H. R. 6—87 
‘‘(1) IN GENERAL.—Not later than January 1, 2021, the 
Secretary shall implement a 4-year demonstration program 
under this title (in this section referred to as the ‘Program’) 
to increase access of applicable beneficiaries to opioid use dis-
order treatment services, improve physical and mental health 
outcomes for such beneficiaries, and to the extent possible, 
reduce expenditures under this title. Under the Program, the 
Secretary shall make payments under subsection (e) to partici-
pants (as defined in subsection (c)(1)(A)) for furnishing opioid 
use disorder treatment services delivered through opioid use 
disorder care teams, or arranging for such services to be fur-
nished, to applicable beneficiaries participating in the Program. 
‘‘(2) OPIOID USE DISORDER TREATMENT SERVICES.—For pur-
poses of this section, the term ‘opioid use disorder treatment 
services’— 
‘‘(A) means, with respect to an applicable beneficiary, 
services that are furnished for the treatment of opioid 
use disorders and that utilize drugs approved under section 
505 of the Federal Food, Drug, and Cosmetic Act for the 
treatment of opioid use disorders in an outpatient setting; 
and 
‘‘(B) includes— 
‘‘(i) medication-assisted treatment; 
‘‘(ii) treatment planning; 
‘‘(iii) psychiatric, psychological, or counseling serv-
ices (or any combination of such services), as appro-
priate; 
‘‘(iv) social support services, as appropriate; and 
‘‘(v) care management and care coordination serv-
ices, including coordination with other providers of 
services and suppliers not on an opioid use disorder 
care team. 
‘‘(b) PROGRAM DESIGN.— 
‘‘(1) IN GENERAL.—The Secretary shall design the Program 
in such a manner to allow for the evaluation of the extent 
to which the Program accomplishes the following purposes: 
‘‘(A) Reduces hospitalizations and emergency depart-
ment visits. 
‘‘(B) Increases use of medication-assisted treatment for 
opioid use disorders. 
‘‘(C) Improves health outcomes of individuals with 
opioid use disorders, including by reducing the incidence 
of infectious diseases (such as hepatitis C and HIV). 
‘‘(D) Does not increase the total spending on items 
and services under this title. 
‘‘(E) Reduces deaths from opioid overdose. 
‘‘(F) Reduces the utilization of inpatient residential 
treatment. 
‘‘(2) CONSULTATION.—In designing the Program, including 
the criteria under subsection (e)(2)(A), the Secretary shall, not 
later than 3 months after the date of the enactment of this 
section, consult with specialists in the field of addiction, clini-
cians in the primary care community, and beneficiary groups. 
‘‘(c) PARTICIPANTS; OPIOID USE DISORDER CARE TEAMS.— 
‘‘(1) PARTICIPANTS.— 
‘‘(A) DEFINITION.—In this section, the term ‘participant’ 
means an entity or individual—
H. R. 6—88 
‘‘(i) that is otherwise enrolled under this title and 
that is— 
‘‘(I) a physician (as defined in section 
1861(r)(1)); 
‘‘(II) a group practice comprised of at least 
one physician described in subclause (I); 
‘‘(III) a hospital outpatient department; 
‘‘(IV) a federally qualified health center (as 
defined in section 1861(aa)(4)); 
‘‘(V) a rural health clinic (as defined in section 
1861(aa)(2)); 
‘‘(VI) a community mental health center (as 
defined in section 1861(ff)(3)(B)); 
‘‘(VII) a clinic certified as a certified commu-
nity behavioral health clinic pursuant to section 
223 of the Protecting Access to Medicare Act of 
2014; or 
‘‘(VIII) any other individual or entity specified 
by the Secretary; 
‘‘(ii) that applied for and was selected to participate 
in the Program pursuant to an application and selec-
tion process established by the Secretary; and 
‘‘(iii) that establishes an opioid use disorder care 
team (as defined in paragraph (2)) through employing 
or contracting with health care practitioners described 
in paragraph (2)(A), and uses such team to furnish 
or arrange for opioid use disorder treatment services 
in the outpatient setting under the Program. 
