IIB 
115TH CONGRESS 
2D SESSION 
H. R. 5797 
IN THE SENATE OF THE UNITED STATES 
JUNE 21, 2018 
Received; read twice and referred to the Committee on Finance 
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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Individuals in Medicaid 
Deserve Care that is Appropriate and Responsible in its 
Execution Act’’ or the ‘‘IMD CARE Act’’. 
SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERV-
ICES FOR CERTAIN INDIVIDUALS WITH TAR-
GETED SUDS IN INSTITUTIONS FOR MENTAL 
DISEASES. 
Section 1915 of the Social Security Act (42 U.S.C. 
1396n) is amended by adding at the end the following new 
subsection: 
‘‘(l) STATE PLAN OPTION TO PROVIDE SERVICES 
FOR CERTAIN INDIVIDUALS IN INSTITUTIONS FOR MEN-
TAL DISEASES.— 
‘‘(1) IN GENERAL.—With respect to calendar 
quarters beginning during the period beginning Jan-
uary 1, 2019, and ending December 31, 2023, a 
State may elect, through a State plan amendment, 
to, notwithstanding section 1905(a), provide medical 
assistance for services furnished in institutions for 
mental diseases and for other medically necessary 
services furnished to eligible individuals with tar-
geted SUDs, in accordance with the requirements of 
this subsection. 
‘‘(2) PAYMENTS.— 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
‘‘(A) IN
GENERAL.—Amounts expended 
under a State plan amendment under para-
graph (1) for services described in such para-
graph furnished, with respect to a 12-month pe-
riod, to an eligible individual with a targeted 
SUD who is a patient in an institution for men-
tal diseases shall be treated as medical assist-
ance for which payment is made under section 
1903(a) but only to the extent that such serv-
ices are furnished for not more than a period 
of 30 days (whether or not consecutive) during 
such 12-month period. 
‘‘(B) 
CLARIFICATION.—Payment 
made 
under this paragraph for expenditures under a 
State plan amendment under this subsection 
with respect to services described in paragraph 
(1) furnished to an eligible individual with a 
targeted SUD shall not affect payment that 
would otherwise be made under section 1903(a) 
for expenditures under the State plan (or waiv-
er of such plan) for medical assistance for such 
individual. 
‘‘(3) INFORMATION REQUIRED IN STATE PLAN 
AMENDMENT.— 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
‘‘(A) IN
GENERAL.—A State electing to 
provide medical assistance pursuant to this sub-
section shall include with the submission of the 
State plan amendment under paragraph (1) to 
the Secretary— 
‘‘(i) a plan on how the State will im-
prove access to outpatient care during the 
period of the State plan amendment, in-
cluding a description of— 
‘‘(I) the process by which eligible 
individuals with targeted SUDs will 
make the transition from receiving in-
patient services in an institution for 
mental diseases to appropriate out-
patient care; and 
‘‘(II) the process the State will 
undertake to ensure eligible individ-
uals with targeted SUDs are provided 
care in the most integrated setting ap-
propriate to the needs of the individ-
uals; and 
‘‘(ii) a description of how the State 
plan amendment ensures an appropriate 
clinical screening of eligible individuals 
with targeted SUDs, including assessments 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
to determine level of care and length of 
stay recommendations based upon the 
multidimensional assessment criteria of the 
American Society of Addiction Medicine 
and to determine the appropriate setting 
for such care. 
‘‘(B) REPORT.—Not later than the sooner 
of December 31, 2024, or 1 year after the date 
of the termination of a State plan amendment 
under this subsection, the State shall submit to 
the Secretary a report that includes at least— 
‘‘(i) the number of eligible individuals 
with targeted SUDs who received services 
pursuant to such State plan amendment; 
‘‘(ii) the length of the stay of each 
such individual in an institution for mental 
diseases; 
‘‘(iii) the type of outpatient treatment, 
including medication-assisted treatment, 
each such individual received after being 
discharged from such institution; 
‘‘(iv) the number of eligible individ-
uals with any co-occuring disorders who re-
ceived services pursuant to such State plan 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
amendment and the co-occuring disorders 
from which they suffer; and 
‘‘(v) information regarding the effects 
of a State plan amendment on access to 
community care for individuals suffering 
from a mental disease other than sub-
stance use disorder. 
‘‘(4) DEFINITIONS.—In this subsection: 
‘‘(A) ELIGIBLE INDIVIDUAL WITH A TAR-
GETED SUD.—The term ‘eligible individual with 
a targeted SUD’ means an individual who— 
‘‘(i) with respect to a State, is en-
rolled for medical assistance under the 
State plan (or a waiver of such plan); 
‘‘(ii) is at least 21 years of age; 
‘‘(iii) has not attained 65 years of 
age; and 
‘‘(iv) has been diagnosed with at least 
one targeted SUD. 
‘‘(B) INSTITUTION
FOR
MENTAL
DIS-
EASES.—The term ‘institution for mental dis-
eases’ has the meaning given such term in sec-
tion 1905(i). 
‘‘(C) OPIOID
PRESCRIPTION
PAIN
RE-
LIEVER.—The term ‘opioid prescription pain re-
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
liever’ 
includes 
hydrocodone 
products, 
oxycodone products, tramadol products, codeine 
products, morphine products, fentanyl products, 
buprenorphine products, oxymorphone products, 
meperidine products, hydromorphone products, 
methadone, and any other prescription pain re-
liever identified by the Assistant Secretary for 
Mental Health and Substance Use. 
‘‘(D) 
OTHER
MEDICALLY
NECESSARY 
SERVICES.—The term ‘other medically nec-
essary services’ means, with respect to an eligi-
ble individual with a targeted SUD who is a pa-
tient in an institution for mental diseases, items 
and services that are provided to such indi-
vidual outside of such institution to the extent 
that such items and services would be treated 
as medical assistance for such individual if such 
individual were not a patient in such institu-
tion. 
‘‘(E) TARGETED SUD.— 
‘‘(i) IN
GENERAL.—The term ‘tar-
geted SUD’ means an opioid use disorder 
or a cocaine use disorder. 
‘‘(ii) COCAINE
USE
DISORDER.—The 
term ‘cocaine use disorder’ means a dis-
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
order that meets the criteria of the Diag-
nostic and Statistical Manual of Mental 
Disorders, 4th Edition (or a successor edi-
tion), for either dependence or abuse for 
cocaine, including cocaine base (commonly 
referred to as ‘crack cocaine’). 
‘‘(iii) OPIOID
USE
DISORDER.—The 
term ‘opioid use disorder’ means a disorder 
that meets the criteria of the Diagnostic 
and Statistical Manual of Mental Dis-
orders, 4th Edition (or a successor edi-
tion), for heroin use disorder or pain re-
liever use disorder (including with respect 
to opioid prescription pain relievers).’’. 
SEC. 3. 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 
2024), 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 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
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— 
‘‘(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 at least 85 percent but not greater than 
the minimum medical loss ratio (as so defined) 
that such State applied as of May 31, 2018; 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 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
‘‘(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: 
‘‘(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— 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS
HR 5797 RFS
‘‘(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).’’. 
Passed the House of Representatives June 20, 2018. 
Attest: 
KAREN L. HAAS, 
Clerk. 
VerDate Sep 11 2014 
23:34 Jun 21, 2018
Jkt 079200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H5797.RFS
H5797
lotter on DSKBCFDHB2PROD with BILLS