I 
115TH CONGRESS 
2D SESSION 
H. R. 5776 
To amend title XVIII to provide for Medicare coverage of certain services 
furnished by opioid treatment programs, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 11, 2018 
Mr. NEAL (for himself, Mr. HOLDING, Mr. CARTWRIGHT, and Mr. TAYLOR) 
introduced the following bill; which was referred to the Committee on En-
ergy 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 jurisdic-
tion of the committee concerned 
A BILL 
To amend title XVIII to provide for Medicare coverage of 
certain services furnished by opioid treatment programs, 
and for other purposes. 
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 ‘‘Medicare and Opioid 
Safe Treatment Act’’ or the ‘‘MOST Act’’. 
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SEC. 2. MEDICARE COVERAGE OF CERTAIN SERVICES FUR-
NISHED BY OPIOID TREATMENT PROGRAMS. 
(a) COVERAGE.—Section 1861(s)(2) of the Social Se-
curity Act (42 U.S.C. 1395x(s)(2)) is amended— 
(1) in subparagraph (FF), by striking at the 
end ‘‘and’’; 
(2) in subparagraph (GG), by inserting at the 
end ‘‘; and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(HH) opioid use disorder treatment serv-
ices (as defined in subsection (jjj)).’’. 
(b) OPIOID USE DISORDER TREATMENT SERVICES 
AND OPIOID TREATMENT PROGRAM DEFINED.—Section 
1861 of the Social Security Act is amended by adding at 
the end the following new subsection: 
‘‘(jjj) OPIOID USE DISORDER TREATMENT SERV-
ICES; OPIOID TREATMENT PROGRAM.— 
‘‘(1) OPIOID USE DISORDER TREATMENT SERV-
ICES.—The term ‘opioid use disorder treatment serv-
ices’ means items and services that are furnished by 
an opioid treatment program for the treatment of 
opioid abuse disorder, including— 
‘‘(A) opioid agonist treatment medications 
(including oral versions) that are approved by 
the Food and Drug Administration under sec-
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tion 505 of the Federal Food, Drug and Cos-
metic Act for use in the treatment of opioid use 
disorder; 
‘‘(B) dispensing and administration of 
such medications, if applicable; 
‘‘(C) substance abuse counseling by a pro-
fessional to the extent authorized under State 
law to furnish such services; 
‘‘(D) behavioral individual and group ther-
apy with physicians or psychologists (or other 
mental health professionals to the extent au-
thorized under State law); 
‘‘(E) toxicology testing; and 
‘‘(F) other items and services that the Sec-
retary determines are appropriate. 
‘‘(2) OPIOID TREATMENT PROGRAM.—The term 
‘opioid treatment program’ means an opioid treat-
ment program (as defined in section 8.2 of title 42 
of the Code of Federal Regulations, or any successor 
regulation) that— 
‘‘(A) is enrolled under section 1866(j); 
‘‘(B) has in effect a certification by the 
Substance Abuse and Mental Health Services 
Administration for such a program; 
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‘‘(C) is accredited by an accrediting body 
approved by the Substance Abuse and Mental 
Health Services Administration; and 
‘‘(D) meets such additional conditions as 
the Secretary may find necessary to ensure— 
‘‘(i) the health and safety of individ-
uals being furnished services under such 
program; and 
‘‘(ii) the effective and efficient fur-
nishing of such services.’’. 
(c) PAYMENT.— 
(1) IN GENERAL.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)) is 
amended— 
(A) by striking ‘‘and (BB)’’ and inserting 
‘‘(BB)’’; and 
(B) by inserting before the semicolon at 
the end the following ‘‘, and (CC) with respect 
to opioid use disorder treatment services fur-
nished during an episode of care, the amount 
paid shall be equal to the amount payable in ac-
cordance with section 1834(w) less any copay-
ment required as specified by the Secretary’’. 
(2) PAYMENT DETERMINATION.—Section 1834 
of the Social Security Act (42 U.S.C. 1395m) is 
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amended by adding at the end the following new 
subsection: 
‘‘(w) OPIOID USE DISORDER TREATMENT SERV-
ICES.— 
‘‘(1) IN GENERAL.—The Secretary shall pay to 
an opioid treatment program (as defined in para-
graph (2) of section 1861(jjj)) an amount that is 
equal to 100 percent of a bundled payment under 
this part for opioid use disorder treatment services 
(as defined in paragraph (1) of such section) that 
are furnished by such program to an individual dur-
ing an episode of care (as defined by the Secretary) 
beginning on or after January 1, 2020. The Sec-
retary shall ensure that no duplicative payments are 
made under this part or part D to a physician, prac-
titioner, or pharmacy for items and services fur-
nished by an opioid treatment program. 
