[House Report 115-734]
[From the U.S. Government Publishing Office]


115th Congress }                                          { REPORT
                        HOUSE OF REPRESENTATIVES
  2d Session   }                                          { 115-734

======================================================================
 
                     CHIP MENTAL HEALTH PARITY ACT

                                _______
                                

 June 12, 2018.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

 Mr. Walden, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 3192]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 3192) to amend title XXI of the Social Security 
Act to ensure access to mental health services for children 
under the Children's Health Insurance Program, and for other 
purposes, having considered the same, report favorably thereon 
with an amendment and recommend that the bill as amended do 
pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     3
Committee Action.................................................     5
Committee Votes..................................................     6
Oversight Findings and Recommendations...........................     6
New Budget Authority, Entitlement Authority, and Tax Expenditures     6
Congressional Budget Office Estimate.............................     6
Federal Mandates Statement.......................................    28
Statement of General Performance Goals and Objectives............    28
Duplication of Federal Programs..................................    28
Committee Cost Estimate..........................................    28
Earmark, Limited Tax Benefits, and Limited Tariff Benefits.......    29
Disclosure of Directed Rule Makings..............................    29
Advisory Committee Statement.....................................    29
Applicability to Legislative Branch..............................    29
Section-by-Section Analysis of the Legislation...................    29
Changes in Existing Law Made by the Bill, as Reported............    30

    The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``CHIP Mental Health Parity Act''.

SEC. 2. ENSURING ACCESS TO MENTAL HEALTH AND SUBSTANCE USE DISORDER 
                    SERVICES FOR CHILDREN AND PREGNANT WOMEN UNDER THE 
                    CHILDREN'S HEALTH INSURANCE PROGRAM.

  (a) In General.--Section 2103(c)(1) of the Social Security Act (42 
U.S.C. 1397cc(c)(1)) is amended by adding at the end the following new 
subparagraph:
                  ``(E) Mental health and substance use disorder 
                services (as defined in paragraph (5)).''.
  (b) Mental Health and Substance Use Disorder Services.--
          (1) In general.--Section 2103(c) of the Social Security Act 
        (42 U.S.C. 1397cc(c)) is amended--
                  (A) by redesignating paragraphs (5), (6), (7), and 
                (8) as paragraphs (6), (7), (8), and (9), respectively; 
                and
                  (B) by inserting after paragraph (4) the following 
                new paragraph:
          ``(5) Mental health and substance use disorder services.--In 
        the case of a State that provides child health assistance for 
        targeted low-income children or targeted low-income pregnant 
        women (as defined in section 2112(d)) in the form of providing 
        any health benefits coverage described in subsection (a), such 
        child health assistance shall--
                  ``(A) include coverage of mental health services 
                (including behavioral health treatment) necessary to 
                prevent, diagnose, and treat a broad range of mental 
                health symptoms and disorders, including substance use 
                disorders; and
                  ``(B) be delivered in a culturally and linguistically 
                appropriate manner.''.
          (2) Conforming amendments.--
                  (A) Section 2103(a) of the Social Security Act (42 
                U.S.C. 1397cc(a)) is amended, in the matter before 
                paragraph (1), by striking ``paragraphs (5), (6), and 
                (7)'' and inserting ``paragraphs (5), (6), (7), and 
                (8)''.
                  (B) Section 2110(a) of the Social Security Act (42 
                U.S.C. 1397jj(a)) is amended--
                          (i) in paragraph (18), by striking 
                        ``substance abuse'' each place it appears and 
                        inserting ``substance use''; and
                          (ii) in paragraph (19), by striking 
                        ``substance abuse'' and inserting ``substance 
                        use''.
                  (C) Section 2110(b)(5)(A)(i) of the Social Security 
                Act (42 U.S.C. 1397jj(b)(5)(A)(i)) is amended by 
                striking ``subsection (c)(5)'' and inserting 
                ``subsection (c)(6)''.
  (c) Assuring Access to Care.--Section 2102(a)(7)(B) of the Social 
Security Act (42 U.S.C. 1397bb(c)(2)) is amended by striking ``section 
2103(c)(5)'' and inserting ``paragraphs (5) and (6) of section 
2103(c)''.
  (d) Mental Health Services Parity.--Subparagraph (A) of paragraph (7) 
of section 2103(c) of the Social Security Act (42 U.S.C. 1397cc(c)) (as 
redesignated by subsection (b)(1)) is amended to read as follows:
                  ``(A) In general.--A State child health plan shall 
                ensure that the financial requirements and treatment 
                limitations applicable to mental health and substance 
                use disorder services (as described in paragraph (5)) 
                provided under such plan comply with the requirements 
                of section 2726(a) of the Public Health Service Act in 
                the same manner as such requirements or limitations 
                apply to a group health plan under such section.''.
  (e) Effective Date.--
          (1) In general.--Subject to paragraph (2), the amendments 
        made by this section shall take effect with respect to child 
        health assistance provided on or after the date that is one 
        year after the date of the enactment of this Act.
          (2) Exception for state legislation.--In the case of a State 
        child health plan under title XXI of the Social Security Act 
        (or a waiver of such plan), which the Secretary of Health and 
        Human Services determines requires State legislation in order 
        for the respective plan (or waiver) to meet any requirement 
        imposed by the amendments made by this section, the respective 
        plan (or waiver) shall not be regarded as failing to comply 
        with the requirements of such title solely on the basis of its 
        failure to meet such an additional requirement before the first 
        day of the first calendar quarter beginning after the close of 
        the first regular session of the State legislature that begins 
        after the date of enactment of this section. For purposes of 
        the previous sentence, in the case of a State that has a 2-year 
        legislative session, each year of the session shall be 
        considered to be a separate regular session of the State 
        legislature.

                          Purpose and Summary

    H.R. 3192 was introduced on July 7, 2017, by Rep. Joseph 
Kennedy, III (D-MA). The bill requires comprehensive mental 
health and substance use disorder services as a mandatory 
benefit under the CHIP program for pregnant women and children.

                  Background and Need for Legislation

    Deaths due to overdoses of opioids and other drugs have 
ravaged American communities. According to the Centers for 
Disease Control and Prevention (CDC), on average, 1,000 people 
are treated for opioid misuse in emergency departments per day, 
an average of 115 Americans die per day, and opioid-related 
overdoses have increased steadily since 1999.\1\
---------------------------------------------------------------------------
    \1\Centers for Disease Control and Prevention. ``Drug Overdose 
Death Data.'' December 19, 2017. Available at https://www.cdc.gov/
drugoverdose/data/statedeaths.html.
---------------------------------------------------------------------------
    While the impacts to Americans' health outcomes are 
staggering, the opioid crisis has negatively impacted society 
in numerous ways. The Centers for Disease Control and 
Prevention note that life expectancy dropped in 2015 and 2016 
and that one of the reasons was an increase in unintentional 
injuries, a category that includes drug overdoses.\2\ The 
opioid crisis has also resulted in a contraction in the labor 
force by almost 1 million workers in the years between 1999 and 
2015, which resulted in a loss of $702 billion in real 
output.\3\ In 2015, the total economic burden of the opioid 
epidemic was estimated to be $504 billion.\4\ While all states 
were negatively impacted, there is geographic variation in the 
burden. West Virginia had the greatest loss per person ($4,378) 
and Nebraska had the lowest loss per person ($394).\4\ One 
recent analysis found that the annual cost for private sector 
employers for treating opioid addiction and overdoses has 
increased more than eight-fold since 2004, and more than one in 
five persons aged 55 to 64 had at least one opioid prescription 
in 2016.\5\
---------------------------------------------------------------------------
    \2\Dowell, D., Arias E., Kochanek K. et al. ``Contribution of 
Opioid-Involved Poisoning to the Change in Life Expectancy in the 
United States, 2000-2015.'' JAMA, September 2017. Available at https://
jamanetwork.com/journals/jama/fullarticle/2654372.
    \3\American Action Forum. ``The Labor Force and Output Consequences 
of the Opioid Crisis.'' March 27, 2018. Available at https://
www.americanactionforum.org/research/labor-force-output-consequences-
opioid-crisis/.
    \4\American Enterprise Institute. ``The Geographic Variation in the 
Cost of the Opioid Crisis''. Available at https://www.aei.org/wp-
content/uploads/2018/03/Geographic_Variation_in_Cost_ 
of_Opioid_Crisis.pdf.
    \5\Kaiser Family Foundation, ``A Look at How the Opioid Crisis Has 
Affected People with Employer Coverage,'' April 2018. Available online 
at: https://www.kff.org/health-costs/press-release/analysis-cost-of-
treating-opioid-addiction-rose-rapidly-for-large-employers-as-the-
number-of-prescriptions-has-declined/.
---------------------------------------------------------------------------
    Medicaid is the largest source of federal funding for 
behavioral health services--mental health and substance use 
disorder services--with nearly $71 billion in projected 2017 
spending.\6\ As the Medicaid and CHIP Payment and Access 
Commission (MACPAC) stated in 2017, ``the opioid epidemic, 
which has reached most communities across the U.S., 
disproportionately affects Medicaid beneficiaries.''\7\ 
Medicaid provides care to four in ten adults with opioid use 
disorder and compared to other insurance types, provides a 
significantly higher percentage of inpatient and outpatient 
substance use disorder treatment.\8\
---------------------------------------------------------------------------
    \6\Government Accountability Office, ``Medicaid: States Fund 
Services for Adults in Institutions for Mental Disease Using a Variety 
of Strategies,'' GAO-17-652, August 2017. Available at https://
www.gao.gov/assets/690/686456.pdf.
    \7\Medicaid and CHIP Payment and Access Commission, ``Medicaid and 
the Opioid Epidemic,'' Chapter 2 in June 2017 Report to Congress on 
Medicaid and CHIP. Available at: https://www.macpac.gov/wp-content/
uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf.
    \8\Kaiser Family Foundation. ``Medicaid's Role in Addressing the 
Opioid Epidemic.'' Available at https://www.kff.org/infographic/
medicaids-role-in-addressing-opioid-epidemic/.
---------------------------------------------------------------------------
    MACPAC found that ``Medicaid beneficiaries are prescribed 
pain relievers at higher rates than those with other sources of 
insurance. They also have a higher risk of overdose and other 
negative outcomes, from both prescription opioids and illegal 
opioids such as heroin and illicitly manufactured 
fentanyl.''\9\ Not only are the number of Medicaid 
beneficiaries with opioid misuse disproportionately high, so 
too are the number of overdoses. Studies from North Carolina 
and Washington indicate high rates of opioid-related deaths for 
the Medicaid population (33 percent and 45 percent, 
respectively).
---------------------------------------------------------------------------
    \9\Medicaid and CHIP Payment and Access Commission, ``Medicaid and 
the Opioid Epidemic,'' Chapter 2 in June 2017 Report to Congress on 
Medicaid and CHIP. Available at: https://www.macpac.gov/wp-content/
uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf.
---------------------------------------------------------------------------
    For treatment, Medicaid has several pharmacy and medical 
benefits for treating opioid use disorder that vary by state. A 
primary pharmaceutical treatment offered to patients with 
opioid abuse and/or substance use disorder is medication-
assisted treatment (MAT). The Substance Abuse and Mental Health 
Services Administration (SAMHSA) describes MAT as ``the use of 
FDA-approved medications, in combination with counseling and 
behavioral therapies, to provide a `whole-patient' approach to 
the treatment of substance use disorders.''\10\
---------------------------------------------------------------------------
    \10\See SAMHSA website. Available at: https://www.samhsa.gov/
medication-assisted-treatment.
---------------------------------------------------------------------------
    Non-pharmaceutical treatment of opioid use disorder in 
Medicaid occurs in inpatient, outpatient, residential, and 
community-based settings. MACPAC's 2017 analysis found that 
``Medicaid is responding to the opioid crisis by covering 
treatment, innovating in the delivery of care, and working with 
other state agencies to reduce misuse of prescription 
opioids.'' State Medicaid programs adopt strategies and design 
their programs to meet the needs of their Medicaid 
beneficiaries resulting in variations in covered treatment 
services and settings. It is important state Medicaid programs 
provide a continuum of care to serve the needs of Medicaid 
beneficiaries.
    However, as MACPAC noted, ``there are gaps in the continuum 
of care, and states vary in the extent to which they cover 
needed treatment.'' One of the barriers to appropriate 
treatment consistently identified by Medicaid directors and 
health policy experts is a statutory prohibition on federal 
Medicaid matching funds for paying for care for certain 
Medicaid beneficiaries in Institutions for Mental Diseases 
(IMD). As MACPAC has explained, ``the Medicaid IMD exclusion 
acts a barrier for individuals with an opioid use disorder to 
receive residential treatment, which, depending on an 
individual's treatment plan, may be the most appropriate 
setting for care.'' Given these and other findings, there 
continues to be an opportunity for Congress and state Medicaid 
programs to work to improve access to timely, high-quality 
treatment across the continuum of care.
    States may design their CHIP programs in three ways. They 
may cover eligible children under their Medicaid programs 
(i.e., CHIP Medicaid expansion), create a separate CHIP 
program, or adopt a combination approach where the state 
operates a CHIP Medicaid expansion and one or more separate 
CHIP programs concurrently. Regardless of the choice of benefit 
design, all states must cover emergency services, well-baby and 
well-child care, including age-appropriate immunizations, 
vision, and dental services under CHIP. All CHIP programs cover 
some level of outpatient and inpatient mental health services, 
but not all cover substance use disorder treatment.\11\
---------------------------------------------------------------------------
    \11\Kaiser Family Foundation, ``The Impact of the Children's Health 
Insurance Program (CHIP): What Does the Research Tell US?'', July 17, 
2014. Available at: https://www.kff.org/report-section/the-impact-of-
the-childrens-health-insurance-program-chip-issue-brief/.
---------------------------------------------------------------------------
    In general, states with CHIP Medicaid expansion programs 
must provide CHIP-eligible children with the same benefits 
provided to children enrolled in the Medicaid program. Under 
Medicaid, states are required to provide Early and Periodic 
Screening, Diagnostic, and Treatment (EPSDT) services, which 
covers health screenings and services, including assessments of 
each child's physical and mental health development. States are 
required to provide all federally allowed treatment to correct 
problems identified through screenings--including mental 
health, substance use disorder, and behavioral health treatment 
needs. EPSDT sets Medicaid benefit coverage for children 
(including CHIP children) apart from other sources of health 
insurance in that it permits coverage of all services listed in 
Medicaid statute (regardless of whether a given benefit is 
covered in the state plan). Coverage of EPSDT is deemed to be 
compliant with mental health parity, including the financial 
requirements and treatment limitations for individuals entitled 
to such benefits.\12\\13\
---------------------------------------------------------------------------
    \12\Sec. 1937(b)(6)(B) of the Social Security Act (SSA); 42 C.F.R. 
Sec. 440.395(c).
    \13\Financial requirements refer to deductibles, copayments, 
coinsurance, or out of pocket maximums, while treatment limitations 
include limits on frequency of treatment, number of visits, days of 
coverage, or other similar limits on scope of coverage.
---------------------------------------------------------------------------
    States that offer separate CHIP programs have more latitude 
in designing benefit coverage, and benefits must be on par with 
an approved benchmark plan. Such states can determine which 
services to cover and may place limits on the services that 
they offer. States are not required to offer mental health 
services and substance use disorder services (including 
behavioral health treatment) under separate CHIP programs. 
However, if offered, such services must meet federal mental 
health parity requirements related to financial requirements 
and treatment limitations for such benefits.\14\ This benefit 
coverage must be benchmarked to one of the following: a federal 
employees health benefits program equivalent, state employee 
coverage, or coverage offered through a health maintenance 
organization.\15\ The benchmark can also be an existing 
comprehensive state-based program or one approved by the 
Secretary. Reviews of separate CHIP programs found that nearly 
all covered outpatient and inpatient substance use disorder 
services.\16\ In addition, the level of benefits offered varied 
greatly.
---------------------------------------------------------------------------
    \14\SSA Sec. 2103(c)(6)(A).
    \15\Section 2103 of the Social Security Act.
    \16\Anita Cardwell, et al., National Academy for State Health 
Policy and Georgetown University Health Policy Institute, Center for 
Children and Families; Benefits and Cost Sharing in Separate CHIP 
Programs, May 2014. Available at http://ccf.georgetown.edu/wp-content/
uploads/2014/05/Benefits-and-Cost-Sharing-in-Separate-CHIP-
Programs.pdf.
---------------------------------------------------------------------------

