I 
115TH CONGRESS 
2D SESSION 
H. R. 5605 
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 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for an opioid use disorder treatment demonstration program. 
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 Qual-
ity Treatment for Opioid Use Disorders in Medicare Act’’. 
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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 
applicable beneficiaries to opioid use disorder treat-
ment services, improve physical and mental health 
outcomes for such beneficiaries, and to the extent 
possible, reduce expenditures under this title. Under 
the Program, the Secretary shall make payments 
under subsection (f) to participating care teams (as 
defined in subsection (c)(1)(A)) for providing opioid 
use disorder treatment services to applicable bene-
ficiaries participating under the Program. 
‘‘(2) OPIOID USE DISORDER TREATMENT SERV-
ICES.—For purposes of this section, the term ‘opioid 
use disorder treatment services’— 
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‘‘(A) means, with respect to an applicable 
beneficiary, services that are furnished for the 
treatment of opioid use disorders in an out-
patient setting and— 
‘‘(i) which are supported by the per 
applicable beneficiary per month care man-
agement fee under subsection (f); or 
‘‘(ii) for which payment may otherwise 
be made under this title; and 
‘‘(B) includes— 
‘‘(i) medication assisted treatment; 
‘‘(ii) treatment planning; 
‘‘(iii) 
appropriate 
outpatient 
psy-
chiatric, psychological, or counseling serv-
ices (or any combination of such services); 
‘‘(iv) appropriate social support serv-
ices; and 
‘‘(v) care management and care co-
ordination of opioid use disorder services, 
as well as coordination with other physi-
cians and providers treating the mental 
and physical conditions of such beneficiary. 
‘‘(b) PROGRAM DESIGN.— 
‘‘(1) IN GENERAL.—The Secretary shall design 
the Program in such a manner to evaluate the ex-
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tent to which the Program accomplishes the fol-
lowing purposes: 
‘‘(A) Reduces hospitalizations and emer-
gency department visits. 
‘‘(B) Reduces the occurrence of overdoses 
from opioids, including prescription opioid 
medications as well as illicit opioids. 
‘‘(C) Increases use of medication-assisted 
treatment for opioid use disorders. 
‘‘(D) 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). 
‘‘(E) Does not increase the total spending 
on health care services under this title. 
‘‘(F) Reduces deaths from opioid poi-
soning. 
‘‘(G) Reduces the utilization of inpatient 
residential treatment. 
‘‘(2) CONSULTATION.—In designing the Pro-
gram, the Secretary shall, not later than 3 months 
after the date of the enactment of this section, con-
sult with specialists in the field of addiction and cli-
nicians in the primary care community. 
‘‘(c) PARTICIPATING CARE TEAMS.— 
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‘‘(1) DEFINITION; SELECTION.— 
‘‘(A) DEFINITION.—In this section, the 
term ‘participating care team’ means an opioid 
use disorder care team (as defined in paragraph 
(2)) that is participating under the Program 
pursuant to selection by the Secretary under 
subparagraph (B). 
‘‘(B) SELECTION.—Under the Program, 
the Secretary shall provide for a process for 
opioid use disorder care teams to apply for par-
ticipation under the Program as participating 
care teams and for selecting such teams for 
such participation. 
‘‘(C) PREFERENCE.—In selecting opioid 
use disorder care teams under subparagraph 
(B) for participation under the Program, the 
Secretary shall give preference to opioid use 
disorder care teams that are located in areas 
with a prevalence of opioid use disorders that is 
higher than the national average prevalence, as 
measured by aggregate overdoses of opioids, or 
any other measure that the Secretary deems ap-
propriate. 
‘‘(2) OPIOID USE DISORDER CARE TEAMS.— 
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‘‘(A) IN GENERAL.—For purposes of this 
section, the term ‘opioid use disorder care team’ 
means a group of health care practitioners, or 
an entity employing or contracting with such 
health care practitioners, that— 
‘‘(i) includes at least one physician 
who is providing primary care services or 
addiction treatment services to an applica-
ble beneficiary during the period in which 
the opioid use disorder care team is receiv-
ing payments under subsection (f); 
‘‘(ii) includes at least one eligible 
practitioner (as defined in paragraph 
(3)(A)), who may be a physician who 
meets the criterion in clause (i); and 
‘‘(iii) includes other practitioners— 
‘‘(I) as necessary to deliver ap-
propriate psychiatric, psychological, 
counseling, and social services to ap-
plicable beneficiaries in addition to the 
services delivered by the eligible prac-
titioner; and 
‘‘(II) who only perform services 
that such practitioners are legally au-
thorized to perform under State law. 
