the entity, the limitations described in sub-
clauses (I) and (II) of clause (i) and a 
claims review automated process described 
in subclause (III) of such clause. 
‘‘(iii) RULES
OF
CONSTRUCTION.— 
Nothing in this subparagraph may be con-
strued as prohibiting a State or managed 
care entity from designing and imple-
menting a claims review automated process 
under this subparagraph that provides for 
prospective or retrospective reviews of 
claims. Nothing in this subparagraph shall 
be understood as prohibiting the exercise 
of clinical judgment from a provider en-
rolled as a participating provider in a 
State plan (or waiver of the State plan) or 
contracting with a managed care entity re-
garding the best items and services for an 
individual enrolled under such State plan 
(or waiver). 
‘‘(B) 
PROGRAM
TO
MONITOR 
ANTIPSYCHOTIC MEDICATIONS BY CHILDREN.— 
The State has in place a program (as designed 
and implemented by the State) to monitor and 
manage the appropriate use of antipsychotic 
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medications by children enrolled under the 
State plan (or under a waiver of the State plan) 
and submits annually to the Secretary such in-
formation as the Secretary may require on ac-
tivities carried out under such program for indi-
viduals not more than the age of 18 years gen-
erally and children in foster care specifically. 
‘‘(C) FRAUD
AND
ABUSE
IDENTIFICA-
TION.—The State has in place a process (as de-
signed and implemented by the State) that 
identifies potential fraud or abuse of controlled 
substances by individuals enrolled under the 
State plan (or under a waiver of the State 
plan), health care providers prescribing drugs 
to individuals so enrolled, and pharmacies dis-
pensing drugs to individuals so enrolled. 
‘‘(D) REPORTS.—The State shall include 
in the annual report submitted to the Secretary 
under section 1927(g)(3)(D) information on the 
limitations, requirement, program, and proc-
esses applied by the State under subparagraphs 
(A) through (C) in accordance with such man-
ner and time as specified by the Secretary. 
‘‘(E) CLARIFICATION.—Nothing shall pre-
vent a State from satisfying the requirement— 
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‘‘(i) described in subparagraph (A) by 
having safety edits or a claims review auto-
mated process described in such subpara-
graph that was in place before October 1, 
2019; 
‘‘(ii) described in subparagraph (B) 
by having a program described in such 
subparagraph that was in place before 
such date; or 
‘‘(iii) described in subparagraph (C) 
by having a process described in such sub-
paragraph that was in place before such 
date. 
‘‘(2) ANNUAL
REPORT
BY
SECRETARY.—For 
each fiscal year beginning with fiscal year 2020, the 
Secretary shall submit to Congress a report on the 
most recent information submitted by States under 
paragraph (1)(D). 
‘‘(3) EXCEPTIONS.— 
‘‘(A) CERTAIN INDIVIDUALS EXEMPTED.— 
The drug review and utilization requirements 
under this subsection shall not apply with re-
spect to an individual who— 
‘‘(i) is receiving— 
‘‘(I) hospice or palliative care; or 
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‘‘(II) treatment for cancer; 
‘‘(ii) is a resident of a long-term care 
facility, of a facility described in section 
1905(d), or of another facility for which 
frequently abused drugs are dispensed for 
residents through a contract with a single 
pharmacy; or 
‘‘(iii) the State elects to treat as ex-
empted from such requirements. 
‘‘(B) EXCEPTION RELATING TO ENSURING 
ACCESS.—In order to ensure reasonable access 
to health care, the Secretary shall waive the 
drug review and utilization requirements under 
this subsection, with respect to a State, in the 
case of natural disasters and similar situations, 
and in the case of the provision of emergency 
services (as defined for purposes of section 
1860D–4(c)(5)(D)(ii)(II)).’’. 
(3) MANAGED CARE ENTITIES.—Section 1932 
of the Social Security Act (42 U.S.C. 1396u–2) is 
amended by adding at the end the following new 
subsection: 
‘‘(i) DRUG UTILIZATION REVIEW ACTIVITIES AND 
REQUIREMENTS.—Beginning not later than October 1, 
2019, each contract under a State plan with a managed 
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care entity (other than a primary care case manager) 
under section 1903(m) shall provide that the entity is in 
compliance with the applicable provisions of section 
438.3(s)(2) of title 42 of the Code of Federal Regulations, 
section 483.3(s)(4)) of such title, and section 483.3(s)(5) 
of such title, as such provisions were in effect on March 
31, 2018.’’. 
(b) IDENTIFYING AND ADDRESSING INAPPROPRIATE 
PRESCRIBING
AND BILLING PRACTICES UNDER MED-
ICAID.— 
(1) IN GENERAL.—Section 1927(g) of the So-
cial Security Act (42 U.S.C. 1396r–8(g)) is amend-
ed— 
(A) in paragraph (1)(A)— 
(i) 
by 
striking 
‘‘of 
section 
1903(i)(10)(B)’’ and inserting ‘‘of section 
1902(a)(54)’’; 
(ii) by striking ‘‘, by not later than 
January 1, 1993,’’; 
(iii) by inserting after ‘‘gross over-
use,’’ the following: ‘‘excessive utilization,’’; 
and 
(iv) by striking ‘‘or inappropriate or 
medically unnecessary care’’ and inserting 
‘‘inappropriate or medically unnecessary 
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care, or prescribing or billing practices 
that indicate abuse or excessive utiliza-
tion’’; and 
(B) in paragraph (2)(B)— 
(i) by inserting after ‘‘gross overuse,’’ 
the following: ‘‘excessive utilization,’’; and 
(ii) by striking ‘‘or inappropriate or 
medically unnecessary care’’ and inserting 
‘‘inappropriate or medically unnecessary 
care, or prescribing or billing practices 
that indicate abuse or excessive utiliza-
tion’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall take effect with respect to 
retrospective drug use reviews conducted on or after 
October 1, 2020. 
SEC. 106. GUIDANCE TO IMPROVE CARE FOR INFANTS WITH 
NEONATAL 
ABSTINENCE 
SYNDROME 
AND 
THEIR MOTHERS; GAO STUDY ON GAPS IN 
MEDICAID COVERAGE FOR PREGNANT AND 
POSTPARTUM WOMEN WITH SUBSTANCE USE 
DISORDER. 
