Grants to community-based coverage entities to carry out a coverage program that provides health coverage and educational and occupational training

(a)

In general

Not later than 180 days after the date of the enactment of the Community Multi-share Coverage Program Act, the Secretary shall award at least 3 and not more than 5 grants to support community-based coverage entities to carry out qualifying coverage benefit pilot programs. Such programs shall— (1)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; and (2)test the feasibility of moving individuals eligible for medical assistance under a State plan under the Medicaid program under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) with full-time employment into such programs. (b)

Qualifying coverage benefit program requirements

For purposes of this section, the term qualifying coverage benefit program means a program that satisfies each of the following program requirements: (1)

Health coverage

Under the program, a community-based coverage entity shall provide to qualifying individuals health coverage offered in connection with a qualifying coverage benefit program that satisfies the following: (A)First-dollar coverage (where such coverage is furnished by network providers and community resources) for— (i)diagnostic laboratory tests and x-rays; (ii)emergency ambulance services that are provided by ground transportation; (iii)emergency services (as defined in section 2719A(b)(2)(B) of the Public Health Service Act (42 U.S.C. 300gg–19a(b)(2)(B))); (iv)inpatient and outpatient hospital services; (v)mental health services; (vi)physician services; (vii)population health improvement services; (viii)preventatives services; (ix)prescription drugs; and (x)substance abuse services. (B)Coverage for— (i)community and individual assessment tools to identify any negative influences of health and economic self-sufficiency to assist physicians in understanding the social determinants of health impacting an individual; (ii)a planning process to resolve any negative influences identified pursuant to clause (i) and promote well-being through community partnerships between the community-based coverage entity and— (I)businesses; (II)educational institutions; (III)investors; (IV)local, State, and Federal governmental agencies; and (V)organizations described in section 501(c)(3) of the Internal Revenue Code of 1986 that focuses on human service needs relating to behavioral health, poverty, education, and access and safety; (iii)the monitoring of and support (including health coaching services and coordination of services within a community to address the needs of an individual) with respect to financial, emotional, and physical health; and (iv)any other benefit the community-based coverage entity determines appropriate. (2)

Educational and occupational training

Under the program, a community-based coverage entity shall— (A)connect and foster ongoing relationships between qualifying individuals and educational and occupational training (including classes, workshops, mentorships, and apprenticeships) designed to enhance preparation for work and support economic self-sufficiency in a manner that reflects the needs of such individuals and opportunities in the community; (B)with respect to the comprehensive health improvement process described in subsection (e)(1)(C)(vi), identify and address barriers to employment and increasing income for qualifying individuals; and (C)measure and assess the effectiveness of the program in increasing employment and increasing income for qualifying individuals. (3)

Board of directors

For the purpose of carrying out the program, the community-based coverage entity shall form a board of directors, or utilize an existing board of directors, in accordance with subsection (e). (c)

Community-Based coverage entity

For the purposes of this section, the term community-based coverage entity means an entity that maintains a physical presence within close geographic proximity to the individuals it is serving, with a focus on mitigating barriers to engagement by enabling face-to-face interactions between the entity staff, the individuals served, and community organizations. (d)

Qualifying individual

For the purposes of this section, the term qualifying individual means an individual who meets the following requirements: (1)Subject to any modification made by such program pursuant to subsection (e)(2)(C)(vii), an income that exceeds 100 percent but does not exceed 400 percent of the poverty line applicable to a family of the size involved. (2)Not enrolled under a qualified health plan during the 180-day period preceding the date on which such qualifying individual seeks to enroll under the coverage program under this section. (3)Ineligibility for enrollment in a Federal health care program (including ineligibility to receive health services through the Indian Health Service). (4)Resides or works within the catchment area of a hospital described in subsection (g)(2)(C). (5)Works for a small employer that does not make enrollment in qualified health plans in the small group market such that the combined premium plus deductible cost to cover the employee’s household is less than seven percent of the employee’s household income available to its employees through— (A)in the case that a State elects to provide one exchange in the State for both qualifying individuals and qualified small employers pursuant to paragraph (2) of section 1311(b) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(b)), the American Health Benefit Exchange (as such term is used in paragraph (1) of such section) for the plan year in which such qualifying individual seeks health insurance coverage described in subsection (b)(1) from a qualifying coverage benefit program; and (B)in the case that a State retains separate exchanges for qualifying individuals and qualified small employers, the Small Business Health Options Program (as such term is used in section 1311(b)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(b)(2))) for the plan year in which such qualifying individual seeks health insurance coverage described in subsection (b)(1) from a qualifying coverage benefit program. (6)Any other requirement the Secretary determines appropriate. (e)

