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