‘‘(B) PREFERENCE.—In selecting participants for the 
Program, the Secretary shall give preference to individuals 
and entities that are located in areas with a prevalence 
of opioid use disorders that is higher than the national 
average prevalence. 
‘‘(2) OPIOID USE DISORDER CARE TEAMS.— 
‘‘(A) IN GENERAL.—For purposes of this section, the 
term ‘opioid use disorder care team’ means a team of health 
care practitioners established by a participant described 
in paragraph (1)(A) that— 
‘‘(i) shall include— 
‘‘(I) at least one physician (as defined in section 
1861(r)(1)) furnishing primary care services or 
addiction treatment services to an applicable bene-
ficiary; and 
‘‘(II) at least one eligible practitioner (as 
defined in paragraph (3)), who may be a physician 
who meets the criterion in subclause (I); and 
‘‘(ii) may include other practitioners licensed under 
State law to furnish psychiatric, psychological, coun-
seling, and social services to applicable beneficiaries. 
‘‘(B) REQUIREMENTS FOR RECEIPT OF PAYMENT UNDER 
PROGRAM.—In order to receive payments under subsection 
(e), each participant in the Program shall— 
‘‘(i) furnish opioid use disorder treatment services 
through opioid use disorder care teams to applicable 
beneficiaries who agree to receive the services; 
‘‘(ii) meet minimum criteria, as established by the 
Secretary; and
H. R. 6—89 
‘‘(iii) submit to the Secretary, in such form, 
manner, and frequency as specified by the Secretary, 
with respect to each applicable beneficiary for whom 
opioid use disorder treatment services are furnished 
by the opioid use disorder care team, data and such 
other information as the Secretary determines appro-
priate to— 
‘‘(I) monitor and evaluate the Program; 
‘‘(II) determine if minimum criteria are met 
under clause (ii); and 
‘‘(III) determine the incentive payment under 
subsection (e). 
‘‘(3) ELIGIBLE PRACTITIONER DEFINED.—For purposes of this 
section, the term ‘eligible practitioner’ means a physician or 
other health care practitioner, such as a nurse practitioner, 
that— 
‘‘(A) is enrolled under section 1866(j)(1); 
‘‘(B) is authorized to prescribe or dispense narcotic 
drugs to individuals for maintenance treatment or detoxi-
fication treatment; and 
‘‘(C) has in effect a waiver in accordance with section 
303(g) of the Controlled Substances Act for such purpose 
and is otherwise in compliance with regulations promul-
gated by the Substance Abuse and Mental Health Services 
Administration to carry out such section. 
‘‘(d) PARTICIPATION OF APPLICABLE BENEFICIARIES.— 
‘‘(1) APPLICABLE BENEFICIARY DEFINED.—In this section, the 
term ‘applicable beneficiary’ means an individual who— 
‘‘(A) is entitled to, or enrolled for, benefits under part 
A and enrolled for benefits under part B; 
‘‘(B) is not enrolled in a Medicare Advantage plan 
under part C; 
‘‘(C) has a current diagnosis for an opioid use disorder; 
and 
‘‘(D) meets such other criteria as the Secretary deter-
mines appropriate. 
Such term shall include an individual who is dually eligible 
for benefits under this title and title XIX if such individual 
satisfies the criteria described in subparagraphs (A) through 
(D). 
‘‘(2) VOLUNTARY BENEFICIARY PARTICIPATION; LIMITATION ON 
NUMBER
OF
BENEFICIARIES.—An applicable beneficiary may 
participate in the Program on a voluntary basis and may termi-
nate participation in the Program at any time. Not more than 
20,000 applicable beneficiaries may participate in the Program 
at any time. 
‘‘(3) SERVICES.—In order to participate in the Program, 
an applicable beneficiary shall agree to receive opioid use dis-
order treatment services from a participant. Participation under 
the Program shall not affect coverage of or payment for any 
other item or service under this title for the applicable bene-
ficiary. 
