Section 1 Short title
This Act may be cited as the “Incentivizing Dual-Eligible Alignment Act” or the “IDEAL Act”.
Incentivizing Dual-Eligible Alignment Act
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.
Sec. 2 Social determinants of health pilot program
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.
Program requirements—
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.
Add-on payment—
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)).
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.).
Benefits To address social determinants of health—
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—
transportation for the purpose of obtaining non-medical items and services, such grocery shopping or banking;
pest eradication services, including traps, pest control sprays, and cleaning supplies;
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;
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;
complementary therapies provided by licensed or certified practitioners;
services to assist with decision-making with respect to health care needs;
educational services or classes, including financial literacy classes, technology education, or language classes;
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
benefits to address specific needs of chronically ill individuals, including—
food, produce, and meals for enrollees with a chronic illness, delivered to the home of such individual or in a congregate setting; and
structural home modifications that have a reasonable expectation of improving or maintaining the health, mobility, or overall function of a chronically ill individual.
Authority to add or modify benefits— The Director may add to, or otherwise modify, the covered benefits described in paragraph (1).
Evaluation and reports—
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).
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).
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:
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.
The number of fully integrated dual eligible special needs plans and highly integrated dual eligible special needs plans participating in the program.
A list of the covered benefits provided through the program and the cost to each safety net health plan to provide such benefits.
Information with respect to the utilization of the covered benefits by enrollees.
Enrollee-reported satisfaction with respect to each covered benefit provided under the program.
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.
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).
The per member, per month amount of the add-on payment received by each safety net health plan.
Definitions— In this section:
Cohort— The term “cohort” refers to the safety net health plans that begin participating in the program in the same calendar year.
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.
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—
is incorporated as a nonprofit corporation or operated by a public agency, public entity, local government, or group of governmental units under State law;
no part of the net earnings of which inures to the benefit of any private shareholder or individual;
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
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
in the case of a dual eligible special needs plan—
meets the requirements under subparagraph (D)(i)(I) of such section; or
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.”