(a) GUIDANCE.—Not later than one year after the 
date of the enactment of this Act, the Secretary of Health 
and Human Services shall issue guidance to improve care 
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for infants with neonatal abstinence syndrome and their 
families. Such guidance shall include— 
(1) the types of services, including post-dis-
charge services and parenting supports, for families 
of babies with neonatal abstinence syndrome that 
States may cover under the Medicaid program under 
title XIX of the Social Security Act; 
(2) best practices from States with respect to 
innovative or evidenced-based payment models that 
focus on prevention, screening, treatment, plans of 
safe care, and post-discharge services for mothers 
and fathers with substance use disorders and babies 
with neonatal abstinence syndrome that improve 
care and clinical outcomes; 
(3) recommendations for States on available fi-
nancing options under the Medicaid program under 
title XIX of such Act and under the Children’s 
Health Insurance Program under title XXI of such 
Act for Children’s Health Insurance Program 
Health Services Initiative funds for parents with 
substance use disorders, infants with neonatal absti-
nence syndrome, and home visiting services; and 
(4) guidance and technical assistance to State 
Medicaid agencies regarding additional flexibilities 
and incentives related to screening, prevention, and 
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post-discharge services, including parenting sup-
ports. 
(b) GAO STUDY.—Not later than one year after the 
date of the enactment of this Act, the Comptroller General 
of the United States shall conduct a study, and submit 
to Congress a report, addressing gaps in coverage for 
pregnant women with substance use disorder under the 
Medicaid program under title XIX of the Social Security 
Act, and gaps in coverage for postpartum women with sub-
stance use disorder who had coverage during their preg-
nancy under the Medicaid program under such title. 
SEC. 107. MEDICAID HEALTH HOMES FOR OPIOID-USE-DIS-
ORDER MEDICAID ENROLLEES. 
(a) EXTENSION OF ENHANCED FMAP FOR CERTAIN 
HEALTH HOMES FOR INDIVIDUALS WITH SUBSTANCE 
USE DISORDERS.—Section 1945 of the Social Security 
Act (42 U.S.C. 1396w–4) is amended— 
(1) in subsection (c)— 
(A) in paragraph (1), by inserting ‘‘subject 
to paragraph (4),’’ after ‘‘except that,’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(4) SPECIAL RULE RELATING TO SUBSTANCE 
USE DISORDER HEALTH HOMES.— 
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‘‘(A) IN GENERAL.—In the case of a State 
with an SUD-focused State plan amendment 
approved by the Secretary on or after October 
1, 2018, the Secretary may, at the request of 
the State, extend the application of the Federal 
medical assistance percentage described in 
paragraph (1) to payments for the provision of 
health home services to SUD-eligible individuals 
under such State plan amendment, in addition 
to the first 8 fiscal year quarters the State plan 
amendment is in effect, for the subsequent 2 
fiscal year quarters that the State plan amend-
ment is in effect. Nothing in this section shall 
be construed as prohibiting a State with a State 
plan amendment that is approved under this 
section and that is not an SUD-focused State 
plan amendment from additionally having ap-
proved on or after such date an SUD-focused 
State plan amendment under this section, in-
cluding for purposes of application of this para-
graph. 
‘‘(B) REPORT
REQUIREMENTS.—In the 
case of a State with an SUD-focused State plan 
amendment for which the application of the 
Federal medical assistance percentage has been 
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extended under subparagraph (A), such State 
shall, at the end of the period of such State 
plan amendment, submit to the Secretary a re-
port on the following, with respect to SUD-eli-
gible individuals provided health home services 
under such State plan amendment: 
‘‘(i) The quality of health care pro-
vided to such individuals, with a focus on 
outcomes relevant to the recovery of each 
such individual. 
‘‘(ii) The access of such individuals to 
health care. 
‘‘(iii) The total expenditures of such 
individuals for health care. 
For purposes of this subparagraph, the 
Secretary shall specify all applicable meas-
ures for determining quality, access, and 
expenditures. 
‘‘(C) BEST
PRACTICES.—Not later than 
October 1, 2020, the Secretary shall make pub-
licly available on the Internet website of the 
Centers for Medicare & Medicaid Services best 
practices for designing and implementing an 
SUD-focused State plan amendment, based on 
the experiences of States that have State plan 
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amendments approved under this section that 
include SUD-eligible individuals. 
‘‘(D) DEFINITIONS.—For purposes of this 
paragraph: 
‘‘(i) SUD-ELIGIBLE
INDIVIDUALS.— 
The term ‘SUD-eligible individual’ means, 
with respect to a State, an individual who 
satisfies all of the following: 
‘‘(I) The individual is an eligible 
individual with chronic conditions. 
‘‘(II) The individual is an indi-
vidual with a substance use disorder. 
‘‘(III) The individual has not pre-
viously received health home services 
under any other State plan amend-
ment approved for the State under 
this section by the Secretary. 
‘‘(ii) 
SUD-FOCUSED
STATE
PLAN 
AMENDMENT.—The 
term 
‘SUD-focused 
State plan amendment’ means a State plan 
amendment under this section that is de-
signed to provide health home services pri-
marily to SUD-eligible individuals.’’. 
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(b) REQUIREMENT FOR STATE MEDICAID PLANS TO 
PROVIDE COVERAGE FOR MEDICATION-ASSISTED TREAT-
MENT.— 
(1) REQUIREMENT FOR STATE MEDICAID PLANS 
TO PROVIDE COVERAGE FOR MEDICATION-ASSISTED 
TREATMENT.—Section 1902(a)(10)(A) of the Social 
Security Act (42 U.S.C. 1396a(a)(10)(A)) is amend-
ed, in the matter preceding clause (i), by striking 
‘‘and (28)’’ and inserting ‘‘(28), and (29)’’. 
(2) 
INCLUSION
OF
MEDICATION-ASSISTED 
TREATMENT
AS
MEDICAL
ASSISTANCE.—Section 
1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)) is amended— 
(A) in paragraph (28), by striking ‘‘and’’ 
at the end; 
(B) by redesignating paragraph (29) as 
paragraph (30); and 
(C) by inserting after paragraph (28) the 
following new paragraph: 
‘‘(29) subject to paragraph (2) of subsection 
(ee), for the period beginning October 1, 2020, and 
ending September 30, 2025, medication-assisted 
treatment (as defined in paragraph (1) of such sub-
section); and’’. 
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(3) MEDICATION-ASSISTED
TREATMENT
DE-
FINED; WAIVERS.—Section 1905 of the Social Secu-
rity Act (42 U.S.C. 1396d) is amended by adding at 
the end the following new subsection: 
‘‘(ee) MEDICATION-ASSISTED TREATMENT.— 
‘‘(1) DEFINITION.—For purposes of subsection 
(a)(29), the term ‘medication-assisted treatment’— 
‘‘(A) means all drugs approved under sec-
tion 505 of the Federal Food, Drug, and Cos-
metic Act (21 U.S.C. 355), including metha-
done, and all biological products licensed under 
section 351 of the Public Health Service Act 
(42 U.S.C. 262) to treat opioid use disorders; 
and 
‘‘(B) includes, with respect to the provision 
of such drugs and biological products, coun-
seling services and behavioral therapy. 
