,,ii ,cal5d> ,no4 #bfe #aah? ,,congress 
#a/ ,session  ,s4 #cdcj ,report ,no4    
#aah-aba ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$
 ,,/ates  ,decemb] #g1 #bjbc,mr4 ,wyd51 
f ! ,committee on ,f9ance1 report$ !    
foll[+ orig9al bill2 :i* 0 read twice & 
plac$ on ! cal5d>  ,a ,,bill  ,to am5d  
titles ,,xviii & ,,xix ( ! ,social      
,security ,act to exp& ! m5tal heal? c>e
 work=ce & s]vices1 r$uce prescription  
drug co/s1 & ext5d c]ta9 expir+         
provisions "u ,m$ic>e & ,m$icaid1 & =   
o!r purposes4  #a4 ,%ort title2 table ( 
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,bett] ,m5tal ,heal? ,c>e1  
,l[]-,co/ ,drugs1 & ,ext5d]s ,act (     
#bjbc4  7b7 ,table ( cont5ts ,! table ( 
cont5ts ( ?is ,act is z foll[s3 ,sec4   
#a4 ,%ort title2 table ( cont5ts4,,title
 ,i--,exp&+ m5tal heal? c>e work=ce &   
s]vices "u ,m$ic>e & ,medicaid,sec4     
#aja4 ,exp&+ eligibility = inc5tives "u 
! ,m$ic>e heal? pr(essional %ortage area
 bonus program to practition]s furni%+  
m5tal heal? & sub/ance use disord]      

s]vices4,sec4 #ajb4 ,improv$ access to  
m5tal heal? s]vices "u ! ,m$ic>e        
program4,sec4 #ajc4 ,cl>ify+ cov]age (  
occupational !rapy "u ! ,m$ic>e         
program4,sec4 #ajd4 ,m$ic>e inc5tives = 
behavioral heal? integration ) prim>y   
c>e4,sec4 #aje4 ,e/abli%m5t ( ,m$ic>e   
incid5t to modifi] = m5tal heal? s]vices
 furni%$ ?r\gh teleheal?4,sec4 #ajf4    
,guidance on furni%+ behavioral heal?   
s]vices via teleheal? to individuals )  
limit$ ,engli% pr(ici5cy "u ,m$ic>e     
program4,sec4 #ajg4 ,ensur+ timely      
communication reg>d+ teleheal? &        
int]/ate lic5sure requirem5ts4,sec4     
#ajh4 ,facilitat+ accessibility =       
behavioral heal? s]vices furni%$ ?r\gh  
teleheal?4,sec4 #aji4 ,requir+ ,enhanc$ 
,accurate ,li/s ( 7,,real7 ,heal?       
,provid]s ,act4,sec4 #aaj4 ,guidance to 
,/ates on /rategies "u ,m$icaid & ,,*ip 
to increase m5tal heal? & sub/ance use  
disord] c>e provid] capacity4,sec4 #aaa4
 ,guidance to ,/ates on support+ m5tal  
heal? s]vices & sub/ance use disord] c>e

 = *ildr5 & y\?4,sec4 #aab4 ,recurr+    
analysis & publication ( ,m$icaid heal? 
c>e data relat$ to m5tal heal?          
s]vices4,sec4 #aac4 ,guidance to ,/ates 
on support+ m5tal heal? s]vices or      
sub/ance use disord] c>e integration )  
prim>y c>e 9 ,m$icaid & ,,*ip4,sec4     
#aad4 ,m$icaid ,/ate option relat+ to   
inmates ) a sub/ance use disord] p5d+   
disposition ( *>ges4,sec4 #aae4         
,def9ition ( ,c]tifi$ ,community        
,behavioral ,heal? ,cl9ic ,s]vices "u   
,m$icaid4,,title ,,ii--,r$uc+           
prescription drug co/s "u ,m$ic>e &     
,medicaid,sec4 #bja4 ,assur+ ph>macy    
access & *oice = ,m$ic>e                
b5efici>ies4,sec4 #bjb4 ,ensur+ accurate
 paym5ts to ph>macies "u ,m$icaid4,sec4 
#bjc4 ,protect+ s5iors f excessive      
co/-%>+ = c]ta9 m$ic9es4,,title         
,,iii--,m$icaid ,expir+ ,provisions,sec4
 #cja4 ,delay+ c]ta9 disproportionate   
%>e hospital paym5t r$uctions "u !      
,m$icaid program4,sec4 #cjb4 ,ext5sion (
 ,/ate option to provide m$ical         

assi/ance = c]ta9 individuals :o are    
pati5ts 9 c]ta9 in/itutions = m5tal     
diseases4,,title ,,iv--,m$ic>e ,expir+  
,provisions & ,provid] ,paym5t          
,changes,sec4 #dja4 ,ext5sion ( fund+ = 
quality measure endorsem5t1 input1 &    
selection4,sec4 #djb4 ,ext5sion ( fund+ 
outrea* & assi/ance = l[-income         
programs4,sec4 #djc4 ,ext5sion ( ! "w   
geographic index floor "u ! ,m$ic>e     
program4,sec4 #djd4 ,ext5d+ inc5tive    
paym5ts = p>ticipation 9 eligible       
alt]native paym5t models4,sec4 #dje4    
,paym5t rates = durable m$ical equipm5t 
"u ! ,m$ic>e ,program4,sec4 #djf4       
,ext5d+ ! indep5d5ce at home m$ical     
practice demon/ration program "u !      
,m$ic>e program4,sec4 #djg4 ,increase 9 
support = physicians & o!r pr(essionals 
9 adju/+ to ,m$ic>e paym5t *anges4,sec4 
#djh4 ,revis$ phase-9 ( ,m$ic>e cl9ical 
laboratory te/ paym5t *anges4,sec4 #dji4
 ,ext5sion ( adju/m5t to calculation (  
hospice cap am\nt "u ,m$ic>e4,,title    
,v--,offsets,sec4 #eja4 ,m$icaid        

,improvem5t ,fund4,sec4 #ejb4 ,m$ic>e   
,improvem5t ,fund4  ,i ,exp&+ m5tal     
heal? c>e work=ce & s]vices "u ,m$ic>e &
 ,m$icaid  #aja4 ,exp&+ eligibility =   
inc5tives "u ! ,m$ic>e heal? pr(essional
 %ortage area bonus program to          
practition]s furni%+ m5tal heal? &      
sub/ance use disord] s]vices ,section   
#ahcc7m7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #aciel7m77 is am5d$-- 7#a7 by
 /rik+ p>agraph 7#a7 & ins]t+ ! foll[+  
new p>agraph3  7#a7 ,9 ! case (-- 7,a7  
physicians' s]vices 7o!r ?an specifi$   
heal? s]vices t are eligible = !        
additional paym5t "u subp>agraph 7,b77  
furni%$ 9 a ye> to an individual1 :o is 
cov]$ "u ! insurance program e/abli%$ by
 ?is "p & :o incurs exp5ses = su*       
s]vices1 9 an area t is designat$ 7"u   
section #ccb7;a77#a77;,a7 ( ! ,public   
,heal? ,s]vice ,act7 z a heal?          
pr(essional %ortage area z id5tifi$ by !
 ,secret>y prior to ! beg9n+ ( su* ye>1 
9 addition to ! am\nt o!rwise paid "u   
?is "p1 !re also %all be paid to !      

physician 7or to an employ] or facility 
9 ! cases describ$ 9 clause 7,a7 (      
section #ahdb7;b77#f77 7on a mon?ly or  
qu>t]ly basis7 f ! ,f$]al ,supplem5t>y  
,m$ical ,insurance ,tru/ ,fund an am\nt 
equal to #aj p]c5t ( ! paym5t am\nt = ! 
s]vice "u ?is "p2 &  7,b7 specifi$ heal?
 s]vices 7z def9$ 9 p>agraph 7#e77      
furni%$ 9 a ye> to an individual1 :o is 
cov]$ "u ! insurance program e/abli%$ by
 ?is "p & :o incurs exp5ses = su*       
s]vices1 9 an area t is designat$ 7"u   
su* section #ccb7;a77#a77;,a77 z a m5tal
 heal? pr(essional %ortage area z       
id5tifi$ by ! ,secret>y prior to !      
beg9n+ ( su* ye>1 9 addition to ! am\nt 
o!rwise paid "u ?is "p1 !re also %all be
 paid to ! physician or applicable      
practition] 7z def9$ 9 p>agraph 7#f77   
7or to an employ] or facility 9 ! cases 
describ$ 9 clause 7,a7 ( section        
#ahdb7;b77#f77 7on a mon?ly or qu>t]ly  
basis7 f su* ,tru/ ,fund an am\nt equal 
to #ae p]c5t ( ! paym5t am\nt = ! s]vice
 "u ?is "p4  2  7#b7 9 p>agraph 7#b7--  

7,a7 by /rik+ 9 p>agraph 7#a7 & ins]t+ 9
 subp>agraph 7,a7 or 7,b7 ( p>agraph    
7#a72  7,b7 by ins]t+ or1 9 ! case (    
specifi$ heal? s]vices1 ! physician or  
applicable practition] aft] physician2  
7#c7 9 p>agraph 7#c71 by /rik+ 9        
p>agraph 7#a7 & ins]t+ 9 subp>agraph    
7,a7 or 7,b7 ( p>agraph 7#a72  7#d7 9   
p>agraph 7#d7-- 7,a7 9 subp>agraph 7,b71
 by ins]t+ or applicable practition]    
aft] physician2 &  7,b7 9 subp>agraph   
7,c71 by ins]t+ or applicable           
practition] aft] physician2 &  7#e7 by  
add+ at ! end ! foll[+ new p>agraphs3   
7#e7 ,9 ?is subsection1 ! t]m specifi$  
heal? s]vices means s]vices o!rwise     
cov]$ "u ?is "p t are furni%$ on or aft]
 ,janu>y #a1 #bjbf1 by a physician or an
 applicable practition] to an           
individual-- 7,a7 = purposes (          
diagnosis1 evaluation1 or treatm5t ( a  
m5tal heal? disord]1 z det]m9$ by !     
,secret>y2 or  7,b7 ) a sub/ance use    
disord] diagnosis = purposes ( treatm5t 
( su* disord] or co-occurr+ m5tal heal? 

disord]1 z det]m9$ by ! ,secret>y4  7#f7
 ,9 ?is subsection1 ! t]m applicable    
practition] means ! foll[+3 7,a7 ,a     
physician assi/ant1 nurse practition]1  
or cl9ical nurse speciali/ 7z def9$ 9   
section #ahfa7;aa77#e774  7,b7 ,a       
cl9ical social work] 7z def9$ 9 section 
#ahfa7;hh77#a774  7,c7 ,a cl9ical       
psy*ologi/ 7z def9$ by ! ,secret>y =    
purposes ( section #ahfa7;ii774  7,d7 ,a
 m>riage & family !rapi/ 7z def9$ 9     
section #ahfa7lll77#b774  7,e7 ,a m5tal 
heal? c\nselor 7z def9$ 9 section       
#ahfa7lll77#d774  4  #ajb4 ,improv$     
access to m5tal heal? s]vices "u !      
,m$ic>e program  7a7 ,access to cl9ical 
social work] s]vices provid$ to resid5ts
 ( skill$ nurs+ facilities  7#a7        
,exclusion ( cl9ical social work]       
s]vices f ! skill$ nurs+ facility       
prospective paym5t sy/em ,section       
#ahhh7;e77#b77;,a77iii7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acieyy7e77#b77;,a77iii77 is am5d$ by   
add+ at ! end ! foll[+ new subclause3   

7,,vii7 ,cl9ical social work] s]vices 7z
 def9$ 9 section #ahfa7;hh77#b774  4    
7#b7 ,con=m+ am5dm5t ,section           
#ahfa7;hh77#b7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7hh77#b77 is  
am5d$ by /rik+ & o!r ?an s]vices furni%$
 to an inpati5t ( a skill$ nurs+        
facility :i* ! facility is requir$ to   
provide z a requirem5t = p>ticipation4  
7b7 ,access to ! complete scope (       
cl9ical social work] s]vices ,section   
#ahfa7;hh77#b7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7hh77#b771 z  
am5d$ by subsection 7a77#b71 is am5d$ by
 /rik+ = ! diagnosis & treatm5t ( m5tal 
illnesses 7o!r ?an s]vices furni%$ to an
 inpati5t ( a hospital7 & ins]t+ 1      
includ+ s]vices = ! diagnosis & treatm5t
 ( m5tal illnesses or s]vices = heal?   
behavior assessm5t & int]v5tion         
7id5tifi$ z ( ,janu>y #a1 #bjbc1 by     
,,hcpcs codes #ifafj & #ifafa 7& any    
succe$+ codes771 b n includ+ s]vices    
furni%$ to an inpati5t ( a hospital14   
7c7 ,effective date ,! am5dm5ts made by 

?is section %all apply to items &       
s]vices furni%$ on or aft] ,janu>y #a1  
#bjbf4  #ajc4 ,cl>ify+ cov]age (        
occupational !rapy "u ! ,m$ic>e program 
,n lat] ?an #a ye> aft] ! date (        
enactm5t ( ?is ,act1 ! ,secret>y (      
,heal? & ,human ,s]vices %all use exi/+ 
communication me*anisms to provide      
education & outrea* to /akehold]s ab\t !
 ,m$ic>e ,b5efit ,policy ,manual )      
respect to occupational !rapy s]vices   
furni%$ to individuals "u ! ,m$ic>e     
program = ! treatm5t ( a sub/ance use or
 m5tal heal? disord] diagnosis us+      
applicable ,heal?c>e ,common ,proc$ure  
,cod+ ,sy/em 7,,hcpcs7 codes4  #ajd4    
,m$ic>e inc5tives = behavioral heal?    
integration ) prim>y c>e  7a7 ,inc5tives
  7#a7 ,9 g5]al ,section #ahdh7;b7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7;b77 is am5d$ by add+ at ! end
 ! foll[+ new p>agraph3  7#ac7          
,inc5tives = behavioral heal?           
integration  7,a7 ,9 g5]al ,= s]vices   
describ$ 9 subp>agraph 7,b7 t are       

furni%$ dur+ #bjbf1 #bjbg1 or #bjbh1    
in/ead ( ! paym5t am\nt t w\ld o!rwise  
be det]m9$ "u ?is section = su* ye>1 !  
paym5t am\nt %all be equal to !         
applicable p]c5t 7z def9$ 9 subp>agraph 
7,c77 ( su* paym5t am\nt = su* ye>4     
7,b7 ,s]vices describ$ ,! s]vices       
describ$ 9 ?is subp>agraph are s]vices  
id5tifi$1 z ( ,janu>y #a1 #bjbc1 by     
,,hcpcs codes #iidhd1 #iidib1 #iidic1   
#iidid1 & ,g#bbad 7& any successor or   
simil> codes z det]m9$ appropriate by ! 
,secret>y74  7,c7 ,applicable p]c5t ,9  
?is p>agraph1 ! t]m applicable p]c5t    
means1 ) respect to a s]vice describ$ 9 
subp>agraph 7,a71 ! foll[+3 7i7 ,=      
s]vices furni%$ dur+ #bjbf 1 #age p]c5t4
  7ii7 ,= s]vices furni%$ dur+ #bjbg1   
#aej p]c5t4  7iii7 ,= s]vices furni%$   
dur+ #bjbh1 #abe p]c5t4  4  7#b7 ,waiv] 
( budget neutrality ,section            
#ahdh7;c77#b77;,b77iv7 ( su* ,act 7#db  
,u4,s4,c4 #aciew-#d7;c77#b77;,b77iv77 is
 am5d$-- 7,a7 9 subclause 7,v71 by /rik+
 & at ! end2  7,b7 9 subclause 7,,vi71  

by /rik+ ! p]iod at ! end & ins]t+ 2 & &
  7,c7 by add+ at ! end ! foll[+ new    
subclause3  7,,vii7 ! increase 9 paym5t 
am\nts z a result ( ! application (     
subsection 7b77#ac7 %all n be tak5 into 
acc\nt 9 apply+ clause 7ii77,,ii7 =     
#bjbf1 #bjbg1 or #bjbh4  4  7b7         
,te*nical assi/ance = ! adoption (      
behavioral heal? integration  7#a7 ,9   
g5]al ,n lat] ?an ,janu>y #a1 #bjbe1 !  
,secret>y ( ,heal? & ,human ,s]vices 79 
?is subsection ref]r$ to z ! ,secret>y7 
%all ent] into contracts or agreem5ts ) 
appropriate entities to (f] te*nical    
assi/ance to prim>y c>e practices t are 
seek+ to adopt behavioral heal?         
integration models 9 su* practices4     
7#b7 ,behavioral heal? integration      
models ,= purposes ( p>agraph 7#a71     
behavioral heal? integration models     
include ! ,collaborative ,c>e ,model 7) 
s]vices id5tifi$ z ( ,janu>y #a1 #bjbc1 
by ,,hcpcs codes #iidib1 #iidic1 #iidid1
 & ,g#bbad 7& any successor codes771 !  
,prim>y ,c>e ,behavioral ,heal? model 7)

