[Congressional Record Volume 170, Number 144 (Tuesday, September 17, 2024)]
[House]
[Pages H5292-H5295]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
ACCELERATING KID ACCESS TO CARE ACT
Mrs. MILLER-MEEKS. Mr. Speaker, I move to suspend the rules and pass
the bill (H.R. 4758) to amend title XIX of the Social Security Act to
streamline enrollment under the Medicaid program of certain providers
across State lines, and for other purposes, as amended.
The Clerk read the title of the bill.
The text of the bill is as follows:
H.R. 4758
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
[[Page H5293]]
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''.
The SPEAKER pro tempore. Pursuant to the rule, the gentlewoman from
Iowa (Mrs. Miller-Meeks) and the gentleman from New Jersey (Mr.
Pallone) each will control 20 minutes.
The Chair recognizes the gentlewoman from Iowa.
General Leave
Mrs. MILLER-MEEKS. Mr. Speaker, I ask unanimous consent that all
Members may have 5 legislative days in which to revise and extend their
remarks and include extraneous material in the Record on the bill.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Iowa?
There was no objection.
Mrs. MILLER-MEEKS. Mr. Speaker, I yield myself such time as I may
consume.
[[Page H5294]]
Mr. Speaker, I rise today in strong support of my legislation, H.R.
4758, the Accelerating Kids' Access to Care Act.
Mr. Speaker, for many families facing rare and severe pediatric
conditions, accessing out-of-State care can be a daunting and lengthy
process. The barriers are not just logistical, but also administrative,
leading to unnecessary delays that can be detrimental to a child's
health and even life threatening.
The Accelerating Kids' Access to Care Act addresses this issue by
streamlining the enrollment process for out-of-State pediatric
providers under Medicaid, meaning that, if a child needs to travel out
of State to receive care, bureaucratic hurdles won't stand in their
way.
More specifically, the Accelerating Kids' Access to Care Act will
enable States to adopt a simplified process for out-of-State providers
to enroll in their Medicaid programs. This change will reduce delays
and prevent the denial of care due to administrative inefficiencies.
It will also ensure that, once enrolled, providers remain active for
5 years, unless otherwise terminated, which brings stability and
consistency to care delivery.
In addition, the bill includes provisions to combat abusive pricing
practices in Medicaid, ensuring transparency and fairness in the cost
of prescription drugs. By enforcing transparent pricing models by
banning spread pricing, we can protect both the integrity of Medicaid
dollars and the interests of families relying on this essential
program.
This bipartisan piece of legislation is supported by over 215
organizations, including the Children's Hospital Association and the
Leukemia & Lymphoma Society, reflecting a broad consensus on its
importance.
Mr. Speaker, I thank the gentlewoman from Massachusetts (Mrs. Trahan)
and Senators Grassley and Bennet for their work on this bill, and I ask
all of my colleagues to join us in supporting this vital piece of
legislation.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise today in support of H.R. 4758, the Accelerating
Kids' Access to Care Act, sponsored by the gentlewoman from
Massachusetts (Mrs. Trahan) and the gentlewoman from Iowa (Mrs. Miller-
Meeks).
Mr. Speaker, H.R. 4758 will ensure that children enrolled in Medicaid
who need specialized care from out-of-State providers can receive that
care without undue delay.
Children with complex medical needs often require care that can only
be provided by specialists in States other than the one in which they
live, and it is unacceptable that these children may have to wait
months to receive the care they need, making their condition worse and
adding unnecessary stress and burden to their already overwhelmed
families.
These delays stem from complicated processes that prevent out-of-
State Medicaid providers from quickly enrolling in the child's home
State Medicaid program. H.R. 4758 will streamline that process to
ensure children can more quickly get the care that they need.
This bill also includes a prohibition on so-called spread pricing by
pharmacy benefit managers in the Medicaid program. Spread pricing
occurs when pharmacy benefit managers keep a portion of the amount paid
to them for prescription drugs, charging Medicaid an excess amount for
the drug. I will be pleased to see this wasteful spending come to an
end, frankly.
Mr. Speaker, I thank the gentlewoman from Massachusetts (Mrs. Trahan)
for her leadership on this important bill. I urge all of my colleagues
to vote ``yes,'' and I reserve the balance of my time.
Mrs. MILLER-MEEKS. Mr. Speaker, I yield 5 minutes to the gentleman
from Georgia (Mr. Carter).
Mr. CARTER of Georgia. Mr. Speaker, I thank the gentlewoman for
yielding.
Mr. Speaker, I rise today to express my support for the Accelerating
Kids' Access to Care Act, which will help families access lifesaving
care for children with complex medical conditions.
In Georgia, we are blessed to have world-class children's hospitals
that care for kids across the country. However, in some cases, patients
with rare and complex diseases have to travel out of State to receive
specialized care when the services they need are not available in their
own State.
The process is difficult and full of red tape, often delaying
children and their families from receiving the care they desperately
need and, in some cases, blocking access to care altogether.
The Accelerating Kids' Access to Care Act will allow States to
streamline the process for out-of-State pediatric care providers to
enroll in another State's Medicaid program, while also providing
important guardrails. This is a commonsense policy that will help
children with complex medical conditions access critical care.