‘‘(2) EXCEPTION.—The provisions of paragraph 
(29) of subsection (a) shall not apply with respect to 
a State for the period specified in such paragraph, 
if before the beginning of such period the State cer-
tifies to the satisfaction of the Secretary that imple-
menting such provisions statewide for all individuals 
eligible to enroll in the State plan (or waiver of the 
State plan) would not be feasible by reason of a 
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shortage of qualified providers of medication-assisted 
treatment, or facilities providing such treatment, 
that will contract with the State or a managed care 
entity with which the State has a contract under 
section 1903(m) or under section 1905(t)(3).’’. 
(4) EFFECTIVE DATE.— 
(A) IN
GENERAL.—Subject to subpara-
graph (B), the amendments made by this sub-
section shall apply with respect to medical as-
sistance provided on or after October 1, 2020, 
and before October 1, 2025. 
(B) EXCEPTION
FOR
STATE
LEGISLA-
TION.—In the case of a State plan under title 
XIX of the Social Security Act (42 U.S.C. 1396 
et seq.) that the Secretary of Health and 
Human Services determines requires State leg-
islation in order for the respective plan to meet 
any requirement imposed by the amendments 
made by this subsection, the respective plan 
shall not be regarded as failing to comply with 
the requirements of such title solely on the 
basis of its failure to meet such an additional 
requirement before the first day of the first cal-
endar quarter beginning after the close of the 
first regular session of the State legislature that 
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begins after the date of the enactment of this 
Act. For purposes of the previous sentence, in 
the case of a State that has a 2-year legislative 
session, each year of the session shall be consid-
ered to be a separate regular session of the 
State legislature. 
TITLE 
II—MEDICARE 
PROVI-
SIONS 
TO 
ADDRESS 
THE 
OPIOID CRISIS 
SEC. 201. AUTHORITY NOT TO APPLY CERTAIN MEDICARE 
TELEHEALTH REQUIREMENTS IN THE CASE 
OF CERTAIN TREATMENT OF A SUBSTANCE 
USE DISORDER OR CO-OCCURRING MENTAL 
HEALTH DISORDER. 
Section 1834(m) of the Social Security Act (42 
U.S.C. 1395m(m)) is amended— 
(1) in paragraph (2)(B)(i), by inserting ‘‘and 
paragraph (7)(E)’’ after ‘‘Subject to clause (ii)’’; 
and 
(2) by adding at the end the following new 
paragraphs: 
‘‘(7) AUTHORITY NOT TO APPLY CERTAIN RE-
QUIREMENTS IN THE CASE OF CERTAIN TREATMENT 
OF SUBSTANCE USE DISORDER OR CO-OCCURRING 
MENTAL HEALTH DISORDER.— 
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‘‘(A) IN GENERAL.—For purposes of pay-
ment under this subsection, in the case of tele-
health services described in subparagraph (C) 
furnished on or after January 1, 2020, to an el-
igible beneficiary (as defined in subparagraph 
(F)) for the treatment of a substance use dis-
order or a mental health disorder that is co-oc-
curring with a substance use disorder, the Sec-
retary is authorized to, through rulemaking, not 
apply any of the requirements described in sub-
paragraph (B). 
‘‘(B) REQUIREMENTS
DESCRIBED.—For 
purposes of this paragraph, the requirements 
described in this subparagraph are any of the 
following: 
‘‘(i) Qualifications for an originating 
site under paragraph (4)(C)(ii). 
‘‘(ii) Geographic limitations under 
paragraph (4)(C)(i). 
‘‘(C) 
TELEHEALTH
SERVICES
DE-
SCRIBED.—For purposes of this paragraph, the 
telehealth services described in this subpara-
graph are services that are both telehealth serv-
ices and identified by the Secretary, through 
rulemaking, as services that are the most com-
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monly furnished (as defined by the Secretary) 
under this part to individuals diagnosed with a 
substance use disorder or a mental health dis-
order that is co-occurring with a substance use 
disorder. 
‘‘(D) CLARIFICATION.—Nothing in this 
paragraph shall be construed as limiting or oth-
erwise affecting the authority of the Secretary 
to limit or eliminate the non-application pursu-
ant to this paragraph of any of the require-
ments under subparagraph (B). 
‘‘(E) TREATMENT
OF
ORIGINATING
SITE 
FACILITY FEE.—No facility fee shall be paid 
under paragraph (2)(B) to an originating site 
with respect to a telehealth service described in 
subparagraph (B) for which payment is made 
under this subsection by reason of the non-ap-
plication of a requirement described in subpara-
graph (B) pursuant to this paragraph if pay-
ment for such service would not otherwise be 
permitted under this subsection if such require-
ment were applied. 
‘‘(F) ELIGIBLE BENEFICIARY DEFINED.— 
For purposes of this paragraph, the term ‘eligi-
ble beneficiary’ means an individual who— 
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‘‘(i) is entitled to, or enrolled for, ben-
efits under part A and enrolled for benefits 
under this part; 
‘‘(ii) has a diagnosis for a substance 
use disorder; and 
‘‘(iii) meets such other criteria as the 
Secretary determines appropriate. 
‘‘(G) REPORT.—Not later than 5 years 
after the date of the enactment of this para-
graph, the Secretary shall submit to Congress a 
report on the impact of any non-application 
under this paragraph of any of the require-
ments described in subparagraph (B) on 
‘‘(i) the utilization of health care serv-
ices related to substance use disorder, such 
as behavioral health services and emer-
gency department visits; and 
‘‘(ii) health outcomes related to sub-
stance use disorder, such as substance use 
overdose deaths. 
‘‘(H) FUNDING.—For purposes of carrying 
out this paragraph, in addition to funds other-
wise available, the Secretary shall provide for 
the transfer, from the Federal Supplementary 
Medical Insurance Trust Fund under section 
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1841, of $3,000,000 to the Centers for Medi-
care & Medicaid Services Program Management 
Account to remain available until expended. 
‘‘(8) RULE
OF
CONSTRUCTION.—Nothing in 
this subsection may be construed as waiving require-
ments under this title to comply with applicable 
State law, including State licensure requirements.’’. 
SEC. 202. ENCOURAGING THE USE OF NON-OPIOID ANALGE-
SICS FOR THE MANAGEMENT OF POST-SUR-
GICAL PAIN. 
Section 1833(t)(6) of the Social Security Act (42 
U.S.C. 1395l(t)(6)) is amended— 
(1) in subparagraph (C)(i), by inserting ‘‘or, in 
the case of an eligible non-opioid analgesic (as de-
fined in subparagraph (J)), during a period of 5 
years,’’ after ‘‘3 years,’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(J) ELIGIBLE
NON-OPIOID
ANALGESIC 
DEFINED.—In this paragraph, the term ‘eligible 
non-opioid analgesic’ means a drug or biologi-
cal— 
‘‘(i) that is an analgesic that is not an 
opioid; 
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‘‘(ii) that demonstrated substantial 
clinical improvement; and 
‘‘(iii) for which payment— 
‘‘(I) as an outpatient hospital 
service under this part was not being 
made as of the date of the enactment 
of this subparagraph; or 
‘‘(II) was being made under this 
paragraph as of such date.’’. 
