[Congressional Record Volume 142, Number 131 (Friday, September 20, 1996)]
[Senate]
[Pages S11110-S11121]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HEALTH CENTERS CONSOLIDATION ACT OF 1995
Mr. LOTT. Mr. President, I ask unanimous consent that the Senate now
proceed to the consideration of Calendar No. 279, S. 1044.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:
A bill (S. 1044) to amend title III of the Public Health
Service Act to consolidate and reauthorize provisions
relating to health centers, and for other purposes.
The PRESIDING OFFICER. Is there objection to the immediate
consideration of the bill?
There being no objection, the Senate proceeded to consider the
bill, which had been reported from the Committee on Labor and Human
Resources, with amendments; as follows:
(The parts of the bill intended to be stricken are shown in boldface
brackets and the parts of the bill intended to be inserted are shown in
italic.)
S. 1044
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Health Centers Consolidation
Act of 1995''.
SEC. 2. CONSOLIDATION AND REAUTHORIZATION OF PROVISIONS.
Subpart I of part D of title III of the Public Health
Service Act (42 U.S.C. 254b et seq.) is amended to read as
follows:
``Subpart I--Health Centers
``SEC. 330. HEALTH CENTERS.
``(a) Definition of Health Center.--
``(1) In general.--For purposes of this section, the term
`health center' means an entity that serves a population that
is medically underserved, or a special medically underserved
population comprised of migratory and seasonal agricultural
workers, the homeless, and residents of public housing, by
providing, either through the staff and supporting resources
of the center or through contracts or cooperative
arrangements--
``(A) required primary health services (as defined in
subsection (b)(1)); and
``(B) as may be appropriate for particular centers,
additional health services (as defined in subsection (b)(2))
necessary for the adequate support of the primary health
services required under subparagraph (A);
for all residents of the area served by the center (hereafter
referred to in this section as the `catchment area').
``(2) Limitation.--The requirement in paragraph (1) to
provide services for all residents within a catchment area
shall not apply in the case of a health center receiving a
grant only under subsection (f), (g), or (h).
``(b) Definitions.--For purposes of this section:
``(1) Required primary health services.--
``(A) In general.--The term `required primary health
services' means--
``(i) basic health services which, for purposes of this
section, shall consist of--
``(I) health services related to family medicine, internal
medicine, pediatrics, obstetrics, or gynecology that are
furnished by physicians and where appropriate, physician
assistants, nurse practitioners, and nurse midwives;
``(II) diagnostic laboratory and radiologic services;
``(III) preventive health services, including--
``(aa) prenatal and perinatal services;
``(bb) screening for breast and cervical cancer;
``(cc) well-child services;
``(dd) immunizations against vaccine-preventable diseases;
``(ee) screenings for elevated blood lead levels,
communicable diseases, and cholesterol;
``(ff) pediatric eye, ear, and dental screenings to
determine the need for vision and hearing correction and
dental care;
``(gg) voluntary family planning services; and
``(hh) preventive dental services;
``(IV) emergency medical services; and
``(V) pharmaceutical services as may be appropriate for
particular centers;
``(ii) referrals to providers of medical services and other
health-related services (including substance abuse and mental
health services);
``(iii) patient case management services (including
counseling, referral, and follow-up services) and other
services designed to assist health center patients in
establishing eligibility for and gaining access to Federal,
State, and local programs that provide or financially support
the provision of medical, social, educational, or other
related services;
``(iv) services that enable individuals to use the services
of the health center (including outreach and transportation
services and, if a substantial number of the individuals in
the population served by a center are of limited English-
speaking ability, the services of appropriate personnel
fluent in the language spoken by a predominant number of such
individuals); and
``(v) education of patients and the general population
served by the health center regarding the availability and
proper use of health services.
``(B) Exception.--With respect to a health center that
receives a grant only under subsection (f), the Secretary,
upon a showing of good cause, shall--
``(i) waive the requirement that the center provide all
required primary health services under this paragraph; and
``(ii) approve, as appropriate, the provision of certain
required primary health services only during certain periods
of the year.
``(2) Additional health services.--The term `additional
health services' means services that are not included as
required primary health services and that are appropriate to
meet the health needs of the population served by the health
center involved. Such term may include--
``(A) environmental health services, including--
``(i) the detection and alleviation of unhealthful
conditions associated with water supply;
``(ii) sewage treatment;
``(iii) solid waste disposal;
``(iv) rodent and parasitic infestation;
``(v) field sanitation;
``(vi) housing; and
``(vii) other environmental factors related to health; and
``(B) in the case of health centers receiving grants under
subsection (f), special occupation-related health services
for migratory and seasonal agricultural workers, including--
``(i) screening for and control of infectious diseases,
including parasitic diseases; and
``(ii) injury prevention programs, including prevention of
exposure to unsafe levels of agricultural chemicals including
pesticides.
``(3) Medically underserved populations.--
``(A) In general.--The term `medically underserved
population' means the population of an urban or rural area
designated by the Secretary as an area with a shortage of
personal health services or a population group designated by
the Secretary as having a shortage of such services.
``(B) Criteria.--In carrying out subparagraph (A), the
Secretary shall prescribe criteria for determining the
specific shortages of personal health services of an area or
population group. Such criteria shall--
``(i) take into account comments received by the Secretary
from the chief executive officer of a State and local
officials in a State; and
``(ii) include factors indicative of the health status of a
population group or residents of an area, the ability of the
residents of an area or of a population group to pay for
health services and their accessibility to them, and the
availability of health professionals to residents of an area
or to a population group.
``(C) Limitation.--The Secretary may not designate a
medically underserved population in a State or terminate the
designation of such a population unless, prior to such
designation or termination, the Secretary provides reasonable
notice and opportunity for comment and consults with--
``(i) the chief executive officer of such State;
``(ii) local officials in such State; and
``(iii) the organization, if any, which represents a
majority of health centers in such State.
``(D) Permissible designation.--The Secretary may designate
a medically underserved population that does not meet the
criteria established under subparagraph (B) if the chief
executive officer of the State in which such population is
located and local officials of such State recommend the
designation of such population based on unusual local
conditions which are a barrier to access to or the
availability of personal health services.
``(c) Planning Grants.--
``(1) In general.--
``(A) Centers.--The Secretary may make grants to public and
nonprofit private entities for projects to plan and develop
health centers which will serve medically underserved
populations. A project for which a grant may be made under
this subsection
[[Page S11111]]
may include the cost of the acquisition, expansion, and
modernization of existing buildings and construction of new
buildings (including the costs of amortizing the principal
of, and paying the interest on, loans) and shall include--
``(i) an assessment of the need that the population
proposed to be served by the health center for which the
project is undertaken has for required primary health
services and additional health services;
``(ii) the design of a health center program for such
population based on such assessment;
``(iii) efforts to secure, within the proposed catchment
area of such center, financial and professional assistance
and support for the project;
``(iv) initiation and encouragement of continuing community
involvement in the development and operation of the project;
and
``(v) proposed linkages between the center and other
appropriate provider entities, such as health departments,
local hospitals, and rural health clinics, to provide better
coordinated, higher quality, and more cost-effective
health care services.
``(B) Comprehensive service delivery networks and plans.--
The Secretary may make grants to health centers that receive
assistance under this section to enable the centers to plan
and develop a network or plan for the provision of health
services, which may include the provision of health services
on a prepaid basis or through another managed care
arrangement, to some or to all of the individuals which the
centers serve. Such a grant may only be made for such a
center if--
``(i) the center has received grants under subsection
(d)(1)(A) for at least 2 consecutive years preceding the year
of the grant under this subparagraph or has otherwise
demonstrated, as required by the Secretary, that such center
has been providing primary care services for at least the 2
consecutive years immediately preceding such year; and
``(ii) the center provides assurances satisfactory to the
Secretary that the provision of such services on a prepaid
basis, or under another managed care arrangement, will not
result in the diminution of the level or quality of health
services provided to the medically underserved population
served prior to the grant under this subparagraph.
Any such grant may include the acquisition and lease,
expansion, and modernization of existing buildings,
construction of new buildings, acquisition or lease of
equipment which may include data and information systems, and
providing training and technical assistance related to the
provision of health services on a prepaid basis or under
another managed care arrangement, and for other purposes that
promote the development of managed care networks and plans.
``(2) Limitation.--Not more than two grants may be made
under this subsection for the same project, except that upon
a showing of good cause, the Secretary may make additional
grant awards.
``(d) Operating Grants.--
``(1) Authority.--
``(A) In general.--The Secretary may make grants for the
costs of the operation of public and nonprofit private health
centers that provide health services to medically underserved
populations.
``(B) Entities that fail to meet certain requirements.--The
Secretary may make grants, for a period of not to exceed 2-
years, for the costs of the operation of public and nonprofit
private entities which provide health services to medically
underserved populations but with respect to which the
Secretary is unable to make each of the determinations
required by subsection [(j)](i)(3).
