Congressional Record, Volume 164 Issue 103 (Wednesday, June 20, 2018)

[Congressional Record Volume 164, Number 103 (Wednesday, June 20, 2018)]
[House]
[Pages H5335-H5344]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

INDIVIDUALS IN MEDICAID DESERVE CARE THAT IS APPROPRIATE AND
RESPONSIBLE IN ITS EXECUTION ACT

General Leave

Mrs. MIMI WALTERS of California. Mr. Speaker, I ask unanimous consent
that all Members may have 5 legislative days to revise and extend their
remarks and to include extraneous material on the bill, H.R. 5797.
The SPEAKER pro tempore (Mr. Shimkus). Is there objection to the
request of the gentlewoman from California?
There was no objection.
The SPEAKER pro tempore. Pursuant to House Resolution 949 and rule
XVIII, the Chair declares the House in the Committee of the Whole House
on the state of the Union for the consideration of the bill, H.R. 5797.
The Chair appoints the gentleman from Illinois (Mr. Bost) to preside
over the Committee of the Whole.

{time} 1345

In the Committee of the Whole

Accordingly, the House resolved itself into the Committee of the
Whole House on the state of the Union for the consideration of the bill
(H.R. 5797) to amend title XIX of the Social Security Act to allow
States to provide under Medicaid services for certain individuals with
opioid use disorders in institutions for mental diseases, with Mr. Bost
in the chair.
The Clerk read the title of the bill.
The CHAIR. Pursuant to the rule, the bill is considered read the
first time.
The gentlewoman from California (Mrs. Mimi Walters) and the gentleman
from New Jersey (Mr. Pallone) each will control 30 minutes.
The Chair recognizes the gentlewoman from California.
Mrs. MIMI WALTERS of California. Mr. Chairman, I yield myself such
time as I may consume.
Mr. Chairman, the opioid epidemic is ravaging this Nation. Families
have been torn apart; lives have been destroyed; and communities are
endangered.
This crisis does not discriminate. Americans from all walks of life
in all 50 States are being held hostage by the scourge of opioids.
Tragically, the opioid epidemic claims the lives of 115 Americans on
average each day. In my home of Orange County, California, 361 people
died from opioid overdoses in 2015. That accounts for a 50 percent
increase in overdose deaths since 2006.
According to the OC Health Care Agency's 2017 ``Opioid Overdose and
Death in Orange County'' report, the rate of opioid-related emergency
room visits increased by more than 140 percent since 2005. Between 2011
and 2015, Orange County emergency rooms treated nearly 7,500 opioid
overdose and abuse cases.
We can put an end to these tragic statistics by providing full access
to various treatment options to those seeking help with their
addictions. While many of these patients may benefit from outpatient
help, others need highly specialized inpatient treatment to ensure they
are receiving the most clinically appropriate care.
The IMD CARE Act will increase access to care for certain Medicaid
beneficiaries with opioid use disorder who need the most intensive care
possible: inpatient care.
Current law prohibits the Federal Government from providing Federal
Medicaid matching funds to States to provide mental disease care to
Medicaid-eligible patients aged 21 to 64 in facilities defined as
institutes of mental diseases, commonly known as IMDs. This IMD
exclusion means that Federal dollars may not be provided for the care
of Medicaid-eligible patients in this age group for substance use
disorder treatments at hospitals, nursing facilities, or other
institutions with more than 16 beds.
It is time to repeal the IMD exclusion and remove this outdated
barrier to inpatient treatment. The IMD CARE Act would allow States to
repeal for 5 years the IMD exclusion for adult Medicaid beneficiaries
who have an opioid use disorder, which includes heroin and fentanyl.
These beneficiaries would receive treatment in an IMD for up to 30
days over a 12-month period, during which time the beneficiary would be
regularly assessed to ensure their treatment and health needs require
inpatient care. The bill would also require the IMD to develop an
outpatient plan for the individual's ongoing treatment upon discharge.
Throughout the Energy and Commerce Committee's work on the opioid
crisis, the IMD exclusion is consistently identified as a significant
barrier to care for Medicaid patients. Not every patient needs
treatment in an IMD, but those who do are often among the most
vulnerable. What once was a well-intended exclusion on Federal Medicaid
spending has since prevented individuals from seeking treatment.
In the light of the opioid epidemic, I believe my legislation strikes
the right balance. I know some have suggested States continue to seek
CMS waivers to allow Medicaid to pay for IMD care. Waivers can be a
good option for some States, but not all States want a waiver. In fact,
less than half of the States have applied for a waiver. Additionally, a
waiver can take a substantial amount of time to develop, review, and
approve.
We are losing too many friends and family members to force States to
navigate a lengthy and uncertain waiver process. The IMD CARE Act
allows

[[Page H5336]]

States to act now to ensure patients who are suffering from addiction
get the care they need.
The National Governors Association and the American Hospital
Association have endorsed this legislation. Other organizations, such
as the National Association of State Medicaid Directors and the
National Association of State Mental Health Directors, have supported
the idea of Congress addressing the IMD.
While the repeal of the IMD exclusion would increase mandatory
outlays and add costs to the Medicaid system, the IMD CARE Act is fully
paid for by curbing unnecessary Federal and State Medicaid outlays.
I want to thank Chairman Walden and my colleagues on the House Energy
and Commerce Committee for their support of this bill, which will
provide much needed care to Americans suffering from opioid use
disorder. Through the IMD CARE Act, Congress has a unique opportunity
to remove a barrier to care and bring specialized treatment to Medicaid
patients who desperately need it.