                            Committee Action

    On April 11 and 12, 2018, the Subcommittee on Health held a 
hearing on H.R. 3192. The Subcommittee received testimony from:
           Kimberly Brandt, Principal Deputy 
        Administrator for Operations, Centers for Medicare and 
        Medicaid Services, U.S. Department of Health and Human 
        Services;
           Michael Botticelli, Executive Director, 
        Grayken Center for Addiction, Boston Medical Center;
           Toby Douglas, Senior Vice President, 
        Medicaid Solutions, Centene Corporation;
           David Guth, Chief Executive Officer, 
        Centerstone;
           John Kravitz, Chief Information Officer, 
        Geisinger Health System; and,
           Sam Srivastava, Chief Executive Officer, 
        Magellan Health.
    On April 25, 2018, the Subcommittee on Health met in open 
markup session and forwarded H.R. 3192, without amendment, to 
the full Committee by a voice vote. On May 17, 2018, the full 
Committee on Energy and Commerce met in open markup session and 
ordered H.R. 3192, as amended, favorably reported to the House 
by a voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII requires the Committee to list the 
record votes on the motion to report legislation and amendments 
thereto. There were no record votes taken in connection with 
ordering H.R. 3192 reported.

                 Oversight Findings and Recommendations

    Pursuant to clause 2(b)(1) of rule X and clause 3(c)(1) of 
rule XIII, the Committee held a hearing and made findings that 
are reflected in this report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    Pursuant to clause 3(c)(2) of rule XIII, the Committee 
finds that H.R. 3192 would result in no new or increased budget 
authority, entitlement authority, or tax expenditures or 
revenues.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII, the following is 
the cost estimate provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, June 6, 2018.
Hon. Greg Walden,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed document with cost estimates for the 
opioid-related legislation ordered to be reported on May 9 and 
May 17, 2018.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contacts are Tom Bradley 
and Chad Chirico.
            Sincerely,
                                             Mark P. Hadley
                                        (For Keith Hall, Director).
    Enclosure.

Opioid Legislation

    Summary: On May 9 and May 17, 2018, the House Committee on 
Energy and Commerce ordered 59 bills to be reported related to 
the nation's response to the opioid epidemic. Generally, the 
bills would:
           Provide grants to facilities and providers 
        that treat people with substance use disorders,
           Direct various agencies within the 
        Department of Health and Human Services (HHS) to 
        explore nonopioid approaches to treating pain and to 
        educate providers about those alternatives,
           Modify requirements under Medicaid and 
        Medicare for prescribing controlled substances,
           Expand Medicaid coverage for substance abuse 
        treatment, and
           Direct the Food and Drug Administration 
        (FDA) to modify its oversight of opioid drugs and other 
        medications that are used to manage pain.
    Because of the large number of related bills ordered 
reported by the Committee, CBO is publishing a single 
comprehensive document that includes estimates for each piece 
of legislation.
    CBO estimates that enacting 20 of the bills would affect 
direct spending, and 2 of the bills would affect revenues; 
therefore, pay-as-you-go procedures apply for those bills.
    CBO estimates that enacting H.R. 4998, the Health Insurance 
for Former Foster Youth Act, would increase net direct spending 
by more than $2.5 billion and on-budget deficits by more than 
$5 billion in at least one of the four consecutive 10-year 
periods beginning in 2029. None of the remaining 58 bills 
included in this estimate would increase net direct spending by 
more than $2.5 billion or on-budget deficits by more than $5 
billion in any of the four consecutive 10-year periods 
beginning in 2029.
    One of the bills reviewed for this document, H.R. 5795, 
would impose both intergovernmental and private-sector mandates 
as defined in the Unfunded Mandates Reform Act (UMRA). CBO 
estimates that the costs of those mandates on public and 
private entities would fall below the thresholds in UMRA ($80 
million and $160 million, respectively, in 2018, adjusted 
annually for inflation). Five bills, H.R. 5228, H.R. 5333, H.R. 
5554, H.R. 5687, and H.R. 5811, would impose private-sector 
mandates as defined in UMRA. CBO estimates that the costs of 
the mandates in three of the bills (H.R. 5333, H.R. 5554, and 
H.R. 5811) would not exceed the UMRA threshold for private 
entities. Because CBO is uncertain how federal agencies would 
implement new authority granted in the other two bills, H.R. 
5228 and H.R. 5687, CBO cannot determine whether the costs of 
those mandates would exceed the UMRA threshold.
    Estimated cost to the Federal Government: The estimates in 
this document do not include the effects of interactions among 
the bills. If all 59 bills were combined and enacted as one 
piece of legislation, the budgetary effects would be different 
from the sum of the estimates in this document, although CBO 
expects that any such differences would be small. The costs of 
this legislation fall within budget functions 550 (health), 570 
(Medicare), 750 (administration of justice), and 800 general 
government).
    Basis of estimate: For this estimate, CBO assumes that all 
of the legislation will be enacted late in 2018 and that 
authorized and estimated amounts will be appropriated each 
year. Outlays for discretionary programs are estimated based on 
historical spending patterns for similar programs.

Uncertainty

    CBO aims to produce estimates that generally reflect the 
middle of a range of the most likely budgetary outcomes that 
would result if the legislation was enacted. Because data on 
the utilization of mental health and substance abuse treatment 
under Medicaid and Medicare is scarce, CBO cannot precisely 
predict how patients or providers would respond to some policy 
changes or what budgetary effects would result. In addition, 
several of the bills would give the Department of Health and 
Human Services (HHS) considerable latitude in designing and 
implementing policies. Budgetary effects could differ from 
those provided in CBO's analyses depending on those decisions.

Direct spending and revenues

    Table 1 lists the 22 bills of the 59 ordered to be reported 
that would affect direct spending or revenues.

                                             TABLE 1.--ESTIMATED CHANGES IN MANDATORY SPENDING AND REVENUES
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                         By fiscal year, in millions of dollars--
                                ------------------------------------------------------------------------------------------------------------------------
                                   2018     2019     2020     2021     2022     2023     2024     2025     2026     2027     2028   2019-2023  2019-2028
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                      INCREASES OR DECREASES (-) IN DIRECT SPENDING
 
Legislation Primarily Affecting
 Medicaid:
    H.R. 1925, At-Risk Youth           0        *        5        5        5       10       10       10       10       10       10        25          75
     Medicaid Protection Act of
     2017......................
    H.R. 4998, Health Insurance        0        0        0        0        0        *       10       21       33       46       61         *         171
     for Former Foster Youth
     Act.......................
    H.R. 5477, Rural                   0       13       35       58       68       83       27        9        3        3        3       256         301
     Development of Opioid
     Capacity Services Act.....
    H.R. 5583, a bill to amend         0        *        *        *        *        *        *        *        *        *        *         *           *
     title XI of the Social
     Security Act to require
     States to annually report
     on certain adult health
     quality measures, and for
     other purposes............
    H.R. 5797, IMD CARE Act....        0       38      158      251      265      279        0        0        0        0        0       991         991
    H.R. 5799, Medicaid DRUG           0        *        *        1        1        1        1        1        1        1        1         2           5
     Improvement Acta..........
    H.R. 5801 Medicaid                 0        *        *        *        *        *        *        *        *        *        *         *           *
     Providers Are Required To
     Note Experiences in Record
     Systems to Help In-Need
     Patients (PARTNERSHIP)
     Acta......................
    H.R. 5808, Medicaid                0        *       -1       -1       -1       -1       -2       -2       -2       -2       -2        -4         -13
     Pharmaceutical Home Act of
     2018a.....................
    H.R. 5810, Medicaid Health         0       94       58       62       56       52       48       43       38       32       25       323         509
     HOME Act..................
Legislation Primarily Affecting
 Medicare:
    H.R. 3528, Every                   0        0        0      -24      -35      -33      -30      -33      -32      -31      -32       -92        -250
     Prescription Conveyed
     Securely Act..............
    H.R. 4841, Standardizing           0        0        0        *        *        *        *        *        *        *        *         *           *
     Electronic Prior
     Authorization for Safe
     Prescribing Act of 2018...
    H.R. 5603, Access to               0        2        *        *        *        1        1        1        2        2        2         3          11
     Telehealth Services for
     Opioid Use Disorders Act..
    H.R. 5605, Advancing High          0        0        0       15       26       24       23       23       10        1        *        65         122
     Quality Treatment for
     Opioid Use Disorders in
     Medicare Act..............
    H.R. 5675, a bill to amend         0        0        0       -6       -7       -7       -7       -8       -9       -9      -11       -20         -64
     title XVIII of the Social
     Security Act to require
     prescription drug plan
     sponsors under the
     Medicare program to
     establish drug management
     programs for at-risk
     beneficiaries.............
    H.R. 5684, Protecting              0        0        0        *        *        *        *        *        *        *        *         *           *
     Seniors From Opioid Abuse
     Act.......................
    H.R. 5796, Responsible             0       10       25       50       10        5        0        0        0        0        0       100         100
     Education Achieves Care
     and Healthy Outcomes for
     Users' Treatment Act of
     2018......................
    H.R. 5798, Opioid Screening        0        0        *        1        1        1        1        1        1        1        1         2           5
     and Chronic Pain
     Management Alternatives
     for Seniors Act...........
    H.R. 5804, Post-Surgical           0        0       25       30       25       20       10        5        0        0        0       100         115
     Injections as an Opioid
     Alternative Acta..........
    H.R. 5809, Postoperative           0        0        0        0       10       15       20       25       30       35       45        25         180
     Opioid Prevention Act of
     2018......................
Legislation Primarily Affecting
 the Food and Drug
 Administration:
    H.R. 5333, Over-the-Counter        0        0        *        *        *        *        *        *        *        *        *         *           *
     Monograph Safety,
     Innovation, and Reform Act
     of 2018a..................
 
                                                         INCREASES OR DECREASES (-) IN REVENUESb
 
    H.R. 5752, Stop Illicit            0        *        *        *        *        *        *        *        *        *        *         *          *
     Drug Importation Act of
     2018......................
--------------------------------------------------------------------------------------------------------------------------------------------------------
Annual amounts may not sum to totals because of rounding. * = between -$500,000 and $500,000. Budget authority is equivalent to outlays.
aThis bill also would affect spending subject to appropriation.
bOne additional bill, H.R. 5228, the Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act, would have a negligible effect on revenues.