 s]vices id5tifi$ z ( ,janu>y #a1 #bjbc1
 by ,,hcpcs code #iidhd 7& any successor
 code771 & o!r models id5tifi$ by !     
,secret>y4  7#c7 ,implem5tation ,not)/&+
 any o!r provision ( law1 ! ,secret>y   
may implem5t ! provisions ( ?is         
subsection by program in/ruction or     
o!rwise4  7#d7 ,fund+ ,9 addition to    
am\nts o!rwise available1 !re is        
appropriat$ to ! ,secret>y = fiscal ye> 
#bjbd1 out ( any money 9 ! ,treasury n  
o!rwise appropriat$1 #e1jjj1jjj1 to     
rema9 available until exp5d$1 = purposes
 ( c>ry+ out ?is subsection4  #aje4     
,e/abli%m5t ( ,m$ic>e incid5t to modifi]
 = m5tal heal? s]vices furni%$ ?r\gh    
teleheal? ,section #ahcd7m77#g7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciem7m77#g77 is am5d$ by add+ at ! end
 ! foll[+ new subp>agraph3  7,c7        
,e/abli%m5t ( incid5t to modifi] = m5tal
 heal? s]vices furni%$ ?r\gh teleheal?  
,n lat] ?an #b ye>s aft] ! date ( !     
enactm5t ( ?is subp>agraph1 ! ,secret>y 
%all e/abli% requirem5ts to include a   

code or modifi]1 z det]m9$ appropriate  
by ! ,secret>y1 on claims = m5tal heal? 
s]vices furni%$ ?r\gh teleheal? "u ?is  
p>agraph t are furni%$ by auxili>y      
p]sonnel 7z def9$ 9 section             
#daj4bf7;a77#a7 ( title #db1 ,code (    
,f$]al ,regulations1 or any successor   
regulation7 & bill$ incid5t to a        
physician or practition]'s pr(essional  
s]vices4  4  #ajf4 ,guidance on furni%+ 
behavioral heal? s]vices via teleheal?  
to individuals ) limit$ ,engli%         
pr(ici5cy "u ,m$ic>e program ,n lat] ?an
 #a ye> aft] ! date ( ! enactm5t ( ?is  
section1 ! ,secret>y ( ,heal? & ,human  
,s]vices %all issue & dissem9ate1 or    
update & revise z applicable1 guidance  
on ! foll[+3 7#a7 ,be/ practices =      
provid]s to "w ) int]pret]s to furni%   
behavioral heal? s]vices via video-bas$ 
& audio-only teleheal?1 :5 video-bas$   
teleheal? is n an option4  7#b7 ,be/    
practices on integrat+ ! use ( video    
plat=ms t enable multi-p]son video calls
 into behavioral heal? s]vices furni%$  

via teleheal?4  7#c7 ,be/ practices on  
tea*+ pati5ts1 especially ^? ) limit$   
,engli% pr(ici5cy1 to use video-bas$    
teleheal? plat=ms4  7#d7 ,be/ practices 
= provid+ pati5t mat]ials1              
communications1 & in/ructions 9 multiple
 languages1 includ+ text message        
appo9tm5t rem9d]s & prescription        
in=mation4  #ajg4 ,ensur+ timely        
communication reg>d+ teleheal? &        
int]/ate lic5sure requirem5ts ,!        
,secret>y ( ,heal? & ,human ,s]vices    
%all provide in=mation-- 7#a7 on        
lic5sure requirem5ts = furni%+ teleheal?
 s]vices "u titles ,,xviii & ,,xix ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acie et seq42 #acif et seq472 &  7#b7  
cl>ify+ ! ext5t to :i* lic5ses ?r\gh an 
int]/ate lic5se compact pa?way c qualify
 z valid & full lic5ses = ! purposes (  
meet+ ,f$]al lic5sure requirem5ts "u su*
 titles4  #ajh4 ,facilitat+             
accessibility = behavioral heal? s]vices
 furni%$ ?r\gh teleheal? ,! ,secret>y ( 
,heal? & ,human ,s]vices %all provide   

regul> updates to guidance to facilitate
 ! accessibility ( behavioral heal?     
s]vices furni%$ ?r\gh teleheal? = !     
visually & he>+ impair$4  #aji4 ,requir+
 ,enhanc$  ,accurate ,li/s ( 7,,real7   
,heal? ,provid]s ,act  7a7 ,9 g5]al     
,section #aheb7;c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#bb7;c77 is 
am5d$-- 7#a7 9 p>agraph 7#a77;,c7-- 7,a7
 by /rik+ plan1 & any & ins]t+ plan1    
any2 &  7,b7 by ins]t+ ! foll[+ be=e !  
p]iod3 1 &1 9 ! case ( a network-bas$   
plan 7z def9$ 9 p>agraph 7#c77;,c771 =  
plan ye> #bjbf & subsequ5t plan ye>s1 ! 
in=mation describ$ 9 p>agraph 7#c77;,b72
 &  7#b7 by add+ at ! end ! foll[+ new  
p>agraph3  7#c7 ,provid] directory      
accuracy  7,a7 ,9 g5]al ,= plan ye>     
#bjbf & subsequ5t plan ye>s1 ea* ,,ma   
organization (f]+ a network-bas$ plan 7z
 def9$ 9 subp>agraph 7,c77 %all1 = ea*  
network-bas$ plan (f]$ by !             
organization-- 7i7 ma9ta91 on a publicly
 available int]net website1 an accurate 
provid] directory t includes ! in=mation

 describ$ 9 subp>agraph 7,b72  7ii7 n   
less frequ5tly ?an once e #ij days 7or1 
9 ! case ( a hospital or any o!r        
facility det]m9$ appropriate by !       
,secret>y1 at a less] frequ5cy specifi$ 
by ! ,secret>y b 9 no case less         
frequ5tly ?an once e #ab mon?s71 v]ify !
 provid] directory in=mation ( ea*      
provid] li/$ 9 su* directory &1 if      
applicable1 update su* provid] directory
 in=mation2  7iii7 if ! organization is 
unable to v]ify su* in=mation ) respect 
to a provid]1 include 9 su* directory an
 indication t ! in=mation ( su* provid] 
may n be up to date2  7iv7 remove a     
provid] f su* directory )9 #e bus9ess   
days if ! organization det]m9es t !     
provid] is no long] a provid] p>ticipat+
 9 ! network ( su* plan2 &  7v7 meet su*
 o!r requirem5ts z ! ,secret>y may      
specify4  7,b7 ,provid] directory       
in=mation ,! in=mation describ$ 9 ?is   
subp>agraph is in=mation enrollees may  
ne$ to access cov]$ b5efits f a provid] 
) :i* su* organization (f]+ su* plan has

 an agreem5t = furni%+ items & s]vices  
cov]$ "u su* plan su* z "n1 specialty1  
contact in=mation1 prim>y (fice or      
facility address1 :e!r ! provid] is     
accept+ new pati5ts1 accommodations = p 
) disabilities1 cultural & l+ui/ic      
capabilities1 & teleheal? capabilities4 
7,c7 ,network-bas$ plan ,9 ?is p>agraph1
 ! t]m network-bas$ plan has ! mean+    
giv5 t t]m 9 subsection 7d77#e77;,c71   
except su* t]m includes a ,m$ic>e       
,advantage private fee-=-s]vice plan1 z 
det]m9$ appropriate by ! ,secret>y4  4  
7b7 ,acc\ntability = provid] directory  
accuracy  7#a7 ,co/ ,%>+ = ,s]vices     
,furni%$ ,bas$ on ,reliance on          
,incorrect ,provid] directory ,in=mation
 ,section #aheb7;d7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciew-#bb7;d77 is am5d$-- 7,a7 9       
p>agraph 7#a77;,c7-- 7i7 9 clause 7ii71 
by /rik+ or at ! end2  7ii7 9 clause    
7iii71 by /rik+ ! semicolon at ! end &  
ins]t+ 1 or2 &  7iii7 by add+ at ! end !
 foll[+ new clause3  7iv7 ! s]vices are 

furni%$ by a provid] t is n p>ticipat+ 9
 ! network ( a network-bas$ plan 7z     
def9$ 9 subsection 7c77#c77;,c77 b is   
li/$ 9 ! provid] directory ( su* plan on
 ! date on :i* ! appo9tm5t is made1 z   
describ$ 9 p>agraph 7#g77;,a72  2 &     
7,b7 by add+ at ! end ! foll[+ new      
p>agraph3  7#g7 ,co/ %>+ = s]vices      
furni%$ bas$ on reliance on incorrect   
provid] directory in=mation  7,a7 ,9    
g5]al ,= plan ye> #bjbf & subsequ5t plan
 ye>s1 if an enrollee is furni%$ an item
 or s]vice by a provid] t is n          
p>ticipat+ 9 ! network ( a network-bas$ 
plan 7z def9$ 9 subsection 7c77#c77;,c77
 b is li/$ 9 ! provid] directory ( su*  
plan 7z requir$ to be provid$ to an     
enrollee pursuant to subsection         
7c77#a77;,c77 on ! date on :i* !        
appo9tm5t is made1 & if su* item or     
s]vice w\ld o!rwise be cov]$ "u su* plan
 if furni%$ by a provid] t is p>ticipat+
 9 ! network ( su* plan1 ! ,,ma         
organization (f]+ su* plan %all ensure t
 ! enrollee is only responsible = !     

am\nt ( co/ %>+ t w\ld apply if su*     
provid] _h be5 p>ticipat+ 9 ! network ( 
su* plan4  7,b7 ,notification requirem5t
 ,= plan ye> #bjbf & subsequ5t plan     
ye>s1 ea* ,,ma organization t (f]s a    
network-bas$ plan %all-- 7i7 notify     
enrollees ( _! co/-%>+ protections "u   
?is p>agraph & make su* notifications1  
to ! ext5t practicable1 by n lat] ?an ! 
fir/ day ( an annual1 coord9at$ election
 p]iod "u section #ahea7;e77#c7 )       
respect to a ye>2  7ii7 include         
in=mation reg>d+ su* co/-%>+ protections
 9 ! provid] directory ( ea*            
network-bas$ plan (f]$ by ! ,,ma        
organization42 &  7iii7 notify enrollees
 ( _! co/-%>+ protections "u ?is        
p>agraph 9 an explanation ( b5efits4  4 
7#b7 ,requir$ provid] directory accuracy
 analysis & reports  7,a7 ,9 g5]al      
,section #aheg7;e7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is 
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#f7 ,provid] directory      
accuracy analysis & reports  7,a7 ,9    

g5]al ,beg9n+ ) plan ye>s beg9n+ on or  
aft] ,janu>y #a1 #bjbf1 subject to      
subp>agraph 7,c71 a contract "u ?is     
section ) an ,,ma organization %all     
require ! organization1 = ea*           
network-bas$ plan 7z def9$ 9 section    
#aheb7;c77#c77;,c77 (f]$ by !           
organization1 to annually-- 7i7 conduct 
an analysis e/imat+ ! accuracy ( !      
provid] directory ( su* plan us+ a      
sample ( provid]s includ$ 9 su* provid] 
directory 7includ+ provid] specialties )
 high inaccuracy rates ( provid]        
directory in=mation1 su* z provid]s     
specializ+ 9 m5tal heal? or sub/ance use
 disord] treatm5t1 z det]m9$ by !       
,secret>y72 &  7ii7 submit a report to !
 ,secret>y conta9+ ! results ( su*      
analysis1 includ+ an accuracy score =   
su* provid] directory 7z det]m9$ us+ a  
me?odology specifi$ by ! ,secret>y "u   
subp>agraph 7,b77i771 & o!r in=mation   
requir$ by ! ,secret>y4  7,b7           
,det]m9ation ( accuracy score  7i7 ,9   
g5]al ,! ,secret>y %all specify         

me?odologies = ,,ma plans to use 9      
e/imat+ ! accuracy ( ! provid] directory
 in=mation ( su* plans & det]m9+ !      
accuracy score = ! plan's provid]       
directory4  7ii7 ,consid]ations ,9 c>ry+
 out clause 7i71 ! ,secret>y %all take  
into consid]ation-- 7,i7 data s\rces    
ma9ta9$ by ,,ma organizations2  7,,ii7  
publicly available data sets2  7,,iii7 !
 adm9i/rative burd5 on plans & provid]s2
 &  7,,iv7 ! relative importance ( c]ta9
 provid] directory in=mation on enrollee
 ability to access c>e4  7,c7 ,exception
 ,! ,secret>y may waive ! requirem5ts ( 
?is p>agraph 9 ! case ( a network-bas$  
plan ) l[ enrollm5t 7z def9$ by !       
,secret>y74  7,d7 ,transp>5cy ,beg9n+ ) 
plan ye>s beg9n+ on or aft] ,janu>y #a1 
#bjbg1 ! ,secret>y %all po/ accuracy    
scores 7z report$ "u subp>agraph        
7,a77ii771 9 a ma*9e readable file1 on !
 int]net website ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices4  7,e7 ,implem5tation 
,! ,secret>y %all implem5t ?is p>agraph 
?r\gh notice & comm5t rulemak+4  4  7,b7

 ,provision ( in=mation to b5efici>ies  
,section #ahea7;d77#d7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#ba7;d77#d77 is am5d$ by add+ at 
! end ! foll[+ new subp>agraph3  7,f7   
,provid] ,directory ,beg9n+ ) plan ye>s 
beg9n+ on or aft] ,janu>y #a1 #bjbg1 !  
accuracy score ( ! plan's provid]       
directory 7z report$ "u section         
#aheg7;e77#f77;,a77ii77 on ! plan's     
provid] directory4  4  7,c7 ,fund+ ,9   
addition to am\nts o!rwise available1   
!re is appropriat$ to ! ,c5t]s = ,m$ic>e
  ,m$icaid ,s]vices ,program ,managem5t 
,acc\nt1 out ( any money 9 ! ,treasury n
 o!rwise appropriat$1 #a1jjj1jjj =      
fiscal ye> #bjbe1 to rema9 available    
until exp5d$1 to c>ry out ! am5dm5ts    
made by ?is p>agraph4  7#c7 ,,gao /udy &
 report  7,a7 ,analysis ,! ,comptroll]  
,g5]al ( ! ,unit$ ,/ates 79 ?is p>agraph
 ref]r$ to z ! ,comptroll] ,g5]al7 %all 
conduct /udy ( ! implem5tation ( !      
am5dm5ts made by p>agraphs 7#a7 & 7#b74 
,to ! ext5t data are available &        

reliable1 su* /udy %all include an      
analysis (-- 7i7 ! use ( protections    
requir$ "u section #aheb7;d77#g7 ( !    
,social ,security ,act1 z add$ by       
p>agraph 7#a72  7ii7 ! provid] directory
 accuracy scores tr5ds "u section       
#aheg7;e77#f77;,a77ii7 ( ! ,social      
,security ,act 7z add$ by p>agraph      
7#b77;,a771 bo? ov]all & among provid]s 
specializ+ 9 m5tal heal? or sub/ance    
disord] treatm5t2  7iii7 provid]        
response rates by plan v]ification      
me?ods2 &  7iv7 o!r items det]m9$       
appropriate by ! ,comptroll] ,g5]al4    
7,b7 ,report ,n lat] ?an ,janu>y #ae1   
#bjca1 ! ,comptroll] ,g5]al %all submit 
to ,congress a report conta9+ ! results 
( ! /udy conduct$ "u subp>agraph 7,a71  
toge!r ) recomm5dations = su*           
legislation & adm9i/rative action z !   
,comptroll] ,g5]al det]m9es appropriate4
  7c7 ,guidance on ma9ta9+ accurate     
provid] directories  7#a7 ,/akehold]    
meet+  7,a7 ,9 g5]al ,n lat] ?an #c     
mon?s aft] ! date ( enactm5t ( ?is ,act1