‘‘(4) BENEFICIARY ACCESS TO SERVICES.—Nothing in this 
section shall be construed as encouraging providers to limit 
applicable beneficiary access to services covered under this
H. R. 6—90 
title, and applicable beneficiaries shall not be required to relin-
quish access to any benefit under this title as a condition 
of receiving services from a participant in the Program. 
‘‘(e) PAYMENTS.— 
‘‘(1) PER
APPLICABLE
BENEFICIARY
PER
MONTH
CARE 
MANAGEMENT FEE.— 
‘‘(A) IN
GENERAL.—The Secretary shall establish a 
schedule of per applicable beneficiary per month care 
management fees. Such a per applicable beneficiary per 
month care management fee shall be paid to a participant 
in addition to any other amount otherwise payable under 
this title to the health care practitioners in the participant’s 
opioid use disorder care team or, if applicable, to the partici-
pant. A participant may use such per applicable beneficiary 
per month care management fee to deliver additional serv-
ices to applicable beneficiaries, including services not other-
wise eligible for payment under this title. 
‘‘(B) PAYMENT
AMOUNTS.—In carrying out subpara-
graph (A), the Secretary may— 
‘‘(i) consider payments otherwise payable under 
this title for opioid use disorder treatment services 
and the needs of applicable beneficiaries; 
‘‘(ii) pay a higher per applicable beneficiary per 
month care management fee for an applicable bene-
ficiary who receives more intensive treatment services 
from a participant and for whom those services are 
appropriate based on clinical guidelines for opioid use 
disorder care; 
‘‘(iii) pay a higher per applicable beneficiary per 
month care management fee for the month in which 
the applicable beneficiary begins treatment with a 
participant than in subsequent months, to reflect the 
greater time and costs required for the planning and 
initiation of treatment, as compared to maintenance 
of treatment; and 
‘‘(iv) take into account whether a participant’s 
opioid use disorder care team refers applicable bene-
ficiaries to other suppliers or providers for any opioid 
use disorder treatment services. 
‘‘(C) NO
DUPLICATE
PAYMENT.—The Secretary shall 
make payments under this paragraph to only one partici-
pant for services furnished to an applicable beneficiary 
during a calendar month. 
‘‘(2) INCENTIVE PAYMENTS.— 
‘‘(A) IN GENERAL.—Under the Program, the Secretary 
shall establish a performance-based incentive payment, 
which shall be paid (using a methodology established and 
at a time determined appropriate by the Secretary) to 
participants based on the performance of participants with 
respect to criteria, as determined appropriate by the Sec-
retary, in accordance with subparagraph (B). 
‘‘(B) CRITERIA.— 
‘‘(i) IN GENERAL.—Criteria described in subpara-
graph (A) may include consideration of the following: 
‘‘(I) Patient engagement and retention in treat-
ment.
H. R. 6—91 
‘‘(II) Evidence-based medication-assisted treat-
ment. 
‘‘(III) Other criteria established by the Sec-
retary. 
‘‘(ii) REQUIRED
CONSULTATION
AND
CONSIDER-
ATION.—In determining criteria described in subpara-
graph (A), the Secretary shall— 
‘‘(I) consult with stakeholders, including clini-
cians in the primary care community and in the 
field of addiction medicine; and 
‘‘(II) consider existing clinical guidelines for 
the treatment of opioid use disorders. 
‘‘(C) NO
DUPLICATE
PAYMENT.—The Secretary shall 
ensure that no duplicate payments under this paragraph 
are made with respect to an applicable beneficiary. 
‘‘(f) MULTIPAYER STRATEGY.—In carrying out the Program, the 
Secretary shall encourage other payers to provide similar payments 
and to use similar criteria as applied under the Program under 
subsection (e)(2)(C). The Secretary may enter into a memorandum 
of understanding with other payers to align the methodology for 
payment provided by such a payer related to opioid use disorder 
treatment services with such methodology for payment under the 
Program. 
‘‘(g) EVALUATION.— 
‘‘(1) IN GENERAL.—The Secretary shall conduct an inter-
mediate and final evaluation of the program. Each such evalua-
tion shall determine the extent to which each of the purposes 
described in subsection (b) have been accomplished under the 
Program. 
