I 

115TH CONGRESS 

2D SESSION H. R. 5605 

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 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for an opioid use disorder treatment demonstration program. 

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 Qual5 ity Treatment for Opioid Use Disorders in Medicare Act’’. 


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1 SEC. 2. OPIOID USE DISORDER TREATMENT DEMONSTRA2 TION PROGRAM. 

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

4 1395 et seq.) is amended by inserting after section 1866E 

5 (42 U.S.C. 1395cc–5) the following new section: 

6 ‘‘SEC. 1866F. OPIOID USE DISORDER TREATMENT DEM7 ONSTRATION PROGRAM. 

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

9 PROGRAM.— 

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

11 2021, the Secretary shall implement a 5-year dem12 onstration program under this title (in this section 

13 referred to as the ‘Program’) to increase access of 

14 applicable beneficiaries to opioid use disorder treat15 ment services, improve physical and mental health 

16 outcomes for such beneficiaries, and to the extent 

17 possible, reduce expenditures under this title. Under 

18 the Program, the Secretary shall make payments 

19 under subsection (f) to participating care teams (as 

20 defined in subsection (c)(1)(A)) for providing opioid 

21 use disorder treatment services to applicable bene22 ficiaries participating under the Program. 

23 ‘‘(2) OPIOID USE DISORDER TREATMENT SERV24 ICES.—For purposes of this section, the term ‘opioid 

25 use disorder treatment services’— 


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

2 beneficiary, services that are furnished for the 

3 treatment of opioid use disorders in an out4 patient setting and— 

5 ‘‘(i) which are supported by the per 

6 applicable beneficiary per month care man7 agement fee under subsection (f); or 

8 ‘‘(ii) for which payment may otherwise 

9 be made under this title; and 

10 ‘‘(B) includes— 

11 ‘‘(i) medication assisted treatment; 

12 ‘‘(ii) treatment planning; 

13 ‘‘(iii) appropriate outpatient psy14 chiatric, psychological, or counseling serv15 ices (or any combination of such services); 

16 ‘‘(iv) appropriate social support serv17 ices; and 

18 ‘‘(v) care management and care co19 ordination of opioid use disorder services, 

20 as well as coordination with other physi21 cians and providers treating the mental 

22 and physical conditions of such beneficiary. 

23 ‘‘(b) PROGRAM DESIGN.— 

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

25 the Program in such a manner to evaluate the exVerDate Sep 11 2014 01:54 Apr 27, 2018 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H5605.IH H5605

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1 tent to which the Program accomplishes the fol2 lowing purposes: 

3 ‘‘(A) Reduces hospitalizations and emer4 gency department visits. 

5 ‘‘(B) Reduces the occurrence of overdoses 

6 from opioids, including prescription opioid 

7 medications as well as illicit opioids. 

8 ‘‘(C) Increases use of medication-assisted 

9 treatment for opioid use disorders. 

10 ‘‘(D) Improves health outcomes of individ11 uals with opioid use disorders, including by re12 ducing the incidence of infectious diseases (such 

13 as hepatitis C and HIV). 

14 ‘‘(E) Does not increase the total spending 

15 on health care services under this title. 

16 ‘‘(F) Reduces deaths from opioid poi17 soning. 

18 ‘‘(G) Reduces the utilization of inpatient 

19 residential treatment. 

20 ‘‘(2) CONSULTATION.—In designing the Pro21 gram, the Secretary shall, not later than 3 months 

22 after the date of the enactment of this section, con23 sult with specialists in the field of addiction and cli24 nicians in the primary care community. 

25 ‘‘(c) PARTICIPATING CARE TEAMS.— 


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1 ‘‘(1) DEFINITION; SELECTION.— 

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

3 term ‘participating care team’ means an opioid 

4 use disorder care team (as defined in paragraph 

5 (2)) that is participating under the Program 

6 pursuant to selection by the Secretary under 

7 subparagraph (B). 

8 ‘‘(B) SELECTION.—Under the Program, 

9 the Secretary shall provide for a process for 

10 opioid use disorder care teams to apply for par11 ticipation under the Program as participating 

12 care teams and for selecting such teams for 

13 such participation. 

