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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6742 Introduced in House (IH)]

<DOC>

118th CONGRESS
  1st Session
                                H. R. 6742

 To establish a pilot program to provide an add-on payment to certain 
plans offering benefits designed to address the needs of dual-eligible 
 individuals related to social determinants of health, and to provide 
  administrative flexibility to improve integration for certain dual-
                         eligible individuals.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                           December 13, 2023

Mr. Blumenauer introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL

 
 To establish a pilot program to provide an add-on payment to certain 
plans offering benefits designed to address the needs of dual-eligible 
 individuals related to social determinants of health, and to provide 
  administrative flexibility to improve integration for certain dual-
                         eligible individuals.

    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 ``Incentivizing Dual-Eligible 
Alignment Act'' or the ``IDEAL Act''.

SEC. 2. SOCIAL DETERMINANTS OF HEALTH PILOT PROGRAM.

    (a) In General.-- The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary''), acting through the 
Director of the Federal Coordinated Health Care Office established 
under section 2602 of Public Law 111-148 (in this section referred to 
as the ``Director'') shall conduct a pilot program (in this section 
referred to as the ``program'') to demonstrate improvements in patient 
outcomes through the provision of covered benefits (as described in 
subsection (c)) designed to address social determinants of health with 
respect to certain dual-eligible individuals. Under the program, the 
Director shall provide an add-on payment to 4 cohorts of safety net 
health plans (as defined in subsection (e)) to furnish such benefits to 
dual-eligible individuals enrolled in such plans.
    (b) Program Requirements.--
            (1) In general.--For calendar year 2025 and each year 
        thereafter through 2028, the Director shall enter into 5-year 
        agreements with safety net health plans under which each such 
        safety net health plan that qualifies for a rebate under 
        section 1853(a)(1)(E) of the Social Security Act (42 U.S.C. 
        1395w-23(a)(1)(E)) for a year during the agreement period shall 
        receive the add-on payment described in paragraph (2) for such 
        year, to provide one or more covered benefits to dual-eligible 
        individuals enrolled in such plan.
            (2) Add-on payment.--
                    (A) In general.--The amount of the add-on payment 
                for each year for an safety net health plan 
                participating in the pilot program shall be 5 percent 
                of the amount paid under section 1853(a)(1)(E) of the 
                Social Security Act (42 U.S.C. 1395w-23(a)(1)(E)).
                    (B) Supplement, not supplant.--The add-on payment 
                described in paragraph (1) shall supplement, and not 
                supplant, any other payments made to an safety net 
                health plan under title XVIII or XIX of the Social 
                Security Act (42 U.S.C. 1395 et seq., 1396 et seq.).
    (c) Benefits To Address Social Determinants of Health.--
            (1) Covered benefits.--An safety net health plan 
        participating in the pilot program may use the add-on payment 
        provided under this section to provide one or more covered 
        benefits, including--
                    (A) transportation for the purpose of obtaining 
                non-medical items and services, such grocery shopping 
                or banking;
                    (B) pest eradication services, including traps, 
                pest control sprays, and cleaning supplies;
                    (C) equipment and services, including installation 
                and maintenance of such equipment, to improve indoor 
                air quality, including temporary or portable air 
                conditioning units, humidifiers, dehumidifiers, high 
                efficiency particulate air filters, and carpet 
                cleaning;
                    (D) community or plan-sponsored programs and events 
                to address isolation among enrollees and improve 
                emotional and cognitive function, including programs, 
                events, and other benefits such as non-fitness club 
                memberships, community or social clubs, park passes, 
                and access to companion care, marital or family 
                counseling, or classes for enrollees with primary 
                caregiving responsibilities for a child;
                    (E) complementary therapies provided by licensed or 
                certified practitioners;
                    (F) services to assist with decision-making with 
                respect to health care needs;
                    (G) educational services or classes, including 
                financial literacy classes, technology education, or 
                language classes;
                    (H) general supports for living, including housing 
                consultations, and subsidies for rent or assisted 
                living communities, or subsidies for utilities such as 
                gas, electric, and water; and
                    (I) benefits to address specific needs of 
                chronically ill individuals, including--
                            (i) food, produce, and meals for enrollees 
