H.R. 5477 — what changed

Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by adding at the end the following new subsection:

changed “(aa) Demonstration project To to increase substance use provider capacity

changed “(1) In general—Beginning January 1, 2019, general—Not later than the Secretary shall conduct a 5-year demonstration project under which date that is 180 days after the date of the enactment of this section, the Secretary shall provide to an eligible State (as defined in paragraph (2)(A)) payments, shall, in accordance with paragraph (3), consultation, as appropriate, with respect to expenditures by such eligible State the Director of the Agency for incentives, training, Healthcare Research and technical assistance for providers under Quality and the State plan (or a waiver of such plan) to expand substance use treatment Assistant Secretary for Mental Health and recovery services Substance Use, conduct a 5-year demonstration project for individuals enrolled the purpose described in paragraph (2) under such State plan (or waiver), including each of which the following activities:Secretary shall—

changed “(A) Activities that support the development of an assessment of the behavioral health treatment needs of the State to determine the extent to which providers are needed (including for the types first 18-month period of such providers and geographic area of need) to improve the network of providers that treat substance use disorders under the State plan (or waiver), including:project, award planning grants described in paragraph (3); and

changed “(i) An estimate of the number of individuals enrolled under “(B) for the State plan (or a waiver remaining 42-month period of such plan) who have a substance use disorder.project, provide to each State selected under paragraph (4) payments in accordance with paragraph (5).

changed “(ii) Information on “(2) Purpose—The purpose described in this paragraph is for each State selected under paragraph (4) to increase the treatment capacity of providers participating under the State plan (or a waiver of such plan) to provide substance use disorder treatment or recovery services to individuals enrolled under the State such plan (or waiver), including information on providers who provide such services.waiver) through the following activities:

changed “(iii) Information on “(A) For the gap purpose described in substance use disorder paragraph (3)(C)(i), activities that support an ongoing assessment of the behavioral health treatment under needs of the State plan (or waiver) based on State, taking into account the information matters described in clauses (i) and (ii).subclauses (I) through (IV) of such paragraph.

changed “(iv) Projections regarding “(B) Activities that, taking into account the extent to which participating under results of the demonstration project would increase assessment described in subparagraph (A), support the number recruitment, training, and provision of technical assistance for providers offering substance use disorder services participating under the State plan (or waiver) during the period a waiver of the demonstration project.such plan) that offer substance use disorder treatment or recovery services.

changed “(B) Activities that, taking into account “(C) Improved reimbursement for and expansion of, through the results provision of the assessment described in subparagraph (A), support the recruitment, education, training, and provision of technical assistance for current, new, and prospective participating assistance, the number or treatment capacity of providers participating under the State plan (or a waiver of such plan) that specialize in substance use disorder treatment and recovery.waiver) that—

removed “(C) Activities that specifically expand, including through the provision of incentives, the number of providers participating under the State plan (or waiver) that—

“(i) are authorized to dispense drugs approved by the Food and Drug Administration for individuals with a substance use disorder who need withdrawal management or maintenance treatment for such disorder;

“(ii) have in effect a registration or waiver under section 303(g) of the Controlled Substances Act for purposes of dispensing narcotic drugs to individuals for maintenance treatment or detoxification treatment and are in compliance with any regulation promulgated by the Assistant Secretary for Mental Health and Substance Use for purposes of carrying out the requirements of such section 303(g); and

added “(iii) are qualified under applicable State law to provide substance use disorder treatment or recovery services.

changed “(iii) are licensed “(D) Improved reimbursement for and expansion of, through the provision of education, training, and technical assistance, the number or certified treatment capacity of providers participating under applicable the State law plan (or waiver) that have the qualifications to provide substance use disorder address the treatment and or recovery services.needs of—

removed “(D) Activities that specifically expand, including through the provision of incentives, the number of providers participating under the State plan (or waiver) that have the qualifications to address the treatment and recovery needs of—

“(i) individuals enrolled under the State plan (or a waiver of such plan) who have neonatal abstinence syndrome, in accordance with guidelines issued by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists relating to maternal care and infant care with respect to neonatal abstinence syndrome;

added “(ii) pregnant women, postpartum women, and infants, particularly the concurrent treatment, as appropriate, and comprehensive case management of pregnant women, post­partum women and infants, enrolled under the State plan (or a waiver of such plan);

removed “(ii) postpartum women and infants, particularly the concurrent treatment and comprehensive case management of post­partum women and infants, enrolled under the State plan (or a waiver of such plan);