‘‘(2) REPORTS.—The Secretary shall submit to Congress— 
‘‘(A) a report with respect to the intermediate evalua-
tion under paragraph (1) not later than 3 years after the 
date of the implementation of the Program; and 
‘‘(B) a report with respect to the final evaluation under 
paragraph (1) not later than 6 years after such date. 
‘‘(h) FUNDING.— 
‘‘(1) ADMINISTRATIVE FUNDING.—For the purposes of imple-
menting, administering, and carrying out the Program (other 
than for purposes described in paragraph (2)), $5,000,000 shall 
be available from the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841. 
‘‘(2) CARE MANAGEMENT FEES AND INCENTIVES.—For the 
purposes of making payments under subsection (e), $10,000,000 
shall be available from the Federal Supplementary Medical 
Insurance Trust Fund under section 1841 for each of fiscal 
years 2021 through 2024. 
‘‘(3) AVAILABILITY.—Amounts transferred under this sub-
section for a fiscal year shall be available until expended. 
‘‘(i) WAIVERS.—The Secretary may waive any provision of this 
title as may be necessary to carry out the Program under this 
section.’’.
H. R. 6—92 
Subtitle 
F—Responsible 
Education 
Achieves Care and Healthy Outcomes for 
Users’ Treatment 
SEC. 6051. SHORT TITLE. 
This subtitle may be cited as the ‘‘Responsible Education 
Achieves Care and Healthy Outcomes for Users’ Treatment Act 
of 2018’’ or the ‘‘REACH OUT Act of 2018’’. 
SEC. 6052. GRANTS TO PROVIDE TECHNICAL ASSISTANCE TO OUTLIER 
PRESCRIBERS OF OPIOIDS. 
(a) GRANTS AUTHORIZED.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall, 
through the Centers for Medicare & Medicaid Services, award 
grants, contracts, or cooperative agreements to eligible entities for 
the purposes described in subsection (b). 
(b) USE OF FUNDS.—Grants, contracts, and cooperative agree-
ments awarded under subsection (a) shall be used to support eligible 
entities through technical assistance— 
(1) to educate and provide outreach to outlier prescribers 
of opioids about best practices for prescribing opioids; 
(2) to educate and provide outreach to outlier prescribers 
of opioids about non-opioid pain management therapies; and 
(3) to reduce the amount of opioid prescriptions prescribed 
by outlier prescribers of opioids. 
(c) APPLICATION.—Each eligible entity seeking to receive a 
grant, contract, or cooperative agreement under subsection (a) shall 
submit to the Secretary an application, at such time, in such 
manner, and containing such information as the Secretary may 
require. 
(d) GEOGRAPHIC DISTRIBUTION.—In awarding grants, contracts, 
and cooperative agreements under this section, the Secretary shall 
prioritize establishing technical assistance resources in each State. 
(e) DEFINITIONS.—In this section: 
(1) ELIGIBLE ENTITY.—The term ‘‘eligible entity’’ means— 
(A) an organization— 
(i) that has demonstrated experience providing 
technical assistance to health care professionals on 
a State or regional basis; and 
(ii) that has at least— 
(I) one individual who is a representative of 
consumers on its governing body; and 
(II) one individual who is a representative of 
health care providers on its governing body; or 
(B) an entity that is a quality improvement entity 
with a contract under part B of title XI of the Social 
Security Act (42 U.S.C. 1320c et seq.). 
(2) OUTLIER PRESCRIBER OF OPIOIDS.—The term ‘‘outlier 
prescriber of opioids’’ means, with respect to a period, a pre-
scriber identified by the Secretary under subparagraph (D)(ii) 
of section 1860D–4(c)(4) of the Social Security Act (42 U.S.C. 
1395w–104(c)(4)), as added by section 6065 of this Act, to be 
an outlier prescriber of opioids for such period. 
(3) PRESCRIBERS.—The term ‘‘prescriber’’ means any health 
care professional, including a nurse practitioner or physician
H. R. 6—93 
assistant, who is licensed to prescribe opioids by the State 
or territory in which such professional practices. 
