#aaeth ,,congress #b;d ,session ,h4 ,r4 #eggc ,,an ,,act ,to amend title ,,xviii of the ,social ,security ,act to require electronic prior authorization for covered part ,d drugs and to provide for other program integrity measures under parts ,c and ,d of the ,medicare program4 #a4 ,short title ,this ,act may be cited as the ,preventing ,addiction for ,susceptible ,seniors ,act of #bjah or the ,,pass ,act of #bjah 4 #b4 ,electronic prior authorization for covered part ,d drugs 7a7 ,inclusion in electronic prescription program ,section #ahfj;,d-#d7;e77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;e77#b77 is amended by adding at the end the following new subparagraph3 7,e7 ,electronic prior authorization 7i7 ,in general ,not later than ,january #a1 #bjba1 the program shall provide for the secure electronic transmission of-- 7,i7 a prior authorization request from the prescribing health care professional for coverage of a covered part ,d drug for a part ,d eligible individual enrolled in a part ,d plan 7as defined in section #ahfj;,d-#bc7;a77#e77 to the ,,pdp sponsor or ,medicare ,advantage organization offering such plan2 and 7,,ii7 a response1 in accordance with this subparagraph1 from such ,,pdp sponsor or ,medicare ,advantage organization1 respectively1 to such professional4 7ii7 ,electronic transmission 7,i7 ,exclusions ,for purposes of this subparagraph1 a facsimile1 a proprietary payer portal that does not meet standards specified by the ,secretary1 or an electronic form shall not be treated as an electronic transmission described in clause 7i74 7,,ii7 ,standards ,in order to be treated1 for purposes of this subparagraph1 as an electronic transmission described in clause 7i71 such transmission shall comply with technical standards adopted by the ,secretary in consultation with the ,national ,council for ,prescription ,drug ,programs1 other standard setting organizations determined appropriate by the ,secretary1 and stakeholders including ,,pdp sponsors1 ,medicare ,advantage organizations1 health care professionals1 and health information technology software vendors4 7,,iii7 ,application ,notwithstanding any other provision of law1 for purposes of this subparagraph1 the ,secretary may require the use of such standards adopted under subclause 7,,ii7 in lieu of any other applicable standards for an electronic transmission described in clause 7i7 for a covered part ,d drug for a part ,d eligible individual4 4 7b7 ,sense of ,congress regarding electronic prior authorization ,it is the sense of the ,congress that-- 7#a7 there should be increased use of electronic prior authorizations for coverage of covered part ,d drugs for part ,d eligible individuals enrolled in prescription drug plans under part ,d of title ,,xviii of the ,social ,security ,act and ,,ma-,,pd plans under part ,c of such title to reduce access delays by resolving coverage issues before prescriptions for such drugs are transmitted2 and 7#b7 greater priority should be placed on increasing the adoption of use of such electronic prior authorizations among prescribers of such drugs1 pharmacies1 ,,pdp sponsors1 and ,medicare ,advantage organizations4 #c4 ,program integrity transparency measures under ,medicare parts ,c and ,d 7a7 ,in general ,section #ahei of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7 is amended by adding at the end the following new subsection3 7i7 ,program integrity transparency measures 7#a7 ,program integrity portal 7,a7 ,in general ,not later than #b years after the date of the enactment of this subsection1 the ,secretary shall1 after consultation with stakeholders1 establish a secure ,internet website portal 7or other successor technology7 that would allow a secure path for communication between the ,secretary1 ,,ma plans under this part1 prescription drug plans under part ,d1 and an eligible entity with a contract under section #ahic 7such as a ,medicare drug integrity contractor or an entity responsible for carrying out program integrity activities under this part and part ,d7 for the purpose of enabling through such portal 7or other successor technology7-- 7i7 the referral by such plans of substantiated fraud1 waste1 and abuse for initiating or assisting investigations conducted by the eligible entity2 and 7ii7 data sharing among such ,,ma plans1 prescription drug plans1 and the ,secretary4 7,b7 ,required uses of portal ,the ,secretary shall disseminate the following information