“(iii) adolescents and young adults between the ages of 12 and 21 enrolled under the State plan (or a waiver of such plan); or

“(iv) American Indian and Alaska Native individuals enrolled under the State plan (or a waiver of such plan).

added “(3) Planning grants

changed “(2) Eligible States“(A) In general—The Secretary shall, with respect to the first 18-month period of the demonstration project conducted under paragraph (1), award planning grants to at least 10 States selected in accordance with subparagraph (B) for purposes of preparing an application described in paragraph (4)(C) and carrying out the activities described in subparagraph (C).

changed “(A) Definition—For “(B) Selection—In selecting States for purposes of this subsection, the term eligible State means a State selected by paragraph, the Secretary under subparagraph (B).shall—

changed “(B) Selection—For purposes of this subsection, the Secretary shall “(i) select 10 States that meet have a State plan (or waiver of the criteria for eligibility State plan) approved under subparagraph (C). In selecting such States, the Secretary shall—this title;

changed “(i) “(ii) select States in a manner that ensures geographic diversity;diversity; and

changed “(ii) “(iii) give preference to States with a prevalence of substance use disorders (in particular opioid use disorders) that is comparable to or higher than the national average prevalence, as measured by aggregate per capita drug overdoses, or any other measure that the Secretary deems appropriate; andappropriate.

changed “(iii) take into consideration the quality of applications submitted under “(C) Activities described—Activities described in this subparagraph (D).are, with respect to a State, each of the following:

changed “(C) Criteria for eligibility—To be eligible for selection “(i) Activities that support the development of an initial assessment of the behavioral health treatment needs of the State to determine the extent to which providers are needed (including the types of such providers and geographic area of need) to improve the network of providers that treat substance use disorders under subparagraph (B), a the State shall—plan (or waiver), including the following:

changed “(i) have a “(I) An estimate of the number of individuals enrolled under the State plan (or a waiver of the State such plan) approved under this title; andwho have a substance use disorder.

changed “(ii) submit “(II) Information on the capacity of providers to provide substance use disorder treatment or recovery services to individuals enrolled under the Secretary an application in accordance with State plan (or waiver), including information on providers who provide such services and their participation under the requirements in subparagraph (D).State plan (or waiver).

changed “(D) Applications—For purposes of this paragraph, a State shall submit to “(III) Information on the Secretary, at such time and gap in such form and manner as substance use disorder treatment or recovery services under the Secretary requires, an application that includes such information, provisions, and assurances, as State plan (or waiver) based on the Secretary may require, information described in addition to the following:subclauses (I) and (II).

changed “(i) A proposed process for undertaking “(IV) Projections regarding the assessment described in paragraph (1)(A).extent to which the State participating under the demonstration project would increase the number of providers offering substance use disorder treatment or recovery services under the State plan (or waiver) during the period of the demonstration project.

changed “(ii) A proposed process for reviewing reimbursement methodologies and other policies related Activities that, taking into account the results of the assessment described in clause (i), support the development of State infrastructure to, with respect to the provision of substance use disorder treatment or recovery services under the State plan (or waiver) that may create barriers to increasing the number a waiver of such plan), recruit prospective providers delivering substance use disorder services.and provide training and technical assistance to such providers.

changed “(iii) A proposed process for developing a plan that will result in long-term and sustainable provider networks under the State plan (or waiver) that will offer a continuum “(D) Funding—For purposes of care for substance use disorders. Such plan shall include subparagraph (A), there is appropriated, out of any funds in the following:Treasury not otherwise appropriated, $50,000,000, to remain available until expended.

changed “(I) Specific activities to increase access to providers (including providers that specialize in providing substance use disorder services, hospitals, health care systems, and Federally qualified health centers) that offer substance use disorder treatment, recovery, and support services, including short-term detoxification services, outpatient substance use disorder services, and evidence-based peer recovery services.“(4) Post-planning States

changed “(II) Strategies that will incentivize providers “(A) In general—The Secretary shall, with respect to the remaining 42-month period of the demonstration project conducted under paragraph (1), select not more than 5 States in accordance with subparagraph (B) for purposes of carrying out the activities described in paragraph (1)(C) to obtain the necessary training, education, (2) and support to deliver substance use disorder services receiving payments in the State.accordance with paragraph (5).

