I 

115TH CONGRESS 

2D SESSION H. R. 5799 

To amend title XIX of the Social Security Act to require as a condition 

of receipt of full Federal medical assistance percentage under Medicaid 

that State Medicaid plans have in place certain drug utilization review 

activities. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 15, 2018 

Mrs. BLACKBURN (for herself, Mr. BARR, and Mr. KNIGHT) 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 require 

as a condition of receipt of full Federal medical assistance percentage under Medicaid that State Medicaid 

plans have in place certain drug utilization review activities. 

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 ‘‘Medicaid Drug Review, 

5 Utilization, Good Governance Improvement Act’’ or the 

6 ‘‘Medicaid DRUG Improvement Act’’. 


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1 SEC. 2. MEDICAID DRUG UTILIZATION REVIEW. 

2 (a) STATE PLAN REQUIREMENT.—Section 1902(a) 

3 of the Social Security Act (42 U.S.C. 1396a(a)) is amend4 ed— 

5 (1) in paragraph (82), at the end, by striking 

6 ‘‘and’’; 

7 (2) in paragraph (83), at the end, by striking 

8 the period and inserting ‘‘; and’’; and 

9 (3) by inserting after paragraph (83) the fol10 lowing new paragraph: 

11 ‘‘(84) provide that the State is in compliance 

12 with the drug review and utilization requirements 

13 under subsection (nn)(1).’’. 

14 (b) DRUG REVIEW AND UTILIZATION REQUIRE15 MENTS.—Section 1902 of the Social Security Act (42 

16 U.S.C. 1396a) is amended by adding at the end the fol17 lowing new subsection: 

18 ‘‘(nn) DRUG REVIEW AND UTILIZATION REQUIRE19 MENTS.— 

20 ‘‘(1) IN GENERAL.—For purposes of subsection 

21 (a)(84), the drug review and utilization requirements 

22 under this subsection are, subject to paragraph (3) 

23 and beginning October 1, 2019, the following: 

24 ‘‘(A) CLAIMS REVIEW LIMITATIONS.— 

25 ‘‘(i) IN GENERAL.—The State has in 

26 place— 


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1 ‘‘(I) safety edits (as specified by 

2 the State) for subsequent fills for 

3 opioids and a claims review automated 

4 process (as designed and implemented 

5 by the State) that indicates when an 

6 individual enrolled under the State 

7 plan (or under a waiver of the State 

8 plan) is prescribed a subsequent fill of 

9 opioids in excess of any limitation 

10 that may be identified by the State; 

11 ‘‘(II) safety edits (as specified by 

12 the State) on the maximum daily mor13 phine equivalent that can be pre14 scribed to an individual enrolled under 

15 the State plan (or under a waiver of 

16 the State plan) for treatment of 

17 chronic pain and a claims review auto18 mated process (as designed and imple19 mented by the State) that indicates 

20 when an individual enrolled under the 

21 plan (or waiver) is prescribed the mor22 phine equivalent for such treatment in 

23 excess of any limitation that may be 

24 identified by the State; and 


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1 ‘‘(III) a claims review automated 

2 process (as designed and implemented 

3 by the State) that monitors when an 

4 individual enrolled under the State 

5 plan (or under a waiver of the State 

6 plan) is concurrently prescribed 

7 opioids and— 

8 ‘‘(aa) benzodiazepines; or 

9 ‘‘(bb) antipsychotics. 

10 ‘‘(ii) MANAGED CARE ENTITIES.—The 

11 State requires each managed care entity 

12 (as defined in section 1932(a)(1)(B)) with 

13 respect to which the State has a contract 

14 under section 1903(m) or under section 

15 1905(t)(3) to have in place, subject to 

16 paragraph (3), with respect to individuals 

17 who are eligible for medical assistance 

18 under the State plan (or under a waiver of 

19 the State plan) and who are enrolled with 

20 the entity, the limitations described in sub21 clauses (I) and (II) of clause (i) and a 

22 claims review automated process described 

23 in subclause (III) of such clause. 