``(2) Use of funds.--The costs for which a grant may be
made under subparagraph (A) or (B) of paragraph (1) may
include the costs of acquiring, expanding, and modernizing
existing buildings and constructing new buildings (including
the costs of amortizing the principal of, and paying interest
on, loans), the costs of repaying loans for buildings, and
the costs of providing training related to the provision of
required primary health services and additional health
services and to the management of health center programs.
``(3) Limitation.--Not more than two grants may be made
under subparagraph (B) of paragraph (1) for the same entity.
``(4) Amount.--
``(A) In general.--The amount of any grant made in any
fiscal year under paragraph (1) to a health center shall be
determined by the Secretary, but may not exceed the amount by
which the costs of operation of the center in such fiscal
year exceed the total of--
``(i) State, local, and other operational funding provided
to the center; and
``(ii) the fees, premiums, and third-party reimbursements,
which the center may reasonably be expected to receive for
its operations in such fiscal year.
``(B) Payments.--Payments under grants under subparagraph
(A) or (B) of paragraph (1) shall be made in advance or by
way of reimbursement and in such installments as the
Secretary finds necessary and adjustments may be made for
overpayments or underpayments.
``(C) Use of nongrant funds.--Nongrant funds described in
clauses (i) and (ii) of subparagraph (A), including any such
funds in excess of those originally expected, shall be used
as permitted under this section, and may be used for such
other purposes as are not specifically prohibited under this
section if such use furthers the objectives of the project.
``(e) Infant Mortality Grants.--
``(1) In general.--The Secretary may make grants to health
centers for the purpose of assisting such centers in--
``(A) providing comprehensive health care and support
services for the reduction of--
``(i) the incidence of infant mortality; and
``(ii) morbidity among children who are less than 3 years
of age; and
``(B) developing and coordinating service and referral
arrangements between health centers and other entities for
the health management of pregnant women and children
described in subparagraph (A).
``(2) Priority.--In making grants under this subsection the
Secretary shall give priority to health centers providing
services to any medically underserved population among which
there is a substantial incidence of infant mortality or among
which there is a significant increase in the incidence of
infant mortality.
``(3) Requirements.--The Secretary may make a grant under
this subsection only if the health center involved agrees
that--
``(A) the center will coordinate the provision of services
under the grant to each of the recipients of the services;
``(B) such services will be continuous for each such
recipient;
``(C) the center will provide follow-up services for
individuals who are referred by the center for services
described in paragraph (1);
``(D) the grant will be expended to supplement, and not
supplant, the expenditures of the center for primary health
services (including prenatal care) with respect to the
purpose described in this subsection; and
``(E) the center will coordinate the provision of services
with other maternal and child health providers operating in
the catchment area.
``(f) Migratory and Seasonal Agricultural Workers.--
``(1) In general.--The Secretary may award grants for the
purposes described in subsections (c), (d), and (e) for the
planning and delivery of services to a special medically
underserved population comprised of--
``(A) migratory agricultural workers, seasonal agricultural
workers, and members of the families of such migratory and
seasonal agricultural workers who are within a designated
catchment area; and
``(B) individuals who have previously been migratory
agricultural workers but who no longer meet the requirements
of subparagraph (A) of paragraph (4) because of age or
disability and members of the families of such individuals
who are within such catchment area.
``(2) Environmental concerns.--The Secretary may enter into
grants or contracts under this subsection with public and
private entities to--
``(A) assist the States in the implementation and
enforcement of acceptable environmental health standards,
including enforcement of standards for sanitation in
migratory agricultural worker labor camps, and applicable
Federal and State pesticide control standards; and
``(B) conduct projects and studies to assist the several
States and entities which have received grants or contracts
under this section in the assessment of problems related to
camp and field sanitation, exposure to unsafe levels of
agricultural chemicals including pesticides, and other
environmental health hazards to which migratory agricultural
workers and members of their families are exposed.
``(3) Definitions.--For purposes of this subsection:
``(A) Migratory agricultural worker.--The term `migratory
agricultural worker' means an individual whose principal
employment is in agriculture on a seasonal basis, who has
been so employed within the last 24 months, and who
establishes for the purposes of such employment a temporary
abode.
``(B) Seasonal agricultural worker.--The term `seasonal
agricultural worker' means an individual whose principal
employment is in agriculture on a seasonal basis and who is
not a migratory agricultural worker.
``(C) Agriculture.--The term `agriculture' means farming in
all its branches, including--
``(i) cultivation and tillage of the soil;
``(ii) the production, cultivation, growing, and harvesting
of any commodity grown on, in, or as an adjunct to or part of
a commodity grown in or on, the land; and
``(iii) any practice (including preparation and processing
for market and delivery to storage or to market or to
carriers for transportation to market) performed by a farmer
or on a farm incident to or in conjunction with an activity
described in clause (ii).
``(g) Homeless Population.--
``(1) In general.--The Secretary may award grants for the
purposes described in subsections (c), (d), and (e) for the
planning and delivery of services to a special medically
underserved population comprised of homeless individuals,
including grants for innovative programs that provide
outreach and comprehensive primary health services to
homeless children and children at risk of homelessness.
``(2) Required services.--In addition to required primary
health services (as defined in subsection (b)(1)), an entity
that receives a grant under this subsection shall be required
to provide substance abuse services as a condition of such
grant.
[[Page S11112]]
``(3) Supplement not supplant requirement.--A grant awarded
under this subsection shall be expended to supplement, and
not supplant, the expenditures of the health center and the
value of in kind contributions for the delivery of services
to the population described in paragraph (1).
``(4) Definitions.--For purposes of this section:
``(A) Homeless individual.--The term `homeless individual'
means an individual who lacks housing (without regard to
whether the individual is a member of a family), including an
individual whose primary residence during the night is a
supervised public or private facility that provides temporary
living accommodations and an individual who is a resident in
transitional housing.
``(B) Substance abuse.--The term `substance abuse' has the
same meaning given such term in section 534(4).
``(C) Substance abuse services.--The term `substance abuse
services' includes detoxification and residential treatment
for substance abuse provided in settings other than
hospitals.
``(h) Residents of Public Housing.--
``(1) In general.--The Secretary may award grants for the
purposes described in subsections (c), (d), and (e) for the
planning and delivery of services to a special medically
underserved population comprised of residents of public
housing (such term, for purposes of this subsection, shall
have the same meaning given such term in section 3(b)(1) of
the United States Housing Act of 1937) and individuals living
in areas immediately accessible to such public housing.
``(2) Supplement not supplant.--A grant awarded under this
subsection shall be expended to supplement, and not supplant,
the expenditures of the health center and the value of in
kind contributions for the delivery of services to the
population described in paragraph (1).
``(3) Consultation with residents.--The Secretary may not
make a grant under paragraph (1) unless, with respect to the
residents of the public housing involved, the applicant for
the grant--
``(A) has consulted with the residents in the preparation
of the application for the grant; and
``(B) agrees to provide for ongoing consultation with the
residents regarding the planning and administration of the
program carried out with the grant.
``(i) Applications.--
``(1) Submission.--No grant may be made under this section
unless an application therefore is submitted to, and approved
by, the Secretary. Such an application shall be submitted in
such form and manner and shall contain such information as
the Secretary shall prescribe.
``(2) Description of need.--An application for a grant
under subparagraph (A) or (B) of subsection (d)(1) for a
health center shall include--
``(A) a description of the need for health services in the
catchment area of the center;
``(B) a demonstration by the applicant that the area or the
population group to be served by the applicant has a shortage
of personal health services; and
``(C) a demonstration that the center will be located so
that it will provide services to the greatest number of
individuals residing in the catchment area or included in
such population group.
Such a demonstration shall be made on the basis of the
criteria prescribed by the Secretary under subsection (b)(3)
or on any other criteria which the Secretary may prescribe to
determine if the area or population group to be served by the
applicant has a shortage of personal health services. In
considering an application for a grant under subparagraph (A)
or (B) of subsection (d)(1), the Secretary may require as a
condition to the approval of such application an assurance
that the applicant will provide any health service defined
under paragraphs (1) and (2) of subsection (b) that the
Secretary finds is needed to meet specific health needs of
the area to be served by the applicant. Such a finding shall
be made in writing and a copy shall be provided to the
applicant.
