Home > Committee Reports > 115th Congress > H. Rept. 115-734 > Part 1

H. Rept. 115-734 - CHIP MENTAL HEALTH PARITY ACT115th Congress (2017-2018)

Committee Report

Report Type:	House Report
Accompanies:	H.R.3192
Committees:	Energy and Commerce (Part 1)

Report text available as:

TXT
PDF (PDF provides a complete and accurate display of this text.) Tip ?

115th Congress } { REPORT
HOUSE OF REPRESENTATIVES
2d Session } { 115-734

======================================================================

CHIP MENTAL HEALTH PARITY ACT

_______

June 12, 2018.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed

_______

Mr. Walden, from the Committee on Energy and Commerce, submitted the
following

R E P O R T

[To accompany H.R. 3192]

[Including cost estimate of the Congressional Budget Office]

The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 3192) to amend title XXI of the Social Security
Act to ensure access to mental health services for children
under the Children's Health Insurance Program, and for other
purposes, having considered the same, report favorably thereon
with an amendment and recommend that the bill as amended do
pass.

CONTENTS

Page
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 3
Committee Action................................................. 5
Committee Votes.................................................. 6
Oversight Findings and Recommendations........................... 6
New Budget Authority, Entitlement Authority, and Tax Expenditures 6
Congressional Budget Office Estimate............................. 6
Federal Mandates Statement....................................... 28
Statement of General Performance Goals and Objectives............ 28
Duplication of Federal Programs.................................. 28
Committee Cost Estimate.......................................... 28
Earmark, Limited Tax Benefits, and Limited Tariff Benefits....... 29
Disclosure of Directed Rule Makings.............................. 29
Advisory Committee Statement..................................... 29
Applicability to Legislative Branch.............................. 29
Section-by-Section Analysis of the Legislation................... 29
Changes in Existing Law Made by the Bill, as Reported............ 30

The amendment is as follows:
Strike all after the enacting clause and insert the
following:

SECTION 1. SHORT TITLE.

This Act may be cited as the ``CHIP Mental Health Parity Act''.

SEC. 2. ENSURING ACCESS TO MENTAL HEALTH AND SUBSTANCE USE DISORDER
SERVICES FOR CHILDREN AND PREGNANT WOMEN UNDER THE
CHILDREN'S HEALTH INSURANCE PROGRAM.

(a) In General.--Section 2103(c)(1) of the Social Security Act (42
U.S.C. 1397cc(c)(1)) is amended by adding at the end the following new
subparagraph:
``(E) Mental health and substance use disorder
services (as defined in paragraph (5)).''.
(b) Mental Health and Substance Use Disorder Services.--
(1) In general.--Section 2103(c) of the Social Security Act
(42 U.S.C. 1397cc(c)) is amended--
(A) by redesignating paragraphs (5), (6), (7), and
(8) as paragraphs (6), (7), (8), and (9), respectively;
and
(B) by inserting after paragraph (4) the following
new paragraph:
``(5) Mental health and substance use disorder services.--In
the case of a State that provides child health assistance for
targeted low-income children or targeted low-income pregnant
women (as defined in section 2112(d)) in the form of providing
any health benefits coverage described in subsection (a), such
child health assistance shall--
``(A) include coverage of mental health services
(including behavioral health treatment) necessary to
prevent, diagnose, and treat a broad range of mental
health symptoms and disorders, including substance use
disorders; and
``(B) be delivered in a culturally and linguistically
appropriate manner.''.
(2) Conforming amendments.--
(A) Section 2103(a) of the Social Security Act (42
U.S.C. 1397cc(a)) is amended, in the matter before
paragraph (1), by striking ``paragraphs (5), (6), and
(7)'' and inserting ``paragraphs (5), (6), (7), and
(8)''.
(B) Section 2110(a) of the Social Security Act (42
U.S.C. 1397jj(a)) is amended--
(i) in paragraph (18), by striking
``substance abuse'' each place it appears and
inserting ``substance use''; and
(ii) in paragraph (19), by striking
``substance abuse'' and inserting ``substance
use''.
(C) Section 2110(b)(5)(A)(i) of the Social Security
Act (42 U.S.C. 1397jj(b)(5)(A)(i)) is amended by
striking ``subsection (c)(5)'' and inserting
``subsection (c)(6)''.
(c) Assuring Access to Care.--Section 2102(a)(7)(B) of the Social
Security Act (42 U.S.C. 1397bb(c)(2)) is amended by striking ``section
2103(c)(5)'' and inserting ``paragraphs (5) and (6) of section
2103(c)''.
(d) Mental Health Services Parity.--Subparagraph (A) of paragraph (7)
of section 2103(c) of the Social Security Act (42 U.S.C. 1397cc(c)) (as
redesignated by subsection (b)(1)) is amended to read as follows:
``(A) In general.--A State child health plan shall
ensure that the financial requirements and treatment
limitations applicable to mental health and substance
use disorder services (as described in paragraph (5))
provided under such plan comply with the requirements
of section 2726(a) of the Public Health Service Act in
the same manner as such requirements or limitations
apply to a group health plan under such section.''.
(e) Effective Date.--
(1) In general.--Subject to paragraph (2), the amendments
made by this section shall take effect with respect to child
health assistance provided on or after the date that is one
year after the date of the enactment of this Act.
(2) Exception for state legislation.--In the case of a State
child health plan under title XXI of the Social Security Act
(or a waiver of such plan), which the Secretary of Health and
Human Services determines requires State legislation in order
for the respective plan (or waiver) to meet any requirement
imposed by the amendments made by this section, the respective
plan (or waiver) shall not be regarded as failing to comply
with the requirements of such title solely on the basis of its
failure to meet such an additional requirement 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 enactment of this section. For purposes of
the previous sentence, in the case of a State that has a 2-year
legislative session, each year of the session shall be
considered to be a separate regular session of the State
legislature.

Purpose and Summary

H.R. 3192 was introduced on July 7, 2017, by Rep. Joseph
Kennedy, III (D-MA). The bill requires comprehensive mental
health and substance use disorder services as a mandatory
benefit under the CHIP program for pregnant women and children.

Background and Need for Legislation

Deaths due to overdoses of opioids and other drugs have
ravaged American communities. According to the Centers for
Disease Control and Prevention (CDC), on average, 1,000 people
are treated for opioid misuse in emergency departments per day,
an average of 115 Americans die per day, and opioid-related
overdoses have increased steadily since 1999.\1\
---------------------------------------------------------------------------
\1\Centers for Disease Control and Prevention. ``Drug Overdose
Death Data.'' December 19, 2017. Available at https://www.cdc.gov/
drugoverdose/data/statedeaths.html.
---------------------------------------------------------------------------
While the impacts to Americans' health outcomes are
staggering, the opioid crisis has negatively impacted society
in numerous ways. The Centers for Disease Control and
Prevention note that life expectancy dropped in 2015 and 2016
and that one of the reasons was an increase in unintentional
injuries, a category that includes drug overdoses.\2\ The
opioid crisis has also resulted in a contraction in the labor
force by almost 1 million workers in the years between 1999 and
2015, which resulted in a loss of $702 billion in real
output.\3\ In 2015, the total economic burden of the opioid
epidemic was estimated to be $504 billion.\4\ While all states
were negatively impacted, there is geographic variation in the
burden. West Virginia had the greatest loss per person ($4,378)
and Nebraska had the lowest loss per person ($394).\4\ One
recent analysis found that the annual cost for private sector
employers for treating opioid addiction and overdoses has
increased more than eight-fold since 2004, and more than one in
five persons aged 55 to 64 had at least one opioid prescription
in 2016.\5\
---------------------------------------------------------------------------
\2\Dowell, D., Arias E., Kochanek K. et al. ``Contribution of
Opioid-Involved Poisoning to the Change in Life Expectancy in the
United States, 2000-2015.'' JAMA, September 2017. Available at https://
jamanetwork.com/journals/jama/fullarticle/2654372.
\3\American Action Forum. ``The Labor Force and Output Consequences
of the Opioid Crisis.'' March 27, 2018. Available at https://
www.americanactionforum.org/research/labor-force-output-consequences-
opioid-crisis/.
\4\American Enterprise Institute. ``The Geographic Variation in the
Cost of the Opioid Crisis''. Available at https://www.aei.org/wp-
content/uploads/2018/03/Geographic_Variation_in_Cost_
of_Opioid_Crisis.pdf.
\5\Kaiser Family Foundation, ``A Look at How the Opioid Crisis Has
Affected People with Employer Coverage,'' April 2018. Available online
at: https://www.kff.org/health-costs/press-release/analysis-cost-of-
treating-opioid-addiction-rose-rapidly-for-large-employers-as-the-
number-of-prescriptions-has-declined/.
---------------------------------------------------------------------------
Medicaid is the largest source of federal funding for
behavioral health services--mental health and substance use
disorder services--with nearly $71 billion in projected 2017
spending.\6\ As the Medicaid and CHIP Payment and Access
Commission (MACPAC) stated in 2017, ``the opioid epidemic,
which has reached most communities across the U.S.,
disproportionately affects Medicaid beneficiaries.''\7\
Medicaid provides care to four in ten adults with opioid use
disorder and compared to other insurance types, provides a
significantly higher percentage of inpatient and outpatient
substance use disorder treatment.\8\
---------------------------------------------------------------------------
\6\Government Accountability Office, ``Medicaid: States Fund
Services for Adults in Institutions for Mental Disease Using a Variety
of Strategies,'' GAO-17-652, August 2017. Available at https://
www.gao.gov/assets/690/686456.pdf.
\7\Medicaid and CHIP Payment and Access Commission, ``Medicaid and
the Opioid Epidemic,'' Chapter 2 in June 2017 Report to Congress on
Medicaid and CHIP. Available at: https://www.macpac.gov/wp-content/
uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf.
\8\Kaiser Family Foundation. ``Medicaid's Role in Addressing the
Opioid Epidemic.'' Available at https://www.kff.org/infographic/
medicaids-role-in-addressing-opioid-epidemic/.
---------------------------------------------------------------------------
MACPAC found that ``Medicaid beneficiaries are prescribed
pain relievers at higher rates than those with other sources of
insurance. They also have a higher risk of overdose and other
negative outcomes, from both prescription opioids and illegal
opioids such as heroin and illicitly manufactured
fentanyl.''\9\ Not only are the number of Medicaid
beneficiaries with opioid misuse disproportionately high, so
too are the number of overdoses. Studies from North Carolina
and Washington indicate high rates of opioid-related deaths for
the Medicaid population (33 percent and 45 percent,
respectively).
---------------------------------------------------------------------------
\9\Medicaid and CHIP Payment and Access Commission, ``Medicaid and
the Opioid Epidemic,'' Chapter 2 in June 2017 Report to Congress on
Medicaid and CHIP. Available at: https://www.macpac.gov/wp-content/
uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf.
---------------------------------------------------------------------------
For treatment, Medicaid has several pharmacy and medical
benefits for treating opioid use disorder that vary by state. A
primary pharmaceutical treatment offered to patients with
opioid abuse and/or substance use disorder is medication-
assisted treatment (MAT). The Substance Abuse and Mental Health
Services Administration (SAMHSA) describes MAT as ``the use of
FDA-approved medications, in combination with counseling and
behavioral therapies, to provide a `whole-patient' approach to
the treatment of substance use disorders.''\10\
---------------------------------------------------------------------------
\10\See SAMHSA website. Available at: https://www.samhsa.gov/
medication-assisted-treatment.
---------------------------------------------------------------------------
Non-pharmaceutical treatment of opioid use disorder in
Medicaid occurs in inpatient, outpatient, residential, and
community-based settings. MACPAC's 2017 analysis found that
``Medicaid is responding to the opioid crisis by covering
treatment, innovating in the delivery of care, and working with
other state agencies to reduce misuse of prescription
opioids.'' State Medicaid programs adopt strategies and design
their programs to meet the needs of their Medicaid
beneficiaries resulting in variations in covered treatment
services and settings. It is important state Medicaid programs
provide a continuum of care to serve the needs of Medicaid
beneficiaries.
However, as MACPAC noted, ``there are gaps in the continuum
of care, and states vary in the extent to which they cover
needed treatment.'' One of the barriers to appropriate
treatment consistently identified by Medicaid directors and
health policy experts is a statutory prohibition on federal
Medicaid matching funds for paying for care for certain
Medicaid beneficiaries in Institutions for Mental Diseases
(IMD). As MACPAC has explained, ``the Medicaid IMD exclusion
acts a barrier for individuals with an opioid use disorder to
receive residential treatment, which, depending on an
individual's treatment plan, may be the most appropriate
setting for care.'' Given these and other findings, there
continues to be an opportunity for Congress and state Medicaid
programs to work to improve access to timely, high-quality
treatment across the continuum of care.
States may design their CHIP programs in three ways. They
may cover eligible children under their Medicaid programs
(i.e., CHIP Medicaid expansion), create a separate CHIP
program, or adopt a combination approach where the state
operates a CHIP Medicaid expansion and one or more separate
CHIP programs concurrently. Regardless of the choice of benefit
design, all states must cover emergency services, well-baby and
well-child care, including age-appropriate immunizations,
vision, and dental services under CHIP. All CHIP programs cover
some level of outpatient and inpatient mental health services,
but not all cover substance use disorder treatment.\11\
---------------------------------------------------------------------------
\11\Kaiser Family Foundation, ``The Impact of the Children's Health
Insurance Program (CHIP): What Does the Research Tell US?'', July 17,
2014. Available at: https://www.kff.org/report-section/the-impact-of-
the-childrens-health-insurance-program-chip-issue-brief/.
---------------------------------------------------------------------------
In general, states with CHIP Medicaid expansion programs
must provide CHIP-eligible children with the same benefits
provided to children enrolled in the Medicaid program. Under
Medicaid, states are required to provide Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) services, which
covers health screenings and services, including assessments of
each child's physical and mental health development. States are
required to provide all federally allowed treatment to correct
problems identified through screenings--including mental
health, substance use disorder, and behavioral health treatment
needs. EPSDT sets Medicaid benefit coverage for children
(including CHIP children) apart from other sources of health
insurance in that it permits coverage of all services listed in
Medicaid statute (regardless of whether a given benefit is
covered in the state plan). Coverage of EPSDT is deemed to be
compliant with mental health parity, including the financial
requirements and treatment limitations for individuals entitled
to such benefits.\12\\13\
---------------------------------------------------------------------------
\12\Sec. 1937(b)(6)(B) of the Social Security Act (SSA); 42 C.F.R.
Sec. 440.395(c).
\13\Financial requirements refer to deductibles, copayments,
coinsurance, or out of pocket maximums, while treatment limitations
include limits on frequency of treatment, number of visits, days of
coverage, or other similar limits on scope of coverage.
---------------------------------------------------------------------------
States that offer separate CHIP programs have more latitude
in designing benefit coverage, and benefits must be on par with
an approved benchmark plan. Such states can determine which
services to cover and may place limits on the services that
they offer. States are not required to offer mental health
services and substance use disorder services (including
behavioral health treatment) under separate CHIP programs.
However, if offered, such services must meet federal mental
health parity requirements related to financial requirements
and treatment limitations for such benefits.\14\ This benefit
coverage must be benchmarked to one of the following: a federal
employees health benefits program equivalent, state employee
coverage, or coverage offered through a health maintenance
organization.\15\ The benchmark can also be an existing
comprehensive state-based program or one approved by the
Secretary. Reviews of separate CHIP programs found that nearly
all covered outpatient and inpatient substance use disorder
services.\16\ In addition, the level of benefits offered varied
greatly.
---------------------------------------------------------------------------
\14\SSA Sec. 2103(c)(6)(A).
\15\Section 2103 of the Social Security Act.
\16\Anita Cardwell, et al., National Academy for State Health
Policy and Georgetown University Health Policy Institute, Center for
Children and Families; Benefits and Cost Sharing in Separate CHIP
Programs, May 2014. Available at http://ccf.georgetown.edu/wp-content/
uploads/2014/05/Benefits-and-Cost-Sharing-in-Separate-CHIP-
Programs.pdf.
---------------------------------------------------------------------------

