[Congressional Record Volume 142, Number 57 (Tuesday, April 30, 1996)]
[House]
[Pages H4287-H4299]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                      CONFERENCE REPORT ON S. 641

  Mr. BLILEY submitted the following conference report and statement on 
the bill (S. 641) to reauthorize the Ryan White CARE Act of 1990, and 
for other purposes:

                  Conference Report (H. Rept. 104-545)

       The committee of conference on the disagreeing votes of the 
     two Houses on the amendments of the House to the bill (S. 
     641), to reauthorize the Ryan White CARE Act of 1990, and for 
     other purposes, having met, after full and free conference, 
     have agreed to recommend and do recommend to their respective 
     Houses as follows:
       That the Senate recede from its disagreement to the 
     amendment of the House to the text of the bill and agree to 
     the same with an amendment as follows:
       In lieu of the matter proposed to be inserted by the House 
     amendment, insert the following:

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Ryan White CARE Act 
     Amendments of 1996''.

     SEC. 2. REFERENCES.

       Whenever in this Act an amendment is expressed in terms of 
     an amendment to a section or other provision, the reference 
     shall be considered to be made to a section or other 
     provision of the Public Health Service Act (42 U.S.C. 201 et 
     seq.).

     SEC. 3. GENERAL AMENDMENTS.

       (a) Program of Grants.--
       (1) Number of cases.--Section 2601(a) (42 U.S.C. 300ff-11) 
     is amended--
       (A) by striking ``subject to subsection (b)'' and inserting 
     ``subject to subsections (b) through (d)''; and
       (B) by striking ``metropolitan area'' and all that follows 
     and inserting the following: ``metropolitan area for which 
     there has been reported to the Director of the Centers for 
     Disease Control and Prevention a cumulative total of more 
     than 2,000 cases of acquired immune deficiency syndrome for 
     the most recent period of 5 calendar years for which such 
     data are available.''.
       (2) Other provisions regarding eligibility.--Section 2601 
     (42 U.S.C. 300ff-11) is amended by adding at the end thereof 
     the following new subsections:
       ``(c) Requirements Regarding Population.--
       ``(1) Number of individuals.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     the Secretary may not make a grant under this section for a 
     metropolitan area unless the area has a population of 500,000 
     or more individuals.
       ``(B) Limitation.--Subparagraph (A) does not apply to any 
     metropolitan area that was an eligible area under this part 
     for fiscal year 1995 or any prior fiscal year.
       ``(2) Geographic boundaries.--For purposes of eligibility 
     under this part, the boundaries of each metropolitan area are 
     the boundaries that were in effect for the area for fiscal 
     year 1994.
       ``(d) Continued Status as Eligible Area.--Notwithstanding 
     any other provision of this section, a metropolitan area that 
     was an eligible area under this part for fiscal year 1996 is 
     an eligible area for fiscal year 1997 and each subsequent 
     fiscal year.''.
       (3) Conforming amendment regarding definition of eligible 
     area.--Section 2607(1) (42 U.S.C. 300ff-17(1)) is amended by 
     striking ``The term'' and all that follows and inserting the 
     following: ``The term `eligible area' means a metropolitan 
     area meeting the requirements of section 2601 that are 
     applicable to the area.''.
       (b) Emergency Relief for Areas With Substantial Need for 
     Services.--
       (1) HIV health services planning council.--Subsection (b) 
     of section 2602 (42 U.S.C. 300ff-12(b)) is amended--

[[Page H4288]]

       (A) in paragraph (1)--
       (i) by striking ``include'' and all that follows through 
     the end thereof, and inserting ``reflect in its composition 
     the demographics of the epidemic in the eligible area 
     involved, with particular consideration given to 
     disproportionately affected and historically underserved 
     groups and subpopulations.''; and
       (ii) by adding at the end thereof the following new 
     sentences: ``Nominations for membership on the council shall 
     be identified through an open process and candidates shall be 
     selected based on locally delineated and publicized criteria. 
     Such criteria shall include a conflict-of-interest standard 
     that is in accordance with paragraph (5).'';
       (B) in paragraph (2), by adding at the end thereof the 
     following new subparagraph:
       ``(C) Chairperson.--A planning council may not be chaired 
     solely by an employee of the grantee.'';
       (C) in paragraph (3)--
       (i) in subparagraph (A), by striking ``area;'' and 
     inserting ``area, including how best to meet each such 
     priority and additional factors that a grantee should 
     consider in allocating funds under a grant based on the--
       ``(i) documented needs of the HIV-infected population;
       ``(ii) cost and outcome effectiveness of proposed 
     strategies and interventions, to the extent that such data 
     are reasonably available, (either demonstrated or probable);
       ``(iii) priorities of the HIV-infected communities for whom 
     the services are intended; and
       ``(iv) availability of other governmental and 
     nongovernmental resources;'';
       (ii) by striking ``and'' at the end of subparagraph (B);
       (iii) by striking the period at the end of subparagraph (C) 
     and inserting ``, and at the discretion of the planning 
     council, assess the effectiveness, either directly or through 
     contractual arrangements, of the services offered in meeting 
     the identified needs; ''; and
       (iv) by adding at the end thereof the following new 
     subparagraphs:
       ``(D) participate in the development of the Statewide 
     coordinated statement of need initiated by the State public 
     health agency responsible for administering grants under part 
     B; and
       ``(E) establish methods for obtaining input on community 
     needs and priorities which may include public meetings, 
     conducting focus groups, and convening ad-hoc panels.'';
       (D) by redesignating paragraphs (2) and (3) as paragraphs 
     (3) and (4), respectively;
       (E) by inserting after paragraph (1), the following new 
     paragraph:
       ``(2) Representation.--The HIV health services planning 
     council shall include representatives of--
       ``(A) health care providers, including federally qualified 
     health centers;
       ``(B) community-based organizations serving affected 
     populations and AIDS service organizations;
       ``(C) social service providers;
       ``(D) mental health and substance abuse providers;
       ``(E) local public health agencies;
       ``(F) hospital planning agencies or health care planning 
     agencies;
       ``(G) affected communities, including people with HIV 
     disease or AIDS and historically underserved groups and 
     subpopulations;
       ``(H) nonelected community leaders;
       ``(I) State government (including the State medicaid agency 
     and the agency administering the program under part B);
       ``(J) grantees under subpart II of part C;
       ``(K) grantees under section 2671, or, if none are 
     operating in the area, representatives of organizations with 
     a history of serving children, youth, women, and families 
     living with HIV and operating in the area; and
       ``(L) grantees under other Federal HIV programs.''; and
       (F) by adding at the end thereof the following:
       ``(5) Conflicts of interest.--
       ``(A) In general.--The planning council under paragraph (1) 
     may not be directly involved in the administration of a grant 
     under section 2601(a). With respect to compliance with the 
     preceding sentence, the planning council may not designate 
     (or otherwise be involved in the selection of) particular 
     entities as recipients of any of the amounts provided in the 
     grant.
       ``(B) Required agreements.--An individual may serve on the 
     planning council under paragraph (1) only if the individual 
     agrees that if the individual has a financial interest in an 
     entity, if the individual is an employee of a public or 
     private entity, or if the individual is a member of a public 
     or private organization, and such entity or organization is 
     seeking amounts from a grant under section 2601(a), the 
     individual will not, with respect to the purpose for which 
     the entity seeks such amounts, participate (directly or in an 
     advisory capacity) in the process of selecting entities to 
     receive such amounts for such purpose.
       ``(6) Grievance procedures.--A planning council under 
     paragraph (1) shall develop procedures for addressing 
     grievances with respect to funding under this part, including 
     procedures for submitting grievances that cannot be resolved 
     to binding arbitration. Such procedures shall be described in 
     the by-laws of the planning council and be consistent with 
     the requirements of subsection (c).
       ``(c) Grievance Procedures.--
       ``(1) Federal responsibility.--
       ``(A) Models.--The Secretary shall, through a process that 
     includes consultations with grantees under this part and 
     public and private experts in grievance procedures, 
     arbitration, and mediation, develop model grievance 
     procedures that may be implemented by the planning council 
     under subsection (b)(1) and grantees under this part. Such 
     model procedures shall describe the elements that must be 
     addressed in establishing local grievance procedures and 
     provide grantees with flexibility in the design of such local 
     procedures.
       ``(B) Review.--The Secretary shall review grievance 
     procedures established by the planning council and grantees 
     under this part to determine if such procedures are adequate. 
     In making such a determination, the Secretary shall assess 
     whether such procedures permit legitimate grievances to be 
     filed, evaluated, and resolved at the local level.
       ``(2) Grantees.--To be eligible to receive funds under this 
     part, a grantee shall develop grievance procedures that are 
     determined by the Secretary to be consistent with the model 
     procedures developed under paragraph (1)(A). Such procedures 
     shall include a process for submitting grievances to binding 
     arbitration.''.
       (2) Distribution of grants.--Section 2603 (42 U.S.C. 300ff-
     13) is amended--
       (A) in subsection (a)(2), by striking ``Not later than--'' 
     and all that follows through ``the Secretary shall'' and 
     inserting the following: ``Not later than 60 days after an 
     appropriation becomes available to carry out this part for 
     each of the fiscal years 1996 through 2000, the Secretary 
     shall''; and
       (B) in subsection (b)
       (i) in paragraph (1)--

       (I) by striking ``and'' at the end of subparagraph (D);
       (II) by striking the period at the end of subparagraph (E) 
     and inserting a semicolon; and
       (III) by adding at the end thereof the following new 
     subparagraphs:

       ``(F) demonstrates the inclusiveness of the planning 
     council membership, with particular emphasis on affected 
     communities and individuals with HIV disease; and
       ``(G) demonstrates the manner in which the proposed 
     services are consistent with the local needs assessment and 
     the Statewide coordinated statement of need.''; and
       (ii) by redesignating paragraphs (2), (3), and (4) as 
     paragraphs (3), (4), and (5), respectively; and
       (iii) by inserting after paragraph (1), the following new 
     paragraph:
       ``(2) Definition.--
       ``(A) Severe need.--In determining severe need in 
     accordance with paragraph (1)(B), the Secretary shall 
     consider the ability of the qualified applicant to expend 
     funds efficiently and the impact of relevant factors on the 
     cost and complexity of delivering health care and support 
     services to individuals with HIV disease in the eligible 
     area, including factors such as--
       ``(i) sexually transmitted diseases, substance abuse, 
     tuberculosis, severe mental illness, or other comorbid 
     factors determined relevant by the Secretary;
       ``(ii) new or growing subpopulations of individuals with 
     HIV disease; and
       ``(iii) homelessness.
       ``(B) Prevalence.--In determining the impact of the factors 
     described in subparagraph (A), the Secretary shall, to the 
     extent practicable, use national, quantitative incidence data 
     that are available for each eligible area. Not later than 2 
     years after the date of enactment of this paragraph, the 
     Secretary shall develop a mechanism to utilize such data. In 
     the absence of such data, the Secretary may consider a 
     detailed description and qualitative analysis of severe need, 
     as determined under subparagraph (A), including any local 
     prevalence data gathered and analyzed by the eligible area.
       ``(C) Priority.--Subsequent to the development of the 
     quantitative mechanism described in subparagraph (B), the 
     Secretary shall phase in, over a 3-year period beginning in 
     fiscal year 1998, the use of such a mechanism to determine 
     the severe need of an eligible area compared to other 
     eligible areas and to determine, in part, the amount of 
     supplemental funds awarded to the eligible area under this 
     part.''.
       (3) Distribution of funds.--
       (A) In general.--Section 2603(a)(2) (42 U.S.C. 300ff-
     13(a)(2)) (as amended by paragraph (2)) is further amended--
       (i) by inserting ``, in accordance with paragraph (3)'' 
     before the period; and
       (ii) by adding at the end thereof the following new 
     sentences: ``The Secretary shall reserve an additional 
     percentage of the amount appropriated under section 2677 for 
     a fiscal year for grants under part A to make grants to 
     eligible areas under section 2601(a) in accordance with 
     paragraph (4).''.
       (B) Increase in grant.--Section 2603(a) (42 U.S.C. 300ff-
     13(a)) is amended by adding at the end thereof the following 
     new paragraph:
       ``(4) Increase in grant.--With respect to an eligible area 
     under section 2601(a), the Secretary shall increase the 
     amount of a grant under paragraph (2) for a fiscal year to 
     ensure that such eligible area receives not less than--
       ``(A) with respect to fiscal year 1996, 100 percent;
       ``(B) with respect to fiscal year 1997, 99 percent;
       ``(C) with respect to fiscal year 1998, 98 percent;
       ``(D) with respect to fiscal year 1999, 96.5 percent; and
       ``(E) with respect to fiscal year 2000, 95 percent;