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‘‘(B) 
REQUIREMENTS
FOR
PARTICIPA-
TION.—In order for an opioid use disorder care 
team to participate in the Program as a partici-
pating care team, each of the practitioners par-
ticipating on the team shall agree to— 
‘‘(i) deliver opioid use disorder treat-
ment services to applicable beneficiaries 
who agree to receive the services; 
‘‘(ii) meet minimum standards for 
quality required by the Program; and 
‘‘(iii) submit to the Secretary, with re-
spect to each applicable beneficiary for 
whom such practitioner provides opioid use 
disorder treatment services, data with re-
spect to the quality standards and the 
measures defined in subsection (d) and 
such other information as the Secretary 
determines appropriate to monitor and 
evaluate the Program and to determine the 
performance of each practitioner for pur-
poses of the incentive payment under sub-
section (f), in such form, manner, and fre-
quency as specified by the Secretary. 
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‘‘(3) ELIGIBLE
PRACTITIONERS; OTHER
PRO-
VIDER-RELATED
DEFINITIONS
AND
APPLICATION 
PROVISIONS.— 
‘‘(A) ELIGIBLE PRACTITIONERS.—For pur-
poses of this section, the term ‘eligible practi-
tioner’ means, with respect to an applicable 
beneficiary, a provider of services that— 
‘‘(i) participates in the Medicare pro-
gram under this title; 
‘‘(ii)(I) is authorized to prescribe or 
dispense narcotic drugs to individuals for 
maintenance treatment or detoxification 
treatment; and 
‘‘(II) has in effect a registration or 
waiver in accordance with section 303(g) of 
the Controlled Substances Act for such 
purpose and is otherwise in compliance 
with regulations promulgated by the Sub-
stance Abuse and Mental Health Services 
Administration to carry out such section; 
and 
‘‘(iii) with respect to furnishing opioid 
use disorder treatment services to the ap-
plicable beneficiary, participates in an 
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opioid use disorder care team, which is a 
participating care team. 
‘‘(B) ADDICTION SPECIALISTS.—For pur-
poses of paragraph (2)(C), the term ‘addiction 
specialist’ means a physician that possesses ex-
pert knowledge and skills in addiction medicine, 
as evidenced by— 
‘‘(i) certification by the American So-
ciety of Addiction Medicine or the Amer-
ican Board of Addiction Medicine; 
‘‘(ii) subspecialty certification in ad-
diction medicine by the American Board of 
Preventive Medicine; 
‘‘(iii) subspecialty certification in ad-
diction psychiatry by the American Board 
of Psychiatry and Neurology; 
‘‘(iv) a certificate of added qualifica-
tion in addiction medicine conferred by the 
American Osteopathic Association; or 
‘‘(v) completion of an accredited resi-
dency or fellowship in addiction medicine 
or addiction psychiatry. 
‘‘(d) QUALITY AND OTHER REPORTING REQUIRE-
MENTS.— 
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‘‘(1) ADOPTION AND DEVELOPMENT OF STAND-
ARDS
AND
PERFORMANCE
MEASURES.—Not later 
than 9 months after the date of the enactment of 
this section, the Secretary, in conjunction with 
stakeholders (including clinicians in the primary care 
community and the field of addiction medicine), 
shall adopt or develop (or an appropriate entity with 
which the Secretary contracts shall develop) quality 
standards and methods of assessing the quality of 
care to ensure a minimum level of quality of care 
and to determine whether the services furnished by 
participating care teams are achieving the purposes 
described in subsection (b)(1). For purposes of 
adopting or developing standards for payments 
under subsection (f)(1) and for purposes of adopting 
or developing methods for assessing performance for 
the incentive payments under subsection (f)(2), the 
Secretary may consider existing clinical guidelines 
for the treatment of opioid use disorders and stand-
ards or measures applied for use under the Medicaid 
program under title XIX. Standards and assessment 
methods shall address the following outcomes and 
performance criteria: 
‘‘(A) Patient engagement in treatment. 
‘‘(B) Retention in treatment. 
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‘‘(C) Provision of evidence-based medica-
tion-assisted treatment. 
‘‘(D) Any other criteria the Secretary 
deems appropriate. 
‘‘(2) SUBMISSION.—Each participating care 
team shall submit to the Secretary, in such form, 
manner, and frequency specified by the Secretary, 
data with respect to such standards and assessment 
methods and such other information as the Sec-
retary determines appropriate to monitor and evalu-
ate the Program and to determine the performance 
of such team for purposes of the incentive payment 
under subsection (f)(2). 
‘‘(e) 
PARTICIPATION
OF
APPLICABLE
BENE-
FICIARIES.— 
‘‘(1) APPLICABLE BENEFICIARY DEFINED.—In 
this section, the term ‘applicable beneficiary’ means 
an individual who— 
‘‘(A) is entitled to 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 diagnosis for an opioid use dis-
order; and 
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‘‘(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 
subparagraphs (A) through (D). 
‘‘(2) VOLUNTARY PARTICIPATION.—An applica-
ble beneficiary may participate in the Program on a 
voluntary basis and may terminate participation in 
the Program at any time. 
