Section 1 Short title
This Act may be cited as the “Community Multi-Share Coverage Program Act”.
Community Multi-Share Coverage Program Act
A BILL
To require the Secretary of Health and Human Services to award grants to support community-based coverage entities to carry out a comprehensive coverage program that provides to qualifying individuals and small businesses health coverage and integrated social determinant of health support services to small business workers that promote improved health, long-term economic self-sufficiency, employment and retention, and for other purposes.
Sec. 2 Grants to establish Community Multi-Share Coverage Programs to enable small businesses to provide affordable health coverage and support services to employees with limited income and assets
In general— Not later than 180 days after the date of the enactment of this Act, the Secretary shall award at least 3 and not more than 5 grants to support Community Multi-Share Coverage programs. Such programs shall—
reduce the number of uninsured individuals through hospital-community partnership initiatives that provide an affordable health coverage option for such individuals and provide a coverage transition for those limited to coverage through government-sponsored programs;
promote workforce development for small business by addressing the influencers of health that directly impact employment success and create barriers to exiting Medicaid, resulting in better health and workplace success; and
support small business economic recovery by allowing small businesses to be competitive in their hiring, and to provide high quality, affordable health coverage to workers who are otherwise hesitant to lose Medicaid eligibility.
Community multi-Share coverage program requirements— For purposes of this section, the term Community Multi-Share Coverage Program means a program that satisfies each of the following program requirements—
Physical presence in the community— The program maintains a physical presence within close geographic proximity to the enrollees it is serving, with a focus on mitigating barriers to engagement by enabling face-to-face interactions between the program staff, enrollees, and community organizations.
Health coverage— The program provides enrolled qualifying individuals with health coverage that satisfies the following:
Services covered— Provides coverage for the following categories of services when furnished by network providers and community resources—
physician services;
inpatient and outpatient hospital services;
behavioral health services, including services for substance use disorder prevention and treatment;
preventative services;
diagnostic laboratory tests and x-rays;
prescription drugs;
emergency ambulance services that are provided by ground transportation;
emergency services (as defined in section 2719A(b)(2)(B) of the Public Health Service Act (42 U.S.C. 300gg–1719a(b)(2)(B))); and
population health improvement services.
Cost-sharing— Imposes no deductible on covered services provided by network providers and community resources, and limits co-payments for in-network covered services to levels that do not create a barrier to patient access.
Network providers— Establishes agreements with hospitals and health care providers located within the community to provide care for qualifying individuals.
Integrated continuous health improvement services— The program provides, either directly or through contract, integrated continuous health improvement services that satisfy the following:
Regular assessments of community factors and resources that potentially impact enrollees’ physical, emotional, and economic health.
A community-based planning process to identify and address any negative influences identified pursuant to subparagraph (A), and promote well-being through partnerships and alignment efforts between the community-based coverage entity and—
local small employers;
entities that provide educational and occupational training (including classes, workshops, mentorships, and apprenticeships) designed to enhance preparation for work and support economic self-sufficiency;
community health initiatives;
investors;
local, State, and Federal governmental agencies; and
organizations described in section 501(c)(3) of the Internal Revenue Code of 1986 that focus on human service needs relating to physical health, behavioral health, poverty, education, access to health care, and safety.
Individualized assessment of each enrollee to identify any negative influences on their physical, emotional, and economic health, and ability to achieve economic self-sufficiency. This shall include—
an assessment of any of the enrollee’s social determinants of health, health risks, barriers to long-term employment, and barriers to increasing income; and
a determination of the enrollee’s health domain score, which is a measurement of specific influences of physical, emotional, and financial health with respect to a qualifying individual.
Establishment of an individualized plan to support each enrollee in achieving better health and economic self-sufficiency. Each individualized plan shall—
identify community resources that will support the enrollee in improving their physical, behavioral, or economic health. These may include, but are not limited to—
group classes that address barriers to physical, emotional, and economic health; and
educational and occupational training opportunities that enhance work preparedness and support economic self-sufficiency; and
contain engagement milestones, with a goal of identifying and overcoming obstacles to engagement in personal health improvement and mitigation of root-cause barriers. These milestones shall include, but are not limited to—
participation in individualized health coaching services to address the enrollee’s social determinants of health and to support their physical, emotional, and financial health; and
engagement with community resources, such as participating in group classes, as recommended by the health coach.
Funding structure— The direct costs of the program are shared among the following entities, each of which makes a direct financial contribution—
the public sector;
local health care providers;
enrollees; and
enrollees’ employers or skilled trade organizations.