‘‘(2) CONSIDERATIONS.—The Secretary may 
implement this subsection through one or more bun-
dles based on the type of medication provided (such 
as buprenorphine, methadone, naltrexone, or a new 
innovative drug), the frequency of services, the scope 
of services furnished, characteristics of the individ-
uals furnished such services, or other factors as the 
Secretary determine appropriate. In developing such 
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bundles, the Secretary may consider payment rates 
paid to opioid treatment programs for comparable 
services under State plans under title XIX, under 
the TRICARE program under chapter 55 of title 10 
of the United States Code, or by other health care 
payers. 
‘‘(3) ANNUAL UPDATES.—The Secretary shall 
provide an update each year to the bundled payment 
amounts under this subsection.’’. 
(d) INCLUDING OPIOID TREATMENT PROGRAMS AS 
MEDICARE PROVIDERS.—Section 1866(e) of the Social 
Security Act (42 U.S.C. 1395cc(e)) is amended— 
(1) in paragraph (2), by striking at the end 
‘‘and’’; 
(2) in paragraph (3), by striking the period at 
the end and inserting ‘‘; and’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(3) opioid treatment programs (as defined in 
paragraph (2) of section 1861(jjj)), but only with re-
spect to the furnishing of opioid treatment program 
services (as defined in paragraph (1) of such sec-
tion).’’. 
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SEC. 3. REVIEW AND ADJUSTMENT OF PAYMENTS UNDER 
THE MEDICARE OUTPATIENT PROSPECTIVE 
PAYMENT SYSTEM TO AVOID FINANCIAL IN-
CENTIVES TO USE OPIOIDS INSTEAD OF NON- 
OPIOID ALTERNATIVE TREATMENTS. 
(a) OUTPATIENT
PROSPECTIVE
PAYMENT
SYS-
TEM.—Section 1833(t) of the Social Security Act (42 
U.S.C. 1395l(t)) is amended by adding at the end the fol-
lowing 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— 
‘‘(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 al-
ternatives for pain management (including 
drugs and devices, nerve blocks, surgical 
injections, and neuromodulation) with a 
goal of ensuring that there are not finan-
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cial incentives 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 payments (such as the creation of ad-
ditional groups of covered OPD services to 
classify separately those procedures that 
utilize opioids and non-opioid alternatives 
for pain management) would reduce pay-
ment incentives to use opioids instead of 
non-opioid alternatives for pain manage-
ment. 
‘‘(B) PRIORITY.—In conducting the review 
under clause (i) of subparagraph (A) and con-
sidering revisions under clause (iii) of such sub-
paragraph, the Secretary shall focus on covered 
OPD services (or groups of services) assigned 
to a comprehensive ambulatory payment classi-
fication, ambulatory payment classifications 
that primarily include surgical services, and 
other services determined by the Secretary 
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which generally involve treatment for pain man-
agement. 
‘‘(C) REVISIONS.—If the Secretary identi-
fies revisions to payments pursuant to subpara-
graph (A)(iii), the Secretary shall, as deter-
mined 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 
application 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 non-opioid alternatives for pain 
management.’’. 
(b) AMBULATORY
SURGICAL
CENTERS.—Section 
1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) 
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is amended by adding at the end the following new para-
graph: 
‘‘(8) The Secretary shall apply the provisions of 
paragraph (22) of section 1833(t), including the sec-
ond sentence of subparagraph (C) of such para-
graph, to payment for services under this subsection 
in an appropriate manner (as determined by the 
Secretary).’’. 