 ! ,secret>y ( ,heal? & ,human ,s]vices 
7ref]r$ to 9 ?is subsection z !         
,secret>y7 %all hold a public /akehold] 
meet+ to receive input on approa*es =   
ma9ta9+ accurate provid] directories =  
,m$ic>e ,advantage plans "u "p ,c (     
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#ba et seq471    
includ+ input on approa*es = r$uc+      
adm9i/rative burd5 su* z data           
/&>dization & be/ practices to ma9ta9   
provid] directory in=mation4  7,b7      
,p>ticipants ,p>ticipants ( ! meet+ "u  
subp>agraph 7,a7 %all include           
repres5tatives f ! ,c5t]s = ,m$ic>e     
,m$icaid ,s]vices & ! ,(fice ( !        
,national ,coord9ator = ,heal?          
,in=mation ,te*nology1 heal? c>e        
provid]s1 companies t specialize 9      
relevant te*nologies1 heal? insur]s1 &  
pati5t advocates4  7#b7 ,guidance to    
,m$ic>e ,advantage organizations ,n lat]
 ?an #ab mon?s aft] ! date ( enactm5t ( 
?is ,act1 ! ,secret>y %all issue        
guidance to ,m$ic>e ,advantage          

organizations (f]+ ,m$ic>e ,advantage   
plans "u "p ,c ( title ,,xviii ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#ba et seq47 on ma9ta9+ accurate 
provid] directories = su* plans1 tak+   
into consid]ation input receiv$ dur+ !  
/akehold] meet+ "u p>agraph 7#a74 ,su*  
guidance may include ! foll[+1 z det]m9$
 appropriate by ! ,secret>y3 7,a7 ,be/  
practices = ,m$ic>e ,advantage          
organizations on h[ to "w ) provid]s to 
ma9ta9 ! accuracy ( provid] directories 
& r$uce provid] & ,m$ic>e ,advantage    
organization burd5 ) respect to ma9ta9+ 
! accuracy ( provid] directories 4  7,b7
 ,in=mation on data sets & data s\rces )
 in=mation t c\ld be us$ by ,m$ic>e     
,advantage organizations to ma9ta9      
accurate provid] directories4  7,c7     
,approa*es = utiliz+ data s\rces ma9ta9$
 by ,m$ic>e ,advantage organizations &  
publicly available data sets to ma9ta9  
accurate provid] directories4  7,d7     
,in=mation to be includ$ 9 ! provid]    
directory t may be useful = ,m$ic>e     

b5efici>ies to assess plan networks :5  
select+ a plan & access+ provid]s       
p>ticipat+ 9 plan networks dur+ ! plan  
ye>4  7#c7 ,guidance to "p ,b provid]s  
,n lat] ?an #ab mon?s aft] ! date (     
enactm5t ( ?is ,act1 ! ,secret>y %all   
issue guidance to provid]s ( s]vices &  
suppli]s :o furni% items or s]vices =   
:i* b5efits are available "u "p ,b (    
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;j et seq47 on :5  
to update ! ,national ,plan & ,provid]  
,enum]ation ,sy/em reg>d+ any in=mation 
*anges4  #aaj4 ,guidance to ,/ates on   
/rategies "u ,m$icaid & ,,*ip to        
increase m5tal heal? & sub/ance use     
disord] c>e provid] capacity ,n lat] ?an
 #ab mon?s aft] ! date ( enactm5t ( ?is 
,act1 ! ,secret>y ( ,heal? & ,human     
,s]vices %all issue guidance to ,/ates  
on /rategies "u ,m$icaid & ! ,*ildr5's  
,heal? ,insurance ,program 7,,*ip7 to   
increase access to m5tal heal? &        
sub/ance use disord] c>e provid]s t     
p>ticipate 9 ,m$icaid or ,,*ip1 :i* may 

include education1 tra9+1 recruitm5t1 & 
ret5tion ( su* provid]s1 ) a focus on   
improv+ ! capacity ( ! m5tal heal? &    
sub/ance use disord] c>e work=ce 9 rural
 & und]s]v$ areas by increas+ ! numb]1  
type1 & capacity ( provid]s4 ,su*       
guidance %all include1 b n be limit$    
to-- 7#a7 be/ practices f ,/ates t h us$
 ,m$icaid or ,,*ip waiv]s & au?orities  
"u titles ,,xi1 ,,xix1 & ,,xxi ( su*    
,act 7#db ,u4,s4,c4 #acja et seq41 #acif
 et seq41 #acig;aa et seq47 = su*       
purposes2  7#b7 be/ practices relat$ to 
exp&+ ! availability ( community-bas$   
m5tal heal? & sub/ance use disord]      
s]vices "u ,m$icaid & ,,*ip1 includ+    
?r\gh ! p>ticipation ( p>apr(essionals )
 behavioral heal? exp]tise1 & review (  
,/ate practices = lev]ag+               
p>apr(essionals )9 ,/ate scope (        
practice requirem5ts z well z ,/ate     
sup]vision requirem5ts1 su* z pe]       
support speciali/s & cl9icians )        
baccalaureate degrees2 &  7#c7 be/      
practices relat$ to f9anc+1 support+1 & 

exp&+ ! education & tra9+ ( provid]s (  
m5tal heal? & sub/ance use disord]      
s]vices to increase ! work=ce ( su*     
provid]s :o p>ticipate 9 ,m$icaid &     
,,*ip1 includ+ by support+ on-site tra9+
 9 ! cl9ical sett+ & innovative         
public-private p>tn]%ips4  #aaa4        
,guidance to ,/ates on support+ m5tal   
heal? s]vices & sub/ance use disord] c>e
 = *ildr5 & y\?  7a7 ,guidance on       
increas+ ! availability & provision (   
m5tal heal? s]vices & sub/ance use      
disord] c>e "u ,m$icaid & ,,*ip ,n lat] 
?an #ab mon?s aft] ! date ( enactm5t (  
?is ,act1 ! ,secret>y %all issue        
guidance to ,/ates reg>d+ opportunities 
to improve ! availability & provision ( 
m5tal heal? s]vices & sub/ance use      
disord] c>e ?r\gh ,m$icaid & ,,*ip =    
*ildr5 & y\?4 ,su* guidance %all address
 ! foll[+3 7#a7 ,! design &             
implem5tation ( a cont9uum ( b5efits =  
*ildr5 & y\? ) significant m5tal heal?  
conditions & sub/ance use disord]s cov]$
 by ,m$icaid & ,,*ip1 includ+ ! role (  

,,epsdt1 h[ ,,epsdt requires ,/ates to  
make available a cont9uum ( c>e across  
sett+s1 & :at is requir$ ( ,/ates to    
ensure compliance ) ,,epsdt4  7#b7      
,/rategies to facilitate access to m5tal
 heal? s]vices & sub/ance use disord]   
c>e "u ,m$icaid & ,,*ip t are deliv]$ 9 
! home or 9 community-bas$ sett+s =     
*ildr5 & y\?4 ,su* guidance %all outl9e 
/rategies employ$ by ,/ates to exp& !   
availability ( su* sett+s & include     
specific int]v5tions & f9anc+           
arrangem5ts t c\ld be replicat$4  7#c7  
,/rategies to facilitate access to m5tal
 heal? s]vices & sub/ance use disord]   
c>e "u ,m$icaid & ,,*ip = *ildr5 & y\?  
:o-- 7,a7 are at risk = hav+ a          
significant m5tal heal? condition or    
sub/ance use disord]2  7,b7 h a         
significant m5tal heal? condition or    
sub/ance use disord]2 or  7,c7 h an     
intellectual or developm5tal disability4
  7#d7 ,/rategies to promote scre5+ =   
m5tal heal? & sub/ance use disord] ne$s 
( *ildr5 & y\?1 includ+ *ildr5 & y\?    

provid$1 or at risk = ne$+1 *ild welf>e 
s]vices1 9 coord9ation ) provid]s1      
manag$ c>e organizations 7z def9$ by !  
,secret>y71 prepaid inpati5t heal? plans
 7z def9$ by ! ,secret>y71 prepaid      
ambulatory heal? plans 7z def9$ by !    
,secret>y71 & s*ools 7z def9$ by !      
,secret>y74  7#e7 ,/rategies = support+ 
! provision ( culturally compet5t1      
developm5tally appropriate1 &           
trauma-in=m$ m5tal heal? s]vices &      
sub/ance use disord] c>e to *ildr5 &    
y\?4  7#f7 ,/rategies = provid+ e>ly    
prev5tion1 int]v5tion1 & scre5+ s]vices1
 includ+ = *ildr5 & y\? at high] risk = 
hav+ m5tal heal? or sub/ance use disord]
 ne$s1 *ildr5 & y\? :o d n h a m5tal    
heal? or sub/ance use disord] diagnosis1
 *ildr5 & y\? provid$1 or at risk =     
ne$+1 *ild welf>e s]vices1 & *ildr5 at  
risk ( fir/ episode psy*osis4  7#g7 ,be/
 practices f ,/ate ,m$icaid & ,,*ip     
programs 9 exp&+ access to m5tal heal?  
s]vices & sub/ance use disord] c>e =    
*ildr5 & y\?1 includ+ *ildr5 & y\? t are

 "p ( und]s]v$ communities & *ildr5 &   
y\? ) co-occurr+ intellectual disability
 or autism spectrum disord]1 & =m] fo/] 
y\?4  7#h7 ,/rategies to coord9ate      
s]vices & fund+ provid$ "u p>ts ,b & ,e 
( title ,,iv ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #fba et seq41 #fgj et    
seq471 & o!r fund+ s\rces at !          
discretion ( ! ,secret>y1 ) s]vices =   
:i* ,f$]al f9ancial p>ticipation is     
available "u ,m$icaid or ,,*ip1 to      
support improv$ access to compreh5sive  
m5tal heal? s]vices & sub/ance use      
disord] c>e = *ildr5 & y\? provid$1 or  
at risk = ne$+1 *ild welf>e s]vices4    
7b7 ,consultation ,! ,secret>y %all     
consult ) ! ,adm9i/rator ( ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices1 ! ,assi/ant 
,secret>y = ! ,adm9i/ration = ,*ildr5 & 
,families1 ! ,assi/ant ,secret>y =      
,m5tal ,heal? & ,sub/ance ,use1 & !     
,director ( ! ,(fice ( ,national ,drug  
,control ,policy ) respect to ! guidance
 issu$ "u subsection 7a74  7c7          
,def9itions ,9 ?is section3 7#a7 ,,epsdt

 ,! t]m ,,epsdt means e>ly & p]iodic    
scre5+1 diagno/ic1 & treatm5t s]vices "u
 ,m$icaid 9 accordance ) sections       
#aijb7;a77#dc71 #aije7;a77#d77;,b71 &   
#aije7r7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #acif;a7a77#dc71             
#acif;d7a77#d77;,b71 #acif;d7r774  7#b7 
,secret>y ,! t]m ,secret>y means !      
,secret>y ( ,heal? & ,human ,s]vices4   
7#c7 ,/ate ,! t]m ,/ate has ! mean+ giv5
 t t]m 9 section #aaja7;a77#a7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acja7;a77#a77 = purposes ( titles ,,xix
 & ,,xxi ( su* ,act4  #aab4 ,recurr+    
analysis & publication ( ,m$icaid heal? 
c>e data relat$ to m5tal heal? s]vices  
7a7 ,9 g5]al ,! ,secret>y1 on a bi5nial 
basis1 %all l9k1 analyze1 & publi% on a 
publicly available website ,m$icaid data
 report$ by ,/ates ?r\gh ! ,trans=m$    
,m$icaid ,/ati/ical ,in=mation ,sy/em   
7,t-,,msis7 7or a successor sy/em7      
relat+ to m5tal heal? s]vices provid$ to
 individuals enroll$ 9 ,m$icaid1 includ+
 an analysis by age4 ,su* enrollee      

in=mation %all be de-id5tifi$ ( any     
p]sonally id5tify+ in=mation1 %all adh]e
 to privacy /&>ds e/abli%$ by !         
,dep>tm5t ( ,heal? & ,human ,s]vices1 & 
%all be aggregat$ to protect ! privacy (
 enrollees1 z necess>y4 ,ea* publication
 ( su* analysis %all include = ea* ,/ate
 available data = ! foll[+ measures3    
7#a7 ,! numb] & p]c5tage ( individuals  
by age enroll$ 9 ! ,/ate ,m$icaid plan  
or waiv] ( su* plan 9 ea* ( ! major     
enrollm5t categories 7z def9$ 9 a lett]1
 to be made publicly available on !     
website ( ! ,m$icaid & ,,*ip ,paym5t &  
,access ,commission1 f ! ,m$icaid &     
,,*ip ,paym5t & ,access ,commission to !
 ,secret>y7 :o h be5 diagnos$ ) a m5tal 
heal? condition & :e!r su* individuals  
are enroll$ "u ! ,/ate ,m$icaid plan or 
waiv] ( su* plan1 includ+ ! specific    
waiv] au?ority "u :i* !y are enroll$1 to
 ! ext5t available4  7#b7 ,a li/ ( !    
m5tal heal? treatm5t s]vices1 includ+   
specify+ adult & p$iatric s]vices1 by   
ea* major type ( s]vice1 su* z c\nsel+1 

int5sive home-bas$ s]vices1 int5sive c>e
 coord9ation1 crisis s]vices tailor$ to 
*ildr5 & y\?1 y\? pe] support s]vices1  
family-to-family support1 inpati5t      
hospitalization1 & o!r appropriate      
s]vices z id5tifi$ by ! ,secret>y1 = :i*
 b5efici>ies 9 ea* ,/ate receiv$ at lea/
 #a s]vice "u ! ,/ate ,m$icaid plan or a
 waiv] ( su* plan4  7#c7 ,! numb] &     
p]c5tage ( individuals by age ) a       
sub/ance use disord] diagnosis enroll$ 9
 ! ,/ate ,m$icaid plan or waiv] ( su*   
plan :o receiv$ s]vices = a m5tal heal? 
condition "u su* plan or waiv] by ea*   
major type ( s]vice specifi$ "u p>agraph
 7#b7 )9 ea* major sett+ type1 su* z    
outpati5t1 inpati5t1 resid5tial1 & o!r  
home-bas$ & community-bas$ sett+s4  7#d7
 ,! numb] ( s]vices provid$ "u ! ,/ate  
,m$icaid plan or waiv] ( su* plan p]    
individual ) a m5tal heal? diagnosis1   
includ+ by age1 enroll$ 9 su* plan or   
waiv] = ea* major type ( s]vice specifi$
 "u p>agraph 7#b74  7#e7 ,! numb] &     
p]c5tage ( individuals by age enroll$ 9 

! ,/ate ,m$icaid plan or waiv] by major 
enrollm5t category1 :o receiv$ m5tal    
heal? s]vices ?r\gh-- 7,a7 a ,m$icaid   
manag$ c>e entity 7z def9$ 9 section    
#aicb7;a77#a77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acifu-#b7;a77#a77;,b7771 includ+ !     
numb] ( su* individuals :o receiv$ su*  
assi/ance ?r\gh a prepaid inpati5t heal?
 plan 7z def9$ by ! ,secret>y7 or a     
prepaid ambulatory heal? plan 7z def9$  
by ! ,secret>y72  7,b7 a fee-=-s]vice   
paym5t model2 or  7,c7 an alt]native    
paym5t model1 to ! ext5t available4     
7#f7 ,! numb] & p]c5tage ( individuals  
by age ) a m5tal heal? diagnosis :o     
receiv$ m5tal heal? s]vices 9 an        
outpati5t or home-bas$ & community-bas$ 
sett+ aft] receiv+ s]vices 9 an inpati5t
 or resid5tial sett+ & ! numb] ( s]vices
 receiv$ by su* individuals 9 !         
outpati5t or home-bas$ & community-bas$ 
sett+4  7#g7 ,! numb] & p]c5tage (      
inpati5t admissions by age 9 :i* s]vices
 = a m5tal heal? condition 7 provid$ to 

an individual enroll$ 9 ! ,/ate ,m$icaid
 plan or a waiv] ( su* plan t occurr$ )9
 #cj days aft] dis*>ge f a hospital or  
inpati5t facility 9 :i* s]vices = a     
m5tal heal? condition previ\sly 7       
provid$ to su* individual1 disaggregat$ 
by type ( facility1 to ! ext5t su*      
in=mation is available4  7#h7 ,! numb] (
 em]g5cy dep>tm5t visits by an          
individual by age enroll$ 9 ! ,/ate     
,m$icaid plan or a waiv] ( su* plan =   
treatm5t ( a m5tal heal? condition )9 #g
 days ( su* individual be+ dis*>g$ f a  
hospital inpati5t facility 9 :i* s]vices
 = a m5tal heal? condition 7 provid$1 or
 f a m5tal heal? facility1 an indep5d5t 
psy*iatric w+ ( acute c>e hospital1 or  
an int]m$iate c>e facility = individuals
 ) intellectual disabilities1           
disaggregat$ by type ( facility1 to !   
ext5t su* in=mation is available4  7#i7 
,! numb] & p]c5tage ( individuals by age
 enroll$ 9 ! ,/ate ,m$icaid plan or a   
waiv] ( su* plan-- 7,a7 :o receiv$ an   
assessm5t to diagnose a m5tal heal?     

condition2 &  7,b7 ! numb] ( m5tal heal?
 s]vices provid$ to individuals describ$
 9 subp>agraph 7,a7 9 ! #cj days        
po/-assessm5t4  7#aj7 ,prescription     
,national ,drug ,code codes1 fill dates1
 & numb] ( days supply ( any cov]$      
outpati5t drug 7z def9$ 9 section       
#aibg7k77#b7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #acifr-#h7k77#b77 to     
treat a m5tal heal? condition t 7       
disp5s$ to an individual by age enroll$ 
9 ! ,/ate ,m$icaid plan or waiv] ) an   
episode describ$ 9 p>agraph 7#g7 or 7#h7
 dur+ any p]iod t occurs aft] !         
individual's dis*>ge date def9$ 9       
p>agraph 7#g7 or 7#h7 7z applicable71 & 
be=e ! admission date applicable "u     
p>agraph 7#g7 or ! date ( ! em]g5cy     
dep>tm5t visit applicable "u p>agraph   
7#h74  7b7 ,publication  7#a7 ,9 g5]al  
,n lat] ?an #ah mon?s aft] ! date (     
enactm5t ( ?is ,act1 ! ,secret>y %all   
make publicly available ! fir/ analysis 
requir$ by subsection 7a74  7#b7 ,use ( 
,t-,,msis data ,! report requir$ "u     

p>agraph 7#a7 & updates requir$ "u      
p>agraph 7#c7 %all-- 7,a7 use data &    
def9itions f ! ,trans=m$ ,m$icaid       
,/ati/ical ,in=mation ,sy/em 7,t-,,msis7
 7or a successor sy/em7 data set t is no
 m ?an #ab mon?s old on ! date t !      
report or update is publi%$2 &  7,b7 z  
appropriate1 include a description )    
respect to ea* ,/ate ( ! quality &      
complet5ess ( ! data & caveats describ+ 
! limitations ( ! data report$ to !     
,secret>y by ! ,/ate t is suffici5t to  
communicate ! appropriate uses = !      
in=mation4  7#c7 ,revis$ publication ,n 
lat] ?an #c ye>s aft] ! date ( enactm5t 
( ?is ,act1 ! ,secret>y %all publi% a   
revis$ publication ( ! analysis requir$ 
by subsection 7a7 t all[s = a           
rese>*-ready & publicly accessible      
int]face ( ! publication t is develop$  
aft] consultation ) /akehold]s on !     
usability ( ! data conta9$ 9 !          
publication4  7c7 ,mak+ p]man5t !       
requirem5t to annually update ! ,,sud   
data book ,section #ajae ( ! ,,support =

