H. R. 6—96 
‘‘(C) REGULATIONS.—For purposes of this paragraph, 
including as applied under section 1860D–12(b)(3)(D), the 
Secretary shall, pursuant 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 subpara-
graph (B) and the types of information that shall be 
submitted through such process.’’. 
(c) REFERENCE UNDER PART D TO PROGRAM INTEGRITY TRANS-
PARENCY MEASURES.—Section 1860D–4 of the Social Security Act 
(42 U.S.C. 1395w–104) is amended by adding at the end the fol-
lowing new subsection: 
‘‘(m) PROGRAM INTEGRITY TRANSPARENCY MEASURES.—For pro-
gram integrity transparency measures applied 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 subclause: 
‘‘(II) Beginning January 1, 2021, at-risk bene-
ficiaries for prescription drug abuse (as defined 
in paragraph (5)(C)).’’. 
SEC. 6065. COMMIT TO OPIOID MEDICAL PRESCRIBER ACCOUNT-
ABILITY 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: 
‘‘(D) NOTIFICATION
AND
ADDITIONAL
REQUIREMENTS 
WITH RESPECT TO OUTLIER PRESCRIBERS OF OPIOIDS.— 
‘‘(i) NOTIFICATION.—Not later than January 1, 
2021, the Secretary shall, in the case of a prescriber 
identified by the Secretary under clause (ii) to be an 
outlier prescriber of opioids, provide, subject to clause 
(iv), an annual notification to such prescriber that such 
prescriber has been so identified and that includes 
resources on proper prescribing methods and other 
information 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 
subparagraph (A) on claims for covered part D 
drugs for part D eligible individuals enrolled in 
prescription drug plans under this part or MA– 
PD plans under part C and based on the thresholds
H. R. 6—97 
established under subclause (II), identify pre-
scribers that are outlier opioids prescribers for a 
period of time specified by the Secretary. 
‘‘(II) ESTABLISHMENT
OF
THRESHOLDS.—For 
purposes of subclause (I) and subject to subclause 
(III), the Secretary shall, after consultation with 
stakeholders, establish thresholds, based on pre-
scriber specialty and geographic area, for identi-
fying whether a prescriber in a specialty and 
geographic area is an outlier prescriber of opioids 
as compared to other prescribers of opioids within 
such specialty and area. 
‘‘(III) EXCLUSIONS.—The following 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 
hospice care under this title. 
‘‘(bb) Claims for covered part D drugs for 
part D eligible individuals who are receiving 
oncology 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 Serv-
ices. 
‘‘(iii) CONTENTS OF NOTIFICATION.—The Secretary 
shall include the following information in the notifica-
tions provided under clause (i): 
‘‘(I) Information on how such prescriber com-
pares to other prescribers within the same spe-
cialty and geographic area. 
‘‘(II) Information on opioid prescribing guide-
lines, based on input from stakeholders, that may 
include the Centers for Disease Control and 
Prevention guidelines for prescribing opioids for 
chronic pain and guidelines developed by physician 
organizations. 
‘‘(III) Other information determined appro-
priate by the Secretary. 
‘‘(iv) MODIFICATIONS AND EXPANSIONS.— 
‘‘(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 PRESCRIPTIONS.— 
The Secretary may expand notifications under this 
subparagraph 
to 
include 
identifications 
and 
notifications with respect to concurrent prescrip-
tions of covered Part D drugs used in combination 
with opioids that are considered to have adverse 
side effects when so used in such combination, 
as determined by the Secretary. 
‘‘(v) ADDITIONAL
REQUIREMENTS
FOR
PERSISTENT 
OUTLIER PRESCRIBERS.—In the case of a prescriber who
H. R. 6—98 
the Secretary determines is persistently identified 
under clause (ii) as an outlier prescriber of opioids, 
the following shall apply: 
‘‘(I) Such prescriber may be required 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 edu-
cation funded through section 6052 of the SUP-
PORT 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 annually (and 
in a form and manner determined appropriate by 
the Secretary), the Secretary, consistent with 
clause(iv)(I), shall communicate information on 
such prescribers to sponsors of a prescription drug 
plan 
and 
Medicare 
Advantage 
organizations 
offering an MA–PD plan. 
‘‘(vi) PUBLIC AVAILABILITY OF INFORMATION.—The 
Secretary shall make aggregate information under this 
subparagraph available on the internet website of the 
Centers for Medicare & Medicaid Services. Such 
information shall be in a form and manner determined 
appropriate by the Secretary and shall not identify 
any specific prescriber. In carrying out this clause, 
the Secretary shall consult with interested stake-
holders. 
‘‘(vii) OPIOIDS
DEFINED.—For purposes of this 
subparagraph, the term ‘opioids’ has such meaning 
as specified by the Secretary. 