    Legislation Primarily Affecting Medicaid. The following 
nine bills would affect direct spending for the Medicaid 
program.
    H.R. 1925, the At-Risk Youth Medicaid Protection Act of 
2017, would require states to suspend, rather than terminate, 
Medicaid eligibility for juvenile enrollees (generally under 21 
years of age) who become inmates of public correctional 
institutions. States also would have to redetermine those 
enrollees' Medicaid eligibility before their release and 
restore their coverage upon release if they qualify for the 
program. States would be required to process Medicaid 
applications submitted by or on behalf of juveniles in public 
correctional institutions who were not enrolled in Medicaid 
before becoming inmates and ensure that Medicaid coverage is 
provided when they are released if they are found to be 
eligible. On the basis of an analysis of juvenile incarceration 
trends and of the per enrollee spending for Medicaid foster 
care children, who have a similar health profile to 
incarcerated juveniles, CBO estimates that implementing the 
bill would cost $75 million over the 2019-2028 period.
    H.R. 4998, the Health Insurance for Former Foster Youth 
Act, would require states to provide Medicaid coverage to 
adults up to age 25 who had aged out of foster care in any 
state. Under current law, such coverage is mandatory only if 
the former foster care youth has aged out in the state in which 
the individual applies for coverage. The policy also would 
apply to former foster children who had been in foster care 
upon turning 14 years of age but subsequently left foster care 
to enter into a legal guardianship with a kinship caregiver. 
The provisions would take effect respect for foster youth who 
turn 18 on or after January 1, 2023. On the basis of spending 
for Medicaid foster care children and data from the Census 
Bureau regarding annual migration rates between states, CBO 
estimates that implementing the bill would cost $171 million 
over the 2019-2028 period.
    H.R. 5477, the Rural Development of Opioid Capacity 
Services Act, would direct the Secretary of HHS to conduct a 
five-year demonstration to increase the number and ability of 
providers participating in Medicaid to provide treatment for 
substance use disorders. On the basis of an analysis of federal 
and state spending for treatment of substance use disorders and 
the prevalence of such disorders, CBO estimates that enacting 
the bill would increase direct spending by $301 million over 
the 2019-2028 period.
    H.R. 5583, a bill to amend title XI of the Social Security 
Act to require States to annually report on certain adult 
health quality measures, and for other purposes, would require 
states to include behavioral health indicators in their annual 
reports on the quality of care under Medicaid. Although the 
bill would add a requirement for states, CBO estimates that its 
enactment would not have a significant budgetary effect because 
most states have systems in place for reporting such measures 
to the federal government.
    H.R. 5797, the IMD CARE Act, would expand Medicaid coverage 
for people with opioid use disorder who are in institutions for 
mental disease (IMDs) for up to 30 days per year. Under a 
current-law policy known as the IMD exclusion, the federal 
government generally does not make matching payments to state 
Medicaid programs for most services provided by IMDs to adults 
between the ages of 21 and 64. Recent administrative changes 
have made federal financing for IMDs available in limited 
circumstances, but the statutory prohibition remains in place. 
CBO analyzed several data sets, primarily those collected by 
the Substance Abuse and Mental Health Services Administration 
(SAMHSA), to estimate current federal spending under Medicaid 
for IMD services and to estimate spending under H.R. 5797. 
Using that analysis, CBO estimates that enacting H.R. 5797 
would increase direct spending by $991 million over the 2019-
2028 period.
    H.R. 5799, the Medicaid DRUG Improvement Act, would require 
state Medicaid programs to implement additional reviews of 
opioid prescriptions, monitor concurrent prescribing of opioids 
and certain other drugs, and monitor use of antipsychotic drugs 
by children. CBO estimates that the bill would increase direct 
spending by $5 million over 2019-2028 period to cover the 
administrative costs of complying with those requirements. On 
the basis of stakeholder feedback, CBO expects that the bill 
would not have a significant effect on Medicaid spending for 
prescription drugs because many of the bill's requirements 
would duplicate current efforts to curb opioid and 
antipsychotic drug use. (If enacted, H.R. 5799 also would 
affect spending subject to appropriation; CBO has not completed 
an estimate of that amount.)
    H.R. 5801, the Medicaid Providers Are Required To Note 
Experiences in Record Systems to Help In-Need Patients 
(PARTNERSHIP) Act, would require providers who are permitted to 
prescribe controlled substances and who participate in Medicaid 
to query prescription drug monitoring programs (PDMPs) before 
prescribing controlled substances to Medicaid patients. PDMPs 
are statewide electronic databases that collect data on 
controlled substances dispensed in the state. The bill also 
would require PDMPs to comply with certain data and system 
criteria, and it would provide additional federal matching 
funds to certain states to help cover administrative costs. On 
the basis of a literature review and stakeholder feedback, CBO 
estimates that the net budgetary effect of enacting H.R. 5801 
would be insignificant. Costs for states to come into 
compliance with the systems and administrative requirements 
would be roughly offset by savings from small reductions in the 
number of controlled substances paid for by Medicaid under the 
proposal. (If enacted, H.R. 5801 also would affect spending 
subject to appropriation; CBO has not completed an estimate of 
that amount.)
    H.R. 5808, the Medicaid Pharmaceutical Home Act of 2018, 
would require state Medicaid programs to operate pharmacy 
programs that would identify people at high risk of abusing 
controlled substances and require those patients to use a 
limited number of providers and pharmacies. Although nearly all 
state Medicaid programs currently meet such a requirement, a 
small number of high-risk Medicaid beneficiaries are not now 
monitored. Based on an analysis of information about similar 
state and federal programs, CBO estimates that net Medicaid 
spending under the bill would decrease by $13 million over the 
2019-2028 period. That amount represents a small increase in 
administrative costs and a small reduction in the number of 
controlled substances paid for by Medicaid under the proposal. 
(If enacted, H.R. 5808 also would affect spending subject to 
appropriation; CBO has not completed an estimate of that 
amount.)
    H.R. 5810, the Medicaid Health HOME Act, would allow states 
to receive six months of enhanced federal Medicaid funding for 
programs that coordinate care for people with substance use 
disorders. Based on enrollment and spending data from states 
that currently participate in Medicaid's Health Homes program, 
CBO estimates that the expansion would cost approximately $469 
million over the 2019-2028 period. The bill also would require 
states to cover all FDA-approved drugs used in medication-
assisted treatment for five years, although states could seek a 
waiver from that requirement. (Medication-assisted treatment 
combines behavioral therapy and pharmaceutical treatment for 
substance use disorders.) Under current law, states already 
cover most FDA-approved drugs used in such programs in some 
capacity, although a few exclude methadone dispensed by opioid 
treatment programs. CBO estimates that a small share of those 
states would begin to cover methadone if this bill was enacted 
at a federal cost of about $39 million over the 2019-2028 
period. In sum, CBO estimates that the enacting H.R. 5810 would 
increase direct spending by $509 million over the 2019-2028 
period.
    Legislation Primarily Affecting Medicare. The following ten 
bills would affect direct spending for the Medicare program.
    H.R. 3528, the Every Prescription Conveyed Securely Act, 
would require prescriptions for controlled substances covered 
under Medicare Part D to be transmitted electronically, 
starting on January 1, 2021. Based on CBO's analysis of 
prescription drug spending, spending for controlled substances 
is a small share of total drug spending. CBO also assumes a 
small share of those prescriptions would not be filled because 
they are not converted to an electronic format. Therefore, CBO 
expects that enacting H.R. 3528 would reduce the number of 
prescriptions filled and estimates that Medicare spending be 
reduced by $250 million over the 2019-2028 period.
    H.R. 4841, the Standardizing Electronic Prior Authorization 
for Safe Prescribing Act of 2018, would require health care 
professionals to submit prior authorization requests 
electronically, starting on January 1, 2021, for drugs covered 
under Medicare Part D. Taking into account that many 
prescribers already use electronic methods to submit such 
requests, CBO estimates that enacting H.R. 4841 would not 
significantly affect direct spending for Part D.
    H.R. 5603, the Access to Telehealth Services for Opioid Use 
Disorders Act, would permit the Secretary of HHS to lift 
current geographic and other restrictions on coverage of 
telehealth services under Medicare for treatment of substance 
use disorders or co-occurring mental health disorders. Under 
the bill, the Secretary of HHS would be directed to encourage 
other payers to coordinate payments for opioid use disorder 
treatments and to evaluate the extent to which the 
demonstration reduces hospitalizations, increases the use of 
medication-assisted treatments, and improves the health 
outcomes of individuals with opioid use disorders during and 
after the demonstration. Based on current use of Medicare 
telehealth services for treatment of substance use disorders, 
CBO estimates that expanding that coverage would increase 
direct spending by $11 million over the 2019-2028 period.
    H.R. 5605, the Advancing High Quality Treatment for Opioid 
Use Disorders in Medicare Act, would establish a five-year 
demonstration program to increase access to treatment for 
opioid use disorder. The demonstration would provide incentive 
payments and funding for care management services based on 
criteria such as patient engagement, use of evidence-based 
treatments, and treatment length and intensity. Under the bill, 
the Secretary of HHS would be directed to encourage other 
payers to coordinate payments for opioid use disorder 
treatments and to evaluate the extent to which the 
demonstration reduces hospitalizations, increases the use of 
medication-assisted treatments, and improves the health 
outcomes of individuals with opioid use disorders during and 
after the demonstration. Based on historical utilization of 
opioid use disorder treatments and projected spending on 
incentive payments and care management fees, CBO estimates that 
increased use of treatment services and the demonstration's 
incentive payments would increase direct spending by $122 
million over the 2019-2028 period.
    H.R. 5675, a bill to amend title XVIII of the Social 
Security Act to require prescription drug plan sponsors under 
the Medicare program to establish drug management programs for 
at-risk beneficiaries, would require Part D prescription drug 
plans to provide drug management programs for Medicare 
beneficiaries who are at risk for prescription drug abuse. 
(Under current law, Part D plans are permitted but not required 
to establish such programs as of 2019.) Based on an analysis of 
the number of plans currently providing those programs, CBO 
estimates that enacting H.R. 5675 would lower federal spending 
by $64 million over the 2019-2028 period by reducing the number 
of prescriptions filled and Medicare's payments for controlled 
substances.
    H.R. 5684, the Protecting Seniors From Opioid Abuse Act, 
would expand medication therapy management programs under 
Medicare Part D to include beneficiaries who are at risk for 
prescription drug abuse. Because relatively few beneficiaries 
would be affected by this bill, CBO estimates that its 
enactment would not significantly affect direct spending for 
Part D.
    H.R. 5796, the Responsible Education Achieves Care and 
Healthy Outcomes for Users' Treatment Act of 2018, would allow 
the Secretary of HHS to award grants to certain organizations 
that provide technical assistance and education to high-volume 
prescribers of opioids. The bill would appropriate $100 million 
for fiscal year 2019. Based on historical spending patterns for 
similar activities, CBO estimates that implementing H.R. 5796 
would cost $100 million over the 2019-2028 period.
    H.R. 5798, the Opioid Screening and Chronic Pain Management 
Alternatives for Seniors Act, would add an assessment of 
current opioid prescriptions and screening for opioid use 
disorder to the Welcome to Medicare Initial Preventive Physical 
Examination. Based on historical use of the examinations and 
pain management alternatives, CBO expects that enacting the 
bill would increase use of pain management services and 
estimates that direct spending would increase by $5 million 
over the 2019-2028 period.
    H.R. 5804, the Post-Surgical Injections as an Opioid 
Alternative Act, would freeze the Medicare payment rate for 
certain analgesic injections provided in ambulatory surgical 
centers (ASCs). (For injections identified by specific billing 
codes, Medicare would pay the 2016 rate, which is higher than 
the current rate, during the 2020-2024 period.) Based on 
current utilization in the ASC setting, CBO estimates that 
enacting the legislation would increase direct spending by 
about $115 million over the 2019-2028 period. (If enacted, H.R. 
5804 also would affect spending subject to appropriation; see 
Table 3.)
    H.R. 5809, the Postoperative Opioid Prevention Act of 2018, 
would create an additional payment under Medicare for nonopioid 
analgesics. Under current law, certain new drugs and devices 
may receive an additional payment--separate from the bundled 
payment for a surgical procedure--in outpatient hospital 
departments and ambulatory surgical centers. The bill would 
allow nonopioid analgesics to qualify for a five-year period of 
additional payments. Based on its assessment of current 
spending for analgesics and on the probability of new nonopioid 
analgesics coming to market, CBO estimates that H.R. 5809 would 
increase direct spending by about $180 million over the 2019-
2028 period.
    Legislation Primarily Affecting the Food and Drug 
Administration. One bill related to the FDA would affect direct 
spending.
    H.R. 5333, the Over-the-Counter Monograph Safety, 
Innovation, and Reform Act of 2018, would change the way that 
the FDA regulates the marketing of over-the-counter (OTC) 
medicines, and it would authorize that agency to grant 18 
months of exclusive market protection for certain qualifying 
OTC drugs, thus delaying the entry of other versions of the 
same qualifying OTC product. Medicaid currently provides some 
coverage for OTC medicines, but only if a medicine is the least 
costly alternative in its drug class. On the basis of 
stakeholder feedback, CBO expects that delaying the 
availability of additional OTC versions of a drug would not 
significantly affect the average net price paid by Medicaid. As 
a result, CBO estimates that enacting H.R. 5333 would have a 
negligible effect on the federal budget. (If enacted, H.R. 5333 
also would affect spending subject to appropriation; see Table 
3.)
    Legislation with Revenue Effects. Two bills would affect 
revenues. However, CBO estimates that one bill, H.R. 5228, the 
Stop Counterfeit Drugs by Regulating and Enhancing Enforcement 
Now Act, would have only a negligible effect.
    H.R. 5752, the Stop Illicit Drug Importation Act of 2018, 
would amend the Federal, Food, Drug, and Cosmetic Act (FDCA) to 
strengthen the FDA's seizure powers and enhance its authority 
to detain, refuse, seize, or destroy illegal products offered 
for import. The legislation would subject more people to 
debarment under the FDCA and thus increase the potential for 
violations, and subsequently, the assessment of civil 
penalties, which are recorded in the budget as revenues. CBO 
estimates that those collections would result in an 
insignificant increase in revenues. Because H.R. 5752 would 
prohibit the importation of drugs that are in the process of 
being scheduled, it also could reduce amounts collected in 
customs duties. CBO anticipates that the result would be a 
negligible decrease in revenues. With those results taken 
together, CBO estimates, enacting H.R. 5752 would generate an 
insignificant net increase in revenues over the 2019-2028 
period.

Spending subject to appropriation

    For this document, CBO has grouped bills with spending that 
would be subject to appropriation into four general categories:
           Bills that would have no budgetary effect,
           Bills with provisions that would authorize 
        specified amounts to be appropriated (see Table 2),
           Bills with provisions for which CBO has 
        estimated an authorization of appropriations (see Table 
        3), and
           Bills with provisions that would affect 
        spending subject to appropriation for which CBO has not 
        yet completed an estimate.
    No Budgetary Effect. CBO estimates that 6 of the 59 bills 
would have no effect on direct spending, revenues, or spending 
subject to appropriation.
    H.R. 3192, the CHIP Mental Health Parity Act, would require 
all Children's Health Insurance Program (CHIP) plans to cover 
mental health and substance abuse treatment. In addition, 
states would not be allowed to impose financial or utilization 
limits on mental health treatment that are lower than limits 
placed on physical health treatment. Based on information from 
the Centers for Medicare and Medicaid Services, CBO estimates 
that enacting the bill would have no budgetary effect because 
all CHIP enrollees are already in plans that meet those 
requirements.
    H.R. 3331, a bill to amend title XI of the Social Security 
Act to promote testing of incentive payments for behavioral 
health providers for adoption and use of certified electronic 
health record technology, would give the Center for Medicare 
and Medicaid Innovation (CMMI) explicit authorization to test a 
program offering incentive payments to behavioral health 
providers that adopt and use certified electronic health record 
technology. Because it is already clear to CMMI that it has 
that authority, CBO estimates that enacting the legislation 
would not affect federal spending.
    H.R. 5202, the Ensuring Patient Access to Substance Use 
Disorder Treatments Act of 2018, would clarify permission for 
pharmacists to deliver controlled substances to providers under 
certain circumstances. Because this provision would codify 
current practice, CBO estimates that H.R. 5202 would not affect 
direct spending or revenues during the 2019-2028 period.
    H.R. 5685, the Medicare Opioid Safety Education Act of 
2018, would require the Secretary of HHS to include information 
on opioid use, pain management, and nonopioid pain management 
treatments in future editions of Medicare & You, the program's 
handbook for beneficiaries, starting on January 1, 2019. 
Because H.R. 5685 would add information to an existing 
administrative document, CBO estimates that enacting the bill 
would have no budgetary effect.
    H.R. 5686, the Medicare Clear Health Options in Care for 
Enrollees Act of 2018, would require prescription drug plans 
that provide coverage under Medicare Part D to furnish 
information to beneficiaries about the risks of opioid use and 
the availability of alternative treatments for pain. CBO 
estimates that enacting the bill would not affect direct 
spending because the required activities would not impose 
significant administrative costs.
    H.R. 5716, the Commit to Opioid Medical Prescriber 
Accountability and Safety for Seniors Act, would require the 
Secretary of HHS on an annual basis to identify high 
prescribers of opioids and furnish them with information about 
proper prescribing methods. Because HHS already has the 
capacity to meet those requirements, CBO estimates that 
enacting that provision would not impose additional 
administrative costs on the agency.
    Specified Authorizations. Table 2 lists the ten bills that 
would authorize specified amounts to be appropriated over the 
2019-2023 period. Spending from those authorized amounts would 
be subject to appropriation.