Committee Action

On April 11 and 12, 2018, the Subcommittee on Health held a
hearing on H.R. 3192. The Subcommittee received testimony from:
Kimberly Brandt, Principal Deputy
Administrator for Operations, Centers for Medicare and
Medicaid Services, U.S. Department of Health and Human
Services;
Michael Botticelli, Executive Director,
Grayken Center for Addiction, Boston Medical Center;
Toby Douglas, Senior Vice President,
Medicaid Solutions, Centene Corporation;
David Guth, Chief Executive Officer,
Centerstone;
John Kravitz, Chief Information Officer,
Geisinger Health System; and,
Sam Srivastava, Chief Executive Officer,
Magellan Health.
On April 25, 2018, the Subcommittee on Health met in open
markup session and forwarded H.R. 3192, without amendment, to
the full Committee by a voice vote. On May 17, 2018, the full
Committee on Energy and Commerce met in open markup session and
ordered H.R. 3192, as amended, favorably reported to the House
by a voice vote.

Committee Votes

Clause 3(b) of rule XIII requires the Committee to list the
record votes on the motion to report legislation and amendments
thereto. There were no record votes taken in connection with
ordering H.R. 3192 reported.

Oversight Findings and Recommendations

Pursuant to clause 2(b)(1) of rule X and clause 3(c)(1) of
rule XIII, the Committee held a hearing and made findings that
are reflected in this report.

New Budget Authority, Entitlement Authority, and Tax Expenditures

Pursuant to clause 3(c)(2) of rule XIII, the Committee
finds that H.R. 3192 would result in no new or increased budget
authority, entitlement authority, or tax expenditures or
revenues.

Congressional Budget Office Estimate

Pursuant to clause 3(c)(3) of rule XIII, the following is
the cost estimate provided by the Congressional Budget Office
pursuant to section 402 of the Congressional Budget Act of
1974:

U.S. Congress,
Congressional Budget Office,
Washington, DC, June 6, 2018.
Hon. Greg Walden,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed document with cost estimates for the
opioid-related legislation ordered to be reported on May 9 and
May 17, 2018.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contacts are Tom Bradley
and Chad Chirico.
Sincerely,
Mark P. Hadley
(For Keith Hall, Director).
Enclosure.

Opioid Legislation

Summary: On May 9 and May 17, 2018, the House Committee on
Energy and Commerce ordered 59 bills to be reported related to
the nation's response to the opioid epidemic. Generally, the
bills would:
Provide grants to facilities and providers
that treat people with substance use disorders,
Direct various agencies within the
Department of Health and Human Services (HHS) to
explore nonopioid approaches to treating pain and to
educate providers about those alternatives,
Modify requirements under Medicaid and
Medicare for prescribing controlled substances,
Expand Medicaid coverage for substance abuse
treatment, and
Direct the Food and Drug Administration
(FDA) to modify its oversight of opioid drugs and other
medications that are used to manage pain.
Because of the large number of related bills ordered
reported by the Committee, CBO is publishing a single
comprehensive document that includes estimates for each piece
of legislation.
CBO estimates that enacting 20 of the bills would affect
direct spending, and 2 of the bills would affect revenues;
therefore, pay-as-you-go procedures apply for those bills.
CBO estimates that enacting H.R. 4998, the Health Insurance
for Former Foster Youth Act, would increase net direct spending
by more than $2.5 billion and on-budget deficits by more than
$5 billion in at least one of the four consecutive 10-year
periods beginning in 2029. None of the remaining 58 bills
included in this estimate would increase net direct spending by
more than $2.5 billion or on-budget deficits by more than $5
billion in any of the four consecutive 10-year periods
beginning in 2029.
One of the bills reviewed for this document, H.R. 5795,
would impose both intergovernmental and private-sector mandates
as defined in the Unfunded Mandates Reform Act (UMRA). CBO
estimates that the costs of those mandates on public and
private entities would fall below the thresholds in UMRA ($80
million and $160 million, respectively, in 2018, adjusted
annually for inflation). Five bills, H.R. 5228, H.R. 5333, H.R.
5554, H.R. 5687, and H.R. 5811, would impose private-sector
mandates as defined in UMRA. CBO estimates that the costs of
the mandates in three of the bills (H.R. 5333, H.R. 5554, and
H.R. 5811) would not exceed the UMRA threshold for private
entities. Because CBO is uncertain how federal agencies would
implement new authority granted in the other two bills, H.R.
5228 and H.R. 5687, CBO cannot determine whether the costs of
those mandates would exceed the UMRA threshold.
Estimated cost to the Federal Government: The estimates in
this document do not include the effects of interactions among
the bills. If all 59 bills were combined and enacted as one
piece of legislation, the budgetary effects would be different
from the sum of the estimates in this document, although CBO
expects that any such differences would be small. The costs of
this legislation fall within budget functions 550 (health), 570
(Medicare), 750 (administration of justice), and 800 general
government).
Basis of estimate: For this estimate, CBO assumes that all
of the legislation will be enacted late in 2018 and that
authorized and estimated amounts will be appropriated each
year. Outlays for discretionary programs are estimated based on
historical spending patterns for similar programs.

Uncertainty

CBO aims to produce estimates that generally reflect the
middle of a range of the most likely budgetary outcomes that
would result if the legislation was enacted. Because data on
the utilization of mental health and substance abuse treatment
under Medicaid and Medicare is scarce, CBO cannot precisely
predict how patients or providers would respond to some policy
changes or what budgetary effects would result. In addition,
several of the bills would give the Department of Health and
Human Services (HHS) considerable latitude in designing and
implementing policies. Budgetary effects could differ from
those provided in CBO's analyses depending on those decisions.

Direct spending and revenues

Table 1 lists the 22 bills of the 59 ordered to be reported
that would affect direct spending or revenues.

TABLE 1.--ESTIMATED CHANGES IN MANDATORY SPENDING AND REVENUES
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------------------------------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2019-2023 2019-2028
--------------------------------------------------------------------------------------------------------------------------------------------------------
INCREASES OR DECREASES (-) IN DIRECT SPENDING

Legislation Primarily Affecting
Medicaid:
H.R. 1925, At-Risk Youth 0 * 5 5 5 10 10 10 10 10 10 25 75
Medicaid Protection Act of
2017......................
H.R. 4998, Health Insurance 0 0 0 0 0 * 10 21 33 46 61 * 171
for Former Foster Youth
Act.......................
H.R. 5477, Rural 0 13 35 58 68 83 27 9 3 3 3 256 301
Development of Opioid
Capacity Services Act.....
H.R. 5583, a bill to amend 0 * * * * * * * * * * * *
title XI of the Social
Security Act to require
States to annually report
on certain adult health
quality measures, and for
other purposes............
H.R. 5797, IMD CARE Act.... 0 38 158 251 265 279 0 0 0 0 0 991 991
H.R. 5799, Medicaid DRUG 0 * * 1 1 1 1 1 1 1 1 2 5
Improvement Acta..........
H.R. 5801 Medicaid 0 * * * * * * * * * * * *
Providers Are Required To
Note Experiences in Record
Systems to Help In-Need
Patients (PARTNERSHIP)
Acta......................
H.R. 5808, Medicaid 0 * -1 -1 -1 -1 -2 -2 -2 -2 -2 -4 -13
Pharmaceutical Home Act of
2018a.....................
H.R. 5810, Medicaid Health 0 94 58 62 56 52 48 43 38 32 25 323 509
HOME Act..................
Legislation Primarily Affecting
Medicare:
H.R. 3528, Every 0 0 0 -24 -35 -33 -30 -33 -32 -31 -32 -92 -250
Prescription Conveyed
Securely Act..............
H.R. 4841, Standardizing 0 0 0 * * * * * * * * * *
Electronic Prior
Authorization for Safe
Prescribing Act of 2018...
H.R. 5603, Access to 0 2 * * * 1 1 1 2 2 2 3 11
Telehealth Services for
Opioid Use Disorders Act..
H.R. 5605, Advancing High 0 0 0 15 26 24 23 23 10 1 * 65 122
Quality Treatment for
Opioid Use Disorders in
Medicare Act..............
H.R. 5675, a bill to amend 0 0 0 -6 -7 -7 -7 -8 -9 -9 -11 -20 -64
title XVIII of the Social
Security Act to require
prescription drug plan
sponsors under the
Medicare program to
establish drug management
programs for at-risk
beneficiaries.............
H.R. 5684, Protecting 0 0 0 * * * * * * * * * *
Seniors From Opioid Abuse
Act.......................
H.R. 5796, Responsible 0 10 25 50 10 5 0 0 0 0 0 100 100
Education Achieves Care
and Healthy Outcomes for
Users' Treatment Act of
2018......................
H.R. 5798, Opioid Screening 0 0 * 1 1 1 1 1 1 1 1 2 5
and Chronic Pain
Management Alternatives
for Seniors Act...........
H.R. 5804, Post-Surgical 0 0 25 30 25 20 10 5 0 0 0 100 115
Injections as an Opioid
Alternative Acta..........
H.R. 5809, Postoperative 0 0 0 0 10 15 20 25 30 35 45 25 180
Opioid Prevention Act of
2018......................
Legislation Primarily Affecting
the Food and Drug
Administration:
H.R. 5333, Over-the-Counter 0 0 * * * * * * * * * * *
Monograph Safety,
Innovation, and Reform Act
of 2018a..................

INCREASES OR DECREASES (-) IN REVENUESb

H.R. 5752, Stop Illicit 0 * * * * * * * * * * * *
Drug Importation Act of
2018......................
--------------------------------------------------------------------------------------------------------------------------------------------------------
Annual amounts may not sum to totals because of rounding. * = between -$500,000 and $500,000. Budget authority is equivalent to outlays.
aThis bill also would affect spending subject to appropriation.
bOne additional bill, H.R. 5228, the Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act, would have a negligible effect on revenues.

