180 
health and substance use disorder services (as de-
scribed in paragraph (5)) provided under such 
plan comply with the requirements of section 
2726(a) of the Public Health Service Act in the 
same manner as such requirements or limita-
tions apply to a group health plan under such 
section.’’. 
(e) EFFECTIVE DATE.— 
(1) IN GENERAL.—Subject to paragraph (2), the 
amendments made by this section shall take effect 
with respect to child health assistance provided on or 
after the date that is 1 year after the date of the en-
actment of this Act. 
(2) EXCEPTION
FOR
STATE
LEGISLATION.—In 
the case of a State child health plan under title XXI 
of the Social Security Act (or a waiver of such plan), 
which the Secretary of Health and Human Services 
determines requires State legislation in order for the 
respective plan (or waiver) to meet any requirement 
imposed by the amendments made by this section, the 
respective plan (or waiver) 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 addi-
tional requirement before the first day of the first cal-
endar quarter beginning after the close of the first
181 
regular session of the State legislature that begins 
after the date of enactment of this section. For pur-
poses of the previous sentence, in the case of a State 
that has a 2-year legislative session, each year of the 
session shall be considered to be a separate regular 
session of the State legislature. 
Subtitle D—Medicaid Reentry 
SEC. 5031. SHORT TITLE. 
This subtitle may be cited as the ‘‘Medicaid Reentry 
Act’’. 
SEC. 5032. PROMOTING STATE INNOVATIONS TO EASE 
TRANSITIONS INTEGRATION TO THE COMMU-
NITY FOR CERTAIN INDIVIDUALS. 
(a) STAKEHOLDER GROUP DEVELOPMENT OF BEST 
PRACTICES; STATE MEDICAID PROGRAM INNOVATION.— 
(1) STAKEHOLDER GROUP BEST PRACTICES.— 
Not later than 6 months after the date of the enact-
ment of this Act, the Secretary of Health and Human 
Services shall convene a stakeholder group of rep-
resentatives of managed care organizations, Medicaid 
beneficiaries, health care providers, the National Asso-
ciation of Medicaid Directors, and other relevant rep-
resentatives from local, State, and Federal jail and 
prison systems to develop best practices (and submit
182 
to the Secretary and Congress a report on such best 
practices) for States— 
(A) to ease the health care-related transition 
of an individual who is an inmate of a public 
institution from the public institution to the 
community, including best practices for ensuring 
continuity of health insurance coverage or cov-
erage under the State Medicaid plan under title 
XIX of the Social Security Act, as applicable, 
and relevant social services; and 
(B) to carry out, with respect to such an in-
dividual, such health care-related transition not 
later than 30 days after such individual is re-
leased from the public institution. 
(2) STATE MEDICAID PROGRAM INNOVATION.— 
The Secretary of Health and Human Services shall 
work with States on innovative strategies to help in-
dividuals who are inmates of public institutions and 
otherwise eligible for medical assistance under the 
Medicaid program under title XIX of the Social Secu-
rity Act transition, with respect to enrollment for 
medical assistance under such program, seamlessly to 
the community. 
(b) GUIDANCE
ON INNOVATIVE SERVICE DELIVERY 
SYSTEMS DEMONSTRATION PROJECT OPPORTUNITIES.—
183 
Not later than 1 year after the date of the enactment of 
this Act, the Secretary of Health and Human Services, 
through the Administrator of the Centers for Medicare & 
Medicaid Services, shall issue a State Medicaid Director let-
ter, based on best practices developed under subsection 
(a)(1), regarding opportunities to design demonstration 
projects under section 1115 of the Social Security Act (42 
U.S.C. 1315) to improve care transitions for certain indi-
viduals who are soon-to-be former inmates of a public insti-
tution and who are otherwise eligible to receive medical as-
sistance under title XIX of such Act, including systems for, 
with respect to a period (not to exceed 30 days) immediately 
prior to the day on which such individuals are expected 
to be released from such institution— 
(1) providing assistance and education for en-
rollment under a State plan under the Medicaid pro-
gram under title XIX of such Act for such individuals 
during such period; and 
(2) providing health care services for such indi-
viduals during such period. 
(c) RULE OF CONSTRUCTION.—Nothing under title 
XIX of the Social Security Act or any other provision of 
law precludes a State from reclassifying or suspending 
(rather than terminating) eligibility of an individual for 
medical assistance under title XIX of the Social Security
184 
Act while such individual is an inmate of a public institu-
tion. 
Subtitle E—Medicaid Partnership 
SEC. 5041. SHORT TITLE. 
This subtitle may be cited as the ‘‘Medicaid Providers 
Are Required To Note Experiences in Record Systems to 
Help In-need Patients Act’’ or the ‘‘Medicaid PARTNER-
SHIP Act’’. 
SEC. 5042. MEDICAID PROVIDERS ARE REQUIRED TO NOTE 
EXPERIENCES IN RECORD SYSTEMS TO HELP 
IN-NEED PATIENTS. 
(a) REQUIREMENTS UNDER THE MEDICAID PROGRAM 
RELATING
TO QUALIFIED PRESCRIPTION DRUG MONI-
TORING
PROGRAMS
AND
PRESCRIBING
CERTAIN
CON-
TROLLED SUBSTANCES.—Title XIX of the Social Security 
Act (42 U.S.C. 1396 et seq.) is amended by inserting after 
section 1943 the following new section: 
‘‘SEC. 1944. REQUIREMENTS RELATING TO QUALIFIED PRE-
SCRIPTION DRUG MONITORING PROGRAMS 
AND PRESCRIBING CERTAIN CONTROLLED 
SUBSTANCES. 
‘‘(a) IN GENERAL.—Subject to subsection (d), begin-
ning October 1, 2021, a State— 
‘‘(1) shall require each covered provider to check, 
in accordance with such timing, manner, and form as
185 
specified by the State, the prescription drug history of 
a covered individual being treated by the covered pro-
vider through a qualified prescription drug moni-
toring program described in subsection (b) before pre-
scribing to such individual a controlled substance; 
and 
‘‘(2) in the case that such a provider is not able 
to conduct such a check despite a good faith effort by 
such provider— 
‘‘(A) shall require the provider to document 
such good faith effort, including the reasons why 
the provider was not able to conduct the check; 
and 
‘‘(B) may require the provider to submit, 
upon request, such documentation to the State. 
‘‘(b) QUALIFIED PRESCRIPTION DRUG MONITORING 
PROGRAM
DESCRIBED.—A qualified prescription drug 
monitoring program described in this subsection is, with 
respect to a State, a prescription drug monitoring program 
administered by the State that, at a minimum, satisfies 
each of the following criteria: 
‘‘(1) The program facilitates access by a covered 
provider to, at a minimum, the following information 
with respect to a covered individual, in as close to 
real-time as possible:
186 
‘‘(A) Information regarding the prescription 
drug history of a covered individual with respect 
to controlled substances. 
‘‘(B) The number and type of controlled 
substances prescribed to and filled for the covered 
individual during at least the most recent 12- 
month period. 
‘‘(C) The name, location, and contact infor-
mation (or other identifying number selected by 
the State, such as a national provider identifier 
issued by the National Plan and Provider Enu-
meration System of the Centers for Medicare & 
Medicaid Services) of each covered provider who 
prescribed a controlled substance to the covered 
individual during at least the most recent 12- 
month period. 
‘‘(2) The program facilitates the integration of 
information described in paragraph (1) into the 
workflow of a covered provider, which may include 
the electronic system the covered provider uses to pre-
scribe controlled substances. 
A qualified prescription drug monitoring program de-
scribed in this subsection, with respect to a State, may have 
in place, in accordance with applicable State and Federal 
law, a data-sharing agreement with the State Medicaid pro-
187 
gram that allows the medical director and pharmacy direc-
tor of such program (and any designee of such a director 
who reports directly to such director) to access the informa-
tion described in paragraph (1) in an electronic format. 
The State Medicaid program under this title may facilitate 
reasonable and limited access, as determined by the State 
and ensuring documented beneficiary protections regarding 
the use of such data, to such qualified prescription drug 
monitoring program for the medical director or pharmacy 
director of any managed care entity (as defined under sec-
tion 1932(a)(1)(B)) that has a contract with the State 
under section 1903(m) or under section 1905(t)(3), or the 
medical director or pharmacy director of any entity that 
has a contract to manage the pharmaceutical benefit with 
respect to individuals enrolled in the State plan (or under 
a waiver of the State plan). All applicable State and Fed-
eral security and privacy laws shall apply to the directors 
or designees of such directors of any State Medicaid pro-
gram or entity accessing a qualified prescription drug mon-
itoring program under this section. 
‘‘(c) APPLICATION
OF PRIVACY RULES CLARIFICA-
TION.—The Secretary shall clarify privacy requirements, 
including requirements under the regulations promulgated 
pursuant to section 264(c) of the Health Insurance Port-
ability and Accountability Act of 1996 (42 U.S.C. 1320d–
188 
2 note), related to the sharing of data under subsection (b) 
in the same manner as the Secretary is required under sub-
paragraph (J) of section 1860D–4(c)(5) to clarify privacy 
requirements related to the sharing of data described in such 
subparagraph. 
‘‘(d) ENSURING ACCESS.—In order to ensure reason-
able access to health care, the Secretary shall waive the ap-
plication of the requirement under subsection (a), with re-
spect 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)). 
‘‘(e) REPORTS.— 
‘‘(1) STATE REPORTS.—Each State shall include 
in the annual report submitted to the Secretary under 
section 1927(g)(3)(D), beginning with such reports 
submitted for 2023, information including, at a min-
imum, the following information for the most recent 
12-month period: 
‘‘(A) The percentage of covered providers (as 
determined pursuant to a process established by 
the State) who checked the prescription drug his-
tory of a covered individual through a qualified 
prescription drug monitoring program described
189 
in subsection (b) before prescribing to such indi-
vidual a controlled substance. 
‘‘(B) Aggregate trends with respect to pre-
scribing controlled substances such as— 
‘‘(i) the quantity of daily morphine 
milligram equivalents prescribed for con-
trolled substances; 
‘‘(ii) the number and quantity of daily 
morphine milligram equivalents prescribed 
for controlled substances per covered indi-
vidual; and 
‘‘(iii) the types of controlled substances 
prescribed, including the dates of such pre-
scriptions, the supplies authorized (includ-
ing the duration of such supplies), and the 
period of validity of such prescriptions, in 
different populations (such as individuals 
who are elderly, individuals with disabil-
ities, and individuals who are enrolled 
under both this title and title XVIII). 
‘‘(C) Whether or not the State requires (and 
a detailed explanation as to why the State does 
or does not require) pharmacists to check the 
prescription drug history of a covered individual 
through a qualified prescription drug monitoring
190 
program described in subsection (b) before dis-
pensing a controlled substance to such indi-
vidual. 
‘‘(D) An accounting of any data or privacy 
breach of a qualified prescription drug moni-
toring program described in subsection (b), the 
number of covered individuals impacted by each 
such breach, and a description of the steps the 
State has taken to address each such breach, in-
cluding, to the extent required by State or Fed-
eral law or otherwise determined appropriate by 
the State, alerting any such impacted individual 
and law enforcement of the breach. 
‘‘(2) REPORT BY CMS.—Not later than October 1, 
2023, the Administrator of the Centers for Medicare 
& Medicaid Services shall publish on the publicly 
available website of the Centers for Medicare & Med-
icaid Services a report including the following infor-
mation: 
‘‘(A) Guidance for States on how States can 
increase the percentage of covered providers who 
use qualified prescription drug monitoring pro-
grams described in subsection (b). 
‘‘(B) Best practices for how States and cov-
ered providers should use such qualified prescrip-
191 
tion drug monitoring programs to reduce the oc-
currence of abuse of controlled substances. 
‘‘(f) INCREASE TO FMAP AND FEDERAL MATCHING 
RATES FOR CERTAIN EXPENDITURES RELATING TO QUALI-
FIED PRESCRIPTION DRUG MONITORING PROGRAMS.— 
‘‘(1) IN GENERAL.—With respect to a State that 
meets the condition described in paragraph (2) and 
any quarter occurring during fiscal year 2019 or fis-
cal year 2020, the Federal medical assistance percent-
age or Federal matching rate that would otherwise 
apply to such State under section 1903(a) for such 
quarter, with respect to expenditures by the State for 
activities under the State plan (or a waiver of such 
plan) to design, develop, or implement a prescription 
drug monitoring program (and to make connections 
to such program) that satisfies the criteria described 
in paragraphs (1) and (2) of subsection (b), shall be 
equal to 100 percent. 
‘‘(2) CONDITION.—The condition described in 
this paragraph, with respect to a State, is that the 
State (in this paragraph referred to as the ‘admin-
istering State’) has in place agreements with all 
States that are contiguous to such administering 
State that, when combined, enable covered providers 
in all such contiguous States to access, through the
192 
prescription drug monitoring program, the informa-
tion that is described in subsection (b)(1) of covered 
individuals of such administering State and that cov-
ered providers in such administering State are able 
to access through such program. 
‘‘(g) RULE OF CONSTRUCTION.—Nothing in this sec-
tion prevents a State from requiring pharmacists to check 
the prescription drug history of covered individuals through 
a qualified prescription drug monitoring program before 
dispensing controlled substances to such individuals. 
‘‘(h) DEFINITIONS.—In this section: 
‘‘(1) CONTROLLED SUBSTANCE.—The term ‘con-
trolled substance’ means a drug that is included in 
schedule II of section 202(c) of the Controlled Sub-
stances Act and, at the option of the State involved, 
a drug included in schedule III or IV of such section. 