[[Page H4289]]


     of the amount allocated for fiscal year 1995 to such entity 
     under this subsection.''.
       (C) Additional requirements for grants.--Section 2603 (42 
     U.S.C. 300ff-13) is amended by adding at the end thereof the 
     following subsection:
       ``(c) Compliance With Priorities of HIV Planning Council.--
     Notwithstanding any other provision of this part, the 
     Secretary, in carrying out section 2601(a), may not make any 
     grant under subsection (a) or (b) to an eligible area unless 
     the application submitted by such area under section 2605 for 
     the grant involved demonstrates that the grants made under 
     subsections (a) and (b) to the area for the preceding fiscal 
     year (if any) were expended in accordance with the priorities 
     applicable to such year that were established, pursuant to 
     section 2602(b)(3)(A), by the planning council serving the 
     area.''.
       (4) Use of amounts.--Section 2604 (42 U.S.C. 300ff-14) is 
     amended--
       (A) in subsection (b)(1)(A)--
       (i) by inserting ``, substance abuse treatment and mental 
     health treatment,'' after ``case management''; and
       (ii) by inserting ``which shall include treatment education 
     and prophylactic treatment for opportunistic infections,'' 
     after ``treatment services,'';
       (B) in subsection (b)(2)(A)--
       (i) by inserting ``, or private for-profit entities if such 
     entities are the only available provider of quality HIV care 
     in the area,'' after ``nonprofit private entities,''; and
       (ii) by striking ``and homeless health centers'' and 
     inserting ``homeless health centers, substance abuse 
     treatment programs, and mental health programs'';
       (C) by adding at the end of subsection (b), the following 
     new paragraph:
       ``(3) Priority for women, infants and children.--For the 
     purpose of providing health and support services to infants, 
     children, and women with HIV disease, including treatment 
     measures to prevent the perinatal transmission of HIV, the 
     chief elected official of an eligible area, in accordance 
     with the established priorities of the planning council, 
     shall use, from the grants made for the area under section 
     2601(a) for a fiscal year, not less than the percentage 
     constituted by the ratio of the population in such area of 
     infants, children, and women with acquired immune deficiency 
     syndrome to the general population in such area of 
     individuals with such syndrome.''; and
       (C) in subsection (e)--
       (i) in the subsection heading, by striking ``and 
     Planning'';
       (ii) by striking ``The chief'' and inserting:
       ``(1) In general.--The chief'';
       (iii) by striking ``accounting, reporting, and program 
     oversight functions'';
       (iv) by adding at the end thereof the following new 
     sentence: ``In the case of entities and subcontractors to 
     which such officer allocates amounts received by the officer 
     under the grant, the officer shall ensure that, of the 
     aggregate amount so allocated, the total of the expenditures 
     by such entities for administrative expenses does not exceed 
     10 percent (without regard to whether particular entities 
     expend more than 10 percent for such expenses).''; and
       (v) by adding at the end thereof the following new 
     paragraphs:
       ``(2) Administrative activities.--For the purposes of 
     paragraph (1), amounts may be used for administrative 
     activities that include--
       ``(A) routine grant administration and monitoring 
     activities, including the development of applications for 
     part A funds, the receipt and disbursal of program funds, the 
     development and establishment of reimbursement and accounting 
     systems, the preparation of routine programmatic and 
     financial reports, and compliance with grant conditions and 
     audit requirements; and
       ``(B) all activities associated with the grantee's contract 
     award procedures, including the development of requests for 
     proposals, contract proposal review activities, negotiation 
     and awarding of contracts, monitoring of contracts through 
     telephone consultation, written documentation or onsite 
     visits, reporting on contracts, and funding reallocation 
     activities.
       ``(3) Subcontractor administrative costs.--For the purposes 
     of this subsection, subcontractor administrative activities 
     include--
       ``(A) usual and recognized overhead, including established 
     indirect rates for agencies;
       ``(B) management oversight of specific programs funded 
     under this title; and
       ``(C) other types of program support such as quality 
     assurance, quality control, and related activities.''.
       (5) Application.--Section 2605 (42 U.S.C. 300ff-15) is 
     amended--
       (A) in subsection (a)--
       (i) in the matter preceding paragraph (1), by inserting ``, 
     in accordance with subsection (c) regarding a single 
     application and grant award,'' after ``application'';
       (ii) in paragraph (1)(B), by striking ``1-year period'' and 
     all that follows through ``eligible area'' and inserting 
     ``preceding fiscal year'';
       (iii) in paragraph (4), by striking ``and'' at the end 
     thereof;
       (iv) in paragraph (5), by striking the period at the end 
     thereof and inserting ``; and''; and
       (v) by adding at the end thereof the following new 
     paragraph:
       ``(6) that the applicant has participated, or will agree to 
     participate, in the Statewide coordinated statement of need 
     process where it has been initiated by the State public 
     health agency responsible for administering grants under part 
     B, and ensure that the services provided under the 
     comprehensive plan are consistent with the Statewide 
     coordinated statement of need.'';
       (B) in subsection (b)--
       (i) in the subsection heading, by striking ``Additional''; 
     and
       (ii) in the matter preceding paragraph (1), by striking 
     ``additional application'' and inserting ``application, in 
     accordance with subsection (c) regarding a single application 
     and grant award,''; and
       (C) by redesignating subsections (c) and (d) as subsections 
     (d) and (e), respectively; and
       (D) by inserting after subsection (b), the following new 
     subsection:
       ``(c) Single Application and Grant Award.--
       ``(1) Application.--The Secretary may phase in the use of a 
     single application that meets the requirements of subsections 
     (a) and (b) of section 2603 with respect to an eligible area 
     that desires to receive grants under section 2603 for a 
     fiscal year.
       ``(2) Grant award.--The Secretary may phase in the awarding 
     of a single grant to an eligible area that submits an 
     approved application under paragraph (1) for a fiscal 
     year.''.
       (6) Technical assistance.--Section 2606 (42 U.S.C. 300ff-
     16) is amended--
       (A) by striking ``may'' and inserting ``shall'';
       (B) by inserting after ``technical assistance'' the 
     following: ``, including assistance from other grantees, 
     contractors or subcontractors under this title to assist 
     newly eligible metropolitan areas in the establishment of HIV 
     health services planning councils and,''; and
       (C) by adding at the end thereof the following new 
     sentences: ``The Administrator may make planning grants 
     available to metropolitan areas, in an amount not to exceed 
     $75,000 for any metropolitan area, projected to be eligible 
     for funding under section 2601 in the following fiscal year. 
     Such grant amounts shall be deducted from the first year 
     formula award to eligible areas accepting such grants. Not to 
     exceed 1 percent of the amount appropriated for a fiscal year 
     under section 2677 for grants under part A may be used to 
     carry out this section.''.
       (c) Care Grant Program.--
       (1) Priority for women, infants and children.--Section 2611 
     (42 U.S.C. 300ff-21) is amended--
       (A) by striking ``The'' and inserting ``(a) In General.--
     The''; and
       (B) by adding at the end thereof the following new 
     subsection:
       ``(b) Priority for Women, Infants and Children.--For the 
     purpose of providing health and support services to infants, 
     children, and women with HIV disease, including treatment 
     measures to prevent the perinatal transmission of HIV, a 
     State shall use, of the funds allocated under this part to 
     the State for a fiscal year, not less than the percentage 
     constituted by the ratio of the population in the State of 
     infants, children, and women with acquired immune deficiency 
     syndrome to the general population in the State of 
     individuals with such syndrome.''.
       (2) Use of Grants.--Section 2612 (42 U.S.C. 300ff-22) is 
     amended--
       (A) in subsection (a)--
       (i) by striking the subsection designation and heading;
       (ii) by redesignating paragraphs (1) through (4) as 
     paragraphs (2) through (5), respectively;
       (iii) by inserting the following new paragraph:
       ``(1) to provide the services described in section 
     2604(b)(1) for individuals with HIV disease;'';
       (iv) in paragraph (5) (as so redesignated), by striking 
     ``treatments'' and all that follows through ``health,'' and 
     inserting ``therapeutics to treat HIV disease''; and
       (v) by adding at the end thereof the following flush 
     sentences:

     ``Services described in paragraph (1) shall be delivered 
     through consortia designed as described in paragraph (2), 
     where such consortia exist, unless the State demonstrates to 
     the Secretary that delivery of such services would be more 
     effective when other delivery mechanisms are used. In making 
     a determination regarding the delivery of services, the State 
     shall consult with appropriate representatives of service 
     providers and recipients of services who would be affected by 
     such determination, and shall include in its demonstration to 
     the Secretary the findings of the State regarding such 
     consultation.''; and
       (B) by striking subsection (b).
       (2) HIV care consortia.--Section 2613 (42 U.S.C. 300ff-23) 
     is amended--
       (A) in subsection (a)--
       (i) in paragraph (1), by inserting ``(or private for-profit 
     providers or organizations if such entities are the only 
     available providers of quality HIV care in the area)'' after 
     ``nonprofit private,''; and
       (ii) in paragraph (2)(A)--

       (I) by inserting ``substance abuse treatment, mental health 
     treatment,'' after ``nursing,''; and
       (II) by inserting ``prophylactic treatment for 
     opportunistic infections, treatment education to take place 
     in the context of health care delivery,'' after 
     ``monitoring,''; and

       (B) in subsection (c)--
       (i) in subparagraph (C) of paragraph (1), by inserting 
     before ``care'' ``and youth centered''; and
       (ii) in paragraph (2)--

[[Page H4290]]

       (I) in clause (ii) of subparagraph (A), by striking 
     ``served; and'' and inserting ``served;'';
       (II) in subparagraph (B), by striking the period at the end 
     and inserting ``; and''; and
       (III) by adding after subparagraph (B), the following new 
     subparagraph:

       ``(C) grantees under section 2671, or, if none are 
     operating in the area, representatives in the area of 
     organizations with a history of serving children, youth, 
     women, and families living with HIV.''.
       (3) Provision of treatments.--Section 2616 (42 U.S.C. 
     300ff-26) is amended--
       (A) in subsection (a)--
       (i) by striking ``may use amounts'' and inserting ``shall 
     use a portion of the amounts'';
       (ii) by striking ``section 2612(a)(4)'' and all that 
     follows through ``prolong life'' and inserting ``section 
     2612(a)(5) to provide therapeutics to treat HIV disease''; 
     and
       (iii) by inserting before the period the following: ``, 
     including measures for the prevention and treatment of 
     opportunistic infections'';
       (B) in subsection (c)--
       (i) in paragraph (3), by striking ``and'' at the end 
     thereof;
       (ii) in paragraph (4), by striking the period and inserting 
     ``; and''; and
       (iii) by adding at the end thereof the following new 
     paragraph:
       ``(5) document the progress made in making therapeutics 
     described in subsection (a) available to individuals eligible 
     for assistance under this section.''; and
       (C) by adding at the end thereof the following new 
     subsection:
       ``(d) Duties of the Secretary.--In carrying out this 
     section, the Secretary shall review the current status of 
     State drug reimbursement programs established under section 
     2612(2) and assess barriers to the expanded availability of 
     the treatments described in subsection (a). The Secretary 
     shall also examine the extent to which States coordinate with 
     other grantees under this title to reduce barriers to the 
     expanded availability of the treatments described in 
     subsection (a).''.
       (4) State application.--Section 2617(b) (42 U.S.C. 300ff-
     27(b)) is amended--
       (A) in paragraph (2)--
       (i) in subparagraph (A), by striking ``and'' at the end 
     thereof; and
       (ii) by adding at the end thereof the following new 
     subparagraph:
       ``(C) a description of how the allocation and utilization 
     of resources are consistent with the Statewide coordinated 
     statement of need (including traditionally underserved 
     populations and subpopulations) developed in partnership with 
     other grantees in the State that receive funding under this 
     title; and'';
       (B) by redesignating paragraph (3) as paragraph (4);
       (C) by inserting after paragraph (2), the following new 
     paragraph:
       ``(3) an assurance that the public health agency 
     administering the grant for the State will periodically 
     convene a meeting of individuals with HIV, representatives of 
     grantees under each part under this title, providers, and 
     public agency representatives for the purpose of developing a 
     Statewide coordinated statement of need; and''.
       (5) Planning, evaluation and administration.--Section 
     2618(c) (42 U.S.C. 300ff-28(c)) is amended--
       (A) by striking paragraph (1);
       (B) in paragraphs (3) and (4), to read as follows:
       ``(3) Planning and evaluations.--Subject to paragraph (5) 
     and except as provided in paragraph (6), a State may not use 
     more than 10 percent of amounts received under a grant 
     awarded under this part for planning and evaluation 
     activities.
       ``(4) Administration.--
       ``(A) In general.--Subject to paragraph (5) and except as 
     provided in paragraph (6), a State may not use more than 10 
     percent of amounts received under a grant awarded under this 
     part for administration. In the case of entities and 
     subcontractors to which the State allocates amounts received 
     by the State under the grant (including consortia under 
     section 2613), the State shall ensure that, of the aggregate 
     amount so allocated, the total of the expenditures by such 
     entities for administrative expenses does not exceed 10 
     percent (without regard to whether particular entities expend 
     more than 10 percent for such expenses).
       ``(B) Administrative activities.--For the purposes of 
     subparagraph (A), amounts may be used for administrative 
     activities that include routine grant administration and 
     monitoring activities.
       ``(C) Subcontractor administrative costs.--For the purposes 
     of this paragraph, subcontractor administrative activities 
     include--
       ``(i) usual and recognized overhead, including established 
     indirect rates for agencies;
       ``(ii) management oversight of specific programs funded 
     under this title; and
       ``(iii) other types of program support such as quality 
     assurance, quality control, and related activities.'';
       (C) by redesignating paragraph (5) as paragraph (7); and
       (D) by inserting after paragraph (4), the following new 
     paragraphs:
       ``(5) Limitation on use of funds.--Except as provided in 
     paragraph (6), a State may not use more than a total of 15 
     percent of amounts received under a grant awarded under this 
     part for the purposes described in paragraphs (3) and (4).
       ``(6) Exception.--With respect to a State that receives the 
     minimum allotment under subsection (a)(1) for a fiscal year, 
     such State, from the amounts received under a grant awarded 
     under this part for such fiscal year for the activities 
     described in paragraphs (3) and (4), may, notwithstanding 
     paragraphs (3), (4), and (5), use not more than that amount 
     required to support one full-time-equivalent employee.''.
       (6) Technical assistance.--Section 2619 (42 U.S.C. 300ff-
     29) is amended--
       (A) by striking ``may'' and inserting ``shall''; and
       (B) by inserting before the period the following: ``, 
     including technical assistance for the development and 
     implementation of Statewide coordinated statements of need''.
       (7) Coordination.--Part B of title XXVI (42 U.S.C. 300ff-21 
     et seq.) is amended by adding at the end thereof the 
     following new section:

     ``SEC. 2621. COORDINATION.

