由加州第27選區議員趙美心和印第安納州第二選區議員傑克· 瓦羅斯基共同提出的H.R.6110法案今天在在聯邦眾議院全票通過。該法案將指導醫保和醫療補助服務中心（CMS）去研究在醫保系統中，用非藥物替代療法代替阿片以處理急慢性疼痛可能遇到的障礙， 並且就任何現存的障礙寫一個報告給國會。 替代療法包括針灸、物理治療、職業治療、醫療設備及其他。該法案也包括指導衛生與人類服務部去開發一個關於非阿片替代治療的益處的教育工具。該法案也指導醫保和醫療補助服務中心以檢查各種使受益者熟悉他們能享受的心理學家服務的途徑，並且要求政府問責辦公室提供一個研究關於在醫保系統推行心理和行為健康服務的可行性。
H.R.6110法案與趙美心議員Judy Chu 的Medicare 針灸法案 H.R 2838和退伍軍人針灸法案H.R.2839不一樣。但H.R.6110法案對針灸也是非常有利的，為針灸治療進入聯邦政府醫療保險系統邁出可喜的一步。
此法案能成功通過，是因為美國現存醫療系統面對日益嚴重的阿片類止痛藥濫用造成可怕的社會危機束手無策。2017年，美國總統和政府將濫用阿片類止痛藥物每年造成數萬美國人死亡列為嚴重的社會危機。美國最高學術機構「三科院」（美國科學院、工程科學院、醫學科學院)，2017報告將針灸列為非藥物治療疼痛的主要療法，這對針灸在美國的發展有著極大正面意義。
中醫針灸在美國也迎來了新的發展機遇，我們美國針灸界也不失時機地努力爭取。在2016年9月份，美國針灸和安全聯盟AAPAS(由全美近二十個最大和最有影響力華裔中醫針灸團體/學校組成)與全美最大的白人為主的全美針灸公會ASA聯合在首都國會山莊舉辦了「針灸在阿片危機的作用「的通報會，取得空前成功。美國中醫針灸聯盟也於2016年在國會山莊舉行了支持趙美心Medicare針灸法案的大型活動。
美國中醫公會作為AAPAS 的重要成員一直努力地推動針灸進入聯邦保險系統，並在今年5月份參加了趙美心眾議員的籌款活動，捐款$2700，是捐款最多的中醫針灸團體之一。美國中醫公會將一如既往，與全國各族裔針灸同業一道，齊心協力，共同將美國的針灸事業推向前進！
美國中醫公會政治行動委員會
7/9/2018
Rep. Chu Opioid Alternative Bill Passed Unanimously
June 19, 2018
Press Release
Washington, DC — Today, the House of Representatives voted unanimously in favor of H.R. 6110, the MOST Act, which was introduced by Reps. Judy Chu (CA-27) and Jackie Walorski (IN-02). The bill would direct the Centers for Medicare and Medicaid Services (CMS) to study barriers to accessing non-drug alternatives to opioids to manage chronic and acute pain within the Medicare program, and provide a report to Congress on any existing barriers. Alternative treatments include acupuncture, physical therapy, occupational therapy, medical devices, and others. It also includes a directive for the Department of Health and Human Services (HHS) to develop a toolkit to educate beneficiaries about non-drug opioid alternatives. The bill also directs CMS to examine ways for beneficiaries to familiarize themselves with coverage for psychologist services, and requests a study from the Government Accountability Office (GAO) on the viability of mental and behavioral health services in the Medicare Program. Rep. Chu released the following statement:
“The opioid epidemic has plagued every state and community in our country, impacting Americans both young and old. Individuals aged 65 and older are seeing radical increases in opioid-related hospital stays, including in my home state of California. And this crisis is especially acute for the non-elderly Medicare population. For instance, in 2015, nonelderly Medicare beneficiaries, or those who qualify on the basis of disability, had opioid utilization rates more than twice that of elderly beneficiaries. And so, to combat it, we need a strategy that is equally broad and targeted at all ages and means. That is what this bill will help us do.
“I particularly want to thank Rep. Walorski for working with me on language that would direct CMS to study barriers to patient access to non-drug alternatives for opioids in chronic care settings. Studies conducted by the NIH have concluded that alternative treatments like acupuncture can be effective in treating conditions like chronic pain without the dangerous risk of addiction. And I have heard firsthand what a difference acupuncture can make in the lives of patients. I remember very clearly when I heard the testimony of a woman who had severe back pain but did not want invasive surgery, and risk possible addiction to morphine. Instead, she sought acupuncture, and it worked for her, and she avoided the risks associated with surgery and certain pain medications. We also know access to physical and occupational therapy helps alleviate pain and eliminates the need for an opioid prescription. By asking CMS to examine where barriers to these alternatives exist, we can open the door to more treatment options for beneficiaries.