SEC. 4. 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.— 
Section 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 PRACTITIONERS RECEIVING DATA 2000 
CERTIFICATION.— 
‘‘(A) IN GENERAL.—In the case of a Fed-
erally qualified health center with respect to 
which, beginning January 1, 2019, Federally- 
qualified health center services (as defined in 
section 1861(aa)(3)) are furnished by a health 
care practitioner who first receives on or after 
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such date a registration or waiver under section 
303(g) of the Controlled Substances Act to pre-
scribe or dispense methadone, buprenorphine, 
or suboxone for the purpose of maintenance or 
detoxification treatment, the Secretary shall, 
subject to availability of funds under subpara-
graph (B), make a payment (in accordance with 
such timing, method, and procedures as speci-
fied by the Secretary) to such Federally quali-
fied health center in an amount determined by 
the Secretary, based on an approximation of the 
cost to receive training for purposes of such 
registration or waiver, as applicable. For pur-
poses of the previous sentence, a Federally- 
qualified health center shall apply for a pay-
ment described in such sentence at such time 
and in such manner as specified by the Sec-
retary and may apply for such a payment for 
each practitioner furnishing such services at 
such center who is described in such sentence. 
‘‘(B) FUNDING.—For purposes of making 
payments under this paragraph, there are ap-
propriated, out of amounts in the Treasury not 
otherwise appropriated, $6,000,000, which shall 
remain available until expended.’’. 
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(b) RURAL HEALTH CLINIC.—Section 1833 of the 
Social Security Act (42 U.S.C. 1395l) is amended— 
(1) by redesignating the subsection (z) relating 
to medical review of spinal subluxation services as 
subsection (aa); and 
(2) by adding at the end the following new sub-
section: 
‘‘(bb) ADDITIONAL PAYMENTS FOR CERTAIN RURAL 
HEALTH
CLINICS
WITH
PRACTITIONERS
RECEIVING 
DATA 2000 CERTIFICATION.— 
‘‘(1) IN
GENERAL.—In the case of a rural 
health clinic with respect to which, beginning Janu-
ary 1, 2019, rural health clinic services (as defined 
in section 1861(aa)(1)) are furnished by a health 
care practitioner who first receives on or after such 
date a registration or waiver under section 303(g) of 
the Controlled Substances Act to prescribe or dis-
pense methadone, buprenorphine, or suboxone for 
the purpose of maintenance or detoxification treat-
ment, the Secretary shall, subject to availability of 
funds under subparagraph (B), make a payment (in 
accordance with such timing, method, and proce-
dures as specified by the Secretary) to such rural 
health clinic in an amount determined by the Sec-
retary, based on an approximation of the cost to re-
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ceive training for purposes of such registration or 
waiver, as applicable. For purposes of the previous 
sentence, a rural health clinic shall apply for a pay-
ment described in such sentence at such time and in 
such manner as specified by the Secretary and may 
apply for such a payment for each practitioner fur-
nishing such services at such clinic who is described 
in such sentence. 
‘‘(2) FUNDING.—For purposes of making pay-
ments under this subsection, there are appropriated, 
out of amounts in the Treasury not otherwise appro-
priated, $2,000,000, which shall remain available 
until expended.’’. 
SEC. 5. STUDYING THE AVAILABILITY OF SUPPLEMENTAL 
BENEFITS DESIGNED TO TREAT OR PREVENT 
SUBSTANCE USE DISORDERS UNDER MEDI-
CARE 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 
‘‘Secretary’’) shall submit to Congress a report on the 
availability of supplemental health care benefits (as de-
scribed in section 1852(a)(3)(A) of the Social Security Act 
(42 U.S.C. 1395w–22(a)(3)(A))) designed to treat or pre-
vent substance use disorders under Medicare Advantage 
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plans offered under part C of title XVIII of such Act. Such 
report shall include the analysis described in subsection 
(c) and any differences in the availability of such benefits 
under specialized MA plans for special needs individuals 
(as defined in section 1859(b)(6) of such Act (42 U.S.C. 
1395w–28(b)(6))) offered to individuals entitled to med-
ical 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— 
(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: 
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(1) The extent to which plans described in such 
subsection offer supplemental health care benefits 
relating 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 
furnished 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-
erage of items and services described in subpara-
graph (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 
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sage, and items and services furnished by inte-
grated pain management programs. 
(5) An analysis on 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) Medical devices, non-opioid based 
drugs, and other therapies (including inter-
ventional and integrative pain therapies) ap-
proved or cleared by the Food and Drug Ad-
ministration for the treatment of pain. 
(F) Items and services furnished to bene-
ficiaries with psychiatric disorders, substance 
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