[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4758 Referred in Senate (RFS)]
<DOC>
118th CONGRESS
2d Session
H. R. 4758
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
September 18, 2024
Received; read twice and referred to the Committee on Finance
_______________________________________________________________________
AN ACT
To amend title XIX of the Social Security Act to streamline enrollment
under the Medicaid program of certain providers across State lines, and
to prevent the use of abusive spread pricing in Medicaid.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Accelerating Kids' Access to Care
Act''.
SEC. 2. STREAMLINED ENROLLMENT PROCESS FOR ELIGIBLE OUT-OF-STATE
PROVIDERS UNDER MEDICAID AND CHIP.
(a) In General.--Section 1902(kk) of the Social Security Act (42
U.S.C. 1396a(kk)) is amended by adding at the end the following new
paragraph:
``(10) Streamlined enrollment process for eligible out-of-
state providers.--
``(A) In general.--The State--
``(i) adopts and implements a process to
allow an eligible out-of-State provider to
enroll under the State plan (or a waiver of
such plan) to furnish items and services to, or
order, prescribe, refer, or certify eligibility
for items and services for, qualifying
individuals without the imposition of screening
or enrollment requirements in addition to those
imposed by the State in which the eligible out-
of-State provider is located; and
``(ii) provides that an eligible out-of-
State provider that enrolls as a participating
provider in the State plan (or a waiver of such
plan) through such process shall be so enrolled
for a 5-year period, unless the provider is
terminated or excluded from participation
during such period.
``(B) Definitions.--In this paragraph:
``(i) Eligible out-of-state provider.--The
term `eligible out-of-State provider' means,
with respect to a State, a provider--
``(I) that is located in any other
State;
``(II) that--
``(aa) was determined by
the Secretary to have a limited
risk of fraud, waste, and abuse
for purposes of determining the
level of screening to be
conducted under section
1866(j)(2), has been so
screened under such section
1866(j)(2), and is enrolled in
the Medicare program under
title XVIII; or
``(bb) was determined by
the State agency administering
or supervising the
administration of the State
plan (or a waiver of such plan)
of such other State to have a
limited risk of fraud, waste,
and abuse for purposes of
determining the level of
screening to be conducted under
paragraph (1) of this
subsection, has been so
screened under such paragraph
(1), and is enrolled under such
State plan (or a waiver of such
plan); and
``(III) that has not been--
``(aa) excluded from
participation in any Federal
health care program pursuant to
section 1128 or 1128A;
``(bb) excluded from
participation in the State plan
(or a waiver of such plan)
pursuant to part 1002 of title
42, Code of Federal Regulations
(or any successor regulation),
or State law; or
``(cc) terminated from
participating in a Federal
health care program or the
State plan (or a waiver of such
plan) for a reason described in
paragraph (8)(A).
``(ii) Qualifying individual.--The term
`qualifying individual' means an individual
under 21 years of age who is enrolled under the
State plan (or waiver of such plan).
``(iii) State.--The term `State' means 1 of
the 50 States or the District of Columbia.''.
(b) Conforming Amendments.--
(1) Section 1902(a)(77) of the Social Security Act (42
U.S.C. 1396a(a)(77)) is amended by inserting ``enrollment,''
after ``screening,''.
(2) The subsection heading for section 1902(kk) of such Act
(42 U.S.C. 1396a(kk)) is amended by inserting ``Enrollment,''
after ``Screening,''.
(3) Section 2107(e)(1)(G) of such Act (42 U.S.C.
1397gg(e)(1)(G)) is amended by inserting ``enrollment,'' after
``screening,''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date that is 3 years after the date of enactment of this
section.
SEC. 3. PREVENTING THE USE OF ABUSIVE SPREAD PRICING IN MEDICAID.
(a) In General.--Section 1927 of the Social Security Act (42 U.S.C.
1396r-8) is amended--
(1) in subsection (e), by adding at the end the following
new paragraph:
``(6) Transparent prescription drug pass-through pricing
required.--
``(A) In general.--A contract between the State and
a pharmacy benefit manager (referred to in this
paragraph as a `PBM'), or a contract between the State
and a managed care entity or other specified entity (as
such terms are defined in section 1903(m)(9)(D) and
collectively referred to in this paragraph as the
`entity') that includes provisions making the entity
responsible for coverage of covered outpatient drugs
dispensed to individuals enrolled with the entity,
shall require that payment for such drugs and related
administrative services (as applicable), including
payments made by a PBM on behalf of the State or
entity, is based on a transparent prescription drug
pass-through pricing model under which--
``(i) any payment made by the entity or the
PBM (as applicable) for such a drug--
``(I) is limited to--
``(aa) ingredient cost; and
``(bb) a professional
dispensing fee that is not less
than the professional
dispensing fee that the State
would pay if the State were
making the payment directly in
accordance with the State plan;
``(II) is passed through in its
entirety (except as reduced under
Federal or State laws and regulations
in response to instances of waste,
fraud, or abuse) by the entity or PBM
to the pharmacy or provider that
dispenses the drug; and
``(III) is made in a manner that is
consistent with sections 447.502,
447.512, 447.514, and 447.518 of title
42, Code of Federal Regulations (or any
successor regulation) as if such
requirements applied directly to the
entity or the PBM, except that any
payment by the entity or the PBM for
the ingredient cost of such drug
purchased by a covered entity (as
defined in subsection (a)(5)(B)) may
exceed the actual acquisition cost (as
defined in 447.502 of title 42, Code of
Federal Regulations, or any successor
regulation) for such drug if--
``(aa) such drug was