“I’m also proud that this bill includes a provision I authored with the Rep. Kristi Noem (ND), to address the need for more psychologists in the Medicare program. This bill would direct the Center for Medicare and Medicaid Innovation to examine ways for beneficiaries to familiarize themselves with coverage for psychologist services, and requests a study from the Government Accountability Office on the viability of mental and behavioral health services in the Medicare Program. As one of only two psychologists in Congress, I firmly believe that expanding access to psychologist services in Medicare is one of the most important things we can do to improve the mental health of our senior population.”
趙美心議員提出的鴉片替代法案無異議一致通過
2018年6月19日
新聞發布
華盛頓特區 – 今天，眾議院無異議一致通過H.R. 6110 提案，MOST法案，由加州第27選區議員趙美心和印第安納州第二選區議員傑克· 瓦羅斯基共同提出。該法案將指導醫保和醫療補助服務中心（CMS）去研究在醫保系統中，用非藥物替代療法代替鴉片以處理急慢性疼痛可能遇到的障礙， 並且就任何現存的障礙寫一個報告給國會。替代療法包括針灸、物理治療、職業治療、醫療設備及其他。該法案也包括指導衛生與人類服務部去開發一個關於非鴉片替代治療的益處的教育工具。該法案也指導醫保和醫療補助服務中心以檢查各種使受益者熟悉他們能享受的心理學家服務的途徑，並且要求政府問責辦公室提供一個研究關於在醫保系統推行心理和行為健康服務的可行性。趙議員發布了以下聲明：
“阿片類藥物的流行一直困擾著我們國家的每個州和社區，影響著美國的年輕人和老年人。65歲及以上的人看到與阿片類藥物相關的住院費用急劇增加，包括在我的家鄉加利福尼亞。對於非老年人醫療保險人口而言，這場危機尤為嚴重。例如，2015年，非醫療保險受益者或符合殘疾資格的受益者的阿片類藥物使用率是老年受益者的兩倍多。因此，為了對抗這種情況，我們需要一種同樣廣泛且針對所有年齡和手段的戰略。 這是該法案將幫助我們做的事情。
“我特別要感謝瓦洛斯基議員與我在文字上的合作，該文字將指導CMS研究患者獲取慢性病治療中阿片類藥物的非藥物替代品的障礙。美國國立衛生研究院進行的研究得出結論，針灸等替代療法可以有效治療慢性疼痛等疾
病，而不會有成癮的危險。我已經從第一首資料中了解到針灸對患者生活可以產生如何不同的影響。我清楚地記得，我聽到一位婦女的證詞，她患有嚴重背部疼痛但不想進行侵入性手術也不想冒嗎啡成癮風險，相反，她尋求針灸的幫助，而針灸對她有效果，她避免了接受手術和服用某些止痛藥可能帶來的風險。我們還知道獲得物理和職業治療有助於減輕疼痛，並消除了對阿片類藥物處方的需求。通過要求CMS檢查這些替代品存在哪些障礙，我們可以為受益者打開更多治療選擇的大門。
“我也很自豪這項法案包括我與眾議員可克里絲蒂· 諾易姆（ND）合著的一項條款，以滿足醫療保險計劃中更多心理學家的需求。 該法案將指導醫療保險和醫療補助創新中心研究受益人如何熟悉心理學家服務的覆蓋範圍，並要求政府問責辦公室研究在醫療保險系統中精神和行為健康服務的可行性。作為國會中僅有的兩位心理學家之一，我堅信，擴大醫療保險系統中心理學家服務的可及性是我們為改善老年人心理健康所能做的最重要的事情之一。 ”
H.R. 6110
IN THE SENATE OF THE UNITED STATES
June 20, 2018
Received; read twice and referred to the Committee on Finance
AN ACT
To amend title XVIII of the Social Security Act to provide for the review and adjustment of payments under the Medicare outpatient prospective payment system to avoid financial incentives to use opioids instead of non-opioid alternative treatments, and for other purposes.
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 “Dr. Todd Graham Pain Management, Treatment, and Recovery Act of 2018”.