       ``The Secretary shall ensure that the Health Resources and 
     Services Administration, the Centers for Disease Control and 
     Prevention, and the Substance Abuse and Mental Health 
     Services Administration coordinate the planning and 
     implementation of Federal HIV programs in order to facilitate 
     the local development of a complete continuum of HIV-related 
     services for individuals with HIV disease and those at risk 
     of such disease. Not later than October 1, 1996, and 
     biennially thereafter, the Secretary shall submit to the 
     appropriate committees of the Congress a report concerning 
     coordination efforts under this title at the Federal, State, 
     and local levels, including a statement of whether and to 
     what extent there exist Federal barriers to integrating HIV-
     related programs.''.
       (d) Early Intervention Services.--
       (1) Establishment of program.--Section 2651(b) (42 U.S.C. 
     300ff-51(b)) is amended--
       (A) in paragraph (1), by inserting before the period the 
     following: ``, and unless the applicant agrees to expend not 
     less than 50 percent of the grant for such services that are 
     specified in subparagraphs (B) through (E) of such paragraph 
     for individuals with HIV disease''; and
       (B) in paragraph (4)--
       (i) by striking ``The Secretary'' and inserting ``(A) In 
     general.--The Secretary'';
       (ii) by inserting ``, or private for-profit entities if 
     such entities are the only available provider of quality HIV 
     care in the area,'' after ``nonprofit private entities'';
       (iii) by realigning the margin of subparagraph (A) so as to 
     align with the margin of paragraph (3)(A); and
       (iv) by adding at the end thereof the following new 
     subparagraph:
       ``(B) Other requirements.--Grantees described in--
       ``(i) paragraphs (1), (2), (5), and (6) of section 2652(a) 
     shall use not less than 50 percent of the amount of such a 
     grant to provide the services described in subparagraphs (A), 
     (B), (D), and (E) of section 2651(b)(2) directly and on-site 
     or at sites where other primary care services are rendered; 
     and
       ``(ii) paragraphs (3) and (4) of section 2652(a) shall 
     ensure the availability of early intervention services 
     through a system of linkages to community-based primary care 
     providers, and to establish mechanisms for the referrals 
     described in section 2651(b)(2)(C), and for follow-up 
     concerning such referrals.''.
       (2) Minimum qualifications.--Section 2652(b)(1)(B) (42 
     U.S.C. 300ff-52(b)(1)(B)) is amended by inserting ``, or a 
     private for-profit entity if such entity is the only 
     available provider of quality HIV care in the area,'' after 
     ``nonprofit private entity''.
       (3) Miscellaneous provisions.--Section 2654 (42 U.S.C. 
     300ff-54) is amended by adding at the end thereof the 
     following new subsection:
       ``(c) Planning and Development Grants.--
       ``(1) In general.--The Secretary may provide planning 
     grants, in an amount not to exceed $50,000 for each such 
     grant, to public and nonprofit private entities for the 
     purpose of enabling such entities to provide HIV early 
     intervention services.
       ``(2) Requirement.--The Secretary may only award a grant to 
     an entity under paragraph (1) if the Secretary determines 
     that the entity will use such grant to assist the entity in 
     qualifying for a grant under section 2651.
       ``(3) Preference.--In awarding grants under paragraph (1), 
     the Secretary shall give preference to entities that provide 
     primary care services in rural or underserved communities.
       ``(4) Limitation.--Not to exceed 1 percent of the amount 
     appropriated for a fiscal year under section 2655 may be used 
     to carry out this section.''.
       (4) Authorization of appropriations.--Section 2655 (42 
     U.S.C. 300ff-55) is amended by striking ``$75,000,000'' and 
     all that follows through the end of the section, and 
     inserting ``such sums as may be necessary in each of the 
     fiscal years 1996, 1997, 1998, 1999, and 2000.''.
       (5) Required agreements.--Section 2664(g) (42 U.S.C. 300ff-
     64(g)) is amended--
       (A) in paragraph (2), by striking ``and'' at the end 
     thereof;
       (B) in paragraph (3)--
       (i) by striking ``5 percent'' and inserting ``7.5 percent 
     including planning and evaluation''; and
       (ii) by striking the period and inserting ``; and''; and
       (C) by adding at the end thereof the following new 
     paragraph:

[[Page H4291]]

       ``(4) the applicant will submit evidence that the proposed 
     program is consistent with the Statewide coordinated 
     statement of need and agree to participate in the ongoing 
     revision of such statement of need.''.
       (e) Demonstration Grants for Research and Services for 
     Pediatric Patients.--Section 2671 (42 U.S.C. 300f-71) is 
     amended to read as follows:

     ``SEC. 2671. GRANTS FOR COORDINATED SERVICES AND ACCESS TO 
                   RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND 
                   YOUTH.

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Director of the 
     National Institutes of Health, shall make grants to public 
     and nonprofit private entities that provide primary care 
     (directly or through contracts) for the following purposes:
       ``(1) Providing through such entities, in accordance with 
     this section, opportunities for women, infants, children, and 
     youth to be voluntary participants in research of potential 
     clinical benefit to individuals with HIV disease.
       ``(2) In the case of women, infants, children, and youth 
     with HIV disease, and the families of such individuals, 
     providing to such individuals--
       ``(A) health care on an outpatient basis; and
       ``(B) additional services in accordance with subsection 
     (d).
       ``(b) Provisions Regarding Participation in Research.--
       ``(1) In general.--With respect to the projects of research 
     with which an applicant under subsection (a) is concerned, 
     the Secretary may make a grant under such subsection to the 
     applicant only if the following conditions are met:
       ``(A) The applicant agrees to make reasonable efforts--
       ``(i) to identify which of the patients of the applicant 
     are women, infants, children, and youth who would be 
     appropriate participants in the projects;
       ``(ii) to carry out clause (i) through the use of criteria 
     provided for such purpose by the entities that will be 
     conducting the projects of research; and
       ``(iii) to offer women, infants, children, and youth the 
     opportunity to participate in the projects (as appropriate), 
     including the provision of services under subsection (d)(3).
       ``(B) The applicant agrees that, in the case of the 
     research-related functions to be carried out by the applicant 
     pursuant to subsection (a)(1), the applicant will comply with 
     accepted standards that are applicable to such functions 
     (including accepted standards regarding informed consent and 
     other protections for human subjects).
       ``(C) For the first and second fiscal years for which 
     grants under subsection (a) are to be made to the applicant, 
     the applicant agrees that, not later than the end of the 
     second fiscal year of receiving such a grant, a significant 
     number of women, infants, children, and youth who are 
     patients of the applicant will be participating in the 
     projects of research.
       ``(D) Except as provided in paragraph (3) (and paragraph 
     (4), as applicable), for the third and subsequent fiscal 
     years for which such grants are to be made to the applicant, 
     the Secretary has determined that a significant number of 
     such individuals are participating in the projects.
       ``(2) Prohibition.--Receipt of services by a patient shall 
     not be conditioned upon the consent of the patient to 
     participate in research.
       ``(3) Significant participation; consideration by secretary 
     of certain circumstances.--In administering the requirement 
     of paragraph (1)(D), the Secretary shall take into account 
     circumstances in which a grantee under subsection (a) is 
     temporarily unable to comply with the requirement for reasons 
     beyond the control of the grantee, and shall in such 
     circumstances provide to the grantee a reasonable period of 
     opportunity in which to reestablish compliance with the 
     requirement.
       ``(4) Significant participation; temporary waiver for 
     original grantees.--
       ``(A) In general.--In the case of an applicant under 
     subsection (a) who received a grant under such subsection for 
     fiscal year 1995, the Secretary may, subject to subparagraph 
     (B), provide to the applicant a waiver of the requirement of 
     paragraph (1)(D) if the Secretary determines that the 
     applicant is making reasonable progress toward meeting the 
     requirement.
       ``(B) Termination of authority for waivers.--The Secretary 
     may not provide any waiver under subparagraph (A) on or after 
     October 1, 1998. Any such waiver provided prior to such date 
     terminates on such date, or on such earlier date as the 
     Secretary may specify.
       ``(c) Provisions Regarding Conduct of Research.--
       ``(1) In general.--With respect to eligibility for a grant 
     under subsection (a):
       ``(A) A project of research for which subjects are sought 
     pursuant to such subsection may be conducted by the applicant 
     for the grant, or by an entity with which the applicant has 
     made arrangements for purposes of the grant. The grant may 
     not be expended for the conduct of any project of research, 
     except for such research-related functions as are appropriate 
     for providing opportunities under subsection (a)(1) 
     (including the functions specified in subsection (b)(1)).
       ``(B) The grant may be made only if the Secretary makes the 
     following determinations:
       ``(i) The applicant or other entity (as the case may be 
     under subparagraph (A)) is appropriately qualified to conduct 
     the project of research. An entity shall be considered to be 
     so qualified if any research protocol of the entity has been 
     recommended for funding under this Act pursuant to technical 
     and scientific peer review through the National Institutes of 
     Health.
       ``(ii) The project of research is being conducted in 
     accordance with a research protocol to which the Secretary 
     gives priority regarding the prevention or treatment of HIV 
     disease in women, infants, children, or youth, subject to 
     paragraph (2).
       ``(2) List of research protocols.--
       ``(A) In general.--From among the research protocols 
     described in paragraph (1)(B)(ii), the Secretary shall 
     establish a list of research protocols that are appropriate 
     for purposes of subsection (a)(1). Such list shall be 
     established only after consultation with public and private 
     entities that conduct such research, and with providers of 
     services under subsection (a) and recipients of such 
     services.
       ``(B) Discretion of secretary.--The Secretary may authorize 
     the use, for purposes of subsection (a)(1), of a research 
     protocol that is not included on the list under subparagraph 
     (A). The Secretary may waive the requirement specified in 
     paragraph (1)(B)(ii) in such circumstances as the Secretary 
     determines to be appropriate.
       ``(d) Additional Services for Patients and Families.--A 
     grant under subsection (a) may be made only if the applicant 
     for the grant agrees as follows:
       ``(1) The applicant will provide for the case management of 
     the patient involved and the family of the patient.
       ``(2) The applicant will provide for the patient and the 
     family of the patient--
       ``(A) referrals for inpatient hospital services, treatment 
     for substance abuse, and mental health services; and
       ``(B) referrals for other social and support services, as 
     appropriate.
       ``(3) The applicant will provide the patient and the family 
     of the patient with such transportation, child care, and 
     other incidental services as may be necessary to enable the 
     patient and the family to participate in the program 
     established by the applicant pursuant to such subsection.
       ``(e) Coordination With Other Entities.--A grant under 
     subsection (a) may be made only if the applicant for the 
     grant agrees as follows:
       ``(1) The applicant will coordinate activities under the 
     grant with other providers of health care services under this 
     Act, and under title V of the Social Security Act.
       ``(2) The applicant will participate in the statewide 
     coordinated statement of need under part B (where it has been 
     initiated by the public health agency responsible for 
     administering grants under part B) and in revisions of such 
     statement.
       ``(f) Application.--A grant under subsection (a) may be 
     made only if an application for the grant is submitted to the 
     Secretary and the application is in such form, is made in 
     such manner, and contains such agreements, assurances, and 
     information as the Secretary determines to be necessary to 
     carry out this section.
       ``(g) Coordination With National Institutes of Health.--The 
     Secretary shall develop and implement a plan that provides 
     for the coordination of the activities of the National 
     Institutes of Health with the activities carried out under 
     this section. In carrying out the preceding sentence, the 
     Secretary shall ensure that projects of research conducted or 
     supported by such Institutes are made aware of applicants and 
     grantees under subsection (a), shall require that the 
     projects, as appropriate, enter into arrangements for 
     purposes of such subsection, and shall require that each 
     project entering into such an arrangement inform the 
     applicant or grantee under such subsection of the needs of 
     the project for the participation of women, infants, 
     children, and youth.
       ``(h) Annual Review of Programs; Evaluations.--
       ``(1) Review regarding access to and participation in 
     programs.--With respect to a grant under subsection (a) for 
     an entity for a fiscal year, the Secretary shall, not later 
     than 180 days after the end of the fiscal year, provide for 
     the conduct and completion of a review of the operation 
     during the year of the program carried out under such 
     subsection by the entity. The purpose of such review shall be 
     the development of recommendations, as appropriate, for 
     improvements in the following:
       ``(A) Procedures used by the entity to allocate 
     opportunities and services under subsection (a) among 
     patients of the entity who are women, infants, children, or 
     youth.
       ``(B) Other procedures or policies of the entity regarding 
     the participation of such individuals in such program.
       ``(2) Evaluations.--The Secretary shall, directly or 
     through contracts with public and private entities, provide 
     for evaluations of programs carried out pursuant to 
     subsection (a).
       ``(i) Training and Technical Assistance.--Of the amounts 
     appropriated under subsection (j) for a fiscal year, the 
     Secretary may use not more than five percent to provide, 
     directly or through contracts with public and private 
     entities (which may include grantees under subsection (a)), 
     training and technical assistance to assist applicants and

[[Page H4292]]

     grantees under subsection (a) in complying with the 
     requirements of this section.
       ``(j) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 1996 through 2000.''.
       (f) Evaluations and Reports.--Section 2674 (42 U.S.C. 
     300ff-74) is amended--
       (1) in subsection (b)--
       (A) in the matter preceding paragraph (1), by striking 
     ``not later than 1 year'' and all that follows through 
     ``title,'' and inserting the following: ``not later than 
     October 1, 1996,'';
       (B) by striking paragraphs (1) through (3) and inserting 
     the following paragraph:
       ``(1) evaluating the programs carried out under this title; 
     and''; and
       (C) by redesignating paragraph (4) as paragraph (2); and
       (2) by adding at the end the following subsection:
       ``(d) Allocation of Funds.--The Secretary shall carry out 
     this section with amounts available under section 241. Such 
     amounts are in addition to any other amounts that are 
     available to the Secretary for such purpose.''.
       (g) Demonstration and Training.--
       (1) In general.--Title XXVI is amended by adding at the 
     end, the following new part:

                  ``PART F--DEMONSTRATION AND TRAINING

         ``Subpart I--Special Projects of National Significance

     ``SEC. 2691. SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE.

