‘‘(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— 
‘‘(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-
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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-
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 
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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). 
‘‘(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 
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(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-
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. 
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‘‘(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 
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— 
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‘‘(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. 
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 
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