SEC. 2. REVIEW AND ADJUSTMENT OF PAYMENTS UNDER THE MEDICARE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM TO AVOID FINANCIAL INCENTIVES TO USE OPIOIDS INSTEAD OF NON-OPIOID ALTERNATIVE TREATMENTS.
(a) Outpatient Prospective Payment System.—Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is amended by adding at the end the following new paragraph:
“(22) REVIEW AND REVISIONS OF PAYMENTS FOR NON-OPIOID ALTERNATIVE TREATMENTS.—
“(A) IN GENERAL.—With respect to payments made under this subsection for covered OPD services (or groups of services), including covered OPD services assigned to a comprehensive ambulatory payment classification, the Secretary—
“(i) shall, as soon as practicable, conduct a review (part of which may include a request for information) of payments for opioids and evidence-based non-opioid alternatives for pain management (including drugs and devices, nerve blocks, surgical injections, and neuromodulation) with a goal of ensuring that there are not financial incentives to use opioids instead of non-opioid alternatives;
“(ii) may, as the Secretary determines appropriate, conduct subsequent reviews of such payments; and
“(iii) shall consider the extent to which revisions under this subsection to such payments (such as the creation of additional groups of covered OPD services to classify separately those procedures that utilize opioids and non-opioid alternatives for pain management) would reduce payment incentives to use opioids instead of non-opioid alternatives for pain management.
“(B) PRIORITY.—In conducting the review under clause (i) of subparagraph (A) and considering revisions under clause (iii) of such subparagraph, the Secretary shall focus on covered OPD services (or groups of services) assigned to a comprehensive ambulatory payment classification, ambulatory payment classifications that primarily include surgical services, and other services determined by the Secretary which generally involve treatment for pain management.
“(C) REVISIONS.—If the Secretary identifies revisions to payments pursuant to subparagraph (A)(iii), the Secretary shall, as determined appropriate, begin making such revisions for services furnished on or after January 1, 2020. Revisions under the previous sentence shall be treated as adjustments for purposes of application of paragraph (9)(B).
“(D) RULES OF CONSTRUCTION.—Nothing in this paragraph shall be construed to preclude the Secretary—
“(i) from conducting a demonstration before making the revisions described in subparagraph (C); or
“(ii) prior to implementation of this paragraph, from changing payments under this subsection for covered OPD services (or groups of services) which include opioids or non-opioid alternatives for pain management.”.
(b) Ambulatory Surgical Centers.—Section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) is amended by adding at the end the following new paragraph:
“(8) The Secretary shall conduct a similar type of review as required under paragraph (22) of section 1833(t)), including the second sentence of subparagraph (C) of such paragraph, to payment for services under this subsection, and make such revisions under this paragraph, in an appropriate manner (as determined by the Secretary).”.
SEC. 3. EXPANDING ACCESS UNDER THE MEDICARE PROGRAM TO ADDICTION TREATMENT IN FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS.
(a) Federally Qualified Health Centers.—Section 1834(o) of the Social Security Act (42 U.S.C. 1395m(o)) is amended by adding at the end the following new paragraph:
“(3) ADDITIONAL PAYMENTS FOR CERTAIN FQHCS WITH PHYSICIANS OR OTHER PRACTITIONERS RECEIVING DATA 2000 WAIVERS.—
“(A) IN GENERAL.—In the case of a Federally qualified health center with respect to which, beginning on or after January 1, 2019, Federally-qualified health center services (as defined in section 1861(aa)(3)) are furnished for the treatment of opioid use disorder by a physician or practitioner who meets the requirements described in subparagraph (C) the Secretary shall, subject to availability of funds under subparagraph (D), make a payment (at such time and in such manner as specified by the Secretary) to such Federally qualified health center after receiving and approving an application submitted by such Federally qualified health center under subparagraph (B). Such a payment shall be in an amount determined by the Secretary, based on an estimate of the average costs of training for purposes of receiving a waiver described in subparagraph (C)(ii). Such a payment may be made only one time with respect to each such physician or practitioner.
“(B) APPLICATION.—In order to receive a payment described in subparagraph (A), a Federally-qualified health center shall submit to the Secretary an application for such a payment at such time, in such manner, and containing such information as specified by the Secretary. A Federally-qualified health center may apply for such a payment for each physician or practitioner described in subparagraph (A) furnishing services described in such subparagraph at such center.
“(C) REQUIREMENTS.—For purposes of subparagraph (A), the requirements described in this subparagraph, with respect to a physician or practitioner, are the following:
“(i) The physician or practitioner is employed by or working under contract with a Federally qualified health center described in subparagraph (A) that submits an application under subparagraph (B).