          TABLE 2.--ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH SPECIFIED AUTHORIZATIONS
----------------------------------------------------------------------------------------------------------------
                                                                By fiscal year, in millions of dollars--
                                                      ----------------------------------------------------------
                                                        2018    2019    2020    2021    2022    2023   2019-2023
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
H.R. 4684, Ensuring Access to Quality Sober Living
 Act:
    Authorization Level..............................       0       3       0       0       0       0         3
    Estimated Outlays................................       0       1       2       *       *       *         3
H.R. 5102, Substance Use Disorder Workforce Loan
 Repayment Act of 2018:
    Authorization Level..............................       0      25      25      25      25      25       125
    Estimated Outlays................................       0       9      19      23      25      25       100
H.R. 5176, Preventing Overdoses While in Emergency
 Rooms Act of 2018:
    Authorization Level..............................       0      50       0       0       0       0        50
    Estimated Outlays................................       0      16      26       6       2       1        50
H.R. 5197, Alternatives to Opioids (ALTO) in the
 Emergency Department Act:
    Authorization Level..............................       0      10      10      10       0       0        30
    Estimated Outlays................................       0       3       8      10       7       2        30
H.R. 5261, Treatment, Education, and Community Help
 to Combat Addiction Act of 2018:
    Authorization Level..............................       0       4       4       4       4       4        20
    Estimated Outlays................................       0       1       3       4       4       4        16
H.R. 5327, Comprehensive Opioid Recovery Centers Act
 of 2018:
    Authorization Level..............................       0      10      10      10      10      10        50
    Estimated Outlays................................       0       3       8      10      10      10        41
H.R. 5329, Poison Center Network Enhancement Act of
 2018:
    Authorization Level..............................       0      30      30      30      30      30       151
    Estimated Outlays................................       0      12      25      29      29      29       125
H.R. 5353, Eliminating Opioid-Related Infectious
 Diseases Act of 2018:
    Authorization Level..............................       0      40      40      40      40      40       200
    Estimated Outlays................................       0      15      34      38      39      40       166
H.R. 5580, Surveillance and Testing of Opioids to
 Prevent Fentanyl Deaths Act of 2018:
    Authorization Level..............................      30      30      30      30      30       0       120
    Estimated Outlays................................       0      11      25      29      29      19       113
H.R. 5587, Peer Support Communities of Recovery Act:
    Authorization Level..............................       0      15      15      15      15      15        75
    Estimated Outlays................................       0       5      13      14      15      15       62
----------------------------------------------------------------------------------------------------------------
Annual amounts may not sum to totals because of rounding. * = between zero and $500,000.

    H.R. 4684, the Ensuring Access to Quality Sober Living Act, 
would direct the Secretary of HHS to develop and disseminate 
best practices for organizations that operate housing designed 
for people recovering from substance use disorders. The bill 
would authorize a total of $3 million over the 2019-2021 period 
for that purpose. Based on historical spending patterns for 
similar activities, CBO estimates that implementing H.R. 4684 
would cost $3 million over the 2019-2023 period.
    H.R. 5102, the Substance Use Disorder Workforce Loan 
Repayment Act of 2018, would establish a loan repayment program 
for mental health professionals who practice in areas with few 
mental health providers or with high rates of death from 
overdose and would authorize $25 million per year over the 
2019-2028 period for that purpose. Based on historical spending 
patterns for similar activities, CBO estimates that 
implementing H.R. 5102 would cost $100 million over the 2019-
2023 period; the remaining amounts would be spent in years 
after 2023.
    H.R. 5176, the Preventing Overdoses While in Emergency 
Rooms Act of 2018, would require the Secretary of HHS to 
develop protocols and a grant program for health care providers 
to address the needs of people who survive a drug overdose, and 
it would authorize $50 million in 2019 for that purpose. Based 
on historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5176 would cost $50 million 
over the 2019-2023 period.
    H.R. 5197, the Alternatives to Opioids (ALTO) in the 
Emergency Department Act, would direct the Secretary of HHS to 
carry out a demonstration program for hospitals and emergency 
departments to develop alternative protocols for pain 
management that limit the use of opioids and would authorize 
$10 million annually in grants for fiscal years 2019 through 
2021. Based on historical spending patterns for similar 
programs, CBO estimates that implementing H.R. 5197 would cost 
$30 million over the 2019-2023 period.
    H.R. 5261, the Treatment, Education, and Community Help to 
Combat Addiction Act of 2018,  would direct the Secretary of 
HHS to designate regional centers of excellence to improve the 
training of health professionals who treat substance use 
disorders. The bill would authorize $4 million annually for 
grants to those programs over the 2019-2023 period. Based on 
historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5261 would cost $16 million 
over the 2019-2023 period; the remaining amounts would be spent 
in years after 2023.
    H.R. 5327, the Comprehensive Opioid Recovery Centers Act of 
2018, would direct the Secretary of HHS to award grants to at 
least 10 providers that offer treatment services for people 
with opioid use disorder, and it would authorize $10 million 
per year over the 2019-2023 period for that purpose. Based on 
historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5327 would cost $41 million 
over the 2019-2023 period; the remaining amounts would be spent 
in years after 2023.
    H.R. 5329, the Poison Center Network Enhancement Act of 
2018, would reauthorize the poison control center toll-free 
number, national media campaign, and grant program under the 
Public Health Service Act. Among other actions, H.R. 5329 would 
increase the share of poison control center funding that could 
be provided by federal grants. The bill would authorize a total 
of about $30 million per year over the 2019-2023 period. Based 
on historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5329 would cost $125 million 
over the 2019-2023 period; the remaining amounts would be spent 
in years after 2023.
    H.R. 5353, the Eliminating Opioid Related Infectious 
Diseases Act of 2018, would amend Public Health Service Act by 
broadening the focus of surveillance and education programs 
from preventing and treating hepatitis C virus to preventing 
and treating infections associated with injection drug use. It 
would authorize $40 million per year over 2019-2023 period for 
that purpose. Based on historical spending patterns for similar 
activities, CBO estimates that implementing H.R. 5353 would 
cost $166 million over the 2019-2023 period; the remaining 
amounts would be spent in years after 2023.
    H.R. 5580, the Surveillance and Testing of Opioids to 
Prevent Fentanyl Deaths Act of 2018, would establish a grant 
program for public health laboratories that conduct testing for 
fentanyl and other synthetic opioids. It also would direct the 
Centers for Disease Control and Prevention to expand its drug 
surveillance program, with a particular focus on collecting 
data on fentanyl. The bill would authorize a total of $30 
million per year over the 2018-2022 period for those 
activities. Based on historical spending patterns for similar 
activities, CBO estimates that implementing H.R. 5580 would 
cost $113 million over the 2019-2023 period; the remaining 
amounts would be spent in years after 2023.
    H.R. 5587, Peer Support Communities of Recovery Act, would 
direct the Secretary of HHS to award grants to nonprofit 
organizations that support community-based, peer-delivered 
support, including technical support for the establishment of 
recovery community organizations, independent, nonprofit groups 
led by people in recovery and their families. The bill would 
authorize $15 million per year for the 2019-2023 period. Based 
on historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5587 would cost $62 million 
over the 2019-2023 period; the remaining amounts would be spent 
in years after 2023.
    Estimated Authorizations. Table 3 shows CBO's estimates of 
the appropriations that would be necessary to implement 19 of 
the bills. Spending would be subject to appropriation of those 
amounts.
    H.R. 449, the Synthetic Drug Awareness Act of 2018, would 
require the Surgeon General to report to the Congress on the 
health effects of synthetic psychoactive drugs on children 
between the ages of 12 and 18. Based on spending patterns for 
similar activities, CBO estimates that implementing H.R. 449 
would cost approximately $1 million over the 2019-2023 period.
    H.R. 4005, the Medicaid Reentry Act, would direct the 
Secretary of HHS to convene a group of stakeholders to develop 
and report to the Congress on best practices for addressing 
issues related to health care faced by those returning from 
incarceration to their communities. The bill also would require 
the Secretary to issue a letter to state Medicaid directors 
about relevant demonstration projects. Based on an analysis of 
anticipated workload, CBO estimates that implementing H.R. 4005 
would cost less than $500,000 over the 2018-2023 period.
    H.R. 4275, the Empowering Pharmacists in the Fight Against 
Opioid Abuse Act, would require the Secretary of HHS to develop 
and disseminate materials for training pharmacists, health care 
practitioners, and the public about the circumstances under 
which a pharmacist may decline to fill a prescription. Based on 
historical spending patterns for similar activities, CBO 
estimates that costs to the federal government for the 
development and distribution of those materials would not be 
significant.

          TABLE 3.--ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH ESTIMATED AUTHORIZATIONS
----------------------------------------------------------------------------------------------------------------
                                                              By fiscal year, in millions of dollars--
                                                   -------------------------------------------------------------
                                                     2018   2019     2020     2021     2022     2023   2019-2023
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
H.R. 449, Synthetic Drug Awareness Act of 2018:
    Estimated Authorization Level.................      0       *        *        *        0        0         1
    Estimated Outlays.............................      0       *        *        *        0        0         1
 
H.R. 4005, Medicaid Reentry Act:
    Estimated Authorization Level.................      *       *        0        0        0        0         *
    Estimated Outlays.............................      *       *        0        0        0        0         *
 
H.R. 4275, Empowering Pharmacists in the Fight
 Against Opioid Abuse Act:
    Estimated Authorization Level.................      0       *        *        *        *        *         *
    Estimated Outlays.............................      0       *        *        *        *        *         *
 
H.R. 5009, Jessie's Law:
    Estimated Authorization Level.................      0       *        *        *        *        *         *
    Estimated Outlays.............................      0       *        *        *        *        *         *
 
H.R. 5041, Safe Disposal of Unused Medication Act:      0       *        *        *        *        *         *
    Estimated Authorization Level.................      0       *        *        *        *        *         *
    Estimated Outlays.............................      0       *        *        *        *        *         *
 
H.R. 5272, Reinforcing Evidence-Based Standards
 Under Law in Treating Substance Abuse Act of
 2018:
    Estimated Authorization Level.................      0       1        1        1        1        1         4
    Estimated Outlays.............................      0       1        1        1        1        1         4
 
H.R. 5333, Over-the-Counter Monograph Safety,
 Innovation, and Reform Act of 2018:a
    Food and Drug Administration:
        Collections from fees:
            Estimated Authorization Level.........      0     -22      -22      -26      -35      -42      -147
            Estimated Outlays.....................      0     -22      -22      -26      -35      -42      -147
        Spending of fees:
            Estimated Authorization Level.........      0      22       22       26       35       42       147
            Estimated Outlays.....................      0       6       17       30       44       41       137
        Net effect on FDA:
            Estimated Authorization Level.........      0       0        0        0        0        0         0
            Estimated Outlays.....................      0     -17       -6        4        9        *       -10
    Government Accountability Office:
        Estimated Authorization Level.............      0       0        0        0        0        *         *
        Estimated Outlays.........................      0       0        0        0        0        *         *
    Total, H.R. 5333:
        Estimated Authorization Level.............      0       0        0        0        0        *         *
        Estimated Outlays.........................      0     -17       -6        4        9        *       -10
 
H.R. 5473, Better Pain Management Through Better
 Data Act of 2018:
    Estimated Authorization Level.................      0       *        *        *        *        0         1
    Estimated Outlays.............................      0       *        *        *        *        *         1
 
H.R. 5483, Special Registration for Telemedicine
 Clarification Act of 2018:
    Estimated Authorization Level.................      0       *        *        *        *        *         *
    Estimated Outlays.............................      0       *        *        *        *        *         *
 
H.R. 5554, Animal Drug and Animal Generic Drug
 User Fee Amendments of 2018:
    Collections from fees:
        Animal drug fees..........................      0     -30      -31      -32      -33      -34      -159
        Generic animal drug fees..................      0     -18      -19      -19      -20      -21       -97
            Total, Estimated Authorization Level..      0     -49      -50      -51      -53      -55      -257
            Total, Estimated Outlays..............      0     -49      -50      -51      -53      -55      -257
    Spending of fees:
        Animal drug fees..........................      0      30       31       32       33       34       159
        Generic animal drug fees..................      0      18       19       19       20       21        97
            Total, Estimated Authorization Level..      0      49       50       51       53       55       257
            Total, Estimated Outlays..............      0      39       47       51       52       54       243
    Net changes in fees:
        Estimated Authorization Level.............      0       0        0        0        0        0         0
        Estimated Outlays.........................      0     -10       -3        *        *        *       -14
    Other effects:
        Estimated Authorization Level.............      0       3        1        1        1        1         6
        Estimated Outlays.........................      0       2        1        1        1        1         6
    Total, H.R. 5554:
        Estimated Authorization Level.............      0       3        1        1        1        1         6
        Estimated Outlays.........................      0      -8       -2        1        *        *        -8
 