to ,,ma plans under this part and prescription drug plans under part ,d through the secure ,internet website portal 7or other successor technology7 established under subparagraph 7,a73 7i7 ,providers of services and suppliers that have been referred pursuant to subparagraph 7,a77i7 during the previous #ab-month period4 7ii7 ,providers of services and suppliers who are the subject of an active exclusion under section #aabh or who are subject to a suspension of payment under this title pursuant to section #ahfb7o7 or otherwise4 7iii7 ,providers of services and suppliers who are the subject of an active revocation of participation under this title1 including for not satisfying conditions of participation4 7iv7 ,in the case of such a plan that makes a referral under subparagraph 7,a77i7 through the portal 7or other successor technology7 with respect to activities of substantiated fraud1 waste1 or abuse of a provider of services or supplier1 if such provider or supplier has been the subject of an administrative action under this title or title ,,xi with respect to similar activities1 a notification to such plan of such action so taken4 7,c7 ,rulemaking ,for purposes of this paragraph1 the ,secretary shall1 through rulemaking1 specify what constitutes substantiated fraud1 waste1 and abuse1 using guidance such as what is provided in the ,medicare ,program ,integrity ,manual #d4g4a4 ,in carrying out this subsection1 a fraud hotline tip 7as defined by the ,secretary7 without further evidence shall not be treated as sufficient evidence for substantiated fraud1 waste1 or abuse 7,d7 ,,hipaa compliant information only ,for purposes of this subsection1 communications may only occur if the communications are permitted under the ,federal regulations 7concerning the privacy of individually identifiable health information7 promulgated under section #bfd7;c7 of the ,health ,insurance ,portability and ,accountability ,act of #aiif4 7#b7 ,quarterly reports ,beginning #b years after the date of enactment of this subsection1 the ,secretary shall make available to ,,ma plans under this part and prescription drug plans under part ,d in a timely manner 7but no less frequently than quarterly7 and using information submitted to an entity described in paragraph 7#a7 through the portal 7or other successor technology7 described in such paragraph or pursuant to section #ahic1 information on fraud1 waste1 and abuse schemes and trends in identifying suspicious activity4 ,information included in each such report shall-- 7,a7 include administrative actions1 pertinent information related to opioid overprescribing1 and other data determined appropriate by the ,secretary in consultation with stakeholders2 and 7,b7 be anonymized information submitted by plans without identifying the source of such information4 7#c7 ,clarification ,nothing in this subsection shall be construed as precluding or otherwise affecting referrals described in subparagraph 7,a7 that may otherwise be made to law enforcement entities or to the ,secretary4 4 7b7 ,contract requirement to communicate plan corrective actions against opioid over-prescribers ,section #aheg7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is amended by adding at the end the following new paragraph3 7#e7 ,communicating plan corrective actions against opioids over-prescribers 7,a7 ,in general ,beginning with plan years beginning on or after ,january #a1 #bjba1 a contract under this section with an ,,ma organization shall require the organization to submit to the ,secretary1 through the process established under subparagraph 7,b71 information on the investigations and other actions taken by such plans related to providers of services who prescribe a high volume of opioids4 7,b7 ,process ,not later than ,january #a1 #bjba1 the ,secretary shall1 in consultation with stakeholders1 establish a process under which ,,ma plans and prescription drug plans shall submit to the ,secretary information described in subparagraph 7,a74 7,c7 ,regulations ,for purposes of this paragraph1 including as applied under section #ahfj;,d-#ab7;b77#c77;,d71 the ,secretary shall1 pursuant to rulemaking-- 7i7 specify a definition for the term high volume of opioids and a method for determining if a provider of services prescribes such a high volume2 and 7ii7 establish the process described in subparagraph 7,b7 and the types of information that shall be submitted through such process4 4 7c7 ,reference under part ,d to program integrity transparency measures ,section #ahfj;,d-#d of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7 is amended by adding at the end the following new subsection3 7m7 ,program integrity transparency measures ,for program integrity transparency measures applied with respect to prescription drug plan and ,,ma plans1 see section #ahei7;i74 4 #d4 ,expanding eligibility for medication therapy management programs under part ,d ,section #ahfj;,d-#d7;c77#b77;,a77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;c77#b77;,a77ii77 is amended-- 7#a7 by redesignating subclauses 7,i7 through 7,,iii7 as items 7aa7 through 7cc71 respectively1 and adjusting the margins accordingly2 7#b7 by striking are part ,d eligible individuals who-- and inserting are the following3 7,i7 ,part ,d eligible individuals who-- 2 and 7#c7 by adding at the end the following new subclause3 7,,ii7 ,beginning ,january #a1 #bjba1 at-risk beneficiaries for prescription drug abuse 7as defined in paragraph 7#e77;,c774 4 #e4 ,medicare notifications to outlier prescribers of opioids ,section #ahfj;,d-#d7;c77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;c77#d77 is amended by adding at the end the following new subparagraph3 7,d7 ,outlier prescriber notification 7i7 ,notification ,beginning not later than #b years after the date of the enactment of this subparagraph1 the ,secretary shall1 in the case of a prescriber identified by the ,secretary under clause 7ii7 to be an outlier prescriber of opioids1 provide1 subject to clause 7iv71 an annual notification to such prescriber that such prescriber has been so identified and that includes resources on proper prescribing methods and other information specified in accordance with clause 7iii74 7ii7 ,identification of outlier prescribers of opioids 7,i7 ,in general ,the ,secretary shall1 subject to subclause 7,,iii71 using the valid prescriber ,national ,provider ,identifiers included pursuant to subparagraph 7,a7 on claims for covered part ,d drugs for part ,d eligible individuals enrolled in prescription drug plans under this part or ,,ma-,,pd plans under part ,c and based on the threshold established under subclause 7,,ii71 conduct an analysis to identify prescribers that are outlier opioid prescribers for a period specified by the ,secretary4 7,,ii7 ,establishment of threshold ,for purposes of subclause 7,i7 and subject to subclause 7,,iii71 the ,secretary shall1 after consultation with stakeholders1 establish a threshold1 based on prescriber specialty and geographic area1 for identifying whether a prescriber in a specialty and geographic area is an outlier prescriber of opioids as compared to other prescribers of opioids within such specialty and area4 7,,iii7 ,exclusions ,the ,secretary may exclude the following individuals and prescribers from the analysis under this clause3 7aa7 ,individuals receiving hospice services4 7bb7 ,individuals with a cancer diagnosis4 7cc7 ,prescribers who are the subject of an investigation by the ,centers for ,medicare ,medicaid ,services or the ,office of ,inspector ,general of the ,department of ,health and ,human ,services4 7iii7 ,contents of notification ,the ,secretary shall1 based on input from stakeholders1 specify the resources and other information to be included in notifications provided under clause 7i74 7iv7 ,modifications and expansions 7,i7 ,frequency ,beginning #e years after the date of the enactment of this subparagraph1 the ,secretary may change the frequency of the notifications described in clause 7i7 based on stakeholder input4 7,,ii7 ,expansion to other prescriptions ,the ,secretary may expand notifications under this subparagraph to include identifications and notifications with respect to concurrent prescriptions of covered ,part ,d drugs used in combination with opioids that are considered to have adverse side effects when so used in such combination1 as determined by the ,secretary4 7v7 ,opioids defined ,for purposes of this subparagraph1 the term opioids has such meaning as specified by the ,secretary through program instruction or otherwise4 4 #f4 ,no additional funds authorized ,no additional funds are authorized to be appropriated to carry out the requirements of this ,act and the amendments made by this ,act4 ,such requirements shall be carried out using amounts otherwise authorized to be appropriated4 ,passed the ,house of ,representatives ,june #ai1 #bjah4;,clerk4