“(ii) The physician or practitioner first receives a waiver under section 303(g) of the Controlled Substances Act on or after January 1, 2019.
“(D) FUNDING.—For purposes of making payments under this paragraph, there are appropriated, out of amounts in the Treasury not otherwise appropriated, $6 million, which shall remain available until expended.”.
(b) Rural Health Clinic.—Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended—
(1) by redesignating the subsection (z) relating to medical review of spinal subluxation services as subsection (aa); and
(2) by adding at the end the following new subsection:
“(bb) Additional Payments For Certain Rural Health Clinics With Physicians Or Practitioners Receiving DATA 2000 Waivers.—
“(1) IN GENERAL.—In the case of a rural health clinic with respect to which, beginning on or after January 1, 2019, rural health clinic services (as defined in section 1861(aa)(1)) are furnished for the treatment of opioid use disorder by a physician or practitioner who meets the requirements described in paragraph (3), the Secretary shall, subject to availability of funds under paragraph (4), make a payment (at such time and in such manner as specified by the Secretary) to such rural health clinic after receiving and approving an application described in paragraph (2). Such payment shall be in an amount determined by the Secretary, based on an estimate of the average costs of training for purposes of receiving a waiver described in paragraph (3)(B). Such payment may be made only one time with respect to each such physician or practitioner.
“(2) APPLICATION.—In order to receive a payment described in paragraph (1), a rural health clinic shall submit to the Secretary an application for such a payment at such time, in such manner, and containing such information as specified by the Secretary. A rural health clinic may apply for such a payment for each physician or practitioner described in paragraph (1) furnishing services described in such paragraph at such clinic.
“(3) REQUIREMENTS.—For purposes of paragraph (1), the requirements described in this paragraph, with respect to a physician or practitioner, are the following:
“(A) The physician or practitioner is employed by or working under contract with a rural health clinic described in paragraph (1) that submits an application under paragraph (2).
“(B) The physician or practitioner first receives a waiver under section 303(g) of the Controlled Substances Act on or after January 1, 2019.
“(4) FUNDING.—For purposes of making payments under this subsection, there are appropriated, out of amounts in the Treasury not otherwise appropriated, $2 million, which shall remain available until expended.”.
SEC. 4. STUDYING THE AVAILABILITY OF SUPPLEMENTAL BENEFITS DESIGNED TO TREAT OR PREVENT SUBSTANCE USE DISORDERS UNDER MEDICARE ADVANTAGE PLANS.
(a) In General.—Not later than 2 years after the date of the enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall submit to Congress a report on the availability of supplemental health care benefits (as described in section 1852(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w–22(a)(3)(A))) designed to treat or prevent substance use disorders under Medicare Advantage plans offered under part C of title XVIII of such Act. Such report shall include the analysis described in subsection (c) and any differences in the availability of such benefits under specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of such Act (42 U.S.C. 1395w–28(b)(6))) offered to individuals entitled to medical assistance under title XIX of such Act and other such Medicare Advantage plans.
(b) Consultation.—The Secretary shall develop the report described in subsection (a) in consultation with relevant stakeholders, including—
(1) individuals entitled to benefits under part A or enrolled under part B of title XVIII of the Social Security Act;
(2) entities who advocate on behalf of such individuals;
(3) Medicare Advantage organizations;
(4) pharmacy benefit managers; and
(5) providers of services and suppliers (as such terms are defined in section 1861 of such Act (42 U.S.C. 1395x)).
(c) Contents.—The report described in subsection (a) shall include an analysis on the following:
(1) The extent to which plans described in such subsection offer supplemental health care benefits relating to coverage of—
(A) medication-assisted treatments for opioid use, substance use disorder counseling, peer recovery support services, or other forms of substance use disorder treatments (whether furnished in an inpatient or outpatient setting); and
(B) non-opioid alternatives for the treatment of pain.
(2) Challenges associated with such plans offering supplemental health care benefits relating to coverage of items and services described in subparagraph (A) or (B) of paragraph (1).
(3) The impact, if any, of increasing the applicable rebate percentage determined under section 1854(b)(1)(C) of the Social Security Act (42 U.S.C. 1395w–24(b)(1)(C)) for plans offering such benefits relating to such coverage would have on the availability of such benefits relating to such coverage offered under Medicare Advantage plans.
(4) Potential ways to improve upon such coverage or to incentivize such plans to offer additional supplemental health care benefits relating to such coverage.
