Title: MOST Act
Policy area: Health

Summary:
Medicare and Opioid Safe Treatment Act or the MOST Act
This bill establishes several requirements for the Centers for Medicare & Medicaid Services (CMS), and alters requirements under Medicare and Medicare Advantage, related to pain management and opioid use.
For example, the bill requires certified opioid treatment program services to be covered under Medicare.
Additionally, among other requirements, the CMS must review payments under Medicare for opioid and non-opioid pain management procedures, specifically with respect to ambulatory outpatient surgical procedures and hospital outpatient department services. The CMS must ensure that there are no payment incentives for using opioids instead of non-opioid alternatives and must make revisions accordingly.
The bill also requires payment under Medicare to federally qualified health centers and rural health clinics that have health care practitioners who are newly certified to provide medication-assisted treatment (e.g., buprenorphine).

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5776 Introduced in House (IH)]

<DOC>






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 
   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 
                jurisdiction 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 Representatives 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''.

SEC. 2. MEDICARE COVERAGE OF CERTAIN SERVICES FURNISHED BY OPIOID 
              TREATMENT PROGRAMS.

    (a) Coverage.--Section 1861(s)(2) of the Social Security 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 subparagraph:
                    ``(HH) opioid use disorder treatment services (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 Services; Opioid Treatment 
Program.--
            ``(1) Opioid use disorder treatment services.--The term 
        `opioid use disorder treatment services' 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 section 505 of the 
                Federal Food, Drug and Cosmetic 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 professional 
                to the extent authorized under State law to furnish 
                such services;
                    ``(D) behavioral individual and group therapy with 
                physicians or psychologists (or other mental health 
                professionals to the extent authorized under State 
                law);
                    ``(E) toxicology testing; and
                    ``(F) other items and services that the Secretary 
                determines are appropriate.
            ``(2) Opioid treatment program.--The term `opioid treatment 
        program' means an opioid treatment 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;
                    ``(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 individuals 
                        being furnished services under such program; 
                        and
                            ``(ii) the effective and efficient 
                        furnishing 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 furnished during an episode 
                of care, the amount paid shall be equal to the amount 
                payable in accordance with section 1834(w) less any 
                copayment required as specified by the Secretary''.
            (2) Payment determination.--Section 1834 of the Social 
        Security Act (42 U.S.C. 1395m) is amended by adding at the end 
        the following new subsection:
    ``(w) Opioid Use Disorder Treatment Services.--
            ``(1) In general.--The Secretary shall pay to an opioid 
        treatment program (as defined in paragraph (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 during an episode of 
        care (as defined by the Secretary) beginning on or after 
        January 1, 2020. The Secretary shall ensure that no duplicative 
        payments are made under this part or part D to a physician, 
        practitioner, or pharmacy for items and services furnished by 
        an opioid treatment program.
            ``(2) Considerations.--The Secretary may implement this 
        subsection through one or more bundles 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 individuals furnished such services, or other factors as 
        the Secretary determine appropriate. In developing such 
        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 respect to the 
        furnishing of opioid treatment program services (as defined in 
        paragraph (1) of such section).''.

SEC. 3. REVIEW AND ADJUSTMENT OF PAYMENTS UNDER THE MEDICARE 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.--
                    ``(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 
                        management) would reduce payment incentives to 
                        use opioids instead of non-opioid alternatives 
                        for pain management.
                    ``(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 Secretary 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 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)) is amended by adding at the end the 
following new paragraph:
            ``(8) The Secretary shall apply the provisions of paragraph 
        (22) of section 1833(t), including the second sentence of 
        subparagraph (C) of such paragraph, to payment for services 
        under this subsection in an appropriate manner (as determined 
        by the Secretary).''.

SEC. 4. 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 
        practitioners receiving data 2000 certification.--
                    ``(A) In general.--In the case of a Federally 
                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 such date a registration or waiver 
                under section 303(g) of the Controlled Substances Act 
                to prescribe or dispense methadone, buprenorphine, or 
                suboxone for the purpose of maintenance or 
                detoxification treatment, the Secretary shall, subject 
                to availability of funds under subparagraph (B), make a 
                payment (in accordance with such timing, method, and 
                procedures as specified by the Secretary) to such 
                Federally qualified 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 purposes of 
                the previous sentence, a Federally-qualified health 
                center shall apply for a payment 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 furnishing such services at such 
                center who is described in such sentence.
                    ``(B) 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:
    ``(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 January 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 
        dispense methadone, buprenorphine, or suboxone for the purpose 
        of maintenance or detoxification treatment, the Secretary 
        shall, subject to availability of funds under subparagraph (B), 
        make a payment (in accordance with such timing, method, and 
        procedures as specified by the Secretary) to such rural health 
        clinic 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 purposes of the 
        previous sentence, a rural health clinic shall apply for a 
        payment 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 furnishing such services at such 
        clinic who is described in such sentence.
            ``(2) 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. 5. STUDYING THE AVAILABILITY OF SUPPLEMENTAL BENEFITS 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.
    (b) Consultation.--The Secretary shall develop the report described 
in subsection (a) in consultation with relevant 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 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, 
                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 treatment of 
                pain.
            (2) Challenges associated with such plans offering 
        supplemental 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. 6. 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)) is amended by adding at the end the 
following new clauses:
                            ``(xxv) 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)).
                            ``(xxvi) Exploring ways to avoid 
                        unnecessary hospitalizations 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 availability 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 a report, on 
mental and behavioral health services under the Medicare 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 
        payment 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. 7. PAIN MANAGEMENT STUDY.