H.R. 5582, Abuse Deterrent Access Act of 2018:
    Estimated Authorization Level.................      0       0        *        0        0        0         *
    Estimated Outlays.............................      0       0        *        0        0        0         *
 
H.R. 5590, Opioid Addiction Action Plan Act:
    Estimated Authorization Level.................      *       *        *        *        *        *         2
    Estimated Outlays.............................      *       *        *        *        *        *         2
 
H.R. 5687, Securing Opioids and Unused Narcotics
 with Deliberate Disposal and Packaging Act of
 2018:
    Estimated Authorization Level.................      0       *        *        *        *        *         *
    Estimated Outlays.............................      0       *        *        *        *        *         *
 
H.R. 5715, Strengthening Partnerships to Prevent
 Opioid Abuse Act:
    Estimated Authorization Level.................      0       2        2        2        2        2         9
    Estimated Outlays.............................      0       2        2        2        2        2         9
 
H.R. 5789, a bill to require the Secretary of
 Health and Human Services to issue guidance to
 improve care for infants with neonatal abstinence
 syndrome and their mothers, and to require the
 Comptroller General of the United States to
 conduct a study on gaps in Medicaid coverage for
 pregnant and postpartum women with substance use
 disorder:
    Estimated Authorization Level.................      0       2        0        0        0        0         2
    Estimated Outlays.............................      0       2        0        0        0        0         2
 
H.R. 5795, Overdose Prevention and Patient Safety
 Act:
    Estimated Authorization Level.................      0       1        0        0        0        0         1
    Estimated Outlays.............................      0       1        0        0        0        0         1
 
H.R. 5800, Medicaid IMD ADDITIONAL INFO Act:
    Estimated Authorization Level.................      0       1        0        0        0        0         1
    Estimated Outlays.............................      0       *        *        0        0        0         1
 
H.R. 5804, Post-Surgical Injections as an Opioid
 Alternative Act:a
    Estimated Authorization Level.................      0       0        0        0        1        1         1
    Estimated Outlays.............................      0       0        0        0        1        1         1
 
H.R. 5811, a bill to amend the Federal Food, Drug,
 and Cosmetic Act with respect to postapproval
 study requirements for certain controlled
 substances, and for other purposes:
    Estimated Authorization Level.................      0       *        *        *        *        *         *
    Estimated Outlays.............................      0       *        *        *        *        *        *
----------------------------------------------------------------------------------------------------------------
Annual amounts may not sum to totals because of rounding. * = between -$500,000 and $500,000.
aThis bill also would affect mandatory spending (see Table 1).

    H.R. 5009, Jessie's Law, would require HHS, in 
collaboration with outside experts, to develop best practices 
for displaying information about opioid use disorder in a 
patient's medical record. HHS also would be required to develop 
and disseminate written materials annually to health care 
providers about what disclosures could be made while still 
complying with federal laws that govern health care privacy. 
Based on spending patterns for similar activities, CBO 
estimates that implementing H.R. 5009 would have an 
insignificant effect on spending over the 2019-2023 period.
    H.R. 5041, the Safe Disposal of Unused Medication Act, 
would require hospice programs to have written policies and 
procedures for the disposal of controlled substances after a 
patient's death. Certain licensed employees of hospice programs 
would be permitted to assist in the disposal of controlled 
substances that were lawfully dispensed. Using information from 
the Department of Justice (DOJ), CBO estimates that 
implementing the bill would cost less than $500,000 over the 
2019-2023 period.
    H.R. 5272, the Reinforcing Evidence-Based Standards Under 
Law in Treating Substance Abuse Act of 2018, would require the 
newly established National Mental Health and Substance Use 
Policy Laboratory to issue guidance to applicants for SAMHSA 
grants that support evidence-based practices. Using information 
from HHS about the historical cost of similar activities, CBO 
estimates that enacting this bill would cost approximately $4 
million over the 2019-2023 period.
    H.R. 5333, the Over-the-Counter Monograph Safety, 
Innovation, and Reform Act of 2018, would change the FDA's 
oversight of the commercial marketing of OTC medicines and 
authorize the collection and spending of fees through 2023 to 
cover the costs of expediting the FDA's administrative 
procedures for certain regulatory activities relating to OTC 
products. Under H.R. 5333, CBO estimates, the FDA would assess 
about $147 million in fees over the 2019-2023 period that could 
be collected and made available for obligation only to the 
extent and in the amounts provided in advance in appropriation 
acts. Because the FDA could spend those fees, CBO estimates 
that the estimated budget authority for collections and 
spending would offset each other exactly in each year, although 
CBO expects that spending initially would lag behind 
collections. Assuming appropriation action consistent with the 
bill, CBO estimates that implementing H.R. 5333 would reduce 
net discretionary outlays by $10 million over the 2019-2023 
period, primarily because of that lag. The bill also would 
require the Government Accountability Office to study exclusive 
market protections for certain qualifying OTC drugs authorized 
by the bill--a provision that CBO estimates would cost less 
than $500,000. (If enacted, H.R. 5333 also would affect 
mandatory spending; see Table 1.)
    H.R. 5473, the Better Pain Management Through Better Data 
Act of 2018, would require that the FDA conduct a public 
meeting and issue guidance to industry addressing data 
collection and labeling for medical products that reduce pain 
while enabling the reduction, replacement, or avoidance of oral 
opioids. Using information from the agency, CBO estimates that 
implementing H.R. 5473 would cost about $1 million over the 
2019-2023 period.
    H.R. 5483, the Special Registration for Telemedicine 
Clarification Act of 2018, would direct DOJ, within one year of 
the bill's enactment, to issue regulations concerning the 
practice of telemedicine (for remote diagnosis and treatment of 
patients). Using information from DOJ, CBO estimates that 
implementing the bill would cost less than $500,000 over the 
2019-2023 period.
    H.R. 5554, the Animal Drug and Animal Generic Drug User Fee 
Amendments of 2018, would authorize the FDA to collect and 
spend fees to cover the cost of expedited approval for the 
development and marketing of certain drugs for use in animals. 
The legislation would extend through fiscal year 2023, and make 
several changes to, the FDA's existing approval processes and 
fee programs for brand-name and generic veterinary drugs, which 
expire at the end of fiscal year 2018. CBO estimates that 
implementing H.R. 5554 would reduce net discretionary outlays 
by $8 million over the 2019-2023 period, primarily because the 
spending of fees lags somewhat behind their collection.
    Fees authorized under the bill would supplement funds 
appropriated to cover the FDA's cost of reviewing certain 
applications and investigational submissions for brand-name and 
generic drugs for use in animals. Those fees could be collected 
and made available for obligation only to the extent and in the 
amounts provided in advance in appropriation acts. Under H.R. 
5554, CBO estimates, the FDA would assess about $257 million in 
fees over the 2019-2023 period. Because the FDA could spend 
those funds, CBO estimates that budget authority for 
collections and spending would offset each other exactly in 
each year. CBO estimates that the delay between collecting and 
spending fees under the reauthorized programs would reduce net 
discretionary outlays by $14 million over the 2019-2023 period, 
assuming appropriation actions consistent with the bill.
    Enacting H.R. 5554 would increase the FDA's workload 
because the legislation would expand eligibility for 
conditional approval for certain drugs. The agency's 
administrative costs also would increase because of regulatory 
activities required by a provision concerning petitions for 
additives intended for use in animal food. H.R. 5554 also would 
require the FDA to publish guidance or produce regulations on a 
range of topics, transmit a report to the Congress, and hold 
public meetings. CBO expects that the costs associated with 
those activities would not be covered by fees, and it estimates 
that implementing such provisions would cost $6 million over 
the 2019-2023 period.
    H.R. 5582, the Abuse Deterrent Access Act of 2018, would 
require the Secretary of HHS to report to the Congress on 
existing barriers to access to ``abuse-deterrent opioid 
formulations'' by Medicare Part C and D beneficiaries. Such 
formulations make the drugs more difficult to dissolve for 
injection, for example, and thus can impede their abuse. 
Assuming the availability of appropriated funds and based on 
historical spending patterns for similar activities, CBO 
estimates that implementing the legislation would cost less 
than $500,000 over the 2019-2023 period.
    H.R. 5590, the Opioid Addiction Action Plan Act, would 
require the Secretary of HHS to develop an action plan by 
January 1, 2019, for increasing access to medication-assisted 
treatment among Medicare and Medicaid enrollees. The bill also 
would require HHS to convene a stakeholder meeting and issue a 
request for information within three months of enactment, and 
to submit a report to the Congress by June 1, 2019. Based on 
historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5590 would cost approximately 
$2 million over the 2019-2023 period.
    H.R. 5687, the Securing Opioids and Unused Narcotics with 
Deliberate Disposal and Packaging Act of 2018, would permit the 
FDA to require certain packaging and disposal technologies, 
controls, or measures to mitigate the risk of abuse and misuse 
of drugs. Based on information from the FDA, CBO estimates that 
implementing H.R. 5687 would not significantly affect spending 
over the 2019-2023 period. This bill would also require that 
the GAO study the effectiveness and use of packaging 
technologies for controlled substances--a provision that CBO 
estimates would cost less than $500,000.
    H.R. 5715, the Strengthening Partnerships to Prevent Opioid 
Abuse Act, would require the Secretary of HHS to establish a 
secure Internet portal to allow HHS, Medicare Advantage plans, 
and Medicare Part D plans to exchange information about fraud, 
waste, and abuse among providers and suppliers no later than 
two years after enactment. H.R. 5715 also would require 
organizations with Medicare Advantage contracts to submit 
information on investigations related to providers suspected of 
prescribing large volumes of opioids through a process 
established by the Secretary no later than January 2021. Based 
on historical spending patterns for similar activities, CBO 
estimates that implementing H.R. 5715 would cost approximately 
$9 million over the 2019-2023 period.
    H.R. 5789, a bill to require the Secretary of Health and 
Human Services to issue guidance to improve care for infants 
with neonatal abstinence syndrome and their mothers, and to 
require the Comptroller General of the United States to conduct 
a study on gaps in Medicaid coverage for pregnant and 
postpartum women with substance use disorder, would direct the 
Secretary of HHS to issue guidance to states on best practices 
under Medicaid and CHIP for treating infants with neonatal 
abstinence syndrome. H.R. 5789 also would direct the Government 
Accountability Office to study Medicaid coverage for pregnant 
and postpartum women with substance use disorders. Based on 
information from HHS and historical spending patterns for 
similar activities, CBO estimates that enacting H.R. 5789 would 
cost approximately $2 million over the 2019-2023 period.
    H.R. 5795, the Overdose Prevention and Patient Safety Act, 
would amend the Public Health Service Act so that requirements 
pertaining to the confidentiality and disclosure of medical 
records relating to substance use disorders align with the 
provisions of the Health Insurance Portability and 
Accountability Act of 1996. The bill would require the Office 
of the Secretary of HHS to issue regulations prohibiting 
discrimination based on data disclosed from such medical 
records, to issue regulations requiring covered entities to 
provide written notice of privacy practices, and to develop 
model training programs and materials for health care providers 
and patients and their families. Based on spending patterns for 
similar activities, CBO estimates that implementing H.R. 5795 
would cost approximately $1 million over the 2019-2023 period.
    H.R. 5800, Medicaid IMD ADDITIONAL INFO Act, would direct 
the Medicaid and CHIP Payment and Access Commission to study 
institutions for mental diseases in a representative sample of 
states. Based on information from the commission about the cost 
of similar work, CBO estimates that implementing H.R. 5800 
would cost about $1 million over the 2019-2023 period.
    H.R. 5804, the Post-Surgical Injections as an Opioid 
Alternative Act, would freeze the Medicare payment rate for 
certain analgesic injections provided in ambulatory surgical 
centers. The bill also would mandate two studies of Medicare 
coding and payments arising from enactment of this legislation. 
Based on the cost of similar activities, CBO estimates that 
those reports would cost $1 million over the 2019-2023 period. 
(If enacted, H.R. 5804 also would affect mandatory spending; 
see Table 1.)
    H.R. 5811, a bill to amend the Federal Food, Drug, and 
Cosmetic Act with respect to postapproval study requirements 
for certain controlled substances, and for other purposes, 
would allow the FDA to require that pharmaceutical 
manufacturers study certain drugs after they are approved to 
assess any potential reduction in those drugs' effectiveness 
for the conditions of use prescribed, recommended, or suggested 
in labeling. CBO anticipates that implementing H.R. 5811 would 
not significantly affect the FDA's costs over the 2019-2023 
period.
    Other Authorizations. The following nine bills would 
increase authorization levels, but CBO has not completed 
estimates of amounts. All authorizations would be subject to 
future appropriation action.
           H.R. 4284, Indexing Narcotics, Fentanyl, and 
        Opioids Act of 2017
           H.R. 5002, Advancing Cutting Edge Research 
        Act
           H.R. 5228, Stop Counterfeit Drugs by 
        Regulating and Enhancing Enforcement Now Act (see Table 
        1 for an estimate of the revenue effects of H.R. 5228)
           H.R. 5752, Stop Illicit Drug Importation Act 
        of 2018 (see Table 1 for an estimate of the revenue 
        effects of H.R. 5752)
           H.R. 5799, Medicaid DRUG Improvement Act 
        (see Table 1 for an estimate of the direct spending 
        effects of H.R. 5799)
           H.R. 5801, Medicaid Providers and 
        Pharmacists Are Required to Note Experiences in Record 
        Systems to Help In-Need Patients (PARTNERSHIP) Act (see 
        Table 1 for an estimate of the direct spending effects 
        of H.R. 5801)
           H.R. 5806, 21st Century Tools for Pain and 
        Addiction Treatments Act
           H.R. 5808, Medicaid Pharmaceutical Home Act 
        of 2018 (see Table 1 for an estimate of the direct 
        spending effects of H.R. 5808)
           H.R. 5812, Creating Opportunities that 
        Necessitate New and Enhanced Connections That Improve 
        Opioid Navigation Strategies Act (CONNECTIONS) Act
    Pay-As-You-Go considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. Twenty-two of the bills discussed in this document 
contain direct spending or revenues and are subject to pay-as-
you-go procedures. Details about the amount of direct spending 
and revenues in those bills can be found in Table 1.
    Increase in long-term direct spending and deficits: CBO 
estimates that enacting H.R. 4998, the Health Insurance for 
Former Foster Youth Act, would increase net direct spending by 
more than $2.5 billion and on-budget deficits by more than $5 
billion in at least one of the four consecutive 10-year periods 
beginning in 2029.
    CBO estimates that none of the remaining 58 bills included 
in this estimate would increase net direct spending by more 
than $2.5 billion or on-budget deficits by more than $5 billion 
in any of the four consecutive 10-year periods beginning in 
2029.
    Mandates: One of the 59 bills included in this document, 
H.R. 5795, would impose both intergovernmental and private-
sector mandates as defined in UMRA. CBO estimates that the 
costs of that bill's mandates on public and private entities 
would fall below UMRA's thresholds ($80 million and $160 
million, respectively, for public- and private-sector entities 
in 2018, adjusted annually for inflation).
    In addition, five bills would impose private-sector 
mandates as defined in UMRA. CBO estimates that the costs of 
the mandates in three of those bills (H.R. 5333, H.R. 5554, and 
H.R. 5811) would fall below the UMRA threshold. Because CBO 
does not know how federal agencies would implement new 
authority granted in the other two of those five bills, H.R. 
5228 and 5687, CBO cannot determine whether the costs of their 
mandates would exceed the threshold.
    For large entitlement grant programs, including Medicaid 
and CHIP, UMRA defines an increase in the stringency of 
conditions on states or localities as an intergovernmental 
mandate if the affected governments lack authority to offset 
those costs while continuing to provide required services. 
Because states possess significant flexibility to alter their 
responsibilities within Medicaid and CHIP, the requirements 
imposed by various bills in the markup on state administration 
of those programs would not constitute mandates as defined in 
UMRA.