SEC. 5. CLINICAL PSYCHOLOGIST SERVICES MODELS UNDER THE CENTER FOR MEDICARE AND MEDICAID INNOVATION; GAO STUDY AND REPORT.
(a) CMI Models.—Section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 1315a(b)(2)(B) is amended by adding at the end the following new clauses:
“(xxv) Supporting ways to familiarize individuals with the availability of coverage under part B of title XVIII for qualified psychologist services (as defined in section 1861(ii)).
“(xxvi) Exploring ways to avoid unnecessary hospitalizations or emergency department visits for mental and behavioral health services (such as for treating depression) through use of a 24-hour, 7-day a week help line that may inform individuals about the availability of treatment options, including the availability of qualified psychologist services (as defined in section 1861(ii)).”.
(b) GAO Study And Report.—Not later than 18 months after the date of the enactment of this Act, the Comptroller General of the United States shall conduct a study, and submit to Congress a report, on mental and behavioral health services under the Medicare program under title XVIII of the Social Security Act, including an examination of the following:
(1) Information about services furnished by psychiatrists, clinical psychologists, and other professionals.
(2) Information about ways that Medicare beneficiaries familiarize themselves about the availability of Medicare payment for qualified psychologist services (as defined in section 1861(ii) of the Social Security Act (42 U.S.C. 1395x(ii)) and ways that the provision of such information could be improved.
SEC. 6. PAIN MANAGEMENT STUDY.
(a) In General.—Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this section as the “Secretary”) shall conduct a study analyzing best practices as well as payment and coverage for pain management services under title XVIII of the Social Security Act and submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report containing options for revising payment to providers and suppliers of services and coverage related to the use of multi-disciplinary, evidence-based, non-opioid treatments for acute and chronic pain management for individuals entitled to benefits under part A or enrolled under part B of title XVIII of the Social Security Act. The Secretary shall make such report available on the public website of the Centers for Medicare & Medicaid Services.
(b) Consultation.—In developing the report described in subsection (a), the Secretary shall consult with—
(1) relevant agencies within the Department of Health and Human Services;
(2) licensed and practicing osteopathic and allopathic physicians, behavioral health practitioners, physician assistants, nurse practitioners, dentists, pharmacists, and other providers of health services;
(3) providers and suppliers of services (as such terms are defined in section 1861 of the Social Security Act (42 U.S.C. 1395x));
(4) substance abuse and mental health professional organizations;
(5) pain management professional organizations and advocacy entities, including individuals who personally suffer chronic pain;
(6) medical professional organizations and medical specialty organizations;
(7) licensed health care providers who furnish alternative pain management services;
(8) organizations with expertise in the development of innovative medical technologies for pain management;
(9) beneficiary advocacy organizations; and
(10) other organizations with expertise in the assessment, diagnosis, treatment, and management of pain, as determined appropriate by the Secretary.
(c) Contents.—The report described in subsection (a) shall include the following:
(1) An analysis of payment and coverage under title XVIII of the Social Security Act with respect to the following:
(A) Evidence-based treatments and technologies for chronic or acute pain, including such treatments that are covered, not covered, or have limited coverage under such title.
(B) Evidence-based treatments and technologies that monitor substance use withdrawal and prevent overdoses of opioids.
(C) Evidence-based treatments and technologies that treat substance use disorders.
(D) Items and services furnished by practitioners through a multi-disciplinary treatment model for pain management, including the patient-centered medical home.
(E) Medical devices, non-opioid based drugs, and other therapies (including interventional and integrative pain therapies) approved or cleared by the Food and Drug Administration for the treatment of pain.
(F) Items and services furnished to beneficiaries with psychiatric disorders, substance use disorders, or who are at risk of suicide, or have comorbidities and require consultation or management of pain with one or more specialists in pain management, mental health, or addiction treatment.
(2) An evaluation of the following:
(A) Barriers inhibiting individuals entitled to benefits under part A or enrolled under part B of such title from accessing treatments and technologies described in subparagraphs (A) through (F) of paragraph (1).
(B) Costs and benefits associated with potential expansion of coverage under such title to include items and services not covered under such title that may be used for the treatment of pain, such as acupuncture, therapeutic massage, and items and services furnished by integrated pain management programs.
(C) Pain management guidance published by the Federal Government that may be relevant to coverage determinations or other coverage requirements under title XVIII of the Social Security Act.
