[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4758 Engrossed in House (EH)]

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118th CONGRESS
  2d Session
                                H. R. 4758

_______________________________________________________________________

                                 AN ACT


 
To amend title XIX of the Social Security Act to streamline enrollment 
under the Medicaid program of certain providers across State lines, and 
       to prevent the use of abusive spread pricing in Medicaid.

    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 ``Accelerating Kids' Access to Care 
Act''.

SEC. 2. STREAMLINED ENROLLMENT PROCESS FOR ELIGIBLE OUT-OF-STATE 
              PROVIDERS UNDER MEDICAID AND CHIP.

    (a) In General.--Section 1902(kk) of the Social Security Act (42 
U.S.C. 1396a(kk)) is amended by adding at the end the following new 
paragraph:
            ``(10) Streamlined enrollment process for eligible out-of-
        state providers.--
                    ``(A) In general.--The State--
                            ``(i) adopts and implements a process to 
                        allow an eligible out-of-State provider to 
                        enroll under the State plan (or a waiver of 
                        such plan) to furnish items and services to, or 
                        order, prescribe, refer, or certify eligibility 
                        for items and services for, qualifying 
                        individuals without the imposition of screening 
                        or enrollment requirements in addition to those 
                        imposed by the State in which the eligible out-
                        of-State provider is located; and
                            ``(ii) provides that an eligible out-of-
                        State provider that enrolls as a participating 
                        provider in the State plan (or a waiver of such 
                        plan) through such process shall be so enrolled 
                        for a 5-year period, unless the provider is 
                        terminated or excluded from participation 
                        during such period.
                    ``(B) Definitions.--In this paragraph:
                            ``(i) Eligible out-of-state provider.--The 
                        term `eligible out-of-State provider' means, 
                        with respect to a State, a provider--
                                    ``(I) that is located in any other 
                                State;
                                    ``(II) that--
                                            ``(aa) was determined by 
                                        the Secretary to have a limited 
                                        risk of fraud, waste, and abuse 
                                        for purposes of determining the 
                                        level of screening to be 
                                        conducted under section 
                                        1866(j)(2), has been so 
                                        screened under such section 
                                        1866(j)(2), and is enrolled in 
                                        the Medicare program under 
                                        title XVIII; or
                                            ``(bb) was determined by 
                                        the State agency administering 
                                        or supervising the 
                                        administration of the State 
                                        plan (or a waiver of such plan) 
                                        of such other State to have a 
                                        limited risk of fraud, waste, 
                                        and abuse for purposes of 
                                        determining the level of 
                                        screening to be conducted under 
                                        paragraph (1) of this 
                                        subsection, has been so 
                                        screened under such paragraph 
                                        (1), and is enrolled under such 
                                        State plan (or a waiver of such 
                                        plan); and
                                    ``(III) that has not been--
                                            ``(aa) excluded from 
                                        participation in any Federal 
                                        health care program pursuant to 
                                        section 1128 or 1128A;
                                            ``(bb) excluded from 
                                        participation in the State plan 
                                        (or a waiver of such plan) 
                                        pursuant to part 1002 of title 
                                        42, Code of Federal Regulations 
                                        (or any successor regulation), 
                                        or State law; or
                                            ``(cc) terminated from 
                                        participating in a Federal 
                                        health care program or the 
                                        State plan (or a waiver of such 
                                        plan) for a reason described in 
                                        paragraph (8)(A).
                            ``(ii) Qualifying individual.--The term 
                        `qualifying individual' means an individual 
                        under 21 years of age who is enrolled under the 
                        State plan (or waiver of such plan).
                            ``(iii) State.--The term `State' means 1 of 
                        the 50 States or the District of Columbia.''.
    (b) Conforming Amendments.--
            (1) Section 1902(a)(77) of the Social Security Act (42 
        U.S.C. 1396a(a)(77)) is amended by inserting ``enrollment,'' 
        after ``screening,''.
            (2) The subsection heading for section 1902(kk) of such Act 
        (42 U.S.C. 1396a(kk)) is amended by inserting ``Enrollment,'' 
        after ``Screening,''.
            (3) Section 2107(e)(1)(G) of such Act (42 U.S.C. 
        1397gg(e)(1)(G)) is amended by inserting ``enrollment,'' after 
        ``screening,''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on the date that is 3 years after the date of enactment of this 
section.

