I 

115TH CONGRESS 

2D SESSION H. R. 5635 

To amend title XIX of the Social Security Act to impose restrictions under 

the Medicaid program with respect to opioid prescriptions, and for other 

purposes. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 26, 2018 

Mr. GROTHMAN introduced the following bill; which was referred to the 

Committee on Energy and Commerce 

A BILL 

To amend title XIX of the Social Security Act to impose 

restrictions under the Medicaid program with respect 

to opioid prescriptions, 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, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Responsible Opioid 

5 Prescription Act’’. 


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1 SEC. 2. MEDICAID RESTRICTIONS RELATING TO OPIOID 

2 PRESCRIPTIONS. 

3 (a) IN GENERAL.—Section 1927(d) of the Social Se4 curity Act (42 U.S.C. 1396r–8(d)) is amended by adding 

5 at the end the following new paragraph: 

6 ‘‘(8) RESTRICTIONS RELATING TO OPIOIDS.— 

7 ‘‘(A) IN GENERAL.—Subject to subpara8 graph (B), with respect to calendar quarters be9 ginning on or after January 1, 2019, a State 

10 may only provide coverage under the State plan 

11 (or a waiver of such plan) for an opioid dis12 pensed to an individual enrolled under the plan 

13 (or waiver) to the extent that— 

14 ‘‘(i) in the case of an initial prescrip15 tion for the opioid to the individual, such 

16 prescription is limited to a maximum of a 

17 7-day supply; and 

18 ‘‘(ii) in the case of a refill of such pre19 scription, such refill is limited to a max20 imum of a 30-day supply and prescribed 

21 only if a provider— 

22 ‘‘(I) determines that the expected 

23 benefits of using the opioid to treat or 

24 improve the individual’s pain or func25 tion, respectively, outweigh the risks 

26 of such use; 


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1 ‘‘(II) to the extent appropriate, 

2 combines the use of the opioid with 

3 non-pharmacologic therapy and non4 opioid pharmacologic therapy; 

5 ‘‘(III) establishes treatment goals 

6 for the individual and takes steps to 

7 ensure that the use of the opioid will 

8 be discontinued if the provider deter9 mines that the benefits of such use no 

10 longer outweigh the risks; and 

11 ‘‘(IV) discusses with the indi12 vidual the known risks of such use, 

13 the realistic benefits of such use, and 

14 the responsibilities of the provider and 

15 individual in managing such use. 

16 ‘‘(B) EXCEPTION.—Subparagraph (A) 

17 shall not apply with respect to opioids dispensed 

18 to individuals who are— 

19 ‘‘(i) receiving treatment for cancer; 

20 ‘‘(ii) receiving hospice or palliative 

21 care; or 

22 ‘‘(iii) patients in a long-term care fa23 cility or a skilled nursing facility. 

24 ‘‘(C) DEFINITIONS.—In this paragraph: 


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1 ‘‘(i) INITIAL PRESCRIPTION.—The 

2 term ‘initial prescription’, with respect to 

3 an individual, includes the issuance of a 

4 new prescription to the individual for an 

5 opioid that the individual was previously 

6 prescribed, provided that such new pre7 scription is issued more than 60 days after 

8 the expiration of such previous prescrip9 tion. 

10 ‘‘(ii) OPIOID.—The term ‘opioid’ has 

11 the meaning given such term in section 

12 102 of the Controlled Substances Act (21 

13 U.S.C. 802) and includes drugs included in 

14 schedules II, III, and IV of section 202(c) 

15 of such Act (21 U.S.C. 812(c)).’’. 

16 (b) PROHIBITION ON PAYMENTS FOR CERTAIN

17 OPIOID PRESCRIPTIONS.—Section 1903(i) of the Social 

18 Security Act (42 U.S.C. 1396b(i)) is amended by inserting 

19 after paragraph (8) the following new paragraph: 

20 ‘‘(9) with respect to opioids (as defined in sec21 tion 1927(d)(8)) dispensed in calendar quarters be22 ginning on or after January 1, 2019, unless such 

23 opioids are dispensed in accordance with section 

24 1927(d)(8); or’’. 

Æ 


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