‘‘(2) COVERED INDIVIDUAL.—The term ‘covered 
individual’ means, with respect to a State, an indi-
vidual who is enrolled in the State plan (or under a 
waiver of such plan). Such term does not include an 
individual who— 
‘‘(A) is receiving— 
‘‘(i) hospice or palliative care; or 
‘‘(ii) treatment for cancer;
193 
‘‘(B) is a resident of a long-term care facil-
ity, of a facility described in section 1905(d), or 
of another facility for which frequently abused 
drugs are dispensed for residents through a con-
tract with a single pharmacy; or 
‘‘(C) the State elects to treat as exempted 
from such term. 
‘‘(3) COVERED PROVIDER.— 
‘‘(A) IN GENERAL.—The term ‘covered pro-
vider’ means, subject to subparagraph (B), with 
respect to a State, a health care provider who is 
participating under the State plan (or waiver of 
the State plan) and licensed, registered, or other-
wise permitted by the State to prescribe a con-
trolled substance (or the designee of such pro-
vider). 
‘‘(B) EXCEPTIONS.— 
‘‘(i) IN GENERAL.—Beginning October 
1, 2021, for purposes of this section, such 
term does not include a health care provider 
included in any type of health care provider 
determined by the Secretary to be exempt 
from application of this section under 
clause (ii).
194 
‘‘(ii) EXCEPTIONS PROCESS.—Not later 
than October 1, 2020, the Secretary, after 
consultation with the National Association 
of Medicaid Directors, national health care 
provider associations, Medicaid beneficiary 
advocates, and advocates for individuals 
with rare diseases, shall determine, based on 
such consultations, the types of health care 
providers (if any) that should be exempted 
from the definition of the term ‘covered pro-
vider’ for purposes of this section.’’. 
(b) GUIDANCE.—Not later than October 1, 2019, the 
Administrator of the Centers for Medicare & Medicaid Serv-
ices, in consultation with the Director of the Centers for 
Disease Control and Prevention, shall issue guidance on 
best practices on the uses of prescription drug monitoring 
programs required of prescribers and on protecting the pri-
vacy of Medicaid beneficiary information maintained in 
and accessed through prescription drug monitoring pro-
grams. 
(c) DEVELOPMENT OF MODEL STATE PRACTICES.— 
(1) IN
GENERAL.—Not later than October 1, 
2020, the Secretary of Health and Human Services 
shall develop and publish model practices to assist 
State Medicaid program operations in identifying
195 
and implementing strategies to utilize data-sharing 
agreements described in the matter following para-
graph (2) of section 1944(b) of the Social Security 
Act, as added by subsection (a), for the following pur-
poses: 
(A) Monitoring and preventing fraud, 
waste, and abuse. 
(B) Improving health care for individuals 
enrolled in a State plan under title XIX of such 
Act (or under a waiver of such plan) who— 
(i) transition in and out of coverage 
under such title; 
(ii) may have sources of health care 
coverage in addition to coverage under such 
title; or 
(iii) pay for prescription drugs with 
cash. 
(C) Any other purposes specified by the Sec-
retary. 
(2) ELEMENTS
OF
MODEL
PRACTICES.—The 
model practices described in paragraph (1)— 
(A) shall include strategies for assisting 
States in allowing the medical director or phar-
macy director (or designees of such a director) of 
managed care organizations or pharmaceutical
196 
benefit managers to access information with re-
spect to all covered individuals served by such 
managed care organizations or pharmaceutical 
benefit managers to access as a single data set, 
in an electronic format; and 
(B) shall include any appropriate bene-
ficiary protections and privacy guidelines. 
(3) CONSULTATION.—In developing model prac-
tices under this subsection, the Secretary shall consult 
with the National Association of Medicaid Directors, 
managed care entities (as defined in section 
1932(a)(1)(B) of the Social Security Act) with con-
tracts with States pursuant to section 1903(m) of 
such Act, pharmaceutical benefit managers, physi-
cians and other health care providers, beneficiary ad-
vocates, and individuals with expertise in health care 
technology related to prescription drug monitoring 
programs and electronic health records. 
(d) REPORT BY COMPTROLLER GENERAL.—Not later 
than October 1, 2020, the Comptroller General of the United 
States shall issue a report examining the operation of pre-
scription drug monitoring programs administered by 
States, including data security and access standards used 
by such programs.
197 
Subtitle F—IMD CARE Act 
SEC. 5051. SHORT TITLE. 
This title 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. 5052. STATE OPTION TO PROVIDE MEDICAID COV-
ERAGE FOR CERTAIN INDIVIDUALS WITH 
SUBSTANCE USE DISORDERS WHO ARE PA-
TIENTS IN CERTAIN INSTITUTIONS FOR MEN-
TAL DISEASES. 
(a) IN GENERAL.—Title XIX of the Social Security 
Act (42 U.S.C. 1396 et seq.), as amended by preceding sec-
tions of this Act, is further amended— 
(1) in section 1905(a), in the subdivision (B) 
that follows paragraph (30), by inserting ‘‘(except in 
the case of services provided under a State plan 
amendment described in section 1915(l))’’ before the 
period; and 
(2) in section 1915, by adding at the end the fol-
lowing new subsection: 
‘‘(l) STATE PLAN AMENDMENT OPTION TO PROVIDE 
MEDICAL ASSISTANCE FOR CERTAIN INDIVIDUALS WHO 
ARE PATIENTS IN CERTAIN INSTITUTIONS FOR MENTAL 
DISEASES.—
198 
‘‘(1) IN
GENERAL.—With respect to calendar 
quarters beginning during the period beginning Octo-
ber 1, 2019, and ending September 30, 2023, a State 
may elect, through a State plan amendment, to pro-
vide medical assistance for items and services fur-
nished to an eligible individual who is a patient in 
an eligible institution for mental diseases in accord-
ance with the requirements of this subsection. 
‘‘(2) PAYMENTS.—Subject to paragraphs (3) and 
(4), amounts expended under a State plan amend-
ment under paragraph (1) for services described in 
such paragraph furnished, with respect to a 12-month 
period, to an eligible individual who is a patient in 
an eligible institution for mental diseases shall be 
treated as medical assistance for which payment is 
made under section 1903(a) but only to the extent 
that such services are furnished for not more than a 
period of 30 days (whether or not consecutive) during 
such 12-month period. 
‘‘(3) MAINTENANCE OF EFFORT.— 
‘‘(A) IN GENERAL.—As a condition for a 
State receiving payments under section 1903(a) 
for medical assistance provided in accordance 
with this subsection, the State shall (during the 
period in which it so furnished such medical as-
199 
sistance through a State plan amendment under 
this subsection) maintain on an annual basis a 
level of funding expended by the State (and po-
litical subdivisions thereof) other than under this 
title from non-Federal funds for— 
‘‘(i) items and services furnished to eli-
gible individuals who are patients in eligi-
ble institutions for mental diseases that is 
not less than the level of such funding for 
such items and services for the most recently 
ended fiscal year as of the date of enactment 
of this subsection or, if higher, for the most 
recently ended fiscal year as of the date the 
State submits a State plan amendment to 
the Secretary to provide such medical as-
sistance in accordance with this subsection; 
and 
‘‘(ii) items and services (including 
services described in subparagraph (B)) fur-
nished to eligible individuals in outpatient 
and community-based settings that is not 
less than the level of such funding for such 
items and services for the most recently 
ended fiscal year as of the date of enactment 
of this subsection or, if higher, for the most
200 
recently ended fiscal year as of the date the 
State submits a State plan amendment to 
the Secretary to provide such medical as-
sistance in accordance with this subsection. 
‘‘(B) SERVICES DESCRIBED.—For purposes 
of subparagraph (A)(ii), services described in 
this subparagraph are the following: 
‘‘(i) Outpatient and community-based 
substance use disorder treatment. 
‘‘(ii) Evidence-based recovery and sup-
port services. 
‘‘(iii) Clinically-directed therapeutic 
treatment to facilitate recovery skills, re-
lapse prevention, and emotional coping 
strategies. 
‘‘(iv) Outpatient medication-assisted 
treatment, related therapies, and pharma-
cology. 
‘‘(v) Counseling and clinical moni-
toring. 
‘‘(vi) Outpatient withdrawal manage-
ment and related treatment designed to al-
leviate acute emotional, behavioral, cog-
nitive, or biomedical distress resulting from,
201 
or occurring with, an individual’s use of al-
cohol and other drugs. 
‘‘(vii) Routine monitoring of medica-
tion adherence. 
‘‘(viii) Other outpatient and commu-
nity-based services for the treatment of sub-
stance use disorders, as designated by the 
Secretary. 
‘‘(C) STATE REPORTING REQUIREMENT.— 
‘‘(i) IN GENERAL.—Prior to approval 
of a State plan amendment under this sub-
section, as a condition for a State receiving 
payments under section 1903(a) for medical 
assistance provided in accordance with this 
subsection, the State shall report to the Sec-
retary, in accordance with the process estab-
lished by the Secretary under clause (ii), the 
information deemed necessary by the Sec-
retary under such clause. 
‘‘(ii) PROCESS.—Not later than the 
date that is 8 months after the date of en-
actment of this subsection, the Secretary 
shall establish a process for States to report 
to the Secretary, at such time and in such 
manner as the Secretary deems appropriate,
202 
such information as the Secretary deems 
necessary to verify a State’s compliance 
with subparagraph (A). 
‘‘(4) ENSURING A CONTINUUM OF SERVICES.— 
‘‘(A) IN GENERAL.—As a condition for a 
State receiving payments under section 1903(a) 
for medical assistance provided in accordance 
with this subsection, the State shall carry out 
each of the requirements described in subpara-
graphs (B) through (D). 
‘‘(B) NOTIFICATION.—Prior to approval of 
a State plan amendment under this subsection, 
the State shall notify the Secretary of how the 
State will ensure that eligible individuals receive 
appropriate evidence-based clinical screening 
prior to being furnished with items and services 
in an eligible institution for mental diseases, in-
cluding initial and periodic assessments to deter-
mine the appropriate level of care, length of stay, 
and setting for such care for each individual. 
‘‘(C) OUTPATIENT
SERVICES; 
INPATIENT 
AND RESIDENTIAL SERVICES.— 
‘‘(i) 
OUTPATIENT
SERVICES.—The 
State shall, at a minimum, provide medical 
assistance for services that could otherwise
203 
be covered under the State plan, consistent 
with each of the following outpatient levels 
of care: 
‘‘(I) Early intervention for indi-
viduals who, for a known reason, are 
at risk of developing substance-related 
problems and for individuals for whom 
there is not yet sufficient information 
to document a diagnosable substance 
use disorder. 
‘‘(II) Outpatient services for less 
than 9 hours per week for adults, and 
for less than 6 hours per week for ado-
lescents, for recovery or motivational 
enhancement therapies and strategies. 
‘‘(III) Intensive outpatient serv-
ices for 9 hours or more per week for 
adults, and for 6 hours or more per 
week for adolescents, to treat multi-
dimensional instability. 
‘‘(IV) Partial hospitalization serv-
ices for 20 hours or more per week for 
adults and adolescents to treat multi-
dimensional instability that does not 
require 24-hour care.
204 
‘‘(ii) INPATIENT
AND
RESIDENTIAL 
SERVICES.—The State shall provide medical 
assistance for services that could otherwise 
be covered under the State plan, consistent 
with at least 2 of the following inpatient 
and residential levels of care: 
‘‘(I) Clinically managed, low-in-
tensity residential services that provide 
adults and adolescents with 24-hour 
living support and structure with 
trained personnel and at least 5 hours 
of clinical service per week per indi-
vidual. 
‘‘(II) Clinically managed, popu-
lation-specific, high-intensity residen-
tial services that provide adults with 
24-hour care with trained counselors to 
stabilize multidimensional imminent 
danger along with less intense milieu 
and group treatment for those with 
cognitive or other impairments unable 
to use full active milieu or therapeutic 
community. 
‘‘(III) Clinically managed, me-
dium-intensity residential services for
205 
adolescents, and clinically managed, 
high-intensity residential services for 
adults, that provide 24-hour care with 
trained counselors to stabilize multi-
dimensional imminent danger and 
preparation for outpatient treatment. 
‘‘(IV) Medically monitored, high- 
intensity inpatient services for adoles-
cents, and medically monitored, inten-
sive 
inpatient 
services 
withdrawal 
management for adults, that provide 
24-hour nursing care, make physicians 
available for significant problems in 
Dimensions 1, 2, or 3, and provide 
counseling services 16 hours per day. 
‘‘(V) Medically managed, inten-
sive inpatient services for adolescents 
and adults that provide 24-hour nurs-
ing care and daily physician care for 
severe, unstable problems in Dimen-
sions 1, 2 or 3. 
‘‘(D) TRANSITION OF CARE.—In order to 
ensure an appropriate transition for an eligible 
individual from receiving care in an eligible in-
stitution for mental diseases to receiving care at
206 
a lower level of clinical intensity within the con-
tinuum of care (including outpatient services), 
the State shall ensure that— 
‘‘(i) a placement in such eligible insti-
tution for mental diseases would allow for 
an eligible individual’s successful transition 
to the community, considering such factors 
as proximity to an individual’s support 
network (such as family members, employ-
ment, and counseling and other services 
near an individual’s residence); and 
‘‘(ii) all eligible institutions for mental 
diseases that furnish items and services to 
individuals for which medical assistance is 
provided under the State plan— 
‘‘(I) are able to provide care at 
such lower level of clinical intensity; or 
‘‘(II) have an established relation-
ship with another facility or provider 
that is able to provide care at such 
lower level of clinical intensity and ac-
cepts patients receiving medical assist-
ance under this title under which the 
eligible institution for mental diseases 
may arrange for individuals to receive
207 
such care from such other facility or 
provider. 