SEC. 3. PREVENTING THE USE OF ABUSIVE SPREAD PRICING IN MEDICAID.

    (a) In General.--Section 1927 of the Social Security Act (42 U.S.C. 
1396r-8) is amended--
            (1) in subsection (e), by adding at the end the following 
        new paragraph:
            ``(6) Transparent prescription drug pass-through pricing 
        required.--
                    ``(A) In general.--A contract between the State and 
                a pharmacy benefit manager (referred to in this 
                paragraph as a `PBM'), or a contract between the State 
                and a managed care entity or other specified entity (as 
                such terms are defined in section 1903(m)(9)(D) and 
                collectively referred to in this paragraph as the 
                `entity') that includes provisions making the entity 
                responsible for coverage of covered outpatient drugs 
                dispensed to individuals enrolled with the entity, 
                shall require that payment for such drugs and related 
                administrative services (as applicable), including 
                payments made by a PBM on behalf of the State or 
                entity, is based on a transparent prescription drug 
                pass-through pricing model under which--
                            ``(i) any payment made by the entity or the 
                        PBM (as applicable) for such a drug--
                                    ``(I) is limited to--
                                            ``(aa) ingredient cost; and
                                            ``(bb) a professional 
                                        dispensing fee that is not less 
                                        than the professional 
                                        dispensing fee that the State 
                                        would pay if the State were 
                                        making the payment directly in 
                                        accordance with the State plan;
                                    ``(II) is passed through in its 
                                entirety (except as reduced under 
                                Federal or State laws and regulations 
                                in response to instances of waste, 
                                fraud, or abuse) by the entity or PBM 
                                to the pharmacy or provider that 
                                dispenses the drug; and
                                    ``(III) is made in a manner that is 
                                consistent with sections 447.502, 
                                447.512, 447.514, and 447.518 of title 
                                42, Code of Federal Regulations (or any 
                                successor regulation) as if such 
                                requirements applied directly to the 
                                entity or the PBM, except that any 
                                payment by the entity or the PBM for 
                                the ingredient cost of such drug 
                                purchased by a covered entity (as 
                                defined in subsection (a)(5)(B)) may 
                                exceed the actual acquisition cost (as 
                                defined in 447.502 of title 42, Code of 
                                Federal Regulations, or any successor 
                                regulation) for such drug if--
                                            ``(aa) such drug was 
                                        subject to an agreement under 
                                        section 340B of the Public 
                                        Health Service Act;
                                            ``(bb) such payment for the 
                                        ingredient cost of such drug 
                                        does not exceed the maximum 
                                        payment that would have been 
                                        made by the entity or the PBM 
                                        for the ingredient cost of such 
                                        drug if such drug had not been 
                                        purchased by such covered 
                                        entity; and
                                            ``(cc) such covered entity 
                                        reports to the Secretary (in a 
                                        form and manner specified by 
                                        the Secretary), on an annual 
                                        basis and with respect to 
                                        payments for the ingredient 
                                        costs of such drugs so 
                                        purchased by such covered 
                                        entity that are in excess of 
                                        the actual acquisition costs 
                                        for such drugs, the aggregate 
                                        amount of such excess;
                            ``(ii) payment to the entity or the PBM (as 
                        applicable) for administrative services 
                        performed by the entity or PBM is limited to an 
                        administrative fee that reflects the fair 
                        market value (as defined by the Secretary) of 
                        such services;
                            ``(iii) the entity or the PBM (as 
                        applicable) makes available to the State, and 
                        the Secretary upon request in a form and manner 
                        specified by the Secretary, all costs and 
                        payments related to covered outpatient drugs 
                        and accompanying administrative services (as 
                        described in clause (ii)) incurred, received, 
                        or made by the entity or the PBM, broken down 
                        (as specified by the Secretary), to the extent 
                        such costs and payments are attributable to an 
                        individual covered outpatient drug, by each 
