IB 
Union Calendar No. 578 
115TH CONGRESS 
2D SESSION 
H. R. 5605 
[Report No. 115–744, Part I] 
To amend title XVIII of the Social Security Act to provide for an opioid 
use disorder treatment demonstration program. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 24, 2018 
Mr. RUIZ introduced the following bill; which was referred to the Committee 
on Energy and Commerce, and in addition to the Committee on Ways 
and Means, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
JUNE 12, 2018 
Additional sponsors: Mrs. BLACKBURN and Mr. WALDEN 
JUNE 12, 2018 
Reported from the Committee on Energy and Commerce with an amendment 
[Strike out all after the enacting clause and insert the part printed in italic] 
JUNE 12, 2018 
The Committee on Ways and Means discharged; committed to the Committee 
of the Whole House on the State of the Union and ordered to be printed 
[For text of introduced bill, see copy of bill as introduced on April 24, 2018] 
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A BILL 
To amend title XVIII of the Social Security Act to provide 
for an opioid use disorder treatment demonstration program. 
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Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Advancing High Quality 
Treatment for Opioid Use Disorders in Medicare Act’’. 
SEC. 2. OPIOID USE DISORDER TREATMENT DEMONSTRA-
TION 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 5-YEAR DEMONSTRATION 
PROGRAM.— 
‘‘(1) IN GENERAL.—Not later than January 1, 
2021, the Secretary shall implement a 5-year dem-
onstration program under this title (in this section 
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 
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treatment services delivered through opioid use dis-
order care teams, or arranging for such service 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; 
‘‘(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 
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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. 
‘‘(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 
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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 physicians described in subclause 
(I); 
‘‘(III) a hospital outpatient de-
partment; 
‘‘(IV) a federally qualified health 
center 
(as 
defined 
in 
section 
1861(aa)(4)); 
‘‘(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)); 
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‘‘(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 
‘‘(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. 
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‘‘(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)(A)), 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-
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— 
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‘‘(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, for participation 
through the submission of data and infor-
mation described in clause (iii); and 
‘‘(iii) submit to the Secretary, with re-
spect to each applicable beneficiary for 
whom opioid use disorder treatment services 
are furnished by the opioid use disorder 
care team, data with respect to the criteria 
established under subsection (e)(2)(A) and 
such other information as the Secretary de-
termines appropriate to monitor and evalu-
ate the Program, to determine if minimum 
criteria are met under clause (ii), and to 
determine the incentive payment under sub-
section (e), in such form, manner, and fre-
quency as specified by the Secretary. 
‘‘(3) ELIGIBLE
PRACTITIONERS; OTHER
PRO-
VIDER-RELATED DEFINITIONS AND APPLICATION PRO-
VISIONS.— 
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‘‘(A) ELIGIBLE PRACTITIONERS.—For pur-
poses of this section, the term ‘eligible practi-
tioner’ means a physician or other health care 
practitioner, such as a nurse practitioner or ad-
vanced practice nurse, that— 
‘‘(i) is enrolled under section 1861(j); 
‘‘(ii) is authorized to prescribe or dis-
pense narcotic drugs to individuals for 
maintenance treatment or detoxification 
treatment; and 
‘‘(iii) has in effect a registration or 
waiver in accordance with section 303(g) of 
the Controlled Substances Act for such pur-
pose and is otherwise in compliance with 
regulations promulgated by the Substance 
Abuse and Mental Health Services Adminis-
tration to carry out such section. 
‘‘(B) ADDICTION
SPECIALISTS.—For pur-
poses of subsection (e)(1)(B)(iv), the term ‘addic-
tion specialist’ means a physician that possesses 
expert knowledge and skills in addiction medi-
cine, as evidenced by appropriate certification 
from a specialty body, a certificate of advanced 
qualification in addiction medicine, or comple-
tion of an accredited residency or fellowship in 
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addiction medicine or addiction psychiatry, as 
determined by the Secretary. 
‘‘(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; 
‘‘(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 PARTICIPATION; LIMITATION ON 
NUMBER
OF
PARTICIPANTS.—An applicable bene-
ficiary may participate in the Program on a vol-
untary basis and may terminate participation in the 
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Program at any time. Not more than 20,000 applica-
ble beneficiaries may participate in the Program. 
‘‘(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. 
‘‘(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 
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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; 
‘‘(iv) pay higher per applicable bene-
ficiary per month care management fees for 
participants that have established opioid 
use disorder care teams that include an ad-
diction specialist (as defined in subsection 
(c)(3)(B)); and 
‘‘(v) take into account whether a par-
ticipant’s opioid use disorder care team re-
fers applicable beneficiaries to other sup-
pliers or providers for any opioid use dis-
order treatment services. 
‘‘(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). 
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‘‘(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. 
‘‘(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) SUBMISSION OF DATA.—Each partici-
pant shall submit to the Secretary, in such form, 
manner, and frequency specified by the Sec-
retary, data with respect to such criteria de-
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scribed in subparagraph (A) and such other in-
formation as the Secretary determines appro-
priate to evaluate and monitor the effectiveness 
of the Program, to determine the performance of 
the participants for purposes of the incentive 
payment under subparagraph (A), and to ensure 
the participants meet minimum criteria for pro-
gram participation described in subsection 
(c)(2)(B)(ii). 
‘‘(3) NON-DUPLICATION OF PAYMENTS.—In the 
case if an applicable beneficiary receiving services 
supported by the Program from more than one partic-
ipant during any one calendar month, or from a par-
ticipant and a provider who is not a participant dur-
ing any one calendar month, the Secretary shall ad-
just (such as pro-rate) payment under paragraph (1) 
and any payment under paragraph (2) to each such 
participant, with respect to such applicable bene-
ficiary and month to avoid any duplication of pay-
ment. 
‘‘(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 
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with other payers to align the methodology for payment 
provided by such a payer related to opioid use disorder 
treatment services with such methodology for payment 
under the Program. 
‘‘(g) EVALUATION.— 
‘‘(1) IN GENERAL.—The Secretary shall conduct 
an 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 
the Secretary and 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)), the Secretary shall provide for the 
transfer from the Federal Supplementary Medical In-
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surance Trust Fund under section 1841 of $5,000,000 
to the Centers for Medicare & Medicaid Services Pro-
gram Management Account. 
‘‘(2) CARE
MANAGEMENT
FEES
AND
INCEN-
TIVES.—For the purposes of making payments under 
subsection (e), the Secretary shall provide for the 
transfer from the Federal Supplementary Medical In-
surance 
Trust 
Fund 
under 
section 
1841 
of 
$10,000,000 for each of fiscal years 2021 through 
2025. 
‘‘(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.’’. 
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Union Calendar No. 578 
115TH CONGRESS 
2D SESSION 
H. R. 5605 
[Report No. 115–744, Part I] 
A BILL 
To amend title XVIII of the Social Security Act to 
provide for an opioid use disorder treatment 
demonstration program. 
JUNE 12, 2018 
Reported from the Committee on Energy and Commerce 
with an amendment 
JUNE 12, 2018 
The Committee on Ways and Means discharged; com-
mitted to the Committee of the Whole House on the 
State of the Union and ordered to be printed 
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