‘‘(5) APPLICATION
TO
MANAGED
CARE.—Pay-
ments for, and limitations to, medical assistance fur-
nished in accordance with this subsection shall be in 
addition to and shall not be construed to limit or su-
persede the ability of States to make monthly capita-
tion payments to managed care organizations for in-
dividuals receiving treatment in institutions for men-
tal diseases in accordance with section 438.6(e) of 
title 42, Code of Federal Regulations (or any suc-
cessor regulation). 
‘‘(6) OTHER MEDICAL ASSISTANCE.—The provi-
sion of medical assistance for items and services fur-
nished to an eligible individual who is a patient in 
an eligible institution for mental diseases in accord-
ance with the requirements of this subsection shall not 
prohibit Federal financial participation for medical 
assistance for items or services that are provided to 
such eligible individual in or away from the eligible 
institution for mental disease during any period in 
which the eligible individual is receiving items or 
services in accordance with this subsection. 
‘‘(7) DEFINITIONS.—In this subsection:
208 
‘‘(A) DIMENSIONS
1, 2, OR
3.—The term 
‘Dimensions 1, 2, or 3’ has the meaning given 
that term for purposes of the publication of the 
American Society of Addiction Medicine entitled 
‘The ASAM Criteria: Treatment Criteria for Ad-
dictive Substance-Related, and Co-Occurring 
Conditions, 2013’. 
‘‘(B) ELIGIBLE INDIVIDUAL.—The term ‘eli-
gible individual’ means an individual who— 
‘‘(i) with respect to a State, is enrolled 
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 at least 1 substance use dis-
order. 
‘‘(C) ELIGIBLE INSTITUTION FOR MENTAL 
DISEASES.—The term ‘eligible institution for 
mental diseases’ means an institution for mental 
diseases that— 
‘‘(i) follows reliable, evidence-based 
practices; and 
‘‘(ii) offers at least 2 forms of medica-
tion-assisted treatment for substance use
209 
disorders on site, including, in the case of 
medication-assisted treatment for opioid use 
disorder, at least 1 antagonist and 1 partial 
agonist. 
‘‘(D) 
INSTITUTION
FOR
MENTAL
DIS-
EASES.—The term ‘institution for mental dis-
eases’ has the meaning given that term in section 
1905(i).’’. 
(b) RULE OF CONSTRUCTION.—Nothing in the amend-
ments made by subsection (a) shall be construed as encour-
aging a State to place an individual in an inpatient or 
a residential care setting where a home or community-based 
care setting would be more appropriate for the individual, 
or as preventing a State from conducting or pursuing a 
demonstration project under section 1115 of the Social Se-
curity Act to improve access to, and the quality of, sub-
stance use disorder treatment for eligible populations. 
Subtitle G—Medicaid Improvement 
Fund 
SEC. 5061. MEDICAID IMPROVEMENT FUND. 
Section 1941(b)(1) of the Social Security Act (42 
U.S.C. 1396w–1(b)(1)) is amended by striking ‘‘$0’’ and 
inserting ‘‘$31,000,000’’.
210 
TITLE VI—OTHER MEDICARE 
PROVISIONS 
Subtitle 
A—Testing 
of 
Incentive 
Payments for Behavioral Health 
Providers for Adoption and Use 
of Certified Electronic Health 
Record Technology 
SEC. 6001. TESTING OF INCENTIVE PAYMENTS FOR BEHAV-
IORAL HEALTH PROVIDERS FOR ADOPTION 
AND 
USE 
OF 
CERTIFIED 
ELECTRONIC 
HEALTH RECORD TECHNOLOGY. 
Section 1115A(b)(2)(B) of the Social Security Act (42 
U.S.C. 1315a(b)(2)(B)) is amended by adding at the end 
the following new clause: 
‘‘(xxv) Providing, for the adoption and 
use of certified EHR technology (as defined 
in section 1848(o)(4)) to improve the qual-
ity and coordination of care through the 
electronic documentation and exchange of 
health information, incentive payments to 
behavioral health providers (such as psy-
chiatric hospitals (as defined in section 
1861(f)), community mental health centers 
(as defined in section 1861(ff)(3)(B)), hos-
pitals that participate in a State plan
211 
under title XIX or a waiver of such plan, 
treatment facilities that participate in such 
a State plan or such a waiver, mental 
health or substance use disorder providers 
that participate in such a State plan or 
such a waiver, clinical psychologists (as de-
fined in section 1861(ii)), nurse practi-
tioners (as defined in section 1861(aa)(5)) 
with respect to the provision of psychiatric 
services, and clinical social workers (as de-
fined in section 1861(hh)(1))).’’. 
Subtitle B—Abuse Deterrent Access 
SEC. 6011. SHORT TITLE. 
This subtitle may be cited at the ‘‘Abuse Deterrent Ac-
cess Act of 2018’’. 
SEC. 6012. STUDY ON ABUSE-DETERRENT OPIOID FORMULA-
TIONS ACCESS BARRIERS UNDER MEDICARE. 
(a) IN GENERAL.—Not later than 1 year 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— 
(1) the adequacy of access to abuse-deterrent 
opioid formulations for individuals with chronic pain 
enrolled in an MA–PD plan under part C of title 
XVIII of the Social Security Act or a prescription
212 
drug plan under part D of such title of such Act, tak-
ing into account any barriers preventing such indi-
viduals from accessing such formulations under such 
MA–PD or part D plans, such as cost-sharing tiers, 
fail-first requirements, the price of such formulations, 
and prior authorization requirements; and 
(2) the effectiveness of abuse-deterrent opioid for-
mulations in preventing opioid abuse or misuse; the 
impact of the use of abuse-deterrent opioid formula-
tions on the use or abuse of other prescription or il-
licit opioids (including changes in deaths from such 
opioids); and other public health consequences of the 
use of abuse-deterrent opioid formulations, such as an 
increase in rates of human immunodeficiency virus. 
(b) DEFINITION OF ABUSE-DETERRENT OPIOID FOR-
MULATION.—In this section, the term ‘‘abuse-deterrent 
opioid formulation’’ means an opioid that is a prodrug or 
that has certain abuse-deterrent properties, such as physical 
or chemical barriers, agonist or antagonist combinations, 
aversion properties, delivery system mechanisms, or other 
features designed to prevent abuse of such opioid.
213 
Subtitle C—Medicare Opioid Safety 
Education 
SEC. 6021. MEDICARE OPIOID SAFETY EDUCATION. 
(a) IN GENERAL.—Section 1804 of the Social Security 
Act (42 U.S.C. 1395b–2) is amended by adding at the end 
the following new subsection: 
‘‘(d) The notice provided under subsection (a) shall in-
clude— 
‘‘(1) references to educational resources regarding 
opioid use and pain management; 
‘‘(2) a description of categories of alternative, 
non-opioid pain management treatments covered 
under this title; and 
‘‘(3) a suggestion for the beneficiary to talk to a 
physician regarding opioid use and pain manage-
ment.’’. 
(b) EFFECTIVE DATE.—The amendment made by sub-
section (a) shall apply to notices distributed prior to each 
Medicare open enrollment period beginning after January 
1, 2019. 
Subtitle D—Opioid Addiction 
Action Plan 
SEC. 6031. SHORT TITLE. 
This subtitle may be cited as the ‘‘Opioid Addiction 
Action Plan Act’’.
214 
SEC. 6032. ACTION PLAN ON RECOMMENDATIONS FOR 
CHANGES UNDER MEDICARE AND MEDICAID 
TO PREVENT OPIOIDS ADDICTIONS AND EN-
HANCE ACCESS TO MEDICATION-ASSISTED 
TREATMENT. 
(a) IN GENERAL.—Not later than January 1, 2020, 
the Secretary of Health and Human Services (in this sec-
tion referred to as the ‘‘Secretary’’), in collaboration with 
the Pain Management Best Practices Inter-Agency Task 
Force convened under section 101(b) of the Comprehensive 
Addiction and Recovery Act of 2016 (Public Law 114–198), 
shall develop an action plan as described in subsection (b). 
(b) ACTION PLAN COMPONENTS.—The action plan 
shall include a review by the Secretary of Medicare and 
Medicaid payment and coverage policies that may be 
viewed as potential obstacles to an effective response to the 
opioid crisis, and recommendations, as determined appro-
priate by the Secretary, on the following: 
(1) A review of payment and coverage policies 
under the Medicare program under title XVIII of the 
Social Security Act and the Medicaid program under 
title XIX of such Act, including a review of coverage 
and payment under such programs of all medication- 
assisted treatment approved by the Food and Drug 
Administration related to the treatment of opioid use 
disorder and other therapies that manage chronic and
215 
acute pain and treat and minimize risk of opioid 
misuse and abuse, including in such review, payment 
under the Medicare prospective payment system for 
inpatient hospital services under section 1886(d) of 
such Act (42 U.S.C. 1395ww(d)) and the Medicare 
prospective payment system for hospital outpatient 
department services under section 1833(t) of such Act 
(42 U.S.C. 1395I(t)), to determine whether those pay-
ment policies resulted in incentives or disincentives 
that have contributed to the opioid crisis. 
(2) Recommendations for payment and service 
delivery models to be tested as appropriate by the 
Center for Medicare and Medicaid Innovation and 
other federally authorized demonstration projects, in-
cluding value-based models, that may encourage the 
use of appropriate medication-assisted treatment ap-
proved by the Food and Drug Administration for the 
treatment of opioid use disorder and other therapies 
that manage chronic and acute pain and treat and 
minimize risk of opioid misuse and abuse. 
(3) Recommendations for data collection that 
could facilitate research and policy-making regarding 
prevention of opioid use disorder as well as data that 
would aid the Secretary in making coverage and pay-
ment decisions under the Medicare and Medicaid pro-
216 
grams related to the access to appropriate opioid de-
pendence treatments. 
(4) A review of Medicare and Medicaid bene-
ficiaries’ access to the full range of medication-as-
sisted treatment approved by the Food and Drug Ad-
ministration for the treatment of opioid use disorder 
and other therapies that manage chronic and acute 
pain and treat and minimize risk of opioid misuse 
and abuse, including access of beneficiaries residing 
in rural or medically underserved communities. 
(5) A review of payment and coverage policies 
under the Medicare program and the Medicaid pro-
gram related to medical devices that are non-opioid 
based treatments approved by the Food and Drug Ad-
ministration for the management of acute pain and 
chronic pain, for monitoring substance use with-
drawal and preventing overdoses of controlled sub-
stances, and for treating substance use disorder, in-
cluding barriers to patient access. 
(c) STAKEHOLDER MEETINGS.— 
(1) IN GENERAL.—Beginning not later than 3 
months after the date of the enactment of this section, 
the Secretary shall convene a public stakeholder meet-
ing to solicit public comment on the components of 
the action plan described in subsection (b).
217 
(2) PARTICIPANTS.—Participants of meetings de-
scribed in paragraph (1) shall include representatives 
from the Food and Drug Administration and Na-
tional Institutes of Health, biopharmaceutical indus-
try members, medical researchers, health care pro-
viders, the medical device industry, the Medicare pro-
gram, the Medicaid program, and patient advocates. 
(d) REQUEST FOR INFORMATION.—Not later than 3 
months after the date of the enactment of this section, the 
Secretary shall issue a request for information seeking pub-
lic feedback regarding ways in which the Centers for Medi-
care & Medicaid Services can help address the opioid crisis 
through the development of and application of the action 
plan. 
(e) REPORT TO CONGRESS.—Not later than June 1, 
2020, the Secretary shall submit to Congress, and make 
public, a report that includes— 
(1) a summary of the results of the Secretary’s 
review and any recommendations under the action 
plan; 
(2) the Secretary’s planned next steps with re-
spect to the action plan; and 
(3) an evaluation of price trends for drugs used 
to reverse opioid overdoses (such as naloxone), includ-
218 
ing recommendations on ways to lower such prices for 
consumers. 
(f) DEFINITION
OF MEDICATION-ASSISTED TREAT-
MENT.—In this section, the term ‘‘medication-assisted treat-
ment’’ includes opioid treatment programs, behavioral ther-
apy, and medications to treat substance abuse disorder. 
Subtitle E—Advancing High Qual-
ity Treatment for Opioid Use 
Disorders in Medicare 
SEC. 6041. SHORT TITLE. 
This subtitle may be cited as the ‘‘Advancing High 
Quality Treatment for Opioid Use Disorders in Medicare 
Act’’. 
SEC. 6042. OPIOID USE DISORDER TREATMENT DEM-
ONSTRATION PROGRAM. 
Title XVIII of the Social Security Act (42 U.S.C. 1395 
et seq.) is amended by inserting after section 1866E (42 
U.S.C. 1395cc–5) the following new section: 
‘‘SEC. 1866F. OPIOID USE DISORDER TREATMENT DEM-
ONSTRATION PROGRAM. 
‘‘(a) IMPLEMENTATION OF 4-YEAR DEMONSTRATION 
PROGRAM.— 
‘‘(1) IN GENERAL.—Not later than January 1, 
2021, the Secretary shall implement a 4-year dem-
onstration program under this title (in this section
219 
referred to as the ‘Program’) to increase access of ap-
plicable beneficiaries to opioid use disorder treatment 
services, improve physical and mental health out-
comes for such beneficiaries, and to the extent pos-
sible, reduce expenditures under this title. Under the 
Program, the Secretary shall make payments under 
subsection (e) to participants (as defined in sub-
section (c)(1)(A)) for furnishing opioid use disorder 
treatment services delivered through opioid use dis-
order care teams, or arranging for such services to be 
furnished, to applicable beneficiaries participating in 
the Program. 