Mr. Chairman, I urge all Members to support this important bill
today, and I reserve the balance of my time.
Mr. PALLONE. Mr. Chair, I yield myself such time as I may consume.
Mr. Chair, I stand in opposition to H.R. 5797, the IMD CARE Act.
I think we all agree that we need all the tools available to us to
address the opioid crisis. Inpatient treatment centers that focus on
the treatment of behavioral health needs of patients with substance use
disorder are part of that. Congress must do what we can to ease access
to care.
But I believe this legislation, as drafted, is misguided. It is also
counterproductive and an ineffective use of scarce Medicaid dollars.
But more importantly, it may undermine the ongoing efforts to improve
the full continuum of care for people with substance use disorders.
This policy spends more than $1 billion in Medicaid to pay for a
policy that is far narrower in both scope and flexibility than what
many of our States already have and any State could do through Medicaid
substance use disorder waivers.
In addition, as countless data has indicated, there are many gaps in
treatment for Medicaid beneficiaries with substance use disorder. Yet
this bill does nothing to incentivize States to provide the full
continuum of care.
Community-based services are necessary for both people not treated in
residential inpatient facilities and also for people who leave
residential inpatient treatment and need community-based services to
continue their treatment and recovery.
We already face a shortage of community-based care for substance use
disorder and should be working with States to increase this capacity.
Yet this bill doesn't tie Federal funds for IMD care to improvements in
community-based services. Without that connection, States simply will
not pursue these needed improvements.
Without incentives to improve access to treatment more broadly,
repealing the IMD exclusion to only a narrow population--in this case,
opioid use--through legislation may simply encourage greater use of
expensive inpatient treatment, including for people for whom it may not
be the best option.
We can't push a system where people cycle in and out of institutions.
People with substance use disorders need a range of supports to stay
well and sober long term, not just a limited stay in an IMD.
Existing guidance from both the Obama and Trump administrations
allows States to waive the IMD exclusions if the States also take steps
to ensure that people with substance use disorder have access to other
care they need, including preventive, treatment and recovery services.
So far, there are 22 States, Mr. Chair, that have waivers approved or
pending before the administration. I think these waivers are important
to support.
My home State of New Jersey has approval for a waiver right now.
Under that waiver, they expanded access to all substance use disorder
services in their Medicaid program. We should build on that policy,
which emphasizes the full continuum of care, with any bills that repeal
the IMD exclusion.
In addition, I have concerns about creating a system in States
whereby only some of our Medicaid beneficiaries with substance use
disorder have access to the full continuum of care they need.
This bill specifically limits residential treatment to adults with
opioid use disorders, with the possible addition of an amendment for
cocaine use disorders. But it doesn't help the overwhelming majority of
individuals with other substance use disorders, such as alcohol, which
is far more commonly abused.
Treatment for substance use disorder, especially in the midst of our
opioid crisis, must include a comprehensive approach that addresses the
entirety of a patient's medical and psychological conditions. This
legislation creates a perverse incentive toward individuals reporting
opioid abuse or going out and getting addicted to opioids, for
instance, in the hopes of gaining access to the treatment they need.
Expanding access to inpatient residential treatment in a vacuum I
think would undermine State efforts to ensure the availability of
substance use disorder treatment that meets the needs of all patients
in the most appropriate environment.
In the short time this legislation has been publicly available,
countless stakeholders have weighed in vehemently on particulars of
this bill, echoing my concerns today. In fact, coalitions with more
than 300 groups as well as other mental health, substance use, and
disability groups have sent letters in opposition. I think we need to
work with stakeholders. This issue is too important to get wrong.
For these reasons, Mr. Chair, I oppose H.R. 5797. I urge my
colleagues to vote ``no,'' and I reserve the balance of my time.
Mrs. MIMI WALTERS of California. Mr. Chairman, I yield 3 minutes to
the gentleman from Texas (Mr. Burgess).
Mr. BURGESS. Mr. Chair, I want to thank Mrs. Walters for introducing
this legislation.
Throughout this committee's and subcommittee's work on opioids, the
IMD exclusion has been consistently identified by many stakeholders in
conversations not only in my office but with the subcommittee as a
barrier to care for Medicaid patients who need inpatient treatment.
In the face of an epidemic that is taking the lives of 115 Americans
on average every day, I believe this policy strikes the right balance.
The IMD CARE Act targets limited resources to remove a barrier to care
by allowing States to repeal the IMD exclusion for 5 years for Medicaid
beneficiaries between the ages of 21 and 64 who have an opioid use
disorder. This approach will provide States the flexibility to increase
access to institutional care for those who truly need it.

While getting a waiver from CMS for the IMD exclusion is a good
option for many States, less than half the States have applied for a
waiver. We are losing too many of our friends and neighbors each day to
this crisis to ask States to go through what can be a lengthy and
uncertain process to secure a waiver.
The IMD CARE Act allows States to act now to ensure their patients
who are suffering now from a terrible disease can get the care that
they need and get it now.
I ask my fellow Members to join me in support of Mrs. Walters' bill.
Mr. PALLONE. Mr. Chair, I yield myself such time as I may consume.
Mr. Chair, I want to speak briefly on a point that I think is being
lost here.
This bill presumes that expanding access to residential treatment is
the answer, and it is not necessarily. Without any requirement that
States address gaps in Medicaid community-based services, I think there
is a possibility that we risk more harm than good.
The former director of national drug control policy has reminded us
that most of these IMD facilities provide detoxification services. But
detoxification is only the first stage of addiction treatment. Indeed,
it may increase the potential for overdose if patients do not remain or
have any support when released, since, with detoxification, their
tolerance for opioids is significantly reduced.
The proposal before the House will likely create an overreliance on
institutional treatment and may exacerbate

[[Page H5337]]

the dearth of community-based health services.

{time} 1400

People with substance use disorder often find themselves unable to
access intensive community-based behavioral health services when they
need it. Likewise, many cannot access services in the community when
they are discharged following a crisis.
Incentivizing inpatient care may actually increase opioid overdose,
the very harm that Congress is seeking to prevent. Experts have raised
serious concerns with this bill's institutional focus because recent
data suggests that inpatient detoxification is an important predictor
of overdose, largely because many who receive inpatient care aren't
then connected to community-based treatment programs or put on
medication, leaving them extremely vulnerable.
Again, I am concerned that we may be contributing to this crisis with
this legislation.
Mr. Chair, I reserve the balance of my time.
Mrs. MIMI WALTERS of California. Mr. Chair, I yield 5 minutes to the
gentleman from Oregon (Mr. Walden), chairman of the Committee on Energy
and Commerce.
Mr. WALDEN. Mr. Chair, I want to thank my colleague Mimi Walters and
those who have worked so closely with her on this really, really
important legislation. That is why I am here to support it, H.R. 5797,
the IMD CARE Act.
This is really commonsense legislation, and it will make a meaningful
change to the way Medicaid covers opioid use disorder for its
beneficiaries. In other words, low-income people in America who get
their medical assistance through Medicaid are going to get another
option and more help to deal with their addiction.
We are discussing this bill because a severely outdated policy limits
Medicaid's coverage in an institution for mental disease--that is what
an IMD is, institution for mental disease--for just 30 days. It is old.
It is antiquated. It doesn't work with today's treatment regimens.
This exclusion has been in place for decades--decades--certainly long
before the opioid crisis ever hit our country, and it is now a barrier
to critical care for low-income people on Medicaid when this vulnerable
population needs help with their addiction the most.
Representative Walters' thoughtful bill will allow State Medicaid
programs, from 2019 through 2023, to remove this antiquated Federal
barrier to treatment for those on Medicaid, age 21 to 64, with an
opioid use disorder, through a State plan amendment. In doing so,
Medicaid would pay for up to 30 total days of a beneficiary's care in
an IMD during a 12-month period, year.
So this is limited in scope. It is in partnership with the States. It
is low-income people getting more help from Medicaid to pay for this
extraordinarily important treatment.
This bill also collects much-needed data on the process. After taking
up this option, States will have to report on the number of individuals
with opioid use disorder under this plan, their length of stay, and the
type of treatment received upon discharge. This will help inform better
programs down the line.
As a Congress, we have been focused on combating the opioid crisis
for quite some time. This is not our first legislative attempt to help
people not only avoid this addiction, but overcome it. It will not be
our last. We will legislate; we will evaluate; we will legislate; we
will evaluate, as Republicans and Democrats have been doing for some
time.
It is an important step, this bill, that can help get people a vital
treatment to which they now don't have access. The American Hospital
Association, the National Governors Association, Republicans and
Democrats, hospitals and Governors across the country, have said:
Please do this. This is a need that is unmet. Please help us change
this antiquated Federal law.
Many stakeholder groups, including the National Association of State
Medicaid Directors, the people who run the Medicaid programs in States;
the National Association of State Mental Health Program Directors, the
people who know what is needed most to overcome these situations; and
many others have talked to us in the committee. They have talked to me
personally. They are pleading with Congress to get rid of this barrier
to care, this outdated law, and to help people get treatment,
especially the low-income among us.
We have an opportunity to deliver, to help. We have an opportunity to
save lives. It is our responsibility, and we need to pass this
legislation.
Mr. Chair, I commend the gentlewoman from California for bringing
this issue to the committee and shepherding it through. It is so
important to pass this legislation. Let's help these people get the
care they need and want.
Mr. PALLONE. Mr. Chair, I yield myself the balance of my time.
Mr. Chair, in closing and in urging opposition to this bill from my
colleagues, the reason the IMD exclusion was put in place in the
beginning was because of the fear that people who had overdosed, who
had opiate problems, would be put into institutions, if you will, and
then throw away the key. In other words, they put them in there, maybe
they get detoxed, and then they come out. But without any treatment or
any followup, community-based treatment, they would just go back to the
same thing again; they would overdose again and end up back in the
facility.
So the fear was that we would have these large facilities where they
go in and, without any kind of continuum of care, the cycle just keeps
repeating itself. I just want my colleagues to be mindful of that.
What happened was, during the Obama administration, States had asked
for waivers from the IMD exclusion, and the Obama administration
decided they would do that if they provided a continuum of care and
community-based services so that the problem that led to the IMD
exclusion would not repeat itself.
I guess my fear is, today, that this seems like such a simple
solution: Okay. We will get rid of the 16-bed exclusion because we need
people to go into these institutions.
However, since we are not providing any continuum of care or
community care in eliminating this exclusion, it goes back to the same
problem, which is we don't want people to just be warehoused to detox,
come out again, overdose again, and go back in without any kind of
community services.