Board of directors

(1)

Composition

A board of directors formed pursuant to subsection (b)(3) shall be composed of at least 9 members and not more than 15 members with representation from— (A)local health care providers, of which not more than two individuals may be from the sponsoring health care organization; (B)qualifying individuals; (C)contributing employers; (D)government representatives; (E)the local health authority; (F)local education systems; and (G)other representatives as necessary to reflect the community composition. (2)

Duties

(A)

Enactment of bylaws

A board of directors shall enact bylaws relating to— (i)public engagement with the board of directors; (ii)a shared goal of improving health access and increasing affordability; (iii)outcome-based goals for the program that considers the needs of the community; (iv)program costs; and (v)an intent to receive comments regarding the health improvement goals for the community. (B)

Meetings

A board of directors shall meet at least bimonthly. (C)

Qualifying coverage benefits program

A board of directors shall— (i)carry out the qualifying coverage benefit program described in subsection (b); (ii)determine the share of payments for benefits under the health coverage described in subsection (b)(1) that are attributable to— (I)the amount awarded to a community-based coverage entity; (II)a sponsoring health care organization; (III)a qualifying individual; and (IV)an employer of a qualifying individual or a skilled trade organization of a qualifying individual; (iii)determine the premiums and limitations on payments (including deductibles and coinsurance amounts) for the health coverage described in subsection (b)(1) for a qualifying individual enrolled under such coverage and the extent, if any, to which such premiums and limitations for a qualifying individual shall increase as the income of such qualifying individual increases relative to the poverty line applicable to a family of the size involved; (iv)establish a procedure to— (I)assist qualifying individuals in enrolling under the health coverage described in subsection (b)(1); (II)assist a qualifying individual that does not meet the requirements of a qualified individual specified under subsection (d), is eligible for medical assistance under a State plan under the Medicaid program under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), and resides in the catchment area of the hospital described in subsection (g)(2)(C) in enrolling under the appropriate State plan under such program; (III)bill and collect the share of payments for benefits described in clause (ii); (IV)bill and collect the premiums and limitations on payment described in clause (iii); (V)for the purposes of integrating community resources, form partnerships with community population health initiatives; (VI)remove a qualifying individual from the health insurance coverage described in subsection (b)(1) in the case the qualifying individual— (aa)has been enrolled under the qualifying covered benefits program for a 4-year period; and (bb)fails to meet the milestones identified pursuant to clause (vi); and (VII)determine a maximum enrollment period for individual participation, including required milestones for addressing social determinants of health while enrolled; (v)for the purpose of encouraging a qualifying individual to seek a primary care physician, establish incentives for a qualifying individual to initially seek such physician for care (including the reduction of benefits until a primary care physician is engaged in the care of such qualifying individual); (vi)for the purpose of making progress toward health and economic self-sufficiency, establish routine milestones and supportive services (to be known as the comprehensive health improvement process) that a qualifying individual enrolled under health coverage described in subsection (b)(1) shall meet to maintain enrollment and such milestones shall include— (I)an assessment relating to social determinants of health, health risks, and any other assessment that is appropriate as determined by the circumstances of the qualifying individual; (II)meetings with a health coach to address social influences of health and to support the physical, emotional, and financial health of the qualifying individual; (III)connections with local community linkage partners to offer health-related programs and services; and (IV)enrollment in group classes that address barriers to physical, emotional, and financial health; (vii)for the purpose of tailoring a qualifying coverage benefits program to the needs and resources of the catchment area of the hospital described in subsection (g)(2)(C), determine the extent, if any, to narrow the income range specified in subsection (d)(1) with respect to first-time enrollees and continuing enrollees; (viii)incorporate population health improvement strategies into the benefits of health coverage described in subsection (b)(1), including strategies that align with the objectives of the program of the Secretary regarding health-status goals for 2020, commonly referred to as Healthy People 2020; (ix)select a plan administrator pursuant to subsection (g)(2)(E) to carry out administrative and accounting responsibilities of the health coverage described in subsection (b)(1); and (x)conduct a community asset assessment to determine the services to be made available in the community to address social determinants of health and the eligibility requirements for such services. (3)

