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Federal Legislative Proposals Related to Medicaid and Opioids: What to Watch

Table 2: Medicaid Provisions in House Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, H.R. 6, as passed by the House on June 22, 2018
Topic Section Summary CBO Score
Eligibility and Enrollment for Criminal Justice Involved Youth  10011 Prohibits state Medicaid programs from terminating eligibility for an individual under age 21 or former foster care youth up to age 26 while incarcerated. State must redetermine eligibility prior to release, without requiring a new application, and if still eligible, restore coverage upon release. Effective 1 year after enactment. $75 million, 2019-2028
Eligibility and Enrollment for Former Foster Care Youth Across State Lines 10022 Requires states to ensure that Medicaid foster care youth who were enrolled at age 18 can retain coverage in any state until age 26. Effective for those who turn 18 on or after 1/1/23. HHS Secretary must issue guidance on best practices for ensuring streamlined timely Medicaid access and conducting outreach to former foster care youth within 1 year of enactment. $171 million, 2019-2028
Demonstrations to Increase Medicaid SUD Provider Capacity 10033 Authorizes Section 1115 demonstrations to increase Medicaid SUD provider capacity, beginning within 6 months of enactment. In the first 18 months, Secretary shall award planning grants to at least 10 states, totaling $50 million, ensuring geographic diversity and giving preference to states with SUD, particularly opioid use disorder, prevalence comparable to or higher than the national average. In the remaining 36 months, Secretary shall select up to 5 of these states to receive enhanced federal matching funds for a portion of state spending on Medicaid SUD treatment services. $301 million, 2019-2028
Prescription Drug Management (Provider/

Pharmacy Lock-In) Program for Enrollees Identified As At Risk of Abuse

10044 Requires state Medicaid programs to operate drug management programs to limit beneficiaries identified as at risk of drug abuse to 1 to 3 providers and pharmacies for controlled substance prescriptions, beginning 1/1/20. State shall accommodate beneficiary preferences unless state determines that it would contribute to drug abuse or diversion. Exempts those receiving cancer treatment or hospice/palliative care, in long-term care facilities, and those whom state elects to exempt. States shall report annually on their programs to the Secretary and require managed care entities to operate and report on such programs in contracts on or after 1/1/20. MACPAC shall report on these programs within 2 years of enactment. Also adds excessive utilization to existing drug utilization review criteria as of 10/1/20. -$13 million, 2019-2028; also would affect spending subject to appropriation
Prescription Drug Utilization Review Requirements for Opioids and Children’s Antipsychotics 10055 Requires state Medicaid programs to have drug utilization review safety edits for opioid refills and an automated claims review process to identify refills in excess of state limits, monitor concurrent prescribing of opioids and benzodiazepines or antipsychotics, and require managed care plans to have these processes in place as of 10/1/19. States also must have a program to monitor and annually report on antipsychotic prescribing for children generally and those in foster care and a process to identify potential controlled substance fraud or abuse by Medicaid enrollees, providers or pharmacies. Exempts those receiving cancer treatment or hospice/palliative care, in long-term care facilities, and those whom state elects to exempt. Secretary shall waive requirements during natural disasters and for emergency services. $5 million, 2019-2028
HHS Guidance on Services and Payment Models for Infants with Neonatal Abstinence Syndrome and Parents with SUD; GAO Study on Medicaid Gaps for Pregnant Women with SUD 10066 Requires HHS Secretary to issue guidance within 1 year of enactment to improve care for infants with neonatal abstinence syndrome and their families, including services, such as post-discharge and parenting supports, that states may cover under Medicaid; best practices for innovative or evidence-based payment models for parents with SUD and infants with NAS; recommendations on financing options for parents with SUD, infants with NAS, and home visiting services; and technical assistance to states for additional flexibilities and incentives related to screening, prevention, and post-discharge services, including parenting supports. Also requires GAO to study gaps in Medicaid coverage for pregnant and postpartum women with SUD within 1 year of enactment. $2 million, 2019-2023, subject to appropriation
SUD Health Homes  Enhanced FMAP Expansion; Required MAT Coverage 10077 Extends enhanced federal matching rate for new Medicaid health home activities targeted to beneficiaries with SUD from 8 quarters to 10 quarters for SPAs approved on or after 10/1/18. HHS Secretary to post online best practices for SUD focused health homes by 10/1/20.

Also requires state Medicaid programs to cover all FDA-approved MAT drugs, from 10/1/20-9/30/25, including methadone, licensed biological products to treat opioid use disorder, and counseling services and behavioral therapy, unless state certifies to Secretary’s satisfaction that statewide implementation for all Medicaid eligible individuals would not be feasible due to provider or facility shortage.

$509 million, 2019-2028 ($469 million for health home enhanced FMAP expansion; $39 million for MAT coverage)
State Reporting on Behavioral Health Quality Measures 50018 Requires state Medicaid programs to report annually on behavioral health quality measures in CMS’s adult core set beginning with 2024.

 

-$500,000 to $500,000, 2019-2028
IMD Payment MACPAC Study 5011-50129 Directs MACPAC to study Medicaid payments to IMDs in a representative sample of states by January, 2020, including the number of IMDs, facility type, and any coverage limits; services provided and clinical assessment, reassessment, and discharge processes; any federal waivers and other Medicaid funding sources such as supplemental payments; state certification, licensure, and accreditation requirements; state quality, clinical, and facility standards; and recommendations for Congress and CMS to improve care, standards, and data collection. $1 million, 2019-2023, subject to appropriation
Demonstrations to Facilitate Medicaid Enrollment and Provide Services Within 30 days of Incarceration Release 5031-503210 Requires HHS Secretary to issue state Medicaid director letter within 1 year of enactment regarding Section 1115 demonstrations to improve transitions for individuals moving from incarceration to the community, including systems for assistance and education about Medicaid enrollment and providing health care services 30 days prior to release, based on best practices identified by Secretary-convened stakeholder group.  <$500,000, 2019-2023, subject to appropriation
Prescription Drug Monitoring Programs for Controlled Substances 5041-504211 Requires state Medicaid programs to have providers check prescription drug monitoring program for enrollee’s prescription drug history before prescribing a controlled substance, as of 10/1/21. Establishes criteria for PDMPs.  Exempts enrollees who are receiving cancer treatment or hospice/palliative care, in long-term care or other facilities with single pharmacy contract, and those whom state elects to exempt. Secretary shall waive PDMP requirement for natural disasters and emergency services. States shall receive enhanced FMAP (not to exceed 100%) from 10/1/18 through 9/30/21 for PDMP implementation activities if state has agreements with contiguous states for providers to access PDMP. Secretary shall issue guidance on PDMP best practices by 10/1/19; and shall determine which providers should be exempt from PDMP and issue model practices, including MCO and pharmacy benefit manager access to enrollee data and beneficiary protections, to assist states with using PDMP data sharing agreements for monitoring fraud, waste and abuse; improving health care for those who transition in and out of Medicaid, may have other coverage in addition to Medicaid, or pay for prescriptions with cash; or other purposes by 10/1/20. GAO shall report on PDMP operations by 10/1/20. CMS shall publish guidance on increasing provider use of and best practices for PDMPs by 10/1/23. States shall report annually to Secretary on PDMP use and trends beginning in 2023. -$500,000 to $500,000, 2019-2028; also would affect spending subject to appropriation
HHS Recommendations to Improve Coverage and Payment for MAT, Non-Opioid Pain Management, and SUD Treatment Services 6031-603212 Directs HHS Secretary to develop, inter alia, Medicaid recommendations, including (1) program changes to enhance coverage and payment of FDA-approved MAT and other therapies that manage pain and treat and minimize addiction risk; (2) payment and service delivery models to be tested by CMMI and other federal demonstrations, including value-based models, that may encourage MAT use and other therapies that manage pain and minimize addiction risk; (3) data collection to facilitate research and policy making regarding opioid addiction prevention and treatment coverage and payment; (4) policies to expand access for rural or medically underserved communities to MAT and other therapies that manage pain and treat and minimize addiction risk; and (5) changes to address coverage or payment barriers to patient access to FDA-approved non-opioid medical devices to manage pain, monitor SUD withdrawal and prevent overdoses, and treat SUD. Secretary shall convene stakeholder meeting and issue RFI within 3 months of enactment and issue report to Congress by 6/1/19. $2 million, 2019-2023, subject to appropriation, primarily affects Medicare
IMD Payment for Opioid and Cocaine SUD Services 11001-1100213 Creates 5-year state plan option, from CY 2019 through CY 2023, for states to use Medicaid funds for IMD and other medically necessary services for nonelderly adults ages 21-64 with opioid use disorder or cocaine use disorder for up to any 30 days in a 12-month period. State shall include plan for how to improve access to outpatient care, including IMD to outpatient transition process and to ensure care provided in most integrated setting appropriate, and describe how state ensures appropriate clinical screening to determine level of care and length of stay based on ASAM criteria. State shall report to HHS Secretary by 12/31/24, or one year after SPA termination on number of individuals who received IMD services, length of stay, type of outpatient treatment received after discharge, number of individuals with and type of co-occurring disorders, and access to community care for individuals with mental illness other than SUD. $991 million, 2019-2028, for just opioids (prior to cocaine amendment)
Table 3:  Medicaid Provisions in the Senate Helping to End Addiction and Lessen (HEAL) Substance Use Disorders Act, as approved by the Senate Finance Committee, S. 3120, on June 12, 2018
Topic Section Summary CBO Score
Provider Agreements for Residential Pediatric Recovery Centers 2011 Creates Medicaid state plan option to enter into provider agreements with residential pediatric recovery centers for inpatient or outpatient services for infants under age 1 with NAS and their families.  $0
GAO Report on Peer Support Services 2022 Directs GAO to report within 2 years of enactment on Medicaid peer support services, including coverage mechanisms, populations, payment models, and spending, and make legislative and administrative recommendations to improve services and access. $0; also would affect spending subject to appropriation
HHS Guidance and GAO and Secretary Reporting on SUD Telehealth Services 2033 Directs Secretary to issue guidance within 1 year of enactment on state options for federal Medicaid reimbursement for SUD services using telehealth, including services that address needs of high risk individuals, including at least AI/ANs, adults under 40, and individuals with history of nonfatal overdose; SUD provider education using hub and spoke model, through managed care contracts, through administrative claiming for disease management activities, and under DSRIP; and services in school-based health centers.

Directs GAO to report within 1 year of enactment on children’s access to Medicaid SUD services, including options to increase telehealth SUD providers in school-based health centers, particularly in rural or underserved areas, and Medicaid SUD provider reimbursement rates.

Directs Secretary to report to Congress within 1 year of enactment on best practices for reducing barriers to telehealth SUD services for Medicaid children. 

$0; also would affect spending subject to appropriation
HHS Guidance on Non-Opioid Pain Management Services 2044 Directs HHS Secretary to issue guidance on mandatory and optional Medicaid services for non-opioid pain treatment and management by 1/1/19. $0; also would affect spending subject to appropriation
GAO Study on MAT Drug Distribution Models 2055 Directs GAO to report with 15 months of enactment on barriers to providing SUD treatment medication under Medicaid distribution models including purchasing, storage and administration by providers; dispensing by pharmacists; and providers ordering, prescribing, and obtaining on demand from specialty pharmacies. $0; also would affect spending subject to appropriation
Other Medicaid Services for Pregnant Women in IMDs 2066 Authorizes Medicaid payments for services provided outside IMDs for pregnant and postpartum women receiving IMD SUD services.  $48 million, 2019-2029
IMD Managed Care Capitation Payments 2077 Codifies Medicaid managed care regulation allowing capitation payments to include IMD services up to 15 days per month.  $0
MACPAC Report on MAT Utilization Controls 208 Directs MACPAC to report on state Medicaid program policies for MAT utilization control, including managed care and FFS, and identify policies that limit access by limiting quantities without evaluating the potential for fraud, waste, or abuse, within 1 year of enactment. $0
Medicaid Data on SUD Prevalence and Services 2098 Directs HHS Secretary to publish online report with data on SUD prevalence in Medicaid population and Medicaid SUD treatment services, within 1 year of enactment and updated annually through 2024. $0; also would affect spending subject to appropriation
Prescription Drug Monitoring Program 2109 Directs state Medicaid programs to facilitate reasonable access to prescription drug monitoring programs for Medicaid providers and health plans, to the extent allowed under state law.  $0
State Reporting on Behavioral Health Quality Measures 21110 Requires state Medicaid programs to report annually on behavioral health quality measures in CMS’s adult core set beginning with 2024. -$500,00 to $500,000
HHS Report on Housing-Related Services and Supports for Enrollees with SUD at Risk of Homelessness 21211 Directs HHS Secretary to report on Medicaid initiatives and strategies to provide housing-related services and supports to beneficiaries with SUD who are at risk of homelessness within one year of enactment.  $0
Technical Assistance on Housing-Related Services and Supports to Enrollees with SUD 21312 Directs HHS Secretary to provide technical assistance to states seeking to provide Medicaid housing-related services and supports and care coordination services to beneficiaries with SUD and issue action plan to do so within 180 days of enactment. $0
Guidance on SUD Services in Family-Focused Residential Treatment Programs 301 Directs HHS Secretary to issue guidance identifying opportunities for states to use Medicaid funds for family-focused residential treatment programs that allow children to reside with pregnant and postpartum women and parents receiving SUD treatment and to coordinate with Title IV-E funding. $0

Table 5:  House Bills Related to Medicaid and Opioids at Committee Level, as of June 19, 2018
Topic Bill No. Title Sponsor Summary Status
Postpartum Coverage H.R. 5977 MOMMA’s Act Rep. Robin Kelly (D-IL) Extends Medicaid coverage for pregnant women from 60 days to 1 year post partum, Inter alia. Introduced 5/25/18; referred to Energy & Commerce
SUD Payment Rates H.R. 5933 Substance Abuse Prevention Act Rep. Doug Collins (R-GA) Authorizes HHS Secretary to make grants to states to supplement Medicaid reimbursement to credentialed SUD professionals, inter alia. Introduced 5/23/18; referred to Oversight & Government Reform, Judiciary, and Energy & Commerce
Prescription Drug Monitoring Mapping Tool H.R. 5865 Addiction Prevention and Responsible Opioid Practices Act Rep. Matt Cartwright

(D-PA)

Directs HHS Secretary to create publicly available online interactive mapping tool showing Medicaid provider prescribing practices at state, county, and zip code levels for de-identified opioid prescription claims, inter alia. Introduced 5/17/18; referred to Energy and Commerce, Judiciary, Ways & Means, and Education & Workforce Committees, 5/17/18.
Prescription Drug Opioid Quantity Limits H.R. 5635 Responsible Opioid Prescription Act Rep. Glenn Grothman (R-WI) Limits Medicaid coverage of initial opioid prescriptions to 7 days; and refills to 30 days and only if provider determines that expected benefits outweigh risks, combines opioids with non-pharmacologic and non-opioid pharmacologic therapy to extent appropriate, establishes treatment goals, and discusses risks and responsibilities. Effective 1/1/19, except for those receiving cancer treatment or hospice/palliative care or in long-term care or skilled nursing facilities. Introduced 4/26/18; referred to Energy & Commerce
Report on MAT Coverage H.R. 5616 Opioid Minority Health Report to Congress Act Rep. Yvette Clark (D-NY) Requires annual report by the National Institute of Minority Health and Health Disparities on extent to which and funding recommendations for expanding Medicaid coverage of MAT and other treatment options could decrease incidence of opioid use and overdose deaths, inter alia. Introduced 4/25/18; referred to Energy & Commerce Subcommittee on Health
IMD Waiver Required for CARA Grant H.R. 5545 Comprehensive Addiction Resources Emergency Act Rep. Elijah Cummings (D-MD) Requires localities receiving grants to address substance use must be in states that have in effect or have submitted an application for a Section 1115 IMD payment waiver for nonelderly adults, inter alia. Introduced 4/18/18; referred to Subcommittee on Crime, Terrorism, Homeland Security & Investigations
Maternal/ Child Home Visiting Services H.R. 3291 Alleviating Adverse Childhood Experiences Act Rep. Tim Ryan (D-OH) Creates state plan option for maternal, infant, and early childhood visiting program, with priority to families with history of substance abuse or who need substance abuse treatment, inter alia. Introduced 7/18/17; referred to Energy & Commerce
IMD SUD Payment H.R. 2938 Road to Recovery Act Rep. Brian Fitzpatrick (R-PA) Exempts IMD SUD services for those under age 65 from payment exclusion if continued need is reaffirmed at least every 60 days based on Secretary or state-approved criteria. Introduced 6/20/17; referred to Energy & Commerce Subcommittee on Health
IMD SUD Payment; Grants for Youth Residential Treatment Facility Expansion H.R. 2687 Medicaid Coverage for Addiction Recovery Expansion Act Rep. Bill Foster (D-IL) Creates state plan option for IMD SUD and other medically necessary services for nonelderly adults up to 2 consecutive periods of 30 consecutive days in facilities up to 40 beds, as of 1/1/19, if offered as part of full continuum of evidence-based treatment. No limit on additional 30-day periods for pregnant women.

Also establishes $50 million, 5-year grant program for states to expand infrastructure and treatment capabilities of youth addiction treatment facilities that serve Medicaid/CHIP enrollees under 21 in communities with high numbers of medically underserved at-risk youth, with at least 15% of grants awarded to state used for rural areas.

Introduced 5/25/17, referred to Energy & Commerce Subcommittee on Health
Provider Agreements for Residential Pediatric Recovery Centers H.R. 2501 CRIB Act Rep. Evan Jenkins (R-WV) Creates Medicaid state plan option to enter into provider agreements with residential pediatric recovery centers for inpatient or outpatient services for infants under age 1 with neonatal abstinence syndrome and their families. Introduced 5/17/17; referred to Energy & Commerce Subcommittee on Health.
IMD SUD Payment H.R. 2239 Breaking Addiction Act Rep. Marcia Fudge (D-OH) Creates Medicaid state plan option to cover IMD SUD services for nonelderly adults in facilities up to 60 beds. Introduced 4/28/17; referred to Energy & Commerce
EPSDT Trauma Informed Services Demos and GAO Study H.R. 1757 Trauma-Informed Care for Children and Families Act Rep. Danny Davis (D-IL) Authorizes Medicaid demonstration projects in 10 states to test innovative trauma-informed approaches for delivering EPSDT and directs GAO to study how state Medicaid programs use EPSDT to provide trauma-informed services, inter alia. Introduced 3/28/17; referred to Subcommittee on Crime, Terrorism, Homeland Security, and Investigations
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