That is why I am making the argument that the actual waivers that
exist now, which I think almost half of the States have, is a much
better alternative than just lifting and getting rid of the exclusion.
That is why I believe that this bill is misplaced and why I would urge
my colleagues to oppose it, because I think it may actually go back to
the days where we were just warehousing people and we are not actually
giving them the kind of treatment that they need.
Mr. Chair, I would urge my colleagues to vote against the bill, and I
yield back the balance of my time.
Mrs. MIMI WALTERS of California. Mr. Chair, I yield myself the
balance of my time.
Mr. Chair, the opioid crisis requires us to act now. The IMD
exclusion is consistently identified as a significant barrier to care
by State Medicaid directors and numerous other stakeholder groups. We
need to pass this bill in order to increase access to acute, short-term
inpatient treatment. I urge my colleagues to support this bill and help
individuals suffering with opioid addiction.
Mr. Chair, I yield back the balance of my time.
Ms. MAXINE WATERS of California. Mr. Chair, I rise to oppose H.R.
5797, also known as the ``IMD CARE Act.''
H.R. 5797 allows states to use Medicaid funds to treat adult patients
ages 21-64 with opioid abuse disorders in Institutions for Mental
Disease (IMDs) with more than 16 beds. While expanding access to
treatment for substance abuse disorders is an admirable goal, H.R. 5797
is not the way to accomplish this goal.
One obvious limitation of H.R. 5797 is that it only applies to opioid
and heroin use disorders. It does nothing to expand access to treatment
for other types of substance abuse disorders, including alcoholism and
the abuse of other illegal drugs like methamphetamine, crack, and other
forms of cocaine.
A second problem with this bill is that it only expands access to
treatment in inpatient IMD

[[Page H5338]]

facilities. It does not provide Medicaid funding for substance abuse
treatment services in an outpatient setting, nor does it require states
to make such services available. Not all substance abuse patients need
to be treated in an institution, and those that do will also need
outpatient recovery services after they are released from an IMD.
Currently, states can already use Medicaid funds to treat patients in
IMD facilities by means of a waiver from the Centers for Medicare and
Medicaid Services (CMS). In order to qualify for a waiver, states must
take steps to ensure that patients are able to obtain substance abuse
treatment and services in the community, as well as in institutions.
Eleven states already have a waiver for this purpose, and eleven other
states have waiver applications pending. Expanding access to inpatient
treatment in states that do not provide outpatient services risks
forcing patients into treatment that is ineffective and inappropriate
for their situation.
Another option that is already available for states that want to
expand access to substance abuse treatment services is to expand
Medicaid under the Affordable Care Act. Medicaid expansion would ensure
that all low-income people, including those with substance abuse
disorders, are able to obtain treatment for their medical conditions.
I submitted an amendment that would have required states to expand
Medicaid pursuant to the Affordable Care Act as a condition for using
Medicaid funds to treat people with opioid abuse disorders in IMD
facilities. This amendment would have provided an additional incentive
for states to expand Medicaid, which in turn would have expanded access
to a broad range of treatment and services for patients with substance
abuse disorders.
Expanding access to Medicaid will benefit patients with substance
abuse disorders, regardless of the type of addiction from which they
suffer and regardless of whether they would be best served by inpatient
treatment, outpatient treatment, or a combination of the two.
It is especially ironic that this bill is being considered on the
House floor the day after House Republicans unveiled their fiscal year
2019 budget proposal, which would cut $1.5 trillion from Medicaid. If
the majority party cares about Americans suffering from an opioid abuse
disorder, they would not rob them of the health care services thiey
already have.
I urge my colleagues to oppose H.R. 5797 and support a comprehensive
solution to substance abuse disorders that will meet the needs of all
people suffering from these tragic medical conditions.
The Acting CHAIR (Mr. Mitchell). All time for general debate has
expired.
Pursuant to the rule, the bill shall be considered for amendment
under the 5-minute rule.
The amendment in the nature of a substitute recommended by the
Committee on Energy and Commerce, printed in the bill, modified by the
amendment printed in part C of House Report 115-766, shall be
considered as adopted. The bill, as amended, shall be considered as an
original bill for purpose of further amendment under the 5-minute rule,
and shall be considered read.
The text of the bill, as amended, is as follows:

H.R. 5797

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 ``Individuals in Medicaid
Deserve Care that is Appropriate and Responsible in its
Execution Act'' or the ``IMD CARE Act''.

SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERVICES FOR
CERTAIN INDIVIDUALS WITH OPIOID USE DISORDERS
IN INSTITUTIONS FOR MENTAL DISEASES.

``(I) the process by which eligible individuals with opioid
use disorders will make the transition from receiving
inpatient services in an institution for mental diseases to
appropriate outpatient care; and
``(II) the process the State will undertake to ensure
individuals with opioid use disorder are provided care in the
most integrated setting appropriate to the needs of the
individuals; and

``(ii) a description of how the State plan amendment
ensures an appropriate clinical screening of eligible
individuals with an opioid use disorder, including
assessments to determine level of care and length of stay
recommendations based upon the multidimensional assessment
criteria of the American Society of Addiction Medicine.
``(B) Report.--Not later than the sooner of December 31,
2024, or one year after the date of the termination of a
State plan amendment under this subsection, the State shall
submit to the Secretary a report that includes at least--
``(i) the number of eligible individuals with opioid use
disorders who received services pursuant to such State plan
amendment;
``(ii) the length of the stay of each such individual in an
institution for mental diseases; and
``(iii) the type of outpatient treatment, including
medication-assisted treatment, each such individual received
after being discharged from such institution.
``(4) Definitions.--In this subsection:
``(A) Eligible individual with an opioid use disorder.--The
term `eligible individual with an opioid use disorder' means
an individual who--
``(i) with respect to a State, is enrolled for medical
assistance under the State plan (or a waiver of such plan);
``(ii) is at least 21 years of age;
``(iii) has not attained 65 years of age; and
``(iv) has been diagnosed with at least one opioid use
disorder.
``(B) Institution for mental diseases.--The term
`institution for mental diseases' has the meaning given such
term in section 1905(i).
``(C) Opioid prescription pain reliever.--The term `opioid
prescription pain reliever' includes hydrocodone products,
oxycodone products, tramadol products, codeine products,
morphine products, fentanyl products, buprenorphine products,
oxymorphone products, meperidine products, hydromorphone
products, methadone, and any other prescription pain reliever
identified by the Assistant Secretary for Mental Health and
Substance Use.
``(D) Opioid use disorder.--The term `opioid use disorder'
means a disorder that meets the criteria of the Diagnostic
and Statistical Manual of Mental Disorders, 4th Edition (or a
successor edition), for heroin use disorder or pain reliever
use disorder (including with respect to opioid prescription
pain relievers).
``(E) Other medically necessary services.--The term `other
medically necessary services' means, with respect to an
eligible individual with an opioid use disorder who is a
patient in an institution for mental diseases, items and
services that are provided to such individual outside of such
institution to the extent that such items and services would
be treated as medical assistance for such individual if such
individual were not a patient in such institution.''.

SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.

[[Page H5339]]

loss ratio (as defined in subparagraph (D)(ii)) that is at
least 85 percent but not greater than the minimum medical
loss ratio (as so defined) that such State applied as of May
31, 2018; or
``(II) in the case of a State not described in subparagraph
(C), to apply a minimum medical loss ratio that is equal to
85 percent; and
``(ii) recovered all or a portion of the expenditures as a
result of the entity's failure to meet such ratio.
``(C) For purposes of subparagraph (B), a State described
in this subparagraph is a State that as of May 31, 2018,
applied a minimum medical loss ratio (as calculated under
subsection (d) of section 438.8 of title 42, Code of Federal
Regulations (as in effect on June 1, 2018)) for payment for
services provided by entities described in such subparagraph
under the State plan under this title (or a waiver of the
plan) that is equal to or greater than 85 percent.
``(D) For purposes of this paragraph:
``(i) The term `managed care entity' means a medicaid
managed care organization described in section
1932(a)(1)(B)(i).
``(ii) The term `minimum medical loss ratio' means, with
respect to a State, a minimum medical loss ratio (as
calculated under subsection (d) of section 438.8 of title 42,
Code of Federal Regulations (as in effect on June 1, 2018))
for payment for services provided by entities described in
subparagraph (B) under the State plan under this title (or a
waiver of the plan).
``(iii) The term `other specified entity' means--
``(I) a prepaid inpatient health plan, as defined in
section 438.2 of title 42, Code of Federal Regulations (or
any successor regulation); and
``(II) a prepaid ambulatory health plan, as defined in such
section (or any successor regulation).''.

The Acting CHAIR. No further amendment to the bill, as amended, shall
be in order except those printed in part D of House Report 115-766.
Each such further amendment may be offered only in the order printed in
the report, by a Member designated in the report, shall be considered
as read, shall be debatable for the time specified in the report
equally divided and controlled by the proponent and an opponent, shall
not be subject to amendment, and shall not be subject to a demand for
division of the question.

Amendment No. 1 Offered by Mr. Rush

The Acting CHAIR. It is now in order to consider amendment No. 1
printed in part D of House Report 115-766.
Mr. RUSH. Mr. Chair, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:

In section 2, strike ``individuals with opioid use
disorders'' and insert ``individuals with targeted suds''.
In the subsection (l) proposed to be added by section 2 of
the bill to section 1915 of the Social Security Act, strike
``eligible individuals with opioid use disorders'' each place
it appears and insert ``eligible individuals with targeted
SUDs'' each such place.
In the subsection (l) proposed to be added by section 2 of
the bill to section 1915 of the Social Security Act, strike
``eligible individual with an opioid use disorder'' each
place it appears and insert ``eligible individual with a
targeted SUD'' each such place.
Page 5, beginning on line 19, strike ``individuals with
opioid use disorder'' and insert ``eligible individuals with
targeted SUDs''.
Page 6, beginning on line 1, strike ``eligible individuals
with an opioid use disorder'' and insert ``eligible
individuals with targeted SUDs''.
Page 6, line 7, insert before the period the following:
``and to determine the appropriate setting for such care''.
Page 7, line 12, strike ``opioid use disorder'' and insert
``targeted SUD''.
In the subsection (l)(4) proposed to be added by section 2
of the bill to section 1915 of the Social Security Act,
strike subparagraph (D), redesignate subparagraph (E) as
subparagraph (D), and add at the end the following:
``(E) Targeted sud.--
``(i) In general.--The term `targeted SUD' means an opioid
use disorder or a cocaine use disorder.
``(ii) Cocaine use disorder.--The term `cocaine use
disorder' means a disorder that meets the criteria of the
Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition (or a successor edition), for either dependence or
abuse for cocaine, including cocaine base (commonly referred
to as `crack cocaine').
``(iii) Opioid use disorder.--The term `opioid use
disorder' means a disorder that meets the criteria of the
Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition (or a successor edition), for heroin use disorder or
pain reliever use disorder (including with respect to opioid
prescription pain relievers).''.
Strike all that follows after section 2 and insert the
following:

SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.

Section 1903(m) of the Social Security Act (42 U.S.C.
1396b(m)) is amended by adding at the end the following new
paragraph:
``(7)(A) With respect to expenditures described in
subparagraph (B) that are incurred by a State for any fiscal
year after fiscal year 2020 (and before fiscal year 2024), in
determining the pro rata share to which the United States is
equitably entitled under subsection (d)(3), the Secretary
shall substitute the Federal medical assistance percentage
that applies for such fiscal year to the State under section
1905(b) (without regard to any adjustments to such percentage
applicable under such section or any other provision of law)
for the percentage that applies to such expenditures under
section 1905(y).
``(B) Expenditures described in this subparagraph, with
respect to a fiscal year to which subparagraph (A) applies,
are expenditures incurred by a State for payment for medical
assistance provided to individuals described in subclause
(VIII) of section 1902(a)(10)(A)(i) by a managed care entity,
or other specified entity (as defined in subparagraph
(D)(iii)), that are treated as remittances because the
State--
``(i) has satisfied the requirement of section 438.8 of
title 42, Code of Federal Regulations (or any successor
regulation), by electing--
``(I) in the case of a State described in subparagraph (C),
to apply a minimum medical loss ratio (as defined in
subparagraph (D)(ii)) that is at least 85 percent but not
greater than the minimum medical loss ratio (as so defined)
that such State applied as of May 31, 2018; or
``(II) in the case of a State not described in subparagraph
(C), to apply a minimum medical loss ratio that is equal to
85 percent; and
``(ii) recovered all or a portion of the expenditures as a
result of the entity's failure to meet such ratio.
``(C) For purposes of subparagraph (B), a State described
in this subparagraph is a State that as of May 31, 2018,
applied a minimum medical loss ratio (as calculated under
subsection (d) of section 438.8 of title 42, Code of Federal
Regulations (as in effect on June 1, 2018)) for payment for
services provided by entities described in such subparagraph
under the State plan under this title (or a waiver of the
plan) that is equal to or greater than 85 percent.
``(D) For purposes of this paragraph:
``(i) The term `managed care entity' means a medicaid
managed care organization described in section
1932(a)(1)(B)(i).
``(ii) The term `minimum medical loss ratio' means, with
respect to a State, a minimum medical loss ratio (as
calculated under subsection (d) of section 438.8 of title 42,
Code of Federal Regulations (as in effect on June 1, 2018))
for payment for services provided by entities described in
subparagraph (B) under the State plan under this title (or a
waiver of the plan).
``(iii) The term `other specified entity' means--
``(I) a prepaid inpatient health plan, as defined in
section 438.2 of title 42, Code of Federal Regulations (or
any successor regulation); and
``(II) a prepaid ambulatory health plan, as defined in such
section (or any successor regulation).''.

