IB 

Union Calendar No. 578 

115TH CONGRESS 

2D SESSION H. R. 5605 

[Report No. 115–744, Part I] 

To amend title XVIII of the Social Security Act to provide for an opioid 

use disorder treatment demonstration program. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 24, 2018 

Mr. RUIZ introduced the following bill; which was referred to the Committee 

on Energy and Commerce, and in addition to the Committee on Ways 

and Means, for a period to be subsequently determined by the Speaker, 

in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

JUNE 12, 2018 

Additional sponsors: Mrs. BLACKBURN and Mr. WALDEN

JUNE 12, 2018 

Reported from the Committee on Energy and Commerce with an amendment 

[Strike out all after the enacting clause and insert the part printed in italic] 

JUNE 12, 2018 

The Committee on Ways and Means discharged; committed to the Committee 

of the Whole House on the State of the Union and ordered to be printed 

[For text of introduced bill, see copy of bill as introduced on April 24, 2018] 


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A BILL 

To amend title XVIII of the Social Security Act to provide 

for an opioid use disorder treatment demonstration program. 


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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Advancing High Quality 

5 Treatment for Opioid Use Disorders in Medicare Act’’. 

6 SEC. 2. OPIOID USE DISORDER TREATMENT DEMONSTRA7 TION PROGRAM. 

8 Title XVIII of the Social Security Act (42 U.S.C. 1395 

9 et seq.) is amended by inserting after section 1866E (42 

10 U.S.C. 1395cc–5) the following new section: 

11 ‘‘SEC. 1866F. OPIOID USE DISORDER TREATMENT DEM12 ONSTRATION PROGRAM. 

13 ‘‘(a) IMPLEMENTATION OF 5-YEAR DEMONSTRATION

14 PROGRAM.— 

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

16 2021, the Secretary shall implement a 5-year dem17 onstration program under this title (in this section 

18 referred to as the ‘Program’) to increase access of ap19 plicable beneficiaries to opioid use disorder treatment 

20 services, improve physical and mental health out21 comes for such beneficiaries, and to the extent pos22 sible, reduce expenditures under this title. Under the 

23 Program, the Secretary shall make payments under 

24 subsection (e) to participants (as defined in sub25 section (c)(1)(A)) for furnishing opioid use disorder 


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1 treatment services delivered through opioid use dis2 order care teams, or arranging for such service to be 

3 furnished, to applicable beneficiaries participating in 

4 the Program. 

5 ‘‘(2) OPIOID USE DISORDER TREATMENT SERV6 ICES.—For purposes of this section, the term ‘opioid 

7 use disorder treatment services’— 

8 ‘‘(A) means, with respect to an applicable 

9 beneficiary, services that are furnished for the 

10 treatment of opioid use disorders and that utilize 

11 drugs approved under section 505 of the Federal 

12 Food, Drug, and Cosmetic Act for the treatment 

13 of opioid use disorders in an outpatient setting; 

14 and 

15 ‘‘(B) includes— 

16 ‘‘(i) medication assisted treatment; 

17 ‘‘(ii) treatment planning; 

18 ‘‘(iii) psychiatric, psychological, or 

19 counseling services (or any combination of 

20 such services), as appropriate; 

21 ‘‘(iv) social support services, as appro22 priate; and 

23 ‘‘(v) care management and care coordi24 nation services, including coordination with 


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1 other providers of services and suppliers not 

2 on an opioid use disorder care team. 

3 ‘‘(b) PROGRAM DESIGN.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall design 

5 the Program in such a manner to allow for the eval6 uation of the extent to which the Program accom7 plishes the following purposes: 

8 ‘‘(A) Reduces hospitalizations and emer9 gency department visits. 

10 ‘‘(B) Increases use of medication-assisted 

11 treatment for opioid use disorders. 

12 ‘‘(C) Improves health outcomes of individ13 uals with opioid use disorders, including by re14 ducing the incidence of infectious diseases (such 

15 as hepatitis C and HIV). 