‘‘(viii) OTHER ACTIVITIES.—Nothing in this subpara-
graph shall preclude the Secretary from conducting 
activities that provide prescribers with information as 
to how they compare to other prescribers that are 
in addition to the activities under this subparagraph, 
including activities that were being conducted as of 
the date of the enactment 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 appropriated.
H. R. 6—99 
Subtitle H—Expanding Oversight of Opioid 
Prescribing and Payment 
SEC. 6071. SHORT TITLE. 
This subtitle may be cited as the ‘‘Expanding Oversight of 
Opioid Prescribing and Payment Act of 2018’’. 
SEC. 6072. MEDICARE PAYMENT ADVISORY COMMISSION REPORT ON 
OPIOID PAYMENT, ADVERSE INCENTIVES, 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: 
(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 hos-
pital 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 pre-
scribing 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 improving 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 requirements shall be 
carried out using amounts otherwise authorized to be appropriated. 
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 MEDI-
CARE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM TO 
AVOID FINANCIAL INCENTIVES TO USE OPIOIDS INSTEAD 
OF NON-OPIOID ALTERNATIVE TREATMENTS. 
(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.—
H. R. 6—100 
‘‘(A) IN
GENERAL.—With respect to payments made 
under this subsection for covered OPD services (or groups 
of services), including covered OPD services assigned to 
a comprehensive ambulatory payment classification, the 
Secretary— 
‘‘(i) shall, as soon as practicable, conduct a review 
(part of which may include a request for information) 
of payments for opioids and evidence-based non-opioid 
alternatives for pain management (including drugs and 
devices, 
nerve 
blocks, 
surgical 
injections, 
and 
neuromodulation) with a goal of ensuring that there 
are not financial 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 additional groups of covered OPD services 
to classify separately those procedures that utilize 
opioids and non-opioid alternatives for pain manage-
ment) would reduce payment 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 considering revisions under 
clause (iii) of such subparagraph, the Secretary shall focus 
on covered OPD services (or groups of services) assigned 
to a comprehensive ambulatory payment classification, 
ambulatory payment classifications that primarily include 
surgical services, and other services determined by the 
Secretary which generally involve treatment for pain 
management. 
‘‘(C) REVISIONS.—If the Secretary identifies revisions 
to payments pursuant to subparagraph (A)(iii), the Sec-
retary 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 application of para-
graph (9)(B). 
‘‘(D) RULES OF CONSTRUCTION.—Nothing in this para-
graph 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 cov-
ered OPD services (or groups of services) which include 
opioids or 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 review 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
H. R. 6—101 
this paragraph, in an appropriate manner (as determined by the 
Secretary).’’. 
SEC. 6083. EXPANDING ACCESS UNDER THE MEDICARE PROGRAM TO 
ADDICTION 
TREATMENT 
IN 
FEDERALLY 
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 PHYSI-
CIANS OR OTHER PRACTITIONERS RECEIVING DATA 2000 WAIVERS.— 
‘‘(A) IN GENERAL.—In the case of a Federally qualified 
health center with respect to which, beginning on or after 
January 1, 2019, Federally qualified health center services 
(as defined in section 1861(aa)(3)) are furnished for the 
treatment of opioid use disorder by a physician or practi-
tioner who meets the requirements described in subpara-
graph (C), the Secretary shall, subject to availability of 
funds under subparagraph (D), make a payment (at such 
time and in such manner as specified by the Secretary) 
to such Federally qualified health center after receiving 
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 Sec-
retary, based on an estimate of the average costs of training 
for purposes of receiving a waiver described in subpara-
graph (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 Federally qualified health 
center 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 Secretary. 
A Federally qualified health center may apply for such 
a payment for each physician or practitioner described 
in subparagraph (A) furnishing services described in such 
subparagraph at such center. 
‘‘(C) REQUIREMENTS.—For purposes of subparagraph 
(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 described in subparagraph (A) that sub-
mits an application under subparagraph (B). 
‘‘(ii) The physician or practitioner first receives 
a waiver under section 303(g) of the Controlled Sub-
stances Act on or after January 1, 2019. 
‘‘(D) FUNDING.—For purposes of making payments 
under this paragraph, there are appropriated, out of 
amounts in the Treasury not otherwise appropriated, 
$6,000,000, which shall remain available until expended.’’. 
(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 subsection:
H. R. 6—102 
‘‘(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 defined 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 para-
graph (3), the Secretary shall, subject to availability of funds 
under paragraph (4), make a payment (at such time and in 
such manner as specified by the Secretary) to such rural health 
clinic after receiving and approving an application described 
in paragraph (2). Such payment shall be in an amount deter-
mined 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 payment may be made only one 
time with respect to each such physician or practitioner. 
