[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5797 Engrossed in House (EH)]
<DOC>
115th CONGRESS
2d Session
H. R. 5797
_______________________________________________________________________
AN ACT
To amend title XIX of the Social Security Act to allow States to
provide under Medicaid services for certain individuals with opioid use
disorders in institutions for mental diseases.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Individuals in Medicaid Deserve Care
that is Appropriate and Responsible in its Execution Act'' or the ``IMD
CARE Act''.
SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERVICES FOR CERTAIN
INDIVIDUALS WITH TARGETED SUDS IN INSTITUTIONS FOR MENTAL
DISEASES.
Section 1915 of the Social Security Act (42 U.S.C. 1396n) is
amended by adding at the end the following new subsection:
``(l) State Plan Option To Provide Services for Certain Individuals
in Institutions for Mental Diseases.--
``(1) In general.--With respect to calendar quarters
beginning during the period beginning January 1, 2019, and
ending December 31, 2023, a State may elect, through a State
plan amendment, to, notwithstanding section 1905(a), provide
medical assistance for services furnished in institutions for
mental diseases and for other medically necessary services
furnished to eligible individuals with targeted SUDs, in
accordance with the requirements of this subsection.
``(2) Payments.--
``(A) In general.--Amounts expended under a State
plan amendment under paragraph (1) for services
described in such paragraph furnished, with respect to
a 12-month period, to an eligible individual with a
targeted SUD who is a patient in an institution for
mental diseases shall be treated as medical assistance
for which payment is made under section 1903(a) but
only to the extent that such services are furnished for
not more than a period of 30 days (whether or not
consecutive) during such 12-month period.
``(B) Clarification.--Payment made under this
paragraph for expenditures under a State plan amendment
under this subsection with respect to services
described in paragraph (1) furnished to an eligible
individual with a targeted SUD shall not affect payment
that would otherwise be made under section 1903(a) for
expenditures under the State plan (or waiver of such
plan) for medical assistance for such individual.
``(3) Information required in state plan amendment.--
``(A) In general.--A State electing to provide
medical assistance pursuant to this subsection shall
include with the submission of the State plan amendment
under paragraph (1) to the Secretary--
``(i) a plan on how the State will improve
access to outpatient care during the period of
the State plan amendment, including a
description of--
``(I) the process by which eligible
individuals with targeted SUDs will
make the transition from receiving
inpatient services in an institution
for mental diseases to appropriate
outpatient care; and
``(II) the process the State will
undertake to ensure eligible
individuals with targeted SUDs are
provided care in the most integrated
setting appropriate to the needs of the
individuals; and
``(ii) a description of how the State plan
amendment ensures an appropriate clinical
screening of eligible individuals with targeted
SUDs, including assessments to determine level
of care and length of stay recommendations
based upon the multidimensional assessment
criteria of the American Society of Addiction
Medicine and to determine the appropriate
setting for such care.
``(B) Report.--Not later than the sooner of
December 31, 2024, or 1 year after the date of the
termination of a State plan amendment under this
subsection, the State shall submit to the Secretary a
report that includes at least--
``(i) the number of eligible individuals
with targeted SUDs who received services
pursuant to such State plan amendment;
``(ii) the length of the stay of each such
individual in an institution for mental
diseases;
``(iii) the type of outpatient treatment,
including medication-assisted treatment, each
such individual received after being discharged
from such institution;
``(iv) the number of eligible individuals
with any co-occuring disorders who received
services pursuant to such State plan amendment
and the co-occuring disorders from which they
suffer; and
``(v) information regarding the effects of
a State plan amendment on access to community
care for individuals suffering from a mental
disease other than substance use disorder.
``(4) Definitions.--In this subsection:
``(A) Eligible individual with a targeted sud.--The
term `eligible individual with a targeted SUD' means an
individual who--
``(i) with respect to a State, is enrolled
for medical assistance under the State plan (or
a waiver of such plan);
``(ii) is at least 21 years of age;
``(iii) has not attained 65 years of age;
and
``(iv) has been diagnosed with at least one
targeted SUD.
``(B) Institution for mental diseases.--The term
`institution for mental diseases' has the meaning given
such term in section 1905(i).
``(C) Opioid prescription pain reliever.--The term
`opioid prescription pain reliever' includes
hydrocodone products, oxycodone products, tramadol
products, codeine products, morphine products, fentanyl
products, buprenorphine products, oxymorphone products,
meperidine products, hydromorphone products, methadone,
and any other prescription pain reliever identified by
the Assistant Secretary for Mental Health and Substance
Use.
``(D) Other medically necessary services.--The term
`other medically necessary services' means, with
respect to an eligible individual with a targeted SUD
who is a patient in an institution for mental diseases,
items and services that are provided to such individual
outside of such institution to the extent that such
items and services would be treated as medical
assistance for such individual if such individual were
not a patient in such institution.
``(E) Targeted sud.--
``(i) In general.--The term `targeted SUD'
means an opioid use disorder or a cocaine use
disorder.
``(ii) Cocaine use disorder.--The term
`cocaine use disorder' means a disorder that
meets the criteria of the Diagnostic and
Statistical Manual of Mental Disorders, 4th
Edition (or a successor edition), for either
dependence or abuse for cocaine, including
cocaine base (commonly referred to as `crack
cocaine').
``(iii) Opioid use disorder.--The term
`opioid use disorder' means a disorder that
meets the criteria of the Diagnostic and
Statistical Manual of Mental Disorders, 4th
Edition (or a successor edition), for heroin
use disorder or pain reliever use disorder
(including with respect to opioid prescription
pain relievers).''.
SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.
Section 1903(m) of the Social Security Act (42 U.S.C. 1396b(m)) is
amended by adding at the end the following new paragraph:
``(7)(A) With respect to expenditures described in subparagraph (B)
that are incurred by a State for any fiscal year after fiscal year 2020
(and before fiscal year 2024), in determining the pro rata share to
which the United States is equitably entitled under subsection (d)(3),
the Secretary shall substitute the Federal medical assistance
percentage that applies for such fiscal year to the State under section
1905(b) (without regard to any adjustments to such percentage
applicable under such section or any other provision of law) for the
percentage that applies to such expenditures under section 1905(y).
``(B) Expenditures described in this subparagraph, with respect to
a fiscal year to which subparagraph (A) applies, are expenditures
incurred by a State for payment for medical assistance provided to
individuals described in subclause (VIII) of section 1902(a)(10)(A)(i)
by a managed care entity, or other specified entity (as defined in
subparagraph (D)(iii)), that are treated as remittances because the
State--
``(i) has satisfied the requirement of section 438.8 of
title 42, Code of Federal Regulations (or any successor
regulation), by electing--
``(I) in the case of a State described in
subparagraph (C), to apply a minimum medical loss ratio
(as defined in subparagraph (D)(ii)) that is at least
85 percent but not greater than the minimum medical
loss ratio (as so defined) that such State applied as
of May 31, 2018; or
``(II) in the case of a State not described in
subparagraph (C), to apply a minimum medical loss ratio
that is equal to 85 percent; and
``(ii) recovered all or a portion of the expenditures as a
result of the entity's failure to meet such ratio.
``(C) For purposes of subparagraph (B), a State described in this
subparagraph is a State that as of May 31, 2018, applied a minimum
medical loss ratio (as calculated under subsection (d) of section 438.8
of title 42, Code of Federal Regulations (as in effect on June 1,
2018)) for payment for services provided by entities described in such
subparagraph under the State plan under this title (or a waiver of the
plan) that is equal to or greater than 85 percent.
``(D) For purposes of this paragraph:
``(i) The term `managed care entity' means a medicaid
managed care organization described in section
1932(a)(1)(B)(i).
``(ii) The term `minimum medical loss ratio' means, with
respect to a State, a minimum medical loss ratio (as calculated
under subsection (d) of section 438.8 of title 42, Code of
Federal Regulations (as in effect on June 1, 2018)) for payment
for services provided by entities described in subparagraph (B)
under the State plan under this title (or a waiver of the
plan).
``(iii) The term `other specified entity' means--
``(I) a prepaid inpatient health plan, as defined
in section 438.2 of title 42, Code of Federal
Regulations (or any successor regulation); and
``(II) a prepaid ambulatory health plan, as defined
in such section (or any successor regulation).''.
Passed the House of Representatives June 20, 2018.
Attest:
Clerk.
115th CONGRESS
2d Session
H. R. 5797
_______________________________________________________________________
AN ACT
To amend title XIX of the Social Security Act to allow States to
provide under Medicaid services for certain individuals with opioid use
disorders in institutions for mental diseases.