    (a) In General.--Not later than 1 year after the date of enactment 
of this Act, the Secretary of Health and Human Services (referred to in 
this section as the ``Secretary'') shall conduct a study and submit to 
the Committee on Ways and Means and the Committee on Energy and 
Commerce of the House of Representatives and the Committee on Finance 
of the Senate a report containing recommendations on whether and how 
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 should be revised. 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 subsection 
(a), the Secretary shall consult with--
            (1) relevant agencies within the Department of Health and 
        Human Services;
            (2) licensed and practicing osteopathic and allopathic 
        physicians, 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) The recommendations described in subsection (d).
            (2) The impact analysis described in subsection (e).
            (3) An assessment of pain management guidance published by 
        the Federal Government that may be relevant to coverage 
        determinations or other coverage requirements under title XVIII 
        of the Social Security Act. Such assessment shall consider 
        incorporating into such guidance relevant elements of the ``Va/
        DoD Clinical Practice Guideline for Opioid Therapy for Chronic 
        Pain'' published in February 2017 by the Department of Veterans 
        Affairs and Department of Defense, including adoption of 
        elements of the Department of Defense and Veterans 
        Administration pain rating scale.
            (4) An evaluation of the following:
                    (A) Barriers inhibiting individuals entitled to 
                benefits under part A or enrolled under part B of such 
                title from accessing treatments and technologies 
                described in subparagraphs (A) through (F) of paragraph 
                (6).
                    (B) Potential legislative and administrative 
                changes under such title to improve individuals' access 
                to items and services currently covered under such 
                title and used for the treatment of pain, such as 
                cognitive behavioral interventions, physical therapy, 
                occupational therapy, physical medicine, biofeedback 
                therapy, and chiropractic therapy, and other pain 
                treatments services furnished in a hospital or post-
                acute care setting.
                    (C) Costs and benefits associated with potential 
                expansion of coverage under such title to include items 
                and services not covered under such title that may be 
                used for the treatment of pain, such as acupuncture, 
                therapeutic massage, and items and services furnished 
                by integrated 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 technologies 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 technologies that 
                monitor substance use withdrawal and prevent overdoses 
                of opioids.
                    (C) Evidence-based treatments and technologies that 
                treat substance use disorders.
                    (D) Items and services furnished by practitioners 
                through a multi-disciplinary treatment model for pain 
                management, including the patient-centered medical 
                home.
                    (E) Medical devices, non-opioid based drugs, and 
                other therapies (including interventional and 
                integrative pain therapies) approved or cleared by the 
                Food and Drug Administration for the treatment of pain.
                    (F) Items and services furnished to beneficiaries 
                with psychiatric disorders, substance use disorders, or 
                who are at risk of suicide, or have comorbidities and 
                require consultation or management of pain with one or 
                more specialists in pain management, mental health, or 
                addiction treatment.
    (d) Recommendations.--The recommendations described in this 
subsection are, with respect to individuals entitled to benefits under 
part A or enrolled under part B of title XVIII of the Social Security 
Act, legislative and administrative recommendations on the following:
            (1) Options for additional coverage of pain management 
        therapies without the use of opioids, including interventional 
        pain therapies, and options to augment opioid therapy with 
        other clinical and complementary, integrative health services 
        to minimize the risk of substance use disorder, including in a 
        hospital setting.
            (2) Options for coverage and payment modifications of 
        medical devices and non-opioid based pharmacological and non-
        pharmacological therapies (including interventional and 
        integrative pain therapies) approved or cleared by the Food and 
        Drug Administration for the treatment of pain as an alternative 
        or augment to opioid therapy.
            (3) Treatment strategies for beneficiaries with psychiatric 
        disorders, substance use disorders, or who are at risk of 
        suicide, and treatment strategies to address health disparities 
        related to opioid use and opioid abuse treatment.
            (4) Treatment strategies for beneficiaries with 
        comorbidities who require a consultation or comanagement of 
        pain with one or more specialists in pain management, mental 
        health, or addiction treatment, including in a hospital 
        setting.
            (5) Coadministration of opioids and other drugs, 
        particularly benzodiazepines.
            (6) Appropriate case management for beneficiaries who 
        transition between inpatient and outpatient hospital settings, 
        or between opioid therapy to non-opioid therapy, which may 
        include the use of care transition plans.
            (7) Outreach activities designed to educate providers of 
        services and suppliers under the Medicare program and 
        individuals entitled to benefits under part A or under part B 
        of such title on alternative, non-opioid therapies to manage 
        and treat acute and chronic pain.
            (8) Creation of a beneficiary education tool on 
        alternatives to opioids for chronic pain management.
    (e) Impact Analysis.--The impact analysis described in this 
subsection consists of an analysis of any potential effects 
implementing the recommendations described in subsection (d) would 
have--
            (1) on expenditures under the Medicare program; and
            (2) on preventing or reducing opioid addiction for 
        individuals receiving benefits under the Medicare program.
                                 <all>