       ``(a) In General.--Of the amount appropriated under each of 
     parts A, B, C, and D of this title for each fiscal year, the 
     Secretary shall use the greater of $20,000,000 or 3 percent 
     of such amount appropriated under each such part, but not to 
     exceed $25,000,000, to administer a special projects of 
     national significance program to award direct grants to 
     public and nonprofit private entities including community-
     based organizations to fund special programs for the care and 
     treatment of individuals with HIV disease.
       ``(b) Grants.--The Secretary shall award grants under 
     subsection (a) based on--
       ``(1) the need to assess the effectiveness of a particular 
     model for the care and treatment of individuals with HIV 
     disease;
       ``(2) the innovative nature of the proposed activity; and
       ``(3) the potential replicability of the proposed activity 
     in other similar localities or nationally.
       ``(c) Special Projects.--Special projects of national 
     significance shall include the development and assessment of 
     innovative service delivery models that are designed to--
       ``(1) address the needs of special populations;
       ``(2) assist in the development of essential community-
     based service delivery infrastructure; and
       ``(3) ensure the ongoing availability of services for 
     Native American communities to enable such communities to 
     care for Native Americans with HIV disease.
       ``(d) Special Populations.--Special projects of national 
     significance may include the delivery of HIV health care and 
     support services to traditionally underserved populations 
     including--
       ``(1) individuals and families with HIV disease living in 
     rural communities;
       ``(2) adolescents with HIV disease;
       ``(3) Indian individuals and families with HIV disease;
       ``(4) homeless individuals and families with HIV disease;
       ``(5) hemophiliacs with HIV disease; and
       ``(6) incarcerated individuals with HIV disease.
       ``(e) Service Development Grants.--Special projects of 
     national significance may include the development of model 
     approaches to delivering HIV care and support services 
     including--
       ``(1) programs that support family-based care networks and 
     programs that build organizational capacity critical to the 
     delivery of care in minority communities;
       ``(2) programs designed to prepare AIDS service 
     organizations and grantees under this title for operation 
     within the changing health care environment; and
       ``(3) programs designed to integrate the delivery of mental 
     health and substance abuse treatment with HIV services.
       ``(f) Coordination.--The Secretary may not make a grant 
     under this section unless the applicant submits evidence that 
     the proposed program is consistent with the Statewide 
     coordinated statement of need, and the applicant agrees to 
     participate in the ongoing revision process of such statement 
     of need.
       ``(g) Replication.--The Secretary shall make information 
     concerning successful models developed under this part 
     available to grantees under this title for the purpose of 
     coordination, replication, and integration. To facilitate 
     efforts under this subsection, the Secretary may provide for 
     peer-based technical assistance from grantees funded under 
     this part.''.
       (2) Repeal.--Subsection (a) of section 2618 (42 U.S.C. 
     300ff-28(a)) is repealed.
       (h) HIV/AIDS Communities, Schools, Centers.--
       (1) New part.--Part F of title XXVI (as added by subsection 
     (e)) is further amended by adding at the end, the following 
     new subpart:

           ``Subpart II--AIDS Education and Training Centers

     ``SEC. 2692. HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTERS.''.

       (2) Amendments.--Section 776 (42 U.S.C. 294n) is amended--
       (A) by striking the section heading; and
       (B) in subsection (a)(1)--
       (i) by striking subparagraphs (B) and (C);
       (ii) by redesignating subparagraphs (A) and (D) as 
     subparagraphs (B) and (C), respectively;
       (iii) by inserting before subparagraph (B) (as so 
     redesignated) the following new subparagraph:
       ``(A) training health personnel, including practitioners in 
     title XXVI programs and other community providers, in the 
     diagnosis, treatment, and prevention of HIV infection and 
     disease, including the prevention of the perinatal 
     transmission of the disease and including measures for the 
     prevention and treatment of opportunistic infections;''; and
       (iv) in subparagraph (B) (as so redesignated) by adding 
     ``and'' after the semicolon.
       (3) Transfer.--Section 776 (42 U.S.C. 294n) (as amended by 
     paragraph (2)) is amended by transferring such section to 
     section 2692 (as added by paragraph (1)).
       (4) Authorization of appropriations.--Section 2692 (as 
     added by paragraph (1)) is amended by adding at the end 
     thereof the following new subsection:
       ``(d) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, such 
     sums as may be necessary for each of the fiscal years 1996 
     through 2000.''.

     SEC. 4. AMOUNT OF EMERGENCY RELIEF GRANTS.

       Paragraph (3) of section 2603(a) (42 U.S.C. 300ff-13(a)(3)) 
     is amended to read as follows:
       ``(3) Amount of grant.--
       ``(A) In general.--Subject to the extent of amounts made 
     available in appropriations Acts, a grant made for purposes 
     of this paragraph to an eligible area shall be made in an 
     amount equal to the product of--
       ``(i) an amount equal to the amount available for 
     distribution under paragraph (2) for the fiscal year 
     involved; and
       ``(ii) the percentage constituted by the ratio of the 
     distribution factor for the eligible area to the sum of the 
     respective distribution factors for all eligible areas.
       ``(B) Distribution factor.--For purposes of subparagraph 
     (A)(ii), the term `distribution factor' means an amount equal 
     to the estimated number of living cases of acquired immune 
     deficiency syndrome in the eligible area involved, as 
     determined under subparagraph (C).
       ``(C) Estimate of living cases.--The amount determined in 
     this subparagraph is an amount equal to the product of--
       ``(i) the number of cases of acquired immune deficiency 
     syndrome in the eligible area during each year in the most 
     recent 120-month period for which data are available with 
     respect to all eligible areas, as indicated by the number of 
     such cases reported to and confirmed by the Director of the 
     Centers for Disease Control and Prevention for each year 
     during such period; and
       ``(ii) with respect to--

       ``(I) the first year during such period, .06;
       ``(II) the second year during such period, .06;
       ``(III) the third year during such period, .08;
       ``(IV) the fourth year during such period, .10;
       ``(V) the fifth year during such period, .16;
       ``(VI) the sixth year during such period, .16;
       ``(VII) the seventh year during such period, .24;
       ``(VIII) the eighth year during such period, .40;
       ``(IX) the ninth year during such period, .57; and
       ``(X) the tenth year during such period, .88.

     The yearly percentage described in subparagraph (ii) shall be 
     updated biennially by the Secretary, after consultation with 
     the Centers for Disease Control and Prevention. The first 
     such update shall occur prior to the determination of grant 
     awards under this part for fiscal year 1998.
       ``(D) Unexpended funds.--The Secretary may, in determining 
     the amount of a grant for a fiscal year under this paragraph, 
     adjust the grant amount to reflect the amount of unexpended 
     and uncanceled grant funds remaining at the end of the fiscal 
     year preceding the year for which the grant determination is 
     to be made. The amount of any such unexpended funds shall be 
     determined using the financial status report of the 
     grantee.''.

     SEC. 5. AMOUNT OF CARE GRANTS.

       Paragraphs (1) and (2) of section 2618(b) (42 U.S.C. 300ff-
     28(b)(1) and (2)) are amended to read as follows:
       ``(1) Minimum allotment.--Subject to the extent of amounts 
     made available under section 2677, the amount of a grant to 
     be made under this part for--
       ``(A) each of the several States and the District of 
     Columbia for a fiscal year shall be the greater of--
       ``(i)(I) with respect to a State or District that has less 
     than 90 living cases of acquired immune deficiency syndrome, 
     as determined under paragraph (2)(D), $100,000; or
       ``(i)(I) with respect to a State or District that has 90 or 
     more living cases of acquired immune deficiency syndrome, as 
     determined under paragraph (2)(D), $250,000;
       ``(ii) an amount determined under paragraph (2); and
       ``(B) each territory of the United States, as defined in 
     paragraph (3), shall be an amount determined under paragraph 
     (2).

[[Page H4293]]

       ``(2) Determination.--
       ``(A) Formula.--The amount referred to in paragraph 
     (1)(A)(ii) for a State and paragraph (1)(B) for a territory 
     of the United States shall be the product of--
       ``(i) an amount equal to the amount appropriated under 
     section 2677 for the fiscal year involved for grants under 
     part B, subject to subparagraph (H); and
       ``(ii) the percentage constituted by the sum of--

       ``(I) the product of .80 and the ratio of the State 
     distribution factor for the State or territory (as determined 
     under subsection (B)) to the sum of the respective State 
     distribution factors for all States or territories; and
       ``(II) the product of .20 and the ratio of the non-EMA 
     distribution factor for the State or territory (as determined 
     under subparagraph (C)) to the sum of the respective 
     distribution factors for all States or territories.

       ``(B) State distribution factor.--For purposes of 
     subparagraph (A)(ii)(I), the term `State distribution factor' 
     means an amount equal to the estimated number of living cases 
     of acquired immune deficiency syndrome in the eligible area 
     involved, as determined under subparagraph (D).
       ``(C) Non-ema distribution factor.--For purposes of 
     subparagraph (A)(ii)(II), the term `non-ema distribution 
     factor' means an amount equal to the sum of--
       ``(i) the estimated number of living cases of acquired 
     immune deficiency syndrome in the State or territory 
     involved, as determined under subparagraph (D); less
       ``(ii) the estimated number of living cases of acquired 
     immune deficiency syndrome in such State or territory that 
     are within an eligible area (as determined under part A).
       ``(D) Estimate of living cases.--The amount determined in 
     this subparagraph is an amount equal to the product of--
       ``(i) the number of cases of acquired immune deficiency 
     syndrome in the State or territory during each year in the 
     most recent 120-month period for which data are available 
     with respect to all States and territories, as indicated by 
     the number of such cases reported to and confirmed by the 
     Director of the Centers for Disease Control and Prevention 
     for each year during such period; and
       ``(ii) with respect to each of the first through the tenth 
     year during such period, the amount referred to in 
     2603(a)(3)(C)(ii).
       ``(E) Puerto rico, virgin islands, guam.--For purposes of 
     subparagraph (D), the cost index for Puerto Rico, the Virgin 
     Islands, and Guam shall be 1.0.''.
       ``(F) Unexpended funds.--The Secretary may, in determining 
     the amount of a grant for a fiscal year under this 
     subsection, adjust the grant amount to reflect the amount of 
     unexpended and uncanceled grant funds remaining at the end of 
     the fiscal year preceding the year for which the grant 
     determination is to be made. The amount of any such 
     unexpended funds shall be determined using the financial 
     status report of the grantee.
       ``(G) Limitation.--
       ``(i) In general.--The Secretary shall ensure that the 
     amount of a grant awarded to a State or territory for a 
     fiscal year under this part is equal to not less than--

       ``(I) with respect to fiscal year 1996, 100 percent;
       ``(II) with respect to fiscal year 1997, 99 percent;
       ``(III) with respect to fiscal year 1998, 98 percent;
       ``(IV) with respect to fiscal year 1999, 96.5 percent; and
       ``(V) with respect to fiscal year 2000, 95 percent;

     of the amount such State or territory received for fiscal 
     year 1995 under this part. In administering this 
     subparagraph, the Secretary shall, with respect to States 
     that will receive grants in amounts that exceed the amounts 
     that such States received under this part in fiscal year 
     1995, proportionally reduce such amounts to ensure compliance 
     with this subparagraph. In making such reductions, the 
     Secretary shall ensure that no such State receives less than 
     that State received for fiscal year 1995.
       ``(ii) Ratable reduction.--If the amount appropriated under 
     section 2677 and available for allocation under this part is 
     less than the amount appropriated and available under this 
     part for fiscal year 1995, the limitation contained in clause 
     (i) shall be reduced by a percentage equal to the percentage 
     of the reduction in such amounts appropriated and available.
       ``(H) Appropriations for treatment drug program.--With 
     respect to the fiscal year involved, if under section 2677 an 
     appropriations Act provides an amount exclusively for 
     carrying out section 2616, the portion of such amount 
     allocated to a State shall be the product of--
       ``(i) 100 percent of such amount; and
       ``(ii) the percentage constituted by the ratio of the State 
     distribution factor for the State (as determined under 
     subparagraph (B)) to the sum of the State distribution 
     factors for all States.''.

     SEC. 6. CONSOLIDATION OF AUTHORIZATIONS OF APPROPRIATIONS.

       (a) In General.--Part D of title XXVI (42 U.S.C. 300ff-71) 
     is amended by adding at the end thereof the following new 
     section:

     ``SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

       ``(a) In General.--Subject to subsection (b), there are 
     authorized to be appropriated to make grants under parts A 
     and B, such sums as may be necessary for each of the fiscal 
     years 1996 through 2000.
       ``(b) Development of Methodology.--
       ``(1) In general.--With respect to each of the fiscal years 
     1997 through 2000, the Secretary shall develop and implement 
     a methodology for adjusting the percentages allocated to part 
     A and part B to account for grants to new eligible areas 
     under part A and other relevant factors. Not later than July 
     1, 1996, the Secretary shall prepare and submit to the 
     appropriate committees of Congress a report regarding the 
     findings with respect to the methodology developed under this 
     paragraph.
       ``(2) Failure to implement.--If the Secretary determines 
     that such a methodology under paragraph (1) cannot be 
     developed, there are authorized to be appropriated--
       ``(A) such sums as may be necessary to carry out part A for 
     each of the fiscal years 1997 through 2000; and
       ``(B) such sums as may be necessary to carry out part B for 
     each of the fiscal years 1997 through 2000.''.
       (b) Repeals.--Sections 2608 and 2620 (42 U.S.C. 300ff-18 
     and 300ff-30) are repealed.
       (c) Conforming Amendments.--Title XXVI is amended--
       (1) in section 2603 (42 U.S.C. 300ff-13)--
       (A) in subsection (a)(2), by striking ``2608'' and 
     inserting ``2677''; and
       (B) in subsection (b)(1), by striking ``2608'' and 
     inserting ``2677'';
       (2) in section 2605(c)(1) (42 U.S.C. 300ff-15(c)(1)) is 
     amended by striking ``2608'' and inserting ``2677''; and
       (3) in section 2618 (42 U.S.C. 300ff-28)--
       (A) in subsection (a)(1), is amended by striking ``2620'' 
     and inserting ``2677''; and
       (B) in subsection (b)(1), is amended by striking ``2620'' 
     and inserting ``2677''.

     SEC. 7. PERINATAL TRANSMISSION OF HIV DISEASE.