24 ‘‘(iii) RULES OF CONSTRUCTION.— 

25 Nothing in this subparagraph may be conVerDate Sep 11 2014 01:03 May 31, 2018 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H5799.IH H5799

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1 strued as prohibiting a State or managed 

2 care entity from designing and imple3 menting a claims review automated process 

4 under this subparagraph that provides for 

5 prospective or retrospective reviews of 

6 claims. Nothing in this subparagraph shall 

7 be understood as prohibiting the exercise 

8 of clinical judgment from a provider en9 rolled as a participating provider in a 

10 State plan (or waiver of the State plan) or 

11 contracting with a managed care entity re12 garding the best items and services for an 

13 individual enrolled under such State plan 

14 (or waiver). 

15 ‘‘(B) PROGRAM TO MONITOR

16 ANTIPSYCHOTIC MEDICATIONS BY CHILDREN.— 

17 The State has in place a program (as designed 

18 and implemented by the State), including such 

19 a program that the State had in place before 

20 the date of the enactment of this subsection, to 

21 monitor and manage the appropriate use of 

22 antipsychotic medications by children enrolled 

23 under the State plan (or under a waiver of the 

24 State plan) and submits annually to the Sec25 retary such information as the Secretary may 


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1 require on activities carried out under such pro2 gram for individuals not more than the age of 

3 18 years generally and children in foster care 

4 specifically. 

5 ‘‘(C) FRAUD AND ABUSE IDENTIFICA6 TION.—The State has in place a process (as de7 signed and implemented by the State), includ8 ing such a process that the State had in place 

9 before the date of the enactment of this sub10 section, that identifies potential fraud or abuse 

11 of controlled substances by individuals enrolled 

12 under the State plan (or under a waiver of the 

13 State plan), health care providers prescribing 

14 drugs to individuals so enrolled, and pharmacies 

15 dispensing drugs to individuals so enrolled. 

16 ‘‘(D) REPORTS.—The State shall include 

17 in the annual report submitted to the Secretary 

18 under section 1927(g)(3)(D) information on the 

19 limitations, requirement, program, and proc20 esses applied by the State under subparagraphs 

21 (A) through (C) in accordance with such man22 ner and time as specified by the Secretary. 

23 ‘‘(2) ANNUAL REPORT BY SECRETARY.—For 

24 each fiscal year beginning with fiscal year 2020, the 

25 Secretary shall submit to Congress a report on the 


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1 most recent information submitted by States under 

2 paragraph (1)(D). 

3 ‘‘(3) EXCEPTIONS.— 

4 ‘‘(A) CERTAIN INDIVIDUALS EXEMPTED.— 

5 The drug review and utilization requirements 

6 under this subsection shall not apply with re7 spect to an individual who— 

8 ‘‘(i) is receiving— 

9 ‘‘(I) hospice or palliative care; or 

10 ‘‘(II) treatment for cancer; 

11 ‘‘(ii) is a resident of a long-term care 

12 facility, of a facility described in section 

13 1905(d), or of another facility for which 

14 frequently abused drugs are dispensed for 

15 residents through a contract with a single 

16 pharmacy; or 

17 ‘‘(iii) the State elects to treat as ex18 empted from such requirements. 

19 ‘‘(B) EXCEPTION RELATING TO ENSURING

20 ACCESS.—In order to ensure reasonable access 

21 to health care, the Secretary may waive the 

22 drug review and utilization requirements under 

23 this subsection, with respect to a State, in the 

24 case of natural disasters and similar situations, 

25 and in the case of the provision of emergency 


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1 services (as defined for purposes of section 

2 1860D–4(c)(5)(D)(ii)(II)).’’. 

3 (c) MANAGED CARE ENTITIES.—Section 1932 of the 

4 Social Security Act (42 U.S.C. 1396u–2) is amended by 

5 adding at the end the following new subsection: 

6 ‘‘(i) DRUG UTILIZATION REVIEW ACTIVITIES AND

7 REQUIREMENTS.—Beginning not later than October 1, 

8 2019, each contract under a State plan with a managed 

9 care entity (other than a primary care case manager) 

10 under section 1903(m) shall provide that the entity is in 

11 compliance with the applicable provisions of section 

12 438.3(s)(2) of title 42 of the Code of Federal Regulations, 

13 section 483.3(s)(4) of such title, and section 483.3(s)(5) 

14 of such title, as such provisions were in effect on March 

15 31, 2018.’’. 

Æ 


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