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

(a)

In general

Not later than 180 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall award at least 3 and not more than 5 grants to support Community Multi-Share Coverage 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; (2) promote workforce development for small businesses by addressing the psycho-social barriers that directly impact employment success and create barriers to exiting Medicaid, resulting in better health and workplace success; and (3) 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. (b)

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: (1)

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. (2)

Health coverage

The program provides enrolled qualifying individuals with health coverage that satisfies the following: (A)

Services covered

Provides coverage for the following categories of services when furnished by network providers and community resources: (i) Physician services. (ii) Inpatient and outpatient hospital services. (iii) Behavioral health services, including services for substance use disorder prevention and treatment. (iv) Preventative services. (v) Diagnostic laboratory tests and x-rays. (vi) Prescription drugs. (vii) Emergency ambulance services that are provided by ground transportation. (viii) 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))). (ix) Population health improvement services. (B)

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. (C)

Network providers

Establishes agreements with hospitals and health care providers located within the community to provide care for qualifying individuals. (3)

Community collaboration and alignment

The program is carried out in partnership with, or in formal coordination with, an existing community-based collaborative, intermediary, or coordinating entity that— (A) has demonstrated experience aligning safety-net health, human service, and workforce-related services within the community; (B) supports the identification of community-defined needs, priorities, and service gaps through ongoing engagement with community stakeholders; and (C) facilitates coordination among participating health care providers, community-based organizations, employers, and other relevant partners to avoid duplication and promote effective use of community resources. (4)

Integrated continuous health improvement services

The program provides, either directly or through contract, integrated continuous health improvement services that satisfy the following: (A) Regular assessments of community factors and resources that potentially impact enrollees’ physical, emotional, and economic health. (B) 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— (i) local small employers; (ii) entities that provide educational and occupational training (including classes, workshops, mentorships, and apprenticeships) designed to enhance preparation for work and support economic self-sufficiency; (iii) community health and health-related social need initiatives; (iv) investors; (v) local, State, and Federal governmental agencies; and (vi) organizations described in section 501(c)(3) of the Internal Revenue Code of 1986 that focuses on human service needs relating to physical health, behavioral health, poverty, education, access to health care, and safety. (C) Individualized assessment of each enrollee to identify any negative influences on their physical, emotional, and economic health, and ability to achieve economic self-sufficiency, which shall include— (i) an assessment of any of the enrollee’s psycho-social barriers, health risks, barriers to long-term employment, and barriers to increasing income; and (ii) 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. (D) Establishment of an individualized plan to support each enrollee in achieving better health and economic self-sufficiency, which shall— (i) identify community resources that will support the enrollee in improving their physical, behavioral, or economic health, which may include— (I) group classes that address barriers to physical, emotional, and economic health; and (II) educational and occupational training opportunities that enhance work preparedness and support economic self-sufficiency; and (ii) contain engagement milestones, with a goal of identifying and overcoming obstacles to engagement in personal health improvement and mitigation of root-cause barriers, which shall include— (I) participation in individualized health coaching services to address the enrollee’s health-related social needs and to support their physical, emotional, and financial health; and (II) engagement with community resources, such as participating in group classes, as recommended by the health coach. (5)

Funding structure

(A)

In general

The direct costs of the program are shared among the following entities, each of which makes a direct financial contribution: (i) The public sector. (ii) Local health care providers. (iii) Enrollees. (iv) Enrollees’ employers or skilled trade organizations. (B)

Shared financial responsibility and long-term sustainability

The program shall be structured to support long-term financial sustainability through a shared financial responsibility framework that— (i) relies on coordinated and ongoing contributions from multiple levels of government, local resources, and hospital community benefit investment; (ii) avoids dependence on a single funding source by establishing a defined, multi-year transition toward a stable allocation of financial responsibility across participating sectors; and (iii) demonstrates measurable progress toward a mature financing structure in which Federal support is supplemented by sustained contributions from State and local government and hospital community benefit resources. (6)

Enrollees

(A) In the event that a Program is unable to provide services to all qualifying individuals in its catchment area, the Program has a publicly available written policy for determining which qualifying individuals are offered enrollment. (B) The program may rescind a qualifying individual’s enrollment due to sustained failure to meet minimum engagement and personal growth thresholds, which shall be participatory and not health-contingent, and provide for reasonable alternatives, in their individual plan described in subsection (b)(2)(D). (7)

Evaluation

The program formally evaluates its impact on enrollees’ employment status, physical and behavioral health, income, and economic self-sufficiency. (c)

Qualifying individual

The term qualifying individual means an individual who— (1) resides or works within the catchment area of a partner hospital described in subsection (e)(1)(A); (2) 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; (3) 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; (4) is ineligible for enrollment in a Federal health care program, including ineligibility to receive health services through the Indian Health Service or Veterans Administration; (5) 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 (6) meets other requirements the Secretary determines appropriate. (d)

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

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. (e)

Applications

(1)

In general

To be eligible to be awarded a grant under subsection (a), an applicant must— (A) be a non-profit entity with documented commitments from local partner hospitals and small employers to participate in a Community Multi-Share Coverage Plan; and (B) 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

To eligible for funding under this section, an application described in paragraph (1) shall include certifications that the program— (A) 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)(1); (B) 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); (C) will seek to enroll 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); (D) 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)(2); and (E) 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. (f)

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)

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). (4)

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. 31395x(e)); and (B) 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. (5)

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)). (6)

Secretary

The term Secretary means the Secretary of Health and Human Services. (7)

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)). (8)

Health-related social needs

The term health-related social needs has the meaning given such term by the Director of the Centers for Disease Control and Prevention. (g)

Authorization of appropriations

There is authorized to be appropriated to carry out this section— (1) $4,800,000 for fiscal year 2026; (2) $7,200,000 for fiscal year 2027; and (3) $12,000,000 for each of fiscal years 2028 and 2029.