       (a) Findings.--The Congress finds as follows:
       (1) Research studies and Statewide clinical experiences 
     have demonstrated that administration of anti-retroviral 
     medication during pregnancy can significantly reduce the 
     transmission of the human immunodeficiency virus (commonly 
     known as HIV) from an infected mother to her baby.
       (2) The Centers for Disease Control and Prevention have 
     recommended that all pregnant women receive HIV counseling; 
     voluntary, confidential HIV testing; and appropriate medical 
     treatment (including anti-retroviral therapy) and support 
     services.
       (3) The provision of such testing without access to such 
     counseling, treatment, and services will not improve the 
     health of the woman or the child.
       (4) The provision of such counseling, testing, treatment, 
     and services can reduce the number of pediatric cases of 
     acquired immune deficiency syndrome, can improve access to 
     and provision of medical care for the woman, and can provide 
     opportunities for counseling to reduce transmission among 
     adults, and from mother to child.
       (5) The provision of such counseling, testing, treatment, 
     and services can reduce the overall cost of pediatric cases 
     of acquired immune deficiency syndrome.
       (6) The cancellation or limitation of health insurance or 
     other health coverage on the basis of HIV status should be 
     impermissible under applicable law. Such cancellation or 
     limitation could result in disincentives for appropriate 
     counseling, testing, treatment, and services.
       (7) For the reasons specified in paragraphs (1) through 
     (6)--
       (A) routine HIV counseling and voluntary testing of 
     pregnant women should become the standard of care; and
       (B) the relevant medical organizations as well as public 
     health officials should issue guidelines making such 
     counseling and testing the standard of care.
       (b) Additional Requirements for Grants.--Part B of title 
     XXVI (42 U.S.C. 300ff-21 et seq.) is amended--
       (1) by inserting after the part heading the following:

                ``Subpart I--General Grant Provisions'';

       (2) in section 2611(a), by adding at the end the following 
     sentence: ``The authority of the Secretary to provide grants 
     under part B is subject to section 2626(e)(2) (relating to 
     the decrease in perinatal transmission of HIV disease).''; 
     and
       (3) by adding at the end thereof the following new subpart:

      ``Subpart II--Provisions Concerning Pregnancy and Perinatal 
                          Transmission of HIV

     ``SEC. 2625. CDC GUIDELINES FOR PREGNANT WOMEN.

       ``(a) Requirement.--Notwithstanding any other provision of 
     law, a State shall, not later than 120 days after the date of 
     enactment of this subpart, certify to the Secretary that such 
     State has in effect regulations or measures to adopt the 
     guidelines issued by the Centers for Disease Control and 
     Prevention concerning recommendations for human 
     immunodeficiency virus counseling and voluntary testing for 
     pregnant women.
       ``(b) Noncompliance.--If a State does not provide the 
     certification required under subsection (a) within the 120-
     day period described in such subsection, such State shall not 
     be eligible to receive assistance for HIV counseling and 
     testing under this section until such certification is 
     provided.
       ``(c) Additional Funds Regarding Women and Infants.--
       ``(1) In general.--If a State provides the certification 
     required in subsection (a) and is receiving funds under part 
     B for a fiscal year, the Secretary may (from the amounts 
     available pursuant to paragraph (2)) make a

[[Page H4294]]

     grant to the State for the fiscal year for the following 
     purposes:
       ``(A) Making available to pregnant women appropriate 
     counseling on HIV disease.
       ``(B) Making available outreach efforts to pregnant women 
     at high risk of HIV who are not currently receiving prenatal 
     care.
       ``(C) Making available to such women voluntary HIV testing 
     for such disease.
       ``(D) Offsetting other State costs associated with the 
     implementation of this section and subsections (a) and (b) of 
     section 2626.
       ``(E) Offsetting State costs associated with the 
     implementation of mandatory newborn testing in accordance 
     with this title or at an earlier date than is required by 
     this title.
       ``(2) Funding.--For purposes of carrying out this 
     subsection, there are authorized to be appropriated 
     $10,000,000 for each of the fiscal years 1996 through 2000. 
     Amounts made available under section 2677 for carrying out 
     this part are not available for carrying out this section 
     unless otherwise authorized.
       ``(3) Priority.--In awarding grants under this subsection 
     the Secretary shall give priority to States that have the 
     greatest proportion of HIV seroprevalance among child bearing 
     women using the most recent data available as determined by 
     the Centers for Disease Control and Prevention.

     ``SEC. 2626. PERINATAL TRANSMISSION OF HIV DISEASE; 
                   CONTINGENT REQUIREMENT REGARDING STATE GRANTS 
                   UNDER THIS PART.

       ``(a) Annual Determination of Reported Cases.--A State 
     shall annually determine the rate of reported cases of AIDS 
     as a result of perinatal transmission among residents of the 
     State.
       ``(b) Causes of Perinatal Transmission.--In determining the 
     rate under subsection (a), a State shall also determine the 
     possible causes of perinatal transmission. Such causes may 
     include--
       ``(1) the inadequate provision within the State of prenatal 
     counseling and testing in accordance with the guidelines 
     issued by the Centers for Disease Control and Prevention;
       ``(2) the inadequate provision or utilization within the 
     State of appropriate therapy or failure of such therapy to 
     reduce perinatal transmission of HIV, including--
       ``(A) that therapy is not available, accessible or offered 
     to mothers; or
       ``(B) that available therapy is offered but not accepted by 
     mothers; or
       ``(3) other factors (which may include the lack of prenatal 
     care) determined relevant by the State.
       ``(c) CDC Reporting System.--Not later than 4 months after 
     the date of enactment of the this subpart, the Director of 
     the Centers for Disease Control and Prevention shall develop 
     and implement a system to be used by States to comply with 
     the requirements of subsections (a) and (b). The Director 
     shall issue guidelines to ensure that the data collected is 
     statistically valid.
       ``(d) Determination by Secretary.--Not later than 180 days 
     after the expiration of the 18-month period beginning on the 
     date on which the system is implemented under subsection (c), 
     the Secretary shall publish in the Federal Register a 
     determination of whether it has become a routine practice in 
     the provision of health care in the United States to carry 
     out each of the activities described in paragraphs (1) 
     through (5) of section 2627. In making the determination, the 
     Secretary shall consult with the States and with other public 
     or private entities that have knowledge or expertise relevant 
     to the determination.
       ``(e) Contingent Applicability.--
       ``(1) In general.--If the determination published in the 
     Federal Register under subsection (d) is that (for purposes 
     of such subsection) the activities involved have become 
     routine practices, paragraph (2) shall apply on and after the 
     expiration of the 18-month period beginning on the date on 
     which the determination is so published.
       ``(2) Requirement.--Subject to subsection (f), the 
     Secretary shall not make a grant under part B to a State 
     unless the State meets not less than one of the following 
     requirements:
       ``(A) A 50 percent reduction (or a comparable measure for 
     States with less than 10 cases) in the rate of new cases of 
     AIDS (recognizing that AIDS is a suboptimal proxy for 
     tracking HIV in infants and was selected because such data is 
     universally available) as a result of perinatal transmission 
     as compared to the rate of such cases reported in 1993 (a 
     State may use HIV data if such data is available).
       ``(B) At least 95 percent of women in the State who have 
     received at least two prenatal visits (consultations) prior 
     to 34 weeks gestation with a health care provider or provider 
     group have been tested for the human immunodeficiency virus.
       ``(C) The State has in effect, in statute or through 
     regulations, the requirements specified in paragraphs (1) 
     through (5) of section 2627.
       ``(f) Limitation Regarding Availability of Funds.--With 
     respect to an activity described in any of paragraphs (1) 
     through (5) of section 2627, the requirements established by 
     a State under this section apply for purposes of this section 
     only to the extent that the following sources of funds are 
     available for carrying out the activity:
       ``(1) Federal funds provided to the State in grants under 
     part B or under section 2625, or through other Federal 
     sources under which payments for routine HIV testing, 
     counseling or treatment are an eligible use.
       ``(2) Funds that the State or private entities have elected 
     to provide, including through entering into contracts under 
     which health benefits are provided. This section does not 
     require any entity to expend non-Federal funds.

     ``SEC. 2627. TESTING OF PREGNANT WOMEN AND NEWBORN INFANTS.

       ``An activity or requirement described in this section is 
     any of the following:
       ``(1) In the case of newborn infants who are born in the 
     State and whose biological mothers have not undergone 
     prenatal testing for HIV disease, that each such infant 
     undergo testing for such disease.
       ``(2) That the results of such testing of a newborn infant 
     be promptly disclosed in accordance with the following, as 
     applicable to the infant involved:
       ``(A) To the biological mother of the infant (without 
     regard to whether she is the legal guardian of the infant).
       ``(B) If the State is the legal guardian of the infant:
       ``(i) To the appropriate official of the State agency with 
     responsibility for the care of the infant.
       ``(ii) To the appropriate official of each authorized 
     agency providing assistance in the placement of the infant.
       ``(iii) If the authorized agency is giving significant 
     consideration to approving an individual as a foster parent 
     of the infant, to the prospective foster parent.
       ``(iv) If the authorized agency is giving significant 
     consideration to approving an individual as an adoptive 
     parent of the infant, to the prospective adoptive parent.
       ``(C) If neither the biological mother nor the State is the 
     legal guardian of the infant, to another legal guardian of 
     the infant.
       ``(D) To the child's health care provider.
       ``(3) That, in the case of prenatal testing for HIV disease 
     that is conducted in the State, the results of such testing 
     be promptly disclosed to the pregnant woman involved.
       ``(4) That, in disclosing the test results to an individual 
     under paragraph (2) or (3), appropriate counseling on the 
     human immunodeficiency virus be made available to the 
     individual (except in the case of a disclosure to an official 
     of a State or an authorized agency).
       ``(5) With respect to State insurance laws, that such laws 
     require--
       ``(A) that, if health insurance is in effect for an 
     individual, the insurer involved may not (without the consent 
     of the individual) discontinue the insurance, or alter the 
     terms of the insurance (except as provided in subparagraph 
     (C)), solely on the basis that the individual is infected 
     with HIV disease or solely on the basis that the individual 
     has been tested for the disease or its manifestation;
       ``(B) that subparagraph (A) does not apply to an individual 
     who, in applying for the health insurance involved, knowingly 
     misrepresented the HIV status of the individual; and
       ``(C) that subparagraph (A) does not apply to any 
     reasonable alteration in the terms of health insurance for an 
     individual with HIV disease that would have been made if the 
     individual had a serious disease other than HIV disease.

     For purposes of this subparagraph, a statute or regulation 
     shall be deemed to regulate insurance for purposes of this 
     paragraph only to the extent that such statute or regulation 
     is treated as regulating insurance for purposes of section 
     514(b)(2) of the Employee Retirement Income Security Act of 
     1974.

     ``SEC. 2628. REPORT BY THE INSTITUTE OF MEDICINE.

       ``(a) In General.--The Secretary shall request that the 
     Institute of Medicine of the National Academy of Sciences 
     conduct an evaluation of the extent to which State efforts 
     have been effective in reducing the perinatal transmission of 
     the human immunodeficiency virus, and an analysis of the 
     existing barriers to the further reduction in such 
     transmission.
       ``(b) Report to Congress.--The Secretary shall ensure that, 
     not later than 2 years after the date of enactment of this 
     section, the evaluation and analysis described in subsection 
     (a) is completed and a report summarizing the results of such 
     evaluation and analysis is prepared by the Institute of 
     Medicine and submitted to the appropriate committees of 
     Congress together with the recommendations of the Institute.

     ``SEC. 2629. STATE HIV TESTING PROGRAMS ESTABLISHED PRIOR TO 
                   OR AFTER ENACTMENT.

       ``Nothing in this subpart shall be construed to disqualify 
     a State from receiving grants under this title if such State 
     has established at any time prior to or after the date of 
     enactment of this subpart a program of mandatory HIV 
     testing.''.

     SEC. 8. SPOUSAL NOTIFICATION.

       (a) In General.--The Secretary of Health and Human Services 
     shall not make a grant under part B of title XXVI of the 
     Public Health Service Act (42 U.S.C. 300ff-21 et seq.) to any 
     State unless such State takes administrative or legislative 
     action to require that a good faith effort be made to notify 
     a spouse of a known HIV-infected patient that such spouse may 
     have been exposed to the human immunodeficiency virus and 
     should seek testing.
       (b) Definitions.--For purposes of this section:
       (1) Spouse.--The term ``spouse'' means any individual who 
     is the marriage partner of an HIV-infected patient, or who 
     has been the marriage partner of that patient at any time 
     within the 10-year period prior to the diagnosis of HIV 
     infection.

[[Page H4295]]

       (2) HIV-infected patient.--The term ``HIV-infected 
     patient'' means any individual who has been diagnosed to be 
     infected with the human immunodeficiency virus.
       (3) State.--The term ``State'' means any of the 50 States, 
     the District of Columbia, or any territory of the United 
     States.

     SEC. 9. OPTIONAL PARTICIPATION OF FEDERAL EMPLOYEES IN AIDS 
                   TRAINING PROGRAMS.

       (a) In General.--Notwithstanding any other provision of 
     law, a Federal employee may not be required to attend or 
     participate in an AIDS or HIV training program if such 
     employee refuses to consent to such attendance or 
     participation, except for training necessary to protect the 
     health and safety of the Federal employee and the individuals 
     served by such employees. An employer may not retaliate in 
     any manner against such an employee because of the refusal of 
     such employee to consent to such attendance or participation.
       (b) Definition.--As used in subsection (a), the term 
     ``Federal employee'' has the same meaning given the term 
     ``employee'' in section 2105 of title 5, United States Code, 
     and such term shall include members of the armed forces.

     SEC. 10. PROHIBITION ON PROMOTION OF CERTAIN ACTIVITIES.

       Part D of title XXVI of the Public Health Service Act (42 
     U.S.C. 300ff-71) as amended by section 6, is further amended 
     by adding at the end thereof the following new section:

     ``SEC. 2678. PROHIBITION ON PROMOTION OF CERTAIN ACTIVITIES.

       ``None of the funds authorized under this title shall be 
     used to fund AIDS programs, or to develop materials, designed 
     to promote or encourage, directly, intravenous drug use or 
     sexual activity, whether homosexual or heterosexual. Funds 
     authorized under this title may be used to provide medical 
     treatment and support services for individuals with HIV.''.

     SEC. 11. LIMITATION ON APPROPRIATIONS.

