IB 
Union Calendar No. 561 
115TH CONGRESS 
2D SESSION 
H. R. 5808 
[Report No. 115–726] 
To amend title XIX of the Social Security Act to require States to operate 
drug management programs for at-risk beneficiaries, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 15, 2018 
Mr. BILIRAKIS (for himself and Mr. BEN RAY LUJA´N of New Mexico) intro-
duced the following bill; which was referred to the Committee on Energy 
and Commerce 
JUNE 12, 2018 
Additional sponsors: Mrs. BLACKBURN and Mr. WALDEN 
JUNE 12, 2018 
Committed to the Committee of the Whole House on the State of the Union 
and ordered to be printed 
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A BILL 
To amend title XIX of the Social Security Act to require 
States to operate drug management programs for at- 
risk beneficiaries, and for other purposes. 
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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 ‘‘Medicaid Pharma-
ceutical Home Act of 2018’’. 
SEC. 2. DRUG MANAGEMENT PROGRAM FOR AT-RISK BENE-
FICIARIES. 
(a) IN GENERAL.—Title XIX of the Social Security 
Act is amended by inserting after section 1927 (42 U.S.C. 
1396r–8) the following new section: 
‘‘SEC. 1927A. DRUG MANAGEMENT PROGRAM FOR AT-RISK 
BENEFICIARIES. 
‘‘(a) IN GENERAL.—Beginning January 1, 2020, a 
State shall operate a qualified drug management program 
under which a State may enroll certain at-risk bene-
ficiaries identified by the State under the program. 
‘‘(b) QUALIFIED DRUG MANAGEMENT PROGRAM.— 
For purposes of this section, the term ‘qualified drug man-
agement program’ means, with respect to a State, a pro-
gram carried out by the State (including through a con-
tract with a pharmacy benefit manager) that provides at 
least for the following: 
‘‘(1) IDENTIFICATION
OF
AT-RISK
INDIVID-
UALS.—Under the program, the State identifies, in 
accordance with subsection (c), individuals enrolled 
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under the State plan (or waiver of the State plan) 
who are at-risk beneficiaries. 
‘‘(2) ELEMENTS OF PROGRAM.— 
‘‘(A) IN GENERAL.—Under the program, 
the State, with respect to each individual identi-
fied under paragraph (1) and enrolled under 
the program under paragraph (5)— 
‘‘(i) subject to subparagraphs (B) and 
(C), selects at least one, but not more than 
three, health care providers and at least 
one, but not more than three, pharmacies 
for each such individual for purposes of 
clause (ii), in accordance with a selection 
process that takes into account reasonable 
factors such as the individual’s previous 
utilization of items and services from 
health care providers and pharmacies, geo-
graphic proximity of the individual to such 
health care providers and pharmacies, ac-
cess of the individual to health care, rea-
sonable travel time, information regarding 
housing status, and any known preference 
of the individual for a certain health care 
provider or pharmacy; and 
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vider or pharmacy under subparagraph (A) is 
contributing or would contribute to prescription 
drug abuse or drug diversion by the individual, 
the State may select or change the selection of 
health care provider or pharmacy for the indi-
vidual without regard to the preferences of the 
individual described in this subparagraph. If the 
State selects or changes the selection pursuant 
to the preceding sentence without regard to the 
preferences of the individual, the State shall 
provide the individual with at least 30 days 
written notice of the selection or change of se-
lection and a rationale for the selection or 
change. 
‘‘(C) TREATMENT
OF
PHARMACY
WITH 
MULTIPLE LOCATIONS.—For purposes of sub-
paragraph (A)(i), in the case of a pharmacy 
that has multiple locations that share real-time 
electronic prescription data and the same chain 
identification number, all such locations of the 
pharmacy shall collectively be treated as one 
pharmacy. 