 ,pati5ts & ,communities ,act 7,public  
,law #aae-bga7 is am5d$-- 7#a7 9        
subsection 7a77#c71 by /rik+ ?r\gh      
#bjbd2 &  7#b7 9 subsection 7b71 by add+
 at ! end ! foll[+ new p>agraph3  7#d7  
,publication ( data  7,a7 ,9 g5]al ,!   
,secret>y %all publi% 9 ! ,f$]al ,regi/]
 a sy/em ( records notice t modifies !  
sy/em ( records notice requir$ "u       
p>agraph 7#a7 to provide t-- 7i7 ! data 
specifi$ 9 p>agraph 7#b7 %all be publi%$
 on a publicly available website2 &     
7ii7 su* data %all be de-id5tifi$ ( any 
p]sonally id5tify+ in=mation1 %all adh]e
 to privacy /&>ds e/abli%$ by !         
,dep>tm5t ( ,heal? & ,human ,s]vices1 & 
%all be aggregat$ to protect ! privacy (
 enrollees1 z necess>y4  7,b7           
,initiation ( modifi$ data-%>+          
activities ,n lat] ?an ,janu>y #a1      
#bjbe1 ! ,secret>y %all initiate ! data 
%>+ activities outl9$ 9 ! notice requir$
 "u p>agraph 7#a71 z modifi$ pursuant to
 ?is p>agraph4  4  7d7 ,def9itions ,9   
?is section3 7#a7 ,secret>y ,! t]m      

,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4  7#b7 ,/ate ,! t]m     
,/ate has ! mean+ giv5 t t]m 9 section  
#aaja7;a77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acja7;a77#a77 =        
purposes ( title ,,xix ( su* ,act4      
#aac4 ,guidance to ,/ates on support+   
m5tal heal? s]vices or sub/ance use     
disord] c>e integration ) prim>y c>e 9  
,m$icaid & ,,*ip  7a7 ,analysis reg>d+  
c>e integration ,n lat] ?an #ah mon?s   
aft] ! date ( enactm5t ( ?is ,act1 !    
,secret>y %all conduct an analysis (    
,m$icaid & ,,*ip reg>d+ cl9ical outcomes
 among diff]5t models ( integration (   
m5tal heal? s]vices or sub/ance use     
disord] c>e )9 ! prim>y c>e sett+4 ,su* 
analysis %all-- 7#a7 consid] diff]5t    
models = h[ m5tal heal? s]vices or      
sub/ance use disord] c>e is deliv]$ &   
integrat$ )9 ! prim>y c>e sett+1 includ+
 :5 provid]s op]at+ 9 an integrat$ model
 are physically locat$ 9 ! same practice
 or build+1 :5 at lea/ #a provid] 9 an  
integrat$ c>e model is available via    

teleheal?1 & :5 prim>y c>e1 m5tal heal?1
 or sub/ance use disord] c>e provid]s   
seek education & consultation f o!r     
provid]s ?r\gh electronic modalities2 & 
7#b7 evaluate-- 7,a7 ! use ( diff]5t    
paym5t me?odologies1 su* z bundl$       
paym5ts & value-bas$ paym5t arrangem5ts2
 &  7,b7 ! use & quality ( s]vices to   
coord9ate c>e1 includ+ b n limit$ to    
case managem5t1 c>e coord9ation1 enhanc$
 c>e coord9ation1 & enhanc$ c>e         
managem5t1 = m5tal heal? s]vices & =    
sub/ance use disord] c>e4  7b7 ,guidance
 ,n lat] ?an #ab mon?s aft] ! ,secret>y 
completes ! analysis requir$ "u         
subsection 7a71 ! ,secret>y %all issue  
guidance to ,/ates on support+          
integration ( m5tal heal? s]vices or    
sub/ance use disord] c>e ) prim>y c>e "u
 ,m$icaid & ,,*ip4 ,su* guidance %all be
 in=m$ by ! analysis requir$ "u         
subsection 7a7 &1 at m9imum1 %all d !   
foll[+3 7#a7 ,provide an ov]view ( ,/ate
 options = adopt+ & exp&+ value-bas$    
paym5t arrangem5ts & alt]native paym5t  

models1 includ+ acc\ntable c>e          
organizations & o!r %>$ sav+s programs1 
t integrate m5tal heal? s]vices or      
sub/ance use disord] c>e ) prim>y c>e4  
7#b7 ,describe opportunities = ,/ates to
 use & align exi/+ au?orities & res\rces
 to f9ance integration ( m5tal heal?    
s]vices or sub/ance use disord] c>e )   
prim>y c>e1 includ+ ) respect to ! use (
 electronic heal? records 9 m5tal heal? 
c>e sett+s & 9 sub/ance use disord] c>e 
sett+s4  7#c7 ,describe /rategies to    
support integration ( m5tal heal?       
s]vices or sub/ance use disord] c>e )   
prim>y c>e ?r\gh ! use ( non-cl9ical    
pr(essionals & p>apr(essionals1 includ+ 
tra9$ pe] support speciali/s4  7#d7     
,provide examples ( specific /rategies &
 models design$ to support integration (
 m5tal heal? s]vices or sub/ance use    
disord] c>e ) prim>y c>e = diff]+ age   
gr\ps1 includ+ *ildr5 & y\?1 &          
individuals ov] ! age ( #fe4  7#e7      
,describe options = assess+ ! cl9ical   
outcomes ( diff]+ models & /rategies =  

integration ( m5tal heal? s]vices or    
sub/ance use disord] c>e ) prim>y c>e4  
7c7 ,integration ( m5tal heal? s]vices  
or sub/ance use disord] c>e ) prim>y c>e
 ,= purposes ( subsections 7a7 & 7b71   
integration ( m5tal heal? s]vices or    
sub/ance use disord] c>e ) prim>y c>e   
may include 7& %all n be limit$ to1     
includ+ :5 furni%$ via teleheal?1 :5    
appropriate7-- 7#a7 adh]5ce to !        
collaborative c>e model or prim>y c>e   
behavioral heal? model = behavioral     
heal? integration2  7#b7 use (          
behavioral heal? integration models     
prim>ily int5d$ = p$iatric populations )
 non-sev]e m5tal heal? ne$s t are focus$
 on prev5tion & e>ly detection &        
int]v5tion me?ods ?r\gh a               
multidiscipl9>y collaborative behavioral
 heal? team approa* co-manag$ ) prim>y  
c>e1 to include same-day access to      
family-focus$ m5tal heal? treatm5t      
s]vices2  7#c7 hav+ m5tal heal? provid]s
 or sub/ance use disord] provid]s       
physically co-locat$ 9 a prim>y c>e     

sett+ ) same-day visit availability2    
7#d7 implem5t+ or ma9ta9+ enhanc$ c>e   
coord9ation or t>get$ case managem5t :i*
 includes regul> int]actions betwe5 & )9
 c>e teams2  7#e7 provid+ m5tal heal? or
 sub/ance use disord] scre5+ & foll[-up 
assessm5ts1 int]v5tions1 or s]vices )9 !
 same practice or facility z a prim>y   
c>e or physical s]vice sett+2  7#f7 !   
use ( ass]tive community treatm5t t is  
integrat$ ) or facilitat$ by a prim>y   
c>e practice2 &  7#g7 deliv]y (         
integrat$ prim>y c>e & m5tal heal?      
s]vices or sub/ance use disord] c>e 9 ! 
home or 9 community-bas$ sett+s =       
individuals :o *oose & are able to      
receive c>e 9 su* sett+s1 z au?oriz$ "u 
subsections 7b71 7c71 7i71 7j71 & 7k7 ( 
section #aiae ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acifn71 "u a waiv] "u  
section #aaae ( su* ,act 7#db ,u4,s4,c4 
#acae71 or "u section #aicg1 #aide1 or  
#aide;,a ( su* ,act 7#db ,u4,s4,c4      
#acifu-#g1 #acifw-#d1 #acifw-#d;a74  7d7
 ,def9itions ,9 ?is section3 7#a7       

,secret>y ,! t]m ,secret>y means !      
,secret>y ( ,heal? & ,human ,s]vices4   
7#b7 ,/ate ,! t]m ,/ate has ! mean+ giv5
 t t]m 9 section #aaja7;a77#a7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acja7;a77#a77 = purposes ( titles ,,xix
 & ,,xxi ( su* ,act4  #aad4 ,m$icaid    
,/ate option relat+ to inmates ) a      
sub/ance use disord] p5d+ disposition ( 
*>ges  7a7 ,/ate option  7#a7 ,9 g5]al  
,section #aije ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acif;d7 is am5d$-- 
7,a7 9 ! subdivision 7,a7 foll[+ ! la/  
numb]$ p>agraph ( subsection 7a71 by    
ins]t+ subject to subsection 7jj71 be=e 
any su* paym5ts2 &  7,b7 by add+ at !   
end ! foll[+ new subsection3  7jj7 ,/ate
 option to provide m$ical assi/ance to  
c]ta9 inmates ) a sub/ance use disord]  
p5d+ disposition ( *>ges  7#a7 ,9 g5]al 
,subject to p>agraph 7#b71 a ,/ate may  
elect to provide1 &1 not)/&+ !          
subdivision 7,a7 foll[+ ! la/ numb]$    
p>agraph ( subsection 7a71 receive      
,f$]al f9ancial p>ticipation =1 m$ical  

assi/ance = an individual :o-- 7,a7 is  
an inmate ( a public in/itution 7z def9$
 9 section #aijb7nn77#c77 p5d+          
disposition ( *>ges2 &  7,b7 has be5    
diagnos$ ) a sub/ance use disord]4  7#b7
 ,limitation2 conditions  7,a7          
,limitation ,a ,/ate may only receive   
,f$]al f9ancial p>ticipation = m$ical   
assi/ance provid$ to an individual      
describ$ 9 p>agraph 7#a7 dur+ ! #g-;day 
p]iod t beg9s on ! fir/ day t !         
individual is an inmate ( a public      
in/itution4  7,b7 ,conditions ,a ,/ate  
may only receive ,f$]al f9ancial        
p>ticipation = m$ical assi/ance provid$ 
to an individual describ$ 9 p>agraph    
7#a7 if-- 7i7 ! ,/ate has elect$ to n   
t]m9ate eligibility = m$ical assi/ance  
"u ! ,/ate plan = individuals on ! basis
 t !y are inmates ( public in/itutions  
7b may susp5d cov]age dur+ ! p]iod an   
individual is su* an inmate72 &  7ii7 ! 
diagnosis t ! cov]$ individual has a    
sub/ance use disord] is made :ile !     
individual is an inmate ( ! public      

in/itution by a lic5s$ m$ical           
pr(essional us+ a /&>diz$ scre5+ &      
assessm5t model approv$ by ! ,secret>y4 
4  7#b7 ,effective date ,! am5dm5ts made
 by ?is subsection %all take effect on  
,janu>y #a1 #bjbf4  7b7 ,te*nical       
correction & con=m+ am5dm5ts  7#a7      
,te*nical correction ,section           
#eabb7;a77#a7 ( ! ,consolidat$          
,appropriations ,act1 #bjbc 7,public    
,law #aag-cbh7 is am5d$ by /rik+ aft] & 
all t foll[s ?r\gh ! p]iod at ! end &   
ins]t+ aft] or 9 ! case ( an eligible   
juv5ile describ$ 9 section              
#aijb7;a77#hd77;,d7 ) respect to !      
scre5+s1 diagno/ic s]vices1 ref]rals1 & 
t>get$ case managem5t s]vices requir$ "u
 su* section44  7#b7 ,o!r con=m+        
am5dm5ts  7,a7 ,section #aijb7nn77#c7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acif;a7nn77#c771 is am5d$ by /rik+     
foll[+ & all t foll[s ?r\gh section     
#aije7;a7 & ins]t+ foll[+ ! la/ numb]$  
p>agraph ( section #aije7;a74  7,b7 ,!  
fif? s5t5ce ( section #aije7;a7 ( !     

,social ,security ,act 7#db ,u4,s4,c4   
#acif;d7a77 is am5d$ by /rik+ p>agraph  
7#cj7 & ins]t+ ! la/ numb]$ p>agraph4   
#aae4 ,def9ition ( ,c]tifi$ ,community  
,behavioral ,heal? ,cl9ic ,s]vices "u   
,m$icaid  7a7 ,def9ition ( m$ical       
assi/ance ,section #aije ( ! ,social    
,security ,act 7#db ,u4,s4,c4 #acif;d7  
is am5d$-- 7#a7 9 subsection 7a7-- 7,a7 
9 p>agraph 7#cj71 by /rik+ 2 & & ins]t+ 
a semicolon2  7,b7 by r$esignat+        
p>agraph 7#ca7 z p>agraph 7#cb72 &  7,c7
 by ins]t+ aft] p>agraph 7#cj7 ! foll[+ 
new p>agraph3  7#ca7 c]tifi$ community  
behavioral heal? cl9ic s]vices1 z def9$ 
9 subsection 7jj72 &  2 &  7#b7 by add+ 
at ! end ! foll[+ new subsection3  7jj7 
,c]tifi$ community behavioral heal?     
cl9ic s]vices  7#a7 ,9 g5]al ,! t]m     
c]tifi$ community behavioral heal?      
s]vices means any ( ! foll[+ :5 furni%$ 
to an individual z a pati5t ( a c]tifi$ 
community behavioral heal? cl9ic 7z     
def9$ 9 p>agraph 7#b771 9 a mann]       
reflect+ p]son-c5t]$ c>e & :i*1 if n    

available directly ?r\gh a c]tifi$      
community behavioral heal? cl9ic1 may be
 provid$ or ref]r$ ?r\gh =mal           
relation%ips ) o!r provid]s3 7,a7       
,crisis m5tal heal? s]vices1 includ+    
#bd-;h\r mobile crisis teams1 em]g5cy   
crisis int]v5tion s]vices1 & crisis     
/abilization4  7,b7 ,scre5+1 assessm5t1 
& diagnosis1 includ+ risk assessm5t4    
7,c7 ,pati5t-c5t]$ treatm5t plann+ or   
simil> processes1 includ+ risk assessm5t
 & crisis plann+4  7,d7 ,outpati5t m5tal
 heal? & sub/ance use s]vices4  7,e7    
,outpati5t cl9ic prim>y c>e scre5+ &    
monitor+ ( key heal? indicators & heal? 
risk4  7,f7 ,int5sive case managem5t4   
7,g7 ,psy*iatric rehabilitation s]vices4
  7,h7 ,pe] support & c\nselor s]vices &
 family supports4  7,i7 ,int5sive1      
community-bas$ m5tal heal? c>e = memb]s 
( ! arm$ =ces & vet]ans1 p>ticul>ly ^?  
memb]s & vet]ans locat$ 9 rural areas1  
provid$ ! c>e is consi/5t ) m9imum      
cl9ical m5tal heal? guidel9es promulgat$
 by ! ,vet]ans ,heal? ,adm9i/ration1    

includ+ cl9ical guidel9es conta9$ 9 !   
,uni=m ,m5tal ,heal? ,s]vices ,h&book ( 
su* ,adm9i/ration4  7#b7 ,c]tifi$       
community behavioral heal? cl9ic ,! t]m 
c]tifi$ community behavioral heal? cl9ic
 means an organization t-- 7,a7 is      
engag$ 9 furni%+ to pati5ts all ( !     
s]vices describ$ 9 p>agraph 7#a72  7,b7 
is legally au?oriz$ to furni% su*       
s]vices "u ,/ate law2  7,c7 agrees1 z a 
condition ( ! c]tification describ$ 9   
subp>agraph 7,d71 to furni% to ! ,/ate  
or ,secret>y any data requir$ z "p (    
ongo+ monitor+ ( ! organization's       
provision ( s]vices1 includ+ enc\nt]    
data1 cl9ical outcomes data1 quality    
data1 & su* o!r data z ! ,/ate or       
,secret>y may require2 &  7,d7 has be5  
c]tifi$ by a ,/ate z meet+ ! crit]ia    
e/abli%$ by ! ,secret>y pursuant to     
subsection 7a7 ( section #bbc ( !       
,protect+ ,access to ,m$ic>e ,act z (   
,janu>y #a1 #bjbd1 & any subsequ5t      
updates to su* crit]ia1 reg>dless ( :e!r
 ! ,/ate is c>ry+ out a demon/ration    

program "u ?is title "u subsection 7d7 (
 su* section4  4  7b7 ,effective date ,!
 am5dm5ts made by ?is section %all apply
 ) respect to m$ical assi/ance furni%$  
on or aft] ,janu>y #a1 #bjbd4  ,,ii     
,r$uc+ prescription drug co/s "u ,m$ic>e
 & ,m$icaid  #bja4 ,assur+ ph>macy      
access & *oice = ,m$ic>e b5efici>ies    
7a7 ,9 g5]al ,section                   
#ahfj;,d-#d7;b77#a7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;b77#a77 is am5d$ by /rik+  
subp>agraph 7,a7 & ins]t+ ! foll[+3     
7,a7 ,9 g5]al  7i7 ,p>ticipation ( any  
will+ ph>macy ,a ,,pdp sponsor (f]+ a   
prescription drug plan %all p]mit any   
ph>macy t meets ! /&>d contract t]ms &  
conditions "u su* plan to p>ticipate z a
 network ph>macy ( su* plan4  7ii7      
,contract t]ms & conditions  7,i7 ,9    
g5]al ,= plan ye>s beg9n+ on or aft]    
,janu>y #a1 #bjbh1 9 accordance ) clause
 7i71 contract t]ms & conditions (f]$ by
 su* ,,pdp sponsor %all be reasonable & 
relevant accord+ to /&>ds e/abli%$ by ! 