                        with a chronic illness, delivered to the home 
                        of such individual or in a congregate setting; 
                        and
                            (ii) structural home modifications that 
                        have a reasonable expectation of improving or 
                        maintaining the health, mobility, or overall 
                        function of a chronically ill individual.
            (2) Authority to add or modify benefits.--The Director may 
        add to, or otherwise modify, the covered benefits described in 
        paragraph (1).
    (d) Evaluation and Reports.--
            (1) Reporting requirement for safety net health plans.--
        Under the agreements entered into under subsection (a), each 
        safety net health plan shall submit to the Secretary such 
        information as required by the Secretary, at such time and in 
        such manner as determined by the Secretary, for purposes of 
        informing the evaluation under paragraph (2).
            (2) Evaluation.--At the end of each 5-year agreement, the 
        Secretary shall conduct an evaluation of the program under this 
        section. Such evaluation shall incorporate information 
        submitted by each safety net health plan pursuant to paragraph 
        (1).
            (3) Report to congress.--Not later than December 31, 2031, 
        the Secretary shall submit to Congress a report containing the 
        evaluations conducted under paragraph (2). Such report shall 
        also include the following information:
                    (A) The number of enrollees eligible for covered 
                benefits, including the demographic information and, to 
                the extent possible, the health characteristics of 
                enrollees utilizing such benefits.
                    (B) The number of fully integrated dual eligible 
                special needs plans and highly integrated dual eligible 
                special needs plans participating in the program.
                    (C) A list of the covered benefits provided through 
                the program and the cost to each safety net health plan 
                to provide such benefits.
                    (D) Information with respect to the utilization of 
                the covered benefits by enrollees.
                    (E) Enrollee-reported satisfaction with respect to 
                each covered benefit provided under the program.
                    (F) Health outcomes as measured by primary care 
                appointments, visits to an emergency department, the 
                number and length of hospitalizations, admissions to a 
                skilled nursing facility or nursing facility, and other 
                outcomes as determined appropriate by the Secretary.
                    (G) The cost to the Medicare program under title 
                XVIII of the Social Security Act of providing the add-
                on payment described in subsection (b)(2).
                    (H) The per member, per month amount of the add-on 
                payment received by each safety net health plan.
    (e) Definitions.--In this section:
            (1) Cohort.--The term ``cohort'' refers to the safety net 
        health plans that begin participating in the program in the 
        same calendar year.
            (2) Dual eligible special needs plan; highly integrated 
        dual eligible special needs plan; fully integrated dual 
        eligible special needs plan.--The terms ``dual eligible special 
        needs plan'', ``highly integrated dual eligible special needs 
        plan'', and ``fully integrated dual eligible special needs 
        plan'' have the meaning given such terms in section 422.2 of 
        title 42, Code of Federal Regulations.
            (3) Safety net health plan.--The term ``safety net health 
        plan'' means a specialized ma plan for special needs 
        individuals (as such term is defined in section 1859(b)(6) of 
        the Social Security Act (42 U.S.C. 1395w-28(b)(6)) that--
                    (A) is incorporated as a nonprofit corporation or 
                operated by a public agency, public entity, local 
                government, or group of governmental units under State 
                law;
                    (B) no part of the net earnings of which inures to 
                the benefit of any private shareholder or individual;
                    (C) receives more than 80 percent of its annual 
                gross revenue from government programs that target low 
                income, elderly, or disabled populations under title 
                XVIII, XIX, or XXI of the Social Security Act; and
                    (D) in the case of a highly integrated dual 
                eligible special needs plan or a fully integrated dual 
                eligible special needs plan, meets the requirements in 
                subclause (II) or (III) of subparagraph (D)(i) of such 
                section; or
                    (E) in the case of a dual eligible special needs 
                plan--
                            (i) meets the requirements under 
                        subparagraph (D)(i)(I) of such section; or
                            (ii) is likely, as determined by the 
                        Secretary, to meet the requirements under 
                        subclauses (II) and (III) of such subparagraph 
                        within 1 year of a State's request for one or 
                        more administrative flexibilities with respect 
                        to such plan.

