’’; and 

6 (B) by striking ‘‘March 31, 2024’’ and in7 serting ‘‘March 31, 2025’’. 

8 SEC. 409. EXTENSION OF ADJUSTMENT TO CALCULATION 

9 OF HOSPICE CAP AMOUNT UNDER MEDI10 CARE. 

11 Section 1814(i)(2)(B) of the Social Security Act (42 

12 U.S.C. 1395f(i)(2)(B)) is amended— 

13 (1) in clause (ii), by striking ‘‘2032’’ and in14 serting ‘‘2033’’; and 

15 (2) in clause (iii), by striking ‘‘2032’’ and in16 serting ‘‘2033’’. 

17 TITLE V—OFFSETS 

18 SEC. 501. MEDICAID IMPROVEMENT FUND. 

19 Section 1941(b)(3)(A) of the Social Security Act (42 

20 U.S.C. 1396w–1(b)(3)(A)), as amended by section 2342 

21 of the Continuing Appropriations Act, 2024 and Other 

22 Extensions Act (Public Law 118–15), is amended by strik23 ing ‘‘$6,357,117,810’’ and inserting ‘‘$561,000,000’’. 

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1 SEC. 502. MEDICARE IMPROVEMENT FUND. 

2 Section 1898(b)(1) of the Social Security Act (42 

3 U.S.C. 1395iii(b)(1)) is amended by striking 

4 ‘‘$180,000,000’’ and inserting ‘‘756,000,000’’. 

Calendar No. 265 

118TH CONGRESS 

1ST SESSION S. 3430 

[Report No. 118–121] 

A BILL 

To amend titles XVIII and XIX of the Social Secuposes. under Medicare and Medicaid, and for other pur- costs, and extend certain expiring provisions force and services, reduce prescription drug rity Act to expand the mental health care workDECEMBER 7, 2023 

Read twice and placed on the calendar