(3) An assessment of all guidance published by the Department of Health and Human Services on or after January 1, 2016, relating to the prescribing of opioids. Such assessment shall consider incorporating into such guidance relevant elements of the “VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain” published in February 2017 by the Department of Veterans Affairs and Department of Defense, including adoption of elements of the Department of Defense and Veterans Administration pain rating scale.
(4) The options described in subsection (d).
(5) The impact analysis described in subsection (e).
(d) Options.—The options described in this subsection are, with respect to individuals entitled to benefits under part A or enrolled under part B of title XVIII of the Social Security Act, legislative and administrative options for accomplishing the following:
(1) Improving coverage of and payment for pain management therapies without the use of opioids, including interventional pain therapies, and options to augment opioid therapy with other clinical and complementary, integrative health services to minimize the risk of substance use disorder, including in a hospital setting.
(2) Improving coverage of and payment for medical devices and non-opioid based pharmacological and non-pharmacological therapies approved or cleared by the Food and Drug Administration for the treatment of pain as an alternative or augment to opioid therapy.
(3) Improving and disseminating treatment strategies for beneficiaries with psychiatric disorders, substance use disorders, or who are at risk of suicide, and treatment strategies to address health disparities related to opioid use and opioid abuse treatment.
(4) Improving and disseminating treatment strategies for beneficiaries with comorbidities who require a consultation or comanagement of pain with one or more specialists in pain management, mental health, or addiction treatment, including in a hospital setting.
(5) Educating providers on risks of coadministration of opioids and other drugs, particularly benzodiazepines.
(6) Ensuring appropriate case management for beneficiaries who transition between inpatient and outpatient hospital settings, or between opioid therapy to non-opioid therapy, which may include the use of care transition plans.
(7) Expanding outreach activities designed to educate providers of services and suppliers under the Medicare program and individuals entitled to benefits under part A or under part B of such title on alternative, non-opioid therapies to manage and treat acute and chronic pain.
(8) Creating a beneficiary education tool on alternatives to opioids for chronic pain management.
(e) Impact Analysis.—The impact analysis described in this subsection consists of an analysis of any potential effects implementing the options described in subsection (d) would have—
(1) on expenditures under the Medicare program; and
(2) on preventing or reducing opioid addiction for individuals receiving benefits under the Medicare program.
SEC. 7. SUSPENSION OF PAYMENTS BY MEDICARE PRESCRIPTION DRUG PLANS AND MA–PD PLANS PENDING INVESTIGATIONS OF CREDIBLE ALLEGATIONS OF FRAUD BY PHARMACIES.
(a) In General.—Section 1860D–12(b) of the Social Security Act (42 U.S.C. 1395w–112(b)) is amended by adding at the end the following new paragraph:
“(7) SUSPENSION OF PAYMENTS PENDING INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD BY PHARMACIES.—
“(A) IN GENERAL.—The provisions of section 1862(o) shall apply with respect to a PDP sponsor with a contract under this part, a pharmacy, and payments to such pharmacy under this part in the same manner as such provisions apply with respect to the Secretary, a provider of services or supplier, and payments to such provider of services or supplier under this title.
“(B) RULE OF CONSTRUCTION.—Nothing in this paragraph shall be construed as limiting the authority of a PDP sponsor to conduct postpayment review.”.
(b) Application To MA–PD Plans.—Section 1857(f)(3) of the Social Security Act (42 U.S.C. 1395w–27(f)(3)) is amended by adding at the end the following new subparagraph:
“(D) SUSPENSION OF PAYMENTS PENDING INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD BY PHARMACIES.—Section 1860D–12(b)(7).”.
(c) Conforming Amendment.—Section 1862(o)(3) of the Social Security Act (42 U.S.C. 1395y(o)(3)) is amended by inserting “, section 1860D–12(b)(7) (including as applied pursuant to section 1857(f)(3)(D)),” after “this subsection”.
(d) Clarification Relating To Credible Allegation Of Fraud.—Section 1862(o) of the Social Security Act (42 U.S.C. 1395y(o)) is amended by adding at the end the following new paragraph:
“(4) CREDIBLE ALLEGATION OF FRAUD.—In carrying out this subsection, section 1860D–12(b)(7) (including as applied pursuant to section 1857(f)(3)(D)), and section 1903(i)(2)(C), a fraud hotline tip (as defined by the Secretary) without further evidence shall not be treated as sufficient evidence for a credible allegation of fraud.”.
(e) Effective Date.—The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2020.
Passed the House of Representatives June 19, 2018.
| Attest: | karen l. haas, |
| Clerk |