``(3) Requirements.--Except as provided in subsection
(d)(1)(B), the Secretary may not approve an application for a
grant under subparagraph (A) or (B) of subsection (d)(1)
unless the Secretary determines that the entity for which the
application is submitted is a health center (within the
meaning of subsection (a)) and that--
``(A) the required primary health services of the center
will be available and accessible in the catchment area of the
center promptly, as appropriate, and in a manner which
assures continuity;
``(B) the center will have an ongoing quality improvement
system that includes clinical services and management, and
that maintains the confidentiality of patient records;
``(C) the center will demonstrate its financial
responsibility by the use of such accounting procedures and
other requirements as may be prescribed by the Secretary;
``(D) the center--
``(i) has or will have a contractual or other arrangement
with the agency of the State, in which it provides services,
which administers or supervises the administration of a State
plan approved under title XIX of the Social Security Act for
the payment of all or a part of the center's costs in
providing health services to persons who are eligible for
medical assistance under such a State plan; or
``(ii) has made or will make every reasonable effort to
enter into such an arrangement;
``(E) the center has made or will make and will continue to
make every reasonable effort to collect appropriate
reimbursement for its costs in providing health services to
persons who are entitled to insurance benefits under title
XVIII of the Social Security Act, to medical assistance under
a State plan approved under title XIX of such Act, or to
assistance for medical expenses under any other public
assistance program or private health insurance program;
``(F) the center--
``(i) has prepared a schedule of fees or payments for the
provision of its services consistent with locally prevailing
rates or charges and designed to cover its reasonable costs
of operation and has prepared a corresponding schedule of
discounts to be applied to the payment of such fees or
payments, which discounts are adjusted on the basis of the
patient's ability to pay;
``(ii) has made and will continue to make every reasonable
effort--
``(I) to secure from patients payment for services in
accordance with such schedules; and
``(II) to collect reimbursement for health services to
persons described in subparagraph (E) on the basis of the
full amount of fees and payments for such services without
application of any discount; and
``(iii) has submitted to the Secretary such reports as the
Secretary may require to determine compliance with this
subparagraph;
``(G) the center has established a governing board which
except in the case of an entity operated by an Indian tribe
or tribal or Indian organization under the Indian Self-
Determination Act--
``(i) is composed of individuals, a majority of whom are
being served by the center and who, as a group, represent the
individuals being served by the center;
``(ii) meets at least once a month, selects the services to
be provided by the center, schedules the hours during which
such services will be provided, approves the center's annual
budget, approves the selection of a director for the center,
and, except in the case of a governing board of a public
center (as defined in the second sentence of this paragraph),
establishes general policies for the center; and
``(iii) in the case of an application for a second or
subsequent grant for a public center, has approved the
application or if the governing body has not approved the
application, the failure of the governing body to approve the
application was unreasonable;
except that, upon a showing of good cause the Secretary shall
waive all or part of the requirements of this subparagraph in
the case of a health center that receives a grant pursuant to
subsection (f), (g), (h), or (o);
``(H) the center has developed--
``(i) an overall plan and budget that meets the
requirements of the Secretary; and
``(ii) an effective procedure for compiling and reporting
to the Secretary such statistics and other information as the
Secretary may require relating to--
``(I) the costs of its operations;
``(II) the patterns of use of its services;
``(III) the availability, accessibility, and acceptability
of its services; and
``(IV) such other matters relating to operations of the
applicant as the Secretary may require;
``(I) the center will review periodically its catchment
area to--
``(i) ensure that the size of such area is such that the
services to be provided through the center (including any
satellite) are available and accessible to the residents of
the area promptly and as appropriate;
``(ii) ensure that the boundaries of such area conform, to
the extent practicable, to relevant boundaries of political
subdivisions, school districts, and Federal and State health
and social service programs; and
``(iii) ensure that the boundaries of such area eliminate,
to the extent possible, barriers to access to the services of
the center, including barriers resulting from the area's
physical characteristics, its residential patterns, its
economic and social grouping, and available transportation;
``(J) in the case of a center which serves a population
including a substantial proportion of individuals of limited
English-speaking ability, the center has--
``(i) developed a plan and made arrangements responsive to
the needs of such population for providing services to the
extent practicable in the language and cultural context most
appropriate to such individuals; and
``(ii) identified an individual on its staff who is fluent
in both that language and in English and whose
responsibilities shall include providing guidance to such
individuals and to appropriate staff members with respect to
cultural sensitivities and bridging linguistic and cultural
differences; and
``(K) the center, has developed an ongoing referral
relationship with one or more hospitals.
For purposes of subparagraph (G), the term `public center'
means a health center funded (or to be funded) through a
grant under this section to a public agency.
``(4) Approval of new or expanded service applications.--
The Secretary shall approve applications for grants under
subparagraph (A) or (B) of subsection (d)(1) for health
centers which--
``(A) have not received a previous grant under such
subsection; or
[[Page S11113]]
``(B) have applied for such a grant to expand their
services;
in such a manner that the ratio of the medically underserved
populations in rural areas which may be expected to use the
services provided by such centers to the medically
underserved populations in urban areas which may be expected
to use the services provided by such centers is not less than
two to three or greater than three to two.
``(5) New construction.--The Secretary may make a grant
under subsection (c) or (d) for the construction of new
buildings for a health center only if the Secretary
determines that appropriate facilities are not available
through acquiring, modernizing, or expanding existing
buildings and that the entity to which the grant will be made
has made reasonable efforts to secure from other sources
funds, in lieu of the grant, to construct such facilities.
``(j) Technical and Other Assistance.--The Secretary may
provide (either through the Department of Health and Human
Services or by grant or contract) all necessary technical and
other nonfinancial assistance (including fiscal and program
management assistance and training in such management) to any
public or private nonprofit entity to assist entities in
developing plans for, or operating as, health centers, and in
meeting the requirements of subsection (i)(2).
``(k) Authorization of Appropriations.--
``(1) In general.--For the purpose of carrying out this
section there are authorized to be appropriated
[$756,000,000] $756,518,000 for fiscal year 1996, and such
sums as may be necessary for each of the fiscal years 1997
through 2000.
[``(2) Special provisions.--The]
``(2) Special provisions.--
``(A) Public centers.--The Secretary may not expend in
any fiscal year, for grants under this section to public
centers (as defined in the second sentence of subsection
(i)(3)) the governing boards of which (as described in
subsection (i)(3)(G)(ii)) do not establish general policies
for such centers, an amount which exceeds 5 percent of the
amounts appropriated under this section for that fiscal year.
For purposes of applying the preceding sentence, the term
`public centers' shall not include health centers that
receive grants pursuant to subsection (g) or (h).
``(B) Distribution of grants.--
``(i) Fiscal year 1996.--For fiscal year 1996, the
Secretary, in awarding grants under this section shall ensure
that the amounts made available under each of subsections
(f), (g), and (h) in such fiscal year bears the same
relationship to the total amount appropriated for such fiscal
year under paragraph (1) as the amounts appropriated for
fiscal year 1995 under each of sections 329, 340, and 340A
(as such sections existed one day prior to the date of
enactment of this section) bears to the total amount
appropriated under sections 329, 330, 340, and 340A (as such
sections existed one day prior to the date of enactment of
this section) for such fiscal year.
``(ii) Fiscal years 1997 and 1998.--For each of the fiscal
years 1997 and 1998, the Secretary, in awarding grants under
this section shall ensure that the proportion of the amounts
made available under each of subsections (f), (g), and (h) is
equal to the proportion of amounts made available under each
such subsection for the previous fiscal year, as such amounts
relate to the total amounts appropriated for the previous
fiscal year involved, increased or decreased by not more than
10 percent.
``(3) Funding report.--The Secretary shall annually prepare
and submit to the appropriate committees of Congress a report
concerning the distribution of funds under this section that
are provided to meet the health care needs of medically
underserved populations, including the homeless, residents of
public housing, and migratory and seasonal agricultural
workers, and the appropriateness of the delivery systems
involved in responding to the needs of the particular
populations. Such report shall include an assessment of the
relative health care access needs of the targeted populations
and the rationale for any substantial changes in the
distribution of funds.
``(l) Memorandum of Agreement.--In carrying out this
section, the Secretary may enter into a memorandum of
agreement with a State. Such memorandum may include, where
appropriate, provisions permitting such State to--
``(1) analyze the need for primary health services for
medically underserved populations within such State;
``(2) assist in the planning and development of new health
centers;
``(3) review and comment upon annual program plans and
budgets of health centers, including comments upon
allocations of health care resources in the State;
``(4) assist health centers in the development of clinical
practices and fiscal and administrative systems through a
technical assistance plan which is responsive to the requests
of health centers; and
``(5) share information and data relevant to the operation
of new and existing health centers.
``(m) Records.--
``(1) In general.--Each entity which receives a grant under
subsection (d) shall establish and maintain such records as
the Secretary shall require.
``(2) Availability.--Each entity which is required to
establish and maintain records under this subsection shall
make such books, documents, papers, and records available to
the Secretary or the Comptroller General of the United
States, or any of their duly authorized representatives, for
examination, copying or mechanical reproduction on or off the
premises of such entity upon a reasonable request therefore.
The Secretary and the Comptroller General of the United
States, or any of their duly authorized representatives,
shall have the authority to conduct such examination,
copying, and reproduction.
``(n) Delegation of Authority.--The Secretary may delegate
the authority to administer the programs authorized by this
section to any office within the Service, except that the
authority to enter into, modify, or issue approvals with
respect to grants or contracts may be delegated only within
the Health Resources and Services Administration.