SEC. 203. REQUIRING A REVIEW OF CURRENT OPIOID PRE-
SCRIPTIONS 
FOR 
CHRONIC 
PAIN 
AND 
SCREENING FOR OPIOID USE DISORDER TO 
BE INCLUDED IN THE WELCOME TO MEDI-
CARE INITIAL PREVENTIVE PHYSICAL EXAM-
INATION. 
(a) IN GENERAL.—Section 1861(ww) of the Social 
Security Act (42 U.S.C. 1395x(ww)) is amended— 
(1) in paragraph (1), by inserting ‘‘and a re-
view of current opioid prescriptions and screening 
for opioid use disorder (as defined in paragraph 
(4)),’’ before ‘‘but does not include’’; and 
(2) by adding at the end the following new 
paragraph: 
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‘‘(4)(A) For purposes of paragraph (1), the term ‘a 
review of current opioid prescriptions and screening for 
opioid use disorder’ means, with respect to an individual— 
‘‘(i) a review by a physician or qualified non- 
physician practitioner of all current prescriptions of 
the individual; and 
‘‘(ii) in the case of an individual determined by 
the review of a physician or qualified non-physician 
practitioner under subparagraph (A) to have a cur-
rent prescription for opioids for chronic pain that 
has been prescribed for a minimum period of time 
(as specified by the Secretary)— 
‘‘(I) a review by the physician or practi-
tioner of the potential risk factors to the indi-
vidual for opioid use disorder; 
‘‘(II) an evaluation by the physician or 
practitioner of pain of the individual; 
‘‘(III) the provision of information regard-
ing non-opioid treatment options for the treat-
ment and management of any chronic pain of 
the individual; and 
‘‘(IV) if determined necessary by the physi-
cian or practitioner based on the results of the 
review and evaluation conducted as described in 
this paragraph, an appropriate referral by the 
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physician or practitioner for additional treat-
ment. 
‘‘(B) For purposes of this paragraph, the term ‘quali-
fied non-physician practitioner’ means a physician assist-
ant, nurse practitioner, or certified clinical nurse spe-
cialist.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply with respect to initial preventive 
physical examinations furnished on or after January 1, 
2020. 
SEC. 204. MODIFICATION OF PAYMENT FOR CERTAIN OUT-
PATIENT SURGICAL SERVICES. 
(a) FREEZE OF PAYMENT FOR CERTAIN SERVICES 
FURNISHED IN AMBULATORY SURGICAL CENTERS.—Sec-
tion 1833(i)(2) of the Social Security Act (42 U.S.C. 
1395l(i)(2)) is amended by adding at the end the following 
new subparagraph: 
‘‘(F)(i) With respect to a targeted procedure 
(as defined in clause (ii)) furnished during 2020 or 
a subsequent year (before 2024) to an individual in 
an ambulatory surgical center, the payment amount 
for such procedure that would otherwise be deter-
mined under the revised payment system under sub-
paragraph (D), without application of this subpara-
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graph, shall be equal to the payment amount for 
such procedure furnished in 2016. 
‘‘(ii) For purposes of clause (i), the term ‘tar-
geted procedure’ means a procedure to which 
Healthcare Common Procedure Coding System 
62310 (or, for years beginning after 2016, 62321), 
62311 (or, for years beginning after 2016, 62323), 
62264, 64490, 64493, or G0260 (or any successor 
code) applies. 
‘‘(iii) This subparagraph shall not be applied in 
a budget-neutral manner.’’. 
(b) DATA COLLECTION.— 
(1) IN
GENERAL.—The Comptroller General 
shall collect data relating to the cost differential be-
tween targeted procedures (as defined in section 
1833(i)(2)(F)(ii) of the Social Security Act, as 
added by subsection (a)) that are performed in a 
hospital operating room and such procedures that 
are performed in an office setting within a hospital 
in order to determine whether such procedures are 
being properly coded for claims, based on setting, for 
payment under section 1833(i)(2)(D) of the Social 
Security Act (42 U.S.C. 1395l(i)(2)(D)) and to de-
termine if further changes are needed in the classi-
fication system for covered outpatient department 
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services (as described in section 1833(t)(2)(A) of the 
Social Security Act (42 U.S.C. 1395l(t)(2)(A)). 
(2) REPORT.—Not later than 4 years after the 
date of the enactment of this Act, the Comptroller 
General shall submit a report to the Committee on 
Energy and Commerce and the Committee on Ways 
and Means of the House of Representatives and the 
Committee on Finance of the Senate containing— 
(A) a determination of whether procedures 
described in paragraph (1) are being properly 
coded for claims, based on setting, for payment 
under section 1833(i)(2)(D) of the Social Secu-
rity Act (42 U.S.C. 1395l(i)(2)(D)); and 
(B) recommendations on any changes the 
Comptroller General determines are needed in 
the classification system for covered outpatient 
department services (as described in section 
1833(t)(2)(A) of the Social Security Act (42 
U.S.C. 1395l(t)(2)(A)). 
(c) STUDY.—Not later than 3 years after the date 
of the enactment of this Act, the Secretary of Health and 
Human Services shall conduct a study and submit to Con-
gress a report on the extent to which procedures described 
in section 1833(i)(2)(F)(ii) of the Social Security Act, as 
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added by subsection (a), are effective at preventing the 
need for opioids for individuals furnished such procedures. 
SEC. 205. REQUIRING E-PRESCRIBING FOR COVERAGE OF 
COVERED 
PART 
D 
CONTROLLED 
SUB-
STANCES. 
(a) IN GENERAL.—Section 1860D–4(e) of the Social 
Security Act (42 U.S.C. 1395w–104(e)) is amended by 
adding at the end the following: 
‘‘(7) REQUIREMENT
OF
E-PRESCRIBING
FOR 
CONTROLLED SUBSTANCES.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), a prescription for a covered part D 
drug under a prescription drug plan (or under 
an MA–PD plan) for a schedule II, III, IV, or 
V controlled substance shall be transmitted by 
a health care practitioner electronically in ac-
cordance with an electronic prescription drug 
program that meets the requirements of para-
graph (2). 