The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Illinois (Mr. Rush) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentleman from Illinois.
Mr. RUSH. Mr. Chair, I yield myself such time as I may consume.
Mr. Chair, I rise today to offer my amendment that finally addresses
a longstanding and discriminatory gap in coverage and expands treatment
options for those suffering from addiction.
This House, Mr. Chairman, should be commended for its work on opioid
addiction, but let us not forget that we have insidiously ignored
another pervasive and catastrophically destructive addiction that is
known as crack cocaine.
To remedy this, Mr. Chairman, my amendment would expand the bill to
include those individuals suffering from cocaine use disorder and
explicitly clarifies the inclusion of cocaine base, more commonly known
as crack cocaine, which, along with opiates, is a double-barrel cause
of drug-related deaths in communities like mine all across this Nation.
Too often, Mr. Chairman, this House seems to only have focused on
issues when they have affected the majority, the White population. This
leaves vulnerable, non-White, minority Americans without any chance to
escape from their illness and their resulting suffering.
Too often, Mr. Chairman, the government's response to minority
Americans has been mass incarceration instead of treatment. Too often,
Mr. Chairman, crises that impact the African American communities are
seen as a criminal justice problem, while those that affect the White
community are seen as a public health problem. That phenomenon changes
today.

[[Page H5340]]

I know opponents of this amendment will say that we should be
expanding coverage to all those suffering from addiction. I
wholeheartedly agree, Mr. Chairman, with that statement. However, while
more remains to be done, today's action is a step in the right
direction.
This is an important moment for those who have been addicted to crack
and have been denied such access to treatment. Today they will finally
get relief as we make historic progress in the fight against addiction
and the injustice that continues to tear communities apart.
For this reason, I urge all my colleagues on both sides of the aisle
to join me in supporting this worthwhile and meaningful amendment.
Mr. Chair, I reserve the balance of my time.
Mr. WALDEN. Mr. Chair, I claim the time in opposition to the
amendment, though I am not opposed to the amendment.
The Acting CHAIR. Without objection, the gentleman from Oregon is
recognized for 5 minutes.
There was no objection.
Mr. WALDEN. Mr. Chair, I yield myself such time as I may consume.
Mr. Chair, I rise today in support of the Rush amendment to H.R.
5797, the IMD CARE Act. Earlier today, I spoke in support of the
underlying bill. It will make a meaningful change to the way Medicaid
covers opioid use disorder for its beneficiaries.
The amendment offered by my friend and colleague from Illinois,
Representative Bobby Rush, will expand on that definition. It will
allow Medicaid to provide coverage for individuals seeking treatment
from cocaine and crack cocaine usage.
Looking at just 2016, opioids and cocaine caused 82 percent of all
drug overdose deaths in the United States. Cocaine alone kills more
than 10,000 Americans a year. News outlets have also reported fentanyl
being mixed in with cocaine, further complicating this tragic opioid
crisis.
This is an issue that Mr. Rush has passionately led on in the
committee, on the floor, and at home in his community.

{time} 1415

We discussed it in the hearing room and at length in private while
working to fine-tune this legislation so that the best possible version
can become law.
So I want to thank Mr. Rush for this amendment, and I want people to
know that it really will improve and expand the scope of this bill.
Mr. Chairman, I urge my colleagues to adopt this amendment and
support the underlying bill, which will dramatically aid in our
response to the opioid epidemic for all Americans, wherever they live.
Mr. Chairman, how much time do I have remaining?
The Acting CHAIR. The gentleman from Oregon has 3\1/2\ minutes
remaining.
Mr. WALDEN. Mr. Chairman, I yield 1 minute to the gentleman from New
Jersey (Mr. Pallone), the ranking Democrat on the committee.
Mr. PALLONE. Mr. Chairman, I thank the chairman for yielding.
Mr. Chairman, I support Mr. Rush's amendment, but I remain in strong
opposition to the underlying bill. I support my colleague's, Mr.
Rush's, work to add cocaine use disorder.
As Mr. Rush noted in our committee, cocaine use claims more African
American lives than opioid use and has been a larger problem than
opioid use disorder for more than 20 years, yet incarceration, not
treatment, is far too often the response.
Unfortunately, adding a single additional drug does not make this
legislation whole. Nearly half of all States already reimburse for IMDs
for all individuals with substance use disorder. We can and should
build on that policy and strengthen the full continuum of care with any
IMD policy this body passes.
There is no good reason, policy or otherwise, for us to leave the
overwhelming majority of Medicaid beneficiaries out in the cold because
they have the misfortunate to be addicted to, for instance, alcohol or
meth instead of cocaine or opioids.
So, again, I support the amendment, but I remain in strong opposition
to the underlying bill.
Mr. WALDEN. Mr. Chairman, I conclude my comments by expressing my
disappointment that I have yet to persuade my friend from New Jersey to
support the underlying bill, although I appreciate his support of the
Rush amendment.
We know that our Governors, we know that our State Medicaid
directors, and we know those most involved in helping those with
addiction have pled with us to change this antiquated law so that
people of all colors, of all backgrounds, from anywhere in this
country, especially the low-income, can get access to meaningful,
modern, and helpful assistance to overcome their addiction. That is
what this bill does.
Mr. Chairman, I encourage my colleagues to support the amendment, and
I encourage them to support the underlying bill.
Mr. Chairman, I yield back the balance of my time.
Mr. RUSH. Mr. Chairman, may I inquire as to how much time I have
remaining.
The Acting CHAIR. The gentleman from Illinois has 1\1/2\ minutes
remaining.
Mr. RUSH. Mr. Chairman, before I close, I want to, in a most sincere
and humble way, thank Chairman Walden for his outstanding leadership on
this matter, and for his breadth of understanding of the difficulties
that my constituents have as a result of the omission from treatments
for crack cocaine and other similar addictions.
I do understand the ranking member on the full committee's problems
and concerns. I do understand, and I accept it. But, Mr. Chairman, we
have to go forward on this particular amendment and on final passage.
Mr. Chairman, I thank Congressman Walden, and all of the staffs, for
working with my staff on this critically important issue.
Mr. Chairman, I yield back the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentleman from Illinois (Mr. Rush).
The amendment was agreed to.

Amendment No. 2 Offered by Mr. Kildee

The Acting CHAIR. It is now in order to consider amendment No. 2
printed in part D of House Report 115-766.
Mr. KILDEE. Mr. Chairman, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:

Page 6, line 19, strike ``and''.
Page 6, line 23, strike the period at the end and insert
``; and''.
Page 6, after line 23, insert the following:
``(iv) the number of eligible individuals with any co-
occuring disorders who received services pursuant to such
State plan amendment and the co-occuring disorders from which
they suffer; and
``(v) information regarding the effects of a State plan
amendment on access to community care for individuals
suffering from a mental disease other than substance use
disorder.''.