,secret>y "u subclause 7,,ii74  7,,ii7  
,/&>ds ,n lat] ?an ! fir/ ,monday 9     
,april ( #bjbg1 ! ,secret>y %all e/abli%
 /&>ds = reasonable & relevant contract 
t]ms & conditions = purposes ( ?is      
clause4  7,,iii7 ,reque/ = in=mation ,n 
lat] ?an ,janu>y #a1 #bjbe1 = purposes (
 e/abli%+ ! /&>ds "u subclause 7,,ii71 !
 ,secret>y %all issue a reque/ =        
in=mation to seek input on tr5ds 9      
prescription drug plan & network ph>macy
 contract t]ms & conditions1 curr5t     
prescription drug plan & network ph>macy
 contract+ practices1 :e!r ph>macy      
reimbursem5t & disp5s+ fees "u ?is "p   
cov] ph>macy +r$i5t & op]ational co/s1  
areas 9 curr5t regulations or program   
guidance relat$ to contract+ betwe5     
prescription drug plans & network       
ph>macies requir+ cl>ification or       
additional specificity1 factors =       
consid]ation 9 det]m9+ ! reasonabl5ess &
 relevance ( contract t]ms & conditions 
betwe5 prescription drug plans & network
 ph>macies1 & o!r issues det]m9$        

appropriate by ! ,secret>y4  4  7b7     
,treatm5t ( ess5tial retail ph>macies   
,section #ahfj;,d-#d7;b77#a77;,c7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#ajd7;b77#a77;,c77 is am5d$ by   
add+ at ! end ! foll[+ new clause3  7v7 
,ess5tial retail ph>macies  7,i7 ,9     
g5]al ,= plan ye>s beg9n+ on or aft]    
,janu>y #a1 #bjbh1 a ,,pdp sponsor ( a  
prescription drug plan t has pref]r$    
ph>macies 9 its network %all contract )1
 z pref]r$ ph>macies 9 su* plan's       
network1 at lea/-- 7aa7 #hj p]c5t (     
ess5tial retail ph>macies 7z def9$ 9    
subclause 7,,iii77 9 su* plan's s]vice  
area t are indep5d5t community ph>macies
 7z def9$ 9 subclause 7,v77bb772 &  7bb7
 #ej p]c5t ( ess5tial retail ph>macies 9
 su* plan's s]vice area n describ$ 9    
item 7aa74  7,,ii7 ,total reimbursem5t =
 ess5tial retail ph>macies t are        
indep5d5t community ph>macies ,= plan   
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbh1 total reimbursem5t 7z def9$ 9    
subclause 7,v77dd77 paid by a ,,pdp     

sponsor to an ess5tial retail ph>macy t 
is an indep5d5t community ph>macy = a   
cov]$ "p ,d drug %all n be l[] ?an--    
7aa7 9 ! case :]e ,national ,av]age     
,drug ,acquisition ,co/ in=mation = su* 
drug = retail community ph>macies or    
applicable non-retail community         
ph>macies has be5 available "u section  
#aibg7;f7 = at lea/ "o full plan ye>--  
7,,aa7 if su* in=mation is available =  
su* drug = retail community ph>macies1 !
 av]age ,national ,av]age ,drug         
,acquisition ,co/ = su* drug = retail   
community ph>macies = ! mo/ rec5t plan  
ye> = :i* su* in=mation is available2   
7,,bb7 9 ! case :]e su* in=mation =     
retail community ph>macies is n         
available1 ! av]age ,national ,av]age   
,drug ,acquisition ,co/ = su* drug =    
applicable non-retail ph>macies = ! mo/ 
rec5t plan ye> = :i* su* in=mation is   
available2  7bb7 9 ! case :]e ,national 
,av]age ,drug ,acquisition ,co/         
in=mation = su* drug "u section         
#aibg7;f7 is n available = retail       

community ph>macies or applicable       
non-retail ph>macies1 ! :olesale        
acquisition co/ 7z def9$ 9 section      
#ahdg;,a7c77#f77;,b77 = su* drug2 &     
7cc7 9 ! case :]e ,national ,av]age     
,drug ,acquisition ,co/ in=mation "u    
section #aibg7;f7 is available = su*    
drug & end+ on ! date su* survey        
in=mation has be5 available = su* drug b
 has n be5 available = a full plan ye>--
 7,,aa7 ! mo/ rec5t ,national ,av]age   
,drug ,acquisition ,co/ = su* drug =    
retail community ph>macies1 if          
available2 or 7,,bb7 if ! in=mation     
specifi$ 9 subitem 7,,aa7 is n          
available1 ! mo/ rec5t ,national ,av]age
 ,drug ,acquisition ,co/ = su* drug =   
applicable non-retail ph>macies4        
7,,iii7 ,def9ition ( ess5tial retail    
ph>macy ,9 ?is clause1 ! t]m ess5tial   
retail ph>macy means1 ) respect to a    
plan ye>1 a retail ph>macy t-- 7aa7 is n
 an affiliate ( a ph>macy b5efit manag] 
or ,,pdp sponsor2  7bb7 is locat$ 9 a   
m$ically und]s]v$ area 7z designat$     

pursuant to section #ccj7;b77#c77;,a7 ( 
! ,public ,heal? ,s]vice ,act72 &  7cc7 
is designat$ z an ess5tial retail       
ph>macy by ! ,secret>y = su* plan ye> "u
 subclause 7,,iv74  7,,iv7 ,designation 
( ess5tial retail ph>macies  7aa7 ,9    
g5]al ,= ea* plan ye> 7beg9n+ ) plan ye>
 #bjbh71 ! ,secret>y %all designate     
ph>macies t meet ! requirem5ts specifi$ 
9 items 7aa7 & 7bb7 ( subclause 7,,iii7 
z ess5tial retail ph>macies1 9          
accordance ) ?is subclause4  7bb7       
,requir$ submissions f ,,pdp sponsors ,=
 ea* plan ye> beg9n+ ) plan ye> #bjbh1  
ea* ,,pdp sponsor (f]+ a prescription   
drug plan %all submit to ! ,secret>y1 = 
! purposes ( det]m9+ retail ph>macies t 
d n meet ! requirem5t specifi$ 9 item   
7aa7 ( subclause 7,,iii71 a li/ ( any   
retail ph>macy t is an affiliate ( su*  
sponsor1 subject to "t1 mann]1 & =m     
requirem5ts e/abli%$ by ! ,secret>y4    
7cc7 ,publication ,n lat] ?an "o mon?   
prior to ! />t ( ea* plan ye> 7beg9n+ ) 
plan ye> #bjbh71 ! ,secret>y %all li/1  

on a publicly available website ( !     
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices1 all
 ph>macies designat$ z ess5tial retail  
ph>macies = su* plan ye>4  7dd7         
,revocation ( designation ,9 ! case :]e1
 dur+ a plan ye>1 ! ,secret>y det]m9es t
 a ph>macy no long] meets ! requirem5ts 
= designation z an ess5tial retail      
ph>macy1 ! ,secret>y may revoke su*     
designation = su* ph>macy1 z det]m9$    
appropriate by ! ,secret>y4  7,v7 ,o!r  
def9itions ,9 ?is clause3 7aa7          
,affiliate ,! t]m affiliate means any   
entity t is own$ by1 controll$ by1 or   
relat$ "u a common own]%ip /ructure ) a 
ph>macy b5efit manag] or ,,pdp sponsor  
or t acts z a contractor or ag5t to su* 
ph>macy b5efit manag] or ,,pdp sponsor1 
if su* contractor or ag5t p]=ms any ( ! 
functions describ$ 9 item 7cc74  7bb7   
,indep5d5t community ph>macy ,! t]m     
indep5d5t community ph>macy means a     
retail ph>macy1 includ+ a ph>macy t is  
associat$ ) a fran*ise or a ph>macy     
s]vices adm9i/rative organization1 t has

 few] ?an #d locations & is n affiliat$ 
) any p]son or entity o!r ?an its own]s4
  7cc7 ,ph>macy b5efit manag] ,! t]m    
ph>macy b5efit manag] means any p]son or
 entity t1 ei!r directly or ?r\gh an    
int]m$i>y1 acts z a price negotiator or 
gr\p pur*as] on behalf ( a ,,pdp sponsor
 or prescription drug plan1 or manages !
 prescription drug b5efits provid$ by   
su* sponsor or plan1 includ+ ! process+ 
& paym5t ( claims = prescription drugs1 
! p]=mance ( drug utilization review1 ! 
process+ ( drug prior au?orization      
reque/s1 ! adjudication ( appeals or    
grievances relat$ to ! prescription drug
 b5efit1 contract+ ) network ph>macies1 
controll+ ! co/ ( cov]$ "p ,d drugs1 or 
! provision ( relat$ s]vices4 ,su* t]m  
includes any p]son or entity t c>ries   
out "o or m ( ! activities describ$ 9 ! 
prec$+ s5t5ce1 irrespective ( :e!r su*  
p]son or entity id5tifies itself z a    
ph>macy b5efit manag]4  7dd7 ,total     
reimbursem5t ,! t]m total reimbursem5t  
means1 ) respect to a cov]$ "p ,d drug1 

! negotiat$ price 7z def9$ 9 section    
#ahfj;,d-#b7;d77#a77;,b77 plus any      
inc5tive paym5ts paid by ! ,,pdp sponsor
 to su* ess5tial retail ph>macy t is an 
indep5d5t community ph>macy net ( any   
fees1 ph>macy price concessions1        
disc\nts1 or any o!r =ms ( remun]ation  
paid by su* ph>macy & furni%$ by su*    
,,pdp sponsor "u section                
#ahfj;,d-#b7;f77#d74  4  7c7 ,en=cem5t  
7#a7 ,9 g5]al ,section                  
#ahfj;,d-#d7;b77#a7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;b77#a77 is am5d$ by add+ at
 ! end ! foll[+ new subp>agraph3  7,f7  
,en=cem5t ( /&>ds = reasonable &        
relevant contract t]ms & conditions &   
ess5tial retail ph>macy protections  7i7
 ,allegation submission process  7,i7 ,9
 g5]al ,n lat] ?an ,janu>y #a1 #bjbh1 ! 
,secret>y %all e/abli% a process ?r\gh  
:i* a ph>macy may submit an allegation (
 a violation by a ,,pdp sponsor (f]+ a  
prescription drug plan (-- 7aa7 ! /&>ds 
= reasonable & relevant contract t]ms & 

conditions "u subp>agraph 7,a77ii72 or  
7bb7 ! requirem5ts = total reimbursem5t 
= ess5tial retail ph>macies t are       
indep5d5t community ph>macies "u        
subp>agraph 7,c77v77,,ii74  7,,ii7      
,frequ5cy ( submission  7aa7 ,violations
 ( reasonable & relevant contract t]ms &
 conditions 7,,aa7 ,9 g5]al ,except z   
provid$ 9 subitem 7,,bb71 ! allegation  
submission process "u ?is clause %all   
all[ ph>macies to submit any allegations
 ( violations describ$ 9 item 7aa7 (    
subclause 7,i7 n m frequ5tly ?an once p]
 plan ye> p] contract betwe5 a ph>macy &
 a ,,pdp sponsor4 7,,bb7 ,allegations   
relat+ to contract *anges ,9 ! case :]e 
a contract is am5d$ or o!rwise updat$   
foll[+ ! submission ( allegations by a  
ph>macy ) respect to su* contract & plan
 ye>1 ! allegation submission process "u
 ?is clause %all all[ su* ph>macy to    
submit an additional allegation relat$  
to ^? *anges ) respect to su* contract &
 plan ye>4 7,,cc7 ,submissions          
,submissions ( any allegations "u ?is   

item %all be sep>ate f any submissions  
"u item 7bb7 & may include multiple     
allegations ( su* violations4  7bb7     
,violations ( ess5tial retail ph>macy   
protections 7,,aa7 ,9 g5]al ,!          
allegation submission process "u ?is    
clause %all all[ ess5tial retail        
ph>macies t are indep5d5t community     
ph>macies to submit any allegations (   
violations describ$ 9 item 7bb7 (       
subclause 7,i7 once p] cal5d> qu>t]4    
7,,bb7 ,submissions ,submissions ( any  
allegations "u ?is item %all be sep>ate 
f any submissions "u item 7aa7 & may    
include multiple allegations ( su*      
violations4  7,,iii7 ,access to relevant
 docum5ts & mat]ials ,a ,,pdp sponsor   
subject to an allegation "u ?is clause--
 7aa7 %all provide docum5ts or mat]ials1
 z specifi$ by ! ,secret>y1 includ+     
contract (f]s made by su* sponsor to su*
 ph>macy or correspond5ce relat$ to su* 
(f]s1 to ! ,secret>y at a "t & 9 a =m & 
mann] specifi$ by ! ,secret>y2 &  7bb7  
%all n prohibit or o!rwise limit !      

ability ( a ph>macy to submit su*       
docum5ts or mat]ials to ! ,secret>y = ! 
purpose ( submitt+ an allegation or     
provid+ evid5ce = su* an allegation "u  
?is clause4  7,,iv7 ,/&>diz$ template ,!
 ,secret>y %all e/abli% sep>ate /&>diz$ 
templates = ph>macies to use = !        
submission ( allegations describ$ 9     
items 7aa7 & 7bb7 ( subclause 7,i74 ,ea*
 su* template %all require t !          
submission include a c]tification by !  
ph>macy t ! in=mation includ$ is        
accurate1 complete1 & true to ! be/ ( ! 
k1 in=mation1 & belief ( su* ph>macy4   
7,v7 ,prev5t+ frivol\s allegations ,9 ! 
case :]e ! ,secret>y det]m9es t a       
ph>macy has submitt$ frivol\s           
allegations "u ?is clause on a r\t9e    
basis1 ! ,secret>y may tempor>ily       
prohibit su* ph>macy f us+ ! allegation 
submission process "u ?is clause1 z     
det]m9$ appropriate by ! ,secret>y4     
7,,vi7 ,exemption f ,fre$om ( ,in=mation
 ,act ,allegations submitt$ "u ?is      
clause %all be exempt f disclosure "u   

section #eeb ( title #e1 ,unit$ ,/ates  
,code4  7ii7 ,inve/igation ,! ,secret>y 
%all inve/igate1 z det]m9$ appropriate  
by ! ,secret>y1 allegations submitt$    
pursuant to clause 7i74  7iii7 ,en=cem5t
  7,i7 ,reasonable & relevant contract  
t]ms & conditions ,9 ! case :]e !       
,secret>y det]m9es t a ,,pdp sponsor    
(f]+ a prescription drug plan has       
violat$ ! /&>ds = reasonable & relevant 
contract t]ms & conditions "u           
subp>agraph 7,a77ii71 ! ,secret>y %all  
use exi/+ au?orities "u sections        
#aheg7;g7 & #ahfj;,d-#ab7;b77#c77;,e7 to
 impose civil monet>y p5alties or take  
o!r en=cem5t actions4  7,,ii7 ,ess5tial 
retail ph>macy protections ,9 ! case :]e
 ! ,secret>y det]m9es t a ,,pdp sponsor 
(f]+ a prescription drug plan has       
violat$ ! requirem5ts = total           
reimbursem5t = ess5tial retail ph>macies
 t are indep5d5t community ph>macies "u 
subp>agraph 7,c77v77,,ii71 ! ,secret>y  
%all-- 7aa7 if ! am\nt ( total          
reimbursem5t paid by ! sponsor to an    

ess5tial retail ph>macy t is an         
indep5d5t community ph>macy = a cov]$ "p
 ,d drug 0 less ?an ! am\nt ( total     
reimbursem5t requir$ to be paid to !    
ph>macy "u subp>agraph 7,c77v77,,ii7 =  
su* drug1 require ! ,,pdp sponsor to pay
 to ! ph>macy an am\nt equal to !       
diff]5ce betwe5 su* am\nts2 &  7bb7 use 
exi/+ au?orities "u section #aheg7;g7 & 
#ahfj;,d-#ab7;b77#c77;,e7 to impose     
civil monet>y p5alties or take o!r      
en=cem5t actions4  7,,iii7 ,application 
( civil monet>y p5alties ,! provisions (
 section #aabh;,a 7o!r ?an subsections  
7a7 & 7b77 %all apply to a civil monet>y
 p5alty "u ?is clause 9 ! same mann] z  
su* provisions apply to a p5alty or     
proce$+ "u section #aabh;,a7a74  7iv7   
,def9itions ,9 ?is subp>agraph1 ! t]ms  
ess5tial retail ph>macy1 indep5d5t      
community ph>macy1 & total reimbursem5t 
h ! mean+ giv5 ^? t]ms 9 subp>agraph    
7,c77v74  4  7#b7 ,con=m+ am5dm5t       
,section #aheg7;g77#a7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           

#aciew-#bg7;g77#a77 is am5d$-- 7,a7 9   
subp>agraph 7,j71 by /rik+ or aft] !    
semicolon2  7,b7 by r$esignat+          
subp>agraph 7,k7 z subp>agraph 7,l72    
7,c7 by ins]t+ aft] subp>agraph 7,j71 ! 
foll[+ new subp>agraph3  7,k7 fails to  
comply )-- 7i7 ! /&>ds = reasonable &   
relevant contract t]ms & conditions "u  
subp>agraph 7,a77ii7 ( section          
#ahfj;,d-#d7;b77#a72 or  7ii7 !         
requirem5ts = total reimbursem5t =      
ess5tial retail ph>macies t are         
indep5d5t community ph>macies "u        
subp>agraph 7,c77v77,,ii7 ( su* section2
 or  2  7,d7 9 subp>agraph 7,l71 z      
r$esignat$ by subp>agraph 7,b71 by /rik+
 ?r\gh 7,j7 & ins]t+ ?r\gh 7,k72 &  7,e7
 9 ! flu% matt] foll[+ subp>agraph 7,l71
 z s r$esignat$1 by /rik+ subp>agraphs  
7,a7 ?r\gh 7,k7 & ins]t+ subp>agraphs   
7,a7 ?r\gh 7,l74  7d7 ,acc\ntability (  
ph>macy b5efit manag]s = violations (   
reasonable & relevant contract t]ms &   
conditions & ess5tial retail ph>macy    
protections  7#a7 ,9 g5]al ,section     