‘‘(3) SERVICES.—In order to participate in the 
Program, an applicable beneficiary must agree to re-
ceive opioid use disorder treatment services from a 
participating care team. An applicable beneficiary 
may only receive services supported by the Program 
from one participating care team during any one cal-
endar month. 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.— 
Nothing in this section shall be construed as encour-
aging providers to limit applicable beneficiary access 
to services covered under this title and applicable 
beneficiaries shall not be required to relinquish ac-
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cess to any benefit under this title as a condition of 
receiving services from a participating care team. 
‘‘(f) PAYMENTS.— 
‘‘(1) 
PER
APPLICABLE
BENEFICIARY
PER 
MONTH CARE MANAGEMENT FEE.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a schedule of per applicable bene-
ficiary per month care management fees. Such 
a per applicable beneficiary per month care 
management fee shall be paid to a participating 
care team in addition to any other amount oth-
erwise payable under this title to the practi-
tioners participating with the team or, if appli-
cable, the entity with respect to such team em-
ploying or contracting with such practitioners. 
A participating care team may use such per ap-
plicable beneficiary per month care manage-
ment fee to deliver additional services to appli-
cable beneficiaries, including services not other-
wise eligible for payment under this title. 
‘‘(B) APPLICATION.—In carrying out sub-
paragraph (A), the Secretary shall— 
‘‘(i) consider the costs that partici-
pating care teams are expected to incur in 
delivering high-quality opioid use disorder 
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care services that are not covered by pay-
ments otherwise payable to the teams 
under this title; 
‘‘(ii) pay a higher per applicable bene-
ficiary per month care management fee for 
an applicable beneficiary who receives more 
intensive treatment services from a partici-
pating care team and who is appropriate 
for such services based on clinical guide-
lines for opioid use disorder care; 
‘‘(iii) pay a higher per applicable ben-
eficiary per month care management fee 
for the month in which the applicable ben-
eficiary begins treatment with a partici-
pating care team than in subsequent 
months, to reflect the greater time and 
costs required for the team to plan and ini-
tiate treatment, as compared to mainte-
nance of treatment; and 
‘‘(iv) pay higher per applicable bene-
ficiary per month care management fees 
for participating care teams that include 
an addiction specialist who is either deliv-
ering services directly to applicable bene-
ficiaries or providing consulting support to 
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those practitioners participating with such 
teams who are delivering services to appli-
cable beneficiaries. 
‘‘(2) INCENTIVE PAYMENTS.—Under the Pro-
gram, the Secretary shall establish a performance- 
based incentive payment, which shall be paid to par-
ticipating care teams based on the performance of 
such teams with respect to standards and assess-
ment methods adopted or developed by the Secretary 
under subsection (d) and with respect to which the 
teams report under such subsection. 
‘‘(g) MULTIPAYER STRATEGY.—In carrying out the 
Program, the Secretary shall encourage other payers to 
provide similar payments and to use similar quality stand-
ards and methods of assessment as applied under the Pro-
gram. The Secretary may enter into a memorandum of 
understanding 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. 
‘‘(h) EVALUATION.— 
‘‘(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct an intermediate and 
final evaluation of the program. Each such evalua-
tion shall determine the extent to which each of the 
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purposes described in subsection (b) have been ac-
complished under the Program. Each evaluation 
shall also determine the extent to which the struc-
ture and requirements of the Program facilitated or 
impeded the participation of practitioners in the pro-
gram, the participation of beneficiaries with opioid 
use disorder, and the delivery of high-quality opioid 
use disorder treatment services. 
‘‘(2) REPORTS.—The Comptroller General of 
the United States 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 
evaluation under paragraph (1) not later than 
6 years after such date. 
‘‘(i) FUNDING.— 
‘‘(1) ADMINISTRATIVE FUNDING.—For the pur-
poses of implementing, administering, and carrying 
out the Program (other than for purposes described 
in paragraph (2)), there shall be transferred to the 
Secretary for the Center for Medicare & Medicaid 
Services Program Management Account from the 
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Federal Supplementary Medical Insurance Trust 
Fund under section 1841 $5,000,000. 
‘‘(2) CARE
MANAGEMENT
FEES
AND
INCEN-
TIVES.—For the purposes of payments under sub-
section (f), there shall be transferred to the Sec-
retary such sums as are necessary from the Federal 
Supplementary Medical Insurance Trust Fund under 
section 1841 for each of fiscal years 2021 through 
2025. 
‘‘(3) 
AVAILABILITY.—Amounts 
transferred 
under this subsection for a fiscal year shall be avail-
able until expended. 
‘‘(j) WAIVERS.—The Secretary may waive any provi-
sion of this title that conflicts with or impedes the imple-
mentation of the provisions of this section.’’. 
Æ 
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