                        such drug, including any ingredient costs, 
                        professional dispensing fees, administrative 
                        fees (as described in clause (ii)), post-sale 
                        and post-invoice fees, discounts, or related 
                        adjustments such as direct and indirect 
                        remuneration fees, and any and all other 
                        remuneration; and
                            ``(iv) any form of spread pricing whereby 
                        any amount charged or claimed by the entity or 
                        the PBM (as applicable) that exceeds the amount 
                        paid to the pharmacies or providers on behalf 
                        of the State or entity, including any post-sale 
                        or post-invoice fees, discounts, or related 
                        adjustments such as direct and indirect 
                        remuneration fees or assessments (after 
                        allowing for an administrative fee as described 
                        in clause (ii)) is not allowable for purposes 
                        of claiming Federal matching payments under 
                        this title.
                    ``(B) Making certain information available.--The 
                Secretary shall publish, not less frequently than on an 
                annual basis, information received by the Secretary 
                pursuant to subparagraph (A)(i)(III)(cc). Such 
                information shall be so published in an electronic and 
                searchable format, such as through the 340B Office of 
                Pharmacy Affairs Information System (or a successor 
                system).''; and
            (2) in subsection (k), by adding at the end the following 
        new paragraph:
            ``(12) Pharmacy benefit manager.--The term `pharmacy 
        benefit manager' means any person or entity that, either 
        directly or through an intermediary, acts as a price negotiator 
        or group purchaser on behalf of a State, managed care entity 
        (as defined in section 1903(m)(9)(D)), or other specified 
        entity (as so defined), and may also more broadly manage 
        aspects of the prescription drug benefits provided by a State, 
        managed care entity, or other specified entity, including the 
        processing and payment of claims for prescription drugs, the 
        performance of drug utilization review, the processing of drug 
        prior authorization requests, the managing of appeals or 
        grievances related to the prescription drug benefits, 
        contracting with pharmacies, controlling the cost of covered 
        outpatient drugs, or the provision of services related thereto. 
        Such term includes any person or entity that acts as a price 
        negotiator (with regard to payment amounts to pharmacies and 
        providers for a covered outpatient drug or the net cost of the 
        drug) or group purchaser on behalf of a State, managed care 
        entity, or other specified entity, including such a person or 
        entity that carries out 1 or more of the other activities 
        described in the preceding sentence, irrespective of whether 
        such person or entity calls itself a pharmacy benefit 
        manager.''.
    (b) Conforming Amendments.--Section 1903(m) of such Act (42 U.S.C. 
1396b(m)) is amended--
            (1) in paragraph (2)(A)(xiii)--
                    (A) by striking ``and (III)'' and inserting 
                ``(III)'';
                    (B) by inserting before the period at the end the 
                following: ``, and (IV) if the contract includes 
                provisions making the entity responsible for coverage 
                of covered outpatient drugs, the entity shall comply 
                with the requirements of section 1927(e)(6)''; and
                    (C) by moving the left margin 2 ems to the left; 
                and
            (2) by adding at the end the following new paragraph:
            ``(10) No payment shall be made under this title to a State 
        with respect to expenditures incurred by the State for payment 
        for services provided by an other specified entity (as defined 
        in paragraph (9)(D)(iii)) unless such services are provided in 
        accordance with a contract between the State and such entity 
        which satisfies the requirements of paragraph (2)(A)(xiii).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to contracts between States and managed care entities, other 
specified entities, or pharmacy benefit managers that have an effective 
date beginning on or after the date that is 18 months after the date of 
enactment of this Act.
    (d) Implementation.--
            (1) In general.--Notwithstanding any other provision of 
        law, the Secretary of Health and Human Services may implement 
        the amendments made by this section by program instruction or 
        otherwise.
            (2) Nonapplication of administrative procedure act.--
        Implementation of the amendments made by this section shall be 
        exempt from the requirements of section 553 of title 5, United 
        States Code.
    (e) Nonapplication of Paperwork Reduction Act.--Chapter 35 of title 
44, United States Code, shall not apply to any data collection 
undertaken by the Secretary of Health and Human Services under section 
1927(e) of the Social Security Act (42 U.S.C. 1396r-8(f)), as amended 
by this section.

SEC. 4. MEDICAID IMPROVEMENT FUND.

    Section 1941(b)(3)(A) of the Social Security Act (42 U.S.C. 1396w-
1(b)(3)(A)) is amended by striking ``$0'' and inserting 
``$69,000,000''.

            Passed the House of Representatives September 17, 2024.

            Attest:

                                                                 Clerk.
118th CONGRESS

  2d Session

                               H. R. 4758

_______________________________________________________________________

                                 AN ACT

To amend title XIX of the Social Security Act to streamline enrollment 
under the Medicaid program of certain providers across State lines, and 
       to prevent the use of abusive spread pricing in Medicaid.