``(o) Special Consideration.--In making grants under this
section, the Secretary shall give special consideration to
the unique needs of sparsely populated rural areas, including
priority in the awarding of grants for new health centers
under subsections (c) and (d), and the granting of waivers as
appropriate and permitted under subsections (b)(1)(B)(i) and
(i)(3)(G).''.
SEC. 3. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND
TELEMEDICINE GRANT PROGRAM.
(a) In General.--Subpart I of part D of title III of the
Public Health Service Act (42 U.S.C. 254b et seq.) (as
amended by section 2) is further amended by adding at the end
thereof the following new section:
``SEC. 330A. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND
TELEMEDICINE GRANT PROGRAM.
``(a) Administration.--The rural health services outreach
demonstration grant program established under section 301
shall be administered by the Office of Rural Health Policy
(of the Health Resources and Services Administration), in
consultation with State rural health offices or other
appropriate State governmental entities.
``(b) Grants.--Under the program referred to in subsection
(a), the Secretary, acting through the Director of the Office
of Rural Health Policy, may award grants to expand access to,
coordinate, restrain the cost of, and improve the quality of
essential health care services, including preventive and
emergency services, through the development of integrated
health care delivery systems or networks in rural areas and
regions.
``(c) Eligible Networks.--
``(1) Outreach networks.--To be eligible to receive a grant
under this section, an entity shall--
``(A) be a rural public or nonprofit private entity that is
or represents a network or potential network that includes
three or more health care providers or other entities that
provide or support the delivery of health care services; and
``(B) in consultation with the State office of rural health
or other appropriate State entity, prepare and submit to the
Secretary an application, at such time, in such manner, and
containing such information as the Secretary may require,
including--
``(i) a description of the activities which the applicant
intends to carry out using amounts provided under the grant;
``(ii) a plan for continuing the project after Federal
support is ended;
``(iii) a description of the manner in which the activities
funded under the grant will meet health care needs of
underserved rural populations within the State; and
``(iv) a description of how the local community or region
to be served by the network or proposed network will be
involved in the development and ongoing operations of the
network.
``(2) For-profit entities.--An eligible network may include
for-profit entities so long as the network grantee is a
nonprofit entity.
``(3) Telemedicine networks.--
``(A) In general.--An entity that is a health care provider
and a member of an existing or proposed telemedicine network,
or an entity that is a consortium of health care providers
that are members of an existing or proposed telemedicine
network shall be eligible for a grant under this section.
``(B) Requirement.--A telemedicine network referred to in
subparagraph (A) shall, at a minimum, be composed of--
``(i) a multispecialty entity that is located in an urban
or rural area, which can provide 24-hour a day access to a
range of specialty care; and
``(ii) at least two rural health care facilities, which may
include rural hospitals, rural physician offices, rural
health clinics, rural community health clinics, and rural
nursing homes.
``(d) Preference.--In awarding grants under this section,
the Secretary shall give preference to applicant networks
that include--
``(1) a majority of the health care providers serving in
the area or region to be served by the network;
``(2) any federally qualified health centers, rural health
clinics, and local public health departments serving in the
area or region;
``(3) outpatient mental health providers serving in the
area or region; or
``(4) appropriate social service providers, such as
agencies on aging, school systems, and providers under the
women, infants, and children program, to improve access to
and coordination of health care services.
``(e) Use of Funds.--
``(1) In general.--Amounts provided under grants awarded
under this section shall be used--
``(A) for the planning and development of integrated self-
sustaining health care networks; and
``(B) for the initial provision of services.
[[Page S11114]]
``(2) Expenditures in rural areas.--
``(A) In general.--In awarding a grant under this section,
the Secretary shall ensure that not less than 50 percent of
the grant award is expended in a rural area or to provide
services to residents of rural areas.
``(B) Telemedicine networks.--An entity described in
subsection (c)(3) may not use in excess of--
``(i) 40 percent of the amounts provided under a grant
under this section to carry out activities under paragraph
(3)(A)(iii); and
``(ii) 20 percent of the amounts provided under a grant
under this section to pay for the indirect costs associated
with carrying out the purposes of such grant.
``(3) Telemedicine networks.--
``(A) In general.--An entity described in subsection
(c)(3), may use amounts provided under a grant under this
section to--
``(i) demonstrate the use of telemedicine in facilitating
the development of rural health care networks and for
improving access to health care services for rural citizens;
``(ii) provide a baseline of information for a systematic
evaluation of telemedicine systems serving rural areas;
``(iii) purchase or lease and install equipment; and
``(iv) operate the telemedicine system and evaluate the
telemedicine system.
``(B) Limitations.--An entity described in subsection
(c)(3), may not use amounts provided under a grant under this
section--
``(i) to build or acquire real property;
``(ii) purchase or install transmission equipment (such as
laying cable or telephone lines, microwave towers, satellite
dishes, amplifiers, and digital switching equipment); or
``(iii) for construction, except that such funds may be
expended for minor renovations relating to the installation
of equipment;
``(f) Term of Grants.--Funding may not be provided to a
network under this section for in excess of a 3-year period.
``(g) Authorization of Appropriations.--For the purpose of
carrying out this section there are authorized to be
appropriated $36,000,000 for fiscal year 1996, and such sums
as may be necessary for each of the fiscal years 1997 through
2000.''.
(b) Transition.--The Secretary of Health and Human Services
shall ensure the continued funding of grants made, or
contracts or cooperative agreements entered into, under
subpart I of part D of title III of the Public Health Service
Act (42 U.S.C. 254b et seq.) (as such subpart existed on the
day prior to the date of enactment of this Act), until the
expiration of the grant period or the term of the contract or
cooperative agreement. Such funding shall be continued under
the same terms and conditions as were in effect on the date
on which the grant, contract or cooperative agreement was
awarded, subject to the availability of appropriations.
SEC. 4. TECHNICAL AND CONFORMING AMENDMENTS.
(a) In General.--The Public Health Service Act is amended--
(1) in section 224(g)(4) (42 U.S.C. 233(g)(4)) by striking
``under'' and all that follows through the end thereof and
inserting ``under section 330.'';
(2) in section 340C(a)(2) (42 U.S.C. 256c) by striking
[``diseases''] ``Under'' and all that follows through the end
thereof and inserting ``with assistance provided under
section 330.''; and
(3) by repealing subparts V and VI of part D of title III
(42 U.S.C. 256 et seq.).
(b) Social Security Act.--The Social Security Act is
amended--
(1) in clauses (i) and (ii)(I) of section 1861(aa)(4)(A)
(42 U.S.C. 1395x(aa)(4)(A)(i) and (ii)(I)) by striking
``section 329, 330, or 340'' and inserting ``section 330
(other than subsection (h))''; and
(2) in clauses (i) and (ii)(II) of section 1905(l)(2)(B)
(42 U.S.C. 1396d(l)(2)(B)(i) and (ii)(II)) by striking
``section 329, 330, 340, or 340A'' and inserting ``section
330''.
(c) References.--Whenever any reference is made in any
provision of law, regulation, rule, record, or document to a
community health center, migrant health center, public
housing health center, or homeless health center, such
reference shall be considered a reference to a health center.
(d) Additional Amendments.--After consultation with the
appropriate committees of the Congress, the Secretary of
Health and Human Services shall prepare and submit to the
Congress a legislative proposal in the form of an
implementing bill containing technical and conforming
amendments to reflect the changes made by this Act.
SEC. 5. EFFECTIVE DATE.
This Act and the amendments made by this Act shall become
effective on October 1, 1995.
Amendment No. 5397
(Purpose: To provide for a substitute amendment)
Mr. LOTT. Senator Kassebaum has a substitute amendment at desk. I ask
for its immediate consideration.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:
The Senator from Mississippi [Mr. Lott], for Mrs. Kassebaum
proposes an amendment numbered 5397.
Mr. LOTT. Mr. President, I ask unanimous consent that reading of the
amendment be dispensed with.
The PRESIDING OFFICER. Without objection, it is so ordered.
(The text of the amendment is printed in today's Record under
``Amendments Submitted.'')
Mr. KENNEDY. Mr. President, community and migrant health centers play
a vital role in bringing affordable and accessible community-based
primary care to millions of Americans in underserved areas. Since its
beginning in 1966, the Community Health Center Program has been the
backbone of Federal efforts to bring quality health care to needy
persons and areas throughout the country. In inner cities and isolated
rural areas, these health centers have served millions of uninsured and
underinsured people, including the elderly, women and children at risk,
and those with other special needs. Nationwide, over 2,400 health
centers provide basic services to over 9 million persons a year.
In addition to basic care, these centers provide many other services,
including health education, public health screening, laboratory
services, preventive dental care, emergency care, pharmacy services,
substance abuse counseling, and social services. Many centers maintain
extended hours for working families. They offer care at multiple sites,
and use mobile clinics to reach rural patients. They employ
multilingual staff to reduce barriers to care. They stay in touch with
community needs by working closely with local groups.