‘‘(B) 
EXCEPTION
FOR
CERTAIN
CIR-
CUMSTANCES.—The Secretary shall, pursuant 
to rulemaking, specify circumstances with re-
spect to which the Secretary may waive the re-
quirement under subparagraph (A), with re-
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spect to a covered part D drug, including in the 
case of— 
‘‘(i) a prescription issued when the 
practitioner and dispenser are the same 
entity; 
‘‘(ii) a prescription issued that cannot 
be transmitted electronically under the 
most recently implemented version of the 
National Council for Prescription Drug 
Programs SCRIPT Standard; 
‘‘(iii) a prescription issued by a practi-
tioner who has received a waiver or a re-
newal thereof for a specified period deter-
mined by the Secretary, not to exceed one 
year, from the requirement to use elec-
tronic prescribing, pursuant to a process 
established by regulation by the Secretary, 
due to demonstrated economic hardship, 
technological limitations that are not rea-
sonably within the control of the practi-
tioner, or other exceptional circumstance 
demonstrated by the practitioner; 
‘‘(iv) a prescription issued by a practi-
tioner under circumstances in which, not-
withstanding the practitioner’s ability to 
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submit a prescription electronically as re-
quired by this subsection, such practitioner 
reasonably determines that it would be im-
practical for the individual involved to ob-
tain substances prescribed by electronic 
prescription in a timely manner, and such 
delay would adversely impact the individ-
ual’s medical condition involved; 
‘‘(v) a prescription issued by a practi-
tioner allowing for the dispensing of a non- 
patient specific prescription pursuant to a 
standing order, approved protocol for drug 
therapy, collaborative drug management, 
or comprehensive medication management, 
in response to a public health emergency, 
or other circumstances where the practi-
tioner may issue a non-patient specific pre-
scription; 
‘‘(vi) a prescription issued by a practi-
tioner prescribing a drug under a research 
protocol; 
‘‘(vii) a prescription issued by a prac-
titioner for a drug for which the Food and 
Drug Administration requires a prescrip-
tion to contain elements that are not able 
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to be included in electronic prescribing, 
such as a drug with risk evaluation and 
mitigation strategies that include elements 
to assure safe use; and 
‘‘(viii) a prescription issued by a prac-
titioner for an individual who— 
‘‘(I) receives hospice care under 
this title; or 
‘‘(II) is a resident of a skilled 
nursing facility (as defined in section 
1819(a)), or a medical institution or 
nursing facility for which payment is 
made for an institutionalized indi-
vidual under section 1902(q)(1)(B), 
for which frequently abused drugs are 
dispensed for residents through a con-
tract with a single pharmacy, as de-
termined by the Secretary in accord-
ance with this paragraph. 
‘‘(C) DISPENSING.—Nothing in this para-
graph shall be construed as requiring a sponsor 
of a prescription drug plan under this part, MA 
organization offering an MA–PD plan under 
part C, or a pharmacist to verify that a practi-
tioner, with respect to a prescription for a cov-
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ered part D drug, has a waiver (or is otherwise 
exempt) under subparagraph (B) from the re-
quirement under subparagraph (A). Nothing in 
this paragraph shall be construed as affecting 
the ability of the plan to cover or the phar-
macists’ ability to continue to dispense covered 
part D drugs from otherwise valid written, oral 
or fax prescriptions that are consistent with 
laws and regulations. Nothing in this paragraph 
shall be construed as affecting the ability of the 
beneficiary involved to designate a particular 
pharmacy to dispense a prescribed drug to the 
extent consistent with the requirements under 
subsection (b)(1) and under this paragraph. 
‘‘(D) 
ENFORCEMENT.—The 
Secretary 
shall, pursuant to rulemaking, have authority to 
enforce and specify appropriate penalties for 
non-compliance with the requirement under 
subparagraph (A).’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to coverage of drugs prescribed 
on or after January 1, 2021. 
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SEC. 206. REQUIRING PRESCRIPTION DRUG PLAN SPON-
SORS 
UNDER 
MEDICARE 
TO 
ESTABLISH 
DRUG MANAGEMENT PROGRAMS FOR AT- 
RISK BENEFICIARIES. 
Section 1860D–4(c) of the Social Security Act (42 
U.S.C. 1395w–104(c)) is amended— 
(1) in paragraph (1), by inserting after sub-
paragraph (E) the following new subparagraph: 
‘‘(F) With respect to plan years beginning 
on or after January 1, 2021, a drug manage-
ment program for at-risk beneficiaries described 
in paragraph (5).’’; and 
(2) in paragraph (5)(A), by inserting ‘‘(and for 
plan years beginning on or after January 1, 2021, 
a PDP sponsor shall)’’ after ‘‘A PDP sponsor may’’. 
SEC. 207. MEDICARE COVERAGE OF CERTAIN SERVICES 
FURNISHED BY OPIOID TREATMENT PRO-
GRAMS. 
(a) COVERAGE.—Section 1861(s)(2) of the Social Se-
curity Act (42 U.S.C. 1395x(s)(2)) is amended— 
(1) in subparagraph (FF), by striking at the 
end ‘‘and’’; 
(2) in subparagraph (GG), by inserting at the 
end ‘‘; and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
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‘‘(HH) opioid use disorder treatment serv-
ices (as defined in subsection (jjj)).’’. 
(b) OPIOID USE DISORDER TREATMENT SERVICES 
AND OPIOID TREATMENT PROGRAM DEFINED.—Section 
1861 of the Social Security Act is amended by adding at 
the end the following new subsection: 
‘‘(jjj) OPIOID USE DISORDER TREATMENT SERV-
ICES; OPIOID TREATMENT PROGRAM.— 
‘‘(1) OPIOID USE DISORDER TREATMENT SERV-
ICES.—The term ‘opioid use disorder treatment serv-
ices’ means items and services that are furnished by 
an opioid treatment program for the treatment of 
opioid use disorder, including— 
‘‘(A) opioid agonist and antagonist treat-
ment medications (including oral, injected, or 
implanted versions) that are approved by the 
Food and Drug Administration under section 
505 of the Federal Food, Drug and Cosmetic 
Act for use in the treatment of opioid use dis-
order; 
‘‘(B) dispensing and administration of 
such medications, if applicable; 
‘‘(C) substance use counseling by a profes-
sional to the extent authorized under State law 
to furnish such services; 
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‘‘(D) individual and group therapy with a 
physician or psychologist (or other mental 
health professional to the extent authorized 
under State law); 
‘‘(E) toxicology testing, and 
‘‘(F) other items and services that the Sec-
retary determines are appropriate (but in no 
event to include meals or transportation). 
‘‘(2) OPIOID TREATMENT PROGRAM.—The term 
‘opioid treatment program’ means an entity that is 
opioid treatment program (as defined in section 8.2 
of title 42 of the Code of Federal Regulations, or 
any successor regulation) that— 
‘‘(A) is enrolled under section 1866(j); 
‘‘(B) has in effect a certification by the 
Substance Abuse and Mental Health Services 
Administration for such a program; 
‘‘(C) is accredited by an accrediting body 
approved by the Substance Abuse and Mental 
Health Services Administration; and 
‘‘(D) meets such additional conditions as 
the Secretary may find necessary to ensure— 
‘‘(i) the health and safety of individ-
uals being furnished services under such 
program; and 
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‘‘(ii) the effective and efficient fur-
nishing of such services.’’. 