Legislation Primarily Affecting Medicaid. The following
nine bills would affect direct spending for the Medicaid
program.
H.R. 1925, the At-Risk Youth Medicaid Protection Act of
2017, would require states to suspend, rather than terminate,
Medicaid eligibility for juvenile enrollees (generally under 21
years of age) who become inmates of public correctional
institutions. States also would have to redetermine those
enrollees' Medicaid eligibility before their release and
restore their coverage upon release if they qualify for the
program. States would be required to process Medicaid
applications submitted by or on behalf of juveniles in public
correctional institutions who were not enrolled in Medicaid
before becoming inmates and ensure that Medicaid coverage is
provided when they are released if they are found to be
eligible. On the basis of an analysis of juvenile incarceration
trends and of the per enrollee spending for Medicaid foster
care children, who have a similar health profile to
incarcerated juveniles, CBO estimates that implementing the
bill would cost $75 million over the 2019-2028 period.
H.R. 4998, the Health Insurance for Former Foster Youth
Act, would require states to provide Medicaid coverage to
adults up to age 25 who had aged out of foster care in any
state. Under current law, such coverage is mandatory only if
the former foster care youth has aged out in the state in which
the individual applies for coverage. The policy also would
apply to former foster children who had been in foster care
upon turning 14 years of age but subsequently left foster care
to enter into a legal guardianship with a kinship caregiver.
The provisions would take effect respect for foster youth who
turn 18 on or after January 1, 2023. On the basis of spending
for Medicaid foster care children and data from the Census
Bureau regarding annual migration rates between states, CBO
estimates that implementing the bill would cost $171 million
over the 2019-2028 period.
H.R. 5477, the Rural Development of Opioid Capacity
Services Act, would direct the Secretary of HHS to conduct a
five-year demonstration to increase the number and ability of
providers participating in Medicaid to provide treatment for
substance use disorders. On the basis of an analysis of federal
and state spending for treatment of substance use disorders and
the prevalence of such disorders, CBO estimates that enacting
the bill would increase direct spending by $301 million over
the 2019-2028 period.
H.R. 5583, a bill to amend title XI of the Social Security
Act to require States to annually report on certain adult
health quality measures, and for other purposes, would require
states to include behavioral health indicators in their annual
reports on the quality of care under Medicaid. Although the
bill would add a requirement for states, CBO estimates that its
enactment would not have a significant budgetary effect because
most states have systems in place for reporting such measures
to the federal government.
H.R. 5797, the IMD CARE Act, would expand Medicaid coverage
for people with opioid use disorder who are in institutions for
mental disease (IMDs) for up to 30 days per year. Under a
current-law policy known as the IMD exclusion, the federal
government generally does not make matching payments to state
Medicaid programs for most services provided by IMDs to adults
between the ages of 21 and 64. Recent administrative changes
have made federal financing for IMDs available in limited
circumstances, but the statutory prohibition remains in place.
CBO analyzed several data sets, primarily those collected by
the Substance Abuse and Mental Health Services Administration
(SAMHSA), to estimate current federal spending under Medicaid
for IMD services and to estimate spending under H.R. 5797.
Using that analysis, CBO estimates that enacting H.R. 5797
would increase direct spending by $991 million over the 2019-
2028 period.
H.R. 5799, the Medicaid DRUG Improvement Act, would require
state Medicaid programs to implement additional reviews of
opioid prescriptions, monitor concurrent prescribing of opioids
and certain other drugs, and monitor use of antipsychotic drugs
by children. CBO estimates that the bill would increase direct
spending by $5 million over 2019-2028 period to cover the
administrative costs of complying with those requirements. On
the basis of stakeholder feedback, CBO expects that the bill
would not have a significant effect on Medicaid spending for
prescription drugs because many of the bill's requirements
would duplicate current efforts to curb opioid and
antipsychotic drug use. (If enacted, H.R. 5799 also would
affect spending subject to appropriation; CBO has not completed
an estimate of that amount.)
H.R. 5801, the Medicaid Providers Are Required To Note
Experiences in Record Systems to Help In-Need Patients
(PARTNERSHIP) Act, would require providers who are permitted to
prescribe controlled substances and who participate in Medicaid
to query prescription drug monitoring programs (PDMPs) before
prescribing controlled substances to Medicaid patients. PDMPs
are statewide electronic databases that collect data on
controlled substances dispensed in the state. The bill also
would require PDMPs to comply with certain data and system
criteria, and it would provide additional federal matching
funds to certain states to help cover administrative costs. On
the basis of a literature review and stakeholder feedback, CBO
estimates that the net budgetary effect of enacting H.R. 5801
would be insignificant. Costs for states to come into
compliance with the systems and administrative requirements
would be roughly offset by savings from small reductions in the
number of controlled substances paid for by Medicaid under the
proposal. (If enacted, H.R. 5801 also would affect spending
subject to appropriation; CBO has not completed an estimate of
that amount.)
H.R. 5808, the Medicaid Pharmaceutical Home Act of 2018,
would require state Medicaid programs to operate pharmacy
programs that would identify people at high risk of abusing
controlled substances and require those patients to use a
limited number of providers and pharmacies. Although nearly all
state Medicaid programs currently meet such a requirement, a
small number of high-risk Medicaid beneficiaries are not now
monitored. Based on an analysis of information about similar
state and federal programs, CBO estimates that net Medicaid
spending under the bill would decrease by $13 million over the
2019-2028 period. That amount represents a small increase in
administrative costs and a small reduction in the number of
controlled substances paid for by Medicaid under the proposal.
(If enacted, H.R. 5808 also would affect spending subject to
appropriation; CBO has not completed an estimate of that
amount.)
H.R. 5810, the Medicaid Health HOME Act, would allow states
to receive six months of enhanced federal Medicaid funding for
programs that coordinate care for people with substance use
disorders. Based on enrollment and spending data from states
that currently participate in Medicaid's Health Homes program,
CBO estimates that the expansion would cost approximately $469
million over the 2019-2028 period. The bill also would require
states to cover all FDA-approved drugs used in medication-
assisted treatment for five years, although states could seek a
waiver from that requirement. (Medication-assisted treatment
combines behavioral therapy and pharmaceutical treatment for
substance use disorders.) Under current law, states already
cover most FDA-approved drugs used in such programs in some
capacity, although a few exclude methadone dispensed by opioid
treatment programs. CBO estimates that a small share of those
states would begin to cover methadone if this bill was enacted
at a federal cost of about $39 million over the 2019-2028
period. In sum, CBO estimates that the enacting H.R. 5810 would
increase direct spending by $509 million over the 2019-2028
period.
Legislation Primarily Affecting Medicare. The following ten
bills would affect direct spending for the Medicare program.
H.R. 3528, the Every Prescription Conveyed Securely Act,
would require prescriptions for controlled substances covered
under Medicare Part D to be transmitted electronically,
starting on January 1, 2021. Based on CBO's analysis of
prescription drug spending, spending for controlled substances
is a small share of total drug spending. CBO also assumes a
small share of those prescriptions would not be filled because
they are not converted to an electronic format. Therefore, CBO
expects that enacting H.R. 3528 would reduce the number of
prescriptions filled and estimates that Medicare spending be
reduced by $250 million over the 2019-2028 period.
H.R. 4841, the Standardizing Electronic Prior Authorization
for Safe Prescribing Act of 2018, would require health care
professionals to submit prior authorization requests
electronically, starting on January 1, 2021, for drugs covered
under Medicare Part D. Taking into account that many
prescribers already use electronic methods to submit such
requests, CBO estimates that enacting H.R. 4841 would not
significantly affect direct spending for Part D.
H.R. 5603, the Access to Telehealth Services for Opioid Use
Disorders Act, would permit the Secretary of HHS to lift
current geographic and other restrictions on coverage of
telehealth services under Medicare for treatment of substance
use disorders or co-occurring mental health disorders. Under
the bill, the Secretary of HHS would be directed to encourage
other payers to coordinate payments for opioid use disorder
treatments and to evaluate the extent to which the
demonstration reduces hospitalizations, increases the use of
medication-assisted treatments, and improves the health
outcomes of individuals with opioid use disorders during and
after the demonstration. Based on current use of Medicare
telehealth services for treatment of substance use disorders,
CBO estimates that expanding that coverage would increase
direct spending by $11 million over the 2019-2028 period.
H.R. 5605, the Advancing High Quality Treatment for Opioid
Use Disorders in Medicare Act, would establish a five-year
demonstration program to increase access to treatment for
opioid use disorder. The demonstration would provide incentive
payments and funding for care management services based on
criteria such as patient engagement, use of evidence-based
treatments, and treatment length and intensity. Under the bill,
the Secretary of HHS would be directed to encourage other
payers to coordinate payments for opioid use disorder
treatments and to evaluate the extent to which the
demonstration reduces hospitalizations, increases the use of
medication-assisted treatments, and improves the health
outcomes of individuals with opioid use disorders during and
after the demonstration. Based on historical utilization of
opioid use disorder treatments and projected spending on
incentive payments and care management fees, CBO estimates that
increased use of treatment services and the demonstration's
incentive payments would increase direct spending by $122
million over the 2019-2028 period.
H.R. 5675, a bill to amend title XVIII of the Social
Security Act to require prescription drug plan sponsors under
the Medicare program to establish drug management programs for
at-risk beneficiaries, would require Part D prescription drug
plans to provide drug management programs for Medicare
beneficiaries who are at risk for prescription drug abuse.
(Under current law, Part D plans are permitted but not required
to establish such programs as of 2019.) Based on an analysis of
the number of plans currently providing those programs, CBO
estimates that enacting H.R. 5675 would lower federal spending
by $64 million over the 2019-2028 period by reducing the number
of prescriptions filled and Medicare's payments for controlled
substances.
H.R. 5684, the Protecting Seniors From Opioid Abuse Act,
would expand medication therapy management programs under
Medicare Part D to include beneficiaries who are at risk for
prescription drug abuse. Because relatively few beneficiaries
would be affected by this bill, CBO estimates that its
enactment would not significantly affect direct spending for
Part D.
H.R. 5796, the Responsible Education Achieves Care and
Healthy Outcomes for Users' Treatment Act of 2018, would allow
the Secretary of HHS to award grants to certain organizations
that provide technical assistance and education to high-volume
prescribers of opioids. The bill would appropriate $100 million
for fiscal year 2019. Based on historical spending patterns for
similar activities, CBO estimates that implementing H.R. 5796
would cost $100 million over the 2019-2028 period.
H.R. 5798, the Opioid Screening and Chronic Pain Management
Alternatives for Seniors Act, would add an assessment of
current opioid prescriptions and screening for opioid use
disorder to the Welcome to Medicare Initial Preventive Physical
Examination. Based on historical use of the examinations and
pain management alternatives, CBO expects that enacting the
bill would increase use of pain management services and
estimates that direct spending would increase by $5 million
over the 2019-2028 period.
H.R. 5804, the Post-Surgical Injections as an Opioid
Alternative Act, would freeze the Medicare payment rate for
certain analgesic injections provided in ambulatory surgical
centers (ASCs). (For injections identified by specific billing
codes, Medicare would pay the 2016 rate, which is higher than
the current rate, during the 2020-2024 period.) Based on
current utilization in the ASC setting, CBO estimates that
enacting the legislation would increase direct spending by
about $115 million over the 2019-2028 period. (If enacted, H.R.
5804 also would affect spending subject to appropriation; see
Table 3.)
H.R. 5809, the Postoperative Opioid Prevention Act of 2018,
would create an additional payment under Medicare for nonopioid
analgesics. Under current law, certain new drugs and devices
may receive an additional payment--separate from the bundled
payment for a surgical procedure--in outpatient hospital
departments and ambulatory surgical centers. The bill would
allow nonopioid analgesics to qualify for a five-year period of
additional payments. Based on its assessment of current
spending for analgesics and on the probability of new nonopioid
analgesics coming to market, CBO estimates that H.R. 5809 would
increase direct spending by about $180 million over the 2019-
2028 period.
Legislation Primarily Affecting the Food and Drug
Administration. One bill related to the FDA would affect direct
spending.
H.R. 5333, the Over-the-Counter Monograph Safety,
Innovation, and Reform Act of 2018, would change the way that
the FDA regulates the marketing of over-the-counter (OTC)
medicines, and it would authorize that agency to grant 18
months of exclusive market protection for certain qualifying
OTC drugs, thus delaying the entry of other versions of the
same qualifying OTC product. Medicaid currently provides some
coverage for OTC medicines, but only if a medicine is the least
costly alternative in its drug class. On the basis of
stakeholder feedback, CBO expects that delaying the
availability of additional OTC versions of a drug would not
significantly affect the average net price paid by Medicaid. As
a result, CBO estimates that enacting H.R. 5333 would have a
negligible effect on the federal budget. (If enacted, H.R. 5333
also would affect spending subject to appropriation; see Table
3.)
Legislation with Revenue Effects. Two bills would affect
revenues. However, CBO estimates that one bill, H.R. 5228, the
Stop Counterfeit Drugs by Regulating and Enhancing Enforcement
Now Act, would have only a negligible effect.
H.R. 5752, the Stop Illicit Drug Importation Act of 2018,
would amend the Federal, Food, Drug, and Cosmetic Act (FDCA) to
strengthen the FDA's seizure powers and enhance its authority
to detain, refuse, seize, or destroy illegal products offered
for import. The legislation would subject more people to
debarment under the FDCA and thus increase the potential for
violations, and subsequently, the assessment of civil
penalties, which are recorded in the budget as revenues. CBO
estimates that those collections would result in an
insignificant increase in revenues. Because H.R. 5752 would
prohibit the importation of drugs that are in the process of
being scheduled, it also could reduce amounts collected in
customs duties. CBO anticipates that the result would be a
negligible decrease in revenues. With those results taken
together, CBO estimates, enacting H.R. 5752 would generate an
insignificant net increase in revenues over the 2019-2028
period.

Spending subject to appropriation

For this document, CBO has grouped bills with spending that
would be subject to appropriation into four general categories:
Bills that would have no budgetary effect,
Bills with provisions that would authorize
specified amounts to be appropriated (see Table 2),
Bills with provisions for which CBO has
estimated an authorization of appropriations (see Table
3), and
Bills with provisions that would affect
spending subject to appropriation for which CBO has not
yet completed an estimate.
No Budgetary Effect. CBO estimates that 6 of the 59 bills
would have no effect on direct spending, revenues, or spending
subject to appropriation.
H.R. 3192, the CHIP Mental Health Parity Act, would require
all Children's Health Insurance Program (CHIP) plans to cover
mental health and substance abuse treatment. In addition,
states would not be allowed to impose financial or utilization
limits on mental health treatment that are lower than limits
placed on physical health treatment. Based on information from
the Centers for Medicare and Medicaid Services, CBO estimates
that enacting the bill would have no budgetary effect because
all CHIP enrollees are already in plans that meet those
requirements.
H.R. 3331, a bill to amend title XI of the Social Security
Act to promote testing of incentive payments for behavioral
health providers for adoption and use of certified electronic
health record technology, would give the Center for Medicare
and Medicaid Innovation (CMMI) explicit authorization to test a
program offering incentive payments to behavioral health
providers that adopt and use certified electronic health record
technology. Because it is already clear to CMMI that it has
that authority, CBO estimates that enacting the legislation
would not affect federal spending.
H.R. 5202, the Ensuring Patient Access to Substance Use
Disorder Treatments Act of 2018, would clarify permission for
pharmacists to deliver controlled substances to providers under
certain circumstances. Because this provision would codify
current practice, CBO estimates that H.R. 5202 would not affect
direct spending or revenues during the 2019-2028 period.
H.R. 5685, the Medicare Opioid Safety Education Act of
2018, would require the Secretary of HHS to include information
on opioid use, pain management, and nonopioid pain management
treatments in future editions of Medicare & You, the program's
handbook for beneficiaries, starting on January 1, 2019.
Because H.R. 5685 would add information to an existing
administrative document, CBO estimates that enacting the bill
would have no budgetary effect.
H.R. 5686, the Medicare Clear Health Options in Care for
Enrollees Act of 2018, would require prescription drug plans
that provide coverage under Medicare Part D to furnish
information to beneficiaries about the risks of opioid use and
the availability of alternative treatments for pain. CBO
estimates that enacting the bill would not affect direct
spending because the required activities would not impose
significant administrative costs.
H.R. 5716, the Commit to Opioid Medical Prescriber
Accountability and Safety for Seniors Act, would require the
Secretary of HHS on an annual basis to identify high
prescribers of opioids and furnish them with information about
proper prescribing methods. Because HHS already has the
capacity to meet those requirements, CBO estimates that
enacting that provision would not impose additional
administrative costs on the agency.
Specified Authorizations. Table 2 lists the ten bills that
would authorize specified amounts to be appropriated over the
2019-2023 period. Spending from those authorized amounts would
be subject to appropriation.