16 ‘‘(D) Does not increase the total spending 

17 on items and services under this title. 

18 ‘‘(E) Reduces deaths from opioid overdose. 

19 ‘‘(F) Reduces the utilization of inpatient 

20 residential treatment. 

21 ‘‘(2) CONSULTATION.—In designing the Pro22 gram, including the criteria under subsection 

23 (e)(2)(A), the Secretary shall, not later than 3 months 

24 after the date of the enactment of this section, consult 


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1 with specialists in the field of addiction, clinicians in 

2 the primary care community, and beneficiary groups. 

3 ‘‘(c) PARTICIPANTS; OPIOID USE DISORDER CARE

4 TEAMS.— 

5 ‘‘(1) PARTICIPANTS.— 

6 ‘‘(A) DEFINITION.—In this section, the term 

7 ‘participant’ means an entity or individual— 

8 ‘‘(i) that is otherwise enrolled under 

9 this title and that is— 

10 ‘‘(I) a physician (as defined in 

11 section 1861(r)(1); 

12 ‘‘(II) a group practice comprised 

13 of physicians described in subclause 

14 (I); 

15 ‘‘(III) a hospital outpatient de16 partment; 

17 ‘‘(IV) a federally qualified health 

18 center (as defined in section 

19 1861(aa)(4)); 

20 ‘‘(V) a rural health clinic (as de21 fined in section 1861(aa)(2)); 

22 ‘‘(VI) a community mental health 

23 center (as defined in section 

24 1861(ff)(3)(B)); 


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1 ‘‘(VII) a clinic certified as a cer2 tified community behavioral health 

3 clinic pursuant to section 223 of the 

4 Protecting Access to Medicare Act of 

5 2014; or 

6 ‘‘(VIII) any other individual or 

7 entity specified by the Secretary; 

8 ‘‘(ii) that applied for and was selected 

9 to participate in the Program pursuant to 

10 an application and selection process estab11 lished by the Secretary; and 

12 ‘‘(iii) that establishes an opioid use 

13 disorder care team (as defined in paragraph 

14 (2)) through employing or contracting with 

15 health care practitioners described in para16 graph (2)(A), and uses such team to furnish 

17 or arrange for opioid use disorder treatment 

18 services in the outpatient setting under the 

19 Program 

20 ‘‘(B) PREFERENCE.—In selecting partici21 pants for the Program, the Secretary shall give 

22 preference to individuals and entities that are lo23 cated in areas with a prevalence of opioid use 

24 disorders that is higher than the national aver25 age prevalence. 


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1 ‘‘(2) OPIOID USE DISORDER CARE TEAMS.— 

2 ‘‘(A) IN GENERAL.—For purposes of this 

3 section, the term ‘opioid use disorder care team’ 

4 means a team of health care practitioners estab5 lished by a participant described in paragraph 

6 (1)(A) that— 

7 ‘‘(i) shall include— 

8 ‘‘(I) at least one physician (as de9 fined in section 1861(r)(1)) furnishing 

10 primary care services or addiction 

11 treatment services to an applicable 

12 beneficiary; and 

13 ‘‘(II) at least one eligible practi14 tioner (as defined in paragraph 

15 (3)(A)), who may be a physician who 

16 meets the criterion in subclause (I); 

17 and 

18 ‘‘(ii) may include other practitioners 

19 licensed under State law to furnish psy20 chiatric, psychological, counseling, and so21 cial services to applicable beneficiaries. 