(c) PAYMENT.— 
(1) IN GENERAL.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)) is 
amended— 
(A) by striking ‘‘and (BB)’’ and inserting 
‘‘(BB)’’; and 
(B) by inserting before the semicolon at 
the end the following ‘‘, and (CC) with respect 
to opioid use disorder treatment services fur-
nished during an episode of care, the amount 
paid shall be equal to the amount payable under 
section 1834(w) less any copayment required as 
specified by the Secretary’’. 
(2) PAYMENT DETERMINATION.—Section 1834 
of the Social Security Act (42 U.S.C. 1395m) is 
amended by adding at the end the following new 
subsection: 
‘‘(w) OPIOID USE DISORDER TREATMENT SERV-
ICES.— 
‘‘(1) IN GENERAL.—The Secretary shall pay to 
an opioid treatment program (as defined in para-
graph (2) of section 1861(jjj)) an amount that is 
equal to 100 percent of a bundled payment under 
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this part for opioid use disorder treatment services 
(as defined in paragraph (1) of such section) that 
are furnished by such program to an individual dur-
ing an episode of care (as defined by the Secretary) 
beginning on or after January 1, 2020. The Sec-
retary shall ensure, as determined appropriate by 
the Secretary, that no duplicative payments are 
made under this part or part D for items and serv-
ices furnished by an opioid treatment program. 
‘‘(2) CONSIDERATIONS.—The Secretary may 
implement this subsection through one or more bun-
dles based on the type of medication provided (such 
as buprenorphine, methadone, naltrexone, or a new 
innovative drug), the frequency of services, the scope 
of services furnished, characteristics of the individ-
uals furnished such services, or other factors as the 
Secretary determine appropriate. In developing such 
bundles, the Secretary may consider payment rates 
paid to opioid treatment programs for comparable 
services under State plans under title XIX or under 
the TRICARE program under chapter 55 of title 10 
of the United States Code. 
‘‘(3) ANNUAL UPDATES.—The Secretary shall 
provide an update each year to the bundled payment 
amounts under this subsection.’’. 
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(d) INCLUDING OPIOID TREATMENT PROGRAMS AS 
MEDICARE PROVIDERS.—Section 1866(e) of the Social 
Security Act (42 U.S.C. 1395cc(e)) is amended— 
(1) in paragraph (1), by striking at the end 
‘‘and’’; 
(2) in paragraph (2), by striking the period at 
the end and inserting ‘‘; and’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(3) opioid treatment programs (as defined in 
paragraph (2) of section 1861(jjj)), but only with re-
spect to the furnishing of opioid use disorder treat-
ment services (as defined in paragraph (1) of such 
section).’’. 
TITLE III—OTHER HEALTH PRO-
VISIONS TO ADDRESS THE 
OPIOID CRISIS 
SEC. 301. CLARIFYING FDA REGULATION OF NON-ADDICT-
IVE PAIN AND ADDICTION THERAPIES. 
(a) PUBLIC MEETINGS.—Not later than 1 year after 
the date of enactment of this Act, the Secretary of Health 
and Human Services, acting through the Commissioner of 
Food and Drugs, shall hold not less than one public meet-
ing to address the challenges and barriers of developing 
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non-addictive medical products intended to treat pain or 
addiction, which may include— 
(1) the application of novel clinical trial designs 
(consistent with section 3021 of the 21st Century 
Cures Act (Public Law 114–255)), use of real world 
evidence (consistent with section 505F of the Fed-
eral Food, Drug, and Cosmetic Act (21 U.S.C. 
355g)), and use of patient experience data (con-
sistent with section 569C of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 360bbb–8c)) for 
the development of non-addictive medical products 
intended to treat pain or addiction; and 
(2) the application of eligibility criteria under 
sections 506 and 515B of the Federal Food, Drug, 
and Cosmetic Act (21 U.S.C. 356, 360e–3) for non- 
addictive medical products intended to treat pain or 
addiction. 
(b) GUIDANCE.—Not later than one year after the 
public meetings are conducted under subsection (a) the 
Secretary shall issue one or more final guidance docu-
ments, or update existing guidance documents, to help ad-
dress challenges to developing non-addictive medical prod-
ucts to treat pain or addiction. Such guidance documents 
shall include information regarding— 
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(1) how the Food and Drug Administration 
may apply sections 506 and 515B of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 356, 
360e–3) to non-addictive medical products intended 
to treat pain or addiction, including the cir-
cumstances under which the Secretary— 
(A) may apply the eligibility criteria under 
such sections 506 and 515B to non-opioid or 
non-addictive medical products intended to 
treat pain or addiction; 
(B) considers the risk of addiction of con-
trolled substances approved to treat pain when 
establishing unmet medical need; and 
(C) considers pain, pain control, or pain 
management in assessing whether a disease or 
condition is a serious or life-threatening disease 
or condition; and 
(2) the methods by which sponsors may evalu-
ate acute and chronic pain, endpoints for non-addict-
ive medical products intended to treat pain, the 
manner in which endpoints and evaluations of effi-
cacy will be applied across and within review divi-
sions, taking into consideration the etiology of the 
underlying disease, and the manner in which spon-
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sors may use surrogate endpoints, intermediate 
endpoints, and real world evidence. 
(c) MEDICAL PRODUCT DEFINED.—In this section, 
the term ‘‘medical product’’ means a drug (as defined in 
section 201(g)(1) of the Federal Food, Drug, and Cos-
metic Act (21 U.S.C. 321(g)(1))), biological product (as 
defined in section 351(i) of the Public Health Service Act 
(42 U.S.C. 262(i))), or device (as defined in section 
201(h) of the Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 321(h))). 
SEC. 302. SURVEILLANCE AND TESTING OF OPIOIDS TO 
PREVENT FENTANYL DEATHS. 
(a) PUBLIC HEALTH LABORATORIES TO DETECT 
FENTANYL.—Part F of title III of the Public Health Serv-
ice Act (42 U.S.C. 262 et seq.) is amended— 
(1) in the heading of part F, by striking ‘‘AND 
CLINICAL LABORATORIES’’ and inserting ‘‘, CLIN-
ICAL LABORATORIES, AND PUBLIC HEALTH LAB-
ORATORIES’’; and 
(2) by adding at the end the following new sub-
part: 
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‘‘Subpart 4—Public Health Laboratories 
‘‘SEC. 355. PUBLIC HEALTH LABORATORIES TO DETECT 
FENTANYL. 
‘‘(a) IN GENERAL.—The Secretary shall establish a 
program to award grants to Federal, State, and local 
agencies to support the establishment or operation of pub-
lic health laboratories to detect fentanyl, its analogues, 
and other synthetic opioids, as described in subsection (b). 