TABLE 2.--ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH SPECIFIED AUTHORIZATIONS
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
----------------------------------------------------------
2018 2019 2020 2021 2022 2023 2019-2023
----------------------------------------------------------------------------------------------------------------
INCREASES IN SPENDING SUBJECT TO APPROPRIATION

H.R. 4684, Ensuring Access to Quality Sober Living
Act:
Authorization Level.............................. 0 3 0 0 0 0 3
Estimated Outlays................................ 0 1 2 * * * 3
H.R. 5102, Substance Use Disorder Workforce Loan
Repayment Act of 2018:
Authorization Level.............................. 0 25 25 25 25 25 125
Estimated Outlays................................ 0 9 19 23 25 25 100
H.R. 5176, Preventing Overdoses While in Emergency
Rooms Act of 2018:
Authorization Level.............................. 0 50 0 0 0 0 50
Estimated Outlays................................ 0 16 26 6 2 1 50
H.R. 5197, Alternatives to Opioids (ALTO) in the
Emergency Department Act:
Authorization Level.............................. 0 10 10 10 0 0 30
Estimated Outlays................................ 0 3 8 10 7 2 30
H.R. 5261, Treatment, Education, and Community Help
to Combat Addiction Act of 2018:
Authorization Level.............................. 0 4 4 4 4 4 20
Estimated Outlays................................ 0 1 3 4 4 4 16
H.R. 5327, Comprehensive Opioid Recovery Centers Act
of 2018:
Authorization Level.............................. 0 10 10 10 10 10 50
Estimated Outlays................................ 0 3 8 10 10 10 41
H.R. 5329, Poison Center Network Enhancement Act of
2018:
Authorization Level.............................. 0 30 30 30 30 30 151
Estimated Outlays................................ 0 12 25 29 29 29 125
H.R. 5353, Eliminating Opioid-Related Infectious
Diseases Act of 2018:
Authorization Level.............................. 0 40 40 40 40 40 200
Estimated Outlays................................ 0 15 34 38 39 40 166
H.R. 5580, Surveillance and Testing of Opioids to
Prevent Fentanyl Deaths Act of 2018:
Authorization Level.............................. 30 30 30 30 30 0 120
Estimated Outlays................................ 0 11 25 29 29 19 113
H.R. 5587, Peer Support Communities of Recovery Act:
Authorization Level.............................. 0 15 15 15 15 15 75
Estimated Outlays................................ 0 5 13 14 15 15 62
----------------------------------------------------------------------------------------------------------------
Annual amounts may not sum to totals because of rounding. * = between zero and $500,000.

H.R. 4684, the Ensuring Access to Quality Sober Living Act,
would direct the Secretary of HHS to develop and disseminate
best practices for organizations that operate housing designed
for people recovering from substance use disorders. The bill
would authorize a total of $3 million over the 2019-2021 period
for that purpose. Based on historical spending patterns for
similar activities, CBO estimates that implementing H.R. 4684
would cost $3 million over the 2019-2023 period.
H.R. 5102, the Substance Use Disorder Workforce Loan
Repayment Act of 2018, would establish a loan repayment program
for mental health professionals who practice in areas with few
mental health providers or with high rates of death from
overdose and would authorize $25 million per year over the
2019-2028 period for that purpose. Based on historical spending
patterns for similar activities, CBO estimates that
implementing H.R. 5102 would cost $100 million over the 2019-
2023 period; the remaining amounts would be spent in years
after 2023.
H.R. 5176, the Preventing Overdoses While in Emergency
Rooms Act of 2018, would require the Secretary of HHS to
develop protocols and a grant program for health care providers
to address the needs of people who survive a drug overdose, and
it would authorize $50 million in 2019 for that purpose. Based
on historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5176 would cost $50 million
over the 2019-2023 period.
H.R. 5197, the Alternatives to Opioids (ALTO) in the
Emergency Department Act, would direct the Secretary of HHS to
carry out a demonstration program for hospitals and emergency
departments to develop alternative protocols for pain
management that limit the use of opioids and would authorize
$10 million annually in grants for fiscal years 2019 through
2021. Based on historical spending patterns for similar
programs, CBO estimates that implementing H.R. 5197 would cost
$30 million over the 2019-2023 period.
H.R. 5261, the Treatment, Education, and Community Help to
Combat Addiction Act of 2018, would direct the Secretary of
HHS to designate regional centers of excellence to improve the
training of health professionals who treat substance use
disorders. The bill would authorize $4 million annually for
grants to those programs over the 2019-2023 period. Based on
historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5261 would cost $16 million
over the 2019-2023 period; the remaining amounts would be spent
in years after 2023.
H.R. 5327, the Comprehensive Opioid Recovery Centers Act of
2018, would direct the Secretary of HHS to award grants to at
least 10 providers that offer treatment services for people
with opioid use disorder, and it would authorize $10 million
per year over the 2019-2023 period for that purpose. Based on
historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5327 would cost $41 million
over the 2019-2023 period; the remaining amounts would be spent
in years after 2023.
H.R. 5329, the Poison Center Network Enhancement Act of
2018, would reauthorize the poison control center toll-free
number, national media campaign, and grant program under the
Public Health Service Act. Among other actions, H.R. 5329 would
increase the share of poison control center funding that could
be provided by federal grants. The bill would authorize a total
of about $30 million per year over the 2019-2023 period. Based
on historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5329 would cost $125 million
over the 2019-2023 period; the remaining amounts would be spent
in years after 2023.
H.R. 5353, the Eliminating Opioid Related Infectious
Diseases Act of 2018, would amend Public Health Service Act by
broadening the focus of surveillance and education programs
from preventing and treating hepatitis C virus to preventing
and treating infections associated with injection drug use. It
would authorize $40 million per year over 2019-2023 period for
that purpose. Based on historical spending patterns for similar
activities, CBO estimates that implementing H.R. 5353 would
cost $166 million over the 2019-2023 period; the remaining
amounts would be spent in years after 2023.
H.R. 5580, the Surveillance and Testing of Opioids to
Prevent Fentanyl Deaths Act of 2018, would establish a grant
program for public health laboratories that conduct testing for
fentanyl and other synthetic opioids. It also would direct the
Centers for Disease Control and Prevention to expand its drug
surveillance program, with a particular focus on collecting
data on fentanyl. The bill would authorize a total of $30
million per year over the 2018-2022 period for those
activities. Based on historical spending patterns for similar
activities, CBO estimates that implementing H.R. 5580 would
cost $113 million over the 2019-2023 period; the remaining
amounts would be spent in years after 2023.
H.R. 5587, Peer Support Communities of Recovery Act, would
direct the Secretary of HHS to award grants to nonprofit
organizations that support community-based, peer-delivered
support, including technical support for the establishment of
recovery community organizations, independent, nonprofit groups
led by people in recovery and their families. The bill would
authorize $15 million per year for the 2019-2023 period. Based
on historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5587 would cost $62 million
over the 2019-2023 period; the remaining amounts would be spent
in years after 2023.
Estimated Authorizations. Table 3 shows CBO's estimates of
the appropriations that would be necessary to implement 19 of
the bills. Spending would be subject to appropriation of those
amounts.
H.R. 449, the Synthetic Drug Awareness Act of 2018, would
require the Surgeon General to report to the Congress on the
health effects of synthetic psychoactive drugs on children
between the ages of 12 and 18. Based on spending patterns for
similar activities, CBO estimates that implementing H.R. 449
would cost approximately $1 million over the 2019-2023 period.
H.R. 4005, the Medicaid Reentry Act, would direct the
Secretary of HHS to convene a group of stakeholders to develop
and report to the Congress on best practices for addressing
issues related to health care faced by those returning from
incarceration to their communities. The bill also would require
the Secretary to issue a letter to state Medicaid directors
about relevant demonstration projects. Based on an analysis of
anticipated workload, CBO estimates that implementing H.R. 4005
would cost less than $500,000 over the 2018-2023 period.
H.R. 4275, the Empowering Pharmacists in the Fight Against
Opioid Abuse Act, would require the Secretary of HHS to develop
and disseminate materials for training pharmacists, health care
practitioners, and the public about the circumstances under
which a pharmacist may decline to fill a prescription. Based on
historical spending patterns for similar activities, CBO
estimates that costs to the federal government for the
development and distribution of those materials would not be
significant.

TABLE 3.--ESTIMATED SPENDING SUBJECT TO APPROPRIATION FOR BILLS WITH ESTIMATED AUTHORIZATIONS
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2019-2023
----------------------------------------------------------------------------------------------------------------
INCREASES IN SPENDING SUBJECT TO APPROPRIATION

H.R. 449, Synthetic Drug Awareness Act of 2018:
Estimated Authorization Level................. 0 * * * 0 0 1
Estimated Outlays............................. 0 * * * 0 0 1

H.R. 4005, Medicaid Reentry Act:
Estimated Authorization Level................. * * 0 0 0 0 *
Estimated Outlays............................. * * 0 0 0 0 *

H.R. 4275, Empowering Pharmacists in the Fight
Against Opioid Abuse Act:
Estimated Authorization Level................. 0 * * * * * *
Estimated Outlays............................. 0 * * * * * *

H.R. 5009, Jessie's Law:
Estimated Authorization Level................. 0 * * * * * *
Estimated Outlays............................. 0 * * * * * *

H.R. 5041, Safe Disposal of Unused Medication Act: 0 * * * * * *
Estimated Authorization Level................. 0 * * * * * *
Estimated Outlays............................. 0 * * * * * *

H.R. 5272, Reinforcing Evidence-Based Standards
Under Law in Treating Substance Abuse Act of
2018:
Estimated Authorization Level................. 0 1 1 1 1 1 4
Estimated Outlays............................. 0 1 1 1 1 1 4

H.R. 5333, Over-the-Counter Monograph Safety,
Innovation, and Reform Act of 2018:a
Food and Drug Administration:
Collections from fees:
Estimated Authorization Level......... 0 -22 -22 -26 -35 -42 -147
Estimated Outlays..................... 0 -22 -22 -26 -35 -42 -147
Spending of fees:
Estimated Authorization Level......... 0 22 22 26 35 42 147
Estimated Outlays..................... 0 6 17 30 44 41 137
Net effect on FDA:
Estimated Authorization Level......... 0 0 0 0 0 0 0
Estimated Outlays..................... 0 -17 -6 4 9 * -10
Government Accountability Office:
Estimated Authorization Level............. 0 0 0 0 0 * *
Estimated Outlays......................... 0 0 0 0 0 * *
Total, H.R. 5333:
Estimated Authorization Level............. 0 0 0 0 0 * *
Estimated Outlays......................... 0 -17 -6 4 9 * -10

H.R. 5473, Better Pain Management Through Better
Data Act of 2018:
Estimated Authorization Level................. 0 * * * * 0 1
Estimated Outlays............................. 0 * * * * * 1

H.R. 5483, Special Registration for Telemedicine
Clarification Act of 2018:
Estimated Authorization Level................. 0 * * * * * *
Estimated Outlays............................. 0 * * * * * *

H.R. 5554, Animal Drug and Animal Generic Drug
User Fee Amendments of 2018:
Collections from fees:
Animal drug fees.......................... 0 -30 -31 -32 -33 -34 -159
Generic animal drug fees.................. 0 -18 -19 -19 -20 -21 -97
Total, Estimated Authorization Level.. 0 -49 -50 -51 -53 -55 -257
Total, Estimated Outlays.............. 0 -49 -50 -51 -53 -55 -257
Spending of fees:
Animal drug fees.......................... 0 30 31 32 33 34 159
Generic animal drug fees.................. 0 18 19 19 20 21 97
Total, Estimated Authorization Level.. 0 49 50 51 53 55 257
Total, Estimated Outlays.............. 0 39 47 51 52 54 243
Net changes in fees:
Estimated Authorization Level............. 0 0 0 0 0 0 0
Estimated Outlays......................... 0 -10 -3 * * * -14
Other effects:
Estimated Authorization Level............. 0 3 1 1 1 1 6
Estimated Outlays......................... 0 2 1 1 1 1 6
Total, H.R. 5554:
Estimated Authorization Level............. 0 3 1 1 1 1 6
Estimated Outlays......................... 0 -8 -2 1 * * -8

H.R. 5582, Abuse Deterrent Access Act of 2018:
Estimated Authorization Level................. 0 0 * 0 0 0 *
Estimated Outlays............................. 0 0 * 0 0 0 *

H.R. 5590, Opioid Addiction Action Plan Act:
Estimated Authorization Level................. * * * * * * 2
Estimated Outlays............................. * * * * * * 2

H.R. 5687, Securing Opioids and Unused Narcotics
with Deliberate Disposal and Packaging Act of
2018:
Estimated Authorization Level................. 0 * * * * * *
Estimated Outlays............................. 0 * * * * * *

H.R. 5715, Strengthening Partnerships to Prevent
Opioid Abuse Act:
Estimated Authorization Level................. 0 2 2 2 2 2 9
Estimated Outlays............................. 0 2 2 2 2 2 9

H.R. 5789, a bill to require the Secretary of
Health and Human Services to issue guidance to
improve care for infants with neonatal abstinence
syndrome and their mothers, and to require the
Comptroller General of the United States to
conduct a study on gaps in Medicaid coverage for
pregnant and postpartum women with substance use
disorder:
Estimated Authorization Level................. 0 2 0 0 0 0 2
Estimated Outlays............................. 0 2 0 0 0 0 2

H.R. 5795, Overdose Prevention and Patient Safety
Act:
Estimated Authorization Level................. 0 1 0 0 0 0 1
Estimated Outlays............................. 0 1 0 0 0 0 1

H.R. 5800, Medicaid IMD ADDITIONAL INFO Act:
Estimated Authorization Level................. 0 1 0 0 0 0 1
Estimated Outlays............................. 0 * * 0 0 0 1

H.R. 5804, Post-Surgical Injections as an Opioid
Alternative Act:a
Estimated Authorization Level................. 0 0 0 0 1 1 1
Estimated Outlays............................. 0 0 0 0 1 1 1

H.R. 5811, a bill to amend the Federal Food, Drug,
and Cosmetic Act with respect to postapproval
study requirements for certain controlled
substances, and for other purposes:
Estimated Authorization Level................. 0 * * * * * *
Estimated Outlays............................. 0 * * * * * *
----------------------------------------------------------------------------------------------------------------
Annual amounts may not sum to totals because of rounding. * = between -$500,000 and $500,000.
aThis bill also would affect mandatory spending (see Table 1).