changed “(III) Milestones and timeliness “(B) Selection—In selecting States for implementing activities set forth in purposes of this paragraph, the plan.Secretary shall—

changed “(IV) Specific measurable targets for increasing the substance use disorder provider network under the State plan (or “(i) select States that received a waiver of such plan).planning grant under paragraph (3);

changed “(iv) A proposed process for reporting the information required under paragraph (4)(A), including information dem­on­strat­ing the progress of the efforts of the State “(ii) select States that submit to expand the capacity of providers to deliver substance use disorder services during Secretary an application in accordance with the period of requirements in subparagraph (C), taking into consideration the demonstration project under this subsection.quality of each such application;

changed “(v) A projected five-year budget for the State to carry out under the demonstration project under this subsection the activities set forth “(iii) select States in the plan.a manner that ensures geographic diversity; and

changed “(3) Payment“(iv) give preference to States with a prevalence of substance use disorders (in particular opioid use disorders) that is comparable to or higher than the national average prevalence, as measured by aggregate per capita drug overdoses, or any other measure that the Secretary deems appropriate.

changed “(A) In general—For each quarter occurring during the period for which the demonstration project is conducted, the Secretary shall pay under this subsection, subject to subparagraph (B), to each eligible State an amount equal to 90 percent of so much of the sums expended during such quarter as are attributable to activities described in paragraph (1).“(C) Applications

changed “(B) Non-duplication of payment—In the case that payment is made under subparagraph (A) with respect “(i) In general—A State seeking to expenditures be selected for activities carried out by purposes of this paragraph shall submit to the Secretary, at such time and in such form and manner as the Secretary requires, an eligible State under application that includes such information, provisions, and assurances, as the demonstration project under this subsection, payment Secretary may not also be made under subsection (a) with respect require, in addition to expenditures for the same activities carried out by the eligible State.following:

changed “(4) Reports“(I) A proposed process for carrying out the ongoing assessment described in paragraph (2)(A), taking into account the results of the initial assessment described in paragraph (3)(C)(i).

changed “(A) State reports—A State receiving payments under this subsection shall, for the period “(II) A review of the demonstration project under this subsection, submit to the Secretary a quarterly report, with respect to expenditures for activities for which payment is made reimbursement methodologies and other policies related to substance use disorder treatment or recovery services under the State under this subsection, on plan (or waiver) that may create barriers to increasing the following:number of providers delivering such services.

added “(III) The development of a plan, taking into account activities carried out under paragraph (3)(C)(ii), that will result in long-term and sustainable provider networks under the State plan (or waiver) that will offer a continuum of care for substance use disorders. Such plan shall include the following:

added “(aa) Specific activities to increase the number of providers (including providers that specialize in providing substance use disorder treatment or recovery services, hospitals, health care systems, Federally qualified health centers, and, as applicable, certified community behavioral health clinics) that offer substance use disorder treatment, recovery, or support services, including short-term detoxification services, outpatient substance use disorder services, and evidence-based peer recovery services.

added “(bb) Strategies that will incentivize providers described in subparagraphs (C) and (D) of paragraph (2) to obtain the necessary training, education, and support to deliver substance use disorder treatment or recovery services in the State.

added “(cc) Milestones and timeliness for implementing activities set forth in the plan.

added “(dd) Specific measurable targets for increasing the substance use disorder treatment and recovery provider network under the State plan (or a waiver of such plan).

added “(IV) A proposed process for reporting the information required under paragraph (6)(A), including information to assess the effectiveness of the efforts of the State to expand the capacity of providers to deliver substance use disorder treatment or recovery services during the period of the demonstration project under this subsection.

added “(V) The expected financial impact of the demonstration project under this subsection on the State.

added “(VI) A description of all funding sources available to the State to provide substance use disorder treatment or recovery services in the State.

added “(VII) A preliminary plan for how the State will sustain any increase in the capacity of providers to deliver substance use disorder treatment or recovery services resulting from the demonstration project under this subsection after the termination of such demonstration project.

added “(VIII) A description of how the State will coordinate the goals of the demonstration project with any waiver received pursuant to section 1115 for the delivery of substance use services under the State plan, as applicable.

added “(ii) Consultation—In completing an application under clause (i), a State shall consult with relevant stakeholders, including Medicaid managed care plans, health care providers, and Medicaid beneficiary advocates, and include in such application a description of such consultation.

added “(5) Payment

added “(A) In general—For each quarter occurring during the period for which the demonstration project is conducted (after the first 18 months of such period), the Secretary shall pay under this subsection, subject to subparagraphs (C) and (D), to each State selected under paragraph (4) an amount equal to 80 percent of so much of the qualified sums expended during such quarter.