‘‘(b) STANDARDS.—The Secretary, in consultation 
with the Director of the National Institute of Standards 
and Technology, shall— 
‘‘(1) develop standards for safely and effectively 
handling and testing fentanyl, its analogues, and 
other synthetic opioids; 
‘‘(2) develop fentanyl and fentanyl analog ref-
erence materials and quality control standards and 
protocols to calibrate instrumentation for clinical 
diagnostics and postmortem surveillance; and 
‘‘(3) include in the standards developed pursu-
ant to paragraph (1) procedures for encountering 
new and emerging synthetic opioid formulations and 
reporting those findings to other Federal, State, and 
local public health laboratories. 
‘‘(c) LABORATORIES.—The Secretary shall require 
grantees under subsection (a) to— 
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‘‘(1) follow the standards established under 
subsection (b) and be capable of providing system-
atic and routine laboratory testing of drugs for the 
purposes of obtaining and disseminating public 
health information to Federal, State, and local pub-
lic health officials, laboratories, and other entities 
the Secretary deems appropriate; 
‘‘(2) work with law enforcement agencies and 
public health authorities, as feasible, to develop real- 
time information on the purity and movement of 
fentanyl, its analogues, and other synthetic opioids; 
‘‘(3) assist State and local law enforcement 
agencies in testing seized drugs when State and local 
forensic laboratories request additional assistance; 
‘‘(4) provide early warning information and ad-
vice to Federal, State, and local law enforcement 
agencies and public health authorities regarding po-
tential significant changes in the supply of fentanyl, 
its analogues, and other synthetic opioids; 
‘‘(5) provide biosurveillance for non-fatal expo-
sures; and 
‘‘(6) provide diagnostic testing for non-fatal ex-
posures of emergency personnel. 
‘‘(d) AUTHORIZATION
OF
APPROPRIATIONS.—To 
carry out this section, there is authorized to be appro-
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priated $15,000,000 for each of fiscal years 2019 through 
2023.’’. 
(b) ENHANCED FENTANYL SURVEILLANCE.—Title 
III of the Public Health Service Act is amended by insert-
ing after section 317T of such Act (42 U.S.C. 247b–22) 
the following new section: 
‘‘SEC. 317U. ENHANCED FENTANYL SURVEILLANCE. 
‘‘(a) IN GENERAL.—The Director of the Centers for 
Disease Control and Prevention shall enhance its drug 
surveillance program by— 
‘‘(1) expanding its surveillance program to in-
clude all 50 States and the territories of the United 
States; 
‘‘(2) increasing and accelerating the collection 
of data on fentanyl, its analogues, and other syn-
thetic opioids and new emerging drugs of abuse, in-
cluding related overdose data from medical exam-
iners and drug treatment admissions; and 
‘‘(3) utilizing available and emerging informa-
tion on fentanyl, its analogues, and other synthetic 
opioids and new emerging drugs of abuse, including 
information from— 
‘‘(A) the National Drug Early Warning 
System; 
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‘‘(B) State and local public health authori-
ties; and 
‘‘(C) Federal, State, and local public 
health laboratories. 
‘‘(b) AUTHORIZATION
OF
APPROPRIATIONS.—To 
carry out this section, there is authorized to be appro-
priated $10,000,000 for each of fiscal years 2019 through 
2023.’’. 
(c) PILOT PROGRAM FOR POINT-OF-USE TESTING OF 
ILLICIT DRUGS FOR DANGEROUS CONTAMINANTS.—Part 
P of title III of the Public Health Service Act (42 U.S.C. 
280g et seq.) is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 399V–7. PILOT PROGRAM FOR POINT-OF-USE TESTING 
OF ILLICIT DRUGS FOR DANGEROUS CON-
TAMINANTS. 
‘‘(a) IN GENERAL.—The Secretary shall— 
‘‘(1) establish a pilot program through which 5 
State or local agencies conduct, in 5 States, point- 
of-use testing of illicit drugs for dangerous contami-
nants; 
‘‘(2) establish metrics to evaluate the success of 
the pilot program in reducing drug overdose rates; 
and 
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‘‘(3) based on such metrics, conduct an annual 
evaluation of the pilot program and submit an an-
nual report to the Congress containing the results of 
such evaluation. 
‘‘(b) AUTHORIZATION
OF
APPROPRIATIONS.—To 
carry out this section, there is authorized to be appro-
priated $5,000,000 for each of fiscal years 2019 through 
2023.’’. 
SEC. 303. ALLOWING FOR MORE FLEXIBILITY WITH RE-
SPECT 
TO 
MEDICATION-ASSISTED 
TREAT-
MENT FOR OPIOID USE DISORDERS. 
(a) CONFORMING APPLICABLE NUMBER.—Subclause 
(II) of section 303(g)(2)(B)(iii) of the Controlled Sub-
stances Act (21 U.S.C. 823(g)(2)(B)(iii)) is amended to 
read as follows: 
‘‘(II) The applicable number is— 
‘‘(aa) 100 if, not sooner than 1 year after 
the date on which the practitioner submitted 
the initial notification, the practitioner submits 
a second notification to the Secretary of the 
need and intent of the practitioner to treat up 
to 100 patients; 
‘‘(bb) 100 if the practitioner holds addi-
tional credentialing, as defined in section 8.2 of 
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title 42, Code of Federal Regulations (or suc-
cessor regulations); or 
‘‘(cc) 100 if the practitioner provides medi-
cation-assisted treatment (MAT) using covered 
medications (as such terms are defined in sec-
tion 8.2 of title 42, Code of Federal Regula-
tions (or successor regulations)) in a qualified 
practice setting (as described in section 8.615 
of title 42, Code of Federal Regulations (or suc-
cessor regulations)).’’. 
(b) ELIMINATING ANY TIME LIMITATION FOR NURSE 
PRACTITIONERS
AND PHYSICIAN ASSISTANTS TO BE-
COME QUALIFYING PRACTITIONERS.—Clause (iii) of sec-
tion 303(g)(2)(G) of the Controlled Substances Act (21 
U.S.C. 823(g)(2)(G)) is amended— 
(1) in subclause (I), by striking ‘‘or’’ at the 
end; and 
(2) by amending subclause (II) to read as fol-
lows: 
‘‘(II) a qualifying other practitioner, as de-
fined in clause (iv), who is a nurse practitioner 
or physician assistant; or’’. 
(c) IMPOSING A TIME LIMITATION FOR CLINICAL 
NURSE SPECIALISTS, CERTIFIED REGISTERED NURSE 
ANESTHETISTS, AND CERTIFIED NURSE MIDWIFES TO 
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BECOME QUALIFYING PRACTITIONERS.—Clause (iii) of 
section 303(g)(2)(G) of the Controlled Substances Act (21 
U.S.C. 823(g)(2)(G)), as amended by subsection (b), is 
further amended by adding at the end the following: 
‘‘(III) for the period beginning on October 
1, 2018, and ending on October 1, 2023, a 
qualifying other practitioner, as defined in 
clause (iv), who is a clinical nurse specialist, 
certified registered nurse anesthetist, or cer-
tified nurse midwife.’’. 
