Hospital Community Benefit Coverage Model

The Hospital Community Benefit Coverage Model is based on the long-standing success of the Access Health multi-share program that offers health coverage to working, low-income uninsured individuals. Incorporating the Access Health multi-share model with hospital community benefit programs provides an opportunity for hospitals to meet the needs of the uninsured population they serve, and to manage the risk of this population through sustained improvements to the their health.

When integrated with the multi-share model, hospital community benefit programs align critical community resources in an efficient business model that also complies with the criteria for hospital community benefit. Through the multi-share model, a portion of hospital community benefit investment is combined with individual and community contributions to support programs that provide healthcare and care management to the low-income working uninsured.

This model is proven to reduce ED utilization, and mitigate charitable care and bad debt costs to the hospital. It has also demonstrated that the health of uninsured populations can be managed, and that cost drivers, like chronic disease, can be reduced. In return for a zero deductible, affordable healthcare program, uninsured participants agree to engage in long-lasting health improvement activities. These health improvement activities are provided through a proven health-coaching model that supports both participants and providers.

Regulatory Framework

Federal regulations require that non-profit hospitals meet community benefit criteria to maintain their non-profit status. IRS Instructions for Community Benefit defines community benefit activities or programs as: improving access to health services, enhancing public health, advancing increased general knowledge, and providing relief of the government burden to improve health. These community benefit activities or programs are required to:

  • Be available broadly to the public and serve low-income consumers
  • Reduce geographic, financial, or cultural barriers to accessing health services
  • Address federal, state, or local public health priorities such as eliminating disparities in access to health care services or disparities in health status among different populations
  • Leverage or enhance public health department activities
  • Strengthen community health resilience
  • Reduce the burden of government or another tax-exempt organization to improve health.
  • Advance increased general knowledge through education or research that benefits the public

 

Key Eligibility Requirements for the Model

The federal guidance provides a framework for hospitals to meet their required community benefit obligations, in part, by offering community programs that meet the healthcare needs of the uninsured (charitable care) and improves population health. Hospital community benefit coverage programs with a focus on lasting health improvement do meet the federal criteria for community benefit. When designed to also meet the federal requirement for Minimum Essential Coverage (MEC), these innovative programs also meet the Affordable Care Act criteria for the individual mandate.

  • The member’s projected annual household income is from 133% to 275% of the Federal Poverty Level.
  • Participants and their dependents are sponsored by a participating community business partner that does not offer them insurance.
  • The member or dependent may not eligible to participate if they can otherwise receive health benefits under, any type of federal, state or business-sponsored ongoing health insurance, health benefit plan or program of health benefits.

Individual Benefits

Coverage benefits – Comprehensive multi-share benefits, certified to comply with the federal criteria for minimum essential coverage, so participants are not subject to the IRS penalty for being uninsured.

  • MEC healthcare benefits are combined with community health service resources, otherwise available to the uninsured, to ensure affordability and quality care management. For example, community pharmaceutical assistance programs or health department screenings.

 

Personal Health Improvement Benefits – Individualized Continuous Health Improvement (CHI) coaching supporting care coordination and individuals health management, including:

  • Comprehensive health risk assessments
  • Individual health plan and goal setting
  • Face-to-face health coaching
  • Health educational courses
  • Assistance in navigating available community resources
  • Support in chronic disease management

Community Benefits

The Hospital Community Benefit Coverage program provides health care services that benefit the larger community they serve by:

  • Improving access to health services
  • Improving population health
  • Improving health education
  • Reducing the burden on the government to improve health