#ahfj;,d-#ab7;b7 ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#aab7 is     
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#i7 ,acc\ntability ( ph>macy
 b5efit manag]s = violations (          
reasonable & relevant contract t]ms &   
conditions & ess5tial retail ph>macy    
protections ,= plan ye>s beg9n+ on or   
aft] ,janu>y #a1 #bjbh1 ea* contract    
ent]$ into ) a ,,pdp sponsor "u ?is "p )
 respect to a prescription drug plan    
(f]$ by su* sponsor %all provide t any  
ph>macy b5efit manag] act+ on behalf (  
su* sponsor has a writt5 agreem5t ) !   
,,pdp sponsor "u :i* ! ph>macy b5efit   
manag] agrees to reimburse ! ,,pdp      
sponsor = any am\nts paid by su* sponsor
 "u subclause 7,i7 or 7,,ii7 ( section  
#ahfj;,d-#d7;b77#a77;,f77iii7 z a result
 ( a violation describ$ 9 su* subclause 
7,i7 or 7,,ii7 if su* violation is      
relat$ to a responsibility delegat$ to !
 ph>macy b5efit manag] by su* ,,pdp     
sponsor4  4  7#b7 ,ma-pd plans ,section 
#aheg7;f77#c7 ( ! ,social ,security ,act

 7#db ,u4,s4,c4 #aciew-#bg7;f77#c77 is  
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,f7 ,acc\ntability (     
ph>macy b5efit manag]s = violations (   
reasonable & relevant contract t]ms &   
conditions & ess5tial retail ph>macy    
protections ,= plan ye>s beg9n+ on or   
aft] ,janu>y #a1 #bjbh1 section         
#ahfj;,d-#ab7;b77#i74  4  7e7 ,section  
#ahfj;,d-#db ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#aeb7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7e7 ,brief+ & report+ requirem5ts relat$
 to ph>macy price concessions "u ?is "p 
7#a7 ,brief+ requirem5ts ,! ,secret>y   
%all provide p]iodic brief+s to !       
,committee on ,f9ance ( ! ,s5ate1 !     
,committee on ,ways & ,means ( ! ,h\se (
 ,repres5tatives1 & ! ,committee on     
,en]gy & ,comm]ce ( ! ,h\se (           
,repres5tatives1 beg9n+ n lat] ?an #ij  
days aft] ! date ( enactm5t ( ?is       
subsection1 on implem5tation1 ov]sight1 
data collection1 & en=cem5t activities  
relat$ to ! adm9i/ration ( ! ,ph>macy   

,price ,concessions to ,drug ,prices at 
! ,po9t ( ,sale provisions codifi$ "u   
sections #dbc4ajj & #dbc4bcje ( title   
#db1 ,code ( ,f$]al ,regulations 7or any
 successor regulations71 z publi%$ 9 !  
,f$]al ,regi/] on ,may #i1 #bjbb1 9 !   
f9al rule entitl$ ,m$ic>e ,program2     
,contract ,ye> #bjbc ,policy & ,te*nical
 ,*anges to ! ,m$ic>e ,advantage &      
,m$ic>e ,prescription ,drug ,b5efit     
,programs2 ,policy & ,regulatory        
,revisions 9 ,response to ! ,,covid-#ai 
,public ,heal? ,em]g5cy2 ,additional    
,policy & ,regulatory ,revisions 9      
,response to ! ,,covid-#ai ,public      
,heal? ,em]g5cy4  7#b7 ,report+         
requirem5ts ,beg9n+ n lat] ?an #ij days 
aft] ! date ( enactm5t ( ?is subsection1
 & at lea/ once e plan ye> beg9n+       
!reaft] 7?r\gh plan ye> #bjbg71 !       
,secret>y %all develop & submit to      
,congress reports on ! activities       
specifi$ 9 p>agraph 7#a74  7#c7 ,cont5ts
 = brief+s & reports ,! brief+s requir$ 
"u p>agraph 7#a7 & reports requir$ "u   

p>agraph 7#b7 %all include in=mation    
on-- 7,a7 implem5tation1 ov]sight1 data 
collection1 & en=cem5t activities relat$
 to contract t]ms & conditions among    
,,pdp sponsors1 ,,ma organizations1 &   
ph>macies = ! purpose ( e/abli%+ or     
ma9ta9+ ph>macy network p>ticipation or 
pref]r$ ph>macy network p>ticipation2   
7,b7 patt]ns & tr5ds 9 su* t]ms &       
conditions1 to ! ext5t applicable2  7,c7
 implem5tation1 ov]sight1 & en=cem5t    
activities & developm5ts relat$ to      
assur+ ph>macy access "u section        
#ahfj;,d-#d7;b77#a71 along ) applicable 
regulations & program in/ruction or     
guidance2  7,d7 plans1 /rategies1       
initiatives1 or programmatic *anges     
und]tak5 by ! ,secret>y to prev5t1      
mitigate1 or o!rwise address /akehold]  
fe$back & conc]ns relat$ to conv5i5t    
ph>macy access = b5efici>ies "u ?is "p2 
&  7,e7 o!r issues det]m9$ appropriate  
by ! ,secret>y4  4  7f7 ,fund+ ,9       
addition to am\nts o!rwise available1   
!re is appropriat$ to ! ,c5t]s = ,m$ic>e

  ,m$icaid ,s]vices ,program ,managem5t 
,acc\nt1 out ( any money 9 ! ,treasury n
 o!rwise appropriat$1 #bej1jjj1jjj =    
fiscal ye> #bjbd1 to rema9 available    
until exp5d$1 to c>ry out ! am5dm5t made
 by ?is section4  #bjb4 ,ensur+ accurate
 paym5ts to ph>macies "u ,m$icaid  7a7  
,9 g5]al ,section #aibg7;f7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acifr-#h7;f77 is am5d$-- 7#a7 9        
p>agraph 7#a77;,a7-- 7,a7 by r$esignat+ 
clause 7ii7 z clause 7iii72 &  7,b7 by  
/rik+ & aft] ! semicolon at ! end (     
clause 7i7 & all t prec$es x ?r\gh 7#a7 
& ins]t+ ! foll[+3  7#a7 ,det]m9+       
ph>macy actual acquisition co/s ,!      
,secret>y %all conduct a survey ( retail
 community ph>macy drug prices &        
applicable non-retail ph>macy drug      
prices to det]m9e national av]age drug  
acquisition co/ b5*m>ks z foll[s3 7,a7  
,use ( v5dor ,! ,secret>y may contract  
s]vices =-- 7i7 ) respect to retail     
community ph>macies1 ! det]m9ation (    
retail survey prices ( ! national av]age

 drug acquisition co/ = cov]$ outpati5t 
drugs t repres5t a nationwide av]age (  
consum] pur*ase prices = su* drugs1 net 
( all disc\nts & rebates 7to ! ext5t any
 in=mation ) respect to su* disc\nts &  
rebates is available7 bas$ on a mon?ly  
survey ( su* ph>macies2  7ii7 ) respect 
to applicable non-retail ph>macies--    
7,i7 ! det]m9ation ( survey prices1     
sep>ate f ! survey prices describ$ 9    
clause 7i71 ( ! non-retail national     
av]age drug acquisition co/ = cov]$     
outpati5t drugs t repres5t a nationwide 
av]age ( consum] pur*ase prices = su*   
drugs1 net ( all disc\nts & rebates 7to 
! ext5t any in=mation ) respect to su*  
disc\nts & rebates is available7 bas$ on
 a mon?ly survey ( su* ph>macies2 &     
7,,ii7 at ! discretion ( ! ,secret>y1 = 
ea* type ( applicable non-retail ph>macy
 7z id5tifi$ pursuant to ! type         
indicators e/abli%$ by ! ,secret>y "u   
subsection 7k77#ab77;,b77ii771 !        
det]m9ation ( survey prices1 sep>ate f !
 survey prices describ$ 9 clause 7i7 or 

subclause 7,i7 ( ?is clause1 ( !        
national av]age drug acquisition co/ =  
su* type ( ph>macy = cov]$ outpati5t    
drugs t repres5t a nationwide av]age (  
consum] pur*ase prices = su* drugs1 net 
( all disc\nts & rebates 7to ! ext5t any
 in=mation ) respect to su* disc\nts &  
rebates is available7 bas$ on a mon?ly  
survey ( su* ph>macies2 &  2  7#b7 9    
subp>agraph 7,d7 ( p>agraph 7#a71 by    
/rik+ clauses 7ii7 & 7iii7 & ins]t+ !   
foll[+3  7ii7 ,! v5dor mu/ update !     
,secret>y no less (t5 ?an mon?ly on !   
survey prices = cov]$ outpati5t drugs4  
7iii7 ,! v5dor mu/ diff]5tiate1 9       
collect+ & report+ survey data1 !       
relevant ph>macy type indicator = all   
co/ in=mation collect$1 includ+ :e!r a  
ph>macy is own$ by1 op]at$ by1 or       
o!rwise affiliat$ ) a ph>macy b5efit    
manag] & :e!r a ph>macy is a retail     
community ph>macy or an applicable      
non-retail ph>macy1 &1 9 ! case ( an    
applicable non-retail ph>macy1 :i* type 
( applicable non-retail ph>macy 7z      

id5tifi$ pursuant to ! type indicators  
e/abli%$ by ! ,secret>y "u subsection   
7k77#ab77;,b77ii77 x is4  2  7#c7 by    
add+ at ! end ( p>agraph 7#a7 ! foll[+3 
7,f7 ,survey report+ ,9 ord] to meet !  
requirem5t ( section #aijb7;a77#ed71 a  
,/ate %all require t any retail         
community ph>macy or applicable         
non-retail ph>macy 9 ! ,/ate t receives 
any paym5t1 reimbursem5t1 adm9i/rative  
fee1 disc\nt1 or rebate relat$ to !     
disp5s+ ( cov]$ outpati5t drugs to      
individuals receiv+ b5efits "u ?is      
title1 reg>dless ( :e!r su* paym5t1     
reimbursem5t1 adm9i/rative fee1 disc\nt1
 or rebate is receiv$ f ! ,/ate or a    
manag$ c>e entity or o!r specifi$ entity
 7z su* t]ms are def9$ 9 section        
#aijc7m77#i77;,d77 directly or f a      
ph>macy b5efit manag] or ano!r entity t 
has a contract ) ! ,/ate or a manag$ c>e
 entity or o!r specifi$ entity 7z s     
def9$71 %all respond to surveys conduct$
 "u ?is p>agraph4  7,g7 ,survey         
in=mation ,in=mation on national drug   

acquisition prices obta9$ "u ?is        
p>agraph %all be made publicly available
 & %all include at lea/ ! foll[+3 7i7 ,!
 mon?ly response rate to ! survey       
includ+ a li/ ( ph>macies n 9 compliance
 ) subp>agraph 7,f74  7ii7 ,! sampl+    
frame & numb] ( ph>macies sampl$ mon?ly4
  7iii7 ,in=mation on price concessions 
to ! ph>macy1 includ+ disc\nts1 rebates1
 & o!r price concessions1 to ! ext5t t  
su* in=mation may be publicly releas$ & 
has be5 collect$ by ! ,secret>y z "p ( !
 survey4  7,h7 ,p5alties ,! ,secret>y1 9
 consultation ) ! ,(fice ( ! ,inspector 
,g5]al ( ! ,dep>tm5t ( ,heal? & ,human  
,s]vices1 %all en=ce ! provisions ( ?is 
p>agraph ) respect to a ph>macy ?r\gh ! 
e/abli%m5t ( appropriate civil monet>y  
p5alties1 :i* may be assess$ ) respect  
to ea* violation or survey non-response1
 & ) respect to ea* non-compliant       
ph>macy 7includ+ a ph>macy t is "p ( a  
*a971 until compliance ) ?is p>agraph   
has be5 complet$4 ,! provisions (       
section #aabh;,a 7o!r ?an subsections   

7a7 & 7b77 %all apply to a civil money  
p5alty "u ! prec$+ s5t5ce 9 ! same mann]
 z su* provisions apply to a civil money
 p5alty or proce$+ "u section           
#aabh;,a7a74  7,i7 ,limitation on use ( 
applicable non-retail ph>macy pric+     
in=mation ,no ,/ate %all use pric+      
in=mation report$ by applicable         
non-retail ph>macies "u p>agraph        
7#a77;,a77ii7 to develop or in=m        
reimbursem5t rates = retail community   
ph>macies4  2  7#d7 9 p>agraph 7#b7--   
7,a7 9 subp>agraph 7,a71 by ins]t+ 1    
includ+ paym5t rates "u manag$ c>e      
entities or o!r specifi$ entities 7z su*
 t]ms are def9$ 9 section               
#aijc7m77#i77;,d771 aft] "u ?is title2 &
  7,b7 9 subp>agraph 7,b71 by ins]t+ & !
 basis = su* disp5s+ fees be=e !        
semicolon2  7#e7 by r$esignat+ p>agraph 
7#d7 z p>agraph 7#e72  7#f7 by ins]t+   
aft] p>agraph 7#c7 ! foll[+ new         
p>agraph3  7#d7 ,ov]sight  7,a7 ,9 g5]al
 ,! ,inspector ,g5]al ( ! ,dep>tm5t (   
,heal? & ,human ,s]vices %all conduct   

p]iodic /udies ( ! survey data report$  
"u ?is subsection1 z appropriate1       
includ+ ) respect to sub/antial         
v>iations 9 acquisition co/s or o!r     
applicable co/s1 z well z ) respect to  
h[ int]nal transf] prices & relat$ p>ty 
transactions may influ5ce ! co/s report$
 by ph>macies affiliat$ ) ph>macy b5efit
 manag]s1 :olesal]s1 di/ributors1 & o!r 
entities t acquire cov]$ outpati5t drugs
 relative to co/s report$ by ph>macies n
 affiliat$ ) su* entities4 ,! ,inspector
 ,g5]al %all provide p]iodic updates to 
,congress on ! results ( su* /udies1 z  
appropriate1 9 a mann] t does n disclose
 trade secrets or o!r propriet>y        
in=mation4  7,b7 ,appropriation ,!re is 
appropriat$ to ! ,inspector ,g5]al ( !  
,dep>tm5t ( ,heal? & ,human ,s]vices1   
out ( any money 9 ! ,treasury n o!rwise 
appropriat$1 #e1jjj1jjj = fiscal ye>    
#bjbd1 to rema9 available until exp5d$1 
to c>ry out ?is p>agraph4  2 &  7#g7 9  
p>agraph 7#e71 z s r$esignat$1 by ins]t+
 1 & #i1jjj1jjj = fiscal ye> #bjbd & ea*

 fiscal ye> !reaft]1 aft] #bjaj4  7b7   
,def9itions ,section #aibg7k7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acifr-#h7k77 is am5d$ by add+ !        
foll[+--  7#ab7 ,applicable non-retail  
ph>macy  7,a7 ,9 g5]al ,! t]m applicable
 non-retail ph>macy means a ph>macy t is
 lic5s$ z a ph>macy by ! ,/ate & t is n 
a retail community ph>macy1 includ+ a   
ph>macy t disp5ses prescription         
m$ications to pati5ts prim>ily ?r\gh    
mail & specialty ph>macies4 ,su* t]m    
does n include nurs+ home ph>macies1    
long-t]m c>e facility ph>macies1        
hospital ph>macies1 cl9ics1 *>itable or 
n-=-pr(it ph>macies1 gov]nm5t ph>macies1
 or l[ disp5s+ ph>macies 7z def9$ by !  
,secret>y74  7,b7 ,id5tification (      
applicable non-retail ph>macies  7i7 ,9 
g5]al ,= purposes ( subsection 7f71 !   
,secret>y %all1 n lat] ?an ,janu>y #a1  
#bjbe1 9 consultation ) /akehold]s z    
appropriate1 issue guidance specify+    
ph>macies t meet ! def9ition (          
applicable non-retail ph>macies & t w be

 subject to ! survey requirem5ts "u     
subsection 7f77#a74  7ii7 ,inclusion (  
ph>macy type indicators ,! guidance     
promulgat$ "u clause 7i7 %all include   
ph>macy type indicators to di/+ui%      
betwe5 diff]5t types ( applicable       
non-retail ph>macies1 su* z ph>macies t 
disp5se prescriptions prim>ily ?r\gh !  
mail & ph>macies t disp5se prescriptions
 t require special h&l+ or di/ribution4 
,an applicable non-retail ph>macy may be
 id5tifi$ ?r\gh multiple ph>macy type   
indicators4  7#ac7 ,ph>macy b5efit      
manag] ,! t]m ph>macy b5efit manag]     
means any p]son or entity t1 ei!r       
directly or ?r\gh an int]m$i>y1 acts z a
 price negotiator or gr\p pur*as] on    
behalf ( a ,/ate1 manag$ c>e entity or  
o!r specifi$ entity 7z su* t]ms are     
def9$ 9 section #aijc7m77#i77;,d771 or  
manages ! prescription drug b5efits     
provid$ by su* ,/ate1 manag$ c>e entity1
 or o!r specifi$ entity1 includ+ !      
process+ & paym5t ( claims =            
prescription drugs1 ! p]=mance ( drug   