‘‘(2) APPLICATION.—In order to receive a payment 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 containing such information as specified 
by the Secretary. A rural health clinic may apply for such 
a payment for each physician or practitioner described in para-
graph (1) furnishing services described in such paragraph at 
such clinic. 
‘‘(3) REQUIREMENTS.—For purposes of paragraph (1), the 
requirements described in this paragraph, with respect to a 
physician or practitioner, are the following: 
‘‘(A) The physician or practitioner is employed by or 
working under contract with a rural health clinic described 
in paragraph (1) that submits an application under para-
graph (2). 
‘‘(B) The physician or practitioner first receives a 
waiver under section 303(g) of the Controlled Substances 
Act on or after January 1, 2019. 
‘‘(4) FUNDING.—For purposes of making payments under 
this subsection, there are appropriated, out of amounts in the 
Treasury not otherwise appropriated, $2,000,000, which shall 
remain available until expended.’’. 
SEC. 6084. STUDYING THE AVAILABILITY OF SUPPLEMENTAL BENE-
FITS 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 ‘‘Secretary’’) shall submit 
to Congress a report on the availability 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 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 medical assistance under title XIX of such Act and other such 
Medicare Advantage plans.
H. R. 6—103 
(b) CONSULTATION.—The Secretary shall develop the report 
described in subsection (a) in consultation with relevant stake-
holders, 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 individuals; 
(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 relating to coverage 
of— 
(A) medication-assisted treatments for opioid use, sub-
stance use disorder counseling, peer recovery support serv-
ices, or other forms of substance use disorder treatments 
(whether furnished in an inpatient or outpatient setting); 
and 
(B) non-opioid alternatives for the treatment of pain. 
(2) Challenges associated with such plans offering supple-
mental health care benefits relating to coverage of items and 
services described in subparagraph (A) or (B) of paragraph 
(1). 
(3) The impact, if any, of increasing the applicable 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 
availability of such benefits relating to such coverage offered 
under Medicare Advantage plans. 
(4) Potential ways to improve upon such coverage or to 
incentivize such plans to offer additional supplemental health 
care benefits relating to such coverage. 
SEC. 6085. CLINICAL PSYCHOLOGIST SERVICES MODELS UNDER THE 
CENTER FOR MEDICARE AND MEDICAID INNOVATION; 
GAO STUDY AND REPORT. 
(a) CMI MODELS.—Section 1115A(b)(2)(B) of the Social 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 psychologist services (as defined 
in section 1861(ii)). 
‘‘(xxvii) Exploring ways to avoid unnecessary hos-
pitalizations or emergency department visits for mental 
and behavioral health services (such as for treating 
depression) through use of a 24-hour, 7-day a week 
help line that may inform individuals about the avail-
ability of treatment options, including the availability 
of qualified psychologist 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
H. R. 6—104 
a report, on mental and behavioral health services under the Medi-
care program under title XVIII of the Social Security Act, including 
an examination of the following: 
(1) Information about services furnished by psychiatrists, 
clinical psychologists, and other professionals. 
(2) Information about ways that Medicare beneficiaries 
familiarize themselves about the availability of Medicare pay-
ment for qualified psychologist services (as defined in section 
1861(ii) of the Social Security Act (42 U.S.C. 1395x(ii)) and 
ways that the provision 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 enact-
ment of this Act, the Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’) shall conduct a 
study analyzing best practices as well as payment and coverage 
for pain management services under title XVIII of the Social Secu-
rity Act and submit to the Committee on Ways and Means and 
the Committee on Energy and Commerce of the House of Represent-
atives and the Committee on Finance of the Senate a report con-
taining options for revising payment to providers and suppliers 
of services and coverage related to the use of multi-disciplinary, 
evidence-based, non-opioid treatments for acute and chronic pain 
management for individuals entitled 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 Centers for Medicare & Medicaid Services. 
(b) CONSULTATION.—In developing the report described in sub-
section (a), the Secretary shall consult with— 
(1) relevant agencies within the Department of Health 
and Human Services; 
(2) licensed and practicing osteopathic and allopathic physi-
cians, 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 Security Act (42 U.S.C. 
1395x)); 
(4) substance abuse and mental health professional 
organizations; 
(5) pain management professional organizations and 
advocacy entities, including individuals who personally suffer 
chronic pain; 
(6) medical professional organizations and medical specialty 
organizations; 
(7) licensed health care providers who furnish alternative 
pain management services; 
(8) organizations with expertise in the development of 
innovative medical technologies for pain management; 
(9) beneficiary advocacy organizations; and 
(10) other organizations with expertise in the assessment, 
diagnosis, treatment, and management of pain, as determined 
appropriate by the Secretary. 
(c) CONTENTS.—The report described in subsection (a) shall 
include the following: 
(1) An analysis of payment and coverage under title XVIII 
of the Social Security Act with respect to the following: