Union Calendar No. 508
118th CONGRESS 2d Session |
[Report No. 118–610]
To amend title XIX of the Social Security Act to streamline enrollment under the Medicaid program of certain providers across State lines, and for other purposes.
July 19, 2023
Mrs. Trahan (for herself and Mrs. Miller-Meeks) introduced the following bill; which was referred to the Committee on Energy and Commerce
July 23, 2024
Additional sponsors: Ms. Castor of Florida, Mr. Fitzpatrick, Ms. Kuster, Mrs. Cammack, Mr. Tonko, Mr. Bacon, Mr. Van Drew, Ms. Blunt Rochester, Ms. Ross, Ms. Wexton, Mr. McCaul, Mr. Smucker, Ms. Barragán, Mr. Keating, Mr. Cárdenas, Ms. Craig, Ms. Wasserman Schultz, Mrs. Fletcher, Mr. Hudson, Ms. Caraveo, Mr. Johnson of Ohio, Mr. Yakym, Ms. DelBene, Mr. Joyce of Pennsylvania, Ms. Malliotakis, Mr. Valadao, Ms. Pingree, Mrs. Cherfilus-McCormick, Mr. Cohen, Mr. D'Esposito, Mr. Ruppersberger, Mr. Banks, Mr. Wittman, Mr. Phillips, Mr. Crow, Ms. Matsui, Mr. Bilirakis, Mr. Lieu, Mr. Crenshaw, Mrs. Kim of California, Ms. Wild, Mr. Langworthy, Mr. Neguse, Mr. Meuser, Mr. Alford, Mr. Molinaro, Mr. Connolly, Ms. Norton, Mr. Costa, Mr. Carter of Georgia, Mr. Finstad, Mr. Swalwell, Mr. Davis of North Carolina, Mr. Burgess, Ms. Lee of Florida, Ms. Titus, Mr. Kelly of Pennsylvania, Mr. Schneider, Mrs. Spartz, Mr. Soto, Ms. Schrier, Mr. Carey, Mr. Balderson, Mr. Lamborn, Mr. Jackson of Illinois, Mr. Raskin, Mr. Cleaver, Mrs. Harshbarger, Mr. Trone, Mrs. González-Colón, Ms. Kelly of Illinois, Mr. Dunn of Florida, Mr. Pocan, Mr. Wilson of South Carolina, Mr. Baird, Ms. Scanlon, Mr. Lawler, Mr. Horsford, Mr. Luetkemeyer, Mr. Allred, Mr. Evans, Mr. Kean of New Jersey, Mr. Garbarino, Mr. Goldman of New York, Mr. Nunn of Iowa, Mr. Morelle, Mr. James, Ms. Davids of Kansas, Mr. Magaziner, Mr. Nadler, Ms. Pettersen, Ms. Salinas, Mr. Mullin, Ms. Moore of Wisconsin, Mr. Grijalva, Mr. Levin, Ms. Bush, Ms. Brown, Ms. Stansbury, Mr. Huffman, Mr. McGarvey, Mr. Mrvan, Mr. Himes, Mr. Frost, Ms. Underwood, Ms. Tlaib, Mr. Obernolte, Ms. Sherrill, Mr. Thompson of Pennsylvania, Mr. Bucshon, Mr. Nickel, Ms. Bonamici, Mr. Kim of New Jersey, Mr. Lynch, Ms. Adams, Mrs. Miller of West Virginia, Mr. Panetta, Mr. Mann, Ms. Houlahan, Mr. Pappas, Mr. Pascrell, Mrs. Watson Coleman, and Mr. Gomez
July 23, 2024
Reported with amendments, committed to the Committee of the Whole House on the State of the Union, and ordered to be printed
[Strike out all after the enacting clause and insert the part printed in italic]
[For text of introduced bill, see copy of bill as introduced on July 19, 2023]
To amend title XIX of the Social Security Act to streamline enrollment under the Medicaid program of certain providers across State lines, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SEC. 2. Streamlined enrollment process for eligible out-of-State providers under Medicaid and CHIP.
(a) In general.—Section 1902(kk) of the Social Security Act (42 U.S.C. 1396a(kk)) is amended by adding at the end the following new paragraph:
“(10) STREAMLINED ENROLLMENT PROCESS FOR ELIGIBLE OUT-OF-STATE PROVIDERS.—
“(A) IN GENERAL.—If the State does not have a standard agreement with other States governing coverage and payment for services furnished to Medicaid-eligible children with medically complex conditions that was developed consistent with guidance issued by the Secretary under section 1945A, the State—
“(i) adopts and implements a process to allow an eligible out-of-State provider to enroll under the State plan (or a waiver of such plan) to furnish items and services to, or order, prescribe, refer, or certify eligibility for, items and services for qualifying individuals without the imposition of screening or enrollment requirements in addition to those imposed by the State in which the eligible out-of-State provider is located; and
“(B) DEFINITIONS.—In this paragraph:
“(i) ELIGIBLE OUT-OF-STATE PROVIDER.—The term ‘eligible out-of-State provider’ means, with respect to a State, a provider—
“(II) that—
“(aa) was determined by the Secretary to have a limited risk of fraud, waste, and abuse for purposes of determining the level of screening to be conducted under section 1866(j)(2), has been so screened under such section 1866(j)(2), and is enrolled in the Medicare program under title XVIII; or
“(bb) was determined by the State agency administering or supervising the administration of the State plan (or a waiver of such plan) of such other State to have a limited risk of fraud, waste, and abuse for purposes of determining the level of screening to be conducted under paragraph (1) of this subsection, has been so screened under such paragraph (1), and is enrolled under such State plan (or a waiver of such plan); and
“(III) that has not been—
“(aa) excluded from participation in any Federal health care program pursuant to section 1128 or 1128A;
(b) Conforming amendments.—
(1) Section 1902(a)(77) of the Social Security Act (42 U.S.C. 1396a(a)(77)) is amended by inserting “enrollment,” after “screening,”.
(2) The subsection heading for section 1902(kk) of such Act (42 U.S.C. 1396a(kk)) is amended by inserting “Enrollment,” after “Screening,”.
(3) Section 2107(e)(1)(G) of such Act (42 U.S.C. 1397gg(e)(1)(G)) is amended by inserting “enrollment,” after “screening,”.
SEC. 3. Preventing the use of abusive spread pricing in medicaid.
(a) In general.—Section 1927(e) of the Social Security Act (42 U.S.C. 1396r–8(e)) is amended by adding at the end the following:
“(6) TRANSPARENT PRESCRIPTION DRUG PASS-THROUGH PRICING REQUIRED.—
“(A) IN GENERAL.—A contract between the State and a pharmacy benefit manager (referred to in this paragraph as a ‘PBM’), or a contract between the State and a managed care entity or other specified entity (as such terms are defined in section 1903(m)(9)(D) and collectively referred to in this paragraph as the ‘entity’) that includes provisions making the entity responsible for coverage of covered outpatient drugs dispensed to individuals enrolled with the entity, shall require that payment for such drugs and related administrative services (as applicable), including payments made by a PBM on behalf of the State or entity, is based on a transparent prescription drug pass-through pricing model under which—
“(i) any payment made by the entity or the PBM (as applicable) for such a drug—
“(II) is passed through in its entirety (except as reduced under Federal or State laws and regulations in response to instances of waste, fraud, or abuse) by the entity or PBM to the pharmacy or provider that dispenses the drug; and
“(III) is made in a manner that is consistent with sections 447.502, 447.512, 447.514, and 447.518 of title 42, Code of Federal Regulations (or any successor regulation) as if such requirements applied directly to the entity or the PBM, except that any payment by the entity or the PBM for the ingredient cost of such drug purchased by a covered entity (as defined in subsection (a)(5)(B)) may exceed the actual acquisition cost (as defined in 447.502 of title 42, Code of Federal Regulations, or any successor regulation) for such drug if—
“(bb) such payment for the ingredient cost of such drug does not exceed the maximum payment that would have been made by the entity or the PBM for the ingredient cost of such drug if such drug had not been purchased by such covered entity; and
“(cc) such covered entity reports to the Secretary (in a form and manner specified by the Secretary), on an annual basis and with respect to payments for the ingredient costs of such drugs so purchased by such covered entity that are in excess of the actual acquisition costs for such drugs, the aggregate amount of such excess;
“(ii) payment to the entity or the PBM (as applicable) for administrative services performed by the entity or PBM is limited to an administrative fee that reflects the fair market value of such services;
“(iii) the entity or the PBM (as applicable) makes available to the State, and the Secretary upon request, all costs and payments related to covered outpatient drugs and accompanying administrative services incurred, received, or made by the entity or the PBM, including ingredient costs, professional dispensing fees, administrative fees, post-sale and post-invoice fees, discounts, or related adjustments such as direct and indirect remuneration fees, and any and all other remuneration; and
“(iv) any form of spread pricing whereby any amount charged or claimed by the entity or the PBM (as applicable) that exceeds the amount paid to the pharmacies or providers on behalf of the State or entity, including any post-sale or post-invoice fees, discounts, or related adjustments such as direct and indirect remuneration fees or assessments (after allowing for an administrative fee as described in clause (ii)) is not allowable for purposes of claiming Federal matching payments under this title.
“(B) MAKING CERTAIN INFORMATION AVAILABLE.—The Secretary shall publish, not less frequently than on an annual basis, information received by the Secretary pursuant to subparagraph (A)(i)(III)(cc). Such information shall be so published in an electronic and searchable format, such as through the 340B Office of Pharmacy Affairs Information System (or a successor system).”.
(b) Conforming amendments.—Section 1903(m) of such Act (42 U.S.C. 1396b(m)) is amended—
(1) in paragraph (2)(A)(xiii)—
(2) by adding at the end the following new paragraph:
“(10) No payment shall be made under this title to a State with respect to expenditures incurred by the State for payment for services provided by an other specified entity (as defined in paragraph (9)(D)(iii)) unless such services are provided in accordance with a contract between the State and such entity which satisfies the requirements of paragraph (2)(A)(xiii).”.
(c) Effective date.—The amendments made by this section shall apply to contracts between States and managed care entities, other specified entities, or pharmacy benefit managers that have an effective date beginning on or after the date that is 18 months after the date of enactment of this Act.
(d) Implementation.—
(e) Nonapplication of paperwork reduction act.—Chapter 35 of title 44, United States Code, shall not apply to any data collection undertaken by the Secretary of Health and Human Services under section 1927(f) of the Social Security Act (42 U.S.C. 1396r–8(f)), as amended by this section.
SEC. 4. Medicaid improvement fund.
Section 1941(b)(3)(A) of the Social Security Act (42 U.S.C. 1396w–1(b)(3)(A)) is amended by striking “$0” and inserting “$88,000,000”.
Amend the title so as to read: “A bill to amend title XIX of the Social Security Act to streamline enrollment under the Medicaid program of certain providers across State lines, and to prevent the use of abusive spread pricing in Medicaid.”.
Union Calendar No. 508 | |||||
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[Report No. 118–610] | |||||
A BILL | |||||
To amend title XIX of the Social Security Act to streamline enrollment under the Medicaid program of certain providers across State lines, and for other purposes. | |||||
July 23, 2024 | |||||
Reported with amendments, committed to the Committee of the Whole House on the State of the Union, and ordered to be printed |