A key feature of the health centers is their strong emphasis on
preventive care. For the high risk populations they serve, the centers
reduce the demand for costly emergency and in-patient hospital care by
emphasizing prevention, early intervention, and case management with
good followup. One of the many vital missions of the centers is to
reduce infant mortality and low birthweight, by reaching out and
helping pregnant women and their infants receive timely care.
In Massachusetts, these health centers provide vital services to
communities across the State. Over 800,000 persons receive primary and
preventive health care through the centers. This care would otherwise
be delayed or unavailable for those without access to other assistance.
In western Massachusetts, health centers have mobilized to address
complex problems such as high teenage birth rates, increasing rates of
HIV infection, and the high incidence of drug abuse and alcohol-related
problems. In areas hard hit by the recent recession, the centers
provide a real opportunity for uninsured and struggling families to
receive comprehensive care.
Community health centers are becoming even more important as the
number of people who lack insurance continues to rise. Every year,
approximately 1 million more individuals, most of them children, lose
their insurance coverage. Today, over 41 million Americans are
uninsured. Current projections estimate that the number will reach 50
million by the year 2000.
Medicare and Medicaid, together with grants under this program, make
up almost 75 percent of the revenues that support these centers.
Reductions in this support would mean serious financial difficulty for
all community health centers.
The centers already face a changing health landscape that brings with
it both opportunities and threats to the future viability of the
centers. Some centers are responding creatively, but others are having
great difficulty. In particular, the trend toward managed care raises
serious concerns about the ability of these health centers to continue
to provide their communities with high quality, cost-effective
preventive care and primary care services. Several provisions in this
bill are designed to strengthen the centers and help them compete in
the changing marketplace.
The Health Centers Consolidation Act consolidates and reauthorizes
the four health center programs--the Community Health Center Program,
the Migrant Health Center Program, the Health Services for the Homeless
Program, and the Health Services for Residents of Public Housing
Program. Consolidating these programs will eliminate duplication while
maintaining their unique features that have made them so effective.
In addition, the bill helps health centers to address one of the
biggest problems they face--obtaining funds to develop and operate
their own managed
[[Page S11115]]
care networks or plans. Testimony before the Senate Labor and Human
Resources Committee concluded that participation in such networks was
vital to the future of the program, as States move more rapidly to
place their Medicaid population into managed care.
Health centers need to be able to form networks and managed care
plans to serve their patients effectively. But since centers are public
or nonprofit corporations, they have limited revenues and relatively
few assets. As a result, they are often unable to secure loans,
especially for the purpose of establishing risk reserves.
The bill addresses this problem in two ways, by network planning
grants and a Federal loan guarantee program. The grants will help
centers begin the initial phase of setting up links with other health
facilities and health providers. The loan guarantee program will enable
centers to take the next steps in owning and operating a network by
leveraging private dollars to help cover the developmental and initial
operating costs, which can range up to several million dollars.
The loan guarantee for network development establishes a program to
guarantee the principal and interest on loans made by non-Federal
lenders to health centers for the costs of developing and operating
managed care networks. The guarantees are subject to all of the
requirements of the 1990 Federal Credit Reform Act. The Congressional
Budget Office has estimated a 10-percent subsidy rate for the loan
program, which means that every dollar guaranteed by the Federal
Government would support $10 in loans to health centers.
Loans secured through the loan guarantee fund will be used for
activities needed to develop networks, such as establishing risk
reserves, acquiring or leasing buildings and equipment, and purchasing
management information systems. The cost of the program to the Federal
Government will be offset by loan origination fees.
This legislation recognizes the need to concentrate grant funds on
health services. The bill authorizes the Secretary of HHS to award
grants to pay for the costs associated with construction of new
buildings or the renovation of existing buildings--but only if the
projects are approved prior to October 1, 1996. Such approved projects
must be undertaken pursuant to the statutory and contractual terms,
conditions, and assurances in effect at the time Federal assistance for
the project was approved by the Secretary, even though the actual grant
will not be award until after October 1, 1996.
Because of the need to concentrate limited grant funds on providing
services, health centers need more flexibility in the use of their
nongrant funds. This bill enhances local health center decisionmaking
in the use of non-Federal grant revenues, thereby strengthening the
ability of health centers to respond to the changing environment and
compete more effectively as businesses in the health marketplace.
Through the leadership of Senator Kassebaum, this bill helps rural
health centers remove many of the barriers to health care in rural
America by authorizing grants for Rural Health Outreach, Network
Development, and Telemedicine. These grant funds will enable rural
health centers to improve the quality of essential health care
services.
In sum, this legislation is a significant step toward enabling local
health centers to compete and thrive in the changing health
marketplace. The centers are providing quality health care to needy
persons and areas throughout the country, and their ability to do so
will be preserved and strengthened by this important bipartisan
legislation. I urge the Senate to approve it.
Rural Primary Care
Mr. THOMAS. Mr. President, as Senator Kassebaum knows, many areas of
Wyoming, Kansas, and other rural States in the Midwest and West suffer
from severe shortages of primary care providers and services. I
appreciate the opportunity to work with you on S. 1044, legislation
reauthorizing the community health center program, to ensure that this
program is a viable option for rural communities in the Midwest and
West.
One solution that will help preserve and strengthen access to primary
care services in rural areas is a change in the governing board
criteria for the health centers. For a number of reasons related to
such factors as geography and population density, rural hospitals and
other rural providers have had difficulty qualifying for the community
health center program because they cannot meet all of the program's
strict governing board requirements. It is my understanding that the
legislation we are considering today requires the Secretary of Health
and Human Services to waive some or all of these requirements if rural
providers can show that it is not feasible or practicable for them to
meet the requirements. This will certainly make it easier for rural
hospitals and other rural providers who would otherwise qualify to
participate in the program.
Mrs. KASSEBAUM. The Senator is correct. Following up on your
suggestion, S. 1044 provides the Secretary with this waiver authority.
The bill has been modified to ensure that this waiver will be in effect
for the length of the community health center grant. Rural providers
will not be required to repeatedly make their case to the Secretary
over the period of the grant. It is also the committee's intention that
the process for obtaining this waiver be simple, straightforward, and
short. Our rural providers, who are already stretched so thinly, should
not be forced to go through a time-consuming, resource-consuming
paperwork exercise to obtain a waiver.
Mr. THOMAS. I am also pleased that S. 1044 includes a provision
requiring the Secretary to give special consideration to the unique
needs of sparsely populated rural areas and to give priority to such
areas in the awarding of health center planning and operating grants.
These provisions will give greater weight in the awarding of grants to
such factors as the severe shortages of primary care providers and
geographic barriers inhibiting access to care that are characteristic
of many areas in the Midwest and West.
Mrs. KASSEBAUM. I would also note that S. 1044 continues an authority
in current law that permits the Secretary to designate a population as
``medically underserved'' if the chief executive officer of a State and
local officials recommend that designation based on unusual local
conditions which are a barrier to access to care. I would hope that
this authority will also be used to address the unique needs of
sparsely populated rural areas.
I also wanted to assure the Senator from Wyoming that this bill
incorporates your suggestion for improving the coordination of services
in rural communities through collaborative relationships between
community health centers and other rural providers in the center's
service area. As a condition of eligibility for a health center
planning or operating grant, the center must demonstrate its efforts to
develop and maintain such relationships.
Sections 329, 330, 340, 340A
Mr. KENNEDY. The Health Centers Consolidation Act goes a long way in
making many improvements to the health center program. One of these
important improvements is to consolidate and streamline sections 329,
330, 340 and 340A of the Public Health Service Act. What remains clear
is that all centers under the new, consolidated section 330(a) will
have to continue to provide required primary health services to all
residents in the health center's service area. Consistent with the
history of these centers, that means the centers provide the health
services regardless of an individual's ability to pay.
Mrs. KASSEBAUM. Mr. President, I agree, that requirement goes to the
fundamental nature and purpose of these important safety net providers.
All of the health centers must serve all residents of the area served
by the center, regardless of an individual's ability to pay for the
services they receive.
publication of guidelines
Mr. KENNEDY. As part of the loan guarantee program authorized under
S. 1044, we are requiring the Secretary of Health and Human Services to
publish guidance explaining how the requirements and other provisions
of the loan guarantee program will be administered. It is normal for
agencies to put out guidance to the universe of affected entities,
including health centers, primary care associations, and other entities
with which the agency has cooperative agreements when funding is
available to them. The guidance includes things such as what is
required
[[Page S11116]]
in the application, the criteria that will be used to evaluate the
application, and documentation that will be required if the funding is
to be granted, or, in this case, a loan guaranteed for health center
networks or plans.