‘‘(2) OPIOID USE DISORDER TREATMENT SERV-
ICES.—For purposes 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;
220 
‘‘(iii) psychiatric, psychological, or 
counseling services (or any combination of 
such services), as appropriate; 
‘‘(iv) social support services, as appro-
priate; and 
‘‘(v) care management and care coordi-
nation services, 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 eval-
uation of the extent to which the Program accom-
plishes the following purposes: 
‘‘(A) Reduces hospitalizations and emer-
gency department visits. 
‘‘(B) Increases use of medication-assisted 
treatment for opioid use disorders. 
‘‘(C) Improves health outcomes of individ-
uals with opioid use disorders, including by re-
ducing 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.
221 
‘‘(F) Reduces the utilization of inpatient 
residential treatment. 
‘‘(2) CONSULTATION.—In designing the Pro-
gram, 
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, clinicians 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— 
‘‘(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 de-
partment; 
‘‘(IV) a federally qualified health 
center 
(as 
defined 
in 
section 
1861(aa)(4));
222 
‘‘(V) a rural health clinic (as de-
fined 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 cer-
tified community 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 selection process estab-
lished 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 para-
graph (2)(A), and uses such team to furnish 
or arrange for opioid use disorder treatment 
services in the outpatient setting under the 
Program.
223 
‘‘(B) PREFERENCE.—In selecting partici-
pants for the Program, the Secretary shall give 
preference to individuals and entities that are lo-
cated in areas with a prevalence of opioid use 
disorders that is higher than the national aver-
age 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 estab-
lished by a participant described in paragraph 
(1)(A) that— 
‘‘(i) shall include— 
‘‘(I) at least one physician (as de-
fined in section 1861(r)(1)) furnishing 
primary care services or addiction 
treatment services to an applicable 
beneficiary; and 
‘‘(II) at least one eligible practi-
tioner (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 psy-
224 
chiatric, psychological, counseling, and so-
cial services to applicable beneficiaries. 
‘‘(B) REQUIREMENTS FOR RECEIPT OF PAY-
MENT
UNDER
PROGRAM.—In order to receive 
payments under subsection (e), each participant 
in the Program shall— 
‘‘(i) furnish opioid use disorder treat-
ment services through opioid use disorder 
care teams to applicable beneficiaries who 
agree to receive the services; 
‘‘(ii) meet minimum criteria, as estab-
lished by the Secretary; and 
‘‘(iii) submit to the Secretary, in such 
form, manner, and frequency as specified by 
the Secretary, with respect to each applica-
ble 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 de-
termines appropriate to— 
‘‘(I) monitor and evaluate the 
Program; 
‘‘(II) determine if minimum cri-
teria are met under clause (ii); and
225 
‘‘(III) determine the incentive 
payment under subsection (e). 
‘‘(3) ELIGIBLE
PRACTITIONER
DEFINED.—For 
purposes of this section, the term ‘eligible practi-
tioner’ means a physician or other health care practi-
tioner, 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 detoxification 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 compli-
ance with regulations promulgated by the Sub-
stance Abuse and Mental Health Services Ad-
ministration to carry out such section. 
‘‘(d) 
PARTICIPATION
OF
APPLICABLE
BENE-
FICIARIES.— 
‘‘(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;
226 
‘‘(B) is not enrolled in a Medicare Advan-
tage plan under part C; 
‘‘(C) has a current diagnosis for an opioid 
use disorder; and 
‘‘(D) meets such other criteria as the Sec-
retary determines 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 sub-
paragraphs (A) through (D). 
‘‘(2) VOLUNTARY
BENEFICIARY
PARTICIPATION; 
LIMITATION ON NUMBER OF BENEFICIARIES.—An ap-
plicable beneficiary may participate in the Program 
on a voluntary basis and may terminate participa-
tion 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 re-
ceive opioid use disorder 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.
227 
‘‘(4) BENEFICIARY ACCESS TO SERVICES.—Noth-
ing in this section shall be construed as encouraging 
providers to limit applicable beneficiary access to 
services covered under this title, and applicable bene-
ficiaries shall not be required to relinquish 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 es-
tablish a schedule of per applicable beneficiary 
per month care management fees. Such a per ap-
plicable 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 par-
ticipant’s opioid use disorder care team or, if 
applicable, to the participant. A participant 
may use such per applicable beneficiary per 
month care management fee to deliver additional 
services to applicable beneficiaries, including 
services not otherwise eligible for payment under 
this title.
228 
‘‘(B) PAYMENT AMOUNTS.—In carrying out 
subparagraph (A), the Secretary may— 
‘‘(i) consider payments otherwise pay-
able under this title for opioid use disorder 
treatment services and the needs of applica-
ble beneficiaries; 
‘‘(ii) pay a higher per applicable bene-
ficiary per month care management fee for 
an applicable beneficiary who receives more 
intensive treatment services from a partici-
pant and for whom those services are ap-
propriate based on clinical guidelines for 
opioid use disorder care; 
‘‘(iii) pay a higher per applicable ben-
eficiary per month care management fee for 
the month in which the applicable bene-
ficiary begins treatment with a participant 
than in subsequent months, to reflect the 
greater time and costs required for the plan-
ning and initiation of treatment, as com-
pared to maintenance of treatment; and 
‘‘(iv) take into account whether a par-
ticipant’s opioid use disorder care team re-
fers applicable beneficiaries to other sup-
229 
pliers or providers for any opioid use dis-
order treatment services. 
‘‘(C) NO DUPLICATE PAYMENT.—The Sec-
retary shall make payments under this para-
graph to only one participant for services fur-
nished to an applicable beneficiary during a cal-
endar month. 
‘‘(2) INCENTIVE PAYMENTS.— 
‘‘(A) IN GENERAL.—Under the Program, the 
Secretary shall establish a performance-based in-
centive payment, which shall be paid (using a 
methodology established and at a time deter-
mined appropriate by the Secretary) to partici-
pants based on the performance of participants 
with respect to criteria, as determined appro-
priate by the Secretary, in accordance with sub-
paragraph (B). 
‘‘(B) CRITERIA.— 
‘‘(i) IN GENERAL.—Criteria described 
in subparagraph (A) may include consider-
ation of the following: 
‘‘(I) Patient engagement and re-
tention in treatment. 
‘‘(II) Evidence-based medication- 
assisted treatment.
230 
‘‘(III) Other criteria established 
by the Secretary. 
‘‘(ii) REQUIRED
CONSULTATION
AND 
CONSIDERATION.—In determining criteria 
described in subparagraph (A), the Sec-
retary shall— 
‘‘(I) consult with stakeholders, in-
cluding clinicians in the primary care 
community and in the field of addic-
tion medicine; and 
‘‘(II) consider existing clinical 
guidelines for the treatment of opioid 
use disorders. 
‘‘(C) NO DUPLICATE PAYMENT.—The Sec-
retary 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 pro-
vide similar payments and to use similar criteria as ap-
plied 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
231 
treatment services with such methodology for payment 
under the Program. 
‘‘(g) EVALUATION.— 
‘‘(1) IN GENERAL.—The Secretary shall conduct 
an intermediate and final evaluation of the program. 
Each such evaluation 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 inter-
mediate evaluation under paragraph (1) not 
later than 3 years after the date of the imple-
mentation of the Program; and 
‘‘(B) a report with respect to the final eval-
uation under paragraph (1) not later than 6 
years after such date. 
‘‘(h) FUNDING.— 
‘‘(1) ADMINISTRATIVE FUNDING.—For the pur-
poses of implementing, 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 Insurance Trust 
Fund under section 1841.
232 
‘‘(2) CARE
MANAGEMENT
FEES
AND
INCEN-
TIVES.—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 subsection for a fiscal year shall be available 
until expended. 
‘‘(i) WAIVERS.—The Secretary may waive any provi-
sion of this title as may be necessary to carry out the Pro-
gram under this section.’’. 
Subtitle F—Responsible Education 
Achieves Care and Healthy Out-
comes for Users’ Treatment 
SEC. 6051. SHORT TITLE. 
This subtitle may be cited as the ‘‘Responsible Edu-
cation 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 ‘‘Sec-
retary’’) shall, through the Centers for Medicare & Medicaid 
Services, award grants, contracts, or cooperative agreements
233 
to eligible entities for the purposes described in subsection 
(b). 
(b) USE OF FUNDS.—Grants, contracts, and coopera-
tive agreements 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 pre-
scribing opioids; 
(2) to educate and provide outreach to outlier 
prescribers of opioids about non-opioid pain manage-
ment therapies; and 
(3) to reduce the amount of opioid prescriptions 
prescribed by outlier prescribers of opioids. 
(c) APPLICATION.—Each eligible entity seeking to re-
ceive a grant, contract, or cooperative agreement under sub-
section (a) shall submit to the Secretary an application, 
at such time, in such manner, and containing such infor-
mation 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 enti-
ty’’ means—
234 
(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 rep-
resentative of consumers on its gov-
erning body; and 
(II) one individual who is a rep-
resentative 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 re-
spect to a period, a prescriber identified by the Sec-
retary 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
235 
practitioner or physician assistant, who is licensed to 
prescribe opioids by the State or territory in which 
such professional practices. 
(f) FUNDING.—For purposes of implementing this sec-
tion, $75,000,000 shall be available from the Federal Sup-
plementary Medical Insurance Trust Fund under section 
1841 of the Social Security Act (42 U.S.C. 1395t), to re-
main available until expended. 
Subtitle G—Preventing Addiction 
for Susceptible Seniors 
SEC. 6061. SHORT TITLE. 
This subtitle may be cited as the ‘‘Preventing Addic-
tion for Susceptible Seniors Act of 2018’’ or the ‘‘PASS Act 
of 2018’’. 
SEC. 6062. ELECTRONIC PRIOR AUTHORIZATION FOR COV-
ERED 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
AUTHORIZA-
TION.— 
‘‘(i) IN GENERAL.—Not later than Jan-
uary 1, 2021, the program shall provide for 
the secure electronic transmission of—
236 
‘‘(I) a prior authorization request 
from the prescribing health care profes-
sional for coverage of a covered part D 
drug for a part D eligible individual 
enrolled in a part D plan (as defined 
in section 1860D–23(a)(5)) to the PDP 
sponsor or Medicare Advantage organi-
zation offering such plan; and 
‘‘(II) a response, in accordance 
with this subparagraph, from such 
PDP sponsor or Medicare Advantage 
organization, respectively, to such pro-
fessional. 
‘‘(ii) ELECTRONIC TRANSMISSION.— 
‘‘(I) EXCLUSIONS.—For purposes 
of this subparagraph, a facsimile, a 
proprietary payer portal that does not 
meet standards specified by the Sec-
retary, or an electronic form shall not 
be treated as an electronic trans-
mission described in clause (i). 
‘‘(II) STANDARDS.—In order to be 
treated, for purposes of this subpara-
graph, as an electronic transmission 
described in clause (i), such trans-
237 
mission shall comply with technical 
standards adopted by the Secretary in 
consultation with the National Council 
for Prescription Drug Programs, other 
standard setting organizations deter-
mined appropriate by the Secretary, 
and stakeholders including PDP spon-
sors, Medicare Advantage organiza-
tions, health care professionals, and 
health information technology software 
vendors. 
‘‘(III) 
APPLICATION.—Notwith-
standing any other provision of law, 
for purposes of this subparagraph, the 
Secretary may require the use of such 
standards adopted under subclause (II) 
in lieu of any other applicable stand-
ards for an electronic transmission de-
scribed in clause (i) for a covered part 
D drug for a part D eligible indi-
vidual.’’.
238 
SEC. 6063. PROGRAM INTEGRITY TRANSPARENCY MEAS-
URES 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
MEAS-
URES.— 
‘‘(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 stake-
holders, establish a secure internet website portal 
(or other successor technology) 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 in-
tegrity 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 sub-
stantiated or suspicious activities, as de-
fined by the Secretary, of a provider of serv-
ices (including a prescriber) or supplier re-
239 
lated to fraud, waste, and abuse for initi-
ating or assisting investigations conducted 
by the eligible entity; and 
‘‘(ii) data sharing among such MA 
plans, prescription drug plans, and the Sec-
retary. 
‘‘(B) REQUIRED
USES
OF
PORTAL.—The 
Secretary shall disseminate the following infor-
mation to MA plans under this part and pre-
scription drug plans under part D through the 
secure internet website portal (or other successor 
technology) established under subparagraph (A): 
‘‘(i) Providers of services and suppliers 
that have been referred pursuant to sub-
paragraph (A)(i) during the previous 12- 
month period. 
‘‘(ii) Providers of services and sup-
pliers who are the subject of an active exclu-
sion 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 sup-
pliers who are the subject of an active rev-
ocation of participation under this title, in-
240 
cluding for not satisfying conditions of par-
ticipation. 
‘‘(iv) In the case of such a plan that 
makes a referral under subparagraph (A)(i) 
through the portal (or other successor tech-
nology) with respect to activities of substan-
tiated or suspicious activities of fraud, 
waste, or abuse of a provider of services (in-
cluding a prescriber) or supplier, if such 
provider (including a prescriber) or sup-
plier has been the subject of an administra-
tive action under this title or title XI with 
respect to similar activities, a notification 
to such plan of such action so taken. 
