[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5799 Reported in House (RH)]
<DOC>
Union Calendar No. 563
115th CONGRESS
2d Session
H. R. 5799
[Report No. 115-728]
To amend title XIX of the Social Security Act to require as a condition
of receipt of full Federal medical assistance percentage under Medicaid
that State Medicaid plans have in place certain drug utilization review
activities.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 15, 2018
Mrs. Blackburn (for herself, Mr. Barr, and Mr. Knight) introduced the
following bill; which was referred to the Committee on Energy and
Commerce
June 12, 2018
Additional sponsor: Mr. Walden
June 12, 2018
Reported with amendments, committed to the Committee of the Whole House
on the State of the Union, and ordered to be printed
[Strike out all after the enacting clause and insert the part printed
in italic]
[For text of introduced bill, see copy of bill as introduced on May 15,
2018]
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to require as a condition
of receipt of full Federal medical assistance percentage under Medicaid
that State Medicaid plans have in place certain drug utilization review
activities.
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 ``Medicaid Drug Review, Utilization,
Good Governance Improvement Act'' or the ``Medicaid DRUG Improvement
Act''.
SEC. 2. MEDICAID DRUG UTILIZATION REVIEW.
(a) State Plan Requirement.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)) is amended--
(1) in paragraph (82), at the end, by striking ``and'';
(2) in paragraph (83), at the end, by striking the period
and inserting ``; and''; and
(3) by inserting after paragraph (83) the following new
paragraph:
``(84) provide that the State is in compliance with the
drug review and utilization requirements under subsection
(nn)(1).''.
(b) Drug Review and Utilization Requirements.--Section 1902 of the
Social Security Act (42 U.S.C. 1396a) is amended by adding at the end
the following new subsection:
``(nn) Drug Review and Utilization Requirements.--
``(1) In general.--For purposes of subsection (a)(84), the
drug review and utilization requirements under this subsection
are, subject to paragraph (3) and beginning October 1, 2019,
the following:
``(A) Claims review limitations.--
``(i) In general.--The State has in place--
``(I) safety edits (as specified by
the State) for subsequent fills for
opioids and a claims review automated
process (as designed and implemented by
the State) that indicates when an
individual enrolled under the State
plan (or under a waiver of the State
plan) is prescribed a subsequent fill
of opioids in excess of any limitation
that may be identified by the State;
``(II) safety edits (as specified
by the State) on the maximum daily
morphine equivalent that can be
prescribed to an individual enrolled
under the State plan (or under a waiver
of the State plan) for treatment of
chronic pain and a claims review
automated process (as designed and
implemented by the State) that
indicates when an individual enrolled
under the plan (or waiver) is
prescribed the morphine equivalent for
such treatment in excess of any
limitation that may be identified by
the State; and
``(III) a claims review automated
process (as designed and implemented by
the State) that monitors when an
individual enrolled under the State
plan (or under a waiver of the State
plan) is concurrently prescribed
opioids and--
``(aa) benzodiazepines; or
``(bb) antipsychotics.
``(ii) Managed care entities.--The State
requires each managed care entity (as defined
in section 1932(a)(1)(B)) with respect to which
the State has a contract under section 1903(m)
or under section 1905(t)(3) to have in place,
subject to paragraph (3), with respect to
individuals who are eligible for medical
assistance under the State plan (or under a
waiver of the State plan) and who are enrolled
with the entity, the limitations described in
subclauses (I) and (II) of clause (i) and a
claims review automated process described in
subclause (III) of such clause.
``(iii) Rules of construction.--Nothing in
this subparagraph may be construed as
prohibiting a State or managed care entity from
designing and implementing a claims review
automated process under this subparagraph that
provides for prospective or retrospective
reviews of claims. Nothing in this subparagraph
shall be understood as prohibiting the exercise
of clinical judgment from a provider enrolled
as a participating provider in a State plan (or
waiver of the State plan) or contracting with a
managed care entity regarding the best items
and services for an individual enrolled under
such State plan (or waiver).
``(B) Program to monitor antipsychotic medications
by children.--The State has in place a program (as
designed and implemented by the State), including such
a program that the State had in place before the date
of the enactment of this subsection, to monitor and
manage the appropriate use of antipsychotic medications
by children enrolled under the State plan (or under a
waiver of the State plan) and submits annually to the
Secretary such information as the Secretary may require
on activities carried out under such program for
individuals not more than the age of 18 years generally
and children in foster care specifically.