‘‘(D) TREATMENT OF EXISTING FFS DRUG 
MANAGEMENT PROGRAMS.—In the case of a pa-
tient review and restriction program (as identi-
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fied in the annual report submitted to the Sec-
retary under section 1927(g)(3)(D)) operated 
by a State pursuant to section 1915(a)(2) be-
fore the date of the enactment of this section, 
such program shall be treated as a qualified 
drug management program. 
‘‘(E) REASONABLE ACCESS.—The program 
shall ensure, including through waiver of ele-
ments of the program (including under sub-
paragraph (A)(ii)), reasonable access to health 
care (including access to health care providers 
and pharmacies with respect to prescription 
drugs described in subparagraph (A)) in the 
case of individuals with multiple residences, in 
the case of natural disasters and similar situa-
tions, and in the case of the provision of emer-
gency services (as defined for purposes of sec-
tion 1860D–4(c)(5)(D)(ii)(II)). 
‘‘(3) NOTIFICATION
TO
IDENTIFIED
INDIVID-
UALS.—Under the program, the State provides each 
individual who is identified under paragraph (1), 
prior to enrolling such individual under the program, 
at least one notification of each of the following: 
‘‘(A) Notice that the State has identified 
the individual as potentially being an at-risk 
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beneficiary for abuse or misuse of a controlled 
substance. 
‘‘(B) The name, address, and contact in-
formation of each health care provider and 
pharmacy that may be selected for the indi-
vidual under paragraph (2)(A). 
‘‘(C) Information describing all State and 
Federal public health resources that are de-
signed to address such abuse or misuse to 
which the individual has access, including men-
tal health services and other counseling serv-
ices. 
‘‘(D) Notice of, and information about, the 
right of the individual to— 
‘‘(i) submit preferences of the indi-
vidual for health care providers and phar-
macies to be selected under paragraph 
(2)(A), including as described in paragraph 
(2)(B); 
‘‘(ii) appeal under paragraph (4)— 
‘‘(I) such identification described 
in subparagraph (A); and 
‘‘(II) the selection of health care 
providers and pharmacies under para-
graph (2)(A). 
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‘‘(E) An explanation of the meaning and 
consequences of the identification of the indi-
vidual as potentially being an at-risk beneficiary 
for abuse or misuse of a controlled substance, 
including an explanation of the program. 
‘‘(F) Information, including a contact list 
and clear instructions, that explain how the in-
dividual can contact the appropriate entities ad-
ministering the program in order to submit 
preferences described in paragraph (2)(B) and 
any other communications relating to the pro-
gram. 
‘‘(4) APPEALS PROCESS.—Under the program, 
the State provides for an appeals process under 
which, with respect to an individual identified under 
paragraph (1)— 
‘‘(A) such individual may appeal— 
‘‘(i) such identification; and 
‘‘(ii) the selection of a health care pro-
vider or pharmacy under paragraph (2)(A); 
‘‘(B) in the case of an appeal described in 
subparagraph (A)(ii), the State shall accommo-
date the health care provider or pharmacy pre-
ferred by the individual for selection for pur-
poses of paragraph (2)(A), unless the State de-
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termines that a change to the selection of 
health care provider or pharmacy under such 
paragraph is contributing or would contribute 
to prescription drug abuse or drug diversion by 
the individual; 
‘‘(C) such individual is provided a period of 
not less than 30 days following the date of re-
ceipt of the notice described in paragraph (3) to 
submit such appeal; and 
‘‘(D) the State must make a determination 
with respect to an appeal described in subpara-
graph (A), and notify the individual of such de-
termination, prior to enrollment of such indi-
vidual in the program. 
‘‘(5) ENROLLMENT.—Under the program, the 
State initially enrolls individuals who are identified 
under paragraph (1) in the program for a 12-month 
period— 
‘‘(A) in the case of such an individual who 
does not submit an appeal under paragraph (4) 
within the period applied by the State pursuant 
to subparagraph (C) of such paragraph, begin-
ning on the day after the last day of such pe-
riod; and 
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‘‘(B) in the case of such an individual who 
does submit an appeal under paragraph (4) 
within the period applied by the State pursuant 
to subparagraph (C) of such paragraph but 
such appeal is denied, beginning not later than 
30 days after the date of such denial. 