‘‘(C) RULEMAKING.—For purposes of this 
paragraph, the Secretary shall, through rule-
making, specify what constitutes 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 car-
rying out this subsection, a fraud hotline tip (as 
defined by the Secretary) without further evi-
dence shall not be treated as sufficient evidence 
for substantiated fraud, waste, or abuse.
241 
‘‘(D) HIPAA 
COMPLIANT
INFORMATION 
ONLY.—For purposes of this subsection, commu-
nications may only occur if the communications 
are permitted under the Federal regulations 
(concerning the privacy of individually identifi-
able health information) promulgated under sec-
tion 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) de-
scribed in such paragraph or pursuant to section 
1893, information on fraud, waste, and abuse schemes 
and trends in identifying suspicious activity. Infor-
mation included in each such report shall— 
‘‘(A) include administrative actions, perti-
nent information related to opioid overpre-
scribing, and other data determined appropriate 
by the Secretary in consultation with stake-
holders; and
242 
‘‘(B) be anonymized information submitted 
by plans without identifying the source of such 
information. 
‘‘(3) CLARIFICATION.—Nothing in this subsection 
shall preclude or otherwise affect referrals to the In-
spector General of the Department of Health and 
Human Services or other law enforcement entities.’’. 
(b) CONTRACT REQUIREMENT TO COMMUNICATE PLAN 
CORRECTIVE
ACTIONS
AGAINST
OPIOIDS
OVER-PRE-
SCRIBERS.—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
AC-
TIONS AGAINST OPIOIDS OVER-PRESCRIBERS.— 
‘‘(A) IN
GENERAL.—Beginning with plan 
years beginning on or after January 1, 2021, a 
contract under this section with an MA organi-
zation shall require the organization to submit to 
the Secretary, through the process established 
under subparagraph (B), information on the in-
vestigations, credible evidence of suspicious ac-
tivities of a provider of services (including a pre-
scriber) or supplier related to fraud, and other 
actions taken by such plans related to inappro-
priate prescribing of opioids.
243 
‘‘(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 sub-
paragraph (A). 
‘‘(C) REGULATIONS.—For purposes of this 
paragraph, including as applied under section 
1860D–12(b)(3)(D), the Secretary shall, pursu-
ant to rulemaking— 
‘‘(i) specify a definition for the term 
‘inappropriate prescribing’ and a method 
for determining if a provider of services 
prescribes inappropriate prescribing; and 
‘‘(ii) establish the process described in 
subparagraph (B) and the types of informa-
tion that shall be submitted through such 
process.’’. 
(c) REFERENCE UNDER PART D TO PROGRAM INTEG-
RITY TRANSPARENCY MEASURES.—Section 1860D–4 of the 
Social Security Act (42 U.S.C. 1395w–104) is amended by 
adding at the end the following new subsection: 
‘‘(m) PROGRAM INTEGRITY TRANSPARENCY MEAS-
URES.—For program integrity transparency measures ap-
244 
plied with respect to prescription drug plan and MA plans, 
see section 1859(i).’’. 
SEC. 6064. EXPANDING ELIGIBILITY FOR MEDICATION 
THERAPY MANAGEMENT PROGRAMS UNDER 
PART D. 
Section 1860D–4(c)(2)(A)(ii) of the Social Security 
Act (42 U.S.C. 1395w–104(c)(2)(A)(ii)) is amended— 
(1) by redesignating subclauses (I) through (III) 
as items (aa) through (cc), respectively, and adjusting 
the margins accordingly; 
(2) by striking ‘‘are part D eligible individuals 
who—’’ and inserting ‘‘are the following: 
‘‘(I) Part D eligible individuals 
who—’’; and 
(3) by adding at the end the following new sub-
clause: 
‘‘(II) Beginning January 1, 2021, 
at-risk beneficiaries for prescription 
drug abuse (as defined in paragraph 
(5)(C)).’’. 
SEC. 6065. COMMIT TO OPIOID MEDICAL PRESCRIBER AC-
COUNTABILITY AND SAFETY FOR SENIORS. 
Section 1860D–4(c)(4) of the Social Security Act (42 
U.S.C. 1395w–104(c)(4)) is amended by adding at the end 
the following new subparagraph:
245 
‘‘(D) NOTIFICATION
AND
ADDITIONAL
RE-
QUIREMENTS WITH RESPECT TO OUTLIER PRE-
SCRIBERS OF OPIOIDS.— 
‘‘(i) NOTIFICATION.—Not later than 
January 1, 2021, the Secretary shall, in the 
case of a prescriber identified by the Sec-
retary under clause (ii) to be an outlier pre-
scriber of opioids, provide, subject to clause 
(iv), an annual notification to such pre-
scriber that such prescriber has been so 
identified and that includes resources on 
proper prescribing methods and other infor-
mation as specified in accordance with 
clause (iii). 
‘‘(ii) IDENTIFICATION
OF
OUTLIER 
PRESCRIBERS OF OPIOIDS.— 
‘‘(I) IN GENERAL.—The Secretary 
shall, subject to subclause (III), using 
the valid prescriber National Provider 
Identifiers included pursuant to sub-
paragraph (A) on claims for covered 
part D drugs for part D eligible indi-
viduals enrolled in prescription drug 
plans under this part or MA–PD plans 
under part C and based on the thresh-
246 
olds established under subclause (II), 
identify prescribers that are outlier 
opioids prescribers for a period of time 
specified by the Secretary. 
‘‘(II) 
ESTABLISHMENT
OF 
THRESHOLDS.—For purposes of sub-
clause (I) and subject to subclause 
(III), the Secretary shall, after con-
sultation with stakeholders, establish 
thresholds, based on prescriber spe-
cialty and geographic area, for identi-
fying whether a prescriber in a spe-
cialty and geographic area is an 
outlier prescriber of opioids as com-
pared to other prescribers of opioids 
within such specialty and area. 
‘‘(III) 
EXCLUSIONS.—The 
fol-
lowing shall not be included in the 
analysis for identifying outlier pre-
scribers of opioids under this clause: 
‘‘(aa) Claims for covered 
part D drugs for part D eligible 
individuals who are receiving hos-
pice care under this title.
247 
‘‘(bb) Claims for covered part 
D drugs for part D eligible indi-
viduals who are receiving oncol-
ogy services under this title. 
‘‘(cc) Prescribers who are the 
subject of an investigation by the 
Centers for Medicare & Medicaid 
Services or the Inspector General 
of the Department of Health and 
Human Services. 
‘‘(iii) CONTENTS OF NOTIFICATION.— 
The Secretary shall include the following in-
formation in the notifications provided 
under clause (i): 
‘‘(I) Information on how such pre-
scriber compares to other prescribers 
within the same specialty and geo-
graphic area. 
‘‘(II) Information on opioid pre-
scribing guidelines, based on input 
from stakeholders, that may include the 
Centers for Disease Control and Pre-
vention 
guidelines 
for 
prescribing 
opioids for chronic pain and guidelines 
developed by physician organizations.
248 
‘‘(III) Other information deter-
mined appropriate by the Secretary. 
‘‘(iv) 
MODIFICATIONS
AND
EXPAN-
SIONS.— 
‘‘(I) FREQUENCY.—Beginning 5 
years after the date of the enactment of 
this subparagraph, the Secretary may 
change the frequency of the notifica-
tions described in clause (i) based on 
stakeholder input and changes in 
opioid 
prescribing 
utilization 
and 
trends. 
‘‘(II) EXPANSION TO OTHER PRE-
SCRIPTIONS.—The Secretary may ex-
pand notifications under this subpara-
graph to include identifications and 
notifications with respect to concurrent 
prescriptions of covered Part D drugs 
used in combination with opioids that 
are considered to have adverse side ef-
fects when so used in such combina-
tion, as determined by the Secretary. 
‘‘(v) ADDITIONAL REQUIREMENTS FOR 
PERSISTENT
OUTLIER
PRESCRIBERS.—In 
the case of a prescriber who the Secretary
249 
determines is persistently identified under 
clause (ii) as an outlier prescriber of 
opioids, the following shall apply: 
‘‘(I) Such prescriber may be re-
quired to enroll in the program under 
this title under section 1866(j) if such 
prescriber is not otherwise required to 
enroll, but only after other appropriate 
remedies have been provided, such as 
the provision of education funded 
through section 6052 of the SUPPORT 
for Patients and Communities Act, for 
a period determined by the Secretary 
as sufficient to correct the prescribing 
patterns that lead to identification of 
such prescriber as a persistent outlier 
prescriber of opioids. The Secretary 
shall determine the length of the period 
for which such prescriber is required to 
maintain such enrollment, which shall 
be the minimum period necessary to 
correct such prescribing patterns. 
‘‘(II) Not less frequently than an-
nually (and in a form and manner de-
termined appropriate by the Sec-
250 
retary), the Secretary, consistent with 
clause(iv)(I), shall communicate infor-
mation on such prescribers to sponsors 
of a prescription drug plan and Medi-
care Advantage organizations offering 
an MA–PD plan. 
‘‘(vi) PUBLIC AVAILABILITY OF INFOR-
MATION.—The Secretary shall make aggre-
gate information under this subparagraph 
available on the internet website of the Cen-
ters for Medicare & Medicaid Services. Such 
information shall be in a form and manner 
determined appropriate by the Secretary 
and shall not identify any specific pre-
scriber. In carrying out this clause, the Sec-
retary shall consult with interested stake-
holders. 
‘‘(vii) OPIOIDS
DEFINED.—For pur-
poses of this subparagraph, the term 
‘opioids’ has such meaning as specified by 
the Secretary. 
‘‘(viii) OTHER
ACTIVITIES.—Nothing 
in this subparagraph shall preclude the Sec-
retary from conducting activities that pro-
vide prescribers with information as to how
251 
they compare to other prescribers that are 
in addition to the activities under this sub-
paragraph, including activities that were 
being conducted as of the date of the enact-
ment of this subparagraph.’’. 
SEC. 6066. NO ADDITIONAL FUNDS AUTHORIZED. 
No additional funds are authorized to be appropriated 
to carry out the requirements of this subtitle and the 
amendments made by this subtitle. Such requirements shall 
be carried out using amounts otherwise authorized to be ap-
propriated. 
Subtitle H—Expanding Oversight of 
Opioid Prescribing and Payment 
SEC. 6071. SHORT TITLE. 
This subtitle may be cited as the ‘‘Expanding Over-
sight of Opioid Prescribing and Payment Act of 2018’’. 
SEC. 6072. MEDICARE PAYMENT ADVISORY COMMISSION RE-
PORT ON OPIOID PAYMENT, ADVERSE INCEN-
TIVES, AND DATA UNDER THE MEDICARE 
PROGRAM. 
Not later than March 15, 2019, the Medicare Payment 
Advisory Commission shall submit to Congress a report on, 
with respect to the Medicare program under title XVIII of 
the Social Security Act, the following:
252 
(1) A description of how the Medicare program 
pays for pain management treatments (both opioid 
and non-opioid pain management alternatives) in 
both inpatient and outpatient hospital settings. 
(2) The identification of incentives under the 
hospital inpatient prospective payment system under 
section 1886 of the Social Security Act (42 U.S.C. 
1395ww) and incentives under the hospital outpatient 
prospective payment system under section 1833(t) of 
such Act (42 U.S.C. 1395l(t)) for prescribing opioids 
and incentives under each such system for prescribing 
non-opioid treatments, and recommendations as the 
Commission deems appropriate for addressing any of 
such incentives that are adverse incentives. 
(3) A description of how opioid use is tracked 
and monitored through Medicare claims data and 
other mechanisms and the identification of any areas 
in which further data and methods are needed for im-
proving data and understanding of opioid use. 
SEC. 6073. NO ADDITIONAL FUNDS AUTHORIZED. 
No additional funds are authorized to be appropriated 
to carry out the requirements of this subtitle. Such require-
ments shall be carried out using amounts otherwise author-
ized to be appropriated.
253 
Subtitle I—Dr. Todd Graham Pain 
Management, 
Treatment, 
and 
Recovery 
SEC. 6081. SHORT TITLE. 
This subtitle may be cited as the ‘‘Dr. Todd Graham 
Pain Management, Treatment, and Recovery Act of 2018’’. 
SEC. 6082. REVIEW AND ADJUSTMENT OF PAYMENTS 
UNDER THE MEDICARE OUTPATIENT PRO-
SPECTIVE PAYMENT SYSTEM TO AVOID FI-
NANCIAL INCENTIVES TO USE OPIOIDS IN-
STEAD OF NON-OPIOID ALTERNATIVE TREAT-
MENTS. 
(a) OUTPATIENT PROSPECTIVE PAYMENT SYSTEM.— 
Section 1833(t) of the Social Security Act (42 U.S.C. 
1395l(t)) is amended by adding at the end the following 
new paragraph: 
‘‘(22) REVIEW AND REVISIONS OF PAYMENTS FOR 
NON-OPIOID ALTERNATIVE TREATMENTS.— 
‘‘(A) IN GENERAL.—With respect to pay-
ments made under this subsection for covered 
OPD services (or groups of services), including 
covered OPD services assigned to a comprehen-
sive ambulatory payment classification, the Sec-
retary—
254 
‘‘(i) shall, as soon as practicable, con-
duct a review (part of which may include 
a request for information) of payments for 
opioids and evidence-based non-opioid alter-
natives for pain management (including 
drugs and devices, nerve blocks, surgical in-
jections, and neuromodulation) with a goal 
of ensuring that there are not financial in-
centives to use opioids instead of non-opioid 
alternatives; 
‘‘(ii) may, as the Secretary determines 
appropriate, conduct subsequent reviews of 
such payments; and 
‘‘(iii) shall consider the extent to which 
revisions under this subsection to such pay-
ments (such as the creation of additional 
groups of covered OPD services to classify 
separately those procedures that utilize 
opioids and non-opioid alternatives for 
pain management) would reduce payment 
incentives to use opioids instead of non- 
opioid alternatives for pain management. 