14 ‘‘(C) PREFERENCE.—In selecting opioid 

15 use disorder care teams under subparagraph 

16 (B) for participation under the Program, the 

17 Secretary shall give preference to opioid use 

18 disorder care teams that are located in areas 

19 with a prevalence of opioid use disorders that is 

20 higher than the national average prevalence, as 

21 measured by aggregate overdoses of opioids, or 

22 any other measure that the Secretary deems ap23 propriate. 

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


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

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

3 means a group of health care practitioners, or 

4 an entity employing or contracting with such 

5 health care practitioners, that— 

6 ‘‘(i) includes at least one physician 

7 who is providing primary care services or 

8 addiction treatment services to an applica9 ble beneficiary during the period in which 

10 the opioid use disorder care team is receiv11 ing payments under subsection (f); 

12 ‘‘(ii) includes at least one eligible 

13 practitioner (as defined in paragraph 

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

15 meets the criterion in clause (i); and 

16 ‘‘(iii) includes other practitioners— 

17 ‘‘(I) as necessary to deliver ap18 propriate psychiatric, psychological, 

19 counseling, and social services to ap20 plicable beneficiaries in addition to the 

21 services delivered by the eligible prac22 titioner; and 

23 ‘‘(II) who only perform services 

24 that such practitioners are legally au25 thorized to perform under State law. 


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1 ‘‘(B) REQUIREMENTS FOR PARTICIPA2 TION.—In order for an opioid use disorder care 

3 team to participate in the Program as a partici4 pating care team, each of the practitioners par5 ticipating on the team shall agree to— 

6 ‘‘(i) deliver opioid use disorder treat7 ment services to applicable beneficiaries 

8 who agree to receive the services; 

9 ‘‘(ii) meet minimum standards for 

10 quality required by the Program; and 

11 ‘‘(iii) submit to the Secretary, with re12 spect to each applicable beneficiary for 

13 whom such practitioner provides opioid use 

14 disorder treatment services, data with re15 spect to the quality standards and the 

16 measures defined in subsection (d) and 

17 such other information as the Secretary 

18 determines appropriate to monitor and 

19 evaluate the Program and to determine the 

20 performance of each practitioner for pur21 poses of the incentive payment under sub22 section (f), in such form, manner, and fre23 quency as specified by the Secretary. 


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1 ‘‘(3) ELIGIBLE PRACTITIONERS; OTHER PRO2 VIDER-RELATED DEFINITIONS AND APPLICATION

3 PROVISIONS.— 

4 ‘‘(A) ELIGIBLE PRACTITIONERS.—For pur5 poses of this section, the term ‘eligible practi6 tioner’ means, with respect to an applicable 

7 beneficiary, a provider of services that— 

8 ‘‘(i) participates in the Medicare pro9 gram under this title; 

10 ‘‘(ii)(I) is authorized to prescribe or 

11 dispense narcotic drugs to individuals for 

12 maintenance treatment or detoxification 

13 treatment; and 

14 ‘‘(II) has in effect a registration or 

15 waiver in accordance with section 303(g) of 

16 the Controlled Substances Act for such 

17 purpose and is otherwise in compliance 

18 with regulations promulgated by the Sub19 stance Abuse and Mental Health Services 

20 Administration to carry out such section; 

21 and 

22 ‘‘(iii) with respect to furnishing opioid 

23 use disorder treatment services to the ap24 plicable beneficiary, participates in an 


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1 opioid use disorder care team, which is a 

2 participating care team. 

3 ‘‘(B) ADDICTION SPECIALISTS.—For pur4 poses of paragraph (2)(C), the term ‘addiction 

5 specialist’ means a physician that possesses ex6 pert knowledge and skills in addiction medicine, 

7 as evidenced by— 

8 ‘‘(i) certification by the American So9 ciety of Addiction Medicine or the Amer10 ican Board of Addiction Medicine; 

11 ‘‘(ii) subspecialty certification in ad12 diction medicine by the American Board of 

13 Preventive Medicine; 

14 ‘‘(iii) subspecialty certification in ad15 diction psychiatry by the American Board 

16 of Psychiatry and Neurology; 

17 ‘‘(iv) a certificate of added qualifica18 tion in addiction medicine conferred by the 

19 American Osteopathic Association; or 

20 ‘‘(v) completion of an accredited resi21 dency or fellowship in addiction medicine 

22 or addiction psychiatry. 