The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Michigan (Mr. Kildee) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentleman from Michigan.
Mr. KILDEE. Mr. Chairman, this legislation requires States to submit
a report on the number of patients served for opioid use disorder at
institutions for mental diseases, their length of stay, and the care
they received after they were discharged. My amendment would add two
requirements to that report.
The first additional element addresses co-occurring disorders. My
amendment would require that States include information on the number
of individuals suffering from these disorders, as well as the type of
specific disorders from which they suffer.
Co-occurring disorders are a terrible situation in which a person is
simultaneously experiencing a mental illness and a substance use issue.
This is especially prevalent in our veteran population, with the VA
estimating that about one-third of veterans seeking treatment for
substance use disorder also meet the criteria for post-traumatic stress
disorder.
Co-occurring disorders can be especially difficult for doctors to
diagnose because of how complex symptoms can be, with one often masking
the symptoms of the other.
As of 2016, the Substance Abuse and Mental Health Services
Administration estimates that more than 8 million

[[Page H5341]]

adults in the U.S. had co-occurring disorders. Half of them did not
receive proper treatment, and around one-third received no care for
mental illness or substance use disorder.
If we are going to get these individuals the help they need and
deserve, we are going to need to know what care is needed and how large
the existing treatment gap really is. My amendment will help to provide
that data.
The second element of my amendment requires information on access to
community care for individuals suffering from a mental illness other
than substance use disorder.
For decades, our country has shifted mental healthcare services away
from institutional care into community health providers. That is
substantial progress that we certainly don't want to reverse or
endanger.
Make no mistake, passing this legislation will have a direct effect
on access to community care for people with mental diseases. We should
know how much and to what extent that is the case. My amendment will
provide Congress with the data on whether that access is increasing or,
as a result of this potential legislation, decreasing.
We should not, in efforts to combat this epidemic, inadvertently
create uncertainty or greater harm for other groups of people,
especially such vulnerable groups as those with mental illness. My
amendment will provide Congress with greater information for us to know
if we are doing just that.
Mr. Chairman, I urge my colleagues to support this amendment, and I
reserve the balance of my time.
Mrs. MIMI WALTERS of California. Mr. Chairman, I claim the time in
opposition, but I am not opposed to the amendment.
The Acting CHAIR. Without objection, the gentlewoman is recognized
for 5 minutes.
There was no objection.
Mrs. MIMI WALTERS of California. Mr. Chairman, I yield myself such
time as I may consume.
Mr. Chairman, I thank the gentleman from Michigan (Mr. Kildee), my
colleague, for offering this amendment to H.R. 5797.
This amendment seeks to add several components to a State report that
is included in H.R. 5797. I appreciate Mr. Kildee's work on this
amendment. I think that this information would be valuable, and I am
happy to accept the amendment. However, I want to note that we will
need to talk to States about the information this amendment would have,
and then report. Changes may have to be made, depending on that
feedback.
I am committed to working out the technical details of the amendment
as we move into conference.
Mr. Chairman, I yield to the gentleman from New Jersey (Mr. Pallone).
Mr. PALLONE. Mr. Chairman, I thank the gentlewoman for yielding.
Mr. Chairman, I support my colleague's, Representative Kildee's,
amendment to this legislation. It is certainly important to require
States to report information on individuals with co-occurring disorders
and what disorders are suffered, and it is equally important to have
information on access to community care for individuals suffering from
a behavioral health issue other than a substance use disorder.
Mr. Chairman, I want to stress that this information is important,
but the underlying problem with the IMD CARE Act continues. I believe
this bill is, at best, an ineffective use of scarce Medicaid dollars.
More importantly, it may undermine ongoing efforts to improve the full
continuum of care for people with substance use disorders.
Mrs. MIMI WALTERS of California. Mr. Chairman, I yield back the
balance of my time.
Mr. KILDEE. Mr. Chairman, I appreciate the comments of both of my
colleagues.
This is an effort to make sure that, as we take on this epidemic,
whatever path we may take, we do so in a way that gets us the best
information we can to determine whether or not we are making the
progress that this intends. We have our thoughts about that. This
legislation, and this particular amendment, would ensure that Congress
has the information it needs.
I encourage my colleagues to support the amendment, and I yield back
the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentleman from Michigan (Mr. Kildee).
The amendment was agreed to.

Amendment No. 3 Offered by Mr. Fitzpatrick

The Acting CHAIR. It is now in order to consider amendment No. 3
printed in part D of House Report 115-766.
Mr. FITZPATRICK. Mr. Chairman, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:

Page 6, line 7, insert before the period the following:
``or criteria established or endorsed by the State agency
identified by the State pursuant to section 1932(b)(1)(A)(i)
of the Public Health Service Act''.

The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Pennsylvania (Mr. Fitzpatrick) and a Member opposed each will
control 5 minutes.
The Chair recognizes the gentleman from Pennsylvania.
Mr. FITZPATRICK. Mr. Chairman, I yield myself such time as I may
consume.
Mr. Chairman, I intend to withdraw the amendment, but I want to take
a moment to highlight an issue of critical importance to my home State
of Pennsylvania where communities across the Commonwealth have been
suffering from the scourge of the opioid crisis.
First, I want to thank the committee for tackling the IMD exclusion
problem. We must ensure access to treatment to get people suffering
with addiction on the road to recovery. Going forward, we must ensure
that States have the flexibility that they need to provide access to
treatment and not unintentionally create obstacles or bureaucratic
barriers to care.
This is exactly what I had in mind when I introduced my Road to
Recovery Act last year. I worked with various stakeholders across the
Nation and in Pennsylvania, including Pennsylvania State Representative
Gene DiGirolamo and Deb Beck, the head of the Drug and Alcohol Service
Providers Organization of Pennsylvania.
I determined that States deliberately tailoring criteria to meet
their unique situation, whether it be specific local realities or
socioeconomic factors, need flexibility and should not be bound solely
to the proprietary criteria of one organization--which, in fact,
endorsed my Road to Recovery Act that included this same State
flexibility criteria provision.
I am concerned for Pennsylvania and other similarly situated States
that could be left behind, especially in the public patient and
residential treatment context.
For instance, in Pennsylvania, we currently use the Pennsylvania
client placement criteria tool for determining the appropriate level of
care for an individual seeking treatment or already within
Pennsylvania's treatment system. And there are simply differences
between the ASAM standard specified in this bill and the criteria used
by my home State of Pennsylvania.
Additionally, in States that may be transitioning to the ASAM
guidelines, much work is needed to implement these changes. So, States
need the flexibility and assurances to be able to address facility
needs during this transition period. This would ensure access to care
if the State sees a necessity for it.
Furthermore, the CMS guidance for the States applying for 1115
waivers already gives the ability to use either the ASAM criteria or
other patient placement assessment tools.
A manual published by SAMHSA discusses the ASAM criteria and notes
the following: ``. . . The ASAM criteria were not as applicable to
publicly funded programs as to hospitals, practices of private
practitioners, group practices, or other medical settings. Therefore,
some States supplemented or adapted ASAM criteria.''
The same manual goes on to say that several States have adopted
variations of the ASAM criteria to fit their systems and that many
States have made significant improvements in the ASAM criteria to make
them more appropriate to their systems and easier to use.

{time} 1430

So as you can see, Mr. Chairman, one size, or, in this case, one
criteria, might not fit all for States that need