H.R. 5009, Jessie's Law, would require HHS, in
collaboration with outside experts, to develop best practices
for displaying information about opioid use disorder in a
patient's medical record. HHS also would be required to develop
and disseminate written materials annually to health care
providers about what disclosures could be made while still
complying with federal laws that govern health care privacy.
Based on spending patterns for similar activities, CBO
estimates that implementing H.R. 5009 would have an
insignificant effect on spending over the 2019-2023 period.
H.R. 5041, the Safe Disposal of Unused Medication Act,
would require hospice programs to have written policies and
procedures for the disposal of controlled substances after a
patient's death. Certain licensed employees of hospice programs
would be permitted to assist in the disposal of controlled
substances that were lawfully dispensed. Using information from
the Department of Justice (DOJ), CBO estimates that
implementing the bill would cost less than $500,000 over the
2019-2023 period.
H.R. 5272, the Reinforcing Evidence-Based Standards Under
Law in Treating Substance Abuse Act of 2018, would require the
newly established National Mental Health and Substance Use
Policy Laboratory to issue guidance to applicants for SAMHSA
grants that support evidence-based practices. Using information
from HHS about the historical cost of similar activities, CBO
estimates that enacting this bill would cost approximately $4
million over the 2019-2023 period.
H.R. 5333, the Over-the-Counter Monograph Safety,
Innovation, and Reform Act of 2018, would change the FDA's
oversight of the commercial marketing of OTC medicines and
authorize the collection and spending of fees through 2023 to
cover the costs of expediting the FDA's administrative
procedures for certain regulatory activities relating to OTC
products. Under H.R. 5333, CBO estimates, the FDA would assess
about $147 million in fees over the 2019-2023 period that could
be collected and made available for obligation only to the
extent and in the amounts provided in advance in appropriation
acts. Because the FDA could spend those fees, CBO estimates
that the estimated budget authority for collections and
spending would offset each other exactly in each year, although
CBO expects that spending initially would lag behind
collections. Assuming appropriation action consistent with the
bill, CBO estimates that implementing H.R. 5333 would reduce
net discretionary outlays by $10 million over the 2019-2023
period, primarily because of that lag. The bill also would
require the Government Accountability Office to study exclusive
market protections for certain qualifying OTC drugs authorized
by the bill--a provision that CBO estimates would cost less
than $500,000. (If enacted, H.R. 5333 also would affect
mandatory spending; see Table 1.)
H.R. 5473, the Better Pain Management Through Better Data
Act of 2018, would require that the FDA conduct a public
meeting and issue guidance to industry addressing data
collection and labeling for medical products that reduce pain
while enabling the reduction, replacement, or avoidance of oral
opioids. Using information from the agency, CBO estimates that
implementing H.R. 5473 would cost about $1 million over the
2019-2023 period.
H.R. 5483, the Special Registration for Telemedicine
Clarification Act of 2018, would direct DOJ, within one year of
the bill's enactment, to issue regulations concerning the
practice of telemedicine (for remote diagnosis and treatment of
patients). Using information from DOJ, CBO estimates that
implementing the bill would cost less than $500,000 over the
2019-2023 period.
H.R. 5554, the Animal Drug and Animal Generic Drug User Fee
Amendments of 2018, would authorize the FDA to collect and
spend fees to cover the cost of expedited approval for the
development and marketing of certain drugs for use in animals.
The legislation would extend through fiscal year 2023, and make
several changes to, the FDA's existing approval processes and
fee programs for brand-name and generic veterinary drugs, which
expire at the end of fiscal year 2018. CBO estimates that
implementing H.R. 5554 would reduce net discretionary outlays
by $8 million over the 2019-2023 period, primarily because the
spending of fees lags somewhat behind their collection.
Fees authorized under the bill would supplement funds
appropriated to cover the FDA's cost of reviewing certain
applications and investigational submissions for brand-name and
generic drugs for use in animals. Those fees could be collected
and made available for obligation only to the extent and in the
amounts provided in advance in appropriation acts. Under H.R.
5554, CBO estimates, the FDA would assess about $257 million in
fees over the 2019-2023 period. Because the FDA could spend
those funds, CBO estimates that budget authority for
collections and spending would offset each other exactly in
each year. CBO estimates that the delay between collecting and
spending fees under the reauthorized programs would reduce net
discretionary outlays by $14 million over the 2019-2023 period,
assuming appropriation actions consistent with the bill.
Enacting H.R. 5554 would increase the FDA's workload
because the legislation would expand eligibility for
conditional approval for certain drugs. The agency's
administrative costs also would increase because of regulatory
activities required by a provision concerning petitions for
additives intended for use in animal food. H.R. 5554 also would
require the FDA to publish guidance or produce regulations on a
range of topics, transmit a report to the Congress, and hold
public meetings. CBO expects that the costs associated with
those activities would not be covered by fees, and it estimates
that implementing such provisions would cost $6 million over
the 2019-2023 period.
H.R. 5582, the Abuse Deterrent Access Act of 2018, would
require the Secretary of HHS to report to the Congress on
existing barriers to access to ``abuse-deterrent opioid
formulations'' by Medicare Part C and D beneficiaries. Such
formulations make the drugs more difficult to dissolve for
injection, for example, and thus can impede their abuse.
Assuming the availability of appropriated funds and based on
historical spending patterns for similar activities, CBO
estimates that implementing the legislation would cost less
than $500,000 over the 2019-2023 period.
H.R. 5590, the Opioid Addiction Action Plan Act, would
require the Secretary of HHS to develop an action plan by
January 1, 2019, for increasing access to medication-assisted
treatment among Medicare and Medicaid enrollees. The bill also
would require HHS to convene a stakeholder meeting and issue a
request for information within three months of enactment, and
to submit a report to the Congress by June 1, 2019. Based on
historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5590 would cost approximately
$2 million over the 2019-2023 period.
H.R. 5687, the Securing Opioids and Unused Narcotics with
Deliberate Disposal and Packaging Act of 2018, would permit the
FDA to require certain packaging and disposal technologies,
controls, or measures to mitigate the risk of abuse and misuse
of drugs. Based on information from the FDA, CBO estimates that
implementing H.R. 5687 would not significantly affect spending
over the 2019-2023 period. This bill would also require that
the GAO study the effectiveness and use of packaging
technologies for controlled substances--a provision that CBO
estimates would cost less than $500,000.
H.R. 5715, the Strengthening Partnerships to Prevent Opioid
Abuse Act, would require the Secretary of HHS to establish a
secure Internet portal to allow HHS, Medicare Advantage plans,
and Medicare Part D plans to exchange information about fraud,
waste, and abuse among providers and suppliers no later than
two years after enactment. H.R. 5715 also would require
organizations with Medicare Advantage contracts to submit
information on investigations related to providers suspected of
prescribing large volumes of opioids through a process
established by the Secretary no later than January 2021. Based
on historical spending patterns for similar activities, CBO
estimates that implementing H.R. 5715 would cost approximately
$9 million over the 2019-2023 period.
H.R. 5789, a bill to require the Secretary of Health and
Human Services to issue guidance to improve care for infants
with neonatal abstinence syndrome and their mothers, and to
require the Comptroller General of the United States to conduct
a study on gaps in Medicaid coverage for pregnant and
postpartum women with substance use disorder, would direct the
Secretary of HHS to issue guidance to states on best practices
under Medicaid and CHIP for treating infants with neonatal
abstinence syndrome. H.R. 5789 also would direct the Government
Accountability Office to study Medicaid coverage for pregnant
and postpartum women with substance use disorders. Based on
information from HHS and historical spending patterns for
similar activities, CBO estimates that enacting H.R. 5789 would
cost approximately $2 million over the 2019-2023 period.
H.R. 5795, the Overdose Prevention and Patient Safety Act,
would amend the Public Health Service Act so that requirements
pertaining to the confidentiality and disclosure of medical
records relating to substance use disorders align with the
provisions of the Health Insurance Portability and
Accountability Act of 1996. The bill would require the Office
of the Secretary of HHS to issue regulations prohibiting
discrimination based on data disclosed from such medical
records, to issue regulations requiring covered entities to
provide written notice of privacy practices, and to develop
model training programs and materials for health care providers
and patients and their families. Based on spending patterns for
similar activities, CBO estimates that implementing H.R. 5795
would cost approximately $1 million over the 2019-2023 period.
H.R. 5800, Medicaid IMD ADDITIONAL INFO Act, would direct
the Medicaid and CHIP Payment and Access Commission to study
institutions for mental diseases in a representative sample of
states. Based on information from the commission about the cost
of similar work, CBO estimates that implementing H.R. 5800
would cost about $1 million over the 2019-2023 period.
H.R. 5804, the Post-Surgical Injections as an Opioid
Alternative Act, would freeze the Medicare payment rate for
certain analgesic injections provided in ambulatory surgical
centers. The bill also would mandate two studies of Medicare
coding and payments arising from enactment of this legislation.
Based on the cost of similar activities, CBO estimates that
those reports would cost $1 million over the 2019-2023 period.
(If enacted, H.R. 5804 also would affect mandatory spending;
see Table 1.)
H.R. 5811, a bill to amend the Federal Food, Drug, and
Cosmetic Act with respect to postapproval study requirements
for certain controlled substances, and for other purposes,
would allow the FDA to require that pharmaceutical
manufacturers study certain drugs after they are approved to
assess any potential reduction in those drugs' effectiveness
for the conditions of use prescribed, recommended, or suggested
in labeling. CBO anticipates that implementing H.R. 5811 would
not significantly affect the FDA's costs over the 2019-2023
period.
Other Authorizations. The following nine bills would
increase authorization levels, but CBO has not completed
estimates of amounts. All authorizations would be subject to
future appropriation action.
H.R. 4284, Indexing Narcotics, Fentanyl, and
Opioids Act of 2017
H.R. 5002, Advancing Cutting Edge Research
Act
H.R. 5228, Stop Counterfeit Drugs by
Regulating and Enhancing Enforcement Now Act (see Table
1 for an estimate of the revenue effects of H.R. 5228)
H.R. 5752, Stop Illicit Drug Importation Act
of 2018 (see Table 1 for an estimate of the revenue
effects of H.R. 5752)
H.R. 5799, Medicaid DRUG Improvement Act
(see Table 1 for an estimate of the direct spending
effects of H.R. 5799)
H.R. 5801, Medicaid Providers and
Pharmacists Are Required to Note Experiences in Record
Systems to Help In-Need Patients (PARTNERSHIP) Act (see
Table 1 for an estimate of the direct spending effects
of H.R. 5801)
H.R. 5806, 21st Century Tools for Pain and
Addiction Treatments Act
H.R. 5808, Medicaid Pharmaceutical Home Act
of 2018 (see Table 1 for an estimate of the direct
spending effects of H.R. 5808)
H.R. 5812, Creating Opportunities that
Necessitate New and Enhanced Connections That Improve
Opioid Navigation Strategies Act (CONNECTIONS) Act
Pay-As-You-Go considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. Twenty-two of the bills discussed in this document
contain direct spending or revenues and are subject to pay-as-
you-go procedures. Details about the amount of direct spending
and revenues in those bills can be found in Table 1.
Increase in long-term direct spending and deficits: CBO
estimates that enacting H.R. 4998, the Health Insurance for
Former Foster Youth Act, would increase net direct spending by
more than $2.5 billion and on-budget deficits by more than $5
billion in at least one of the four consecutive 10-year periods
beginning in 2029.
CBO estimates that none of the remaining 58 bills included
in this estimate would increase net direct spending by more
than $2.5 billion or on-budget deficits by more than $5 billion
in any of the four consecutive 10-year periods beginning in
2029.
Mandates: One of the 59 bills included in this document,
H.R. 5795, would impose both intergovernmental and private-
sector mandates as defined in UMRA. CBO estimates that the
costs of that bill's mandates on public and private entities
would fall below UMRA's thresholds ($80 million and $160
million, respectively, for public- and private-sector entities
in 2018, adjusted annually for inflation).
In addition, five bills would impose private-sector
mandates as defined in UMRA. CBO estimates that the costs of
the mandates in three of those bills (H.R. 5333, H.R. 5554, and
H.R. 5811) would fall below the UMRA threshold. Because CBO
does not know how federal agencies would implement new
authority granted in the other two of those five bills, H.R.
5228 and 5687, CBO cannot determine whether the costs of their
mandates would exceed the threshold.
For large entitlement grant programs, including Medicaid
and CHIP, UMRA defines an increase in the stringency of
conditions on states or localities as an intergovernmental
mandate if the affected governments lack authority to offset
those costs while continuing to provide required services.
Because states possess significant flexibility to alter their
responsibilities within Medicaid and CHIP, the requirements
imposed by various bills in the markup on state administration
of those programs would not constitute mandates as defined in
UMRA.

Mandates Affecting Public and Private Entities

H.R. 5795, the Overdose Prevention and Patient Safety Act,
would impose intergovernmental and private-sector mandates by
requiring entities that provide treatment for substance use
disorders to notify patients of their privacy rights and also
to notify patients in the event that the confidentiality of
their records is breached. In certain circumstances, H.R. 5795
also would prohibit public and private entities from denying
entry to treatment on the basis of information in patient
health records. Those requirements would either supplant or
narrowly expand responsibilities under existing law, and
compliance with them would not impose significant additional
costs. CBO estimates that the costs of the mandates would fall
below the annual thresholds established in UMRA.