22 ‘‘(B) REQUIREMENTS FOR RECEIPT OF PAY23 MENT UNDER PROGRAM.—In order to receive 

24 payments under subsection (e), each participant 

25 in the Program shall— 


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1 ‘‘(i) furnish opioid use disorder treat2 ment services through opioid use disorder 

3 care teams to applicable beneficiaries who 

4 agree to receive the services; 

5 ‘‘(ii) meet minimum criteria, as estab6 lished by the Secretary, for participation 

7 through the submission of data and infor8 mation described in clause (iii); and 

9 ‘‘(iii) submit to the Secretary, with re10 spect to each applicable beneficiary for 

11 whom opioid use disorder treatment services 

12 are furnished by the opioid use disorder 

13 care team, data with respect to the criteria 

14 established under subsection (e)(2)(A) and 

15 such other information as the Secretary de16 termines appropriate to monitor and evalu17 ate the Program, to determine if minimum 

18 criteria are met under clause (ii), and to 

19 determine the incentive payment under sub20 section (e), in such form, manner, and fre21 quency as specified by the Secretary. 

22 ‘‘(3) ELIGIBLE PRACTITIONERS; OTHER PRO23 VIDER-RELATED DEFINITIONS AND APPLICATION PRO24 VISIONS.— 


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1 ‘‘(A) ELIGIBLE PRACTITIONERS.—For pur2 poses of this section, the term ‘eligible practi3 tioner’ means a physician or other health care 

4 practitioner, such as a nurse practitioner or ad5 vanced practice nurse, that— 

6 ‘‘(i) is enrolled under section 1861(j); 

7 ‘‘(ii) is authorized to prescribe or dis8 pense narcotic drugs to individuals for 

9 maintenance treatment or detoxification 

10 treatment; and 

11 ‘‘(iii) has in effect a registration or 

12 waiver in accordance with section 303(g) of 

13 the Controlled Substances Act for such pur14 pose and is otherwise in compliance with 

15 regulations promulgated by the Substance 

16 Abuse and Mental Health Services Adminis17 tration to carry out such section. 

18 ‘‘(B) ADDICTION SPECIALISTS.—For pur19 poses of subsection (e)(1)(B)(iv), the term ‘addic20 tion specialist’ means a physician that possesses 

21 expert knowledge and skills in addiction medi22 cine, as evidenced by appropriate certification 

23 from a specialty body, a certificate of advanced 

24 qualification in addiction medicine, or comple25 tion of an accredited residency or fellowship in 


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1 addiction medicine or addiction psychiatry, as 

2 determined by the Secretary. 

3 ‘‘(d) PARTICIPATION OF APPLICABLE BENE4 FICIARIES.— 

5 ‘‘(1) APPLICABLE BENEFICIARY DEFINED.—In 

6 this section, the term ‘applicable beneficiary’ means 

7 an individual who— 

8 ‘‘(A) is entitled to, or enrolled for, benefits 

9 under part A and enrolled for benefits under 

10 part B; 

11 ‘‘(B) is not enrolled in a Medicare Advan12 tage plan under part C; 

13 ‘‘(C) has a current diagnosis for an opioid 

14 use disorder; and 

15 ‘‘(D) meets such other criteria as the Sec16 retary determines appropriate. 

17 Such term shall include an individual who is dually 

18 eligible for benefits under this title and title XIX if 

19 such individual satisfies the criteria described in sub20 paragraphs (A) through (D). 

21 ‘‘(2) VOLUNTARY PARTICIPATION; LIMITATION ON

22 NUMBER OF PARTICIPANTS.—An applicable bene23 ficiary may participate in the Program on a vol24 untary basis and may terminate participation in the 


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1 Program at any time. Not more than 20,000 applica2 ble beneficiaries may participate in the Program. 

3 ‘‘(3) SERVICES.—In order to participate in the 

4 Program, an applicable beneficiary shall agree to re5 ceive opioid use disorder treatment services from a 

6 participant. Participation under the Program shall 

7 not affect coverage of or payment for any other item 

8 or service under this title for the applicable bene9 ficiary. 