``(C) Fraud and abuse identification.--The State
has in place a process (as designed and implemented by
the State), including such a process that the State had
in place before the date of the enactment of this
subsection, that identifies potential fraud or abuse of
controlled substances by individuals enrolled under the
State plan (or under a waiver of the State plan),
health care providers prescribing drugs to individuals
so enrolled, and pharmacies dispensing drugs to
individuals so enrolled.
``(D) Reports.--The State shall include in the
annual report submitted to the Secretary under section
1927(g)(3)(D) information on the limitations,
requirement, program, and processes applied by the
State under subparagraphs (A) through (C) in accordance
with such manner and time as specified by the
Secretary.
``(2) Annual report by secretary.--For each fiscal year
beginning with fiscal year 2020, the Secretary shall submit to
Congress a report on the most recent information submitted by
States under paragraph (1)(D).
``(3) Exceptions.--
``(A) Certain individuals exempted.--The drug
review and utilization requirements under this
subsection shall not apply with respect to an
individual who--
``(i) is receiving--
``(I) hospice or palliative care;
or
``(II) treatment for cancer;
``(ii) is a resident of a long-term care
facility, 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
``(iii) the State elects to treat as
exempted from such requirements.
``(B) Exception relating to ensuring access.--In
order to ensure reasonable access to health care, the
Secretary may waive the drug review and utilization
requirements under this subsection, with respect to a
State, in the case of natural disasters and similar
situations, and in the case of the provision of
emergency services (as defined for purposes of section
1860D-4(c)(5)(D)(ii)(II)).''.
(c) Managed Care Entities.--Section 1932 of the Social Security Act
(42 U.S.C. 1396u-2) is amended by adding at the end the following new
subsection:
``(i) Drug Utilization Review Activities and Requirements.--
Beginning not later than October 1, 2019, each contract under a State
plan with a managed care entity (other than a primary care case
manager) under section 1903(m) shall provide that the entity is in
compliance with the applicable provisions of section 438.3(s)(2) of
title 42 of the Code of Federal Regulations, section 483.3(s)(4)) of
such title, and section 483.3(s)(5) of such title, as such provisions
were in effect on March 31, 2018.''.
SEC. 3. IDENTIFYING AND ADDRESSING INAPPROPRIATE PRESCRIBING AND
BILLING PRACTICES UNDER MEDICAID.
(a) In General.--Section 1927(g) of the Social Security Act (42
U.S.C. 1396r-8(g)) is amended--
(1) in paragraph (1)(A)--
(A) by striking ``of section 1903(i)(10)(B)'' and
inserting ``of section 1902(a)(54)'';
(B) by striking ``, by not later than January 1,
1993,'';
(C) by inserting after ``gross overuse,'' the
following: ``excessive utilization,''; and
(D) by striking ``or inappropriate or medically
unnecessary care'' and inserting ``inappropriate or
medically unnecessary care, or prescribing or billing
practices that indicate abuse or excessive
utilization''; and
(2) in paragraph (2)(B)--
(A) by inserting after ``gross overuse,'' the
following: ``excessive utilization,'';
(B) by striking ``or inappropriate or medically
unnecessary care'' and inserting ``inappropriate or
medically unnecessary care, or prescribing or billing
practices that indicate abuse or excessive
utilization''; and
(C) by adding at the end the following new
sentence: ``In the case that the program identifies a
pattern described in the previous sentence, the State
shall take such remedial actions as determined
necessary to address such pattern.''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect with respect to retrospective drug use reviews conducted on
or after October 1, 2020.
Amend the title so as to read: ``A bill to amend title XIX
of the Social Security Act to require under Medicaid that State
Medicaid plans have in place certain drug utilization review
activities, and to require States to identify and address
inappropriate prescribing and billing practices under
Medicaid.''.
Union Calendar No. 563
115th CONGRESS
2d Session
H. R. 5799
[Report No. 115-728]
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to require as a condition
of receipt of full Federal medical assistance percentage under Medicaid
that State Medicaid plans have in place certain drug utilization review
activities.
_______________________________________________________________________
June 12, 2018
Reported with amendments, committed to the Committee of the Whole House
on the State of the Union, and ordered to be printed