Advisory committee

A board of directors shall establish a finance advisory committee and a clinical and population health improvement advisory committee. (f)

Grant terms

(1)

Duration

A grant awarded under this section shall be made for a period of 4 years. (2)

Amount

The Secretary shall determine the maximum amount of each grant awarded under subsection (a). (3)

Number

The Secretary may not award more than 4 grants under subsection (a). (g)

Applications

(1)

In general

To be eligible to be awarded a grant under subsection (a), a community-based coverage entity shall 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. (2)

Certification

An application described in paragraph (1) shall include a certification by the community-based coverage entity that the entity will— (A)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)(1); (B)not later than 2 years after the date on which a grant is awarded under subsection (a), establish a plan to measure quality and efficiency of care provided under the coverage program; (C)partner with a hospital that will establish a network of health care providers sufficient to provide services to qualifying individuals enrolled under the health insurance coverage described in subsection (b)(1); (D)seek to provide to 7 percent of individuals whose household income is more than 300 percent of the poverty line for a family of the size involved and less than the basic cost of living (as determined in a manner consistent the Asset Limited, Income Constrained, Employed or ALICE methodology that determines the cost of a basic household budget in the county of a State in which the catchment area of the hospital described in subparagraph (C) health coverage described in subsection (b)(1) is located) for the size of the family involved living in such catchment area; and (E)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 insurance coverage described in subsection (b)(1). (h)

Reporting

Not later than 1 year after the date of the enactment of this section and annually for each of the 3 succeeding years, the board of directors formed pursuant to subsection (b)(3) shall submit to the Secretary a report that— (1)evaluates the progress of the qualifying coverage benefits program; and (2)evaluates measurements relating to quality and efficiency of care described in subsection (g)(2)(B) collected by the community-based coverage entity. (i)

Definitions

In this section: (1)

Agency

The term agency means a local, State, or Federal agency. (2)

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)). (3)

First dollar coverage

The term first dollar coverage means coverage of a benefit by health coverage described in subsection (b)(1) without requiring any payment by the qualifying individual. (4)

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). (5)

Hospital

The term hospital means an institution that— (A)meets the requirements of section 1861(e) of the Social Security Act (42 U.S.C. 1395x(e)); and (B)is an organization described in paragraphs (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. (6)

Population health improvement service

(A)

In general

The term population health improvement service means a service that supports the physical, emotional, and financial health of a qualifying individual through— (i)health coaching that— (I)identifies any social determinant of health that prevents a qualifying individual from obtaining physical, emotional, and financial health; (II)develops a personalized plan to improve the physical, emotional, and financial health of a qualifying individual based on the circumstances and health domain score of such qualifying individual; and (III)measures and evaluates the health domain score of an individual; (ii)health education courses; and (iii)integrated community linkage partnerships with organizations serving the catchment area of a hospital described in subsection (g)(2)(C) that provide health programs and services to qualifying individuals that— (I)support a qualifying individual with respect to any appropriate social determinant of health; and (II)support a qualifying individual in job retention, including jobs in childcare and transportation. (B)

Health domain score defined

In this paragraph, the term health domain score means a measurement of specific influences of physical, emotional, and financial health with respect to a qualifying individual. (7)

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)). (8)

Secretary

The term Secretary means the Secretary of Health and Human Services. (9)

Small Business Health Options Program

The term Small Business Health Options Program has the meaning given such term in section 1311(b)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(b)(2)). (10)

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)). (11)

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. (j)

Authorization of appropriations

There is authorized to be appropriated to carry out this section— (1)$4,800,000 for fiscal year 2020; (2)$7,200,000 for fiscal year 2021; and (3)$12,000,000 for each of fiscal years 2022 and 2023.