,,ib  ,union ,calendar ,no4 #efc  #aaeth
 ,,congress  #b;d ,session  ,h4 ,r4     
#egii  ,report ,no4 #aae-gbh  ,,in ,,the
 ,,house ,,of ,,representatives  ,may   
#ae1 #bjah ,mrs4 ,blackburn 7for        
herself1 ,mr4 ,barr1 and ,mr4 ,knight7  
introduced the following bill2 which was
 referred to the ,committee on ,energy  
and ,commerce  ,june #ab1               
#bjah;,additional sponsor3 ,mr4 ,walden 
,june #ab1 #bjah ,reported with         
amendments1 committed to the ,committee 
of the ,whole ,house on the ,state of   
the ,union1 and ordered to be printed   
,strike out all after the enacting      
clause and insert the part printed in   
italic ,for text of introduced bill1 see
 copy of bill as introduced on ,may #ae1
 #bjah  ,a ,,bill  ,to amend title ,,xix
 of the ,social ,security ,act to       
require as a condition of receipt of    
full ,federal medical assistance        
percentage under ,medicaid that ,state  
,medicaid plans have in place certain   
drug utilization review activities4  #a4

 ,short title ,this ,act may be cited as
 the ,medicaid ,drug ,review1           
,utilization1 ,good ,governance         
,improvement ,act or the ,medicaid      
,,drug ,improvement ,act4  #b4 ,medicaid
 drug utilization review  7a7 ,state    
plan requirement ,section #aijb7;a7 of  
the ,social ,security ,act 7#db         
,u4,s4,c4 #acif;a7a77 is amended--  7#a7
 in paragraph 7#hb71 at the end1 by     
striking and2  7#b7 in paragraph 7#hc71 
at the end1 by striking the period and  
inserting 2 and2 and  7#c7 by inserting 
after paragraph 7#hc7 the following new 
paragraph3  7#hd7 provide that the      
,state is in compliance with the drug   
review and utilization requirements     
under subsection 7nn77#a74  4  7b7 ,drug
 review and utilization requirements    
,section #aijb of the ,social ,security 
,act 7#db ,u4,s4,c4 #acif;a7 is amended 
by adding at the end the following new  
subsection3  7nn7 ,drug review and      
utilization requirements  7#a7 ,in      
general ,for purposes of subsection     

7a77#hd71 the drug review and           
utilization requirements under this     
subsection are1 subject to paragraph    
7#c7 and beginning ,october #a1 #bjai1  
the following3  7,a7 ,claims review     
limitations  7i7 ,in general ,the ,state
 has in place-- 7,i7 safety edits 7as   
specified by the ,state7 for subsequent 
fills for opioids and a claims review   
automated process 7as designed and      
implemented by the ,state7 that         
indicates when an individual enrolled   
under the ,state plan 7or under a waiver
 of the ,state plan7 is prescribed a    
subsequent fill of opioids in excess of 
any limitation that may be identified by
 the ,state2  7,,ii7 safety edits 7as   
specified by the ,state7 on the maximum 
daily morphine equivalent that can be   
prescribed to an individual enrolled    
under the ,state plan 7or under a waiver
 of the ,state plan7 for treatment of   
chronic pain and a claims review        
automated process 7as designed and      
implemented by the ,state7 that         

indicates when an individual enrolled   
under the plan 7or waiver7 is prescribed
 the morphine equivalent for such       
treatment in excess of any limitation   
that may be identified by the ,state2   
and  7,,iii7 a claims review automated  
process 7as designed and implemented by 
the ,state7 that monitors when an       
individual enrolled under the ,state    
plan 7or under a waiver of the ,state   
plan7 is concurrently prescribed opioids
 and--  7aa7 benzodiazepines2 or  7bb7  
antipsychotics4  7ii7 ,managed care     
entities ,the ,state requires each      
managed care entity 7as defined in      
section #aicb7;a77#a77;,b77 with respect
 to which the ,state has a contract     
under section #aijc7m7 or under section 
#aije7t77#c7 to have in place1 subject  
to paragraph 7#c71 with respect to      
individuals who are eligible for medical
 assistance under the ,state plan 7or   
under a waiver of the ,state plan7 and  
who are enrolled with the entity1 the   
limitations described in subclauses 7,i7

 and 7,,ii7 of clause 7i7 and a claims  
review automated process described in   
subclause 7,,iii7 of such clause4  7iii7
 ,rules of construction ,nothing in this
 subparagraph may be construed as       
prohibiting a ,state or managed care    
entity from designing and implementing a
 claims review automated process under  
this subparagraph that provides for     
prospective or retrospective reviews of 
claims4 ,nothing in this subparagraph   
shall be understood as prohibiting the  
exercise of clinical judgment from a    
provider enrolled as a participating    
provider in a ,state plan 7or waiver of 
the ,state plan7 or contracting with a  
managed care entity regarding the best  
items and services for an individual    
enrolled under such ,state plan 7or     
waiver74  7,b7 ,program to monitor      
antipsychotic medications by children   
,the ,state has in place a program 7as  
designed and implemented by the ,state71
 including such a program that the      
,state had in place before the date of  