Mandates Affecting Public and Private Entities

    H.R. 5795, the Overdose Prevention and Patient Safety Act, 
would impose intergovernmental and private-sector mandates by 
requiring entities that provide treatment for substance use 
disorders to notify patients of their privacy rights and also 
to notify patients in the event that the confidentiality of 
their records is breached. In certain circumstances, H.R. 5795 
also would prohibit public and private entities from denying 
entry to treatment on the basis of information in patient 
health records. Those requirements would either supplant or 
narrowly expand responsibilities under existing law, and 
compliance with them would not impose significant additional 
costs. CBO estimates that the costs of the mandates would fall 
below the annual thresholds established in UMRA.

Mandates Affecting Private Entities

    Five bills included in this document would impose private-
sector mandates:
    H.R. 5228, the Stop Counterfeit Drugs by Regulating and 
Enhancing Enforcement Now Act, would require drug distributors 
to cease distributing any drug that the Secretary of HHS 
determines might present an imminent or substantial hazard to 
public health. CBO cannot determine what drugs could be subject 
to such an order nor can it determine how private entities 
would respond. Consequently, CBO cannot determine whether the 
aggregate cost of the mandate would exceed the annual threshold 
for private-sector mandates.
    H.R. 5333, the Over-the-Counter Monograph Safety, 
Innovation, and Reform Act of 2018, would require developers 
and manufacturers of OTC drugs to pay certain fees to the FDA. 
CBO estimates that about $30 million would be collected each 
year, on average, for a total of $147 million over the 2019-
2023 period. Those amounts would not exceed the annual 
threshold for private-sector mandates in any year during that 
period.
    H.R. 5554, the Animal Drug and Animal Generic Drug User Fee 
Amendments of 2018, would require developers and manufacturers 
of brand-name and generic veterinary drugs to pay application, 
product, establishment, and sponsor fees to the FDA. CBO 
estimates that about $51 million would be collected annually, 
on average, for a total of $257 million over the 2019-2023 
period. Those amounts would not exceed the annual threshold for 
private-sector mandates in any year during that period.
    H.R. 5687, the Securing Opioids and Unused Narcotics with 
Deliberate Disposal and Packaging Act of 2018, would permit the 
Secretary of HHS to require drug developers and manufacturers 
to implement new packaging and disposal technology for certain 
drugs. Based on information from the agency, CBO expects that 
the Secretary would use the new regulatory authority provided 
in the bill; however, it is uncertain how or when those 
requirements would be implemented. Consequently, CBO cannot 
determine whether the aggregate cost of the mandate would 
exceed the annual threshold for private entities.
    H.R. 5811, a bill to amend the Federal Food, Drug, and 
Cosmetic Act with respect to postapproval study requirements 
for certain controlled substances, and for other purposes, 
would expand an existing mandate that requires drug developers 
to conduct postapproval studies or clinical trials for certain 
drugs. Under current law, in certain instances, the FDA can 
require studies or clinical trials after a drug has been 
approved. H.R. 5811 would permit the FDA to use that authority 
if the reduction in a drug's effectiveness meant that its 
benefits no longer outweighed its costs. CBO estimates that the 
incremental cost of the mandate would fall below the annual 
threshold established in UMRA because of the small number of 
drugs affected and the narrow expansion of the authority that 
exists under current law.
    None of the remaining 53 bills included in this document 
would impose an intergovernmental or private-sector mandate.
    Previous CBO estimate: On June 6, 2018, CBO issued an 
estimate for seven opioid-related bills ordered reported by the 
House Committee on Ways and Means on May 16, 2018. Two of those 
bills contain provisions that are identical or similar to the 
legislation ordered reported by the Committee on Energy and 
Commerce, and for those provisions, CBO's estimates are the 
same.
    In particular, five bills listed in this estimate contain 
provisions that are identical or similar to those in several 
sections of H.R. 5773, the Preventing Addiction for Susceptible 
Seniors Act of 2018:
       H.R. 5675, which would require prescription drug 
plans to implement drug management programs, is identical to 
section 2 of H.R. 5773.
       H.R. 4841, regarding electronic prior 
authorization for prescriptions under Medicare's Part D, is 
similar to section 3 of H.R. 5773.
       H.R. 5715, which would mandate the creation of a 
new Internet portal to allow various stakeholders to exchange 
information, is identical to section 4 of H.R. 5773.
       H.R. 5684, which would expand medication therapy 
management, is the same as section 5 of H.R. 5773.
       H.R. 5716, regarding prescriber notification, is 
identical to section 6 of H.R. 5773.
    In addition, in this estimate, a provision related to 
Medicare beneficiary education in H.R. 5686, the Medicare Clear 
Health Options in Care for Enrollees Act of 2018, is the same 
as a provision in section 2 of H.R. 5775, the Providing 
Reliable Options for Patients and Educational Resources Act of 
2018, in CBO's estimate for the Committee on Ways and Means.
    Estimate prepared by: Federal Costs: Rebecca Yip (Centers 
for Disease Control and Prevention), Mark Grabowicz (Drug 
Enforcement Agency), Julia Christensen, Ellen Werble (Food and 
Drug Administration), Emily King, Andrea Noda, Lisa Ramirez-
Branum, Robert Stewart (Medicaid and Children's Health 
Insurance Program), Philippa Haven, Lara Robillard, Colin Yee, 
Rebecca Yip (Medicare), Philippa Haven (National Institutes of 
Health), Alice Burns, Andrea Noda (Office of the Secretary of 
the Department of Health and Human Services), Philippa Haven, 
Lori Housman, Emily King (Substance Abuse and Mental Health 
Services Administration, Health Resources and Services 
Administration); Federal Revenues: Jacob Fabian, Peter Huether, 
and Cecilia Pastrone; Fact Checking: Zachary Byrum and Kate 
Kelly; Mandates: Andrew Laughlin.
    Estimate reviewed by: Tom Bradley, Chief Health Systems and 
Medicare Cost Estimates Unit; Chad M. Chirico, Chief Low-Income 
Health Programs and Prescription Drugs Cost Estimates Unit; 
Sarah Masi, Special Assistant for Health; Susan Willie, Chief, 
Mandates Unit; Leo Lex, Deputy Assistant Director for Budget 
Analysis; Theresa A. Gullo, Assistant Director for Budget 
Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

         Statement of General Performance Goals and Objectives

    Pursuant to clause 3(c)(4) of rule XIII, the general 
performance goal or objective of this legislation is to require 
comprehensive mental health and substance use disorder services 
as a mandatory benefit under the CHIP program for pregnant 
women and children.

                    Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII, no provision of 
H.R. 3192 is known to be duplicative of another Federal 
program, including any program that was included in a report to 
Congress pursuant to section 21 of Public Law 111-139 or the 
most recent Catalog of Federal Domestic Assistance.

                        Committee Cost Estimate

    Pursuant to clause 3(d)(1) of rule XIII, the Committee 
adopts as its own the cost estimate prepared by the Director of 
the Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974.

       Earmark, Limited Tax Benefits, and Limited Tariff Benefits

    Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the 
Committee finds that H.R. 3192 contains no earmarks, limited 
tax benefits, or limited tariff benefits.

                  Disclosure of Directed Rule Makings

    Pursuant to section 3(i) of H. Res. 5, the Committee finds 
that H.R. 3192 contains no directed rule makings.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 provides that the Act may be cited as the ``CHIP 
Mental Health Parity Act.''

Section 2. Ensuring access to mental health services for children under 
        the Children's Health Insurance Program

    Section 2 amends Section 2103(c)(1) of the Social Security 
Act to add mental health services and substance use disorder 
services (including behavioral health treatment) to the list of 
services that must be covered under separate CHIP programs. The 
provision would require mental health services to be delivered 
in a culturally and linguistically appropriate manner and to 
include services necessary to prevent, diagnose, and treat a 
broad range of mental health symptoms and disorders, including 
substance use disorders.
    Section 2 also requires state child health plans to include 
a description of the methods used to monitor access to mental 
health services and substance use disorder services (including 
behavioral health treatment) under separate CHIP programs.
    Section 2 requires separate CHIP programs to ensure the 
financial requirements and treatment limitations applicable to 
mental health services and substance use disorder services 
(including behavioral health treatment) comply with mental 
health parity requirements in the same manner as group health 
plans.
    If, under a state child health plan (or waiver of such 
plan) for a separate CHIP program, state legislation would be 
needed in order for the state to meet a specific statutory 
requirement under H.R. 3192, then the requirement would be 
deemed to take effect on the first day of the first calendar 
quarter beginning after the close of the first regular session 
of the state legislature beginning after enactment.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

                          SOCIAL SECURITY ACT




           *       *       *       *       *       *       *
TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM

           *       *       *       *       *       *       *



SEC. 2102. GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; 
                    OUTREACH.

  (a) General Background and Description.--A State child health 
plan shall include a description, consistent with the 
requirements of this title, of--
          (1) the extent to which, and manner in which, 
        children in the State, including targeted low-income 
        children and other classes of children classified by 
        income and other relevant factors, currently have 
        creditable health coverage (as defined in section 
        2110(c)(2));
          (2) current State efforts to provide or obtain 
        creditable health coverage for uncovered children, 
        including the steps the State is taking to identify and 
        enroll all uncovered children who are eligible to 
        participate in public health insurance programs and 
        health insurance programs that involve public-private 
        partnerships;
          (3) how the plan is designed to be coordinated with 
        such efforts to increase coverage of children under 
        creditable health coverage;
          (4) the child health assistance provided under the 
        plan for targeted low-income children, including the 
        proposed methods of delivery, and utilization control 
        systems;
          (5) eligibility standards consistent with subsection 
        (b);
          (6) outreach activities consistent with subsection 
        (c); and
          (7) methods (including monitoring) used--
                  (A) to assure the quality and appropriateness 
                of care, particularly with respect to well-baby 
                care, well-child care, and immunizations 
                provided under the plan;
                  (B) to assure access to covered services, 
                including emergency services and services 
                described in [section 2103(c)(5)] paragraphs 
                (5) and (6) of section 2103(c); and
                  (C) to ensure that the State agency involved 
                is in compliance with subparagraphs (A), (B), 
                and (C) of section 1128K(b)(2).
  (b) General Description of Eligibility Standards and 
Methodology.--
          (1) Eligibility standards.--
                  (A) In general.--The plan shall include a 
                description of the standards used to determine 
                the eligibility of targeted low-income children 
                for child health assistance under the plan. 
                Such standards may include (to the extent 
                consistent with this title) those relating to 
                the geographic areas to be served by the plan, 
                age, income and resources (including any 
                standards relating to spenddowns and 
                disposition of resources), residency, 
                disability status (so long as any standard 
                relating to such status does not restrict 
                eligibility), access to or coverage under other 
                health coverage, and duration of eligibility. 
                Such standards may not discriminate on the 
                basis of diagnosis.
                  (B) Limitations on eligibility standards.--
                Such eligibility standards--
                          (i) shall, within any defined group 
                        of covered targeted low-income 
                        children, not cover such children with 
                        higher family income without covering 
                        children with a lower family income;
                          (ii) may not deny eligibility based 
                        on a child having a preexisting medical 
                        condition;
                          (iii) may not apply a waiting period 
                        (including a waiting period to carry 
                        out paragraph (3)(C)) in the case of a 
                        targeted low-income pregnant woman 
                        provided pregnancy-related assistance 
                        under section 2112;
                          (iv) at State option, may not apply a 
                        waiting period in the case of a child 
                        provided dental-only supplemental 
                        coverage under section 2110(b)(5); and
                          (v) shall, beginning January 1, 2014, 
                        use modified adjusted gross income and 
                        household income (as defined in section 
                        36B(d)(2) of the Internal Revenue Code 
                        of 1986) to determine eligibility for 
                        child health assistance under the State 
                        child health plan or under any waiver 
                        of such plan and for any other purpose 
                        applicable under the plan or waiver for 
                        which a determination of income is 
                        required, including with respect to the 
                        imposition of premiums and cost-
                        sharing, consistent with section 
                        1902(e)(14).
          (2) Methodology.--The plan shall include a 
        description of methods of establishing and continuing 
        eligibility and enrollment.
          (3) Eligibility screening; coordination with other 
        health coverage programs.--The plan shall include a 
        description of procedures to be used to ensure--
                  (A) through both intake and followup 
                screening, that only targeted low-income 
                children are furnished child health assistance 
                under the State child health plan;
                  (B) that children found through the screening 
                to be eligible for medical assistance under the 
                State medicaid plan under title XIX are 
                enrolled for such assistance under such plan;
                  (C) that the insurance provided under the 
                State child health plan does not substitute for 
                coverage under group health plans;
                  (D) the provision of child health assistance 
                to targeted low-income children in the State 
                who are Indians (as defined in section 4(c) of 
                the Indian Health Care Improvement Act, 25 
                U.S.C. 1603(c)); and
                  (E) coordination with other public and 
                private programs providing creditable coverage 
                for low-income children.
          (4) Reduction of administrative barriers to 
        enrollment.--
                  (A) In general.--Subject to subparagraph (B), 
                the plan shall include a description of the 
                procedures used to reduce administrative 
                barriers to the enrollment of children and 
                pregnant women who are eligible for medical 
                assistance under title XIX or for child health 
                assistance or health benefits coverage under 
                this title. Such procedures shall be 
                established and revised as often as the State 
                determines appropriate to take into account the 
                most recent information available to the State 
                identifying such barriers.
                  (B) Deemed compliance if joint application 
                and renewal process that permits application 
                other than in person.--A State shall be deemed 
                to comply with subparagraph (A) if the State's 
                application and renewal forms and supplemental 
                forms (if any) and information verification 
                process is the same for purposes of 
                establishing and renewing eligibility for 
                children and pregnant women for medical 
                assistance under title XIX and child health 
                assistance under this title, and such process 
                does not require an application to be made in 
                person or a face-to-face interview.
          (5) Nonentitlement.--Nothing in this title shall be 
        construed as providing an individual with an 
        entitlement to child health assistance under a State 
        child health plan.
  (c) Outreach and Coordination.--A State child health plan 
shall include a description of the procedures to be used by the 
State to accomplish the following:
          (1) Outreach.--Outreach (through community health 
        workers and others) to families of children likely to 
        be eligible for child health assistance under the plan 
        or under other public or private health coverage 
        programs to inform these families of the availability 
        of, and to assist them in enrolling their children in, 
        such a program.
          (2) Coordination with other health insurance 
        programs.--Coordination of the administration of the 
        State program under this title with other public and 
        private health insurance programs.
          (3) Premium assistance subsidies.--In the case of a 
        State that provides for premium assistance subsidies 
        under the State child health plan in accordance with 
        paragraph (2)(B), (3), or (10) of section 2105(c), or a 
        waiver approved under section 1115, outreach, 
        education, and enrollment assistance for families of 
        children likely to be eligible for such subsidies, to 
        inform such families of the availability of, and to 
        assist them in enrolling their children in, such 
        subsidies, and for employers likely to provide coverage 
        that is eligible for such subsidies, including the 
        specific, significant resources the State intends to 
        apply to educate employers about the availability of 
        premium assistance subsidies under the State child 
        health plan.