23 ‘‘(d) QUALITY AND OTHER REPORTING REQUIRE24 MENTS.— 


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1 ‘‘(1) ADOPTION AND DEVELOPMENT OF STAND2 ARDS AND PERFORMANCE MEASURES.—Not later 

3 than 9 months after the date of the enactment of 

4 this section, the Secretary, in conjunction with 

5 stakeholders (including clinicians in the primary care 

6 community and the field of addiction medicine), 

7 shall adopt or develop (or an appropriate entity with 

8 which the Secretary contracts shall develop) quality 

9 standards and methods of assessing the quality of 

10 care to ensure a minimum level of quality of care 

11 and to determine whether the services furnished by 

12 participating care teams are achieving the purposes 

13 described in subsection (b)(1). For purposes of 

14 adopting or developing standards for payments 

15 under subsection (f)(1) and for purposes of adopting 

16 or developing methods for assessing performance for 

17 the incentive payments under subsection (f)(2), the 

18 Secretary may consider existing clinical guidelines 

19 for the treatment of opioid use disorders and stand20 ards or measures applied for use under the Medicaid 

21 program under title XIX. Standards and assessment 

22 methods shall address the following outcomes and 

23 performance criteria: 

24 ‘‘(A) Patient engagement in treatment. 

25 ‘‘(B) Retention in treatment. 


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1 ‘‘(C) Provision of evidence-based medica2 tion-assisted treatment. 

3 ‘‘(D) Any other criteria the Secretary 

4 deems appropriate. 

5 ‘‘(2) SUBMISSION.—Each participating care 

6 team shall submit to the Secretary, in such form, 

7 manner, and frequency specified by the Secretary, 

8 data with respect to such standards and assessment 

9 methods and such other information as the Sec10 retary determines appropriate to monitor and evalu11 ate the Program and to determine the performance 

12 of such team for purposes of the incentive payment 

13 under subsection (f)(2). 

14 ‘‘(e) PARTICIPATION OF APPLICABLE BENE15 FICIARIES.— 

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

17 this section, the term ‘applicable beneficiary’ means 

18 an individual who— 

19 ‘‘(A) is entitled to benefits under part A 

20 and enrolled for benefits under part B; 

21 ‘‘(B) is not enrolled in a Medicare Advan22 tage plan under part C; 

23 ‘‘(C) has a diagnosis for an opioid use dis24 order; and 


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1 ‘‘(D) meets such other criteria as the Sec2 retary determines appropriate. 

3 Such term shall include an individual who is dually 

4 eligible for benefits under this title and title XIX if 

5 such individual satisfies the criteria described in 

6 subparagraphs (A) through (D). 

7 ‘‘(2) VOLUNTARY PARTICIPATION.—An applica8 ble beneficiary may participate in the Program on a 

9 voluntary basis and may terminate participation in 

10 the Program at any time. 

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

12 Program, an applicable beneficiary must agree to re13 ceive opioid use disorder treatment services from a 

14 participating care team. An applicable beneficiary 

15 may only receive services supported by the Program 

16 from one participating care team during any one cal17 endar month. Participation under the Program shall 

18 not affect coverage of or payment for any other item 

19 or service under this title for the applicable bene20 ficiary. 

21 ‘‘(4) BENEFICIARY ACCESS TO SERVICES.— 

22 Nothing in this section shall be construed as encour23 aging providers to limit applicable beneficiary access 

24 to services covered under this title and applicable 

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1 cess to any benefit under this title as a condition of 

2 receiving services from a participating care team. 

3 ‘‘(f) PAYMENTS.— 

4 ‘‘(1) PER APPLICABLE BENEFICIARY PER

5 MONTH CARE MANAGEMENT FEE.— 

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

7 establish a schedule of per applicable bene8 ficiary per month care management fees. Such 

9 a per applicable beneficiary per month care 

10 management fee shall be paid to a participating 

11 care team in addition to any other amount oth12 erwise payable under this title to the practi13 tioners participating with the team or, if appli14 cable, the entity with respect to such team em15 ploying or contracting with such practitioners. 

16 A participating care team may use such per ap17 plicable beneficiary per month care manage18 ment fee to deliver additional services to appli19 cable beneficiaries, including services not other20 wise eligible for payment under this title. 