‘‘(B) PRIORITY.—In conducting the review 
under clause (i) of subparagraph (A) and consid-
ering revisions under clause (iii) of such sub-
255 
paragraph, the Secretary shall focus on covered 
OPD services (or groups of services) assigned to 
a comprehensive ambulatory payment classifica-
tion, ambulatory payment classifications that 
primarily include surgical services, and other 
services determined by the Secretary which gen-
erally involve treatment for pain management. 
‘‘(C) REVISIONS.—If the Secretary identi-
fies revisions to payments pursuant to subpara-
graph (A)(iii), the Secretary shall, as determined 
appropriate, begin making such revisions for 
services furnished on or after January 1, 2020. 
Revisions under the previous sentence shall be 
treated as adjustments for purposes of applica-
tion of paragraph (9)(B). 
‘‘(D) RULES OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed to preclude 
the Secretary— 
‘‘(i) from conducting a demonstration 
before making the revisions described in 
subparagraph (C); or 
‘‘(ii) prior to implementation of this 
paragraph, from changing payments under 
this subsection for covered OPD services (or 
groups of services) which include opioids or
256 
non-opioid alternatives for pain manage-
ment.’’. 
(b) 
AMBULATORY
SURGICAL
CENTERS.—Section 
1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) is 
amended by adding at the end the following new paragraph: 
‘‘(8) The Secretary shall conduct a similar type of re-
view as required under paragraph (22) of section 1833(t)), 
including the second sentence of subparagraph (C) of such 
paragraph, to payment for services under this subsection, 
and make such revisions under this paragraph, in an ap-
propriate manner (as determined by the Secretary).’’. 
SEC. 6083. EXPANDING ACCESS UNDER THE MEDICARE PRO-
GRAM TO ADDICTION TREATMENT IN FEDER-
ALLY 
QUALIFIED 
HEALTH 
CENTERS 
AND 
RURAL HEALTH CLINICS. 
(a) FEDERALLY QUALIFIED HEALTH CENTERS.—Sec-
tion 1834(o) of the Social Security Act (42 U.S.C. 
1395m(o)) is amended by adding at the end the following 
new paragraph: 
‘‘(3) 
ADDITIONAL
PAYMENTS
FOR
CERTAIN 
FQHCS WITH PHYSICIANS OR OTHER PRACTITIONERS 
RECEIVING DATA 2000 WAIVERS.— 
‘‘(A) IN GENERAL.—In the case of a Feder-
ally qualified health center with respect to which, 
beginning on or after January 1, 2019, Feder-
257 
ally qualified health center services (as defined 
in section 1861(aa)(3)) are furnished for the 
treatment of opioid use disorder by a physician 
or practitioner who meets the requirements de-
scribed in subparagraph (C), the Secretary shall, 
subject to availability of funds under subpara-
graph (D), make a payment (at such time and 
in such manner as specified by the Secretary) to 
such Federally qualified health center after re-
ceiving and approving an application submitted 
by such Federally qualified health center under 
subparagraph (B). Such a payment shall be in 
an amount determined by the Secretary, based 
on an estimate of the average costs of training 
for purposes of receiving a waiver described in 
subparagraph (C)(ii). Such a payment may be 
made only one time with respect to each such 
physician or practitioner. 
‘‘(B) APPLICATION.—In order to receive a 
payment described in subparagraph (A), a Fed-
erally qualified health center shall submit to the 
Secretary an application for such a payment at 
such time, in such manner, and containing such 
information as specified by the Secretary. A Fed-
erally qualified health center may apply for such
258 
a payment for each physician or practitioner de-
scribed in subparagraph (A) furnishing services 
described in such subparagraph at such center. 
‘‘(C) REQUIREMENTS.—For purposes of sub-
paragraph (A), the requirements described in 
this subparagraph, with respect to a physician 
or practitioner, are the following: 
‘‘(i) The physician or practitioner is 
employed by or working under contract 
with a Federally qualified health center de-
scribed in subparagraph (A) that submits 
an application under subparagraph (B). 
‘‘(ii) The physician or practitioner 
first receives a waiver under section 303(g) 
of the Controlled Substances Act on or after 
January 1, 2019. 
‘‘(D) FUNDING.—For purposes of making 
payments under this paragraph, there are appro-
priated, out of amounts in the Treasury not oth-
erwise appropriated, $6,000,000, which shall re-
main available until expended.’’. 
(b) RURAL HEALTH CLINIC.—Section 1833 of the So-
cial Security Act (42 U.S.C. 1395l) is amended—
259 
(1) by redesignating the subsection (z) relating to 
medical review of spinal subluxation services as sub-
section (aa); and 
(2) by adding at the end the following new sub-
section: 
‘‘(bb) ADDITIONAL PAYMENTS FOR CERTAIN RURAL 
HEALTH CLINICS WITH PHYSICIANS OR PRACTITIONERS 
RECEIVING DATA 2000 WAIVERS.— 
‘‘(1) IN GENERAL.—In the case of a rural health 
clinic with respect to which, beginning on or after 
January 1, 2019, rural health clinic services (as de-
fined in section 1861(aa)(1)) are furnished for the 
treatment of opioid use disorder by a physician or 
practitioner who meets the requirements described in 
paragraph (3), the Secretary shall, subject to avail-
ability of funds under paragraph (4), make a pay-
ment (at such time and in such manner as specified 
by the Secretary) to such rural health clinic after re-
ceiving and approving an application described in 
paragraph (2). Such payment shall be in an amount 
determined by the Secretary, based on an estimate of 
the average costs of training for purposes of receiving 
a waiver described in paragraph (3)(B). Such pay-
ment may be made only one time with respect to each 
such physician or practitioner.
260 
‘‘(2) APPLICATION.—In order to receive a pay-
ment described in paragraph (1), a rural health clinic 
shall submit to the Secretary an application for such 
a payment at such time, in such manner, and con-
taining such information as specified by the Sec-
retary. A rural health clinic may apply for such a 
payment for each physician or practitioner described 
in paragraph (1) furnishing services described in such 
paragraph at such clinic. 
‘‘(3) REQUIREMENTS.—For purposes of para-
graph (1), the requirements described in this para-
graph, with respect to a physician or practitioner, 
are the following: 
‘‘(A) The physician or practitioner is em-
ployed by or working under contract with a 
rural health clinic described in paragraph (1) 
that submits an application under paragraph 
(2). 
‘‘(B) The physician or practitioner first re-
ceives a waiver under section 303(g) of the Con-
trolled Substances Act on or after January 1, 
2019. 
‘‘(4) FUNDING.—For purposes of making pay-
ments under this subsection, there are appropriated, 
out of amounts in the Treasury not otherwise appro-
261 
priated, $2,000,000, which shall remain available 
until expended.’’. 
SEC. 6084. STUDYING THE AVAILABILITY OF SUPPLE-
MENTAL BENEFITS DESIGNED TO TREAT OR 
PREVENT 
SUBSTANCE 
USE 
DISORDERS 
UNDER MEDICARE ADVANTAGE PLANS. 
(a) IN GENERAL.—Not later than 2 years after the 
date of the enactment of this Act, the Secretary of Health 
and Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall submit to Congress a report on the avail-
ability of supplemental health care benefits (as described in 
section 1852(a)(3)(A) of the Social Security Act (42 U.S.C. 
1395w–22(a)(3)(A))) designed to treat or prevent substance 
use disorders under Medicare Advantage plans offered 
under part C of title XVIII of such Act. Such report shall 
include the analysis described in subsection (c) and any dif-
ferences in the availability of such benefits under specialized 
MA plans for special needs individuals (as defined in sec-
tion 1859(b)(6) of such Act (42 U.S.C. 1395w–28(b)(6))) 
offered to individuals entitled to medical assistance under 
title XIX of such Act and other such Medicare Advantage 
plans. 
(b) CONSULTATION.—The Secretary shall develop the 
report described in subsection (a) in consultation with rel-
evant stakeholders, including—
262 
(1) individuals entitled to benefits under part A 
or enrolled under part B of title XVIII of the Social 
Security Act; 
(2) entities who advocate on behalf of such indi-
viduals; 
(3) Medicare Advantage organizations; 
(4) pharmacy benefit managers; and 
(5) providers of services and suppliers (as such 
terms are defined in section 1861 of such Act (42 
U.S.C. 1395x)). 
(c) CONTENTS.—The report described in subsection (a) 
shall include an analysis on the following: 
(1) The extent to which plans described in such 
subsection offer supplemental health care benefits re-
lating to coverage of— 
(A) 
medication-assisted 
treatments 
for 
opioid use, substance use disorder counseling, 
peer recovery support services, or other forms of 
substance use disorder treatments (whether fur-
nished in an inpatient or outpatient setting); 
and 
(B) non-opioid alternatives for the treat-
ment of pain. 
(2) Challenges associated with such plans offer-
ing supplemental health care benefits relating to cov-
263 
erage of items and services described in subparagraph 
(A) or (B) of paragraph (1). 
(3) The impact, if any, of increasing the appli-
cable rebate percentage determined under section 
1854(b)(1)(C) of the Social Security Act (42 U.S.C. 
1395w–24(b)(1)(C)) for plans offering such benefits 
relating to such coverage would have on the avail-
ability of such benefits relating to such coverage of-
fered under Medicare Advantage plans. 
(4) Potential ways to improve upon such cov-
erage or to incentivize such plans to offer additional 
supplemental health care benefits relating to such cov-
erage. 
SEC. 6085. CLINICAL PSYCHOLOGIST SERVICES MODELS 
UNDER THE CENTER FOR MEDICARE AND 
MEDICAID INNOVATION; GAO STUDY AND RE-
PORT. 
(a) CMI MODELS.—Section 1115A(b)(2)(B) of the So-
cial Security Act (42 U.S.C. 1315a(b)(2)(B)), as amended 
by section 6001, is further amended by adding at the end 
the following new clauses: 
‘‘(xxvi) Supporting ways to familiarize 
individuals with the availability of coverage 
under part B of title XVIII for qualified
264 
psychologist services (as defined in section 
1861(ii)). 
‘‘(xxvii) Exploring ways to avoid un-
necessary hospitalizations or emergency de-
partment visits for mental and behavioral 
health services (such as for treating depres-
sion) through use of a 24-hour, 7-day a 
week help line that may inform individuals 
about the availability of treatment options, 
including the availability of qualified psy-
chologist services (as defined in section 
1861(ii)).’’. 
(b) GAO STUDY AND REPORT.—Not later than 18 
months 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, on mental and be-
havioral health services under the Medicare program under 
title XVIII of the Social Security Act, including an exam-
ination of the following: 
(1) Information about services furnished by psy-
chiatrists, clinical psychologists, and other profes-
sionals. 
(2) Information about ways that Medicare bene-
ficiaries familiarize themselves about the availability 
of Medicare payment for qualified psychologist serv-
265 
ices (as defined in section 1861(ii) of the Social Secu-
rity Act (42 U.S.C. 1395x(ii)) and ways that the pro-
vision of such information could be improved. 
SEC. 6086. DR. TODD GRAHAM PAIN MANAGEMENT STUDY. 
(a) IN GENERAL.—Not later than 1 year after the date 
of enactment of this Act, the Secretary of Health and 
Human Services (referred to in this section as the ‘‘Sec-
retary’’) shall conduct a study analyzing best practices as 
well as payment and coverage for pain management serv-
ices under title XVIII of the Social Security Act and submit 
to the Committee on Ways and Means and the Committee 
on Energy and Commerce of the House of Representatives 
and the Committee on Finance of the Senate a report con-
taining options for revising payment to providers and sup-
pliers of services and coverage related to the use of multi- 
disciplinary, evidence-based, non-opioid treatments for 
acute and chronic pain management for individuals enti-
tled to benefits under part A or enrolled under part B of 
title XVIII of the Social Security Act. The Secretary shall 
make such report available on the public website of the Cen-
ters for Medicare & Medicaid Services. 
(b) CONSULTATION.—In developing the report de-
scribed in subsection (a), the Secretary shall consult with— 
(1) relevant agencies within the Department of 
Health and Human Services;
266 
(2) licensed and practicing osteopathic and 
allopathic physicians, behavioral health practitioners, 
physician assistants, nurse practitioners, dentists, 
pharmacists, and other providers of health services; 
(3) providers and suppliers of services (as such 
terms are defined in section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x)); 
(4) substance abuse and mental health profes-
sional organizations; 
(5) pain management professional organizations 
and advocacy entities, including individuals who per-
sonally suffer chronic pain; 
(6) medical professional organizations and med-
ical specialty organizations; 
(7) licensed health care providers who furnish al-
ternative pain management services; 
(8) organizations with expertise in the develop-
ment of innovative medical technologies for pain 
management; 
(9) beneficiary advocacy organizations; and 
(10) other organizations with expertise in the as-
sessment, diagnosis, treatment, and management of 
pain, as determined appropriate by the Secretary. 
(c) CONTENTS.—The report described in subsection (a) 
shall include the following:
267 
(1) An analysis of payment and coverage under 
title XVIII of the Social Security Act with respect to 
the following: 
(A) Evidence-based treatments and tech-
nologies for chronic or acute pain, including 
such treatments that are covered, not covered, or 
have limited coverage under such title. 
(B) Evidence-based treatments and tech-
nologies that monitor substance use withdrawal 
and prevent overdoses of opioids. 
