S.Amdt. 3923

1. Adds TITLE __--THREE-SHARE PROGRAM wherever appropriate

   Adds a title

   Inserted: TITLE __--THREE-SHARE PROGRAM

   Inserted: SEC. __01. THREE-SHARE PROGRAMS.

   Inserted: Title XXIX of the Public Health Service Act, as added by section 201, is amended by adding at the end the following:

   Inserted: "Subtitle C--Providing for the Uninsured "SEC. 2941. THREE-SHARE PROGRAMS.

   Inserted: "(a) Pilot Programs.--The Secretary, acting through the Administrator, shall award grants under this section for the startup and operation of 25 eligible three-share pilot programs for a 5-year period.

   Inserted: "(b) Grants for Three-Share Programs.--

   Inserted: "(1) Establishment.--The Administrator may award grants to eligible entities--

   Inserted: "(A) to establish three-share programs;

   Inserted: "(B) to provide for contributions to the premiums assessed for coverage under a three-share program as provided for in subsection (c)(2)(B)(iii); and

   Inserted: "(C) to establish risk pools.

   Inserted: "(2) Three-share program plan.--Each entity desiring a grant under this subsection shall develop a plan for the establishment and operation of a three-share program that meets the requirements of paragraphs (2) and (3) of subsection (c).

   Inserted: "(3) Application.--Each entity desiring a grant under this subsection shall submit an application to the Administrator at such time, in such manner and containing such information as the Administrator may require, including--

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   Inserted: "(A) the three-share program plan described in paragraph (2); and

   Inserted: "(B) an assurance that the eligible entity will--

   Inserted: "(i) determine a benefit package;

   Inserted: "(ii) recruit businesses and employees for the three-share program;

   Inserted: "(iii) build and manage a network of health providers or contract with an existing network or licensed insurance provider;

   Inserted: "(iv) manage all administrative needs; and

   Inserted: "(v) establish relationships among community, business, and provider interests.

   Inserted: "(4) Priority.--In awarding grants under this section the Administrator shall give priority to an applicant--

   Inserted: "(A) that is an existing three-share program;

   Inserted: "(B) that is an eligible three-share program that has demonstrated community support; or

   Inserted: "(C) that is located in a State with insurance laws and regulations that permit three-share program expansion.

   Inserted: "(c) Grant Eligibility.--

   Inserted: "(1) In general.--The Secretary, acting through the Administrator, shall promulgate regulations providing for the eligibility of three-share programs for participation in the pilot program under this section.

   Inserted: "(2) Three-share program requirements.--

   Inserted: "(A) In general.--To be determined to be an eligible three-share program for purposes of participation in the pilot program under this section a three-share program shall--

   Inserted: "(i) be either a non-profit or local governmental entity;

   Inserted: "(ii) define the region in which such program will provide services;

   Inserted: "(iii) have the capacity to carry out administrative functions of managing health plans, including monthly billings, verification/enrollment of eligible employers and employees, maintenance of membership rosters, development of member materials (such as handbooks and identification cards), customer service, and claims processing; and

   Inserted: "(iv) have demonstrated community involvement.

   Inserted: "(B) Payment.--To be eligible under paragraph (1), a three-share program shall pay the costs of services provided under subparagraph (A)(ii) by charging a monthly premium for each covered individual to be divided as follows:

   Inserted: "(i) Not more than 30 percent of such premium shall be paid by a qualified employee desiring coverage under the three-share program.

   Inserted: "(ii) Not more than 30 percent of such premium shall be paid by the qualified employer of such a qualified employee.

   Inserted: "(iii) At least 40 percent of such premium shall be paid from amounts provided under a grant under this section.

   Inserted: "(iv) Any remaining amount shall be paid by the three-share program from other public, private, or charitable sources.

   Inserted: "(C) Program flexibility.--A three-share program may set an income eligibility guideline for enrollment purposes.

   Inserted: "(3) Coverage.--

   Inserted: "(A) In general.--To be an eligible three-share program under this section, the three-share program shall provide at least the following benefits:

   Inserted: "(i) Physicians services.

   Inserted: "(ii) In-patient hospital services.

   Inserted: "(iii) Out-patient services.

   Inserted: "(iv) Emergency room visits.

   Inserted: "(v) Emergency ambulance services.