       Notwithstanding any other provision of law, the total 
     amounts of Federal funds expended in any fiscal year for AIDS 
     and HIV activities may not exceed the total amounts expended 
     in such fiscal year for activities related to cancer.

     SEC. 12. ADDITIONAL PROVISIONS.

       (a) Definitions.--Section 2676(4) (42 U.S.C. 300ff-76(4)) 
     is amended by inserting ``funeral-service practitioners,'' 
     after ``emergency medical technicians,''.
       (b) Miscellaneous Amendment.--Section 1201(a) (42 U.S.C. 
     300d(a)) is amended in the matter preceding paragraph (1) by 
     striking ``The Secretary,'' and all that follows through 
     ``shall,'' and inserting ``The Secretary shall,''.
       (c) Technical Corrections.--Title XXVI (42 U.S.C. 300ff-11 
     et seq.) is amended--
       (1) in section 2601(a), by inserting ``section'' before 
     ``2604'';
       (2) in section 2603(b)(4)(B), by striking ``an expedited 
     grants'' and inserting ``an expedited grant'';
       (3) in section 2617(b)(3)(B)(iv), by inserting ``section'' 
     before ``2615'';
       (4) in section 2647--
       (A) in subsection (a)(1), by inserting ``to'' before 
     ``HIV'';
       (B) in subsection (c), by striking ``section 2601'' and 
     inserting ``section 2641''; and
       (C) in subsection (d)--
       (i) in the matter preceding paragraph (1), by striking 
     ``section 2601'' and inserting ``section 2641''; and
       (ii) in paragraph (1), by striking ``has in place'' and 
     inserting ``will have in place'';
       (5) in section 2648--
       (A) by converting the heading for the section to boldface 
     type; and
       (B) by redesignating the second subsection (g) as 
     subsection (h);
       (6) in section 2649--
       (A) in subsection (b)(1), by striking ``subsection (a) 
     of''; and
       (B) in subsection (c)(1), by striking ``this subsection'' 
     and inserting ``subsection'';
       (7) in section 2651--
       (A) in subsection (b)(3)(B), by striking ``facility'' and 
     inserting ``facilities''; and
       (B) in subsection (c), by striking ``exist'' and inserting 
     ``exists'';
       (8) in section 2676--
       (A) in paragraph (2), by striking ``section'' and all that 
     follows through ``by the'' and inserting ``section 2686 by 
     the''; and
       (B) in paragraph (10), by striking ``673(a)'' and inserting 
     ``673(2)'';
       (9) in part E, by converting the headings for subparts I 
     and II to Roman typeface; and
       (10) in section 2684(b), in the matter preceding paragraph 
     (1), by striking ``section 2682(d)(2)'' and inserting 
     ``section 2683(d)(2)''.

     SEC. 13. EFFECTIVE DATE.

       (a) In General.--Except as provided in subsection (b), this 
     Act, and the amendments made by this Act, shall become 
     effective on October 1, 1996.
       (b) Exception.--The amendments made by sections 3(a), 5, 6, 
     and 7 of this Act to sections 2601(c), 2601(d), 2603(a), 
     2618(b), 2626, 2677, and 2691 of the Public Health Service 
     Act, shall become effective on the date of enactment of this 
     Act.
       And the House agree to the same.
       That the Senate recede from its disagreement to the 
     amendment of the House to the title of the bill, and agree to 
     the same.
     Tom Bliley,
     Michael Bilirakis,
     Tom Coburn,
     Henry A. Waxman,
     Gerry Studds,
                                Managers on the Part of the House.
     Nancy Landon Kassebaum,
     Jim Jeffords,
     Bill Frist,
     Edward M. Kennedy,
     Christopher J. Dodd,
                               Managers on the Part of the Senate.

       JOINT EXPLANATORY STATEMENT OF THE COMMITTEE ON CONFERENCE


                             1. short title

       The Senate Bill titles the Act the Ryan White CARE 
     Reauthorization Act of 1995. The House bill is titled the 
     Ryan White CARE Act Amendments of 1995. The Senate recedes.


                   2. eligibility and effective dates

       The Conferees agreed to make October 1, 1996 the general 
     effective date for the Act. However, the amendments limiting 
     eligible areas to those with a population of 500,000 or 
     higher, continuing the eligibility of current EMAs, and all 
     formula changes (including the provisions on single 
     appropriations and funding for Special Projects of National 
     Significance) are effective immediately upon passage of the 
     Act. The Secretary is required to make a report to Congress 
     on the single appropriations provision by July 1, 1996.
       It is the intent of the Conferees that, beginning in fiscal 
     year 1996 and continuing through the reauthorization period, 
     no new metropolitan area with fewer than 500,000 people be 
     eligible for Part A funds. On October 1, 1996, the period for 
     counting AIDS cases to determine eligibility is reduced to 
     the most recent five calendar years. The Conferees wish to 
     make clear, however, that metropolitan areas, once eligible 
     to receive Part A funds, and all metropolitan areas currently 
     receiving such funds, shall remain eligible regardless of 
     fluctuations in the five year case count over time.


             3. planning council roles and responsibilities

       The Senate bill prohibits the Planning Council from being 
     chaired solely by an employee of the grantee. The House bill 
     contains no such prohibition. The House recedes.
       The House bill provides that the planning council may not 
     be directly involved in the administration of a grant to a 
     provider under Section 2601(a) nor designate particular 
     entities as recipients of grants. Planning council members 
     must also agree to comply with measures relating to conflicts 
     of interest. The Senate bill does not contain such 
     provisions. The Senate recedes with an amendment that the 
     duties of the planning council, in addition to establishing 
     funding priorities, include making recommendations concerning 
     how best to meet established priorities.
       It is the intent of the Conferees that the planning council 
     provide guidance to the grantee regarding the types of 
     organizations that may best meet each service priority 
     established by the planning council. Types of organizations 
     may, for example, include outpatient clinics, community-based 
     organizations that historically have served affected 
     communities and other types of organizations that meet 
     criteria outlined in the legislation (i.e., cost 
     effectiveness, priority of the affected community, etc.) 
     While the conferees expect the grantee through the grant 
     making process to satisfy the target population, service, and 
     service delivery priorities established by the planning 
     council, they do not intend that the planning council select 
     which particular organizations receive funding, either by 
     specific direction or by narrowly describing a type of 
     organization. The legislation clearly states that such a 
     planning council role is prohibited. The Conferees expect 
     that the planning council will help to guide the grantee in 
     how best to meet the established service priorities.


                        4. grievance procedures

       The Senate bill mandates that planning councils establish 
     operating procedures which include specific policies for 
     resolving disputes, responding to grievances, and minimizing 
     and managing conflicts of interest. The House bill contains 
     no such mandate. The House recedes with an amendment that the 
     operating procedures relating to conflict of interest and 
     grievance procedures be locally developed and included in the 
     eligible area's application for Part A formula funds.
       The Senate bill includes a requirement that the Secretary 
     develop grievance procedures specific to each part of the 
     Act, to resolve egregious violations of each part, and to 
     establish appropriate enforcement mechanisms. The House bill 
     contains no such provision. The Senate recedes with an 
     amendment to require the Secretary to convene a process 
     involving grantees and outside experts to develop models and 
     prototypes for locally established grievance procedures, and 
     lay out key elements that should be addressed in setting up 
     grievance and arbitration processes at the local level.
       The Committee wishes to emphasize that the grievance 
     procedures should be locally established, with assistance 
     from the Secretary. The procedures are to be reviewed by the 
     Health Resources and Services Administration to ensure that 
     they adequately address potential conflicts and grievances. 
     While the bill does not require the Secretary to establish 
     federal grievance procedures, the Committee emphasizes that 
     the Secretary has the power, under this Act and existing law 
     on federal contracts and grants, to withhold funds for 
     violations of the Act.


                         5. supplemental grants

       The Senate bill requires that the supplemental grant 
     application demonstrate that

[[Page H4296]]

     the planning council include representatives of the requisite 
     population groups, service provides, and affected 
     communities. The House bill does not include such a 
     provision. The House recedes.
       The House bill requires that the supplemental grant 
     application demonstrate that both formula and supplemental 
     grant funds from the previous year were distributed according 
     to the priorities established by the planning council. The 
     Senate bill does not contain such a provision. The Senate 
     recedes.


                             6. severe need

       The Conferees agreed to clarify the meaning of ``severe 
     need'' for the purposes of supplemental funding under Title 
     I. The Secretary is directed to develop a quantitative 
     measurement of that need and incorporate it into supplemental 
     funding allocation decisions. The development of a 
     quantitative measurement of severe need is not intended to 
     replace existing factors the Secretary may use to determine 
     supplemental awards, such as comprehensive planning, 
     magnitude of the epidemic, planning council functioning and 
     CEO responsibilities, program and fiscal performance, needs 
     assessment and the match between needs and service 
     priorities.
       The Conferees believe that a comparison of severe need 
     across EMAs should be part of the review of applications for 
     supplemental grants and compare service delivery costs and 
     complexity of delivering services due to comorbidity and 
     other factors listed in the legislation. The Conferees 
     emphasize that the list of factors is not all inclusive and 
     recognizes that data needed to quantify these factors may not 
     be available. The Secretary may consider other factors, to 
     account appropriately for differences in the cost and 
     complexity of service delivery across eligible areas. Those 
     factors which are associated with nationwide quantitative 
     data, however, should be given the highest importance. The 
     Conferees intend that the Secretary have flexibility in 
     developing this quantitative mechanism to carry out 
     comparisons across eligible areas.
       In the past, supplemental awards have been allocated on the 
     basis of the formula grant. By including criteria for severe 
     need, the conferees intend that those eligible areas with the 
     greatest public health challenges be given appropriate 
     consideration for larger supplemental awards.


                    7. women, infants, and children

       The House bill requires Part A and Part B grantees to 
     utilize a portion of their funds to provide health and 
     support services to women, infants, and children. The 
     grantees are required to utilize at least 5 percent of such 
     funds or a percentage of funds equal to the ratio of women, 
     infants, and children with AIDS to the entire population with 
     AIDS, whichever is less. The Senate bill does not contain 
     such provisions. The Senate recedes with an amendment to 
     strike the 15 percent comparison and, in the case of Part A 
     grantees, to require that the grantee utilize the appropriate 
     percentage of funds in accordance with the priorities 
     established by the planning council.
       The House bill requires that these funds be used primarily 
     for the prevention of perinatal HIV transmission. The Senate 
     bill does not contain such a provision. The House recedes 
     with an amendment that language be included which indicates 
     that services funded by the set-aside may include treatments 
     to prevent the perinatal transmission of HIV.
       It is the intent of the conferees that funding be allocated 
     based on the demographics of the epidemic in a local area, 
     and that spending for services for women, infants, and 
     children be equal, on a percentage basis, to the percentage 
     of women, infants, and children with AIDS.


                        8. administrative costs

       Both the House and Senate bills maintain the administrative 
     costs caps for Part A grantees and the Senate bill defines 
     these costs. For Part B, the Senate bill defines 
     administrative costs and modifies existing administrative 
     cost caps for grantees. Part B grantees are limited to 
     spending not more than than 10% of the award they receive in 
     a fiscal year on administrative costs and 10% of that award 
     on planning and evaluation activities. However, total 
     spending on administration, planning, and evaluation cannot 
     exceed 15% of the award a grantee receives in a fiscal year. 
     The House recedes to the definition of administrative costs 
     and to the 15% cap.
       Regarding entities receiving funds from Part A or Part B 
     grantees, the Senate limits expenditures for administrative 
     activities to 12.5% for each such entity. The bill 
     specifically defines administrative costs for these entities. 
     The House bill limits such expenditures to 10% as measured 
     across all entities receiving funding from Part A or Part B 
     grantees, without regard to whether an individual entity is 
     above or below that percentage. For example, if a state or 
     eligible area awards $1 million to 10 service providers, 
     regardless of the amount an individual provider spends on 
     administration, the amount spent on administration added 
     across all 10 providers cannot exceed $100,000 (10% of $1 
     million). For Part B grantees, entities subject to this cost 
     cap include the lead agencies of consortia in carrying out 
     their administrative duties associated with the operation of 
     the consortium. The Senate recedes with an amendment to 
     include the Senate bill's definition of administrative costs.
       The Conferees wish to emphasize that grantees and 
     subcontractors that can restrain administrative costs to less 
     than 10% should do so. The set amount should be regarded as a 
     ceiling, not a floor.


                         9. single application

       The Senate bill allows the Secretary to phase in the use of 
     single application for formula and supplemental Part A funds 
     and the awarding of a single grant. The House bill makes this 
     allowance contingent upon the request of an individual 
     grantee. The House recedes.
       It is the intent of the conferees that the Secretary have 
     the authority to implement mechanisms necessary to make a 
     single grant based on a single application. It is the 
     understanding of the conferees that the use of such a grant 
     and application will reduce the administrative burdens on the 
     Secretary, grantees, and individual providers. Under current 
     methods, these entities often must track two separate funding 
     streams that accrue to a single provider for the same 
     services.
       Use of a single grant or single application, however, must 
     not result in a delay in allocating funding under the Act.


                        10. use of part b funds

       The House bill adds a fifth eligible use of Part B funds, 
     allowing states to fund services directly. The Senate bill 
     does not include such a provision. The Senate recedes with an 
     amendment that, in order to fund these services outside an 
     existing consortia system, the state must demonstrate to the 
     Secretary that utilizing other service delivery mechanisms is 
     more effective. In making that determination, the State must 
     consult with service provider representatives and recipients 
     of services.
       The House bill eliminates the requirement that states with 
     more than 1% of all cases of AIDS expend at least 50% of 
     their Part B funds on consortia. The Senate does not 
     eliminate this provision. The Senate recedes.
       The Conferees want to emphasize that the purpose of the Act 
     is to provide health care services to individuals with HIV 
     and AIDS. It is the expectation of the conferees that states 
     will maximize the funds spent directly on health care 
     services.
       The Conferees wish to emphasize that the eligible funding 
     areas under Part B are flexible enough to allow states to 
     implement an appropriate array of services. With Part B 
     funds, states can establish treatment programs, health 
     insurance continuation programs, home health care programs 
     and consortia. The Conferees expect states to use funds to 
     provide or ensure the provision of services eligible for 
     funding under Part A. Where consortia exist or are 
     established under this part, in areas that would have been 
     eligible for direct part A funding prior to enactment of this 
     Act, they should function as planning bodies for local 
     service delivery, much as planning councils function under 
     Part A.
       The Conferees also emphasize that the elimination of the 
     requirement that states with more than 1% of national AIDS 
     cases expend at least 50% of their Part B award on consortia 
     is not to be interpreted to mean that Part A medical services 
     should not be provided to beneficiaries who reside outside an 
     eligible area. Eliminating the 50% expenditure requirement 
     provides more flexibility to respond to local needs.