The requirement to publish guidance is not intended to delay the
implementaton of the loan guarantee program, and the distribution of
the guidance to the appropriate committees of Congress is meant for
informational purposes. It is my understanding that the Committee does
not intend that the publication of guidance required under S. 1044 to
be subject to the provisions of the Administrative Procedures Act.
Mrs. KASSEBAUM. That is correct. I understand how important the loan
guarantee provisions of S. 1044 are to the health centers. The States
are rapidly moving to managed care systems for Medicaid recipients. In
order to continue serving these individuals and other low-income,
uninsured individuals, centers must have the ability to form viable,
competitive networks and plans. The loan guarantee program will benefit
centers across the country, including rural centers who are now trying
to position themselves for the movement of managed care into rural
areas.
Mr. LOTT. Mr. President, I ask unanimous consent to have printed in
the Record a summary of S. 1044 and the manager's amendment.
There being no objection, the material was ordered to be printed in
the Record, as follows:
Summary of S. 1044, the Health Centers Consolidation Act and the Floor
Manager's Amendment in the Nature of a Substitute
i. summary of s. 1044
S. 1044, reported unanimously by the Senate Committee on
Labor and Human Resources on July 20, 1995, consolidates and
streamlines four separate Public Health Service Act (PHSA)
programs under one authority, a rewritten section 330 of the
PHSA. The consolidated programs are the Migrant Health Center
program (section 329 of the PHSA), the Community Health
Center program (section 330 of the PHSA), the Health Care for
the Homeless program (section 340 of the PHSA), and the
Health Services for Residents of Public Housing program
(section 340A of the PHSA). For these consolidated programs,
S. 1044 authorizes $756.518 million in fiscal year 1996 and
``such sums'' for fiscal years 1997 through 2000.
In addition, the bill formally authorizes as new section
330A of the Public Health Service Act the ``Rural Health
Outreach, Network Development, and Telemedicine Grant''
program. This program consolidates and reforms several
currently funded, discretionary rural health programs. This
program is authorized at $36 million in fiscal year 1996
(current spending) and at ``such sums'' for fiscal years 1997
through 2000.
ii. summary of the manager's amendment
The manager's amendment makes a number of technical
corrections to S. 1044 as reported. In addition, it makes
several policy changes:
A. Loan guarantee program
It replaces the Secretary's authority under S. 1044 to
provide grants for facility construction and modernization
with a loan guarantee fund to provide health centers with the
ability to leverage private-sector resources for the
development and initial operation of health networks and
plans. This permits federal dollars to be focused on the
provision of services, rather than on ``bricks and mortar.''
B. Changes in authorization period and authorization level
Reflecting the fact that fiscal year 1996 is nearly at an
end, the manager's amendment updates the authorization period
from fiscal years 1996 through 2000 to fiscal years 1997
through 2001. Reflecting the appropriation provided for the
health center programs in the House-passed appropriations
bill, the manager's amendment updates the funding level to
$802.124 million in fiscal year 1997 and ``such sums'' in the
out years.
Mr. LOTT. Mr. President, I ask unanimous consent the amendment be
agreed to, the bill be deemed read a third time and passed, as amended,
the motion to reconsider be laid upon the table, and that any
statements relating to the bill appear at this point in the Record. I
have some statements for the Record.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment (No. 5397) was agreed to.
The bill (S. 1044), as amended, was deemed read a third time and
passed, as follows:
S. 1044
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Health Centers Consolidation
Act of 1996''.
SEC. 2. CONSOLIDATION AND REAUTHORIZATION OF PROVISIONS.
Subpart I of part D of title III of the Public Health
Service Act (42 U.S.C. 254b et seq.) is amended to read as
follows:
``Subpart I--Health Centers
``SEC. 330. HEALTH CENTERS.
``(a) Definition of Health Center.--
``(1) In general.--For purposes of this section, the term
`health center' means an entity that serves a population that
is medically underserved, or a special medically underserved
population comprised of migratory and seasonal agricultural
workers, the homeless, and residents of public housing, by
providing, either through the staff and supporting resources
of the center or through contracts or cooperative
arrangements--
``(A) required primary health services (as defined in
subsection (b)(1)); and
``(B) as may be appropriate for particular centers,
additional health services (as defined in subsection (b)(2))
necessary for the adequate support of the primary health
services required under subparagraph (A);
for all residents of the area served by the center (hereafter
referred to in this section as the `catchment area').
``(2) Limitation.--The requirement in paragraph (1) to
provide services for all residents within a catchment area
shall not apply in the case of a health center receiving a
grant only under subsection (g), (h), or (i).
``(b) Definitions.--For purposes of this section:
``(1) Required primary health services.--
``(A) In general.--The term `required primary health
services' means--
``(i) basic health services which, for purposes of this
section, shall consist of--
``(I) health services related to family medicine, internal
medicine, pediatrics, obstetrics, or gynecology that are
furnished by physicians and where appropriate, physician
assistants, nurse practitioners, and nurse midwives;
``(II) diagnostic laboratory and radiologic services;
``(III) preventive health services, including--
``(aa) prenatal and perinatal services;
``(bb) screening for breast and cervical cancer;
``(cc) well-child services;
``(dd) immunizations against vaccine-preventable diseases;
``(ee) screenings for elevated blood lead levels,
communicable diseases, and cholesterol;
``(ff) pediatric eye, ear, and dental screenings to
determine the need for vision and hearing correction and
dental care;
``(gg) voluntary family planning services; and
``(hh) preventive dental services;
``(IV) emergency medical services; and
``(V) pharmaceutical services as may be appropriate for
particular centers;
``(ii) referrals to providers of medical services and other
health-related services (including substance abuse and mental
health services);
``(iii) patient case management services (including
counseling, referral, and follow-up services) and other
services designed to assist health center patients in
establishing eligibility for and gaining access to Federal,
State, and local programs that provide or financially support
the provision of medical, social, educational, or other
related services;
``(iv) services that enable individuals to use the services
of the health center (including outreach and transportation
services and, if a substantial number of the individuals in
the population served by a center are of limited English-
speaking ability, the services of appropriate personnel
fluent in the language spoken by a predominant number of such
individuals); and
``(v) education of patients and the general population
served by the health center regarding the availability and
proper use of health services.
``(B) Exception.--With respect to a health center that
receives a grant only under subsection (g), the Secretary,
upon a showing of good cause, shall--
``(i) waive the requirement that the center provide all
required primary health services under this paragraph; and
``(ii) approve, as appropriate, the provision of certain
required primary health services only during certain periods
of the year.
``(2) Additional health services.--The term `additional
health services' means services that are not included as
required primary health services and that are appropriate to
meet the health needs of the population served by the health
center involved. Such term may include--
``(A) environmental health services, including--
``(i) the detection and alleviation of unhealthful
conditions associated with water supply;
``(ii) sewage treatment;
``(iii) solid waste disposal;
``(iv) rodent and parasitic infestation;
``(v) field sanitation;
``(vi) housing; and
``(vii) other environmental factors related to health; and
``(B) in the case of health centers receiving grants under
subsection (g), special occupation-related health services
for migratory and seasonal agricultural workers, including--
``(i) screening for and control of infectious diseases,
including parasitic diseases; and
[[Page S11117]]
``(ii) injury prevention programs, including prevention of
exposure to unsafe levels of agricultural chemicals including
pesticides.
``(3) Medically underserved populations.--
``(A) In general.--The term `medically underserved
population' means the population of an urban or rural area
designated by the Secretary as an area with a shortage of
personal health services or a population group designated by
the Secretary as having a shortage of such services.
``(B) Criteria.--In carrying out subparagraph (A), the
Secretary shall prescribe criteria for determining the
specific shortages of personal health services of an area or
population group. Such criteria shall--
``(i) take into account comments received by the Secretary
from the chief executive officer of a State and local
officials in a State; and
``(ii) include factors indicative of the health status of a
population group or residents of an area, the ability of the
residents of an area or of a population group to pay for
health services and their accessibility to them, and the
availability of health professionals to residents of an area
or to a population group.
``(C) Limitation.--The Secretary may not designate a
medically underserved population in a State or terminate the
designation of such a population unless, prior to such
designation or termination, the Secretary provides reasonable
notice and opportunity for comment and consults with--
``(i) the chief executive officer of such State;
``(ii) local officials in such State; and
``(iii) the organization, if any, which represents a
majority of health centers in such State.
``(D) Permissible designation.--The Secretary may designate
a medically underserved population that does not meet the
criteria established under subparagraph (B) if the chief
executive officer of the State in which such population is
located and local officials of such State recommend the
designation of such population based on unusual local
conditions which are a barrier to access to or the
availability of personal health services.