subject to an agreement under
section 340B of the Public
Health Service Act;
``(bb) such payment for the
ingredient cost of such drug
does not exceed the maximum
payment that would have been
made by the entity or the PBM
for the ingredient cost of such
drug if such drug had not been
purchased by such covered
entity; and
``(cc) such covered entity
reports to the Secretary (in a
form and manner specified by
the Secretary), on an annual
basis and with respect to
payments for the ingredient
costs of such drugs so
purchased by such covered
entity that are in excess of
the actual acquisition costs
for such drugs, the aggregate
amount of such excess;
``(ii) payment to the entity or the PBM (as
applicable) for administrative services
performed by the entity or PBM is limited to an
administrative fee that reflects the fair
market value (as defined by the Secretary) of
such services;
``(iii) the entity or the PBM (as
applicable) makes available to the State, and
the Secretary upon request in a form and manner
specified by the Secretary, all costs and
payments related to covered outpatient drugs
and accompanying administrative services (as
described in clause (ii)) incurred, received,
or made by the entity or the PBM, broken down
(as specified by the Secretary), to the extent
such costs and payments are attributable to an
individual covered outpatient drug, by each
such drug, including any ingredient costs,
professional dispensing fees, administrative
fees (as described in clause (ii)), post-sale
and post-invoice fees, discounts, or related
adjustments such as direct and indirect
remuneration fees, and any and all other
remuneration; and
``(iv) any form of spread pricing whereby
any amount charged or claimed by the entity or
the PBM (as applicable) that exceeds the amount
paid to the pharmacies or providers on behalf
of the State or entity, including any post-sale
or post-invoice fees, discounts, or related
adjustments such as direct and indirect
remuneration fees or assessments (after
allowing for an administrative fee as described
in clause (ii)) is not allowable for purposes
of claiming Federal matching payments under
this title.
``(B) Making certain information available.--The
Secretary shall publish, not less frequently than on an
annual basis, information received by the Secretary
pursuant to subparagraph (A)(i)(III)(cc). Such
information shall be so published in an electronic and
searchable format, such as through the 340B Office of
Pharmacy Affairs Information System (or a successor
system).''; and
(2) in subsection (k), by adding at the end the following
new paragraph:
``(12) Pharmacy benefit manager.--The term `pharmacy
benefit manager' means any person or entity that, either
directly or through an intermediary, acts as a price negotiator
or group purchaser on behalf of a State, managed care entity
(as defined in section 1903(m)(9)(D)), or other specified
entity (as so defined), and may also more broadly manage
aspects of the prescription drug benefits provided by a State,
managed care entity, or other specified entity, including the
processing and payment of claims for prescription drugs, the
performance of drug utilization review, the processing of drug
prior authorization requests, the managing of appeals or
grievances related to the prescription drug benefits,
contracting with pharmacies, controlling the cost of covered
outpatient drugs, or the provision of services related thereto.
Such term includes any person or entity that acts as a price
negotiator (with regard to payment amounts to pharmacies and
providers for a covered outpatient drug or the net cost of the
drug) or group purchaser on behalf of a State, managed care
entity, or other specified entity, including such a person or
entity that carries out 1 or more of the other activities
described in the preceding sentence, irrespective of whether
such person or entity calls itself a pharmacy benefit
manager.''.
(b) Conforming Amendments.--Section 1903(m) of such Act (42 U.S.C.
1396b(m)) is amended--
(1) in paragraph (2)(A)(xiii)--
(A) by striking ``and (III)'' and inserting
``(III)'';
(B) by inserting before the period at the end the
following: ``, and (IV) if the contract includes
provisions making the entity responsible for coverage
of covered outpatient drugs, the entity shall comply
with the requirements of section 1927(e)(6)''; and
(C) by moving the left margin 2 ems to the left;
and
(2) by adding at the end the following new paragraph:
``(10) No payment shall be made under this title to a State
with respect to expenditures incurred by the State for payment
for services provided by an other specified entity (as defined
in paragraph (9)(D)(iii)) unless such services are provided in
accordance with a contract between the State and such entity
which satisfies the requirements of paragraph (2)(A)(xiii).''.
(c) Effective Date.--The amendments made by this section shall
apply to contracts between States and managed care entities, other
specified entities, or pharmacy benefit managers that have an effective
date beginning on or after the date that is 18 months after the date of
enactment of this Act.
(d) Implementation.--
(1) In general.--Notwithstanding any other provision of
law, the Secretary of Health and Human Services may implement
the amendments made by this section by program instruction or
otherwise.
(2) Nonapplication of administrative procedure act.--
Implementation of the amendments made by this section shall be
exempt from the requirements of section 553 of title 5, United
States Code.
(e) Nonapplication of Paperwork Reduction Act.--Chapter 35 of title
44, United States Code, shall not apply to any data collection
undertaken by the Secretary of Health and Human Services under section
1927(e) of the Social Security Act (42 U.S.C. 1396r-8(f)), as amended
by this section.
SEC. 4. MEDICAID IMPROVEMENT FUND.
Section 1941(b)(3)(A) of the Social Security Act (42 U.S.C. 1396w-
1(b)(3)(A)) is amended by striking ``$0'' and inserting
``$69,000,000''.
Passed the House of Representatives September 17, 2024.
Attest:
KEVIN F. MCCUMBER,
Clerk.