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Union Calendar No. 563 

115TH CONGRESS 

2D SESSION H. R. 5799 

[Report No. 115–728] 

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 

JUNE 12, 2018 

Additional sponsor: Mr. WALDEN

JUNE 12, 2018 

Reported with amendments, committed to the Committee of the Whole House 

on the State of the Union, and ordered to be printed 

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

[For text of introduced bill, see copy of bill as introduced on May 15, 2018] 


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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. 


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•HR 5799 RH

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’’. 

7 SEC. 2. MEDICAID DRUG UTILIZATION REVIEW. 

8 (a) STATE PLAN REQUIREMENT.—Section 1902(a) of 

9 the Social Security Act (42 U.S.C. 1396a(a)) is amended— 

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

11 ‘‘and’’; 

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

13 the period and inserting ‘‘; and’’; and 

14 (3) by inserting after paragraph (83) the fol15 lowing new paragraph: 

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

17 with the drug review and utilization requirements 

18 under subsection (nn)(1).’’. 

19 (b) DRUG REVIEW AND UTILIZATION REQUIRE20 MENTS.—Section 1902 of the Social Security Act (42 

21 U.S.C. 1396a) is amended by adding at the end the fol22 lowing new subsection: 

23 ‘‘(nn) DRUG REVIEW AND UTILIZATION REQUIRE24 MENTS.— 


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

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

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

4 and beginning October 1, 2019, the following: 

5 ‘‘(A) CLAIMS REVIEW LIMITATIONS.— 

6 ‘‘(i) IN GENERAL.—The State has in 

7 place— 

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

9 the State) for subsequent fills for 

10 opioids and a claims review automated 

11 process (as designed and implemented 

12 by the State) that indicates when an 

13 individual enrolled under the State 

14 plan (or under a waiver of the State 

15 plan) is prescribed a subsequent fill of 

16 opioids in excess of any limitation that 

17 may be identified by the State; 

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

19 the State) on the maximum daily mor20 phine equivalent that can be prescribed 

21 to an individual enrolled under the 

22 State plan (or under a waiver of the 

23 State plan) for treatment of chronic 

24 pain and a claims review automated 

25 process (as designed and implemented 


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1 by the State) that indicates when an 

2 individual enrolled under the plan (or 

3 waiver) is prescribed the morphine 

4 equivalent for such treatment in excess 

5 of any limitation that may be identi6 fied by the State; and 

7 ‘‘(III) a claims review automated 

8 process (as designed and implemented 

9 by the State) that monitors when an 

10 individual enrolled under the State 

11 plan (or under a waiver of the State 

12 plan) is concurrently prescribed 

13 opioids and— 

14 ‘‘(aa) benzodiazepines; or 

15 ‘‘(bb) antipsychotics. 

16 ‘‘(ii) MANAGED CARE ENTITIES.—The 

17 State requires each managed care entity (as 

18 defined in section 1932(a)(1)(B)) with re19 spect to which the State has a contract 

20 under section 1903(m) or under section 

21 1905(t)(3) to have in place, subject to para22 graph (3), with respect to individuals who 

23 are eligible for medical assistance under the 

24 State plan (or under a waiver of the State 

25 plan) and who are enrolled with the entity, 


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1 the limitations described in subclauses (I) 

2 and (II) of clause (i) and a claims review 

3 automated process described in subclause 

4 (III) of such clause. 

5 ‘‘(iii) RULES OF CONSTRUCTION.— 

6 Nothing in this subparagraph may be con7 strued as prohibiting a State or managed 

8 care entity from designing and imple9 menting a claims review automated process 

10 under this subparagraph that provides for 

11 prospective or retrospective reviews of 

12 claims. Nothing in this subparagraph shall 

13 be understood as prohibiting the exercise of 

14 clinical judgment from a provider enrolled 

15 as a participating provider in a State plan 

16 (or waiver of the State plan) or contracting 

17 with a managed care entity regarding the 

18 best items and services for an individual en19 rolled under such State plan (or waiver). 

20 ‘‘(B) PROGRAM TO MONITOR ANTIPSYCHOTIC

21 MEDICATIONS BY CHILDREN.—The State has in 

22 place a program (as designed and implemented 

23 by the State), including such a program that the 

24 State had in place before the date of the enact25 ment of this subsection, to monitor and manage 


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1 the appropriate use of antipsychotic medications 

2 by children enrolled under the State plan (or 

3 under a waiver of the State plan) and submits 

4 annually to the Secretary such information as 

5 the Secretary may require on activities carried 

6 out under such program for individuals not more 

7 than the age of 18 years generally and children 

8 in foster care specifically. 

9 ‘‘(C) FRAUD AND ABUSE IDENTIFICATION.— 

10 The State has in place a process (as designed 

11 and implemented by the State), including such a 

12 process that the State had in place before the 

13 date of the enactment of this subsection, that 

14 identifies potential fraud or abuse of controlled 

15 substances by individuals enrolled under the 

16 State plan (or under a waiver of the State plan), 

17 health care providers prescribing drugs to indi18 viduals so enrolled, and pharmacies dispensing 

19 drugs to individuals so enrolled. 

