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 En-
ergy 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 Representa-
tives 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’’. 
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SEC. 2. SOCIAL DETERMINANTS OF HEALTH PILOT PRO-
GRAM. 
(a) IN GENERAL.— The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’), acting through the Director of the Federal Co-
ordinated 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 im-
provements 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 agree-
ment period shall receive the add-on payment de-
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scribed in paragraph (2) for such year, to provide 
one or more covered benefits to dual-eligible individ-
uals 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 pro-
vide one or more covered benefits, including— 
(A) transportation for the purpose of ob-
taining non-medical items and services, such 
grocery shopping or banking; 
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(B) pest eradication services, including 
traps, pest control sprays, and cleaning sup-
plies; 
(C) equipment and services, including in-
stallation and maintenance of such equipment, 
to improve indoor air quality, including tem-
porary or portable air conditioning units, hu-
midifiers, dehumidifiers, high efficiency particu-
late air filters, and carpet cleaning; 
(D) community or plan-sponsored pro-
grams 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 ac-
cess to companion care, marital or family coun-
seling, 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, includ-
ing financial literacy classes, technology edu-
cation, or language classes; 
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(D) Information with respect to the utiliza-
tion of the covered benefits by enrollees. 
(E) Enrollee-reported satisfaction with re-
spect to each covered benefit provided under the 
program. 
(F) Health outcomes as measured by pri-
mary care appointments, visits to an emergency 
department, the number and length of hos-
pitalizations, admissions to a skilled nursing fa-
cility 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 sub-
section (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 
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SPECIAL
NEEDS
PLAN.—The terms ‘‘dual eligible 
special needs plan’’, ‘‘highly integrated dual eligible 
special needs plan’’, and ‘‘fully integrated dual eligi-
ble 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 corpora-
tion or operated by a public agency, public enti-
ty, 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 pro-
grams that target low income, elderly, or dis-
abled 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 
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dual eligible special needs plan, meets the re-
quirements in subclause (II) or (III) of sub-
paragraph (D)(i) of such section; or 
(E) in the case of a dual eligible special 
needs plan— 
(i) meets the requirements under sub-
paragraph (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 subpara-
graph 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 INTE-
GRATION FOR CERTAIN DUAL-ELIGIBLE INDI-
VIDUALS. 
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 Co-
ordinated Health Care Office, shall com-
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mence 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 in-
dividuals enrolled in such plans. In estab-
lishing 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 flexibili-
ties described in this clause include flexi-
bility 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 ma-
terial under paragraphs (1) and (2) of 
section 1851(h); 
‘‘(III) enrollment materials under 
section 1876(c)(3)(C); and 
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‘‘(IV) other administrative re-
quirements such as application proc-
esses under this title and determined 
appropriate by the Federal Coordi-
nated Health Care Office in consulta-
tion with beneficiary advocacy groups. 
‘‘(iii) REPORT.—Beginning on the 
date that is 2 years after the date of enact-
ment of this subparagraph, and annually 
thereafter, the Director of the Federal Co-
ordinated Health Care Office shall submit 
to the Congress a report on the flexibilities 
granted pursuant to this subparagraph, 
and make each such report publicly avail-
able on the website of such Office. 
‘‘(iv) DEFINITIONS.—In this subpara-
graph: 
‘‘(I) 
APPLICABLE
PLAN.—The 
term ‘applicable plan’ means a spe-
cialized MA plan for special needs in-
dividuals (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 
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dual eligible special needs plan, 
meets the requirements in sub-
clause (II) or (III) of subpara-
graph (D)(i); or 
‘‘(bb) in the case of a dual 
eligible special needs plan— 
‘‘(AA) meets the re-
quirements under subpara-
graph (D)(i)(I); or 
‘‘(BB) is likely, as de-
termined 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 ad-
ministrative flexibilities with 
respect to such plan. 
‘‘(II) DUAL
ELIGIBLE
SPECIAL 
NEEDS
PLAN; HIGHLY
INTEGRATED 
DUAL
ELIGIBLE
SPECIAL
NEEDS 
PLAN; FULLY INTEGRATED DUAL ELI-
GIBLE
SPECIAL
NEEDS
PLAN.—The 
terms ‘dual eligible special needs 
plan’, ‘highly integrated dual eligible 
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