(d) DEFINITION
OF QUALIFYING OTHER PRACTI-
TIONER.—Section 303(g)(2)(G)(iv) of the Controlled Sub-
stances Act (21 U.S.C. 823(g)(2)(G)(iv)) is amended by 
striking ‘‘nurse practitioner or physician assistant’’ each 
place it appears and inserting ‘‘nurse practitioner, clinical 
nurse specialist, certified registered nurse anesthetist, cer-
tified nurse midwife, or physician assistant’’. 
(e) REPORT BY SECRETARY.—Not later than two 
years after the date of the enactment of this Act, the Sec-
retary of Health and Human Services, in consultation with 
the Drug Enforcement Administration, shall submit to 
Congress a report that assesses the care provided by quali-
fying practitioners (as defined in section 303(g)(2)(G)(iii) 
of 
the 
Controlled 
Substances 
Act 
(21 
U.S.C. 
823(g)(2)(G)(iii))) who are treating, in the case of physi-
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cians, 100 or more patients, and in the case of qualifying 
practitioners who are not physicians, 30 or more patients. 
Such report shall include recommendations on future ap-
plicable patient number levels and limits. In preparing 
such report, the Secretary shall study, with respect to 
opioid use disorder treatment— 
(1) the average frequency with which qualifying 
practitioners see their patients; 
(2) the average frequency with which patients 
receive counseling, including the rates by which such 
counseling is provided by such a qualifying practi-
tioner directly, or by referral; 
(3) the average frequency with which random 
toxicology testing is administered; 
(4) the average monthly patient caseload for 
each type of qualifying practitioner; 
(5) the treatment retention rates for patients; 
(6) overdose and mortality rates; and 
(7) any available information regarding the di-
version of drugs by patients receiving such treat-
ment from such a qualifying practitioner. 
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TITLE IV—OFFSETS 
SEC. 401. PROMOTING VALUE IN MEDICAID MANAGED 
CARE. 
Section 1903(m) of the Social Security Act (42 
U.S.C. 1396b(m)) is amended by adding at the end the 
following new paragraph: 
‘‘(7)(A) With respect to expenditures described in 
subparagraph (B) that are incurred by a State for any 
fiscal year after fiscal year 2020 (and before fiscal year 
2025), in determining the pro rata share to which the 
United States is equitably entitled under subsection 
(d)(3), the Secretary shall substitute the Federal medical 
assistance percentage that applies for such fiscal year to 
the State under section 1905(b) (without regard to any 
adjustments to such percentage applicable under such sec-
tion or any other provision of law) for the percentage that 
applies to such expenditures under section 1905(y). 
‘‘(B) Expenditures described in this subparagraph, 
with respect to a fiscal year to which subparagraph (A) 
applies, are expenditures incurred by a State for payment 
for medical assistance provided to individuals described in 
subclause (VIII) of section 1902(a)(10)(A)(i) by a man-
aged care entity, or other specified entity (as defined in 
subparagraph (D)(iii)), that are treated as remittances be-
cause the State— 
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‘‘(i) has satisfied the requirement of section 
438.8 of title 42, Code of Federal Regulations (or 
any successor regulation), by electing— 
‘‘(I) in the case of a State described in 
subparagraph (C), to apply a minimum medical 
loss ratio (as defined in subparagraph (D)(ii)) 
that is equal to or greater than 85 percent; or 
‘‘(II) in the case of a State not described 
in subparagraph (C), to apply a minimum med-
ical loss ratio that is equal to 85 percent; and 
‘‘(ii) recovered all or a portion of the expendi-
tures as a result of the entity’s failure to meet such 
ratio. 
‘‘(C) For purposes of subparagraph (B), a State de-
scribed in this subparagraph is a State that as of May 
31, 2018, applied a minimum medical loss ratio (as cal-
culated under subsection (d) of section 438.8 of title 42, 
Code of Federal Regulations (as in effect on June 1, 
2018)) for payment for services provided by entities de-
scribed in such subparagraph under the State plan under 
this title (or a waiver of the plan) that is equal to or great-
er than 85 percent. 
‘‘(D) For purposes of this paragraph: 
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‘‘(i) The term ‘managed care entity’ means a 
medicaid managed care organization described in 
section 1932(a)(1)(B)(i). 
‘‘(ii) The term ‘minimum medical loss ratio’ 
means, with respect to a State, a minimum medical 
loss ratio (as calculated under subsection (d) of sec-
tion 438.8 of title 42, Code of Federal Regulations 
(as in effect on June 1, 2018)) for payment for serv-
ices provided by entities described in subparagraph 
(B) under the State plan under this title (or a waiv-
er of the plan). 
‘‘(iii) The term ‘other specified entity’ means— 
‘‘(I) a prepaid inpatient health plan, as de-
fined in section 438.2 of title 42, Code of Fed-
eral Regulations (or any successor regulation); 
and 
‘‘(II) a prepaid ambulatory health plan, as 
defined in such section (or any successor regu-
lation).’’. 
SEC. 402. EXTENDING PERIOD OF APPLICATION OF MEDI-
CARE SECONDARY PAYER RULES FOR INDI-
VIDUALS WITH END STAGE RENAL DISEASE. 
Section 1862(b)(1)(C) of the Social Security Act (42 
U.S.C. 1395y(b)(1)(C)) is amended— 
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(1) in the last sentence, by inserting ‘‘and be-
fore January 1, 2020’’ after ‘‘date of enactment of 
the Balanced Budget Act of 1997’’; and 
(2) by adding at the end the following new sen-
tence: ‘‘Effective for items and services furnished on 
or after January 1, 2020 (with respect to periods 
beginning on or after July 1, 2018), clauses (i) and 
(ii) shall be applied by substituting ‘33-month’ for 
‘12-month’ each place it appears.’’. 
SEC. 403. REQUIRING REPORTING BY GROUP HEALTH 
PLANS OF PRESCRIPTION DRUG COVERAGE 
INFORMATION FOR PURPOSES OF IDENTI-
FYING PRIMARY PAYER SITUATIONS UNDER 
THE MEDICARE PROGRAM. 
Clause (i) of section 1862(b)(7)(A) of the Social Se-
curity Act (42 U.S.C. 1395y(b)(7)(A)) is amended to read 
as follows: 
‘‘(i) secure from the plan sponsor and 
plan participants such information as the 
Secretary shall specify for the purpose of 
identifying situations where the group 
health plan is or has been— 
‘‘(I) a primary plan to the pro-
gram under this title; or 
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100 
‘‘(II) for calendar quarters begin-
ning on or after January 1, 2020, a 
primary payer with respect to benefits 
relating to prescription drug coverage 
under part D; and’’. 
Æ 
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