I 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Incentivizing Dual5 Eligible Alignment Act’’ or the ‘‘IDEAL Act’’. 

2 

•HR 6742 IH

1 SEC. 2. SOCIAL DETERMINANTS OF HEALTH PILOT PRO2 GRAM. 

3 (a) IN GENERAL.— The Secretary of Health and 

4 Human Services (in this section referred to as the ‘‘Sec5 retary’’), acting through the Director of the Federal Co6 ordinated Health Care Office established under section 

7 2602 of Public Law 111–148 (in this section referred to 

8 as the ‘‘Director’’) shall conduct a pilot program (in this 

9 section referred to as the ‘‘program’’) to demonstrate im10 provements in patient outcomes through the provision of 

11 covered benefits (as described in subsection (c)) designed 

12 to address social determinants of health with respect to 

13 certain dual-eligible individuals. Under the program, the 

14 Director shall provide an add-on payment to 4 cohorts of 

15 safety net health plans (as defined in subsection (e)) to 

16 furnish such benefits to dual-eligible individuals enrolled 

17 in such plans. 

18 (b) PROGRAM REQUIREMENTS.— 

19 (1) IN GENERAL.—For calendar year 2025 and 

20 each year thereafter through 2028, the Director 

21 shall enter into 5-year agreements with safety net 

22 health plans under which each such safety net health 

23 plan that qualifies for a rebate under section 

24 1853(a)(1)(E) of the Social Security Act (42 U.S.C. 

25 1395w–23(a)(1)(E)) for a year during the agree26 ment period shall receive the add-on payment deVerDate Sep 11 2014 00:57 Jan 03, 2024 Jkt 049200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H6742.IH H6742
3 

•HR 6742 IH

1 scribed in paragraph (2) for such year, to provide 

2 one or more covered benefits to dual-eligible individ3 uals enrolled in such plan. 

4 (2) ADD-ON PAYMENT.— 

5 (A) IN GENERAL.—The amount of the 

6 add-on payment for each year for an safety net 

7 health plan participating in the pilot program 

8 shall be 5 percent of the amount paid under 

9 section 1853(a)(1)(E) of the Social Security 

10 Act (42 U.S.C. 1395w–23(a)(1)(E)). 

11 (B) SUPPLEMENT, NOT SUPPLANT.—The 

12 add-on payment described in paragraph (1) 

13 shall supplement, and not supplant, any other 

14 payments made to an safety net health plan 

15 under title XVIII or XIX of the Social Security 

16 Act (42 U.S.C. 1395 et seq., 1396 et seq.). 

17 (c) BENEFITS TO ADDRESS SOCIAL DETERMINANTS

18 OF HEALTH.— 

19 (1) COVERED BENEFITS.—An safety net health 

20 plan participating in the pilot program may use the 

21 add-on payment provided under this section to pro22 vide one or more covered benefits, including— 

23 (A) transportation for the purpose of ob24 taining non-medical items and services, such 

25 grocery shopping or banking; 

4 

•HR 6742 IH

1 (B) pest eradication services, including 

2 traps, pest control sprays, and cleaning sup3 plies; 

4 (C) equipment and services, including in5 stallation and maintenance of such equipment, 

6 to improve indoor air quality, including tem7 porary or portable air conditioning units, hu8 midifiers, dehumidifiers, high efficiency particu9 late air filters, and carpet cleaning; 

10 (D) community or plan-sponsored pro11 grams and events to address isolation among 

12 enrollees and improve emotional and cognitive 

13 function, including programs, events, and other 

14 benefits such as non-fitness club memberships, 

15 community or social clubs, park passes, and ac16 cess to companion care, marital or family coun17 seling, or classes for enrollees with primary 

18 caregiving responsibilities for a child; 

19 (E) complementary therapies provided by 

20 licensed or certified practitioners; 

21 (F) services to assist with decision-making 

22 with respect to health care needs; 

23 (G) educational services or classes, includ24 ing financial literacy classes, technology edu25 cation, or language classes; 

5 

•HR 6742 IH

1 (H) general supports for living, including 

2 housing consultations, and subsidies for rent or 

3 assisted living communities, or subsidies for 

4 utilities such as gas, electric, and water; and 

5 (I) benefits to address specific needs of 

6 chronically ill individuals, including— 

7 (i) food, produce, and meals for en8 rollees with a chronic illness, delivered to 

9 the home of such individual or in a con10 gregate setting; and 

11 (ii) structural home modifications that 

12 have a reasonable expectation of improving 

13 or maintaining the health, mobility, or 

14 overall function of a chronically ill indi15 vidual. 