(f) FUNDING.—For purposes of implementing this section, 
$75,000,000 shall be available from the Federal Supplementary 
Medical Insurance Trust Fund under section 1841 of the Social 
Security Act (42 U.S.C. 1395t), to remain available until expended. 
Subtitle G—Preventing Addiction for 
Susceptible Seniors 
SEC. 6061. SHORT TITLE. 
This subtitle may be cited as the ‘‘Preventing Addiction for 
Susceptible Seniors Act of 2018’’ or the ‘‘PASS Act of 2018’’. 
SEC. 6062. ELECTRONIC PRIOR AUTHORIZATION FOR COVERED PART 
D DRUGS. 
Section 1860D–4(e)(2) of the Social Security Act (42 U.S.C. 
1395w–104(e)(2)) is amended by adding at the end the following 
new subparagraph: 
‘‘(E) ELECTRONIC PRIOR AUTHORIZATION.— 
‘‘(i) IN GENERAL.—Not later than January 1, 2021, 
the program shall provide for the secure electronic 
transmission of— 
‘‘(I) a prior authorization request from the pre-
scribing health care professional for coverage of 
a covered part D drug for a part D eligible indi-
vidual enrolled in a part D plan (as defined in 
section 1860D–23(a)(5)) to the PDP sponsor or 
Medicare Advantage organization offering such 
plan; and 
‘‘(II) a response, in accordance with this 
subparagraph, from such PDP sponsor or Medicare 
Advantage organization, respectively, to such 
professional. 
‘‘(ii) ELECTRONIC TRANSMISSION.— 
‘‘(I) 
EXCLUSIONS.—For 
purposes 
of 
this 
subparagraph, a facsimile, a proprietary payer 
portal that does not meet standards specified by 
the Secretary, or an electronic form shall not be 
treated as an electronic transmission described in 
clause (i). 
‘‘(II) STANDARDS.—In order to be treated, for 
purposes of this subparagraph, as an electronic 
transmission described in clause (i), such trans-
mission shall comply with technical standards 
adopted by the Secretary in consultation with the 
National Council for Prescription Drug Programs, 
other standard setting organizations determined 
appropriate by the Secretary, and stakeholders 
including PDP sponsors, Medicare Advantage 
organizations, health care professionals, and 
health information technology software vendors. 
‘‘(III) 
APPLICATION.—Notwithstanding 
any 
other provision of law, for purposes of this subpara-
graph, the Secretary may require the use of such 
standards adopted under subclause (II) in lieu of
H. R. 6—94 
any other applicable standards for an electronic 
transmission described in clause (i) for a covered 
part D drug for a part D eligible individual.’’. 
SEC. 6063. PROGRAM INTEGRITY TRANSPARENCY MEASURES UNDER 
MEDICARE PARTS C AND D. 
(a) IN GENERAL.—Section 1859 of the Social Security Act (42 
U.S.C. 1395w–28) is amended by adding at the end the following 
new subsection: 
‘‘(i) PROGRAM INTEGRITY TRANSPARENCY MEASURES.— 
‘‘(1) PROGRAM INTEGRITY PORTAL.— 
‘‘(A) IN GENERAL.—Not later than 2 years after the 
date of the enactment of this subsection, the Secretary 
shall, after consultation with stakeholders, establish a 
secure internet website portal (or other successor tech-
nology) that would allow a secure path for communication 
between the Secretary, MA plans under this part, prescrip-
tion drug plans under part D, and an eligible entity with 
a contract under section 1893 (such as a Medicare drug 
integrity contractor or an entity responsible for carrying 
out program integrity activities under this part and part 
D) for the purpose of enabling through such portal (or 
other successor technology)— 
‘‘(i) the referral by such plans of substantiated 
or suspicious activities, as defined by the Secretary, 
of a provider of services (including a prescriber) or 
supplier related to fraud, waste, and abuse for initi-
ating or assisting investigations conducted by the 
eligible entity; and 
‘‘(ii) data sharing among such MA plans, prescrip-
tion drug plans, and the Secretary. 