                       11. minimum drug formulary

       The Senate bill requires the Secretary to develop a minimum 
     drug formulary for suggested use by the states which must 
     document their success in implementing the developed 
     formulary. The House bill requires some portion of Part B 
     funds to be used to fund drug assistance programs, including 
     measures for the prevention and treatment of opportunistic 
     infections. The Senate recedes with an amendment to strike 
     references in Section 2612(a)(2) and Section 2616(a) to 
     ``treatments that have been determined to prolong life'' and 
     replace them with ``therapeutics to treat HIV disease''.
       These amendments expand State flexibility to provide a 
     broader range of treatments through State drug treatment 
     programs funded by Ryan White Care Act funds, by allowing 
     State drug treatment programs to provide any therapeutics 
     that treat HIV and AIDS, rather than only those that ``have 
     been determined to prolong life.'' This is intended to 
     increase access for persons with HIV and AIDS to treatments 
     targeted toward various aspects of the disease, to prolong 
     life. Such treatments may, for example, by addressing certain 
     specific symptoms of HIV and AIDS, improve an individual's 
     quality of life. With this flexibility, states will be able 
     to improve access to the growing range of treatment options 
     for HIV and AIDS, enabling patients to benefit from recent 
     advances in the treatment of the disease.
       The Senate bill requires the Secretary to review the 
     current status of State drug reimbursement programs and 
     assess barriers to the expanded availability of prophylactic 
     treatments for opportunistic infections. The House bill does 
     not contain such provisions. The House recedes with an 
     amendment to replace ``prophylactic treatment'' with 
     ``treatments described in subsection (a)'' and to require 
     states to document their progress in making those treatments 
     available.
       In addition, the amendments require the Secretary to 
     evaluate the effectiveness of State drug treatment programs 
     in removing barriers to the availability of this wider range 
     of therapeutics to treat HIV and AIDS, and also to evaluate 
     the extent to which State drug treatment programs coordinate

[[Page H4297]]

     with other recipients of Ryan White Care Act funds to remove 
     barriers to the availability of treatments for HIV and AIDS. 
     States also are required to document their progress in making 
     treatments available to those eligible for assistance under 
     the Ryan White Care Act, namely low-income individuals who 
     have been medically diagnosed with HIV or AIDS. These 
     requirements for evaluation and documentation are designed to 
     assure that these funds are being used efficiently and 
     effectively to achieve the goals of the Ryan White Care Act, 
     specifically in the area of improving access for low income 
     individuals to medical treatments for HIV and AIDS.
       The Conferees emphasize that the Secretary is encouraged to 
     advise states on classes of drugs that have been found 
     effective in preventing and treating HIV disease as part of 
     the assessment of barriers to expanded availability of 
     therapeutics. For the purposes of this section, the Conferees 
     include as therapeutics as pharmaceuticals (including the 
     necessary equipment to utilize them) and other therapies 
     which prevent the onset of opportunistic infections or 
     deterioration of health.


              12. statewide coordinated statement of need

       The Senate bill requires the state public health agency 
     administering Part B funds to convene an annual meeting for 
     the development of a coordinated statement of need. The House 
     bill does not define the Statewide Coordinated Statement of 
     Need. The House recedes with an amendment to require a 
     periodic convening of such a meeting and to remove the 
     parentheticals which describe required attendees.
       The Conferees intend for this activity to result in a joint 
     written statement developed in partnership with all CARE Act 
     grantees within the State which identifies unmet need, 
     epidemiological trends, barriers to care and other 
     appropriate issues which impact on service availability.
       The Conferees wish to emphasize that the Statewide 
     Coordinated Statement of Need and the process to create it 
     should not supplant existing planning processes utilized by 
     grantees under this Act. It is meant to augment such planning 
     and should be used as a tool to maximize coordination, 
     integration, and effective linkages among the individual 
     entities funded by the Act. For existing grantees, local 
     plans and programs shall be considered consistent with the 
     Coordinated Statement of Need if the grantees can show a good 
     faith effort to participate in crafting the statement and a 
     good faith consideration of the statement in their planning 
     and decision making processes. New grantees must demonstrate 
     their good faith consideration of the statement in making 
     their applications for funding.


                            13. coordination

       The Senate bill requires the Public Health Service to 
     coordinate the activities of the Health Resources and 
     Services Administration, the Centers for Disease Control and 
     Prevention, and the Substance Abuse and Mental Health 
     Services Administration regarding the local development of a 
     complete continuum of HIV-related services for individuals 
     with HIV disease or at risk for HIV disease. The House bill 
     requires the Secretary to submit a report to Congress on 
     coordination of agency activities. The Senate recedes with an 
     amendment that the report be submitted biennially beginning 
     October 1, 1996.


                    14. early intervention programs

       The Senate bill stipulates that early intervention funds 
     are for primary care services for people with HIV. The House 
     bill lists four types of services that are eligible for early 
     intervention funds. The Senate recedes with an amendment that 
     the House listed services are for people with HIV.
       The Senate requires that 50% of early intervention grants 
     to primary health care facilities, including migrant health 
     centers, centers that provide health services for the 
     homeless, and other federally-qualified health centers, be 
     expended on-site or at sites where other primary care 
     services are rendered. The House bill does not contain such a 
     provision. The House recedes.
       The conferees recognize that some grantees operate as 
     consortia to provide services specifically designed for HIV/
     AIDS. These programs and the guidelines developed must meet 
     the needs of people living with HIV/AIDS and assure that 
     direct services are provided consistent with the needs of 
     consumers.
       The Senate bill provides planning and development grants to 
     public and nonprofit entities that are not direct providers 
     of primary health care to provide HIV-specific care services. 
     The House bill provides the grants to all eligible public and 
     private nonprofit entities to provide early intervention 
     services. The Senate recedes with an amendment to add ``HIV'' 
     to ``early intervention services''.
       The Senate bill requires the Secretary to give preference 
     to entities that would provide HIV primary care services in 
     rural or under-served communities. The House bill requires 
     preference to entities that currently provide HIV primary 
     care services in rural and under-served communities. The 
     Senate recedes with an amendment to delete ``HIV'' from ``HIV 
     primary care services''.
       The Senate bill requires family planning and hemophilia 
     center grantees to ensure the availability of early 
     intervention services through a series of linkages to 
     community-based primary care providers and to establish 
     mechanisms for referrals and follow-up. The House bill does 
     not contain such a provision. The House recedes.
       The Senate bill increases the cap on administrative costs 
     to 10% and expands those costs to include planning, 
     evaluation, and technical assistance. The House bill contains 
     no such provision. The House recedes with an amendment to 
     lower the cap to 7.5% and eliminate inclusion of technical 
     assistance.


                              15. title iv

       The House bill titles Section 2671, Coordinated Services 
     and Access to Research for Women, Infants, and Children. The 
     Senate bill titles this section, Grants for Coordinated 
     Services and Access to Research for Children, Youth, and 
     Families. The Senate recedes with an amendment to add 
     ``Grants for'' at the beginning of the title, and ``and 
     Youth'' at the end of the title.
       The House bill makes grants available to primary health 
     care providers to provide opportunities for women, infants, 
     and children to participate as subjects in research of 
     potential clinical benefit. The Senate bill makes available 
     such grants to facilitate voluntary participation of those 
     groups in research protocols at the facility or by direct 
     referral. The Senate recedes with an amendment to include 
     youth in the eligible population group.
       The House bill requires entities to provide outpatient 
     health care to women, infants, and children. The Senate bill 
     requires that health care and support services be provided to 
     children, youth, and women with HIV disease and the families 
     of such individuals. The Senate recedes with an amendment to 
     require applicants to provide to patients and their families 
     case management, transportation, child care, and other 
     incidental services as may be necessary to enable the patient 
     and the family to participate in the applicant's program, and 
     referrals to inpatient hospital services, treatment for 
     substance abuse, mental health services, and other support 
     services as appropriate.
       The House bill requires the grant applicant to make 
     reasonable efforts to identify prospective patients who would 
     be appropriate participants in research projects and to offer 
     patients the opportunity to participate in projects. The 
     Senate bill requires a broader list of assurances from the 
     applicant, including that the grant will be used primarily to 
     serve children, youth, and women; and that the applicant will 
     arrange with research entities to collaborate in the conduct 
     of facilitation of voluntary patient participation in 
     qualified research protocols. The Senate recedes with an 
     amendment to require entities to identify appropriate 
     patients through the use of criteria provided by the entity 
     for that purpose.
       The House bill requires that applicant and the project of 
     research comply with accepted standards of protection for 
     human subjects including the provision of written informed 
     consent. The Senate bill requires the Secretary to establish 
     procedures which ensure those requirements. The Senate 
     recedes.
       The Conferees wish to emphasize that receipt of services by 
     a patient shall not be conditioned upon consent to 
     participate in research.
       The House bill requires that for the third or subsequent 
     fiscal year for which an applicant seeks a grant, the 
     applicant must assure that a significant number, as 
     determined by the Secretary, of women, infants, and children 
     who are patients of the applicant are participating in 
     research projects. The Senate bill does not contain such a 
     provision. The Senate recedes.
       Under the House bill, if the grantee is temporarily unable 
     to comply with the ``significant number'' requirement, the 
     Secretary may grant a reasonable amount of time for the 
     grantee to reestablish compliance, under certain 
     circumstances. The Senate bill does not contain such a 
     provision. The Senate recedes.
       In the House bill, the Secretary may waive the 
     ``significant numbers'' requirement for an applicant who 
     received a grant in fiscal year 1995 if the applicant is 
     making a reasonable effort toward meeting this goal. The 
     authority for the Secretary to issue this waiver expires on 
     October 1, 1998, and waivers issued before October 1, 1998, 
     expire on or before that date. The Senate bill does not 
     contain such a provision. The Senate recedes with an 
     amendment to provide that applicants must, not later than the 
     end of the second fiscal year, meet the requirement that a 
     significant number of women, infants, children, and youth 
     participate in research projects.
       The Conferees intend that the Secretary interpret the term 
     ``significant number'' in a relative way. For grantees 
     located in areas where there is access to many research 
     activities, the ``significant number'' will be higher than 
     for grantees located in more remote areas where research for 
     women, infants, and children is less accessible. The 
     Conferees intend that the Secretary take into account a 
     variety of factors in determining ``significant numbers'', 
     including: the number and type of clients serviced by the 
     grantee, and the nature and availability of research programs 
     accessible to patients of the grantee, and other factors the 
     Secretary considers to be relevant.
       The Senate bill includes a provision requiring submission 
     of an application in such form as the Secretary determines is 
     necessary. The House bill does not contain such a provision. 
     The House recedes.
       The House bill includes a section on Provisions Regarding 
     Conduct of Research, allowing for the project of research to 
     be conducted by the applicant or by an entity with

[[Page H4298]]

     which the applicant has made arrangements. The Senate bill 
     does not contain such a provision. The Senate recedes.
       The House bill requires that the grant may not be expended 
     for the conduct of any research project, that the research 
     entity must be appropriately qualified to conduct the 
     project, and that the research project must be in accordance 
     with the priorities determined and listed by the Secretary in 
     consultation with public and private research entities, 
     providers and recipients of services under Part B. An entity 
     shall be considered qualified if any research protocol of the 
     entity has been recommended for funding under this Act 
     pursuant to technical and scientific peer review through the 
     National Institutes of Health. Under certain circumstances, 
     the Secretary may give priority to a research protocol not on 
     the list of high priority research. The Senate bill requires 
     the Secretary to establish mechanisms, including an 
     independent research review panel, to ensure that the 
     research projects are of potential clinical benefit and meet 
     accepted standards of research design. The Senate recedes 
     with an amendment to allow grantees to fund services that 
     facilitate and coordinate client access to comprehensive care 
     services and research projects.
       The Senate bill allows the Secretary to waive the 
     requirements regarding coordination, statewide coordinated 
     statement of need, and appropriate research opportunities if 
     the applicant provides assurances that the requirements will 
     be met by the end of the second grant year, or, in the case 
     of existing grantees, within one year. The House bill does 
     not contain such a provision. The Senate recedes.
       The Senate bill contains a provision on Evaluations and 
     Data Collection, requiring the Secretary to review the 
     programs carried out under the section at the end of each 
     fiscal year. The review may include recommendations on 
     improving access to and participation in research protocols. 
     The House bill does not contain such a provision. The House 
     recedes with an amendment to title this section ``Review 
     Regarding Access To And Participation in Programs;'' to 
     require the review to be completed not later than 180 days 
     after the end of the fiscal year; to state that the purpose 
     of the review shall be to develop recommendations on 
     procedures to allocate services and opportunities among 
     patients of the entity and other procedures and policies of 
     the entity regarding the participation of women, infants, 
     children, and youth in research programs; and to require the 
     Secretary to provide for evaluations of programs carried out 
     by the entity.
       The Senate bill allows the Secretary to establish reporting 
     requirements necessary to administer the program and carry 
     out the reviews, measure outcomes, and document clients 
     served, services provided and participation in research 
     protocols. The House bill does not contain such provisions. 
     The Senate recedes.
       The Senate bill includes a definition of qualified research 
     entities and qualified research protocols. The House bill 
     does not contain such a provision. The Senate recedes.
       The House bill requires the Secretary to develop a plan 
     that provides for the coordination of the activities of the 
     National Institutes of Health (NIH) with the activities of 
     this section, including that the projects of research 
     conducted or supported by NIH are made aware of applicants 
     and grantees of this section and that those projects as 
     appropriate enter into arrangements for purposes of this 
     section. The Senate bill does not contain such a provision. 
     The Senate recedes.
       The Conferees emphasize that Part D was enacted to provide 
     funds for coordinated health and social services in 
     association with voluntary participation in research 
     programs. Such research will lead to a greater understanding 
     of HIV disease among women, infants and children and to the 
     development of preventive and therapeutic measures 
     appropriate for those populations. The Conferees recognize 
     that participation of children, youth, and pregnant women in 
     HIV research programs is more successful when projects are 
     convenient to women and children with HIV disease, when they 
     are sensitive to needs for nontraditional services such as 
     child care and transportation services, and when the 
     opportunities to participate in research are provided within 
     an established, comprehensive and community based HIV care 
     system. For this reason, it is the intent of the Conferees 
     that entities receiving grants under this program provide or 
     arrange for innovative comprehensive HIV care for children, 
     youth, women, and families with or affected by HIV.
       It is the intent of the Conferees for this program to be 
     flexible but to organize, coordinate and support a broad 
     range of HIV services linking institutional and community-
     based providers. Grantees may provide a wide range of health 
     services and may make referrals for, or provide services to, 
     facilitate access to care.