10 ‘‘(4) BENEFICIARY ACCESS TO SERVICES.—Noth11 ing in this section shall be construed as encouraging 

12 providers to limit applicable beneficiary access to 

13 services covered under this title and applicable bene14 ficiaries shall not be required to relinquish access to 

15 any benefit under this title as a condition of receiving 

16 services from a participant in the Program. 

17 ‘‘(e) PAYMENTS.— 

18 ‘‘(1) PER APPLICABLE BENEFICIARY PER MONTH

19 CARE MANAGEMENT FEE.— 

20 ‘‘(A) IN GENERAL.—The Secretary shall es21 tablish a schedule of per applicable beneficiary 

22 per month care management fees. Such a per ap23 plicable beneficiary per month care management 

24 fee shall be paid to a participant in addition to 

25 any other amount otherwise payable under this 


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1 title to the health care practitioners in the par2 ticipant’s opioid use disorder care team or, if 

3 applicable, to the participant. A participant 

4 may use such per applicable beneficiary per 

5 month care management fee to deliver additional 

6 services to applicable beneficiaries, including 

7 services not otherwise eligible for payment under 

8 this title. 

9 ‘‘(B) PAYMENT AMOUNTS.—In carrying out 

10 subparagraph (A), the Secretary shall— 

11 ‘‘(i) consider payments otherwise pay12 able under this title for opioid use disorder 

13 treatment services and the needs of applica14 ble beneficiaries; 

15 ‘‘(ii) pay a higher per applicable bene16 ficiary per month care management fee for 

17 an applicable beneficiary who receives more 

18 intensive treatment services from a partici19 pant and for whom those services are ap20 propriate based on clinical guidelines for 

21 opioid use disorder care; 

22 ‘‘(iii) pay a higher per applicable ben23 eficiary per month care management fee for 

24 the month in which the applicable bene25 ficiary begins treatment with a participant 


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1 than in subsequent months, to reflect the 

2 greater time and costs required for the plan3 ning and initiation of treatment, as com4 pared to maintenance of treatment; 

5 ‘‘(iv) pay higher per applicable bene6 ficiary per month care management fees for 

7 participants that have established opioid 

8 use disorder care teams that include an ad9 diction specialist (as defined in subsection 

10 (c)(3)(B)); and 

11 ‘‘(v) take into account whether a par12 ticipant’s opioid use disorder care team re13 fers applicable beneficiaries to other sup14 pliers or providers for any opioid use dis15 order treatment services. 

16 ‘‘(2) INCENTIVE PAYMENTS.— 

17 ‘‘(A) IN GENERAL.—Under the Program, the 

18 Secretary shall establish a performance-based in19 centive payment, which shall be paid (using a 

20 methodology established and at a time deter21 mined appropriate by the Secretary) to partici22 pants based on the performance of participants 

23 with respect to criteria, as determined appro24 priate by the Secretary, in accordance with sub25 paragraph (B). 


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1 ‘‘(B) CRITERIA.— 

2 ‘‘(i) IN GENERAL.—Criteria described 

3 in subparagraph (A) may include consider4 ation of the following: 

5 ‘‘(I) Patient engagement and re6 tention in treatment. 

7 ‘‘(II) Evidence-based medication8 assisted treatment. 

9 ‘‘(III) Other criteria established 

10 by the Secretary. 

11 ‘‘(ii) REQUIRED CONSULTATION AND

12 CONSIDERATION.—In determining criteria 

13 described in subparagraph (A), the Sec14 retary shall— 

15 ‘‘(I) consult with stakeholders, in16 cluding clinicians in the primary care 

17 community and in the field of addic18 tion medicine; and 

19 ‘‘(II) consider existing clinical 

20 guidelines for the treatment of opioid 

21 use disorders. 