SEC. 2103. COVERAGE REQUIREMENTS FOR CHILDREN'S HEALTH INSURANCE.

  (a) Required Scope of Health Insurance Coverage.--The child 
health assistance provided to a targeted low-income child under 
the plan in the form described in paragraph (1) of section 
2101(a) shall consist, consistent with [paragraphs (5), (6), 
and (7)] paragraphs (5), (6), (7), and (8) of subsection (c), 
of any of the following:
          (1) Benchmark coverage.--Health benefits coverage 
        that is at least equivalent to the benefits coverage in 
        a benchmark benefit package described in subsection 
        (b).
          (2) Benchmark-equivalent coverage.--Health benefits 
        coverage that meets the following requirements:
                  (A) Inclusion of basic services.--The 
                coverage includes benefits for items and 
                services within each of the categories of basic 
                services described in subsection (c)(1).
                  (B) Aggregate actuarial value equivalent to 
                benchmark package.--The coverage has an 
                aggregate actuarial value that is at least 
                actuarially equivalent to one of the benchmark 
                benefit packages.
                  (C) Substantial actuarial value for 
                additional services included in benchmark 
                package.--With respect to each of the 
                categories of additional services described in 
                subsection (c)(2) for which coverage is 
                provided under the benchmark benefit package 
                used under subparagraph (B), the coverage has 
                an actuarial value that is equal to at least 75 
                percent of the actuarial value of the coverage 
                of that category of services in such package.
          (3) Existing comprehensive state-based coverage.--
        Health benefits coverage under an existing 
        comprehensive State-based program, described in 
        subsection (d)(1).
          (4) Secretary-approved coverage.--Any other health 
        benefits coverage that the Secretary determines, upon 
        application by a State, provides appropriate coverage 
        for the population of targeted low-income children 
        proposed to be provided such coverage.
  (b) Benchmark Benefit Packages.--The benchmark benefit 
packages are as follows:
          (1) FEHBP-equivalent children's health insurance 
        coverage.--The standard Blue Cross/Blue Shield 
        preferred provider option service benefit plan, 
        described in and offered under section 8903(1) of title 
        5, United States Code.
          (2) State employee coverage.--A health benefits 
        coverage plan that is offered and generally available 
        to State employees in the State involved.
          (3) Coverage offered through hmo.--The health 
        insurance coverage plan that--
                  (A) is offered by a health maintenance 
                organization (as defined in section 2791(b)(3) 
                of the Public Health Service Act), and
                  (B) has the largest insured commercial, non-
                medicaid enrollment of covered lives of such 
                coverage plans offered by such a health 
                maintenance organization in the State involved.
  (c) Categories of Services; Determination of Actuarial Value 
of Coverage.--
          (1) Categories of basic services.--For purposes of 
        this section, the categories of basic services 
        described in this paragraph are as follows:
                  (A) Inpatient and outpatient hospital 
                services.
                  (B) Physicians' surgical and medical 
                services.
                  (C) Laboratory and x-ray services.
                  (D) Well-baby and well-child care, including 
                age-appropriate immunizations.
                  (E) Mental health and substance use disorder 
                services (as defined in paragraph (5)).
          (2) Categories of additional services.--For purposes 
        of this section, the categories of additional services 
        described in this paragraph are as follows:
                  (A) Coverage of prescription drugs.
                  (B) Vision services.
                  (C) Hearing services.
          (3) Treatment of other categories.--Nothing in this 
        subsection shall be construed as preventing a State 
        child health plan from providing coverage of benefits 
        that are not within a category of services described in 
        paragraph (1) or (2).
          (4) Determination of actuarial value.--The actuarial 
        value of coverage of benchmark benefit packages, 
        coverage offered under the State child health plan, and 
        coverage of any categories of additional services under 
        benchmark benefit packages and under coverage offered 
        by such a plan, shall be set forth in an actuarial 
        opinion in an actuarial report that has been prepared--
                  (A) by an individual who is a member of the 
                American Academy of Actuaries;
                  (B) using generally accepted actuarial 
                principles and methodologies;
                  (C) using a standardized set of utilization 
                and price factors;
                  (D) using a standardized population that is 
                representative of privately insured children of 
                the age of children who are expected to be 
                covered under the State child health plan;
                  (E) applying the same principles and factors 
                in comparing the value of different coverage 
                (or categories of services);
                  (F) without taking into account any 
                differences in coverage based on the method of 
                delivery or means of cost control or 
                utilization used; and
                  (G) taking into account the ability of a 
                State to reduce benefits by taking into account 
                the increase in actuarial value of benefits 
                coverage offered under the State child health 
                plan that results from the limitations on cost 
                sharing under such coverage.
        The actuary preparing the opinion shall select and 
        specify in the memorandum the standardized set and 
        population to be used under subparagraphs (C) and (D).
          (5) Mental health and substance use disorder 
        services.--In the case of a State that provides child 
        health assistance for targeted low-income children or 
        targeted low-income pregnant women (as defined in 
        section 2112(d)) in the form of providing any health 
        benefits coverage described in subsection (a), such 
        child health assistance shall--
                  (A) include coverage of mental health 
                services (including behavioral health 
                treatment) necessary to prevent, diagnose, and 
                treat a broad range of mental health symptoms 
                and disorders, including substance use 
                disorders; and
                  (B) be delivered in a culturally and 
                linguistically appropriate manner.
          [(5)] (6) Dental benefits.--
                  (A) In general.--The child health assistance 
                provided to a targeted low-income child shall 
                include coverage of dental services necessary 
                to prevent disease and promote oral health, 
                restore oral structures to health and function, 
                and treat emergency conditions.
                  (B) Permitting use of dental benchmark plans 
                by certain states.--A State may elect to meet 
                the requirement of subparagraph (A) through 
                dental coverage that is equivalent to a 
                benchmark dental benefit package described in 
                subparagraph (C).
                  (C) Benchmark dental benefit packages.--The 
                benchmark dental benefit packages are as 
                follows:
                          (i) FEHBP children's dental 
                        coverage.--A dental benefits plan under 
                        chapter 89A of title 5, United States 
                        Code, that has been selected most 
                        frequently by employees seeking 
                        dependent coverage, among such plans 
                        that provide such dependent coverage, 
                        in either of the previous 2 plan years.
                          (ii) State employee dependent dental 
                        coverage.--A dental benefits plan that 
                        is offered and generally available to 
                        State employees in the State involved 
                        and that has been selected most 
                        frequently by employees seeking 
                        dependent coverage, among such plans 
                        that provide such dependent coverage, 
                        in either of the previous 2 plan years.
                          (iii) Coverage offered through 
                        commercial dental plan.--A dental 
                        benefits plan that has the largest 
                        insured commercial, non-medicaid 
                        enrollment of dependent covered lives 
                        of such plans that is offered in the 
                        State involved.
          [(6)] (7) Mental health services parity.--
                  [(A) In general.--In the case of a State 
                child health plan that provides both medical 
                and surgical benefits and mental health or 
                substance use disorder benefits, such plan 
                shall ensure that the financial requirements 
                and treatment limitations applicable to such 
                mental health or substance use disorder 
                benefits comply with the requirements of 
                section 2705(a) of the Public Health Service 
                Act in the same manner as such requirements 
                apply to a group health plan.]
                  (A) In general.--A State child health plan 
                shall ensure that the financial requirements 
                and treatment limitations applicable to mental 
                health and substance use disorder services (as 
                described in paragraph (5)) provided under such 
                plan comply with the requirements of section 
                2726(a) of the Public Health Service Act in the 
                same manner as such requirements or limitations 
                apply to a group health plan under such 
                section.
                  (B) Deemed compliance.--To the extent that a 
                State child health plan includes coverage with 
                respect to an individual described in section 
                1905(a)(4)(B) and covered under the State plan 
                under section 1902(a)(10)(A) of the services 
                described in section 1905(a)(4)(B) (relating to 
                early and periodic screening, diagnostic, and 
                treatment services defined in section 1905(r)) 
                and provided in accordance with section 
                1902(a)(43), such plan shall be deemed to 
                satisfy the requirements of subparagraph (A).
          [(7)] (8) Construction on prohibited coverage.--
        Nothing in this section shall be construed as requiring 
        any health benefits coverage offered under the plan to 
        provide coverage for items or services for which 
        payment is prohibited under this title, notwithstanding 
        that any benchmark benefit package includes coverage 
        for such an item or service.
          [(8)] (9) Availability of coverage for items and 
        services furnished through school-based health 
        centers.--Nothing in this title shall be construed as 
        limiting a State's ability to provide child health 
        assistance for covered items and services that are 
        furnished through school-based health centers (as 
        defined in section 2110(c)(9)).
  (d) Description of Existing Comprehensive State-Based 
Coverage.--
          (1) In general.--A program described in this 
        paragraph is a child health coverage program that--
                  (A) includes coverage of a range of benefits;
                  (B) is administered or overseen by the State 
                and receives funds from the State;
                  (C) is offered in New York, Florida, or 
                Pennsylvania; and
                  (D) was offered as of the date of the 
                enactment of this title.
          (2) Modifications.--A State may modify a program 
        described in paragraph (1) from time to time so long as 
        it continues to meet the requirement of subparagraph 
        (A) and does not reduce the actuarial value of the 
        coverage under the program below the lower of--
                  (A) the actuarial value of the coverage under 
                the program as of the date of the enactment of 
                this title, or
                  (B) the actuarial value described in 
                subsection (a)(2)(B),
        evaluated as of the time of the modification.
  (e) Cost-Sharing.--
          (1) Description; general conditions.--
                  (A) Description.--A State child health plan 
                shall include a description, consistent with 
                this subsection, of the amount (if any) of 
                premiums, deductibles, coinsurance, and other 
                cost sharing imposed. Any such charges shall be 
                imposed pursuant to a public schedule.
                  (B) Protection for lower income children.--
                The State child health plan may only vary 
                premiums, deductibles, coinsurance, and other 
                cost sharing based on the family income of 
                targeted low-income children in a manner that 
                does not favor children from families with 
                higher income over children from families with 
                lower income.
          (2) No cost sharing on benefits for preventive 
        services or pregnancy-related assistance.--The State 
        child health plan may not impose deductibles, 
        coinsurance, or other cost sharing with respect to 
        benefits for services within the category of services 
        described in subsection (c)(1)(D) or for pregnancy-
        related assistance.
          (3) Limitations on premiums and cost-sharing.--
                  (A) Children in families with income below 
                150 percent of poverty line.--In the case of a 
                targeted low-income child whose family income 
                is at or below 150 percent of the poverty line, 
                the State child health plan may not impose--
                          (i) an enrollment fee, premium, or 
                        similar charge that exceeds the maximum 
                        monthly charge permitted consistent 
                        with standards established to carry out 
                        section 1916(b)(1) (with respect to 
                        individuals described in such section); 
                        and
                          (ii) a deductible, cost sharing, or 
                        similar charge that exceeds an amount 
                        that is nominal (as determined 
                        consistent with regulations referred to 
                        in section 1916(a)(3), with such 
                        appropriate adjustment for inflation or 
                        other reasons as the Secretary 
                        determines to be reasonable).
                  (B) Other children.--For children not 
                described in subparagraph (A), subject to 
                paragraphs (1)(B) and (2), any premiums, 
                deductibles, cost sharing or similar charges 
                imposed under the State child health plan may 
                be imposed on a sliding scale related to 
                income, except that the total annual aggregate 
                cost-sharing with respect to all targeted low-
                income children in a family under this title 
                may not exceed 5 percent of such family's 
                income for the year involved.
                  (C) Premium grace period.--The State child 
                health plan--
                          (i) shall afford individuals enrolled 
                        under the plan a grace period of at 
                        least 30 days from the beginning of a 
                        new coverage period to make premium 
                        payments before the individual's 
                        coverage under the plan may be 
                        terminated; and
                          (ii) shall provide to such an 
                        individual, not later than 7 days after 
                        the first day of such grace period, 
                        notice--
                                  (I) that failure to make a 
                                premium payment within the 
                                grace period will result in 
                                termination of coverage under 
                                the State child health plan; 
                                and
                                  (II) of the individual's 
                                right to challenge the proposed 
                                termination pursuant to the 
                                applicable Federal regulations.
                For purposes of clause (i), the term ``new 
                coverage period'' means the month immediately 
                following the last month for which the premium 
                has been paid.
          (4) Relation to medicaid requirements.--Nothing in 
        this subsection shall be construed as affecting the 
        rules relating to the use of enrollment fees, premiums, 
        deductions, cost sharing, and similar charges in the 
        case of targeted low-income children who are provided 
        child health assistance in the form of coverage under a 
        medicaid program under section 2101(a)(2).
  (f) Application of Certain Requirements.--
          (1) Restriction on application of preexisting 
        condition exclusions.--
                  (A) In general.--Subject to subparagraph (B), 
                the State child health plan shall not permit 
                the imposition of any preexisting condition 
                exclusion for covered benefits under the plan.
                  (B) Group health plans and group health 
                insurance coverage.--If the State child health 
                plan provides for benefits through payment for, 
                or a contract with, a group health plan or 
                group health insurance coverage, the plan may 
                permit the imposition of a preexisting 
                condition exclusion but only insofar as it is 
                permitted under the applicable provisions of 
                part 7 of subtitle B of title I of the Employee 
                Retirement Income Security Act of 1974 and 
                title XXVII of the Public Health Service Act.
          (2) Compliance with other requirements.--Coverage 
        offered under this section shall comply with the 
        requirements of subpart 2 of part A of title XXVII of 
        the Public Health Service Act insofar as such 
        requirements apply with respect to a health insurance 
        issuer that offers group health insurance coverage.
          (3) Compliance with managed care requirements.--The 
        State child health plan shall provide for the 
        application of subsections (a)(4), (a)(5), (b), (c), 
        (d), and (e) of section 1932 (relating to requirements 
        for managed care) to coverage, State agencies, 
        enrollment brokers, managed care entities, and managed 
        care organizations under this title in the same manner 
        as such subsections apply to coverage and such entities 
        and organizations under title XIX.