utilization review1 ! process+ ( drug   
prior au?orization reque/s1 ! manag+ (  
appeals or grievances relat$ to !       
prescription drug b5efits1 contract+ )  
ph>macies1 controll+ ! co/ ( cov]$      
outpati5t drugs1 or ! provision (       
s]vices relat$ !reto4 ,su* t]m includes 
any p]son or entity t c>ries out #a or m
 ( ! activities describ$ 9 ! prec$+     
s5t5ce1 irrespective ( :e!r su* p]son or
 entity calls itself a ph>macy b5efit   
manag]4  4  7c7 ,effective date ,!      
am5dm5ts made by ?is section take effect
 on ! fir/ day ( ! fir/ qu>t] t beg9s on
 or aft] ! date t is #ah mon?s aft] !   
date ( enactm5t ( ?is ,act4  #bjc4      
,protect+ s5iors f excessive co/-%>+ =  
c]ta9 m$ic9es ,section #ahfj;,d-#b ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#ajb7 is am5d$-- 7#a7 9          
subsection 7b7-- 7,a7 9 p>agraph        
7#b77;,a71 9 ! matt] prec$+ clause 7i71 
by /rik+ & 7#i7 & ins]t+ 1 7#i71 7#aj71 
& 7#aa72 &  7,b7 by add+ at ! end !     
foll[+ new p>agraphs3  7#aj7 ,ty+       

co/-%>+ to net price = c]ta9 m$ications 
7,a7 ,9 g5]al ,= plan ye>s beg9n+ on or 
aft] ,janu>y #a1 #bjbh1 = co/s above !  
annual d$uctible specifi$ 9 p>agraph    
7#a7 & bel[ ! annual out-(-pocket       
?re%old specifi$ 9 p>agraph 7#d71 any   
co9surance am\nt = a disc\nt-eligible   
drug t is includ$ on ! plan's =mul>y &  
subject to co9surance r ?an a copaym5t  
%all be calculat$ bas$ on ! net price ( 
su* disc\nt-eligible drug4  7,b7        
,report+ to ! ,secret>y ,= plan ye>s    
beg9n+ on or aft] ,janu>y #a1 #bjbh1 a  
,,pdp sponsor ( a prescription drug plan
 & an ,,ma organization (f]+ an         
,,ma-,,pd plan %all annually submit to !
 ,secret>y1 9 a =m & mann] det]m9$      
appropriate by ! ,secret>y-- 7i7        
approximate price concessions & net     
prices = ea* disc\nt-eligible drug2 &   
7ii7 a writt5 explanation ( ! me?odology
 us$ to calculate su* approximate price 
concessions & net prices4  7,c7         
,requirem5ts = approximate price        
concessions  7i7 ,9 g5]al ,approximate  

price concessions submitt$ "u           
subp>agraph 7,b7 %all comply )-- 7,i7 ! 
drug-specific ?re%old "u clause 7ii7 = !
 applicable plan ye>2 &  7,,ii7 !       
aggregate ?re%old "u clause 7iii7 = !   
applicable plan ye>4  7ii7 ,?re%olds    
7,i7 ,plan ye>s #bjbh ?r\gh #bjcb ,=    
plan ye>s #bjbh ?r\gh #bjcb-- 7aa7 !    
drug-specific ?re%old is #bj p]c5t2 &   
7bb7 ! aggregate ?re%old is #ae p]c5t4  
7,,ii7 ,subsequ5t plan ye>s  7aa7 ,9    
g5]al ,= plan ye>s beg9n+ ) #bjcc1 !    
,secret>y may1 z det]m9$ appropriate by 
! ,secret>y1 adju/ ! drug-specific &    
aggregate ?re%olds "u ?is clause4  7bb7 
,consid]ations ,9 mak+ any su*          
adju/m5ts1 ! ,secret>y may consid]      
hi/orical v>iations 9 expect$ & actual  
manufactur] price concessions = cov]$ "p
 ,d drugs1 factors t may result 9       
manufactur] price concession unc]ta9ty  
or v>iation 9 a giv5 plan ye>1 ,,pdp    
sponsor & ,,ma organization behavioral  
responses1 effects ( precise manufactur]
 price concession disclosures1 b5efici>y

 out-(-pocket co/s1 exp5ditures "u ?is  
"p1 & o!r factors det]m9$ appropriate by
 ! ,secret>y4  7cc7 ,requirem5ts ,9 mak+
 any su* adju/m5ts1 ! ,secret>y %all    
ensure t ! aggregate ?re%old = an       
applicable plan ye> is l[] ?an !        
drug-specific ?re%old = su* applicable  
plan ye>4  7dd7 ,publication ,!         
,secret>y %all publi% any adju/m5ts to !
 drug-specific & aggregate ?re%olds "u  
?is clause no lat] ?an ! fir/ ,monday ( 
,april ( ! ye> be=e ! />t ( ! plan ye> =
 :i* su* adju/$ ?re%olds are applicable4
  7,d7 ,publication ( disc\nt-eligible  
drugs ,n lat] ?an #ae mon?s be=e ! />t (
 ea* plan ye> 7beg9n+ ) plan ye> #bjbh71
 ! ,secret>y %all publi% on a publicly  
available website a li/ ( !             
disc\nt-eligible drugs t apply ) respect
 to su* plan ye> 7z det]m9$ by !        
,secret>y "u subp>agraph 7,f77iv774     
7,e7 ,en=cem5t  7i7 ,monitor+ compliance
 ,! ,secret>y1 9 consultation ) ! ,(fice
 ( ! ,inspector ,g5]al1 %all conduct    
p]iodic audits ( prescription drug plans

 & ,,ma-,,pd plans to monitor compliance
 ) ! requirem5ts "u ?is p>agraph4 ,all  
in=mation report$ by a ,,pdp sponsor or 
,,ma organization "u ?is p>agraph may be
 subject to audit by ! ,secret>y & !    
,(fice ( ! ,inspector ,g5]al4  7ii7     
,p5alties  7,i7 ,9 g5]al ,a ,,pdp       
sponsor or an ,,ma organization t       
violates ! requirem5ts "u ?is p>agraph  
may be subject to civil monet>y         
p5alties1 consi/5t ) sections #aheg7;g7 
& #ahfj;,d-#ab7;b77#c77;,e71 z det]m9$  
appropriate by ! ,secret>y4  7,,ii7     
,application ,! provisions ( section    
#aabh;,a 7o!r ?an subsections 7a7 & 7b77
 %all apply to a civil monet>y p5alty "u
 ?is clause 9 ! same mann] z su*        
provisions apply to a p5alty or proce$+ 
"u section #aabh;,a7a74  7,f7           
,def9itions ,9 ?is p>agraph3 7i7 ,actual
 price concessions ,! t]m actual price  
concessions means1 ) respect to a cov]$ 
"p ,d drug1 ! am\nt ( manufactur] price 
concessions t ! ,,pdp sponsor or ,,ma   
organization reports = su* drug 9 !     

,detail$ ,,dir ,report 7or successor    
report7 = ! applicable plan ye>4  7ii7  
,aggregate ?re%old ,! t]m aggregate     
?re%old means ! maximum p]c5tage by :i* 
! total approximate price concessions = 
all disc\nt-eligible drugs may v>y f !  
total actual manufactur] price          
concessions = all su* disc\nt-eligible  
drugs z report$ 9 ! ,detail$ ,,dir      
,report 7or successor report7 = !       
applicable plan ye>4  7iii7 ,approximate
 price concessions ,! t]m approximate   
price concessions means1 ) respect to a 
cov]$ "p ,d drug1 ! am\nt ( price       
concessions f manufactur]s t ! ,,pdp    
sponsor or ,,ma organization e/imates x 
w receive ) respect to an applicable    
plan ye>1 subject to ! ?re%olds e/abli%$
 "u subp>agraph 7,c77ii71 & reflect$ 9 !
 net price4  7iv7 ,disc\nt-eligible drug
  7,i7 ,9 g5]al ,! t]m disc\nt-eligible 
drug means a cov]$ "p ,d drug 7o!r ?an a
 cov]$ "p ,d drug describ$ 9 p>agraph   
7#h7 or 7#i77-- 7aa7 t is 9 an          
applicable category or class describ$ 9 

subclause 7,,ii72 &  7bb7 = :i* !       
aggregate manufactur] price concessions 
receiv$ by ,,pdp sponsors & ,,ma        
organizations 7or ph>macy b5efit manag]s
 act+ on behalf ( su* sponsors or       
organizations7 = su* drug are equal to  
or exce$ #ej p]c5t ( aggregate gross    
cov]$ prescription drug co/s = su* drug 
9 ! mo/ rec5t plan ye> = :i* data is    
available1 z det]m9$ by ! ,secret>y bas$
 on previ\s submissions ( ,detail$ ,,dir
 ,reports 7or successor reports7 or o!r 
relevant report+ f ,,pdp sponsors or    
,,ma organizations4  7,,ii7 ,applicable 
category or class ,! applicable         
categories & classes describ$ 9 ?is     
subclause are ! foll[+1 z specifi$ by ! 
,unit$ ,/ates ,ph>macopeia3 7aa7        
,anti-inflammatories 7,inhal$           
,cortico/]oids74  7bb7 ,bron*odilators1 
,anti*ol9]gic4  7cc7 ,bron*odilators1   
,sympa?omimetic4  7dd7 ,respiratory     
tract ag5ts4  7ee7 ,anticoagulants4     
7ff7 ,c>diovascul> ag5ts4  7v7          
,drug-specific ?re%old ,! t]m           

drug-specific ?re%old means ! maximum   
p]c5tage by :i* approximate price       
concessions ) respect to a              
disc\nt-eligible drug may v>y f ! actual
 manufactur] price concessions = su*    
drug1 z report$ 9 ! ,detail$ ,,dir      
,report 7or successor report7 = !       
applicable plan ye>4  7vi7 ,net price ,!
 t]m net price means1 ) respect to a    
cov]$ "p ,d drug1 ! negotiat$ price (   
su* drug1 net ( all approximate price   
concessions 7e/imat$ on an av]age       
p]-unit basis1 z ne$$7 n already        
reflect$ 9 ! negotiat$ price = !        
applicable plan ye>4  7vii7 ,manufactur]
 price concessions ,! t]m manufactur]   
price concessions means1 ) respect to a 
cov]$ "p ,d drug1 rebates t ! ,,pdp     
sponsor or ,,ma organization receives f 
manufactur]s4  7,g7 ,nonapplication (   
,pap]work ,r$uction ,act ,*apt] #ce (   
title #dd1 ,unit$ ,/ates ,code1 %all n  
apply to any data collection und]tak5 by
 ! ,secret>y "u ?is p>agraph4  7#aa7    
,limit+ co/-%>+ to net price  7,a7 ,9   

g5]al ,= plan ye>s beg9n+ on or aft]    
,janu>y #a1 #bjbh1 ! co/-%>+ 7= co/s    
above ! annual d$uctible specifi$ 9     
p>agraph 7#a77 = a cov]$ "p ,d drug 7o!r
 ?an a cov]$ "p ,d drug describ$ 9      
p>agraph 7#h7 or 7#i77 %all n exce$ !   
negotiat$ price = su* cov]$ "p ,d drug  
net ( all price concessions 7z def9$ 9  
p>agraph 7#aj77;,f77v771 z report$ 9 !  
,detail$ ,,dir ,report 7or successor    
report7 = ! applicable plan ye>4  7,b7  
,en=cem5t  7i7 ,monitor+ compliance ,!  
,secret>y %all monitor compliance ) !   
requirem5ts "u subp>agraph 7,a7 on an   
ongo+ basis1 includ+ ?r\gh p]iodic      
audits4  7ii7 ,retroactive p5alties     
7,i7 ,9 g5]al ,a ,,pdp sponsor or an    
,,ma organization t violates !          
requirem5ts "u subp>agraph 7,a7 may be  
subject to civil monet>y p5alties1      
consi/5t ) sections #aheg7;g7 &         
#ahfj;,d-#ab7;b77#c77;,e71 z det]m9$    
appropriate by ! ,secret>y4 ,! ,secret>y
 may impose su* p5alties retroactively  
^u review ( ! ,detail$ ,,dir ,report 7or

 any successor report7 ) respect to a   
giv5 plan ye>4  7,,ii7 ,application ,!  
provisions ( section #aabh;,a 7o!r ?an  
subsections 7a7 & 7b77 %all apply to a  
civil monet>y p5alty "u ?is clause 9 !  
same mann] z su* provisions apply to a  
p5alty or proce$+ "u section            
#aabh;,a7a74  7#ab7 ,,gao /udy & report 
on implem5tation & effects ( co/-%>+    
relief provisions  7,a7 ,/udy ,!        
,comptroll] ,g5]al ( ! ,unit$ ,/ates 79 
?is p>agraph ref]r$ to z ! ,comptroll]  
,g5]al7 %all conduct a /udy on c]ta9    
effects ( ! implem5tation ( !           
requirem5ts specifi$ "u ! provisions (  
p>agraphs 7#aj7 & 7#aa74  7,b7 ,report  
,once ! data & in=mation ne$$ to conduct
 ! /udy describ$ 9 subp>agraph 7,a7 has 
become available & ! ,comptroll] ,g5]al 
has _h suffici5t opportunity to review &
 analyze su* data & in=mation1 !        
,comptroll] ,g5]al %all develop & publi%
 a report on ! f9d+s ( su* /udy1 includ+
 ) respect to ! foll[+3 7i7 ,effects on 
enrollee co/-%>+1 utilization & adh]5ce1

 =mul>y cov]age & placem5t1 &           
utilization managem5t ) respect to      
affect$ cov]$ "p ,d drugs               
7disc\nt-eligible drugs & cov]$ "p ,d   
drugs = :i*1 prior to implem5tation (   
su* provisions1 co/-%>+ exce$$ net price
 = "s b5efici>ies74  7ii7 ,*anges to    
ph>macy reimbursem5t me?odologies &     
levels1 if any1 ) respect to            
disc\nt-eligible drugs4  7iii7 ,*anges 9
 manufactur] rebat+ levels 7relative to 
gross co/s7 = disc\nt-eligible drugs4   
7iv7 ,o!r behavioral responses by ,,pdp 
sponsors1 enrollees1 manufactur]s1      
ph>macies1 or o!r entities relat$ to !  
implem5tation ( su* provisions4  7v7    
,effects ( su* provisions on enrollee   
premiums & ,f$]al outlays4  7vi7 ,o!r   
issues det]m9$ appropriate by !         
,comptroll] ,g5]al4  7,c7 ,subsequ5t    
reports ,! ,comptroll] ,g5]al may1 z    
det]m9$ appropriate1 conduct subsequ5t  
/udies & produce subsequ5t reports )    
respect to ! ongo+ implem5tation &      
effects ( ! provisions ( p>agraphs 7#aj7

 & 7#aa74  2 &  7#b7 9 subsection 7c71  
by add+ at ! end ! foll[+ new p>agraphs3
  7#g7 ,ty+ co/-%>+ to net price = c]ta9
 drugs ,! cov]age is provid$ 9          
accordance ) subsection 7b77#aj74  7#h7 
,limit+ co/-%>+ to net price ,! cov]age 
is provid$ 9 accordance ) subsection    
7b77#aa74  4  ,,iii ,m$icaid ,expir+    
,provisions  #cja4 ,delay+ c]ta9        
disproportionate %>e hospital paym5t    
r$uctions "u ! ,m$icaid program ,section
 #aibc7;f77#g77;,a7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#acifr-#d7;f77#g77;,a771 z am5d$ by     
section #bcda ( title ,,iii ( division  
,b ( ! ,cont9u+ ,appropriations ,act1   
#bjbd & ,o!r ,ext5sions ,act 7,public   
,law #aah-ae71 is fur!r am5d$-- 7#a7 9  
clause 7i7-- 7,a7 9 ! matt] prec$+      
subclause 7,i71 by /rik+ ,= ! p]iod     
beg9n+ & all t foll[s ?r\gh #bjbg &     
ins]t+ ,= ea* ( fiscal ye>s #bjbf &     
#bjbg2 &  7,b7 9 subclauses 7,i7 &      
7,,ii71 by /rik+ or p]iod ea* place x   
appe>s2 &  7#b7 9 clause 7ii71 by /rik+ 