‘‘(6) NOTIFICATION
OF
HEALTH
CARE
PRO-
VIDERS AND PHARMACIES.—Under the program, the 
State provides to each health care provider and 
pharmacy selected for an individual under paragraph 
(2)— 
‘‘(A) notification that the individual is an 
at-risk beneficiary enrolled under the program 
and that the provider or pharmacy has been se-
lected for the individual under paragraph (2); 
‘‘(B) information on such program and the 
role of being so selected; and 
‘‘(C) a process through which the provider 
or pharmacy can submit a concern or complaint 
with respect to being so selected and refuse to 
be a provider or pharmacy so selected. 
‘‘(7) CONTINUATION OF ENROLLMENT.—Under 
the program, the State, with respect to an individual 
enrolled under the program, provides for a process 
to— 
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‘‘(A) not later than 30 days before the end 
of the 12-month period for which the individual 
is so enrolled pursuant to paragraph (5)— 
‘‘(i) assess, in accordance with pub-
licly available evidence-based guidelines, 
whether or not such individual should con-
tinue to be enrolled under the program; 
and 
‘‘(ii) notify such individual of the re-
sults of the assessment under clause (i); 
‘‘(B) continue, subject to subparagraph 
(C), enrollment of such individual if such as-
sessment recommends such continuation; and 
‘‘(C) appeal the continuation of enrollment 
in accordance with the appeals process de-
scribed in paragraph (4). 
‘‘(c) AT-RISK BENEFICIARY.— 
‘‘(1) IDENTIFICATION.—For purposes of this 
section, a State shall identify an individual enrolled 
under the State plan (or waiver of the State plan) 
as an at-risk beneficiary if the individual is not an 
exempted individual described in paragraph (2) 
and— 
‘‘(A) is identified as such an at-risk bene-
ficiary through the use of publicly available evi-
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dence-based guidelines that indicate misuse or 
abuse of a controlled substance; or 
‘‘(B) the State received notification from a 
PDP sponsor or Medicare Advantage organiza-
tion that such individual was identified as being 
an at-risk beneficiary for prescription drug 
abuse for enrollment in a drug management 
program established by the sponsor or organiza-
tion pursuant to section 1860D–4(c)(5) and 
such identification has not been terminated 
under subparagraph (F) of such section. 
‘‘(2) EXEMPTED INDIVIDUAL DESCRIBED.—For 
purposes of paragraph (1), an exempted individual 
described in this paragraph is an individual who— 
‘‘(A) is receiving— 
‘‘(i) hospice or palliative care; or 
‘‘(ii) treatment for cancer; 
‘‘(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 
contract with a single pharmacy; or 
‘‘(C) the State elects to treat as an ex-
empted individual for purposes of paragraph 
(1). 
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‘‘(d) 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– 
2 note), related to the sharing of data under subsection 
(b)(6) in the same manner as the Secretary is required 
under subparagraph (J) of section 1860D–4(c)(5) to clar-
ify privacy requirements related to the sharing of data de-
scribed in such subparagraph. 
‘‘(e) REPORTS.— 
‘‘(1) ANNUAL REPORTS.—A State operating a 
qualified drug management program shall include in 
the annual report submitted to the Secretary under 
section 1927(g)(3)(D), beginning with such reports 
submitted for 2021, the following information: 
‘‘(A) The number of individuals enrolled 
under the State plan (or waiver of the State 
plan) who are enrolled under the program and 
the percentage of individuals enrolled under the 
State plan (or waiver) who are enrolled under 
such program. 
‘‘(B) The number of prescriptions for con-
trolled substances that were dispensed per 
month during each such year per individual en-
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rolled under the program, including the dosage 
and pill count for each such prescription. 