‘‘(B) REQUIRED USES OF PORTAL.—The Secretary shall 
disseminate the following information to MA plans under 
this part and prescription drug plans under part D through 
the secure internet website portal (or other successor tech-
nology) established under subparagraph (A): 
‘‘(i) Providers of services and suppliers that have 
been referred pursuant to subparagraph (A)(i) during 
the previous 12-month period. 
‘‘(ii) Providers of services and suppliers who are 
the subject of an active exclusion under section 1128 
or who are subject to a suspension of payment under 
this title pursuant to section 1862(o) or otherwise. 
‘‘(iii) Providers of services and suppliers who are 
the subject of an active revocation of participation 
under this title, including for not satisfying conditions 
of participation. 
‘‘(iv) In the case of such a plan that makes a 
referral under subparagraph (A)(i) through the portal 
(or other successor technology) with respect to activities 
of substantiated or suspicious activities of fraud, waste, 
or abuse of a provider of services (including a pre-
scriber) or supplier, if such provider (including a pre-
scriber) or supplier has been the subject of an adminis-
trative action under this title or title XI with respect 
to similar activities, a notification to such plan of such 
action so taken.
H. R. 6—95 
‘‘(C) RULEMAKING.—For purposes of this paragraph, 
the Secretary shall, through rulemaking, specify what con-
stitutes substantiated or suspicious activities of fraud, 
waste, and abuse, using guidance such as what is provided 
in the Medicare Program Integrity Manual 4.8. In carrying 
out this subsection, a fraud hotline tip (as defined by the 
Secretary) without further evidence shall not be treated 
as sufficient evidence for substantiated fraud, waste, or 
abuse. 
‘‘(D) HIPAA COMPLIANT INFORMATION ONLY.—For pur-
poses of this subsection, communications may only occur 
if the communications are permitted under the Federal 
regulations (concerning the privacy of individually identifi-
able health information) promulgated under section 264(c) 
of the Health Insurance Portability and Accountability Act 
of 1996. 
‘‘(2) QUARTERLY
REPORTS.—Beginning not later than 2 
years after the date of the enactment of this subsection, the 
Secretary shall make available to MA plans under this part 
and prescription drug plans under part D in a timely manner 
(but no less frequently than quarterly) and using information 
submitted to an entity described in paragraph (1) through 
the portal (or other successor technology) described in such 
paragraph or pursuant to section 1893, information on fraud, 
waste, and abuse schemes and trends in identifying suspicious 
activity. Information included in each such report shall— 
‘‘(A) include administrative actions, pertinent informa-
tion related to opioid overprescribing, and other data deter-
mined appropriate by the Secretary in consultation with 
stakeholders; and 
‘‘(B) be anonymized information submitted by plans 
without identifying the source of such information. 
‘‘(3) CLARIFICATION.—Nothing in this subsection shall pre-
clude or otherwise affect referrals to the Inspector General 
of the Department of Health and Human Services or other 
law enforcement entities.’’. 
(b) CONTRACT REQUIREMENT TO COMMUNICATE PLAN CORREC-
TIVE ACTIONS AGAINST OPIOIDS OVER-PRESCRIBERS.—Section 1857(e) 
of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended 
by adding at the end the following new paragraph: 
‘‘(5) COMMUNICATING PLAN CORRECTIVE ACTIONS AGAINST 
OPIOIDS OVER-PRESCRIBERS.— 
‘‘(A) IN GENERAL.—Beginning with plan years begin-
ning on or after January 1, 2021, a contract under this 
section with an MA organization shall require the organiza-
tion to submit to the Secretary, through the process estab-
lished under subparagraph (B), information on the inves-
tigations, credible evidence of suspicious activities of a 
provider of services (including a prescriber) or supplier 
related to fraud, and other actions taken by such plans 
related to inappropriate prescribing of opioids. 
‘‘(B) PROCESS.—Not later than January 1, 2021, the 
Secretary shall, in consultation with stakeholders, establish 
a process under which MA plans and prescription drug 
plans shall submit to the Secretary information described 
in subparagraph (A).