Mandates Affecting Private Entities

Five bills included in this document would impose private-
sector mandates:
H.R. 5228, the Stop Counterfeit Drugs by Regulating and
Enhancing Enforcement Now Act, would require drug distributors
to cease distributing any drug that the Secretary of HHS
determines might present an imminent or substantial hazard to
public health. CBO cannot determine what drugs could be subject
to such an order nor can it determine how private entities
would respond. Consequently, CBO cannot determine whether the
aggregate cost of the mandate would exceed the annual threshold
for private-sector mandates.
H.R. 5333, the Over-the-Counter Monograph Safety,
Innovation, and Reform Act of 2018, would require developers
and manufacturers of OTC drugs to pay certain fees to the FDA.
CBO estimates that about $30 million would be collected each
year, on average, for a total of $147 million over the 2019-
2023 period. Those amounts would not exceed the annual
threshold for private-sector mandates in any year during that
period.
H.R. 5554, the Animal Drug and Animal Generic Drug User Fee
Amendments of 2018, would require developers and manufacturers
of brand-name and generic veterinary drugs to pay application,
product, establishment, and sponsor fees to the FDA. CBO
estimates that about $51 million would be collected annually,
on average, for a total of $257 million over the 2019-2023
period. Those amounts would not exceed the annual threshold for
private-sector mandates in any year during that period.
H.R. 5687, the Securing Opioids and Unused Narcotics with
Deliberate Disposal and Packaging Act of 2018, would permit the
Secretary of HHS to require drug developers and manufacturers
to implement new packaging and disposal technology for certain
drugs. Based on information from the agency, CBO expects that
the Secretary would use the new regulatory authority provided
in the bill; however, it is uncertain how or when those
requirements would be implemented. Consequently, CBO cannot
determine whether the aggregate cost of the mandate would
exceed the annual threshold for private entities.
H.R. 5811, a bill to amend the Federal Food, Drug, and
Cosmetic Act with respect to postapproval study requirements
for certain controlled substances, and for other purposes,
would expand an existing mandate that requires drug developers
to conduct postapproval studies or clinical trials for certain
drugs. Under current law, in certain instances, the FDA can
require studies or clinical trials after a drug has been
approved. H.R. 5811 would permit the FDA to use that authority
if the reduction in a drug's effectiveness meant that its
benefits no longer outweighed its costs. CBO estimates that the
incremental cost of the mandate would fall below the annual
threshold established in UMRA because of the small number of
drugs affected and the narrow expansion of the authority that
exists under current law.
None of the remaining 53 bills included in this document
would impose an intergovernmental or private-sector mandate.
Previous CBO estimate: On June 6, 2018, CBO issued an
estimate for seven opioid-related bills ordered reported by the
House Committee on Ways and Means on May 16, 2018. Two of those
bills contain provisions that are identical or similar to the
legislation ordered reported by the Committee on Energy and
Commerce, and for those provisions, CBO's estimates are the
same.
In particular, five bills listed in this estimate contain
provisions that are identical or similar to those in several
sections of H.R. 5773, the Preventing Addiction for Susceptible
Seniors Act of 2018:
H.R. 5675, which would require prescription drug
plans to implement drug management programs, is identical to
section 2 of H.R. 5773.
H.R. 4841, regarding electronic prior
authorization for prescriptions under Medicare's Part D, is
similar to section 3 of H.R. 5773.
H.R. 5715, which would mandate the creation of a
new Internet portal to allow various stakeholders to exchange
information, is identical to section 4 of H.R. 5773.
H.R. 5684, which would expand medication therapy
management, is the same as section 5 of H.R. 5773.
H.R. 5716, regarding prescriber notification, is
identical to section 6 of H.R. 5773.
In addition, in this estimate, a provision related to
Medicare beneficiary education in H.R. 5686, the Medicare Clear
Health Options in Care for Enrollees Act of 2018, is the same
as a provision in section 2 of H.R. 5775, the Providing
Reliable Options for Patients and Educational Resources Act of
2018, in CBO's estimate for the Committee on Ways and Means.
Estimate prepared by: Federal Costs: Rebecca Yip (Centers
for Disease Control and Prevention), Mark Grabowicz (Drug
Enforcement Agency), Julia Christensen, Ellen Werble (Food and
Drug Administration), Emily King, Andrea Noda, Lisa Ramirez-
Branum, Robert Stewart (Medicaid and Children's Health
Insurance Program), Philippa Haven, Lara Robillard, Colin Yee,
Rebecca Yip (Medicare), Philippa Haven (National Institutes of
Health), Alice Burns, Andrea Noda (Office of the Secretary of
the Department of Health and Human Services), Philippa Haven,
Lori Housman, Emily King (Substance Abuse and Mental Health
Services Administration, Health Resources and Services
Administration); Federal Revenues: Jacob Fabian, Peter Huether,
and Cecilia Pastrone; Fact Checking: Zachary Byrum and Kate
Kelly; Mandates: Andrew Laughlin.
Estimate reviewed by: Tom Bradley, Chief Health Systems and
Medicare Cost Estimates Unit; Chad M. Chirico, Chief Low-Income
Health Programs and Prescription Drugs Cost Estimates Unit;
Sarah Masi, Special Assistant for Health; Susan Willie, Chief,
Mandates Unit; Leo Lex, Deputy Assistant Director for Budget
Analysis; Theresa A. Gullo, Assistant Director for Budget
Analysis.

Federal Mandates Statement

The Committee adopts as its own the estimate of Federal
mandates prepared by the Director of the Congressional Budget
Office pursuant to section 423 of the Unfunded Mandates Reform
Act.

Statement of General Performance Goals and Objectives

Pursuant to clause 3(c)(4) of rule XIII, the general
performance goal or objective of this legislation is to require
comprehensive mental health and substance use disorder services
as a mandatory benefit under the CHIP program for pregnant
women and children.

Duplication of Federal Programs

Pursuant to clause 3(c)(5) of rule XIII, no provision of
H.R. 3192 is known to be duplicative of another Federal
program, including any program that was included in a report to
Congress pursuant to section 21 of Public Law 111-139 or the
most recent Catalog of Federal Domestic Assistance.

Committee Cost Estimate

Pursuant to clause 3(d)(1) of rule XIII, the Committee
adopts as its own the cost estimate prepared by the Director of
the Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974.

Earmark, Limited Tax Benefits, and Limited Tariff Benefits

Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the
Committee finds that H.R. 3192 contains no earmarks, limited
tax benefits, or limited tariff benefits.

Disclosure of Directed Rule Makings

Pursuant to section 3(i) of H. Res. 5, the Committee finds
that H.R. 3192 contains no directed rule makings.

Advisory Committee Statement

No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act were created by this
legislation.

Applicability to Legislative Branch

The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.

Section-by-Section Analysis of the Legislation

Section 1. Short title

Section 1 provides that the Act may be cited as the ``CHIP
Mental Health Parity Act.''

Section 2. Ensuring access to mental health services for children under
the Children's Health Insurance Program

Section 2 amends Section 2103(c)(1) of the Social Security
Act to add mental health services and substance use disorder
services (including behavioral health treatment) to the list of
services that must be covered under separate CHIP programs. The
provision would require mental health services to be delivered
in a culturally and linguistically appropriate manner and to
include services necessary to prevent, diagnose, and treat a
broad range of mental health symptoms and disorders, including
substance use disorders.
Section 2 also requires state child health plans to include
a description of the methods used to monitor access to mental
health services and substance use disorder services (including
behavioral health treatment) under separate CHIP programs.
Section 2 requires separate CHIP programs to ensure the
financial requirements and treatment limitations applicable to
mental health services and substance use disorder services
(including behavioral health treatment) comply with mental
health parity requirements in the same manner as group health
plans.
If, under a state child health plan (or waiver of such
plan) for a separate CHIP program, state legislation would be
needed in order for the state to meet a specific statutory
requirement under H.R. 3192, then the requirement would be
deemed to take effect on the first day of the first calendar
quarter beginning after the close of the first regular session
of the state legislature beginning after enactment.

Changes in Existing Law Made by the Bill, as Reported

In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):

SOCIAL SECURITY ACT

* * * * * * *
TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM

* * * * * * *

SEC. 2102. GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY;
OUTREACH.

(a) General Background and Description.--A State child health
plan shall include a description, consistent with the
requirements of this title, of--
(1) the extent to which, and manner in which,
children in the State, including targeted low-income
children and other classes of children classified by
income and other relevant factors, currently have
creditable health coverage (as defined in section
2110(c)(2));
(2) current State efforts to provide or obtain
creditable health coverage for uncovered children,
including the steps the State is taking to identify and
enroll all uncovered children who are eligible to
participate in public health insurance programs and
health insurance programs that involve public-private
partnerships;
(3) how the plan is designed to be coordinated with
such efforts to increase coverage of children under
creditable health coverage;
(4) the child health assistance provided under the
plan for targeted low-income children, including the
proposed methods of delivery, and utilization control
systems;
(5) eligibility standards consistent with subsection
(b);
(6) outreach activities consistent with subsection
(c); and
(7) methods (including monitoring) used--
(A) to assure the quality and appropriateness
of care, particularly with respect to well-baby
care, well-child care, and immunizations
provided under the plan;
(B) to assure access to covered services,
including emergency services and services
described in [section 2103(c)(5)] paragraphs
(5) and (6) of section 2103(c); and
(C) to ensure that the State agency involved
is in compliance with subparagraphs (A), (B),
and (C) of section 1128K(b)(2).
(b) General Description of Eligibility Standards and
Methodology.--
(1) Eligibility standards.--
(A) In general.--The plan shall include a
description of the standards used to determine
the eligibility of targeted low-income children
for child health assistance under the plan.
Such standards may include (to the extent
consistent with this title) those relating to
the geographic areas to be served by the plan,
age, income and resources (including any
standards relating to spenddowns and
disposition of resources), residency,
disability status (so long as any standard
relating to such status does not restrict
eligibility), access to or coverage under other
health coverage, and duration of eligibility.
Such standards may not discriminate on the
basis of diagnosis.
(B) Limitations on eligibility standards.--
Such eligibility standards--
(i) shall, within any defined group
of covered targeted low-income
children, not cover such children with
higher family income without covering
children with a lower family income;
(ii) may not deny eligibility based
on a child having a preexisting medical
condition;
(iii) may not apply a waiting period
(including a waiting period to carry
out paragraph (3)(C)) in the case of a
targeted low-income pregnant woman
provided pregnancy-related assistance
under section 2112;
(iv) at State option, may not apply a
waiting period in the case of a child
provided dental-only supplemental
coverage under section 2110(b)(5); and
(v) shall, beginning January 1, 2014,
use modified adjusted gross income and
household income (as defined in section
36B(d)(2) of the Internal Revenue Code
of 1986) to determine eligibility for
child health assistance under the State
child health plan or under any waiver
of such plan and for any other purpose
applicable under the plan or waiver for
which a determination of income is
required, including with respect to the
imposition of premiums and cost-
sharing, consistent with section
1902(e)(14).
(2) Methodology.--The plan shall include a
description of methods of establishing and continuing
eligibility and enrollment.
(3) Eligibility screening; coordination with other
health coverage programs.--The plan shall include a
description of procedures to be used to ensure--
(A) through both intake and followup
screening, that only targeted low-income
children are furnished child health assistance
under the State child health plan;
(B) that children found through the screening
to be eligible for medical assistance under the
State medicaid plan under title XIX are
enrolled for such assistance under such plan;
(C) that the insurance provided under the
State child health plan does not substitute for
coverage under group health plans;
(D) the provision of child health assistance
to targeted low-income children in the State
who are Indians (as defined in section 4(c) of
the Indian Health Care Improvement Act, 25
U.S.C. 1603(c)); and
(E) coordination with other public and
private programs providing creditable coverage
for low-income children.
(4) Reduction of administrative barriers to
enrollment.--
(A) In general.--Subject to subparagraph (B),
the plan shall include a description of the
procedures used to reduce administrative
barriers to the enrollment of children and
pregnant women who are eligible for medical
assistance under title XIX or for child health
assistance or health benefits coverage under
this title. Such procedures shall be
established and revised as often as the State
determines appropriate to take into account the
most recent information available to the State
identifying such barriers.
(B) Deemed compliance if joint application
and renewal process that permits application
other than in person.--A State shall be deemed
to comply with subparagraph (A) if the State's
application and renewal forms and supplemental
forms (if any) and information verification
process is the same for purposes of
establishing and renewing eligibility for
children and pregnant women for medical
assistance under title XIX and child health
assistance under this title, and such process
does not require an application to be made in
person or a face-to-face interview.
(5) Nonentitlement.--Nothing in this title shall be
construed as providing an individual with an
entitlement to child health assistance under a State
child health plan.
(c) Outreach and Coordination.--A State child health plan
shall include a description of the procedures to be used by the
State to accomplish the following:
(1) Outreach.--Outreach (through community health
workers and others) to families of children likely to
be eligible for child health assistance under the plan
or under other public or private health coverage
programs to inform these families of the availability
of, and to assist them in enrolling their children in,
such a program.
(2) Coordination with other health insurance
programs.--Coordination of the administration of the
State program under this title with other public and
private health insurance programs.
(3) Premium assistance subsidies.--In the case of a
State that provides for premium assistance subsidies
under the State child health plan in accordance with
paragraph (2)(B), (3), or (10) of section 2105(c), or a
waiver approved under section 1115, outreach,
education, and enrollment assistance for families of
children likely to be eligible for such subsidies, to
inform such families of the availability of, and to
assist them in enrolling their children in, such
subsidies, and for employers likely to provide coverage
that is eligible for such subsidies, including the
specific, significant resources the State intends to
apply to educate employers about the availability of
premium assistance subsidies under the State child
health plan.

SEC. 2103. COVERAGE REQUIREMENTS FOR CHILDREN'S HEALTH INSURANCE.