22 ‘‘(C) SUBMISSION OF DATA.—Each partici23 pant shall submit to the Secretary, in such form, 

24 manner, and frequency specified by the Sec25 retary, data with respect to such criteria deVerDate Sep 11 2014 01:04 Jun 13, 2018 Jkt 079200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6203 E:\BILLS\H5605.RH H5605

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1 scribed in subparagraph (A) and such other in2 formation as the Secretary determines appro3 priate to evaluate and monitor the effectiveness 

4 of the Program, to determine the performance of 

5 the participants for purposes of the incentive 

6 payment under subparagraph (A), and to ensure 

7 the participants meet minimum criteria for pro8 gram participation described in subsection 

9 (c)(2)(B)(ii). 

10 ‘‘(3) NON-DUPLICATION OF PAYMENTS.—In the 

11 case if an applicable beneficiary receiving services 

12 supported by the Program from more than one partic13 ipant during any one calendar month, or from a par14 ticipant and a provider who is not a participant dur15 ing any one calendar month, the Secretary shall ad16 just (such as pro-rate) payment under paragraph (1) 

17 and any payment under paragraph (2) to each such 

18 participant, with respect to such applicable bene19 ficiary and month to avoid any duplication of pay20 ment. 

21 ‘‘(f) MULTIPAYER STRATEGY.—In carrying out the 

22 Program, the Secretary shall encourage other payers to pro23 vide similar payments and to use similar criteria as ap24 plied under the Program under subsection (e)(2)(C). The 

25 Secretary may enter into a memorandum of understanding 


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1 with other payers to align the methodology for payment 

2 provided by such a payer related to opioid use disorder 

3 treatment services with such methodology for payment 

4 under the Program. 

5 ‘‘(g) EVALUATION.— 

6 ‘‘(1) IN GENERAL.—The Secretary shall conduct 

7 an intermediate and final evaluation of the program. 

8 Each such evaluation shall determine the extent to 

9 which each of the purposes described in subsection (b) 

10 have been accomplished under the Program. 

11 ‘‘(2) REPORTS.—The Secretary shall submit to 

12 the Secretary and Congress— 

13 ‘‘(A) a report with respect to the inter14 mediate evaluation under paragraph (1) not 

15 later than 3 years after the date of the imple16 mentation of the Program; and 

17 ‘‘(B) a report with respect to the final eval18 uation under paragraph (1) not later than 6 

19 years after such date. 

20 ‘‘(h) FUNDING.— 

21 ‘‘(1) ADMINISTRATIVE FUNDING.—For the pur22 poses of implementing, administering, and carrying 

23 out the Program (other than for purposes described in 

24 paragraph (2)), the Secretary shall provide for the 

25 transfer from the Federal Supplementary Medical InVerDate Sep 11 2014 01:04 Jun 13, 2018 Jkt 079200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6203 E:\BILLS\H5605.RH H5605

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1 surance Trust Fund under section 1841 of $5,000,000 

2 to the Centers for Medicare & Medicaid Services Pro3 gram Management Account. 

4 ‘‘(2) CARE MANAGEMENT FEES AND INCEN5 TIVES.—For the purposes of making payments under 

6 subsection (e), the Secretary shall provide for the 

7 transfer from the Federal Supplementary Medical In8 surance Trust Fund under section 1841 of 

9 $10,000,000 for each of fiscal years 2021 through 

10 2025. 

11 ‘‘(3) AVAILABILITY.—Amounts transferred under 

12 this subsection for a fiscal year shall be available 

13 until expended. 

14 ‘‘(i) WAIVERS.—The Secretary may waive any provi15 sion of this title as may be necessary to carry out the Pro16 gram under this section.’’. 


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Union Calendar No. 578 

115TH CONGRESS 

2D SESSION H. R. 5605 

[Report No. 115–744, Part I] 

A BILL 

To amend title XVIII of the Social Security Act to 

demonstration program. provide for an opioid use disorder treatment 

JUNE 12, 2018 

Reported from the Committee on Energy and Commerce 

with an amendment 

JUNE 12, 2018 

The Committee on Ways and Means discharged; comState of the Union and ordered to be printed mitted to the Committee of the Whole House on the 


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