Enrollees—
In the event that a Program is unable to provide services to all qualifying individuals in its catchment area, the Program has a written policy for determining which qualifying individuals are offered enrollment. This policy is publicly available and does not discriminate based on age, race, ethnicity, religion, gender, or sexual orientation.
The program may rescind a qualifying individual’s enrollment due to sustained failure to meet minimum engagement thresholds, which shall be participatory and not health-contingent, and provide for reasonable alternatives, in their individual plan described in subsection (b)(2)(C).
Evaluation— The program formally evaluates its impact on enrollees’ employment status, physical and behavioral health, income, and economic self-sufficiency.
Qualifying individual— The term qualifying individual means an individual who—
resides or works within the catchment area of a partner hospital described in subsection (e)(1)(A);
subject to any modification made by such program to narrow the income eligibility range, has a household income that exceeds the Medicaid eligibility limit applicable to the qualifying individual in their State of residence but does not exceed 400 percent of the Federal poverty line applicable to their household size;
is not enrolled in a qualified health plan during the 180-day period preceding the date on which such qualifying individual seeks to enroll in the Community Multi-Share Coverage Program, unless a such coverage is terminated due to a qualifying special event;
is ineligible for enrollment in a Federal health care program other than Affordable Care Act Plans, (including but not limited to ineligibility to receive health services through the Indian Health Service or Veterans Administration);
works for a small employer which does not offer its employees coverage in a qualified health plan under which the combined premium plus deductible cost to cover the employee’s household is less than seven percent of the employee’s household income; and
other requirements the Secretary determines appropriate.
Grant terms—
Duration— A grant awarded under this section shall be made for a period of 4 years.
Amount— The Secretary shall determine the maximum amount of each grant awarded under subsection (a).
Number— At least one award must be made to a Community Multi-Share Coverage Program that is operating at the time that this section is enacted.
Applications—
In general— To be eligible to be awarded a grant under subsection (a), an applicant must—
be a nonprofit entity with documented commitments from local partner hospitals and small employers to participate in a Community Multi-Share Coverage Plan; and
submit to the Secretary an application at such time, in such manner, and containing the certification described in paragraph (2) and such other information as the Secretary may require.
Certification— To be eligible for funding under this section, an application described in paragraph (1) shall include certifications that the program—
will not impose any preexisting condition exclusion (as such term is defined in section 2704(b)(1)(A)) of the Public Health Service Act (42 U.S.C. 300gg–3(b)(1)(A)) with respect to the health coverage described in subsection (b)(2);
has or will establish a network of health care providers and community resources sufficient to provide services to qualifying individuals enrolled under the health coverage described in subsection (b)(2);
will seek to enroll eligible individuals whose household income is less than the basic cost of living (as determined in a manner consistent with the “Asset Limited, Income Constrained, Employed” or “ALICE” methodology);
select an entity to carry out administrative and accounting responsibilities (including monthly billing, verification of eligibility of qualifying individuals, enrollment of qualifying individuals, maintenance of a list of active enrollees, and operation of a benefit utilization management program) necessary with respect to the health coverage described in subsection (b)(2); and
shall submit written reports to the Secretary on an annual basis evaluating the progress on advancing access to health care, increasing economic self-sufficiency, and other elements that the Secretary requires.
Definitions— In this section:
Agency— The term agency means a local, State, or Federal agency.
Federal health care program— The term Federal health care program has the meaning given such term in section 1128B(f) of the Social Security Act (42 U.S.C. 1320a–7b(f)).
Health coach— The term health coach means an individual who is a member of the staff of the community-based coverage entity that has received training to provide health coaching services (including health improvement program services).
Hospital— The term hospital means an institution that—
meets the requirements of section 1861(e) of the Social Security Act (42 U.S.C. 1395x(e)); and
is an organization described in subsections (c)(3) and (r)(3) of section 501 of the Internal Revenue Code of 1986 and is exempt from taxation under section 501(a) of such Code.
Qualified health plan— The term qualified health plan has the meaning given such term in section 1301(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18021(a)).
Secretary— The term Secretary means the Secretary of Health and Human Services.
Small employer— The term small employer has the meaning given such term in section 1304(b)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18024(b)(2)).
Social determinants of health— The term social determinants of health has the meaning given such term by the Director of the Centers for Disease Control and Prevention.
Authorization of appropriations— There is authorized to be appropriated to carry out this section—
$4,800,000 for fiscal year 2022;
$7,200,000 for fiscal year 2023; and
$12,000,000 for each of fiscal years 2024 and 2025.