16 (2) AUTHORITY TO ADD OR MODIFY BENE17 FITS.—The Director may add to, or otherwise mod18 ify, the covered benefits described in paragraph (1). 

19 (d) EVALUATION AND REPORTS.— 

20 (1) REPORTING REQUIREMENT FOR SAFETY

21 NET HEALTH PLANS.—Under the agreements en22 tered into under subsection (a), each safety net 

23 health plan shall submit to the Secretary such infor24 mation as required by the Secretary, at such time 

25 and in such manner as determined by the Secretary, 

6 

•HR 6742 IH

1 for purposes of informing the evaluation under para2 graph (2). 

3 (2) EVALUATION.—At the end of each 5-year 

4 agreement, the Secretary shall conduct an evaluation 

5 of the program under this section. Such evaluation 

6 shall incorporate information submitted by each 

7 safety net health plan pursuant to paragraph (1). 

8 (3) REPORT TO CONGRESS.—Not later than De9 cember 31, 2031, the Secretary shall submit to Con10 gress a report containing the evaluations conducted 

11 under paragraph (2). Such report shall also include 

12 the following information: 

13 (A) The number of enrollees eligible for 

14 covered benefits, including the demographic in15 formation and, to the extent possible, the health 

16 characteristics of enrollees utilizing such bene17 fits. 

18 (B) The number of fully integrated dual el19 igible special needs plans and highly integrated 

20 dual eligible special needs plans participating in 

21 the program. 

22 (C) A list of the covered benefits provided 

23 through the program and the cost to each safe24 ty net health plan to provide such benefits. 

7 

•HR 6742 IH

1 (D) Information with respect to the utiliza2 tion of the covered benefits by enrollees. 

3 (E) Enrollee-reported satisfaction with re4 spect to each covered benefit provided under the 

5 program. 

6 (F) Health outcomes as measured by pri7 mary care appointments, visits to an emergency 

8 department, the number and length of hos9 pitalizations, admissions to a skilled nursing fa10 cility or nursing facility, and other outcomes as 

11 determined appropriate by the Secretary. 

12 (G) The cost to the Medicare program 

13 under title XVIII of the Social Security Act of 

14 providing the add-on payment described in sub15 section (b)(2). 

16 (H) The per member, per month amount 

17 of the add-on payment received by each safety 

18 net health plan. 

19 (e) DEFINITIONS.—In this section: 

20 (1) COHORT.—The term ‘‘cohort’’ refers to the 

21 safety net health plans that begin participating in 

22 the program in the same calendar year. 

23 (2) DUAL ELIGIBLE SPECIAL NEEDS PLAN; 

24 HIGHLY INTEGRATED DUAL ELIGIBLE SPECIAL

25 NEEDS PLAN; FULLY INTEGRATED DUAL ELIGIBLE

8 

•HR 6742 IH

1 SPECIAL NEEDS PLAN.—The terms ‘‘dual eligible 

2 special needs plan’’, ‘‘highly integrated dual eligible 

3 special needs plan’’, and ‘‘fully integrated dual eligi4 ble special needs plan’’ have the meaning given such 

5 terms in section 422.2 of title 42, Code of Federal 

6 Regulations. 

7 (3) SAFETY NET HEALTH PLAN.—The term 

8 ‘‘safety net health plan’’ means a specialized ma 

9 plan for special needs individuals (as such term is 

10 defined in section 1859(b)(6) of the Social Security 

11 Act (42 U.S.C. 1395w–28(b)(6)) that— 

12 (A) is incorporated as a nonprofit corpora13 tion or operated by a public agency, public enti14 ty, local government, or group of governmental 

15 units under State law; 

16 (B) no part of the net earnings of which 

17 inures to the benefit of any private shareholder 

18 or individual; 

19 (C) receives more than 80 percent of its 

20 annual gross revenue from government pro21 grams that target low income, elderly, or dis22 abled populations under title XVIII, XIX, or 

23 XXI of the Social Security Act; and 

24 (D) in the case of a highly integrated dual 

25 eligible special needs plan or a fully integrated 

9 

•HR 6742 IH

1 dual eligible special needs plan, meets the re2 quirements in subclause (II) or (III) of sub3 paragraph (D)(i) of such section; or 

4 (E) in the case of a dual eligible special 

5 needs plan— 

6 (i) meets the requirements under sub7 paragraph (D)(i)(I) of such section; or 

8 (ii) is likely, as determined by the 

9 Secretary, to meet the requirements under 

10 subclauses (II) and (III) of such subpara11 graph within 1 year of a State’s request 

12 for one or more administrative flexibilities 

13 with respect to such plan. 