(a) Required Scope of Health Insurance Coverage.--The child
health assistance provided to a targeted low-income child under
the plan in the form described in paragraph (1) of section
2101(a) shall consist, consistent with [paragraphs (5), (6),
and (7)] paragraphs (5), (6), (7), and (8) of subsection (c),
of any of the following:
(1) Benchmark coverage.--Health benefits coverage
that is at least equivalent to the benefits coverage in
a benchmark benefit package described in subsection
(b).
(2) Benchmark-equivalent coverage.--Health benefits
coverage that meets the following requirements:
(A) Inclusion of basic services.--The
coverage includes benefits for items and
services within each of the categories of basic
services described in subsection (c)(1).
(B) Aggregate actuarial value equivalent to
benchmark package.--The coverage has an
aggregate actuarial value that is at least
actuarially equivalent to one of the benchmark
benefit packages.
(C) Substantial actuarial value for
additional services included in benchmark
package.--With respect to each of the
categories of additional services described in
subsection (c)(2) for which coverage is
provided under the benchmark benefit package
used under subparagraph (B), the coverage has
an actuarial value that is equal to at least 75
percent of the actuarial value of the coverage
of that category of services in such package.
(3) Existing comprehensive state-based coverage.--
Health benefits coverage under an existing
comprehensive State-based program, described in
subsection (d)(1).
(4) Secretary-approved coverage.--Any other health
benefits coverage that the Secretary determines, upon
application by a State, provides appropriate coverage
for the population of targeted low-income children
proposed to be provided such coverage.
(b) Benchmark Benefit Packages.--The benchmark benefit
packages are as follows:
(1) FEHBP-equivalent children's health insurance
coverage.--The standard Blue Cross/Blue Shield
preferred provider option service benefit plan,
described in and offered under section 8903(1) of title
5, United States Code.
(2) State employee coverage.--A health benefits
coverage plan that is offered and generally available
to State employees in the State involved.
(3) Coverage offered through hmo.--The health
insurance coverage plan that--
(A) is offered by a health maintenance
organization (as defined in section 2791(b)(3)
of the Public Health Service Act), and
(B) has the largest insured commercial, non-
medicaid enrollment of covered lives of such
coverage plans offered by such a health
maintenance organization in the State involved.
(c) Categories of Services; Determination of Actuarial Value
of Coverage.--
(1) Categories of basic services.--For purposes of
this section, the categories of basic services
described in this paragraph are as follows:
(A) Inpatient and outpatient hospital
services.
(B) Physicians' surgical and medical
services.
(C) Laboratory and x-ray services.
(D) Well-baby and well-child care, including
age-appropriate immunizations.
(E) Mental health and substance use disorder
services (as defined in paragraph (5)).
(2) Categories of additional services.--For purposes
of this section, the categories of additional services
described in this paragraph are as follows:
(A) Coverage of prescription drugs.
(B) Vision services.
(C) Hearing services.
(3) Treatment of other categories.--Nothing in this
subsection shall be construed as preventing a State
child health plan from providing coverage of benefits
that are not within a category of services described in
paragraph (1) or (2).
(4) Determination of actuarial value.--The actuarial
value of coverage of benchmark benefit packages,
coverage offered under the State child health plan, and
coverage of any categories of additional services under
benchmark benefit packages and under coverage offered
by such a plan, shall be set forth in an actuarial
opinion in an actuarial report that has been prepared--
(A) by an individual who is a member of the
American Academy of Actuaries;
(B) using generally accepted actuarial
principles and methodologies;
(C) using a standardized set of utilization
and price factors;
(D) using a standardized population that is
representative of privately insured children of
the age of children who are expected to be
covered under the State child health plan;
(E) applying the same principles and factors
in comparing the value of different coverage
(or categories of services);
(F) without taking into account any
differences in coverage based on the method of
delivery or means of cost control or
utilization used; and
(G) taking into account the ability of a
State to reduce benefits by taking into account
the increase in actuarial value of benefits
coverage offered under the State child health
plan that results from the limitations on cost
sharing under such coverage.
The actuary preparing the opinion shall select and
specify in the memorandum the standardized set and
population to be used under subparagraphs (C) and (D).
(5) Mental health and substance use disorder
services.--In the case of a State that provides child
health assistance for targeted low-income children or
targeted low-income pregnant women (as defined in
section 2112(d)) in the form of providing any health
benefits coverage described in subsection (a), such
child health assistance shall--
(A) include coverage of mental health
services (including behavioral health
treatment) necessary to prevent, diagnose, and
treat a broad range of mental health symptoms
and disorders, including substance use
disorders; and
(B) be delivered in a culturally and
linguistically appropriate manner.
[(5)] (6) Dental benefits.--
(A) In general.--The child health assistance
provided to a targeted low-income child shall
include coverage of dental services necessary
to prevent disease and promote oral health,
restore oral structures to health and function,
and treat emergency conditions.
(B) Permitting use of dental benchmark plans
by certain states.--A State may elect to meet
the requirement of subparagraph (A) through
dental coverage that is equivalent to a
benchmark dental benefit package described in
subparagraph (C).
(C) Benchmark dental benefit packages.--The
benchmark dental benefit packages are as
follows:
(i) FEHBP children's dental
coverage.--A dental benefits plan under
chapter 89A of title 5, United States
Code, that has been selected most
frequently by employees seeking
dependent coverage, among such plans
that provide such dependent coverage,
in either of the previous 2 plan years.
(ii) State employee dependent dental
coverage.--A dental benefits plan that
is offered and generally available to
State employees in the State involved
and that has been selected most
frequently by employees seeking
dependent coverage, among such plans
that provide such dependent coverage,
in either of the previous 2 plan years.
(iii) Coverage offered through
commercial dental plan.--A dental
benefits plan that has the largest
insured commercial, non-medicaid
enrollment of dependent covered lives
of such plans that is offered in the
State involved.
[(6)] (7) Mental health services parity.--
[(A) In general.--In the case of a State
child health plan that provides both medical
and surgical benefits and mental health or
substance use disorder benefits, such plan
shall ensure that the financial requirements
and treatment limitations applicable to such
mental health or substance use disorder
benefits comply with the requirements of
section 2705(a) of the Public Health Service
Act in the same manner as such requirements
apply to a group health plan.]
(A) In general.--A State child health plan
shall ensure that the financial requirements
and treatment limitations applicable to mental
health and substance use disorder services (as
described in paragraph (5)) provided under such
plan comply with the requirements of section
2726(a) of the Public Health Service Act in the
same manner as such requirements or limitations
apply to a group health plan under such
section.
(B) Deemed compliance.--To the extent that a
State child health plan includes coverage with
respect to an individual described in section
1905(a)(4)(B) and covered under the State plan
under section 1902(a)(10)(A) of the services
described in section 1905(a)(4)(B) (relating to
early and periodic screening, diagnostic, and
treatment services defined in section 1905(r))
and provided in accordance with section
1902(a)(43), such plan shall be deemed to
satisfy the requirements of subparagraph (A).
[(7)] (8) Construction on prohibited coverage.--
Nothing in this section shall be construed as requiring
any health benefits coverage offered under the plan to
provide coverage for items or services for which
payment is prohibited under this title, notwithstanding
that any benchmark benefit package includes coverage
for such an item or service.
[(8)] (9) Availability of coverage for items and
services furnished through school-based health
centers.--Nothing in this title shall be construed as
limiting a State's ability to provide child health
assistance for covered items and services that are
furnished through school-based health centers (as
defined in section 2110(c)(9)).
(d) Description of Existing Comprehensive State-Based
Coverage.--
(1) In general.--A program described in this
paragraph is a child health coverage program that--
(A) includes coverage of a range of benefits;
(B) is administered or overseen by the State
and receives funds from the State;
(C) is offered in New York, Florida, or
Pennsylvania; and
(D) was offered as of the date of the
enactment of this title.
(2) Modifications.--A State may modify a program
described in paragraph (1) from time to time so long as
it continues to meet the requirement of subparagraph
(A) and does not reduce the actuarial value of the
coverage under the program below the lower of--
(A) the actuarial value of the coverage under
the program as of the date of the enactment of
this title, or
(B) the actuarial value described in
subsection (a)(2)(B),
evaluated as of the time of the modification.
(e) Cost-Sharing.--
(1) Description; general conditions.--
(A) Description.--A State child health plan
shall include a description, consistent with
this subsection, of the amount (if any) of
premiums, deductibles, coinsurance, and other
cost sharing imposed. Any such charges shall be
imposed pursuant to a public schedule.
(B) Protection for lower income children.--
The State child health plan may only vary
premiums, deductibles, coinsurance, and other
cost sharing based on the family income of
targeted low-income children in a manner that
does not favor children from families with
higher income over children from families with
lower income.
(2) No cost sharing on benefits for preventive
services or pregnancy-related assistance.--The State
child health plan may not impose deductibles,
coinsurance, or other cost sharing with respect to
benefits for services within the category of services
described in subsection (c)(1)(D) or for pregnancy-
related assistance.
(3) Limitations on premiums and cost-sharing.--
(A) Children in families with income below
150 percent of poverty line.--In the case of a
targeted low-income child whose family income
is at or below 150 percent of the poverty line,
the State child health plan may not impose--
(i) an enrollment fee, premium, or
similar charge that exceeds the maximum
monthly charge permitted consistent
with standards established to carry out
section 1916(b)(1) (with respect to
individuals described in such section);
and
(ii) a deductible, cost sharing, or
similar charge that exceeds an amount
that is nominal (as determined
consistent with regulations referred to
in section 1916(a)(3), with such
appropriate adjustment for inflation or
other reasons as the Secretary
determines to be reasonable).
(B) Other children.--For children not
described in subparagraph (A), subject to
paragraphs (1)(B) and (2), any premiums,
deductibles, cost sharing or similar charges
imposed under the State child health plan may
be imposed on a sliding scale related to
income, except that the total annual aggregate
cost-sharing with respect to all targeted low-
income children in a family under this title
may not exceed 5 percent of such family's
income for the year involved.
(C) Premium grace period.--The State child
health plan--
(i) shall afford individuals enrolled
under the plan a grace period of at
least 30 days from the beginning of a
new coverage period to make premium
payments before the individual's
coverage under the plan may be
terminated; and
(ii) shall provide to such an
individual, not later than 7 days after
the first day of such grace period,
notice--
(I) that failure to make a
premium payment within the
grace period will result in
termination of coverage under
the State child health plan;
and
(II) of the individual's
right to challenge the proposed
termination pursuant to the
applicable Federal regulations.
For purposes of clause (i), the term ``new
coverage period'' means the month immediately
following the last month for which the premium
has been paid.
(4) Relation to medicaid requirements.--Nothing in
this subsection shall be construed as affecting the
rules relating to the use of enrollment fees, premiums,
deductions, cost sharing, and similar charges in the
case of targeted low-income children who are provided
child health assistance in the form of coverage under a
medicaid program under section 2101(a)(2).
(f) Application of Certain Requirements.--
(1) Restriction on application of preexisting
condition exclusions.--
(A) In general.--Subject to subparagraph (B),
the State child health plan shall not permit
the imposition of any preexisting condition
exclusion for covered benefits under the plan.
(B) Group health plans and group health
insurance coverage.--If the State child health
plan provides for benefits through payment for,
or a contract with, a group health plan or
group health insurance coverage, the plan may
permit the imposition of a preexisting
condition exclusion but only insofar as it is
permitted under the applicable provisions of
part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 and
title XXVII of the Public Health Service Act.
(2) Compliance with other requirements.--Coverage
offered under this section shall comply with the
requirements of subpart 2 of part A of title XXVII of
the Public Health Service Act insofar as such
requirements apply with respect to a health insurance
issuer that offers group health insurance coverage.
(3) Compliance with managed care requirements.--The
State child health plan shall provide for the
application of subsections (a)(4), (a)(5), (b), (c),
(d), and (e) of section 1932 (relating to requirements
for managed care) to coverage, State agencies,
enrollment brokers, managed care entities, and managed
care organizations under this title in the same manner
as such subsections apply to coverage and such entities
and organizations under title XIX.

* * * * * * *

SEC. 2110. DEFINITIONS.