SEC. 3. ADMINISTRATIVE FLEXIBILITY TO IMPROVE INTEGRATION FOR CERTAIN 
              DUAL-ELIGIBLE INDIVIDUALS.

    Section 1859(f)(8) of the Social Security Act (42 U.S.C. 1395w-
28(f)(8)) is amended by adding at the end the following new 
subparagraph:
                    ``(F) Administrative flexibility.--
                            ``(i) In general.--Not later than 60 days 
                        after the date of enactment of this 
                        subparagraph, the Secretary, acting through the 
                        Director of the Federal Coordinated Health Care 
                        Office, shall commence rulemaking to establish 
                        procedures for States to request one or more of 
                        the administrative flexibilities described in 
                        clause (ii) for applicable plans (as defined in 
                        clause (iv)) to improve integration under this 
                        title and title XIX for dual-eligible 
                        individuals enrolled in such plans. In 
                        establishing such procedures, the Secretary 
                        shall ensure that such procedures do not reduce 
                        such individuals' choices with respect to plans 
                        under this title, or such individuals' access 
                        to care.
                            ``(ii) Administrative flexibilities 
                        described.--The administrative flexibilities 
                        described in this clause include flexibility 
                        with respect to--
                                    ``(I) enrollment timelines and 
                                processes under section 1851(e)(2) and 
                                clauses (iii) and (iv) of section 
                                1860D-1(b)(1)(B);
                                    ``(II) approval of marketing 
                                material under paragraphs (1) and (2) 
                                of section 1851(h);
                                    ``(III) enrollment materials under 
                                section 1876(c)(3)(C); and
                                    ``(IV) other administrative 
                                requirements such as application 
                                processes under this title and 
                                determined appropriate by the Federal 
                                Coordinated Health Care Office in 
                                consultation with beneficiary advocacy 
                                groups.
                            ``(iii) Report.--Beginning on the date that 
                        is 2 years after the date of enactment of this 
                        subparagraph, and annually thereafter, the 
                        Director of the Federal Coordinated Health Care 
                        Office shall submit to the Congress a report on 
                        the flexibilities granted pursuant to this 
                        subparagraph, and make each such report 
                        publicly available on the website of such 
                        Office.
                            ``(iv) Definitions.--In this subparagraph:
                                    ``(I) Applicable plan.--The term 
                                `applicable plan' means a specialized 
                                MA plan for special needs individuals 
                                (as described in subsection 
                                (b)(6)(B)(ii)) that--
                                            ``(aa) in the case of a 
                                        highly integrated dual eligible 
                                        special needs plan or a fully 
                                        integrated dual eligible 
                                        special needs plan, meets the 
                                        requirements in subclause (II) 
                                        or (III) of subparagraph 
                                        (D)(i); or
                                            ``(bb) in the case of a 
                                        dual eligible special needs 
                                        plan--

                                                    ``(AA) meets the 
                                                requirements under 
                                                subparagraph (D)(i)(I); 
                                                or

                                                    ``(BB) is likely, 
                                                as determined by the 
                                                Secretary, to meet the 
                                                requirements under 
                                                subclauses (II) and 
                                                (III) of such 
                                                subparagraph within 1 
                                                year of a State's 
                                                request for one or more 
                                                administrative 
                                                flexibilities with 
                                                respect to such plan.

                                    ``(II) Dual eligible special needs 
                                plan; highly integrated dual eligible 
                                special needs plan; fully integrated 
                                dual eligible special needs plan.--The 
                                terms `dual eligible special needs 
                                plan', `highly integrated dual eligible 
                                special needs plan', and `fully 
                                integrated dual eligible special needs 
                                plan' have the meaning given such terms 
                                in section 422.2 of title 42, Code of 
                                Federal Regulations.''.
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