   Inserted: "(vi) Diagnostic lab fees and x-rays.

   Inserted: "(vii) Prescription drug benefits.

   Inserted: "(B) Limitation.--Nothing in subparagraph (A) shall be construed to require that a three-share program provide coverage for services performed outside the region described in paragraph (2)(A)(i).

   Inserted: "(C) Preexisting conditions.--A program described in subparagraph (A) shall not be an eligible three-share program under paragraph (1) if any individual can be excluded from coverage under such program because of a preexisting health condition.

   Inserted: "(d) Grants for Existing Three-Share Programs To Meet Certification Requirements.--

   Inserted: "(1) In general.--The Administrator may award grants to three-share programs that are operating on the date of enactment of this section.

   Inserted: "(2) Application.--Each eligible entity desiring a grant under this subsection shall submit an application to the Administrator at such time, in such manner, and containing such information as the Administrator may require.

   Inserted: "(e) Application of State Laws.--Nothing in this section shall be construed to preempt State law.

   Inserted: "(f) Distressed Business Formula.--

   Inserted: "(1) In general.--Not later than 60 days after the date of enactment of this section, the Administrator of the Health Resources and Services Administration shall develop a formula to determine which businesses qualify as distressed businesses for purposes of this section.

   Inserted: "(2) Effect on insurance market.--Granting eligibility to a distressed business using the formula under paragraph (1) shall not interfere with the insurance market. Any business found to have reduced benefits to qualify as a distressed business under the formula under paragraph (1) shall not be eligible to be a three-share program for purposes of this section.

   Inserted: "(g) Definitions.--In this section:

   Inserted: "(1) Administrator.--The term 'Administrator' means the Administrator of the Health Resources and Services Administration.

   Inserted: "(2) Covered individual.--The term 'covered individual' means--

   Inserted: "(A) a qualified employee; or

   Inserted: "(B) a child under the age of 23 or a spouse of such qualified employee who--

   Inserted: "(i) lacks access to health care coverage through their employment or employer;

   Inserted: "(ii) lacks access to health coverage through a family member;

   Inserted: "(iii) is not eligible for coverage under the medicare program under title XVIII or the medicaid program under title XIX; and

   Inserted: "(iv) does not qualify for benefits under the State Children's Health Insurance Program under title XXI.

   Inserted: "(3) Distressed business.--The term 'distressed business' means a business that--

   Inserted: "(A) in light of economic hardship and rising health care premiums may be forced to discontinue or scale back its health care coverage; and

   Inserted: "(B) qualifies as a distressed business according to the formula under subsection (g).

   Inserted: "(4) Eligible entity.--The term 'eligible entity' means an entity that meets the requirements of subsection (a)(2)(A).

   Inserted: "(5) Qualified employee.--The term 'qualified employee' means any individual employed by a qualified employer who meets certain criteria including--

   Inserted: "(A) lacking access to health coverage through a family member or common law partner;

   Inserted: "(B) not being eligible for coverage under the medicare program under title XVIII or the medicaid program under title XIX; and

   Inserted: "(C) agreeing that the share of fees described in subsection (a)(2)(B)(i) shall be paid in the form of payroll deductions from the wages of such individual.

   Inserted: "(6) Qualified employer.--The term 'qualified employer' means an employer as defined in section 3(d) of the Fair Labor Standards Act of 1938 (29 U.S.C. 203(d)) who--

   Inserted: "(A) is a small business concern as defined in section 3(a) of the Small Business Act (15 U.S.C. 632);

   Inserted: "(B) is located in the region described in subsection (a)(2)(A)(i); and

   Inserted: "(C) has not contributed to the health care benefits of its employees for at least 12 months consecutively or currently provides insurance but is classified as a distressed business.

   Inserted: "(h) Evaluation.--Not later than 90 days after the end of the 5-year period during which grants are available under this section, the Government Accountability Office shall submit to the Secretary and the appropriate committees of Congress a report concerning--

   Inserted: "(1) the effectiveness of the programs established under this section;

   Inserted: "(2) the number of individuals covered under such programs;

   Inserted: "(3) any resulting best practices; and

   Inserted: "(4) the level of community involvement.

   Inserted: "(i) Authorization of Appropriations.--There are authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2006 through 2011.".

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As printed