           *       *       *       *       *       *       *


SEC. 2110. DEFINITIONS.

  (a) Child Health Assistance.--For purposes of this title, the 
term ``child health assistance'' means payment for part or all 
of the cost of health benefits coverage for targeted low-income 
children that includes any of the following (and includes, in 
the case described in section 2105(a)(1)(D)(i), payment for 
part or all of the cost of providing any of the following), as 
specified under the State plan:
          (1) Inpatient hospital services.
          (2) Outpatient hospital services.
          (3) Physician services.
          (4) Surgical services.
          (5) Clinic services (including health center 
        services) and other ambulatory health care services.
          (6) Prescription drugs and biologicals and the 
        administration of such drugs and biologicals, only if 
        such drugs and biologicals are not furnished for the 
        purpose of causing, or assisting in causing, the death, 
        suicide, euthanasia, or mercy killing of a person.
          (7) Over-the-counter medications.
          (8) Laboratory and radiological services.
          (9) Prenatal care and prepregnancy family planning 
        services and supplies.
          (10) Inpatient mental health services, other than 
        services described in paragraph (18) but including 
        services furnished in a State-operated mental hospital 
        and including residential or other 24-hour 
        therapeutically planned structured services.
          (11) Outpatient mental health services, other than 
        services described in paragraph (19) but including 
        services furnished in a State-operated mental hospital 
        and including community-based services.
          (12) Durable medical equipment and other medically-
        related or remedial devices (such as prosthetic 
        devices, implants, eyeglasses, hearing aids, dental 
        devices, and adaptive devices).
          (13) Disposable medical supplies.
          (14) Home and community-based health care services 
        and related supportive services (such as home health 
        nursing services, home health aide services, personal 
        care, assistance with activities of daily living, chore 
        services, day care services, respite care services, 
        training for family members, and minor modifications to 
        the home).
          (15) Nursing care services (such as nurse 
        practitioner services, nurse midwife services, advanced 
        practice nurse services, private duty nursing care, 
        pediatric nurse services, and respiratory care 
        services) in a home, school, or other setting.
          (16) Abortion only if necessary to save the life of 
        the mother or if the pregnancy is the result of an act 
        of rape or incest.
          (17) Dental services.
          (18) Inpatient [substance abuse] substance use 
        treatment services and residential [substance abuse] 
        substance use treatment services.
          (19) Outpatient [substance abuse] substance use 
        treatment services.
          (20) Case management services.
          (21) Care coordination services.
          (22) Physical therapy, occupational therapy, and 
        services for individuals with speech, hearing, and 
        language disorders.
          (23) Hospice care (concurrent, in the case of an 
        individual who is a child, with care related to the 
        treatment of the child's condition with respect to 
        which a diagnosis of terminal illness has been made.
          (24) Any other medical, diagnostic, screening, 
        preventive, restorative, remedial, therapeutic, or 
        rehabilitative services (whether in a facility, home, 
        school, or other setting) if recognized by State law 
        and only if the service is--
                  (A) prescribed by or furnished by a physician 
                or other licensed or registered practitioner 
                within the scope of practice as defined by 
                State law,
                  (B) performed under the general supervision 
                or at the direction of a physician, or
                  (C) furnished by a health care facility that 
                is operated by a State or local government or 
                is licensed under State law and operating 
                within the scope of the license.
          (25) Premiums for private health care insurance 
        coverage.
          (26) Medical transportation.
          (27) Enabling services (such as transportation, 
        translation, and outreach services) only if designed to 
        increase the accessibility of primary and preventive 
        health care services for eligible low-income 
        individuals.
          (28) Any other health care services or items 
        specified by the Secretary and not excluded under this 
        section.
  (b) Targeted Low-Income Child Defined.--For purposes of this 
title--
          (1) In general.--Subject to paragraph (2), the term 
        ``targeted low-income child'' means a child--
                  (A) who has been determined eligible by the 
                State for child health assistance under the 
                State plan;
                  (B)(i) who is a low-income child, or
                  (ii) is a child--
                          (I) whose family income (as 
                        determined under the State child health 
                        plan) exceeds the medicaid applicable 
                        income level (as defined in paragraph 
                        (4)), but does not exceed 50 percentage 
                        points above the medicaid applicable 
                        income level;
                          (II) whose family income (as so 
                        determined) does not exceed the 
                        medicaid applicable income level (as 
                        defined in paragraph (4) but determined 
                        as if ``June 1, 1997'' were substituted 
                        for ``March 31, 1997''); or
                          (III) who resides in a State that 
                        does not have a medicaid applicable 
                        income level (as defined in paragraph 
                        (4)); and
                  (C) who is not found to be eligible for 
                medical assistance under title XIX or, subject 
                to paragraph (5), covered under a group health 
                plan or under health insurance coverage (as 
                such terms are defined in section 2791 of the 
                Public Health Service Act).
          (2) Children excluded.--Such term does not include--
                  (A) a child who is an inmate of a public 
                institution or a patient in an institution for 
                mental diseases; or
                  (B) except as provided in paragraph (6), a 
                child who is a member of a family that is 
                eligible for health benefits coverage under a 
                State health benefits plan on the basis of a 
                family member's employment with a public agency 
                in the State.
          (3) Special rule.--A child shall not be considered to 
        be described in paragraph (1)(C) notwithstanding that 
        the child is covered under a health insurance coverage 
        program that has been in operation since before July 1, 
        1997, and that is offered by a State which receives no 
        Federal funds for the program's operation.
          (4) Medicaid applicable income level.--The term 
        ``medicaid applicable income level'' means, with 
        respect to a child, the effective income level 
        (expressed as a percent of the poverty line) that has 
        been specified under the State plan under title XIX 
        (including under a waiver authorized by the Secretary 
        or under section 1902(r)(2)), as of March 31, 1997, for 
        the child to be eligible for medical assistance under 
        section 1902(l)(2) or 1905(n)(2) (as selected by a 
        State) for the age of such child.
          (5) Option for states with a separate chip program to 
        provide dental-only supplemental coverage.--
                  (A) In general.--Subject to subparagraphs (B) 
                and (C), in the case of any child who is 
                enrolled in a group health plan or health 
                insurance coverage offered through an employer 
                who would, but for the application of paragraph 
                (1)(C), satisfy the requirements for being a 
                targeted low-income child under a State child 
                health plan that is implemented under this 
                title, a State may waive the application of 
                such paragraph to the child in order to 
                provide--
                          (i) dental coverage consistent with 
                        the requirements of [subsection (c)(5)] 
                        subsection (c)(6) of section 2103; or
                          (ii) cost-sharing protection for 
                        dental coverage consistent with such 
                        requirements and the requirements of 
                        subsection (e)(3)(B) of such section.
                  (B) Limitation.--A State may limit the 
                application of a waiver of paragraph (1)(C) to 
                children whose family income does not exceed a 
                level specified by the State, so long as the 
                level so specified does not exceed the maximum 
                income level otherwise established for other 
                children under the State child health plan.
                  (C) Conditions.--A State may not offer 
                dental-only supplemental coverage under this 
                paragraph unless the State satisfies the 
                following conditions:
                          (i) Income eligibility.--The State 
                        child health plan under this title--
                                  (I) has the highest income 
                                eligibility standard permitted 
                                under this title (or a waiver) 
                                as of January 1, 2009;
                                  (II) does not limit the 
                                acceptance of applications for 
                                children or impose any 
                                numerical limitation, waiting 
                                list, or similar limitation on 
                                the eligibility of such 
                                children for child health 
                                assistance under such State 
                                plan; and
                                  (III) provides benefits to 
                                all children in the State who 
                                apply for and meet eligibility 
                                standards.
                          (ii) No more favorable treatment.--
                        The State child health plan may not 
                        provide more favorable dental coverage 
                        or cost-sharing protection for dental 
                        coverage to children provided dental-
                        only supplemental coverage under this 
                        paragraph than the dental coverage and 
                        cost-sharing protection for dental 
                        coverage provided to targeted low-
                        income children who are eligible for 
                        the full range of child health 
                        assistance provided under the State 
                        child health plan.
          (6) Exceptions to exclusion of children of employees 
        of a public agency in the state.--
                  (A) In general.--A child shall not be 
                considered to be described in paragraph (2)(B) 
                if--
                          (i) the public agency that employs a 
                        member of the child's family to which 
                        such paragraph applies satisfies 
                        subparagraph (B); or
                          (ii) subparagraph (C) applies to such 
                        child.
                  (B) Maintenance of effort with respect to 
                agency contribution for family coverage.--For 
                purposes of subparagraph (A)(i), a public 
                agency satisfies this subparagraph if the 
                amount of annual agency expenditures made on 
                behalf of employees enrolled in health coverage 
                paid for by the agency that includes dependent 
                coverage for the most recent State fiscal year 
                is not less than the amount of such 
                expenditures made by the agency for the 1997 
                State fiscal year, increased by the percentage 
                increase in the medical care expenditure 
                category of the Consumer Price Index for All-
                Urban Consumers (all items: U.S. City Average) 
                for such preceding fiscal year.
                  (C) Hardship exception.--For purposes of 
                subparagraph (A)(ii), this subparagraph applies 
                to a child if the State determines that the 
                annual aggregate amount of premiums and cost-
                sharing imposed for coverage of the family of 
                the child would exceed 5 percent of such 
                family's income for the year involved.
  (c) Additional Definitions.--For purposes of this title:
          (1) Child.--The term ``child'' means an individual 
        under 19 years of age.
          (2) Creditable health coverage.--The term 
        ``creditable health coverage'' has the meaning given 
        the term ``creditable coverage'' under section 2701(c) 
        of the Public Health Service Act (42 U.S.C. 300gg(c)) 
        and includes coverage that meets the requirements of 
        section 2103 provided to a targeted low-income child 
        under this title or under a waiver approved under 
        section 2105(c)(2)(B) (relating to a direct service 
        waiver).
          (3) Group health plan; health insurance coverage; 
        etc.--The terms ``group health plan'', ``group health 
        insurance coverage'', and ``health insurance coverage'' 
        have the meanings given such terms in section 2791 of 
        the Public Health Service Act.
          (4) Low-income.--The term ``low-income child'' means 
        a child whose family income is at or below 200 percent 
        of the poverty line for a family of the size involved.
          (5) Poverty line defined.--The term ``poverty line'' 
        has the meaning given such term in section 673(2) of 
        the Community Services Block Grant Act (42 U.S.C. 
        9902(2)), including any revision required by such 
        section.
          (6) Preexisting condition exclusion.--The term 
        ``preexisting condition exclusion'' has the meaning 
        given such term in section 2701(b)(1)(A) of the Public 
        Health Service Act (42 U.S.C. 300gg(b)(1)(A)).
          (7) State child health plan; plan.--Unless the 
        context otherwise requires, the terms ``State child 
        health plan'' and ``plan'' mean a State child health 
        plan approved under section 2106.
          (8) Uncovered child.--The term ``uncovered child'' 
        means a child that does not have creditable health 
        coverage.
          (9) School-based health center.--
                  (A) In general.--The term ``school-based 
                health center'' means a health clinic that--
                          (i) is located in or near a school 
                        facility of a school district or board 
                        or of an Indian tribe or tribal 
                        organization;
                          (ii) is organized through school, 
                        community, and health provider 
                        relationships;
                          (iii) is administered by a sponsoring 
                        facility;
                          (iv) provides through health 
                        professionals primary health services 
                        to children in accordance with State 
                        and local law, including laws relating 
                        to licensure and certification; and
                          (v) satisfies such other requirements 
                        as a State may establish for the 
                        operation of such a clinic.
                  (B) Sponsoring facility.--For purposes of 
                subparagraph (A)(iii), the term ``sponsoring 
                facility'' includes any of the following:
                          (i) A hospital.
                          (ii) A public health department.
                          (iii) A community health center.
                          (iv) A nonprofit health care agency.
                          (v) A local educational agency (as 
                        defined under section 8101 of the 
                        Elementaryand Secondary Education Act 
                        of 1965.
                          (vi) A program administered by the 
                        Indian Health Service or the Bureau of 
                        Indian Affairs or operated by an Indian 
                        tribe or a tribal organization.

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