Mr. Speaker, I am also pleased to see the bipartisan amendment
includes crucial pharmacy benefit manager reforms for my Drug Price
Transparency and Medicaid Act. This provision would prohibit spread
pricing in Medicaid and clarify that States should reimburse PBMs
contracting with Medicaid managed care organizations for an
administrative fee for managing the pharmacy benefit for Medicaid
beneficiaries.
This will save taxpayers millions of dollars and will protect
patients, pharmacies, and others from middleman tactics that drive up
prescription drug prices.
Mr. Speaker, I commend the gentlewoman from Iowa (Mrs. Miller-Meeks)
and the gentlewoman from Massachusetts (Mrs. Trahan) for working on
this issue, and I urge my colleagues to support the Accelerating Kids'
Access to Care Act.
Mr. PALLONE. Mr. Speaker, I yield such time as she may consume to the
gentlewoman from Massachusetts (Mrs. Trahan), the main author of this
bill.
Mrs. TRAHAN. Mr. Speaker, I thank the gentleman from New Jersey (Mr.
Pallone) for yielding.
Mr. Speaker, I express my sincere gratitude to Ranking Member
Pallone, Chair Rodgers, Ranking Member Eshoo, Chairman Guthrie,
Congresswoman Miller-Meeks, and my colleagues on the Energy and
Commerce Committee for their unanimous support of this important
bipartisan, bicameral legislation.
When medical professionals determine that clinical care is necessary
to treat a child battling a rare disease, there should be no reason
that administrative burdens get in the way. However, that is exactly
what happens far too often to children with complex medical needs.
In fact, when children with serious health conditions lack access to
the specialized care that they need in their home State, parents can be
forced to navigate the complicated process of working with healthcare
providers and State Medicaid officials to arrange for out-of-State
care.
Unfortunately, those same parents are often met with burdensome
requirements that can lead to significant delays for children in
desperate need of care. In some cases, it can prevent access to care
entirely.
Mr. Speaker, the Accelerating Kids' Access to Care Act is urgently
needed to eliminate this red tape and ensure that children receive
appropriate, often lifesaving care that they deserve.
Mr. Speaker, to highlight the importance of getting this bipartisan
legislation over the finish line, I highlight a story from a patient
who was negatively impacted by the onerous and time-consuming Medicaid
provider screening and enrollment process.
Almost 3 years ago, a baby, who I will name Lily, was born in a rural
State with her esophagus in two separate segments and connected
abnormally to her windpipe. Since this condition requires a
particularly complicated procedure to correct it, doctors explained to
the family that there are only two places in the country where it could
be done. One of them was Boston Children's Hospital, in my home State
of Massachusetts.
Mr. Speaker, like most parents, Lily's mom and dad were immediately
ready to travel to Boston, where the surgeons were standing by to
perform the lifesaving operation. Instead, Lily, who was a Medicaid
recipient, was waiting for her home State to enroll the eight providers
at Boston Children's Hospital who had the expertise to perform this
complex surgery.
[[Page H5295]]
Her State, confused about the rules concerning out-of-State provider
enrollment, wouldn't authorize the surgery that Lily desperately
needed. Over the next 7 months, Lily's surgery was delayed and
rescheduled over 3 times. As she waited, she lived with a floppy airway
that could have collapsed at any moment.
Mr. Speaker, clearly the stakes are far too high to allow
bureaucratic hurdles to stand in the way of urgent medical care for
children like Lily. Failing to address this issue will have severe and
far-reaching consequences, not only on children who are battling
complications that could be addressed with immediate care, but also
their families, who are forced to endure significant financial and
emotional strain when the care is delayed.
What is worse is that these delays also lead to a greater reliance on
emergency services and drive up overall healthcare costs.
Passage of the Accelerating Kids' Access to Care Act is instrumental
in fixing this issue. This bipartisan legislation will get us one step
closer to ensuring that no child on Medicaid has to endure unnecessary
delays when they need critical care outside of their home State.
That is why I am so grateful to my colleagues on both sides of the
aisle and in both Chambers who were instrumental in drafting the
advancement of this legislation, including Congresswoman Miller-Meeks
and Senators Grassley and Bennet.
Mr. Speaker, that is why I urge Members on both sides of the aisle to
join us in passing this strong, bipartisan, and potentially lifesaving
legislation.
{time} 1945
Mrs. MILLER-MEEKS. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I think we heard from Representative Trahan
why this is so important. I urge all colleagues to vote for it on a
bipartisan basis, and I yield back the balance of my time.
Mrs. MILLER-MEEKS. Mr. Speaker, this bipartisan, bicameral
legislation is critical in making sure that kids have the access to
lifesaving care that they need without burdensome overregulation.
Mr. Speaker, I encourage a ``yes'' vote on this bill, and I yield
back the balance of my time.
The SPEAKER pro tempore. The question is on the motion offered by the
gentlewoman from Iowa (Mrs. Miller-Meeks) that the House suspend the
rules and pass the bill, H.R. 4758, as amended.
The question was taken; and (two-thirds being in the affirmative) the
rules were suspended and the bill, as amended, was passed.
The title of the bill was amended so as to read: ``A bill 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.''.
A motion to reconsider was laid on the table.
____________________