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H.R. 4758 — what changed

Accelerating Kids’ Access to Care Act

From Introduced in House to Reported in House. 1 section amended and 2 added between Introduced in House and Reported in House.

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

changed “(A) In general—The State adopts and implements a process that enables an eligible out-of-State provider to enroll as a participating provider in the State plan (or a waiver of such plan) without the imposition of additional screening requirements by the State, unless general—If the State has 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 in accordance consistent with guidance issued by the Secretary under section 1945A. An eligible out-of-State provider that enrolls as a participating provider in the State plan (or a waiver of such plan) through such process shall be enrolled for a 5-year period unless 1945A, the provider is terminated or excluded from participation during such period.State—

added “(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

added “(ii) provides that an eligible out-of-State provider that enrolls as a participating provider in the State plan (or a waiver of such plan) through such process shall be so enrolled for a 5-year period, unless the provider is terminated or excluded from participation during such period.

“(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—

removed “(I) that furnishes to a qualifying individual any item or service for which Federal financial assistance is available under the State plan (or a waiver of such plan);

removed “(II) that is located in any other State;

changed “(III) with respect to which the Secretary has determined (or, in the case of a provider for which no risk level determination has been made by the Secretary, the State agency administering or supervising the administration of the State plan (or a waiver of such plan) has determined) there “(I) that is a limited risk of fraud, waste, and abuse for purposes of determining the level of screening to be conducted under section 1866(j)(2) (except that, if such State agency has designated a higher risk level for the provider than the Secretary, the State agency's designation shall apply);located in any other State;

changed “(IV) that has been screened under such section 1866(j)(2) and enrolled in the Medicare program under title XVIII, or screened under paragraph (1) of this subsection and enrolled in the State plan (or a waiver of such plan) in which such provider is located; and“(II) that—

changed “(V) that has not been excluded from participation in any Federal health care program pursuant to section 1128 or 1128A, excluded from participation in “(aa) was determined by the State plan (or a waiver of such plan) pursuant Secretary to part 1002 have a limited risk of title 42, Code fraud, waste, and abuse for purposes of Federal Regulations, or State law, or terminated from participating in a Federal health care program or determining the State plan (or a waiver level of screening to be conducted under section 1866(j)(2), has been so screened under such plan) for a reason described section 1866(j)(2), and is enrolled in paragraph (8)(A) of this subsection.the Medicare program under title XVIII; or

changed “(ii) Qualifying individual—The term qualifying individual means, with respect to an eligible out-of-State provider, an individual under 21 years “(bb) was determined by the State agency administering or supervising the administration of age to whom the provider furnishes items State plan (or a waiver of such plan) of such other State to have a limited risk of fraud, waste, and services abuse for purposes of determining the treatment 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 condition.waiver of such plan); and

added “(III) that has not been—

added “(aa) excluded from participation in any Federal health care program pursuant to section 1128 or 1128A;

added “(bb) excluded from participation in the State plan (or a waiver of such plan) pursuant to part 1002 of title 42, Code of Federal Regulations (or any successor regulation), or State law; or

added “(cc) terminated from participating in a Federal health care program or the State plan (or a waiver of such plan) for a reason described in paragraph (8)(A).

added “(ii) Qualifying individual—The term qualifying individual means an individual under 21 years of age who is enrolled under the State plan (or waiver of such plan).

“(iii) State—The term State means 1 of the 50 States or the District of Columbia.”

(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,”.
(c)
added Effective date— The amendments made by this section shall take effect on the date that is 3 years after the date of enactment of this section.
(c)
removed Effective date—
(1)
removed In general— Except as provided in paragraph (2), the amendments made by this section take effect on the date that is 2 years after the date of enactment of this Act.
(2)
removed Exception for State legislation— In the case of a State plan under Medicaid or a State child health plan under CHIP which the Secretary determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, such State plan or State child health plan shall not be regarded as failing to comply with the requirements of Medicaid or CHIP, respectively, solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.

Sec. 3 Preventing the use of abusive spread pricing in medicaid

added
(a)
added 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:

added “(6) Transparent prescription drug pass-through pricing required

added “(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—

added “(i) any payment made by the entity or the PBM (as applicable) for such a drug—

added “(I) is limited to—

added “(aa) ingredient cost; and

added “(bb) a professional dispensing fee that is not less than the professional dispensing fee that the State plan or waiver would pay if the plan or waiver was making the payment directly;

added “(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

added “(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—

added “(aa) such drug was subject to an agreement under section 340B of the Public Health Service Act;

added “(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

added “(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;

added “(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;

added “(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

added “(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.

added “(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)
added Conforming amendments— Section 1903(m) of such Act (42 U.S.C. 1396b(m)) is amended—
(1)
added in paragraph (2)(A)(xiii)—
(A)
added by striking “and (III)” and inserting “(III)”;
(B)
added by inserting before the period at the end the following: “, and (IV) if the contract includes provisions making the entity responsible for coverage of covered outpatient drugs, the entity shall comply with the requirements of section 1927(e)(6)”; and
(C)
added by moving the left margin 4 ems to the left; and
(2)
added by adding at the end the following new paragraph:

added “(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)
added 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)
added Implementation—
(1)
added In general— Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the amendments made by this section by program instruction or otherwise.
(2)
added Nonapplication of Administrative Procedure Act— Implementation of the amendments made by this section shall be exempt from the requirements of section 553 of title 5, United States Code.
(e)
added 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

added

added 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”.