(C) Evidence-based treatments and tech-
nologies that treat substance use disorders. 
(D) Items and services furnished by practi-
tioners through a multi-disciplinary treatment 
model for pain management, including the pa-
tient-centered medical home. 
(E) Items and services furnished to bene-
ficiaries with psychiatric disorders, substance 
use disorders, or who are at risk of suicide, or 
have comorbidities and require consultation or 
management of pain with one or more specialists 
in pain management, mental health, or addic-
tion treatment. 
(2) An evaluation of the following:
268 
(A) Barriers inhibiting individuals entitled 
to benefits under part A or enrolled under part 
B of such title from accessing treatments and 
technologies described in subparagraphs (A) 
through (E) of paragraph (1). 
(B) Costs and benefits associated with po-
tential expansion of coverage under such title to 
include items and services not covered under 
such title that may be used for the treatment of 
pain, such as acupuncture, therapeutic massage, 
and items and services furnished by integrated 
pain management programs. 
(C) Pain management guidance published 
by the Federal Government that may be relevant 
to coverage determinations or other coverage re-
quirements under title XVIII of the Social Secu-
rity Act. 
(3) An assessment of all guidance published by 
the Department of Health and Human Services on or 
after January 1, 2016, relating to the prescribing of 
opioids. Such assessment shall consider incorporating 
into such guidance relevant elements of the ‘‘Va/DoD 
Clinical Practice Guideline for Opioid Therapy for 
Chronic Pain’’ published in February 2017 by the 
Department of Veterans Affairs and Department of
269 
Defense, including adoption of elements of the Depart-
ment of Defense and Department of Veterans Affairs 
pain rating scale. 
(4) The options described in subsection (d). 
(5) The impact analysis described in subsection 
(e). 
(d) OPTIONS.—The options described in this subsection 
are, with respect to individuals entitled to benefits under 
part A or enrolled under part B of title XVIII of the Social 
Security Act, legislative and administrative options for ac-
complishing the following: 
(1) Improving coverage of and payment for pain 
management therapies without the use of opioids, in-
cluding interventional pain therapies, and options to 
augment opioid therapy with other clinical and com-
plementary, integrative health services to minimize 
the risk of substance use disorder, including in a hos-
pital setting. 
(2) Improving coverage of and payment for med-
ical devices and non-opioid based pharmacological 
and non-pharmacological therapies approved or 
cleared by the Food and Drug Administration for the 
treatment of pain as an alternative or augment to 
opioid therapy.
270 
(3) Improving and disseminating treatment 
strategies for beneficiaries with psychiatric disorders, 
substance use disorders, or who are at risk of suicide, 
and treatment strategies to address health disparities 
related to opioid use and opioid abuse treatment. 
(4) Improving and disseminating treatment 
strategies for beneficiaries with comorbidities who re-
quire a consultation or comanagement of pain with 
one or more specialists in pain management, mental 
health, or addiction treatment, including in a hos-
pital setting. 
(5) Educating providers on risks of coadminis-
tration of opioids and other drugs, particularly 
benzodiazepines. 
(6) Ensuring appropriate case management for 
beneficiaries who transition between inpatient and 
outpatient hospital settings, or between opioid ther-
apy to non-opioid therapy, which may include the use 
of care transition plans. 
(7) Expanding outreach activities designed to 
educate providers of services and suppliers under the 
Medicare program and individuals entitled to benefits 
under part A or under part B of such title on alter-
native, non-opioid therapies to manage and treat 
acute and chronic pain.
271 
(8) Creating a beneficiary education tool on al-
ternatives to opioids for chronic pain management. 
(e) IMPACT ANALYSIS.—The impact analysis described 
in this subsection consists of an analysis of any potential 
effects implementing the options described in subsection (d) 
would have— 
(1) on expenditures under the Medicare program; 
and 
(2) on preventing or reducing opioid addiction 
for individuals receiving benefits under the Medicare 
program. 
Subtitle J—Combating Opioid 
Abuse for Care in Hospitals 
SEC. 6091. SHORT TITLE. 
This subtitle may be cited as the ‘‘Combating Opioid 
Abuse for Care in Hospitals Act of 2018’’ or the ‘‘COACH 
Act of 2018’’. 
SEC. 6092. DEVELOPING GUIDANCE ON PAIN MANAGEMENT 
AND OPIOID USE DISORDER PREVENTION 
FOR HOSPITALS RECEIVING PAYMENT UNDER 
PART A OF THE MEDICARE PROGRAM. 
(a) IN GENERAL.—Not later than July 1, 2019, the 
Secretary of Health and Human Services (in this section 
referred to as the ‘‘Secretary’’) shall develop and publish 
on the public website of the Centers for Medicare & Med-
272 
icaid Services guidance for hospitals receiving payment 
under part A of title XVIII of the Social Security Act (42 
U.S.C. 1395c et seq.) on pain management strategies and 
opioid use disorder prevention strategies with respect to in-
dividuals entitled to benefits under such part. 
(b) CONSULTATION.—In developing the guidance de-
scribed in subsection (a), the Secretary shall consult with 
relevant stakeholders, including— 
(1) medical professional organizations; 
(2) providers and suppliers of services (as such 
terms are defined in section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x)); 
(3) health care consumers or groups representing 
such consumers; and 
(4) other entities determined appropriate by the 
Secretary. 
(c) CONTENTS.—The guidance described in subsection 
(a) shall include, with respect to hospitals and individuals 
described in such subsection, the following: 
(1) Best practices regarding evidence-based 
screening and practitioner education initiatives relat-
ing to screening and treatment protocols for opioid 
use disorder, including—
273 
(A) methods to identify such individuals at- 
risk of opioid use disorder, including risk strati-
fication; 
(B) ways to prevent, recognize, and treat 
opioid overdoses; and 
(C) resources available to such individuals, 
such as opioid treatment programs, peer support 
groups, and other recovery programs. 
(2) Best practices for such hospitals to educate 
practitioners furnishing items and services at such 
hospital with respect to pain management and sub-
stance use disorders, including education on— 
(A) the adverse effects of prolonged opioid 
use; 
(B) non-opioid, evidence-based, non-phar-
macological pain management treatments; 
(C) monitoring programs for individuals 
who have been prescribed opioids; and 
(D) the prescribing of naloxone along with 
an initial opioid prescription. 
(3) Best practices for such hospitals to make such 
individuals aware of the risks associated with opioid 
use (which may include use of the notification tem-
plate described in paragraph (4)).
274 
(4) A notification template developed by the Sec-
retary, for use as appropriate, for such individuals 
who are prescribed an opioid that— 
(A) explains the risks and side effects asso-
ciated with opioid use (including the risks of ad-
diction and overdose) and the importance of ad-
hering to the prescribed treatment regimen, 
avoiding medications that may have an adverse 
interaction with such opioid, and storing such 
opioid safely and securely; 
(B) highlights multimodal and evidence- 
based non-opioid alternatives for pain manage-
ment; 
(C) encourages such individuals to talk to 
their health care providers about such alter-
natives; 
(D) provides for a method (through signa-
ture or otherwise) for such an individual, or per-
son acting on such individual’s behalf, to ac-
knowledge receipt of such notification template; 
(E) is worded in an easily understandable 
manner and made available in multiple lan-
guages determined appropriate by the Secretary; 
and
275 
(F) includes any other information deter-
mined appropriate by the Secretary. 
(5) Best practices for such hospital to track 
opioid prescribing trends by practitioners furnishing 
items and services at such hospital, including— 
(A) ways for such hospital to establish tar-
get levels, taking into account the specialties of 
such practitioners and the geographic area in 
which such hospital is located, with respect to 
opioids prescribed by such practitioners; 
(B) guidance on checking the medical 
records of such individuals against information 
included in prescription drug monitoring pro-
grams; 
(C) strategies to reduce long-term opioid 
prescriptions; and 
(D) methods to identify such practitioners 
who may be over-prescribing opioids. 
(6) Other information the Secretary determines 
appropriate, including any such information from the 
Opioid Safety Initiative established by the Depart-
ment of Veterans Affairs or the Opioid Overdose Pre-
vention Toolkit published by the Substance Abuse and 
Mental Health Services Administration.
276 
SEC. 6093. REQUIRING THE REVIEW OF QUALITY MEASURES 
RELATING TO OPIOIDS AND OPIOID USE DIS-
ORDER 
TREATMENTS 
FURNISHED 
UNDER 
THE MEDICARE PROGRAM AND OTHER FED-
ERAL HEALTH CARE PROGRAMS. 
Section 1890A of the Social Security Act (42 U.S.C. 
1395aaa–1) is amended by adding at the end the following 
new subsection: 
‘‘(g) TECHNICAL EXPERT PANEL REVIEW OF OPIOID 
AND OPIOID USE DISORDER QUALITY MEASURES.— 
‘‘(1) IN
GENERAL.—Not later than 180 days 
after the date of the enactment of this subsection, the 
Secretary shall establish a technical expert panel for 
purposes of reviewing quality measures relating to 
opioids and opioid use disorders, including care, pre-
vention, diagnosis, health outcomes, and treatment 
furnished to individuals with opioid use disorders. 
The Secretary may use the entity with a contract 
under section 1890(a) and amend such contract as 
necessary to provide for the establishment of such 
technical expert panel. 
‘‘(2) REVIEW AND ASSESSMENT.—Not later than 
1 year after the date the technical expert panel de-
scribed in paragraph (1) is established (and periodi-
cally thereafter as the Secretary determines appro-
priate), the technical expert panel shall—
279 
tract under subsection (a) of section 1890 in con-
nection with endorsement of measures described 
in subsection (b)(2) of such section; and 
‘‘(B) on and after January 1, 2024, may 
prioritize the endorsement of such measures by 
such entity.’’. 
SEC. 6094. TECHNICAL EXPERT PANEL ON REDUCING SUR-
GICAL SETTING OPIOID USE; DATA COLLEC-
TION ON PERIOPERATIVE OPIOID USE. 
(a) TECHNICAL EXPERT PANEL ON REDUCING SUR-
GICAL SETTING OPIOID USE.— 
(1) IN GENERAL.—Not later than 6 months after 
the date of the enactment of this Act, the Secretary of 
Health and Human Services shall convene a technical 
expert panel, including medical and surgical spe-
cialty societies and hospital organizations, to provide 
recommendations on reducing opioid use in the inpa-
tient and outpatient surgical settings and on best 
practices for pain management, including with re-
spect to the following: 
(A) Approaches that limit patient exposure 
to opioids during the perioperative period, in-
cluding pre-surgical and post-surgical injections, 
and that identify such patients at risk of opioid 
use disorder pre-operation.
280 
(B) Shared decision making with patients 
and families on pain management, including a 
review of payment to ensure payment under the 
Medicare program under title XVIII of the So-
cial Security Act accounts for time spent on 
shared decision making. 
(C) Education on the safe use, storage, and 
disposal of opioids. 
(D) Prevention of opioid misuse and abuse 
after discharge. 
(E) Development of a clinical algorithm to 
identify and treat at-risk, opiate-tolerant pa-
tients and reduce reliance on opioids for acute 
pain during the perioperative period. 
(2) REPORT.—Not later than 1 year after the 
date of the enactment of this Act, the Secretary shall 
submit to Congress and make public a report con-
taining the recommendations developed under para-
graph (1) and an action plan for broader implemen-
tation of pain management protocols that limit the 
use of opioids in the perioperative setting and upon 
discharge from such setting. 
(b) DATA COLLECTION
ON PERIOPERATIVE OPIOID 
USE.—Not later than 1 year after the date of the enactment 
of this Act, the Secretary of Health and Human Services
281 
shall submit to Congress a report that contains the fol-
lowing: 
(1) The diagnosis-related group codes identified 
by the Secretary as having the highest volume of sur-
geries. 
(2) With respect to each of such diagnosis-related 
group codes so identified, a determination by the Sec-
retary of the data that is both available and reported 
on opioid use following such surgeries, such as with 
respect to— 
(A) surgical volumes, practices, and opioid 
prescribing patterns; 
(B) opioid consumption, including— 
(i) perioperative days of therapy; 
(ii) average daily dose at the hospital, 
including dosage greater than 90 milligram 
morphine equivalent; 
(iii) post-discharge prescriptions and 
other combination drugs that are used be-
fore intervention and after intervention; 
(iv) quantity and duration of opioid 
prescription at discharge; and 
(v) quantity consumed and number of 
refills;
282 
(C) regional anesthesia and analgesia prac-
tices, including pre-surgical and post-surgical 
injections; 
(D) naloxone reversal; 
(E) post-operative respiratory failure; 
(F) information about storage and disposal; 
and 
(G) such other information as the Secretary 
may specify. 
(3) Recommendations for improving data collec-
tion on perioperative opioid use, including an anal-
ysis to identify and reduce barriers to collecting, re-
porting, and analyzing the data described in para-
graph (2), including barriers related to technological 
availability. 
SEC. 6095. REQUIRING THE POSTING AND PERIODIC UP-
DATE OF OPIOID PRESCRIBING GUIDANCE 
FOR MEDICARE BENEFICIARIES. 
(a) IN GENERAL.—Not later than 180 days after the 
date of the enactment of this Act, the Secretary of Health 
and Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall post on the public website of the Centers for 
Medicare & Medicaid Services all guidance published by the 
Department of Health and Human Services on or after 
January 1, 2016, relating to the prescribing of opioids and
283 
applicable to opioid prescriptions for individuals entitled 
to benefits under part A of title XVIII of the Social Security 
Act (42 U.S.C. 1395c et seq.) or enrolled under part B of 
such title of such Act (42 U.S.C. 1395j et seq.). 