``(c) Planning Grants.--
``(1) In general.--
``(A) Centers.--The Secretary may make grants to public and
nonprofit private entities for projects to plan and develop
health centers which will serve medically underserved
populations. A project for which a grant may be made under
this subsection may include the cost of the acquisition and
lease of buildings and equipment (including the costs of
amortizing the principal of, and paying the interest on,
loans) and shall include--
``(i) an assessment of the need that the population
proposed to be served by the health center for which the
project is undertaken has for required primary health
services and additional health services;
``(ii) the design of a health center program for such
population based on such assessment;
``(iii) efforts to secure, within the proposed catchment
area of such center, financial and professional assistance
and support for the project;
``(iv) initiation and encouragement of continuing community
involvement in the development and operation of the project;
and
``(v) proposed linkages between the center and other
appropriate provider entities, such as health departments,
local hospitals, and rural health clinics, to provide better
coordinated, higher quality, and more cost-effective health
care services.
``(B) Comprehensive service delivery networks and plans.--
The Secretary may make grants to health centers that receive
assistance under this section to enable the centers to plan
and develop a network or plan for the provision of health
services, which may include the provision of health services
on a prepaid basis or through another managed care
arrangement, to some or to all of the individuals which the
centers serve. Such a grant may only be made for such a
center if--
``(i) the center has received grants under subsection
(e)(1)(A) for at least 2 consecutive years preceding the year
of the grant under this subparagraph or has otherwise
demonstrated, as required by the Secretary, that such center
has been providing primary care services for at least the 2
consecutive years immediately preceding such year; and
``(ii) the center provides assurances satisfactory to the
Secretary that the provision of such services on a prepaid
basis, or under another managed care arrangement, will not
result in the diminution of the level or quality of health
services provided to the medically underserved population
served prior to the grant under this subparagraph.
Any such grant may include the acquisition and lease of
buildings and equipment which may include data and
information systems (including the costs of amortizing the
principal of, and paying the interest on, loans), and
providing training and technical assistance related to the
provision of health services on a prepaid basis or under
another managed care arrangement, and for other purposes that
promote the development of managed care networks and plans.
``(2) Limitation.--Not more than two grants may be made
under this subsection for the same project, except that upon
a showing of good cause, the Secretary may make additional
grant awards.
``(d) Managed Care Loan Guarantee Program.--
``(1) Establishment.--
``(A) In general.--The Secretary shall establish a program
under which the Secretary may, in accordance with this
subsection and to the extent that appropriations are provided
in advance for such program, guarantee the principal and
interest on loans made by non-Federal lenders to health
centers funded under this section for the costs of developing
and operating managed care networks or plans.
``(B) Use of funds.--Loan funds guaranteed under this
subsection may be used--
``(i) to establish reserves for the furnishing of services
on a pre-paid basis; or
``(ii) for costs incurred by the center or centers,
otherwise permitted under this section, as the Secretary
determines are necessary to enable a center or centers to
develop, operate, and own the network or plan.
``(C) Publication of guidance.--Prior to considering an
application submitted under this subsection, the Secretary
shall publish guidelines to provide guidance on the
implementation of this section. The Secretary shall make such
guidelines available to the universe of parties affected
under this subsection, distribute such guidelines to such
parties upon the request of such parties, and provide a copy
of such guidelines to the appropriate committees of Congress.
``(2) Protection of financial interests.--
``(A) In general.--The Secretary may not approve a loan
guarantee for a project under this subsection unless the
Secretary determines that--
``(i) the terms, conditions, security (if any), and
schedule and amount of repayments with respect to the loan
are sufficient to protect the financial interests of the
United States and are otherwise reasonable, including a
determination that the rate of interest does not exceed such
percent per annum on the principal obligation outstanding as
the Secretary determines to be reasonable, taking into
account the range of interest rates prevailing in the private
market for similar loans and the risks assumed by the United
States, except that the Secretary may not require as security
any center asset that is, or may be, needed by the center or
centers involved to provide health services;
``(ii) the loan would not be available on reasonable terms
and conditions without the guarantee under this subsection;
and
``(iii) amounts appropriated for the program under this
subsection are sufficient to provide loan guarantees under
this subsection.
``(B) Recovery of payments.--
``(i) In general.--The United States shall be entitled to
recover from the applicant for a loan guarantee under this
subsection the amount of any payment made pursuant to such
guarantee, unless the Secretary for good cause waives such
right of recovery (subject to appropriations remaining
available to permit such a waiver) and, upon making any such
payment, the United States shall be subrogated to all of the
rights of the recipient of the payments with respect to which
the guarantee was made. Amounts recovered under this clause
shall be credited as reimbursements to the financing account
of the program.
``(ii) Modification of terms and conditions.--To the extent
permitted by clause (iii) and subject to the requirements of
section 504(e) of the Credit Reform Act of 1990 (2 U.S.C.
661c(e)), any terms and conditions applicable to a loan
guarantee under this subsection (including terms and
conditions imposed under clause (iv)) may be modified or
waived by the Secretary to the extent the Secretary
determines it to be consistent with the financial interest of
the United States.
``(iii) Incontestability.--Any loan guarantee made by the
Secretary under this subsection shall be incontestable--
``(I) in the hands of an applicant on whose behalf such
guarantee is made unless the applicant engaged in fraud or
misrepresentation in securing such guarantee; and
``(II) as to any person (or successor in interest) who
makes or contracts to make a loan to such applicant in
reliance thereon unless such person (or successor in
interest) engaged in fraud or misrepresentation in making or
contracting to make such loan.
``(iv) Further terms and conditions.--Guarantees of loans
under this subsection shall be subject to such further terms
and conditions as the Secretary determines to be necessary to
assure that the purposes of this section will be achieved.
``(3) Loan origination fees.--
``(A) In general.--The Secretary shall collect a loan
origination fee with respect to loans to be guaranteed under
this subsection, except as provided in subparagraph (C).
``(B) Amount.--The amount of a loan origination fee
collected by the Secretary under subparagraph (A) shall be
equal to the estimated long term cost of the loan guarantees
involved to the Federal Government (excluding administrative
costs), calculated on a net present value basis, after taking
into account any appropriations that may be made for the
purpose of offsetting such costs, and in accordance with the
criteria used to award loan guarantees under this subsection.
``(C) Waiver.--The Secretary may waive the loan origination
fee for a health center applicant who demonstrates to the
Secretary that the applicant will be unable to meet the
conditions of the loan if the applicant incurs the additional
cost of the fee.
``(4) Defaults.--
[[Page S11118]]
``(A) In general.--Subject to the requirements of the
Credit Reform Act of 1990 (2 U.S.C. 661 et seq.), the
Secretary may take such action as may be necessary to prevent
a default on a loan guaranteed under this subsection,
including the waiver of regulatory conditions, deferral of
loan payments, renegotiation of loans, and the expenditure of
funds for technical and consultative assistance, for the
temporary payment of the interest and principal on such a
loan, and for other purposes. Any such expenditure made under
the preceding sentence on behalf of a health center or
centers shall be made under such terms and conditions as the
Secretary shall prescribe, including the implementation of
such organizational, operational, and financial reforms as
the Secretary determines are appropriate and the disclosure
of such financial or other information as the Secretary may
require to determine the extent of the implementation of such
reforms.
``(B) Foreclosure.--The Secretary may take such action,
consistent with State law respecting foreclosure procedures
and, with respect to reserves required for furnishing
services on a prepaid basis, subject to the consent of the
affected States, as the Secretary determines appropriate to
protect the interest of the United States in the event of a
default on a loan guaranteed under this subsection, except
that the Secretary may only foreclose on assets offered as
security (if any) in accordance with paragraph (2)(A)(i).
``(5) Limitation.--Not more than one loan guarantee may be
made under this subsection for the same network or plan,
except that upon a showing of good cause the Secretary may
make additional loan guarantees.
``(6) Annual report.--Not later than April 1, 1998, and
each April 1 thereafter, the Secretary shall prepare and
submit to the appropriate committees of Congress a report
concerning loan guarantees provided under this subsection.
Such report shall include--
``(A) a description of the number, amount, and use of funds
received under each loan guarantee provided under this
subsection;
``(B) a description of any defaults with respect to such
loans and an analysis of the reasons for such defaults, if
any; and
``(C) a description of the steps that may have been taken
by the Secretary to assist an entity in avoiding such a
default.
``(7) Program evaluation.--Not later than June 30, 1999,
the Secretary shall prepare and submit to the appropriate
committees of Congress a report containing an evaluation of
the program authorized under this subsection. Such evaluation
shall include a recommendation with respect to whether or not
the loan guarantee program under this subsection should be
continued and, if so, any modifications that should be made
to such program.
``(8) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection
such sums as may be necessary.
``(e) Operating Grants.--
``(1) Authority.--
``(A) In general.--The Secretary may make grants for the
costs of the operation of public and nonprofit private health
centers that provide health services to medically underserved
populations.
``(B) Entities that fail to meet certain requirements.--The
Secretary may make grants, for a period of not to exceed 2-
years, for the costs of the operation of public and nonprofit
private entities which provide health services to medically
underserved populations but with respect to which the
Secretary is unable to make each of the determinations
required by subsection (j)(3).