added “(B) Qualified sums defined—For purposes of subparagraph (A), the term “qualified sums” means, with respect to a State and a quarter, the amount equal to the amount (if any) by which the sums expended by the State during such quarter attributable to substance use treatment or recovery services furnished by providers participating under the State plan (or a waiver of such plan) exceeds 1/4 of such sums expended by the State during fiscal year 2018 attributable to substance use treatment or recovery services.

added “(C) Non-duplication of payment—In the case that payment is made under subparagraph (A) with respect to expenditures for substance use treatment or recovery services furnished by providers participating under the State plan (or a waiver of such plan), payment may not also be made under subsection (a) with respect to expenditures for the same services so furnished.

added “(D) Conditions—In the case of a State selected under paragraph (4) that provides substance use disorder treatment and recovery services under a waiver under section 1115, such State shall, as a condition of receiving payments under subparagraph (A)—

added “(i) coordinate such services under such waiver with substance use disorder treatment and recovery services provided under the demonstration project under this subsection; and

added “(ii) take such actions as appropriate under the demonstration project to expand such services under such waiver.

added “(6) Reports

added “(A) State reports—A State receiving payments under paragraph (5) shall, for the period of the demonstration project under this subsection, submit to the Secretary a quarterly report, with respect to expenditures for substance use treatment or recovery services for which payment is made to the State under this subsection, on the following:

“(i) The specific activities with respect to which payment under this subsection was provided.

added “(ii) The number of providers that delivered substance use disorder treatment or recovery services in the State under the demonstration project compared to the estimated number of providers that would have otherwise delivered such services in the absence of such demonstration project.

added “(iii) The number of individuals enrolled under the State plan (or a waiver of such plan) who received substance use disorder treatment or recovery services under the demonstration project compared to the estimated number of such individuals who would have otherwise received such services in the absence of such demonstration project.

removed “(ii) The number of providers that delivered substance use disorder services in the State under the demonstration project compared to the estimated number of providers that would have otherwise delivered such services in the absence of such demonstration project.

removed “(iii) The number of individuals enrolled under the State plan (or a waiver of such plan) who received substance use disorder services under the demonstration project compared to the estimated number of such individuals who would have otherwise received such services in the absence of such demonstration project.

“(iv) Other matters as determined by the Secretary.

“(B) CMS reports

added “(i) Initial report—Not later than October 1, 2020, the Administrator of the Centers for Medicare & Medicaid Services shall, in consultation with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, submit to Congress an initial report on—

added “(I) the States awarded planning grants under paragraph (3);

added “(II) the criteria used in such selection; and

added “(III) the activities carried out by such States under such planning grants.

added “(ii) Interim report—Not later than October 1, 2022, the Administrator of the Centers for Medicare & Medicaid Services shall, in consultation with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, submit to Congress an interim report—

added “(I) on activities carried out under the demonstration project under this subsection;

added “(II) on the extent to which States selected under paragraph (4) have achieved the stated goals submitted in their applications under subparagraph (C) of such paragraph;

added “(III) with a description of the strengths and limitations of such demonstration project; and

added “(IV) with a plan for the sustainability of such project.

added “(iii) Final report—Not later than October 1, 2024, the Administrator of the Centers for Medicare & Medicaid Services shall, in consultation with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, submit to Congress a final report—

added “(I) providing updates on the matters reported in the interim report under clause (ii);

added “(II) including a description of any changes made with respect to the demonstration project under this subsection after the submission of such interim report; and

added “(III) evaluating such demonstration project.

added “(C) AHRQ report—Not later than three years after the date of the enactment of this subsection, the Director of the Agency for Healthcare Research and Quality shall submit to Congress a summary on the experiences of States awarded planning grants under paragraph (3) and States selected under paragraph (4).

added “(7) Data sharing and best practices—During the period of the demonstration project under this subsection, the Secretary shall, in collaboration with States selected under paragraph (4), facilitate data sharing and the development of best practices between such States and States that were not so selected.

added “(8) CMS funding—There is appropriated, out of any funds in the Treasury not otherwise appropriated, $5,000,000 to the Centers for Medicare & Medicaid Services for purposes of implementing this subsection. Such amount shall remain available until expended.”

removed “(i) Interim report—Not later than October 1, 2022, the Administrator of the Centers for Medicare & Medicaid Services shall submit to Congress an interim report on activities carried out under the demonstration project under this subsection.

removed “(ii) Final report—Not later than October 1, 2024, the Administrator of the Centers for Medicare & Medicaid Services shall submit to Congress a final report on activities carried out under the demonstration project under this subsection.”