(b) UPDATE OF GUIDANCE.— 
(1) PERIODIC UPDATE.—The Secretary shall, in 
consultation with the entities specified in paragraph 
(2), periodically (as determined appropriate by the 
Secretary) update guidance described in subsection 
(a) and revise the posting of such guidance on the 
website described in such subsection. 
(2) CONSULTATION.—The entities specified in 
this paragraph are the following: 
(A) Medical professional organizations. 
(B) Providers and suppliers of services (as 
such terms are defined in section 1861 of the So-
cial Security Act (42 U.S.C. 1395x)). 
(C) Health care consumers or groups rep-
resenting such consumers. 
(D) Other entities determined appropriate 
by the Secretary.
284 
Subtitle K—Providing Reliable Op-
tions 
for 
Patients 
and 
Edu-
cational Resources 
SEC. 6101. SHORT TITLE. 
This subtitle may be cited as the ‘‘Providing Reliable 
Options for Patients and Educational Resources Act of 
2018’’ or the ‘‘PROPER Act of 2018’’. 
SEC. 6102. REQUIRING MEDICARE ADVANTAGE PLANS AND 
PART D PRESCRIPTION DRUG PLANS TO IN-
CLUDE INFORMATION ON RISKS ASSOCIATED 
WITH OPIOIDS AND COVERAGE OF NON-
PHARMACOLOGICAL 
THERAPIES 
AND 
NONOPIOID MEDICATIONS OR DEVICES USED 
TO TREAT PAIN. 
Section 1860D–4(a)(1) of the Social Security Act (42 
U.S.C. 1395w–104(a)(1)) is amended— 
(1) in subparagraph (A), by inserting ‘‘, subject 
to subparagraph (C),’’ before ‘‘including’’; 
(2) in subparagraph (B), by adding at the end 
the following new clause: 
‘‘(vi) For plan year 2021 and each 
subsequent plan year, subject to subpara-
graph (C), with respect to the treatment of 
pain—
285 
‘‘(I) the risks associated with pro-
longed opioid use; and 
‘‘(II) coverage of nonpharma-
cological 
therapies, 
devices, 
and 
nonopioid medications— 
‘‘(aa) in the case of an MA– 
PD plan under part C, under 
such plan; and 
‘‘(bb) in the case of a pre-
scription drug plan, under such 
plan and under parts A and B.’’; 
and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(C) TARGETED
PROVISION
OF
INFORMA-
TION.—A PDP sponsor of a prescription drug 
plan may, in lieu of disclosing the information 
described in subparagraph (B)(vi) to each en-
rollee under the plan, disclose such information 
through mail or electronic communications to a 
subset of enrollees under the plan, such as enroll-
ees who have been prescribed an opioid in the 
previous 2-year period.’’.
286 
SEC. 6103. REQUIRING MEDICARE ADVANTAGE PLANS AND 
PRESCRIPTION DRUG PLANS TO PROVIDE IN-
FORMATION ON THE SAFE DISPOSAL OF PRE-
SCRIPTION DRUGS. 
(a) MEDICARE ADVANTAGE.—Section 1852 of the So-
cial Security Act (42 U.S.C. 1395w–22) is amended by add-
ing at the end the following new subsection: 
‘‘(n) PROVISION OF INFORMATION RELATING TO THE 
SAFE DISPOSAL OF CERTAIN PRESCRIPTION DRUGS.— 
‘‘(1) IN GENERAL.—In the case of an individual 
enrolled under an MA or MA–PD plan who is fur-
nished an in-home health risk assessment on or after 
January 1, 2021, such plan shall ensure that such as-
sessment includes information on the safe disposal of 
prescription drugs that are controlled substances that 
meets the criteria established under paragraph (2). 
Such information shall include information on drug 
takeback programs that meet such requirements deter-
mined appropriate by the Secretary and information 
on in-home disposal. 
‘‘(2) CRITERIA.—The Secretary shall, through 
rulemaking, establish criteria the Secretary deter-
mines appropriate with respect to information pro-
vided to an individual to ensure that such informa-
tion sufficiently educates such individual on the safe
287 
disposal of prescription drugs that are controlled sub-
stances.’’. 
(b) PRESCRIPTION DRUG PLANS.—Section 1860D– 
4(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w– 
104(c)(2)(B)) is amended— 
(1) by striking ‘‘may include elements that pro-
mote’’; 
(2) by redesignating clauses (i) through (iii) as 
subclauses (I) through (III) and adjusting the mar-
gins accordingly; 
(3) by inserting before subclause (I), as so redes-
ignated, the following new clause: 
‘‘(i) may include elements that pro-
mote—’’; 
(4) in subclause (III), as so redesignated, by 
striking the period at the end and inserting ‘‘; and’’; 
and 
(5) by adding at the end the following new 
clause: 
‘‘(ii) with respect to plan years begin-
ning on or after January 1, 2021, shall pro-
vide for— 
‘‘(I) the provision of information 
to the enrollee on the safe disposal of 
prescription drugs that are controlled
288 
substances that meets the criteria es-
tablished under section 1852(n)(2), in-
cluding information on drug takeback 
programs that meet such requirements 
determined appropriate by the Sec-
retary and information on in-home 
disposal; and 
‘‘(II) cost-effective means by which 
an enrollee may so safely dispose of 
such drugs.’’. 
SEC. 6104. REVISING MEASURES USED UNDER THE HOS-
PITAL 
CONSUMER 
ASSESSMENT 
OF 
HEALTHCARE PROVIDERS AND SYSTEMS SUR-
VEY RELATING TO PAIN MANAGEMENT. 
(a) RESTRICTION ON THE USE OF PAIN QUESTIONS 
IN HCAHPS.—Section 1886(b)(3)(B)(viii) of the Social 
Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended 
by adding at the end the following new subclause: 
‘‘(XII)(aa) With respect to a Hospital Consumer As-
sessment of Healthcare Providers and Systems survey (or 
a successor survey) conducted on or after January 1, 2020, 
such survey may not include questions about communica-
tion by hospital staff with an individual about such indi-
vidual’s pain unless such questions take into account, as 
applicable, whether an individual experiencing pain was
289 
informed about risks associated with the use of opioids and 
about non-opioid alternatives for the treatment of pain. 
‘‘(bb) The Secretary shall not include on the Hospital 
Compare internet website any measures based on the ques-
tions appearing on the Hospital Consumer Assessment of 
Healthcare Providers and Systems survey in 2018 or 2019 
about communication by hospital staff with an individual 
about such individual’s pain.’’. 
(b) RESTRICTION ON USE OF 2018 AND 2019 PAIN 
QUESTIONS IN THE HOSPITAL VALUE-BASED PURCHASING 
PROGRAM.—Section 1886(o)(2)(B) of the Social Security 
Act (42 U.S.C. 1395ww(o)(2)(B)) is amended by adding at 
the end the following new clause: 
‘‘(iii) HCAHPS PAIN
QUESTIONS.— 
The Secretary may not include under sub-
paragraph (A) a measure that is based on 
the questions appearing on the Hospital 
Consumer Assessment of Healthcare Pro-
viders and Systems survey in 2018 or 2019 
about communication by hospital staff with 
an individual about the individual’s pain.’’.
290 
Subtitle L—Fighting the Opioid 
Epidemic With Sunshine 
SEC. 6111. FIGHTING THE OPIOID EPIDEMIC WITH SUN-
SHINE. 
(a) INCLUSION
OF INFORMATION REGARDING PAY-
MENTS TO ADDITIONAL PRACTITIONERS.— 
(1) IN GENERAL.—Section 1128G(e)(6) of the So-
cial Security Act (42 U.S.C. 1320a–7h(e)(6)) is 
amended— 
(A) in subparagraph (A), by adding at the 
end the following new clauses: 
‘‘(iii) A physician assistant, nurse 
practitioner, or clinical nurse specialist (as 
such 
terms 
are 
defined 
in 
section 
1861(aa)(5)). 
‘‘(iv) A certified registered nurse anes-
thetist (as defined in section 1861(bb)(2)). 
‘‘(v) A certified nurse-midwife (as de-
fined in section 1861(gg)(2)).’’; and 
(B) in subparagraph (B), by inserting ‘‘, 
physician assistant, nurse practitioner, clinical 
nurse specialist, certified nurse anesthetist, or 
certified nurse-midwife’’ after ‘‘physician’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to infor-
291 
mation required to be submitted under section 1128G 
of the Social Security Act (42 U.S.C. 1320a–7h) on 
or after January 1, 2022. 
(b) SUNSET OF EXCLUSION OF NATIONAL PROVIDER 
IDENTIFIER
OF COVERED RECIPIENT
IN INFORMATION 
MADE
PUBLICLY
AVAILABLE.—Section 
1128G(c)(1)(C)(viii) of the Social Security Act (42 U.S.C. 
1320a–7h(c)(1)(C)(viii)) is amended by striking ‘‘does not 
contain’’ and inserting ‘‘in the case of information made 
available under this subparagraph prior to January 1, 
2022, does not contain’’. 
(c) ADMINISTRATION.—Chapter 35 of title 44, United 
States Code, shall not apply to this section or the amend-
ments made by this section. 
TITLE VII—PUBLIC HEALTH 
PROVISIONS 
Subtitle A—Awareness and 
Training 
SEC. 7001. REPORT ON EFFECTS ON PUBLIC HEALTH OF 
SYNTHETIC DRUG USE. 
(a) IN GENERAL.—Not later than 3 years after the 
date of the enactment of this Act, the Secretary of Health 
and Human Services, in coordination with the Surgeon 
General of the Public Health Service, shall submit to the 
Committee on Energy and Commerce of the House of Rep-
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Health, the Indian Health Service, and the Substance Abuse 
and Mental Health Services Administration, shall develop 
and submit to the Committee on Health, Education, Labor, 
and Pensions of the Senate and the Committee on Energy 
and Commerce of the House of Representatives a report that 
includes— 
(1) information on opioid, non-opioid, and non- 
pharmacologic pain management practices during 
pregnancy and after pregnancy; 
(2) recommendations for increasing public 
awareness and education about substance use dis-
orders, including opioid use disorders, during and 
after pregnancy, including available treatment re-
sources in urban and rural areas; 
(3) recommendations to prevent, identify, and 
reduce substance use disorders, including opioid use 
disorders, during pregnancy to improve care for preg-
nant women with substance use disorders and their 
infants; and 
(4) an identification of areas in need of further 
research with respect to acute and chronic pain man-
agement during and after pregnancy. 
(b) NO ADDITIONAL FUNDS.—No additional funds are 
authorized to be appropriated for purposes of carrying out 
subsection (a).
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meaningful engagement with and takes 
into account the unique needs of each 
family and addresses differences be-
tween medically supervised substance 
use, including for the treatment of sub-
stance use disorder, and substance use 
disorder; 
‘‘(II) ensuring that treatment ap-
proaches for serving infants, pregnant 
women, and perinatal and postnatal 
women whose infants may be affected 
by substance use, withdrawal symp-
toms, or a fetal alcohol spectrum dis-
order, are designed to, where appro-
priate, keep infants with their mothers 
during both inpatient and outpatient 
treatment; and 
‘‘(III) increasing access to all evi-
dence-based medication-assisted treat-
ment approved by the Food and Drug 
Administration, behavioral therapy, 
and counseling services for the treat-
ment of substance use disorders, as ap-
propriate.
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‘‘(e) EVALUATION.—The Secretary shall evaluate each 
project carried out by an entity receiving an award under 
this section and shall disseminate the findings with respect 
to each such evaluation to appropriate public and private 
entities. 
‘‘(f) FUNDING.—There is authorized to be appropriated 
to carry out this section, $4,000,000 for each of fiscal years 
2019 through 2023.’’. 
SEC. 7102. YOUTH PREVENTION AND RECOVERY. 
(a) SUBSTANCE ABUSE TREATMENT SERVICES FOR 
CHILDREN, ADOLESCENTS, AND YOUNG ADULTS.—Section 
514 of the Public Health Service Act (42 U.S.C. 290bb– 
7) is amended— 
(1) in the section heading, by striking ‘‘CHIL-
DREN AND ADOLESCENTS’’ and inserting ‘‘CHIL-
DREN, ADOLESCENTS, AND YOUNG ADULTS’’; 
(2) in subsection (a)(2), by striking ‘‘children, 
including’’ and inserting ‘‘children, adolescents, and 
young adults, including’’; and 
(3) by striking ‘‘children and adolescents’’ each 
place it appears and inserting ‘‘children, adolescents, 
and young adults’’. 
(b) RESOURCE CENTER.—The Secretary of Health and 
Human Services (referred to in this section as the ‘‘Sec-
retary’’, except as otherwise provided), in consultation with
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drug use (including the effects on children), sup-
ply reduction, demand reduction, drug-related 
law enforcement, and the implementation of the 
National Drug Control Strategy. 
‘‘(M) A systematic plan for increasing data 
collection to enable real time surveillance of drug 
control threats, developing analysis and moni-
toring capabilities, and identifying and address-
ing policy questions related to the National Drug 
Control Strategy and Program, which shall in-
clude— 
‘‘(i) a list of policy-relevant questions 
for which the Director and each National 
Drug Control Program Agency intends to 
develop evidence to support the National 
Drug Control Program and Strategy; 
‘‘(ii) a list of data the Director and 
each National Drug Control Program Agen-
cy intends to collect, use, or acquire to fa-
cilitate the use of evidence in drug control 
policymaking and monitoring; 
‘‘(iii) a list of methods and analytical 
approaches that may be used to develop evi-
dence to support the National Drug Control 
Program and Strategy and related policy;