21 ‘‘(B) APPLICATION.—In carrying out sub22 paragraph (A), the Secretary shall— 

23 ‘‘(i) consider the costs that partici24 pating care teams are expected to incur in 

25 delivering high-quality opioid use disorder 


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1 care services that are not covered by pay2 ments otherwise payable to the teams 

3 under this title; 

4 ‘‘(ii) pay a higher per applicable bene5 ficiary per month care management fee for 

6 an applicable beneficiary who receives more 

7 intensive treatment services from a partici8 pating care team and who is appropriate 

9 for such services based on clinical guide10 lines for opioid use disorder care; 

11 ‘‘(iii) pay a higher per applicable ben12 eficiary per month care management fee 

13 for the month in which the applicable ben14 eficiary begins treatment with a partici15 pating care team than in subsequent 

16 months, to reflect the greater time and 

17 costs required for the team to plan and ini18 tiate treatment, as compared to mainte19 nance of treatment; and 

20 ‘‘(iv) pay higher per applicable bene21 ficiary per month care management fees 

22 for participating care teams that include 

23 an addiction specialist who is either deliv24 ering services directly to applicable bene25 ficiaries or providing consulting support to 


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1 those practitioners participating with such 

2 teams who are delivering services to appli3 cable beneficiaries. 

4 ‘‘(2) INCENTIVE PAYMENTS.—Under the Pro5 gram, the Secretary shall establish a performance6 based incentive payment, which shall be paid to par7 ticipating care teams based on the performance of 

8 such teams with respect to standards and assess9 ment methods adopted or developed by the Secretary 

10 under subsection (d) and with respect to which the 

11 teams report under such subsection. 

12 ‘‘(g) MULTIPAYER STRATEGY.—In carrying out the 

13 Program, the Secretary shall encourage other payers to 

14 provide similar payments and to use similar quality stand15 ards and methods of assessment as applied under the Pro16 gram. The Secretary may enter into a memorandum of 

17 understanding with other payers to align the methodology 

18 for payment provided by such a payer related to opioid 

19 use disorder treatment services with such methodology for 

20 payment under the Program. 

21 ‘‘(h) EVALUATION.— 

22 ‘‘(1) IN GENERAL.—The Comptroller General of 

23 the United States shall conduct an intermediate and 

24 final evaluation of the program. Each such evalua25 tion shall determine the extent to which each of the 


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1 purposes described in subsection (b) have been ac2 complished under the Program. Each evaluation 

3 shall also determine the extent to which the struc4 ture and requirements of the Program facilitated or 

5 impeded the participation of practitioners in the pro6 gram, the participation of beneficiaries with opioid 

7 use disorder, and the delivery of high-quality opioid 

8 use disorder treatment services. 

9 ‘‘(2) REPORTS.—The Comptroller General of 

10 the United States shall submit to the Secretary and 

11 Congress— 

12 ‘‘(A) a report with respect to the inter13 mediate evaluation under paragraph (1) not 

14 later than 3 years after the date of the imple15 mentation of the Program; and 

16 ‘‘(B) a report with respect to the final 

17 evaluation under paragraph (1) not later than 

18 6 years after such date. 

19 ‘‘(i) FUNDING.— 

20 ‘‘(1) ADMINISTRATIVE FUNDING.—For the pur21 poses of implementing, administering, and carrying 

22 out the Program (other than for purposes described 

23 in paragraph (2)), there shall be transferred to the 

24 Secretary for the Center for Medicare & Medicaid 

25 Services Program Management Account from the 


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1 Federal Supplementary Medical Insurance Trust 

2 Fund under section 1841 $5,000,000. 

3 ‘‘(2) CARE MANAGEMENT FEES AND INCEN4 TIVES.—For the purposes of payments under sub5 section (f), there shall be transferred to the Sec6 retary such sums as are necessary from the Federal 

7 Supplementary Medical Insurance Trust Fund under 

8 section 1841 for each of fiscal years 2021 through 

9 2025. 

10 ‘‘(3) AVAILABILITY.—Amounts transferred 

11 under this subsection for a fiscal year shall be avail12 able until expended. 

13 ‘‘(j) WAIVERS.—The Secretary may waive any provi14 sion of this title that conflicts with or impedes the imple15 mentation of the provisions of this section.’’. 

Æ 


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