115TH CONGRESS 

2D SESSION H. R. 5797 

AN ACT 

To amend title XIX of the Social Security Act to allow 

States to provide under Medicaid services for certain 

individuals with opioid use disorders in institutions for 

mental diseases. 

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. 

2 This Act may be cited as the ‘‘Individuals in Medicaid 

3 Deserve Care that is Appropriate and Responsible in its 

4 Execution Act’’ or the ‘‘IMD CARE Act’’. 

5 SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERV6 ICES FOR CERTAIN INDIVIDUALS WITH TAR7 GETED SUDS IN INSTITUTIONS FOR MENTAL 

8 DISEASES. 

9 Section 1915 of the Social Security Act (42 U.S.C. 

10 1396n) is amended by adding at the end the following new 

11 subsection: 

12 ‘‘(l) STATE PLAN OPTION TO PROVIDE SERVICES

13 FOR CERTAIN INDIVIDUALS IN INSTITUTIONS FOR MEN14 TAL DISEASES.— 

15 ‘‘(1) IN GENERAL.—With respect to calendar 

16 quarters beginning during the period beginning Jan17 uary 1, 2019, and ending December 31, 2023, a 

18 State may elect, through a State plan amendment, 

19 to, notwithstanding section 1905(a), provide medical 

20 assistance for services furnished in institutions for 

21 mental diseases and for other medically necessary 

22 services furnished to eligible individuals with tar23 geted SUDs, in accordance with the requirements of 

24 this subsection. 

25 ‘‘(2) PAYMENTS.— 
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1 ‘‘(A) IN GENERAL.—Amounts expended 

2 under a State plan amendment under para3 graph (1) for services described in such para4 graph furnished, with respect to a 12-month pe5 riod, to an eligible individual with a targeted 

6 SUD who is a patient in an institution for men7 tal diseases shall be treated as medical assist8 ance for which payment is made under section 

9 1903(a) but only to the extent that such serv10 ices are furnished for not more than a period 

11 of 30 days (whether or not consecutive) during 

12 such 12-month period. 

13 ‘‘(B) CLARIFICATION.—Payment made 

14 under this paragraph for expenditures under a 

15 State plan amendment under this subsection 

16 with respect to services described in paragraph 

17 (1) furnished to an eligible individual with a 

18 targeted SUD shall not affect payment that 

19 would otherwise be made under section 1903(a) 

20 for expenditures under the State plan (or waiv21 er of such plan) for medical assistance for such 

22 individual. 

23 ‘‘(3) INFORMATION REQUIRED IN STATE PLAN

24 AMENDMENT.— 
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1 ‘‘(A) IN GENERAL.—A State electing to 

2 provide medical assistance pursuant to this sub3 section shall include with the submission of the 

4 State plan amendment under paragraph (1) to 

5 the Secretary— 

6 ‘‘(i) a plan on how the State will im7 prove access to outpatient care during the 

8 period of the State plan amendment, in9 cluding a description of— 

10 ‘‘(I) the process by which eligible 

11 individuals with targeted SUDs will 

12 make the transition from receiving in13 patient services in an institution for 

14 mental diseases to appropriate out15 patient care; and 

16 ‘‘(II) the process the State will 

17 undertake to ensure eligible individ18 uals with targeted SUDs are provided 

19 care in the most integrated setting ap20 propriate to the needs of the individ21 uals; and 

22 ‘‘(ii) a description of how the State 

23 plan amendment ensures an appropriate 

24 clinical screening of eligible individuals 

25 with targeted SUDs, including assessments 
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1 to determine level of care and length of 

2 stay recommendations based upon the 

3 multidimensional assessment criteria of the 

4 American Society of Addiction Medicine 

5 and to determine the appropriate setting 

6 for such care. 

7 ‘‘(B) REPORT.—Not later than the sooner 

8 of December 31, 2024, or 1 year after the date 

9 of the termination of a State plan amendment 

10 under this subsection, the State shall submit to 

11 the Secretary a report that includes at least— 

12 ‘‘(i) the number of eligible individuals 

13 with targeted SUDs who received services 

14 pursuant to such State plan amendment; 

15 ‘‘(ii) the length of the stay of each 

16 such individual in an institution for mental 

17 diseases; 

18 ‘‘(iii) the type of outpatient treatment, 

19 including medication-assisted treatment, 

20 each such individual received after being 

21 discharged from such institution; 

22 ‘‘(iv) the number of eligible individ23 uals with any co-occuring disorders who re24 ceived services pursuant to such State plan 
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1 amendment and the co-occuring disorders 

2 from which they suffer; and 

3 ‘‘(v) information regarding the effects 

4 of a State plan amendment on access to 

5 community care for individuals suffering 

6 from a mental disease other than sub7 stance use disorder. 

8 ‘‘(4) DEFINITIONS.—In this subsection: 

9 ‘‘(A) ELIGIBLE INDIVIDUAL WITH A TAR10 GETED SUD.—The term ‘eligible individual with 

11 a targeted SUD’ means an individual who— 

12 ‘‘(i) with respect to a State, is en13 rolled for medical assistance under the 

14 State plan (or a waiver of such plan); 

15 ‘‘(ii) is at least 21 years of age; 

16 ‘‘(iii) has not attained 65 years of 

17 age; and 

18 ‘‘(iv) has been diagnosed with at least 

19 one targeted SUD. 

20 ‘‘(B) INSTITUTION FOR MENTAL DIS21 EASES.—The term ‘institution for mental dis22 eases’ has the meaning given such term in sec23 tion 1905(i). 