20 ‘‘(D) REPORTS.—The State shall include in 

21 the annual report submitted to the Secretary 

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

23 limitations, requirement, program, and processes 

24 applied by the State under subparagraphs (A) 


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1 through (C) in accordance with such manner 

2 and time as specified by the Secretary. 

3 ‘‘(2) ANNUAL REPORT BY SECRETARY.—For each 

4 fiscal year beginning with fiscal year 2020, the Sec5 retary shall submit to Congress a report on the most 

6 recent information submitted by States under para7 graph (1)(D). 

8 ‘‘(3) EXCEPTIONS.— 

9 ‘‘(A) CERTAIN INDIVIDUALS EXEMPTED.— 

10 The drug review and utilization requirements 

11 under this subsection shall not apply with re12 spect to an individual who— 

13 ‘‘(i) is receiving— 

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

15 ‘‘(II) treatment for cancer; 

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

17 facility, of a facility described in section 

18 1905(d), or of another facility for which fre19 quently abused drugs are dispensed for resi20 dents through a contract with a single phar21 macy; or 

22 ‘‘(iii) the State elects to treat as ex23 empted from such requirements. 

24 ‘‘(B) EXCEPTION RELATING TO ENSURING

25 ACCESS.—In order to ensure reasonable access to 


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1 health care, the Secretary may waive the drug 

2 review and utilization requirements under this 

3 subsection, with respect to a State, in the case of 

4 natural disasters and similar situations, and in 

5 the case of the provision of emergency services 

6 (as defined for purposes of section 1860D– 

7 4(c)(5)(D)(ii)(II)).’’. 

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

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

10 adding at the end the following new subsection: 

11 ‘‘(i) DRUG UTILIZATION REVIEW ACTIVITIES AND RE12 QUIREMENTS.—Beginning not later than October 1, 2019, 

13 each contract under a State plan with a managed care enti14 ty (other than a primary care case manager) under section 

15 1903(m) shall provide that the entity is in compliance with 

16 the applicable provisions of section 438.3(s)(2) of title 42 

17 of the Code of Federal Regulations, section 483.3(s)(4)) of 

18 such title, and section 483.3(s)(5) of such title, as such pro19 visions were in effect on March 31, 2018.’’. 

20 SEC. 3. IDENTIFYING AND ADDRESSING INAPPROPRIATE 

21 PRESCRIBING AND BILLING PRACTICES 

22 UNDER MEDICAID. 

23 (a) IN GENERAL.—Section 1927(g) of the Social Secu24 rity Act (42 U.S.C. 1396r–8(g)) is amended— 

25 (1) in paragraph (1)(A)— 


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1 (A) by striking ‘‘of section 1903(i)(10)(B)’’ 

2 and inserting ‘‘of section 1902(a)(54)’’; 

3 (B) by striking ‘‘, by not later than Janu4 ary 1, 1993,’’; 

5 (C) by inserting after ‘‘gross overuse,’’ the 

6 following: ‘‘excessive utilization,’’; and 

7 (D) by striking ‘‘or inappropriate or medi8 cally unnecessary care’’ and inserting ‘‘inappro9 priate or medically unnecessary care, or pre10 scribing or billing practices that indicate abuse 

11 or excessive utilization’’; and 

12 (2) in paragraph (2)(B)— 

13 (A) by inserting after ‘‘gross overuse,’’ the 

14 following: ‘‘excessive utilization,’’; 

15 (B) by striking ‘‘or inappropriate or medi16 cally unnecessary care’’ and inserting ‘‘inappro17 priate or medically unnecessary care, or pre18 scribing or billing practices that indicate abuse 

19 or excessive utilization’’; and 

20 (C) by adding at the end the following new 

21 sentence: ‘‘In the case that the program identifies 

22 a pattern described in the previous sentence, the 

23 State shall take such remedial actions as deter24 mined necessary to address such pattern.’’. 


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1 (b) EFFECTIVE DATE.—The amendments made by sub2 section (a) shall take effect with respect to retrospective drug 

3 use reviews conducted on or after October 1, 2020. 

Amend the title so as to read: ‘‘A bill to amend title 

XIX of the Social Security Act to require under Medicaid 

that State Medicaid plans have in place certain drug utilization review activities, and to require States to identify 

and address inappropriate prescribing and billing practices under Medicaid.’’. 


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Union Calendar No. 563 

115TH CONGRESS 

2D SESSION H. R. 5799 

[Report No. 115–728] 

A BILL 

To amend title XIX of the Social Security Act to 

drug utilization review activities. that State Medicaid plans have in place certain medical assistance percentage under Medicaid require as a condition of receipt of full Federal 

JUNE 12, 2018 

Reported with amendments, committed to the Committee 

dered to be printed of the Whole House on the State of the Union, and orVerDate Sep 11 2014 01:06 Jun 13, 2018 Jkt 079200 PO 00000 Frm 00012 Fmt 6651 Sfmt 6651 E:\BILLS\H5799.RH H5799

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