‘‘(C) The number of pharmacies filling pre-
scriptions for controlled substances for individ-
uals enrolled under such program. 
‘‘(D) The number of health care providers 
writing prescriptions for controlled substances 
(other than prescriptions for a refill) for indi-
viduals enrolled under such program. 
‘‘(E) Any other data that the Secretary 
may require. 
‘‘(F) Any report submitted by a managed 
care entity under subsection (e)(2) with respect 
to years. 
For each such report for a year after 2021, the in-
formation described in this paragraph shall be pro-
vided in a manner that compares such information 
with respect to the prior calendar year to such infor-
mation with respect to the second prior calendar 
year. 
‘‘(2) MACPAC REPORTS
AND
REVIEW.—Not 
later than two years after the date of the enactment 
of this section, the Medicaid and CHIP Payment 
and Access Commission (in this section referred to 
as ‘MACPAC’), in consultation with the National 
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Association of Medicaid Directors, pharmacy benefit 
managers, managed care organizations, health care 
providers (including pharmacists), beneficiary advo-
cates, and other stakeholders, shall publish a report 
that includes— 
‘‘(A) best practices for operating drug 
management programs, based on a review of a 
representative sample of States administering 
such a program; 
‘‘(B) a summary of the experience of the 
appeals process under drug management pro-
grams operated by several States, such as the 
frequency at which individuals appealed the 
identification of being an at-risk individual, the 
frequency at which individuals appealed the se-
lection of a health care provider or pharmacy 
under such a program, the timeframes for such 
appeals, a summary of the reasons for such ap-
peals, and the design of such appeals processes; 
‘‘(C) a summary of trends and the effec-
tiveness of qualified drug management pro-
grams operated under this section; and 
‘‘(D) recommendations to States on how 
improvements can be made with respect to the 
operation of such programs. 
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In reporting on State practices, the MACPAC shall 
consider how such programs have been implemented 
in rural areas, under fee-for-service as well as man-
aged care arrangements, and the extent to which 
such programs have resulted in increased efficiencies 
to such States or to the Federal Government under 
this title. 
‘‘(3) REPORT
ON
PLAN
FOR
COORDINATED 
CARE.—Not later than January 1, 2021, each State 
operating a qualified drug management program 
shall submit to the Administrator of the Centers for 
Medicare & Medicaid Services a report on how such 
State plans to provide coordinated care for individ-
uals enrolled under the State plan (or waiver of the 
State plan) and— 
‘‘(A) who are enrolled under the program; 
or 
‘‘(B) who are enrolled with a managed care 
entity and enrolled under such a qualified drug 
management program operated by such entity. 
‘‘(f) APPLICABILITY
TO
MANAGED
CARE
ENTI-
TIES.— 
‘‘(1) IN GENERAL.—With respect to any con-
tract that a State enters into on or after January 
1, 2020, with a managed care entity (as defined in 
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section 1932(a)(1)(B)) pursuant to section 1903(m), 
the State shall, as a condition of the contract, re-
quire the managed care entity— 
‘‘(A) to operate a qualified drug manage-
ment program (as defined in subsection (b)) for 
at-risk beneficiaries who are enrolled with such 
entity and identified by the managed care entity 
by means of application of paragraph (2); 
‘‘(B) to submit to the State an annual re-
port on the matters described in subparagraphs 
(A) through (E) of subsection (e)(1); and 
‘‘(C) to submit to the State a list (and as 
necessary update such list) of individuals en-
rolled with such entity under the qualified drug 
management program operated by such entity 
under subparagraph (A) for purposes of allow-
ing State plans for which medical assistance is 
paid on a fee-for-service basis to have access to 
such information. 
‘‘(2) APPLICATION.—For purposes of applying, 
with respect to a managed care entity— 
‘‘(A) under paragraph (1)(A)— 
‘‘(i) the definition of the term ‘quali-
fied drug management program’ under 
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