24 ‘‘(C) OPIOID PRESCRIPTION PAIN RE25 LIEVER.—The term ‘opioid prescription pain re-
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1 liever’ includes hydrocodone products, 

2 oxycodone products, tramadol products, codeine 

3 products, morphine products, fentanyl products, 

4 buprenorphine products, oxymorphone products, 

5 meperidine products, hydromorphone products, 

6 methadone, and any other prescription pain re7 liever identified by the Assistant Secretary for 

8 Mental Health and Substance Use. 

9 ‘‘(D) OTHER MEDICALLY NECESSARY

10 SERVICES.—The term ‘other medically nec11 essary services’ means, with respect to an eligi12 ble individual with a targeted SUD who is a pa13 tient in an institution for mental diseases, items 

14 and services that are provided to such indi15 vidual outside of such institution to the extent 

16 that such items and services would be treated 

17 as medical assistance for such individual if such 

18 individual were not a patient in such institu19 tion. 

20 ‘‘(E) TARGETED SUD.— 

21 ‘‘(i) IN GENERAL.—The term ‘tar22 geted SUD’ means an opioid use disorder 

23 or a cocaine use disorder. 

24 ‘‘(ii) COCAINE USE DISORDER.—The 

25 term ‘cocaine use disorder’ means a dis-
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1 order that meets the criteria of the Diag2 nostic and Statistical Manual of Mental 

3 Disorders, 4th Edition (or a successor edi4 tion), for either dependence or abuse for 

5 cocaine, including cocaine base (commonly 

6 referred to as ‘crack cocaine’). 

7 ‘‘(iii) OPIOID USE DISORDER.—The 

8 term ‘opioid use disorder’ means a disorder 

9 that meets the criteria of the Diagnostic 

10 and Statistical Manual of Mental Dis11 orders, 4th Edition (or a successor edi12 tion), for heroin use disorder or pain re13 liever use disorder (including with respect 

14 to opioid prescription pain relievers).’’. 

15 SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE. 

16 Section 1903(m) of the Social Security Act (42 

17 U.S.C. 1396b(m)) is amended by adding at the end the 

18 following new paragraph: 

19 ‘‘(7)(A) With respect to expenditures described in 

20 subparagraph (B) that are incurred by a State for any 

21 fiscal year after fiscal year 2020 (and before fiscal year 

22 2024), in determining the pro rata share to which the 

23 United States is equitably entitled under subsection 

24 (d)(3), the Secretary shall substitute the Federal medical 

25 assistance percentage that applies for such fiscal year to 
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1 the State under section 1905(b) (without regard to any 

2 adjustments to such percentage applicable under such sec3 tion or any other provision of law) for the percentage that 

4 applies to such expenditures under section 1905(y). 

5 ‘‘(B) Expenditures described in this subparagraph, 

6 with respect to a fiscal year to which subparagraph (A) 

7 applies, are expenditures incurred by a State for payment 

8 for medical assistance provided to individuals described in 

9 subclause (VIII) of section 1902(a)(10)(A)(i) by a man10 aged care entity, or other specified entity (as defined in 

11 subparagraph (D)(iii)), that are treated as remittances be12 cause the State— 

13 ‘‘(i) has satisfied the requirement of section 

14 438.8 of title 42, Code of Federal Regulations (or 

15 any successor regulation), by electing— 

16 ‘‘(I) in the case of a State described in 

17 subparagraph (C), to apply a minimum medical 

18 loss ratio (as defined in subparagraph (D)(ii)) 

19 that is at least 85 percent but not greater than 

20 the minimum medical loss ratio (as so defined) 

21 that such State applied as of May 31, 2018; or 

22 ‘‘(II) in the case of a State not described 

23 in subparagraph (C), to apply a minimum med24 ical loss ratio that is equal to 85 percent; and 
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1 ‘‘(ii) recovered all or a portion of the expendi2 tures as a result of the entity’s failure to meet such 

3 ratio. 

4 ‘‘(C) For purposes of subparagraph (B), a State de5 scribed in this subparagraph is a State that as of May 

6 31, 2018, applied a minimum medical loss ratio (as cal7 culated under subsection (d) of section 438.8 of title 42, 

8 Code of Federal Regulations (as in effect on June 1, 

9 2018)) for payment for services provided by entities de10 scribed in such subparagraph under the State plan under 

11 this title (or a waiver of the plan) that is equal to or great12 er than 85 percent. 

13 ‘‘(D) For purposes of this paragraph: 

14 ‘‘(i) The term ‘managed care entity’ means a 

15 medicaid managed care organization described in 

16 section 1932(a)(1)(B)(i). 

17 ‘‘(ii) The term ‘minimum medical loss ratio’ 

18 means, with respect to a State, a minimum medical 

19 loss ratio (as calculated under subsection (d) of sec20 tion 438.8 of title 42, Code of Federal Regulations 

21 (as in effect on June 1, 2018)) for payment for serv22 ices provided by entities described in subparagraph 

23 (B) under the State plan under this title (or a waiv24 er of the plan). 

25 ‘‘(iii) The term ‘other specified entity’ means— 
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1 ‘‘(I) a prepaid inpatient health plan, as de2 fined in section 438.2 of title 42, Code of Fed3 eral Regulations (or any successor regulation); 

4 and 

5 ‘‘(II) a prepaid ambulatory health plan, as 

6 defined in such section (or any successor regu7 lation).’’. 

Passed the House of Representatives June 20, 2018. 

Attest: 

Clerk. 
115TH CONGRESS 

2D SESSION H. R. 5797 

AN ACT 

To amend title XIX of the Social Security Act to 

in institutions for mental diseases. for certain individuals with opioid use disorders allow States to provide under Medicaid services