14 SEC. 3. ADMINISTRATIVE FLEXIBILITY TO IMPROVE INTE15 GRATION FOR CERTAIN DUAL-ELIGIBLE INDI16 VIDUALS. 

17 Section 1859(f)(8) of the Social Security Act (42 

18 U.S.C. 1395w–28(f)(8)) is amended by adding at the end 

19 the following new subparagraph: 

20 ‘‘(F) ADMINISTRATIVE FLEXIBILITY.— 

21 ‘‘(i) IN GENERAL.—Not later than 60 

22 days after the date of enactment of this 

23 subparagraph, the Secretary, acting 

24 through the Director of the Federal Co25 ordinated Health Care Office, shall comVerDate Sep 11 2014 00:57 Jan 03, 2024 Jkt 049200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H6742.IH H6742
10 

•HR 6742 IH

1 mence rulemaking to establish procedures 

2 for States to request one or more of the 

3 administrative flexibilities described in 

4 clause (ii) for applicable plans (as defined 

5 in clause (iv)) to improve integration under 

6 this title and title XIX for dual-eligible in7 dividuals enrolled in such plans. In estab8 lishing such procedures, the Secretary shall 

9 ensure that such procedures do not reduce 

10 such individuals’ choices with respect to 

11 plans under this title, or such individuals’ 

12 access to care. 

13 ‘‘(ii) ADMINISTRATIVE FLEXIBILITIES

14 DESCRIBED.—The administrative flexibili15 ties described in this clause include flexi16 bility with respect to— 

17 ‘‘(I) enrollment timelines and 

18 processes under section 1851(e)(2) 

19 and clauses (iii) and (iv) of section 

20 1860D–1(b)(1)(B); 

21 ‘‘(II) approval of marketing ma22 terial under paragraphs (1) and (2) of 

23 section 1851(h); 

24 ‘‘(III) enrollment materials under 

25 section 1876(c)(3)(C); and 

11 

•HR 6742 IH

1 ‘‘(IV) other administrative re2 quirements such as application proc3 esses under this title and determined 

4 appropriate by the Federal Coordi5 nated Health Care Office in consulta6 tion with beneficiary advocacy groups. 

7 ‘‘(iii) REPORT.—Beginning on the 

8 date that is 2 years after the date of enact9 ment of this subparagraph, and annually 

10 thereafter, the Director of the Federal Co11 ordinated Health Care Office shall submit 

12 to the Congress a report on the flexibilities 

13 granted pursuant to this subparagraph, 

14 and make each such report publicly avail15 able on the website of such Office. 

16 ‘‘(iv) DEFINITIONS.—In this subpara17 graph: 

18 ‘‘(I) APPLICABLE PLAN.—The 

19 term ‘applicable plan’ means a spe20 cialized MA plan for special needs in21 dividuals (as described in subsection 

22 (b)(6)(B)(ii)) that— 

23 ‘‘(aa) in the case of a highly 

24 integrated dual eligible special 

25 needs plan or a fully integrated 

12 

•HR 6742 IH

1 dual eligible special needs plan, 

2 meets the requirements in sub3 clause (II) or (III) of subpara4 graph (D)(i); or 

5 ‘‘(bb) in the case of a dual 

6 eligible special needs plan— 

7 ‘‘(AA) meets the re8 quirements under subpara9 graph (D)(i)(I); or 

10 ‘‘(BB) is likely, as de11 termined by the Secretary, 

12 to meet the requirements 

13 under subclauses (II) and 

14 (III) of such subparagraph 

15 within 1 year of a State’s 

16 request for one or more ad17 ministrative flexibilities with 

18 respect to such plan. 

19 ‘‘(II) DUAL ELIGIBLE SPECIAL

20 NEEDS PLAN; HIGHLY INTEGRATED

21 DUAL ELIGIBLE SPECIAL NEEDS

22 PLAN; FULLY INTEGRATED DUAL ELI23 GIBLE SPECIAL NEEDS PLAN.—The 

24 terms ‘dual eligible special needs 

25 plan’, ‘highly integrated dual eligible 

13 

•HR 6742 IH

1 special needs plan’, and ‘fully inte2 grated dual eligible special needs plan’ 

3 have the meaning given such terms in 

4 section 422.2 of title 42, Code of Fed5 eral Regulations.’’. 

Æ