= ! p]iod beg9n+ & all t foll[s ?r\gh   
#bjbg & ins]t+ = ea* ( fiscal ye>s #bjbf
 & #bjbg4  #cjb4 ,ext5sion ( ,/ate      
option to provide m$ical assi/ance =    
c]ta9 individuals :o are pati5ts 9 c]ta9
 in/itutions = m5tal diseases  7a7 ,mak+
 p]man5t ,/ate ,plan ,am5dm5t ,option   
,to ,provide ,m$ical ,assi/ance = ,c]ta9
 ,individuals ,:o ,are ,pati5ts 9 ,c]ta9
 ,in/itutions = ,m5tal ,diseases        
,section #aiae7l77#a7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acifn7l77#a77 is am5d$ by /rik+ ,)     
respect to cal5d> qu>t]s beg9n+ dur+ !  
p]iod beg9n+ ,octob] #a1 #bjai1 & end+  
,septemb] #cj1 #bjbc1 & ins]t+ ,)       
respect to cal5d> qu>t]s beg9n+ on or   
aft] ,octob] #a1 #bjai14  7b7 ,ma9t5ance
 ( ef=t revision ,section #aiae7l77#c7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acifn7l77#c77 is am5d$-- 7#a7 9       
subp>agraph 7,a7-- 7,a7 9 ! matt] prec$+
 clause 7i71 by /rik+ o!r ?an "u ?is    
title2 &  7,b7 9 clause 7i71 by /rik+   
or1 if high]1 & all t foll[s ?r\gh 9    

accordance ) ?is subsection2 &  7#b7 by 
add+ at ! end ! foll[+ new subp>agraph3 
7,d7 ,application ( ma9t5ance ( ef=t    
requirem5ts to c]ta9 ,/ates ,9 ! case ( 
a ,/ate ) a ,/ate plan am5dm5t 9 effect 
z ( ,septemb] #cj1 #bjbc1 = ! #a-ye>    
p]iod beg9n+ on ! date ( enactm5t ( ?is 
subp>agraph1 ! provisions ( subp>agraph 
7,a7 %all be appli$ z if ! am5dm5ts to t
 subp>agraph made by ! ,bett] ,m5tal    
,heal? ,c>e1 ,l[]-,co/ ,drugs1 &        
,ext5d]s ,act ( #bjbc _h nev] be5 made4 
4  7c7 ,additional requirem5ts  7#a7 ,9 
g5]al ,section #aiae7l77#d7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acifn7l77#d77 is am5d$-- 7,a7 9        
subp>agraph 7,a71 by /rik+ ?r\gh 7,d7 & 
ins]t+ ?r\gh 7,f72  7,b7 9 subp>agraph  
7,d71 by add+ at & bel[ clause          
7ii77,,ii71 ! foll[+ flu% s5t5ce3 ,)    
respect to cal5d> qu>t]s beg9n+ on or   
aft] ,octob] #a1 #bjbe1 ! ,/ate %all h 9
 place evid5ce-bas$1 sub/ance use       
disord]-specific individual placem5t    
crit]ia & utilization managem5t         

approa*es to ensure placem5t ( an       
eligible individual 9 an appropriate    
level ( c>e &1 prior to ! approval ( a  
,/ate plan am5dm5t = :i* approval is    
s\ght on or aft] su* date1 %all notify !
 ,secret>y ( h[ ! ,/ate w ensure t !    
requirem5ts ( clauses 7i7 & 7ii7 w be   
met4 2 &  7,c7 by add+ at ! end ! foll[+
 new subp>agraph3  7,e7 ,review process 
,) respect to cal5d> qu>t]s beg9n+ on or
 aft] ,octob] #a1 #bjbe1 ! ,/ate %all h 
9 place a process to review ! compliance
 ( eligible in/itutions = m5tal diseases
 ) nationally recogniz$1 evid5ce-bas$1  
sub/ance use disord]-specific program   
/&>ds specifi$ by ! ,/ate4  4  7#b7     
,"o-"t assessm5t ,section #aiae7l77#d7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acifn7l77#d771 z am5d$ by p>agraph    
7#a71 is fur!r am5d$ by add+ at ! end ! 
foll[+ new subp>agraph3  7,f7 ,assessm5t
  7i7 ,9 g5]al ,! ,/ate %all1 n lat] ?an
 #ab mon?s aft] ! approval ( a ,/ate    
plan am5dm5t describ$ 9 ?is subsection  
7or1 9 ! case su* ,/ate has su* an      

am5dm5t approv$ z ( ,septemb] #cj1      
#bjbc1 n lat] ?an #ab mon?s aft] ! date 
( enactm5t ( ?is subp>agraph71 comm5ce  
an assessm5t (-- 7,i7 ! availability =  
individuals enroll$ "u a ,/ate plan "u  
?is title 7or waiv] ( su* plan7 (       
treatm5t 9-- 7aa7 ea* level ( c>e       
describ$ 9 clause 7i7 ( subp>agraph     
7,c72 &  7bb7 ea* level ( c>e describ$ 9
 clause 7ii7 ( subp>agraph 7,c7 at :i* !
 ,/ate provides m$ical assi/ance2 &     
7,,ii7 ! availability ( m$ication-assi/$
 treatm5t & m$ically sup]vis$ )drawal   
managem5t s]vices = su* individuals4    
7ii7 ,requir$ completion ,! ,/ate %all  
complete ! assessm5t describ$ 9 clause  
7i7 n lat] ?an #ab mon?s aft] ! date !  
,/ate comm5ces su* assessm5t4  4  7#c7  
,cl>ification ( levels ( c>e ,section   
#aiae7l77#g77;,a7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acifn7l77#g77;,a77 
is am5d$ by ins]t+ 7or any successor    
publication7 be=e ! p]iod4  ,,iv ,m$ic>e
 ,expir+ ,provisions & ,provid] ,paym5t 
,*anges  #dja4 ,ext5sion ( fund+ =      

quality measure endorsem5t1 input1 &    
selection ,section #ahij7;d77#b7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acie;aaa7d77#b77 is am5d$-- 7#a7 9 !   
fir/ s5t5ce-- 7,a7 by /rik+ &           
#bj1jjj1jjj & ins]t+ #bj1jjj1jjj2 &     
7,b7 by ins]t+ ! foll[+ be=e ! p]iod at 
! end3 1 & #bj1jjj1jjj = fiscal ye>     
#bjbd2 &  7#b7 9 ! ?ird s5t5ce1 by /rik+
 & #bjbc & ins]t+ #bjbc1 & #bjbd4  #djb4
 ,ext5sion ( fund+ outrea* & assi/ance =
 l[-income programs  7a7 ,/ate heal?    
insurance assi/ance programs ,subsection
 7a77#a77;,b7 ( section #aai ( ! ,m$ic>e
 ,improvem5ts = ,pati5ts & ,provid]s    
,act ( #bjjh 7#db ,u4,s4,c4 #acie;b-#c  
note71 z am5d$ by section #ccjf ( !     
,pati5t ,protection & ,af=dable ,c>e    
,act 7,public ,law #aaa-adh71 section   
#faj ( ! ,am]ican ,taxpay] ,relief ,act 
( #bjab 7,public ,law #aab-bdj71 section
 #aaaj ( ! ,pa?way = ,,sgr ,re=m ,act ( 
#bjac 7,public ,law #aac-fg71 section   
#aaj ( ! ,protect+ ,access to ,m$ic>e   
,act ( #bjad 7,public ,law #aac-ic71    

section #bjh ( ! ,m$ic>e ,access & ,,*ip
 ,reau?orization ,act ( #bjae 7,public  
,law #aad-aj71 section #ejbjg ( division
 ,e ( ! ,bip>tisan ,budget ,act ( #bjah 
7,public ,law #aae-abc71 section #adjb (
 division ,b ( ! ,cont9u+               
,appropriations ,act1 #bjbj1 & ,heal?   
,ext5d]s ,act ( #bjai 7,public ,law     
#aaf-ei71 section #adjb ( division ,b ( 
! ,fur!r ,cont9u+ ,appropriations ,act1 
#bjbj1 & ,fur!r ,heal? ,ext5d]s ,act (  
#bjai 7,public ,law #aaf-fi71 section   
#ajc ( division ,n ( ! ,fur!r           
,consolidat$ ,appropriations ,act1 #bjbj
 7,public ,law #aaf-id71 section #chjc (
 ! ,,c>es ,act 7,public ,law #aaf-acf71 
section #bbjc ( ! ,cont9u+              
,appropriations ,act1 #bjba & ,o!r      
,ext5sions ,act 7,public ,law #aaf-aei71
 section #aajb ( ! ,fur!r ,cont9u+      
,appropriations ,act1 #bjba1 & ,o!r     
,ext5sions ,act 7,public ,law #aaf-bae71
 & section #ajc ( division ,,cc ( !     
,consolidat$ ,appropriations ,act1 #bjba
 7,public ,law #aaf-bfj71 is am5d$--    

7#a7 9 ! matt] prec$+ clause 7i71 by    
/rik+ ,c5t]s = ,m$ic>e  ,m$icaid        
,s]vices ,program ,managem5t ,acc\nt &  
ins]t+ ,adm9i/ration = ,community ,liv+2
  7#b7 9 clause 7xii71 by /rik+ & at !  
end2  7#c7 9 clause 7xiii71 by /rik+ !  
p]iod at ! end & ins]t+ 2 &2 &  7#d7 by 
ins]t+ aft] clause 7xiii7 ! foll[+ new  
clause3  7xiv7 = fiscal ye> #bjbd1      
#ae1jjj1jjj4  4  7b7 ,area ag5cies on   
ag+ ,subsection 7b77#a77;,b7 ( su*      
section #aai1 z s am5d$1 is am5d$-- 7#a7
 9 clause 7xii71 by /rik+ & at ! end2   
7#b7 9 clause 7xiii71 by /rik+ ! p]iod  
at ! end & ins]t+ 2 &2 &  7#c7 by ins]t+
 aft] clause 7xiii7 ! foll[+ new clause3
  7xiv7 = fiscal ye> #bjbd1 #ae1jjj1jjj4
  4  7c7 ,ag+ & disability res\rce c5t]s
 ,subsection 7c77#a77;,b7 ( su* section 
#aai1 z s am5d$1 is am5d$-- 7#a7 9      
clause 7xii71 by /rik+ & at ! end2  7#b7
 9 clause 7xiii71 by /rik+ ! comma at ! 
end & ins]t+ 2 &2 &  7#c7 by ins]t+ aft]
 clause 7xiii7 ! foll[+ new clause3     
7xiv7 = fiscal ye> #bjbd1 #e1jjj1jjj4  4

  7d7 ,coord9ation ( ef=ts to in=m old] 
am]icans ab\t b5efits available "u      
,f$]al & ,/ate programs ,subsection     
7d77#b7 ( su* section #aai1 z s am5d$1  
is am5d$-- 7#a7 9 clause 7xii71 by /rik+
 & at ! end2  7#b7 9 clause 7xiii71 by  
/rik+ ! p]iod at ! end & ins]t+ 2 &2 &  
7#c7 by ins]t+ aft] clause 7xiii7 !     
foll[+ new clause3  7xiv7 = fiscal ye>  
#bjbd1 #ae1jjj1jjj4  4  #djc4 ,ext5sion 
( ! "w geographic index floor "u !      
,m$ic>e program ,section                
#ahdh7;e77#a77;,e7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#d7;e77#a77;,e77 is am5d$ by     
/rik+ ,janu>y #a1 #bjbd & ins]t+ ,janu>y
 #a1 #bjbe4  #djd4 ,ext5d+ inc5tive     
paym5ts = p>ticipation 9 eligible       
alt]native paym5t models  7a7 ,9 g5]al  
,section #ahcc7z7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciel7z77 is       
am5d$-- 7#a7 9 p>agraph 7#a77;,a7-- 7,a7
 by /rik+ ) #bjbe & ins]t+ ) #bjbf2 &   
7,b7 by ins]t+ 1 or1 ) respect to #bjbf1
 #a4ge p]c5t aft] #c4e p]c5t4  7#b7 9   

p>agraph 7#b7-- 7,a7 9 subp>agraph      
7,b7-- 7i7 9 ! head]1 by /rik+ #bjbe &  
ins]t+ #bjbf2 &  7ii7 9 ! matt] prec$+  
clause 7i71 by /rik+ #bjbe & ins]t+     
#bjbf2  7,b7 9 subp>agraph 7,c7-- 7i7 9 
! head]1 by /rik+ #bjbf & ins]t+ #bjbg2 
&  7ii7 9 ! matt] prec$+ clause 7i71 by 
/rik+ #bjbf & ins]t+ #bjbg2 &  7,c7 9   
subp>agraph 7,d71 by /rik+ & #bjbe &    
ins]t+ #bjbe1 & #bjbf2 &  7#c7 9        
p>agraph 7#d77;,b71 by ins]t+ 1 or1 )   
respect to #bjbf1 #a4ge p]c5t aft] #c4e 
p]c5t4  7b7 ,con=m+ am5dm5ts ,section   
#ahdh7q77#a77;,c77iii7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7q77#a77;,c77iii77 is am5d$--  
7#a7 9 subclause 7,,ii71 by /rik+ #bjbe 
& ins]t+ #bjbf2 &  7#b7 9 subclause     
7,,iii71 by /rik+ #bjbf & ins]t+ #bjbg4 
#dje4 ,paym5t rates = durable m$ical    
equipm5t "u ! ,m$ic>e ,program  7a7     
,areas o!r ?an rural & noncontigu\s     
areas ,! ,secret>y %all implem5t section
 #dad4baj7;g77#i77v7 ( title #db1 ,code 
( ,f$]al ,regulations 7or any successor 

regulation71 to apply ! transition rule 
describ$ 9 ! fir/ s5t5ce ( su* section  
to all applicable items & s]vices       
furni%$ 9 areas o!r ?an rural or        
noncontigu\s areas 7z su* t]ms are def9$
 = purposes ( su* section7 ?r\gh        
,decemb] #ca1 #bjbd4  7b7 ,all areas ,! 
,secret>y %all n implem5t section       
#dad4baj7;g77#i77vi7 ( title #db1 ,code 
( ,f$]al ,regulations 7or any successor 
regulation7 until ,janu>y #a1 #bjbe4    
7c7 ,implem5tation ,not)/&+ any o!r     
provision ( law1 ! ,secret>y may        
implem5t ! provisions ( ?is section by  
program in/ruction or o!rwise4  #djf4   
,ext5d+ ! indep5d5ce at home m$ical     
practice demon/ration program "u !      
,m$ic>e program  7a7 ,9 g5]al ,section  
#ahff;,e ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #acie;cc-#e7 is am5d$-- 7#a7 
9 subsection 7e7-- 7,a7 9 p>agraph 7#a71
 by /rik+ #aj-ye> & ins]t+ #ab-ye>2 &   
7,b7 9 p>agraph 7#e7-- 7i7 9 ! second   
s5t5ce1 by /rik+ t5? & ins]t+ twelf?2 & 
7ii7 9 ! ?ird s5t5ce1 by /rik+ t5? &    

ins]t+ twelf?2 &  7#b7 9 subsection 7h71
 by /rik+ & #i1jjj1jjj = fiscal ye>     
#bjba & ins]t+ 1 #i1jjj1jjj = fiscal ye>
 #bjba1 & #c1jjj1jjj = fiscal ye> #bjbd4
  7b7 ,effective date ,! am5dm5ts made  
by subsection 7a7 %all take effect z if 
includ$ 9 ! enactm5t ( ,public ,law     
#aaa-adh4  #djg4 ,increase 9 support =  
physicians & o!r pr(essionals 9 adju/+  
to ,m$ic>e paym5t *anges ,section       
#ahdh7t77#a77;,d7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4                     
#aciew-#d7t77#a77;,d77 is am5d$ by /rik+
 #a4be p]c5t & ins]t+ #b4e p]c5t4  #djh4
 ,revis$ phase-9 ( ,m$ic>e cl9ical      
laboratory te/ paym5t *anges  7a7       
,revis$ phase-9 ( r$uctions f private   
payor rate implem5tation ,section       
#ahcd;,a7b77#c7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #aciem-#a7;b77#c77  
is am5d$-- 7#a7 9 subp>agraph 7,a71 by  
/rik+ ?r\gh #bjbf & ins]t+ ?r\gh #bjbg2 
&  7#b7 9 subp>agraph 7,b7-- 7,a7 9     
clause 7ii71 by /rik+ ?r\gh #bjbc &     
ins]t+ ?r\gh #bjbd2 &  7,b7 9 clause    

7iii71 by /rik+ #bjbd ?r\gh #bjbf &     
ins]t+ #bjbe ?r\gh #bjbg4  7b7 ,revis$  
,report+ ,p]iod = ,report+ ( ,private   
,sector ,paym5t ,rates = ,e/abli%m5t (  
,m$ic>e ,paym5t ,rates ,section         
#ahcd;,a7a77#a77;,b7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciem-#a7;a77#a77;,b77 is am5d$-- 7#a7 
9 clause 7i71 by /rik+ ,decemb] #ca1    
#bjbc & ins]t+ ,decemb] #ca1 #bjbd2 &   
7#b7 9 clause 7ii7-- 7,a7 by /rik+      
,janu>y #a1 #bjbd & ins]t+ ,janu>y #a1  
#bjbe2 &  7,b7 by /rik+ ,m>* #ca1 #bjbd 
& ins]t+ ,m>* #ca1 #bjbe4  #dji4        
,ext5sion ( adju/m5t to calculation (   
hospice cap am\nt "u ,m$ic>e ,section   
#ahad7;i77#b77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;f7i77#b77;,b77 is am5d$-- 7#a7 9  
clause 7ii71 by /rik+ #bjcb & ins]t+    
#bjcc2 &  7#b7 9 clause 7iii71 by /rik+ 
#bjcb & ins]t+ #bjcc4  ,v ,(fsets  #eja4
 ,m$icaid ,improvem5t ,fund ,section    
#aida7;b77#c77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    

#acifw-#a7;b77#c77;,a771 z am5d$ by     
section #bcdb ( ! ,cont9u+              
,appropriations ,act1 #bjbd & ,o!r      
,ext5sions ,act 7,public ,law #aah-ae71 
is am5d$ by /rik+ #f1ceg1aag1haj &      
ins]t+ #efa1jjj1jjj4  #ejb4 ,m$ic>e     
,improvem5t ,fund ,section #ahih7;b77#a7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #acie;iii7b77#a77 is am5d$ by 
/rik+ #ahj1jjj1jjj & ins]t+             
#gef1jjj1jjj4  ,decemb] #g1 #bjbc,read  
twice & plac$ on ! cal5d>