[[Page H5342]]

to tailor their criteria for their specific public health needs.
I look forward to working with the committee and with the Senate in
conference to ensure that States have the flexibility that they need to
provide access to care.
Mr. Chair, I yield such time as he may consume to the gentleman from
Oregon (Mr. Walden).
Mr. WALDEN. Mr. Chair, I thank Mr. Fitzpatrick and his team for
agreeing to work with us on this issue. Unfortunately, this well-
thought-out amendment would significantly alter the quality standards
we have built into the base bill, and such a change would require more
substantial vetting with key stakeholders than we have time for at this
point.
Because of that, we are not in position of being able to accept the
amendment at this time. However, we do feel that Mr. Fitzpatrick has
made a good start, so I will have our team do a comprehensive vetting
of the language and work with stakeholders to see if this is something
we could add as we move into conference with the Senate.
Mr. Chair, I thank the gentleman for his work and I look forward to
continuing to work with him on this and other issues and with the
Senate as we continue work on this legislation.
Mr. FITZPATRICK. Mr. Chair, I appreciate the remarks from the
chairman.
I yield back the balance of my time.
Mr. Chair, I ask unanimous consent to withdraw the amendment.
The Acting CHAIR. Is there objection to the request of the gentleman
from Pennsylvania?
There was no objection.
The Acting CHAIR. The amendment is withdrawn.
There being no further amendments, under the rule, the Committee
rises.
Accordingly, the Committee rose; and the Speaker pro tempore (Mr. Poe
of Texas) having assumed the chair, Mr. Mitchell, Acting Chair of the
Committee of the Whole House on the state of the Union, reported that
that Committee, having had under consideration the bill (H.R. 5797) to
amend title XIX of the Social Security Act to allow States to provide
under Medicaid services for certain individuals with opioid use
disorders in institutions for mental diseases, and, pursuant to House
Resolution 949, he reported the bill, as amended by that resolution,
back to the House with sundry further amendments adopted in the
Committee of the Whole.
The SPEAKER pro tempore. Under the rule, the previous question is
ordered.
Is a separate vote demanded on any further amendment reported from
the Committee of the Whole? If not, the Chair will put them en gros.
The amendments were agreed to.
The SPEAKER pro tempore. The question is on the engrossment and third
reading of the bill.
The bill was ordered to be engrossed and read a third time, and was
read the third time.

Motion to Recommit

Ms. CASTOR of Florida. Mr. Speaker, I have a motion to recommit at
the desk.
The SPEAKER pro tempore. Is the gentlewoman opposed to the bill?
Ms. CASTOR of Florida. I am opposed in its current form.
The SPEAKER pro tempore. The Clerk will report the motion to
recommit.
The Clerk read as follows:

Ms. Castor of Florida moves to recommit the bill H.R. 5797
to the Committee on Energy and Commerce with instructions to
report the same back to the House forthwith with the
following amendment:
Strike all that follows after section 1 and insert the
following:

SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERVICES FOR
CERTAIN INDIVIDUALS WITH SUBSTANCE USE
DISORDERS IN QUALIFIED INSTITUTIONS FOR MENTAL
DISEASES.

Section 1915 of the Social Security Act (42 U.S.C. 1396n)
is amended by adding at the end the following new subsection:
``(l) State Plan Option To Provide Services for Certain
Individuals in Qualified Institutions for Mental Diseases.--
``(1) In general.--With respect to calendar quarters
beginning during the period beginning January 1, 2019, and
ending December 31, 2023, a State may elect, through a State
plan amendment, to, notwithstanding section 1905(a), provide
medical assistance for addiction treatment services and other
medically necessary services furnished to eligible
individuals with substance use disorders who are patients in
qualified institutions for mental diseases, in accordance
with the requirements of this subsection.
``(2) Payments.--
``(A) In general.--Subject to subparagraph (B), amounts
expended under a State plan amendment under paragraph (1) for
services described in such paragraph furnished, with respect
to a 12-month period, to an eligible individual with a
substance use disorder who is a patient in a qualified
institution for mental diseases shall be treated as medical
assistance for which payment is made under section 1903(a)
but only to the extent that such services are furnished for
not more than a period of 30 days (whether or not
consecutive) during such 12-month period.
``(B) Conditions.--As a condition of receiving payment
under this paragraph, a State shall satisfy each of the
following:
``(i) Coverage of continuum of care recommended by asam.--
Provide medical assistance under the State plan for all nine
levels of the continuum of care recommended, as of the date
of the enactment of this section, by the American Society of
Addiction Medicine.
``(ii) Coverage of newly eligible individuals.--Provide for
making medical assistance available under the State plan to
all individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).
``(C) Clarification.--Payment made under this paragraph for
expenditures under a State plan amendment under this
subsection with respect to services described in paragraph
(1) furnished to an eligible individual with a substance use
disorder shall not affect payment that would otherwise be
made under section 1903(a) for expenditures under the State
plan (or waiver of such plan) for medical assistance for such
individual.
``(3) Definitions.--In this subsection:
``(A) Addiction treatment services.--The term `addiction
treatment services' means, with respect to a State and
eligible individuals with substance use disorders who are
patients in qualified institutions for mental diseases,
services that are offered as part of a full continuum of
evidence-based treatment services under the State plan (or a
waiver of such plan), including residential, non-residential,
and community-based care, for such individuals.
``(B) Eligible individual with a substance use disorder.--
The term `eligible individual with a substance use disorder'
means an individual who--
``(i) with respect to a State, is enrolled for medical
assistance under the State plan (or a waiver of such plan);
``(ii) is at least 21 years of age;
``(iii) has not attained 65 years of age; and
``(iv) has been diagnosed with at least one substance use
disorder.
``(C) Qualified institution for mental diseases.--
``(i) In general.--The term `qualified institution for
mental diseases' means an institution described in section
1905(i) that--

``(I) has fewer than 40 beds;
``(II) is accredited for the treatment of substance use
disorders by the Joint Commission on Accreditation of
Healthcare Organizations, the Commission on Accreditation of
Rehabilitation Facilities, the Council on Accreditation, or
any other accrediting agency that the Secretary deems
appropriate as necessary to ensure nationwide applicability,
including qualified national organizations and State-level
accrediting agencies; and
``(III) employs at least one provider who, for purposes of
treating eligible individuals with a substance use disorder--

``(aa) is licensed to prescribe at least one form of each
type of medication-assisted treatment specified in clause
(ii);
``(bb) provides, with respect to the prescription of any
such medication-assisted treatment, counseling services and
behavioral therapy; and
``(cc) can discuss with any such individual the risks,
benefits, and alternatives of any such medication-assisted
treatment so prescribed.
``(ii) Types of medication-assisted treatment specified.--
For purposes of clause (i), the types of medication-assisted
treatment specified in this clause are each of the following:

``(I) Methadone.
``(II) Buprenorphine.
``(III) Naltrexone.

``(D) Other medically necessary services.--The term `other
medically necessary services' means, with respect to an
eligible individual with a substance use disorder who is a
patient in a qualified institution for mental diseases, items
and services that are provided to such individual outside of
such institution to the extent that such items and services
would be treated as medical assistance for such individual if
such individual were not a patient in such institution.''.

SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.

[[Page H5343]]

which subparagraph (A) applies, are expenditures incurred by
a State for payment for medical assistance provided to
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i) by a managed care entity, or other
specified entity (as defined in subparagraph (D)(iii)), that
are treated as remittances because the State--
``(i) has satisfied the requirement of section 438.8 of
title 42, Code of Federal Regulations (or any successor
regulation), by electing--
``(I) in the case of a State described in subparagraph (C),
to apply a minimum medical loss ratio (as defined in
subparagraph (D)(ii)) that is at least 85 percent but not
greater than the minimum medical loss ratio (as so defined)
that such State applied as of May 31, 2018; or
``(II) in the case of a State not described in subparagraph
(C), to apply a minimum medical loss ratio that is equal to
85 percent; and
``(ii) recovered all or a portion of the expenditures as a
result of the entity's failure to meet such ratio.
``(C) For purposes of subparagraph (B), a State described
in this subparagraph is a State that as of May 31, 2018,
applied a minimum medical loss ratio (as calculated under
subsection (d) of section 438.8 of title 42, Code of Federal
Regulations (as in effect on June 1, 2018)) for payment for
services provided by entities described in such subparagraph
under the State plan under this title (or a waiver of the
plan) that is equal to or greater than 85 percent.
``(D) For purposes of this paragraph:
``(i) The term `managed care entity' means a medicaid
managed care organization described in section
1932(a)(1)(B)(i).
``(ii) The term `minimum medical loss ratio' means, with
respect to a State, a minimum medical loss ratio (as
calculated under subsection (d) of section 438.8 of title 42,
Code of Federal Regulations (as in effect on June 1, 2018))
for payment for services provided by entities described in
subparagraph (B) under the State plan under this title (or a
waiver of the plan).
``(iii) The term `other specified entity' means--
``(I) a prepaid inpatient health plan, as defined in
section 438.2 of title 42, Code of Federal Regulations (or
any successor regulation); and
``(II) a prepaid ambulatory health plan, as defined in such
section (or any successor regulation).''.