(a) Child Health Assistance.--For purposes of this title, the
term ``child health assistance'' means payment for part or all
of the cost of health benefits coverage for targeted low-income
children that includes any of the following (and includes, in
the case described in section 2105(a)(1)(D)(i), payment for
part or all of the cost of providing any of the following), as
specified under the State plan:
(1) Inpatient hospital services.
(2) Outpatient hospital services.
(3) Physician services.
(4) Surgical services.
(5) Clinic services (including health center
services) and other ambulatory health care services.
(6) Prescription drugs and biologicals and the
administration of such drugs and biologicals, only if
such drugs and biologicals are not furnished for the
purpose of causing, or assisting in causing, the death,
suicide, euthanasia, or mercy killing of a person.
(7) Over-the-counter medications.
(8) Laboratory and radiological services.
(9) Prenatal care and prepregnancy family planning
services and supplies.
(10) Inpatient mental health services, other than
services described in paragraph (18) but including
services furnished in a State-operated mental hospital
and including residential or other 24-hour
therapeutically planned structured services.
(11) Outpatient mental health services, other than
services described in paragraph (19) but including
services furnished in a State-operated mental hospital
and including community-based services.
(12) Durable medical equipment and other medically-
related or remedial devices (such as prosthetic
devices, implants, eyeglasses, hearing aids, dental
devices, and adaptive devices).
(13) Disposable medical supplies.
(14) Home and community-based health care services
and related supportive services (such as home health
nursing services, home health aide services, personal
care, assistance with activities of daily living, chore
services, day care services, respite care services,
training for family members, and minor modifications to
the home).
(15) Nursing care services (such as nurse
practitioner services, nurse midwife services, advanced
practice nurse services, private duty nursing care,
pediatric nurse services, and respiratory care
services) in a home, school, or other setting.
(16) Abortion only if necessary to save the life of
the mother or if the pregnancy is the result of an act
of rape or incest.
(17) Dental services.
(18) Inpatient [substance abuse] substance use
treatment services and residential [substance abuse]
substance use treatment services.
(19) Outpatient [substance abuse] substance use
treatment services.
(20) Case management services.
(21) Care coordination services.
(22) Physical therapy, occupational therapy, and
services for individuals with speech, hearing, and
language disorders.
(23) Hospice care (concurrent, in the case of an
individual who is a child, with care related to the
treatment of the child's condition with respect to
which a diagnosis of terminal illness has been made.
(24) Any other medical, diagnostic, screening,
preventive, restorative, remedial, therapeutic, or
rehabilitative services (whether in a facility, home,
school, or other setting) if recognized by State law
and only if the service is--
(A) prescribed by or furnished by a physician
or other licensed or registered practitioner
within the scope of practice as defined by
State law,
(B) performed under the general supervision
or at the direction of a physician, or
(C) furnished by a health care facility that
is operated by a State or local government or
is licensed under State law and operating
within the scope of the license.
(25) Premiums for private health care insurance
coverage.
(26) Medical transportation.
(27) Enabling services (such as transportation,
translation, and outreach services) only if designed to
increase the accessibility of primary and preventive
health care services for eligible low-income
individuals.
(28) Any other health care services or items
specified by the Secretary and not excluded under this
section.
(b) Targeted Low-Income Child Defined.--For purposes of this
title--
(1) In general.--Subject to paragraph (2), the term
``targeted low-income child'' means a child--
(A) who has been determined eligible by the
State for child health assistance under the
State plan;
(B)(i) who is a low-income child, or
(ii) is a child--
(I) whose family income (as
determined under the State child health
plan) exceeds the medicaid applicable
income level (as defined in paragraph
(4)), but does not exceed 50 percentage
points above the medicaid applicable
income level;
(II) whose family income (as so
determined) does not exceed the
medicaid applicable income level (as
defined in paragraph (4) but determined
as if ``June 1, 1997'' were substituted
for ``March 31, 1997''); or
(III) who resides in a State that
does not have a medicaid applicable
income level (as defined in paragraph
(4)); and
(C) who is not found to be eligible for
medical assistance under title XIX or, subject
to paragraph (5), covered under a group health
plan or under health insurance coverage (as
such terms are defined in section 2791 of the
Public Health Service Act).
(2) Children excluded.--Such term does not include--
(A) a child who is an inmate of a public
institution or a patient in an institution for
mental diseases; or
(B) except as provided in paragraph (6), a
child who is a member of a family that is
eligible for health benefits coverage under a
State health benefits plan on the basis of a
family member's employment with a public agency
in the State.
(3) Special rule.--A child shall not be considered to
be described in paragraph (1)(C) notwithstanding that
the child is covered under a health insurance coverage
program that has been in operation since before July 1,
1997, and that is offered by a State which receives no
Federal funds for the program's operation.
(4) Medicaid applicable income level.--The term
``medicaid applicable income level'' means, with
respect to a child, the effective income level
(expressed as a percent of the poverty line) that has
been specified under the State plan under title XIX
(including under a waiver authorized by the Secretary
or under section 1902(r)(2)), as of March 31, 1997, for
the child to be eligible for medical assistance under
section 1902(l)(2) or 1905(n)(2) (as selected by a
State) for the age of such child.
(5) Option for states with a separate chip program to
provide dental-only supplemental coverage.--
(A) In general.--Subject to subparagraphs (B)
and (C), in the case of any child who is
enrolled in a group health plan or health
insurance coverage offered through an employer
who would, but for the application of paragraph
(1)(C), satisfy the requirements for being a
targeted low-income child under a State child
health plan that is implemented under this
title, a State may waive the application of
such paragraph to the child in order to
provide--
(i) dental coverage consistent with
the requirements of [subsection (c)(5)]
subsection (c)(6) of section 2103; or
(ii) cost-sharing protection for
dental coverage consistent with such
requirements and the requirements of
subsection (e)(3)(B) of such section.
(B) Limitation.--A State may limit the
application of a waiver of paragraph (1)(C) to
children whose family income does not exceed a
level specified by the State, so long as the
level so specified does not exceed the maximum
income level otherwise established for other
children under the State child health plan.
(C) Conditions.--A State may not offer
dental-only supplemental coverage under this
paragraph unless the State satisfies the
following conditions:
(i) Income eligibility.--The State
child health plan under this title--
(I) has the highest income
eligibility standard permitted
under this title (or a waiver)
as of January 1, 2009;
(II) does not limit the
acceptance of applications for
children or impose any
numerical limitation, waiting
list, or similar limitation on
the eligibility of such
children for child health
assistance under such State
plan; and
(III) provides benefits to
all children in the State who
apply for and meet eligibility
standards.
(ii) No more favorable treatment.--
The State child health plan may not
provide more favorable dental coverage
or cost-sharing protection for dental
coverage to children provided dental-
only supplemental coverage under this
paragraph than the dental coverage and
cost-sharing protection for dental
coverage provided to targeted low-
income children who are eligible for
the full range of child health
assistance provided under the State
child health plan.
(6) Exceptions to exclusion of children of employees
of a public agency in the state.--
(A) In general.--A child shall not be
considered to be described in paragraph (2)(B)
if--
(i) the public agency that employs a
member of the child's family to which
such paragraph applies satisfies
subparagraph (B); or
(ii) subparagraph (C) applies to such
child.
(B) Maintenance of effort with respect to
agency contribution for family coverage.--For
purposes of subparagraph (A)(i), a public
agency satisfies this subparagraph if the
amount of annual agency expenditures made on
behalf of employees enrolled in health coverage
paid for by the agency that includes dependent
coverage for the most recent State fiscal year
is not less than the amount of such
expenditures made by the agency for the 1997
State fiscal year, increased by the percentage
increase in the medical care expenditure
category of the Consumer Price Index for All-
Urban Consumers (all items: U.S. City Average)
for such preceding fiscal year.
(C) Hardship exception.--For purposes of
subparagraph (A)(ii), this subparagraph applies
to a child if the State determines that the
annual aggregate amount of premiums and cost-
sharing imposed for coverage of the family of
the child would exceed 5 percent of such
family's income for the year involved.
(c) Additional Definitions.--For purposes of this title:
(1) Child.--The term ``child'' means an individual
under 19 years of age.
(2) Creditable health coverage.--The term
``creditable health coverage'' has the meaning given
the term ``creditable coverage'' under section 2701(c)
of the Public Health Service Act (42 U.S.C. 300gg(c))
and includes coverage that meets the requirements of
section 2103 provided to a targeted low-income child
under this title or under a waiver approved under
section 2105(c)(2)(B) (relating to a direct service
waiver).
(3) Group health plan; health insurance coverage;
etc.--The terms ``group health plan'', ``group health
insurance coverage'', and ``health insurance coverage''
have the meanings given such terms in section 2791 of
the Public Health Service Act.
(4) Low-income.--The term ``low-income child'' means
a child whose family income is at or below 200 percent
of the poverty line for a family of the size involved.
(5) Poverty line defined.--The term ``poverty line''
has the meaning given such term in section 673(2) of
the Community Services Block Grant Act (42 U.S.C.
9902(2)), including any revision required by such
section.
(6) Preexisting condition exclusion.--The term
``preexisting condition exclusion'' has the meaning
given such term in section 2701(b)(1)(A) of the Public
Health Service Act (42 U.S.C. 300gg(b)(1)(A)).
(7) State child health plan; plan.--Unless the
context otherwise requires, the terms ``State child
health plan'' and ``plan'' mean a State child health
plan approved under section 2106.
(8) Uncovered child.--The term ``uncovered child''
means a child that does not have creditable health
coverage.
(9) School-based health center.--
(A) In general.--The term ``school-based
health center'' means a health clinic that--
(i) is located in or near a school
facility of a school district or board
or of an Indian tribe or tribal
organization;
(ii) is organized through school,
community, and health provider
relationships;
(iii) is administered by a sponsoring
facility;
(iv) provides through health
professionals primary health services
to children in accordance with State
and local law, including laws relating
to licensure and certification; and
(v) satisfies such other requirements
as a State may establish for the
operation of such a clinic.
(B) Sponsoring facility.--For purposes of
subparagraph (A)(iii), the term ``sponsoring
facility'' includes any of the following:
(i) A hospital.
(ii) A public health department.
(iii) A community health center.
(iv) A nonprofit health care agency.
(v) A local educational agency (as
defined under section 8101 of the
Elementaryand Secondary Education Act
of 1965.
(vi) A program administered by the
Indian Health Service or the Bureau of
Indian Affairs or operated by an Indian
tribe or a tribal organization.

* * * * * * *

[all]

All Congresses 93-116 (1973-2020)
116 (2019-2020)
115 (2017-2018)
114 (2015-2016)
113 (2013-2014)
112 (2011-2012)
111 (2009-2010)
110 (2007-2008)
109 (2005-2006)
108 (2003-2004)
107 (2001-2002)
106 (1999-2000)
105 (1997-1998)
104 (1995-1996)
103 (1993-1994)
102 (1991-1992)
101 (1989-1990)
100 (1987-1988)
99 (1985-1986)
98 (1983-1984)
97 (1981-1982)
96 (1979-1980)
95 (1977-1978)
94 (1975-1976)
93 (1973-1974)

Any Version of Legislation
AS - Amendment Ordered to be Printed
ATH - Agreed to House
ATS - Agreed to Senate
CDH - Committee Discharged House
CDS - Committee Discharged Senate
CPH - Considered and Passed House
CPS - Considered and Passed Senate
EAH - Engrossed Amendment House
EAS - Engrossed Amendment Senate
EH - Engrossed in House
ENR - Enrolled
ES - Engrossed in Senate
FPH - Failed Passage House
HDS - Held at Desk Senate
IH - Introduced in House
IPS - Indefinitely Postponed Senate
IS - Introduced in Senate
LTH - Laid on Table in House
LTS - Laid on Table in Senate
PAP - Printed as Passed
PCS - Placed on Calendar Senate
PCS2 - Placed on Calendar Senate
PP - Public Print
RCH - Reference Change House
RCS - Reference Change Senate
RDS - Received in Senate
RFH - Referred in House
RFS - Referred in Senate
RH - Reported in House
RIH - Referral Instructions House
RS - Reported to Senate
RTH - Referred to Committee House
RTS - Referred to Committee Senate

All Congresses 97-116 (1981-2020)
116 (2019-2020)
115 (2017-2018)
114 (2015-2016)
113 (2013-2014)
112 (2011-2012)
111 (2009-2010)
110 (2007-2008)
109 (2005-2006)
108 (2003-2004)
107 (2001-2002)
106 (1999-2000)
105 (1997-1998)
104 (1995-1996)
103 (1993-1994)
102 (1991-1992)
101 (1989-1990)
100 (1987-1988)
99 (1985-1986)
98 (1983-1984)
97 (1981-1982)

Any State or Territory
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming

Any Committee
Agriculture (70th-116th)
Appropriations (70th-116th)
Armed Services (79th-116th)
Budget (93rd-116th)
Education and the Workforce (70th-116th)
Energy and Commerce (70th-116th)
Ethics (90th-116th)
Financial Services (70th-116th)
Foreign Affairs (70th-116th)
Homeland Security (107th-116th)
House Administration (79th-116th)
Intelligence (Permanent Select) (94th-116th)
Judiciary (70th-116th)
Natural Resources (70th-116th)
Oversight and Government Reform (70th-116th)
Rules (70th-116th)
Science, Space, and Technology (86th-116th)
Small Business (77th-116th)
Transportation and Infrastructure (79th-116th)
Veterans' Affairs (79th-116th)
Ways and Means (70th-116th)

Any State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming

All Congresses 96-116 (1979-2020)
116 (2019-2020)
115 (2017-2018)
114 (2015-2016)
113 (2013-2014)
112 (2011-2012)
111 (2009-2010)
110 (2007-2008)
109 (2005-2006)
108 (2003-2004)
107 (2001-2002)
106 (1999-2000)
105 (1997-1998)
104 (1995-1996)
103 (1993-1994)
102 (1991-1992)
101 (1989-1990)
100 (1987-1988)
99 (1985-1986)
98 (1983-1984)
97 (1981-1982)
96 (1979-1980)

Any Committee
Aging (Special) (87th-116th)
Agriculture, Nutrition, and Forestry (70th-116th)
Appropriations (70th-116th)
Armed Services (79th-116th)
Banking, Housing, and Urban Affairs (70th-116th)
Budget (93rd-116th)
Commerce, Science, and Transportation (79th-116th)
Energy and Natural Resources (70th-116th)
Environment and Public Works (79th-116th)
Ethics (Select) (88th-116th)
Finance (70th-116th)
Foreign Relations (70th-116th)
Governmental Affairs (70th-116th)
Intelligence (Select) (94th-116th)
Judiciary (70th-116th)
Labor and Human Resources (70th-116th)
Rules and Administration (79th-116th)
Select Committee on Indian Affairs (95th-116th)
Small Business (81st-116th)
Veterans' Affairs (91st-116th)

All Congresses 81-116 (1949-2020)
116 (2019-2020)
115 (2017-2018)
114 (2015-2016)
113 (2013-2014)
112 (2011-2012)
111 (2009-2010)
110 (2007-2008)
109 (2005-2006)
108 (2003-2004)
107 (2001-2002)
106 (1999-2000)
105 (1997-1998)
104 (1995-1996)
103 (1993-1994)
102 (1991-1992)
101 (1989-1990)
100 (1987-1988)
99 (1985-1986)
98 (1983-1984)
97 (1981-1982)
96 (1979-1980)
95 (1977-1978)
94 (1975-1976)
93 (1973-1974)
92 (1971-1972)
91 (1969-1970)
90 (1967-1968)
89 (1965-1966)
88 (1963-1964)
87 (1961-1962)
86 (1959-1960)
85 (1957-1958)
84 (1955-1956)
83 (1953-1954)
82 (1951-1952)
81 (1949-1950)

Any Topic
Agriculture
Arms Control
Aviation
Commercial
Consular
Dispute Settlement and Arbitration
Drugs/Illegal Substances
Environment
Extradition
Extradition and Criminal Assistance
Fisheries and Wildlife
Human Rights
Intellectual Property/Copyrights
International Law
International Law and Organization
Investment
Labor
Maritime Boundaries and Claims
Mutual Legal Assistance
Shipping and Marine Pollution
Taxation
Telecommunications
Terrorism
Trademarks/Patents
United Nations