the enactment of this subsection1 to    
monitor and manage the appropriate use  
of antipsychotic medications by children
 enrolled under the ,state plan 7or     
under a waiver of the ,state plan7 and  
submits annually to the ,secretary such 
information as the ,secretary may       
require on activities carried out under 
such program for individuals not more   
than the age of #ah years generally and 
children in foster care specifically4   
7,c7 ,fraud and abuse identification    
,the ,state has in place a process 7as  
designed and implemented by the ,state71
 including such a process that the      
,state had in place before the date of  
the enactment of this subsection1 that  
identifies potential fraud or abuse of  
controlled substances by individuals    
enrolled under the ,state plan 7or under
 a waiver of the ,state plan71 health   
care providers prescribing drugs to     
individuals so enrolled1 and pharmacies 
dispensing drugs to individuals so      
enrolled4  7,d7 ,reports ,the ,state    

shall include in the annual report      
submitted to the ,secretary under       
section #aibg7;g77#c77;,d7 information  
on the limitations1 requirement1        
program1 and processes applied by the   
,state under subparagraphs 7,a7 through 
7,c7 in accordance with such manner and 
time as specified by the ,secretary4    
7#b7 ,annual report by ,secretary ,for  
each fiscal year beginning with fiscal  
year #bjbj1 the ,secretary shall submit 
to ,congress a report on the most recent
 information submitted by ,states under 
paragraph 7#a77;,d74  7#c7 ,exceptions  
7,a7 ,certain individuals exempted ,the 
drug review and utilization requirements
 under this subsection shall not apply  
with respect to an individual who--  7i7
 is receiving-- 7,i7 hospice or         
palliative care2 or  7,,ii7 treatment   
for cancer2  7ii7 is a resident of a    
long-term care facility1 of a facility  
described in section #aije7;d71 or of   
another facility for which frequently   
abused drugs are dispensed for residents

 through a contract with a single       
pharmacy2 or  7iii7 the ,state elects to
 treat as exempted from such            
requirements4  7,b7 ,exception relating 
to ensuring access ,in order to ensure  
reasonable access to health care1 the   
,secretary may waive the drug review and
 utilization requirements under this    
subsection1 with respect to a ,state1 in
 the case of natural disasters and      
similar situations1 and in the case of  
the provision of emergency services 7as 
defined for purposes of section         
#ahfj;,d-#d7;c77#e77;,d77ii77,,ii774  4 
7c7 ,managed care entities ,section     
#aicb of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acifu-#b7 is amended by     
adding at the end the following new     
subsection3  7i7 ,drug utilization      
review activities and requirements      
,beginning not later than ,october #a1  
#bjai1 each contract under a ,state plan
 with a managed care entity 7other than 
a primary care case manager7 under      
section #aijc7m7 shall provide that the 

entity is in compliance with the        
applicable provisions of section        
#dch4c7s77#b7 of title #db of the ,code 
of ,federal ,regulations1 section       
#dhc4c7s77#d77 of such title1 and       
section #dhc4c7s77#e7 of such title1 as 
such provisions were in effect on ,march
 #ca1 #bjah4  4  #c4 ,identifying and   
addressing inappropriate prescribing and
 billing practices under ,medicaid  7a7 
,in general ,section #aibg7;g7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acifr-#h7;g77 is amended-- 7#a7 in     
paragraph 7#a77;,a7--  7,a7 by striking 
of section #aijc7;i77#aj77;,b7 and      
inserting of section #aijb7;a77#ed72    
7,b7 by striking 1 by not later than    
,january #a1 #aiic12  7,c7 by inserting 
after gross overuse1 the following3     
excessive utilization12 and  7,d7 by    
striking or inappropriate or medically  
unnecessary care and inserting          
inappropriate or medically unnecessary  
care1 or prescribing or billing         
practices that indicate abuse or        

excessive utilization2 and  7#b7 in     
paragraph 7#b77;,b7-- 7,a7 by inserting 
after gross overuse1 the following3     
excessive utilization12  7,b7 by        
striking or inappropriate or medically  
unnecessary care and inserting          
inappropriate or medically unnecessary  
care1 or prescribing or billing         
practices that indicate abuse or        
excessive utilization2 and  7,c7 by     
adding at the end the following new     
sentence3 ,in the case that the program 
identifies a pattern described in the   
previous sentence1 the ,state shall take
 such remedial actions as determined    
necessary to address such pattern44  7b7
 ,effective date ,the amendments made by
 subsection 7a7 shall take effect with  
respect to retrospective drug use       
reviews conducted on or after ,october  
#a1 #bjbj4  ,amend the title so as to   
read3 ,a bill to amend title ,,xix of   
the ,social ,security ,act to require   
under ,medicaid that ,state ,medicaid   
plans have in place certain drug        

utilization review activities1 and to   
require ,states to identify and address 
inappropriate prescribing and billing   
practices under ,medicaid44  ,june #ab1 
#bjah ,reported with amendments1        
committed to the ,committee of the      
,whole ,house on the ,state of the      
,union1 and ordered to be printed