Mrs. MIMI WALTERS of California (during the reading). Mr. Speaker, I
reserve a point of order on the motion to recommit.
The SPEAKER pro tempore. A point of order is reserved.
The Clerk will continue to read.
The Clerk continued to read.
Ms. CASTOR of Florida (during the reading). Mr. Speaker, I ask
unanimous consent to dispense with the reading.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Florida?
There was no objection.
The SPEAKER pro tempore. The gentlewoman from Florida is recognized
for 5 minutes in support of her motion.
Ms. CASTOR of Florida. Mr. Speaker, this is the final amendment to
the bill. It will not kill the bill or send it back to committee. If
adopted, the bill will immediately proceed to passage, as amended.
Mr. Speaker, the House has been debating legislation to combat the
opioid epidemic. While many of the bills we heard last week and this
week are fine, together they fail to meet the challenge of this very
serious public health crisis where in America today, we are losing
about 40,000 lives a year due to opioid addiction.
Now, in the Energy and Commerce Committee over the past few months,
we have had numerous hearings and heard from all sorts of experts and
families and the DEA and health providers. And then back home, families
have been educating us on the challenges of dealing with opioid
addiction.
Families and public health experts and the medical community, they
have reached a consensus that we need a more comprehensive approach to
tackle the opioid epidemic that includes prevention, community-based
treatment, and integrated recovery plans. But it is very difficult for
us to be proactive in a meaningful way on the opioid crisis when the
Republicans and the White House continue to press us backwards when it
comes to access to affordable healthcare.
Just last week, the Trump administration launched a new attack on
Americans with preexisting conditions, and that includes families
struggling with opioid addiction. President Trump and the GOP asked a
Federal court to strike down the protection that prevents insurance
companies from denying coverage or charging more for a preexisting
condition.
This would be a devastating blow to those suffering from addiction,
not to mention cancer or diabetes or a heart condition or more. This
would leave more families without insurance and more families without
addiction treatment.
President Trump and the GOP were not successful last year in ripping
health coverage away from families across this country through
legislation, so now they are trying to do this through the court
system: take away the guarantee of health coverage for millions of
Americans with preexisting conditions. This is wrong and it will make
the opioid epidemic worse. Instead, we should be working together to
develop and fund a comprehensive robust plan to combat and treat
addiction.
Mr. Speaker, this is why I am proposing an amendment to strengthen
the underlying bill. My amendment, most importantly, makes the 5-year
limited repeal of the IMD exclusion for individuals with substance use
disorders contingent on the State expanding Medicaid. It is based on
the most up-to-date research and everything we know about how important
Medicaid and Medicaid expansion is to treating opioid addiction.
Mr. Speaker, Medicaid is central to treating addiction, because
families can get early intervention and treatment, including the
important medical-assisted treatment. In fact, Medicaid serves four out
of ten of nonelderly adults with opioid addiction.
According to a 2016 study by the National Council on Behavioral
Health, about 1.6 million people with substance use disorders now have
coverage because they live in one of the 31 States at the time that
expanded Medicaid. So they are more likely to receive treatment,
including access to naloxone and other drugs that help them stay off
the opioids.
The Agency for Healthcare Research and Quality highlighted the
importance of Medicaid expansion in increasing insurance coverage among
people with opioid use disorders just recently. They found that the
share of hospitalizations in which the patient was uninsured fell
dramatically in States that had expanded Medicaid, from over 13 percent
in 2013 to just 2.9 percent 2 years later after those States expanded
Medicaid. The steep decline indicates that many uninsured people coping
with opioid addiction gained coverage through Medicaid expansion.
Medicaid is part of the solution to the opioid crisis, and
Republicans should not irresponsibly press to cut millions of
Americans, take away their lifeline as they propose massive cuts again
to Medicaid.
The Republican budget came out just yesterday. Surprise, surprise.
Again, they go after families who rely on Medicaid, not just Medicaid
expansion that has been so important to treating folks who suffer from
addiction, but families, children, our neighbors with disabilities,
folks that rely on skilled nursing care, the Republican budget released
yesterday says $1.5 trillion in cuts to those families. That is not
going to help solve the opioid epidemic.
Republicans in Congress cannot, on one hand, say we are facing up to
the addiction crisis, and on the other say we are taking away your
healthcare, whether it is Medicaid or preexisting conditions.
Mr. Speaker, I urge approval of my motion, and I yield back the
balance of my time.
Mrs. MIMI WALTERS of California. Mr. Speaker, I withdraw my point of
order.
The SPEAKER pro tempore (Mr. Mitchell). The reservation of a point of
order is withdrawn.
Mrs. MIMI WALTERS of California. Mr. Speaker, I claim the time in
opposition to the motion.
The SPEAKER pro tempore. The gentlewoman from California is
recognized for 5 minutes.
Mrs. MIMI WALTERS of California. Mr. Speaker, the Energy and Commerce
Committee has worked hard to make this monumental first step in
removing a decades-old barrier.
Currently the law prohibits Medicaid beneficiaries aged 21 to 64 from
receiving care in an institution for mental disease, or IMD. This
prohibition was set into law in the 1960s, long before the opioid
crisis, and the time to repeal it in a targeted manner is now.
Now is the time, because 115 Americans are dying each day from
opioid-related deaths. Now is the time, because

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on average, 1,000 people are treated in emergency rooms for opioid
misuse.
I am happy to work with my colleagues on expanding addiction
treatment services, but that should not distract from what we are
considering today: increasing access to specialized inpatient treatment
for the most vulnerable in society who are struggling with an opioid
addiction.
We are helping to ensure that people get the care they need in the
midst of this crisis, and most importantly, it will save lives.
A recent MACPAC report clearly stated that the Medicaid IMD exclusion
acts as a barrier for individuals with an opioid use disorder and is
one of the few instances in Medicaid where Federal financial
participation cannot be used for medically necessary and otherwise
covered services for a specific Medicaid enrollee population receiving
treatment in a specific setting.
The IMD CARE Act is vital to helping our communities end the opioid
epidemic by removing that barrier. This bill provides for a targeted
repeal of the IMD prohibition. The bill gives States a quicker
alternative than Medicaid waivers to provide this much needed care.
This bill was carefully crafted to ensure that patients are not being
held in IMDs for longer than necessary and the bill also includes an
offset.
For these reasons, the National Governors Association and the
American Hospital Association support the bill.
Numerous stakeholder groups have identified the IMD exclusion repeal
as one of the most significant reforms we can make to end the opioid
crisis.
This is such a critical first step.
Mr. Speaker, I urge my colleagues to oppose this motion to recommit
and to vote ``yes'' on final passage.
Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore. Without objection, the previous question is
ordered on the motion to recommit.
There was no objection.
The SPEAKER pro tempore. The question is on the motion to recommit.
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.
Ms. CASTOR of Florida. Mr. Speaker, on that I demand the yeas and
nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further
proceedings on this question will be postponed.

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