                    16. aids dental school training

       The House bill reauthorizes the current program and 
     transfers it from Title 7 of the Public health Service Act to 
     Title 26. The Senate bill does not reauthorize the program. 
     The Senate recedes.


                 17. evaluation of ryan white programs

       The House bill authorizes funding for the evaluation of 
     Ryan White programs to come from the 1% Public Health Service 
     set aside. The Senate bill does not contain such a provision. 
     The Senate recedes.


             18. special projects of national significance

       The Senate bill includes service delivery grants as special 
     projects and describes those grants, which include programs 
     that support family-based care networks critical to the 
     delivery of care in minority communities and programs that 
     build organizational capacity in disenfranchised communities. 
     The House bill does not specifically define such grants. The 
     House recedes with an amendment to replace the term 
     ``disenfranchised communities'' with ``minority 
     communities''.


                19. aids education and training centers

       The House bill includes as an eligible activity the 
     training of health providers in the prevention of perinatal 
     HIV transmission and prevention and treatment of 
     opportunistic infections. The Senate bill does not include 
     such language. The Senate recedes.
       By including the AIDS Education and Training Centers in the 
     CARE Act reauthorization, the conferees reaffirm that this is 
     an important federal program and will serve an important role 
     in the future.


                              20. formulas

       The Senate bill distributes Part A funds to eligible 
     metropolitan areas with a formula based only on weighted AIDS 
     case counts. The Senate formula caps funding losses such that 
     no eligible area will receive less than 98% of its FY 95 
     award in FY 96, 97% of its FY 95 award in FY 97, 95.5% of its 
     FY 95 award in FY 98, 94% of its FY 95 award in FY 99, and 
     92.5% of its FY 95 award in FY 2000. The House bill uses the 
     same weighted AIDS case count, but includes in its formula 
     the Medicare Hospital Wage Index for each metropolitan area 
     as a measure of service delivery cost. The House formula caps 
     funding losses such that no eligible area will receive less 
     than 99% of its FY 95 award in FY 96, 98% of its FY 95 award 
     in FY 97, 97% of its FY 95 award in FY 98, 96% of its FY 95 
     award in FY 99, and 95% of its FY 95 award in FY 2000. The 
     House recedes with an amendment to replace the Senate funding 
     loss caps with losses such that no eligible area will receive 
     less than 100% of its FY 95 award in FY 96, 99% of its FY 95 
     award in FY 97, 98% of its FY 95 award in FY 98, 96.5% of its 
     FY 95 award in FY 99, and 95% of its FY 95 award in FY 2000.
       The conferees feel that the formula changes for Part A, 
     including the hold harmless provisions, adequately respond to 
     the geographic diversification of the epidemic while 
     simultaneously protecting against major disruptions in 
     service delivery. The Committee understands that the formula 
     changes will reduce the amount of supplemental funds that 
     have been traditionally available to all Part A grantees 
     because supplemental funds will be used to fund the hold 
     harmless provisions. The Committee further understands that 
     this reduction in the availability of supplemental funds 
     could result in resource shifts beyond those built into the 
     revised formula depending on the quality of the supplemental 
     application as determined by the review process.
       The Senate bill distributes Part B funds to states based on 
     a formula that calculates two distribution factors: the state 
     factor, based on weighted AIDS case counts for each state and 
     the non-EMA factor based on weighted AIDS case counts for 
     areas within the state outside of Part A eligible areas. Each 
     of these distribution factors is weighted equally. The Senate 
     bill also includes a provisions to cap funding losses such 
     that no state will receive less than 98% of its FY 95 award 
     in FY 96, 97% of its FY 95 award in FY 97, 95.5% of its FY 95 
     award in FY 98, 94% of its FY 95 award in FY 99, and 92.5% of 
     its FY 95 award in FY 2000. The House bill retains the Part B 
     formula contained in current law and sets aside 7% of 
     available funds for distribution to states without Part A 
     eligible areas, based on the relative case counts within 
     those states. The House recedes with an amendment to weight 
     the state factor in the Senate formula by a constant of .8 
     and the non-EMA factor by a constant of .2, and to substitute 
     the Senate loss caps with the same loss caps used in the 
     House version of the Part A formula.
       Neither the House bill nor the Senate bill contained a 
     provision allowing for the adjustment of the weights used to 
     determine the estimate of living AIDS cases over the required 
     120 month period, in either the Part A or Part B formulas. 
     The Conferees feel that such an adjustment may be necessary 
     over time as life expectancy and disease progression changes 
     for people living with AIDS. Therefore the Conferees expect 
     the Secretary, in consultation with the Centers for Disease 
     Control, to evaluate the need to update those weights every 
     two years beginning with the grant awards in FY 1998 and 
     report to the appropriate congressional committees.
       The Conferees intend that if funds are appropriated 
     specifically for the Drug Assistance Program, such funds be 
     allocated according to the states entire weighted case 
     counts.


                        21. single appropriation

       Under the Senate bill, after one year, if the Secretary is 
     unable to devise a methodology to adjust the split in the 
     single appropriation between Parts A and B, the single 
     appropriation reverts to two separate appropriations, 
     beginning in FY 1997. Under the House bill, the single 
     appropriation and the 64%/36% split between the two Parts 
     remains

[[Page H4299]]

     in effect over the entire reauthorization period. The 
     Secretary has the discretion to adjust the apportionment of 
     the single appropriation between the two Parts. The House 
     recedes with an amendment that, by July 1, 1996, the 
     Secretary devise the methodology or recommend that such a 
     methodology is not feasible. In addition, the appropriation 
     committee will determine the relative allocation of funds for 
     Part A and Part B for fiscal year 1996.


                         22. perinatal testing

       The Senate bill mandates that states with an incidence of 
     HIV among childbearing women of .25 or greater or an 
     estimated number of births to HIV positive women in 1993 of 
     175 or greater have in effect regulations implementing the 
     guidelines issued by the Centers for Disease Control (CDC) 
     concerning voluntary HIV testing and counseling for pregnant 
     women. The House bill does not contain such a provision. The 
     House recedes with an amendment to require all states to 
     implement the CDC guidelines.
       In the Senate bill, for states providing such 
     certification, $10 million in grant funds are made available 
     to implement the CDC guidelines, to provide outreach to at-
     risk pregnant women and to make available appropriate 
     counseling and voluntary testing. The House bill makes 
     available $10 million in grants for states to offer HIV 
     testing and counseling to pregnant women, to test newborns 
     for HIV, and to collect data on pregnant women and newborns 
     who have undergone HIV testing. In order to be eligible for 
     these grants, the state by statute or regulation must require 
     that all newborns whose biological mother has not undergone 
     prenatal testing for HIV, be tested for HIV at birth and that 
     the results be made available to the biological mother or 
     guardian of the infant. The House recedes with an amendment 
     to restrict access to these funds to states that have 
     implemented the CDC guidelines and to prioritize the $10 
     million to those states with high HIV seroprevalence rates 
     among childbearing women.
       In the Senate bill, the Secretary is required to evaluate 
     the effect of these grants on reducing the perinatal 
     transmission of HIV. In the House bill, in two years, if the 
     Secretary establishes that testing newborns for HIV has 
     become routine practice in the provision of health care, 
     states, by regulation or statute, must require such testing 
     of newborns and notification to the mother or guardian in 
     order to receive Ryan White Part B funds. Alternatively, 
     states can demonstrate that of newborns in the state, the HIV 
     status of 95% of the infants is known. The House recedes with 
     an amendment to require the following.
       (1) Within four months of enactment of this Act, the CDC, 
     in consultation with states, will develop and implement a 
     reporting system for states to use in determining the rate of 
     new cases of AIDS resulting from perinatal transmission and 
     the possible causes for that transmission.
       The Secretary of HHS is directed to contract with the 
     Institute of Medicine to conduct an evaluation of the extent 
     to which state efforts have been effective in reducing 
     perinatal transmission of HIV and an analysis of the existing 
     barriers to further reduction in such transmission. The 
     Secretary shall report these findings to Congress along with 
     any recommendation made by the Institute.
       (2) Within two years following the implementation of such a 
     system, the Secretary will make a determination whether 
     mandatory HIV testing of all infants born in the U.S. whose 
     mothers have not undergone prenatal HIV testing has become a 
     routine practice. This determination will be made in 
     consultation with states and experts. If the Secretary 
     determines that such mandatory testing has become a routine 
     practice, after an additional 18 month period, a state will 
     not recieve Title 2 Ryan White funding unless it can 
     demonstrate one of the following:
       (A) A 50% reduction (or a comparable measure for low-
     incidence states) in the rate of new AIDS cases resulting 
     from perinatal transmission, comparing the most recent data 
     to 1993 data;
       (B) At least 95% of women who have received at least two 
     prenatal visits with a health care provider or provider group 
     have been tested for HIV; or
       (C) A program for mandatory testing of all newborns whose 
     mothers have not undergone prenatal HIV testing.
       The House bill requires states by statute or regulation to 
     prohibit health insurance companies from discontinuing 
     coverage for a person solely on the basis that the person is 
     infected with HIV or that the individual has been tested for 
     HIV. The Senate bill does not contain such a provision. The 
     Senate recedes with an amendment that only states which 
     implement mandatory testing of newborn infants be required to 
     implement such insurance regulations. The conferees intend 
     for these insurance provisions to augment, and in no way 
     diminish, existing federal or state law.
       The House bill requirements on insurance regulations do not 
     apply to persons who knowingly misrepresent their HIV status, 
     facts regarding whether the person has been tested for HIV, 
     and facts regarding whether the person has engaged in any 
     behavior that places the person at risk for HIV. The Senate 
     recedes with an amendment to delete the last two exemptions 
     on testing and behavior.
       The Conferees wish to emphasize that nothing in this 
     provision should be construed to mean that states are 
     required to implement HIV reporting.


                        23. spousal notification

       The Senate bill prohibits the Secretary from making any 
     grant under the Act to any state, political subdivision of 
     any state, or other recipient of CARE Act funds within the 
     state unless the state requires a good faith effort to notify 
     the spouses of AIDS-infected patients that the patients are 
     infected with HIV. The House bill does not contain such a 
     provision. The House recedes with an amendment to tie the 
     provision to Part B funds only, change ``AIDS-infected 
     patient'' to ``known HIV-infected patient'', replace ``such 
     AIDS infected patients is infected with the human 
     immunodeficiency virus'' with ``he or she may have been 
     exposed to the human immunodeficiency virus and should seek 
     testing,'' define HIV-infected as any person diagnosed with 
     the human immunodeficiency virus, and change the definition 
     of spouse to mean a current marriage partner or a person that 
     was the marriage partner at any time within the ten years 
     prior to the diagnosis of HIV infection.
       The Conferees wish to emphasize that nothing in this 
     provision should be construed to require states to implement 
     HIV name reporting.


                     24. study on allotment formula

       The Senate bill requires the Secretary to conduct a study 
     of the funding formulas contained in the Act and submit a 
     report to Congress. The House bill does not contain such a 
     provision. The Senate recedes.


 25. prohibitions on the use of federal funds and promotion of certain 
                               activities

       The Senate bill prohibits funds appropriated under the Act 
     from being used to promote or encourage, directly or 
     indirectly, homosexuality or intravenous drug use. The House 
     bill does not contain such a prohibition or definition. The 
     Senate recedes.
       The Senate bill prohibits funds appropriated under the Act 
     from being used to develop materials designed to promote or 
     encourage directly intravenous drug use or sexual activity, 
     whether homosexual or heterosexual. The House bill does not 
     contain such a provision. The House recedes.


    26. optional participation of federal employees in aids training

       The Senate bill prohibits the federal government from 
     requiring any employee to attend or participate in an AIDS or 
     HIV training program if the employee refuses to participate. 
     The House bill does not contain such a provision. The House 
     recedes with an amendment that exempts from this provision 
     federal training programs necessary to protect the health and 
     safety of federal employees and those they serve.
       This provision is intended to apply to those employees 
     whose position requires knowledge of the universal 
     precautions for the prevention of the transmission of the HIV 
     virus.


                    27. limitation on appropriations

       The Senate bill requires that of the total amounts of 
     Federal funds expended in any fiscal year, funds expended for 
     AIDS and HIV activities not exceed the amounts expended for 
     activities related to cancer. The House bill does not contain 
     such a provision. The House recedes.
       The Conferees wish to make clear that the term ``total 
     amounts'' includes all research, treatment and prevention 
     funding, including amounts expended through the Medicare and 
     Medicaid programs, wherhe administered by the federal 
     government or paid to states in block grants.
     Tom Bliley,
     Michael Bilirakis,
     Tom Coburn,
     Henry A. Waxman,
     Gerry Studds,
                                Managers on the Part of the House.

     Nancy Landon Kassebaum,
     Jim Jeffords,
     Bill Frist,
     Edward M. Kennedy,
     Christopher J. Dodd,
     Managers on the Part of the Senate.

                          ____________________