``(2) Use of funds.--The costs for which a grant may be
made under subparagraph (A) or (B) of paragraph (1) may
include the costs of acquiring and leasing buildings and
equipment (including the costs of amortizing the principal
of, and paying interest on, loans), and the costs of
providing training related to the provision of required
primary health services and additional health services and to
the management of health center programs.
``(3) Construction.--The Secretary may award grants which
may be used to pay the costs associated with expanding and
modernizing existing buildings or constructing new buildings
(including the costs of amortizing the principal of, and
paying the interest on, loans) for projects approved prior to
October 1, 1996.
``(4) Limitation.--Not more than two grants may be made
under subparagraph (B) of paragraph (1) for the same entity.
``(5) Amount.--
``(A) In general.--The amount of any grant made in any
fiscal year under paragraph (1) to a health center shall be
determined by the Secretary, but may not exceed the amount by
which the costs of operation of the center in such fiscal
year exceed the total of--
``(i) State, local, and other operational funding provided
to the center; and
``(ii) the fees, premiums, and third-party reimbursements,
which the center may reasonably be expected to receive for
its operations in such fiscal year.
``(B) Payments.--Payments under grants under subparagraph
(A) or (B) of paragraph (1) shall be made in advance or by
way of reimbursement and in such installments as the
Secretary finds necessary and adjustments may be made for
overpayments or underpayments.
``(C) Use of nongrant funds.--Nongrant funds described in
clauses (i) and (ii) of subparagraph (A), including any such
funds in excess of those originally expected, shall be used
as permitted under this section, and may be used for such
other purposes as are not specifically prohibited under this
section if such use furthers the objectives of the project.
``(f) Infant Mortality Grants.--
``(1) In general.--The Secretary may make grants to health
centers for the purpose of assisting such centers in--
``(A) providing comprehensive health care and support
services for the reduction of--
``(i) the incidence of infant mortality; and
``(ii) morbidity among children who are less than 3 years
of age; and
``(B) developing and coordinating service and referral
arrangements between health centers and other entities for
the health management of pregnant women and children
described in subparagraph (A).
``(2) Priority.--In making grants under this subsection the
Secretary shall give priority to health centers providing
services to any medically underserved population among which
there is a substantial incidence of infant mortality or among
which there is a significant increase in the incidence of
infant mortality.
``(3) Requirements.--The Secretary may make a grant under
this subsection only if the health center involved agrees
that--
``(A) the center will coordinate the provision of services
under the grant to each of the recipients of the services;
``(B) such services will be continuous for each such
recipient;
``(C) the center will provide follow-up services for
individuals who are referred by the center for services
described in paragraph (1);
``(D) the grant will be expended to supplement, and not
supplant, the expenditures of the center for primary health
services (including prenatal care) with respect to the
purpose described in this subsection; and
``(E) the center will coordinate the provision of services
with other maternal and child health providers operating in
the catchment area.
``(g) Migratory and Seasonal Agricultural Workers.--
``(1) In general.--The Secretary may award grants for the
purposes described in subsections (c), (e), and (f) for the
planning and delivery of services to a special medically
underserved population comprised of--
``(A) migratory agricultural workers, seasonal agricultural
workers, and members of the families of such migratory and
seasonal agricultural workers who are within a designated
catchment area; and
``(B) individuals who have previously been migratory
agricultural workers but who no longer meet the requirements
of subparagraph (A) of paragraph (3) because of age or
disability and members of the families of such individuals
who are within such catchment area.
``(2) Environmental concerns.--The Secretary may enter into
grants or contracts under this subsection with public and
private entities to--
``(A) assist the States in the implementation and
enforcement of acceptable environmental health standards,
including enforcement of standards for sanitation in
migratory agricultural worker labor camps, and applicable
Federal and State pesticide control standards; and
``(B) conduct projects and studies to assist the several
States and entities which have received grants or contracts
under this section in the assessment of problems related to
camp and field sanitation, exposure to unsafe levels of
agricultural chemicals including pesticides, and other
environmental health hazards to which migratory agricultural
workers and members of their families are exposed.
``(3) Definitions.--For purposes of this subsection:
``(A) Migratory agricultural worker.--The term `migratory
agricultural worker' means an individual whose principal
employment is in agriculture on a seasonal basis, who has
been so employed within the last 24 months, and who
establishes for the purposes of such employment a temporary
abode.
``(B) Seasonal agricultural worker.--The term `seasonal
agricultural worker' means an individual whose principal
employment is in agriculture on a seasonal basis and who is
not a migratory agricultural worker.
``(C) Agriculture.--The term `agriculture' means farming in
all its branches, including--
``(i) cultivation and tillage of the soil;
``(ii) the production, cultivation, growing, and harvesting
of any commodity grown on, in, or as an adjunct to or part of
a commodity grown in or on, the land; and
``(iii) any practice (including preparation and processing
for market and delivery to storage or to market or to
carriers for transportation to market) performed by a farmer
or on a farm incident to or in conjunction with an activity
described in clause (ii).
``(h) Homeless Population.--
``(1) In general.--The Secretary may award grants for the
purposes described in subsections (c), (e), and (f) for the
planning and delivery of services to a special medically
underserved population comprised of homeless individuals,
including grants for innovative programs that provide
outreach and comprehensive primary health services to
homeless children and children at risk of homelessness.
[[Page S11119]]
``(2) Required services.--In addition to required primary
health services (as defined in subsection (b)(1)), an entity
that receives a grant under this subsection shall be required
to provide substance abuse services as a condition of such
grant.
``(3) Supplement not supplant requirement.--A grant awarded
under this subsection shall be expended to supplement, and
not supplant, the expenditures of the health center and the
value of in kind contributions for the delivery of services
to the population described in paragraph (1).
``(4) Definitions.--For purposes of this section:
``(A) Homeless individual.--The term `homeless individual'
means an individual who lacks housing (without regard to
whether the individual is a member of a family), including an
individual whose primary residence during the night is a
supervised public or private facility that provides temporary
living accommodations and an individual who is a resident in
transitional housing.
``(B) Substance abuse.--The term `substance abuse' has the
same meaning given such term in section 534(4).
``(C) Substance abuse services.--The term `substance abuse
services' includes detoxification and residential treatment
for substance abuse provided in settings other than
hospitals.
``(i) Residents of Public Housing.--
``(1) In general.--The Secretary may award grants for the
purposes described in subsections (c), (e), and (f) for the
planning and delivery of services to a special medically
underserved population comprised of residents of public
housing (such term, for purposes of this subsection, shall
have the same meaning given such term in section 3(b)(1) of
the United States Housing Act of 1937) and individuals living
in areas immediately accessible to such public housing.
``(2) Supplement not supplant.--A grant awarded under this
subsection shall be expended to supplement, and not supplant,
the expenditures of the health center and the value of in
kind contributions for the delivery of services to the
population described in paragraph (1).
``(3) Consultation with residents.--The Secretary may not
make a grant under paragraph (1) unless, with respect to the
residents of the public housing involved, the applicant for
the grant--
``(A) has consulted with the residents in the preparation
of the application for the grant; and
``(B) agrees to provide for ongoing consultation with the
residents regarding the planning and administration of the
program carried out with the grant.
``(j) Applications.--
``(1) Submission.--No grant may be made under this section
unless an application therefore is submitted to, and approved
by, the Secretary. Such an application shall be submitted in
such form and manner and shall contain such information as
the Secretary shall prescribe.
``(2) Description of need.--An application for a grant
under subparagraph (A) or (B) of subsection (e)(1) for a
health center shall include--
``(A) a description of the need for health services in the
catchment area of the center;
``(B) a demonstration by the applicant that the area or the
population group to be served by the applicant has a shortage
of personal health services; and
``(C) a demonstration that the center will be located so
that it will provide services to the greatest number of
individuals residing in the catchment area or included in
such population group.
Such a demonstration shall be made on the basis of the
criteria prescribed by the Secretary under subsection (b)(3)
or on any other criteria which the Secretary may prescribe to
determine if the area or population group to be served by the
applicant has a shortage of personal health services. In
considering an application for a grant under subparagraph (A)
or (B) of subsection (e)(1), the Secretary may require as a
condition to the approval of such application an assurance
that the applicant will provide any health service defined
under paragraphs (1) and (2) of subsection (b) that the
Secretary finds is needed to meet specific health needs of
the area to be served by the applicant. Such a finding shall
be made in writing and a copy shall be provided to the
applicant.
``(3) Requirements.--Except as provided in subsection
(e)(1)(B), the Secretary may not approve an application for a
grant under subparagraph (A) or (B) of subsection (e)(1)
unless the Secretary determines that the entity for which the
application is submitted is a health center (within the
meaning of subsection (a)) and that--
``(A) the required primary health services of the center
will be available and accessible in the catchment area of the
center promptly, as appropriate, and in a manner which
assures continuity;
``(B) the center has made and will continue to make every
reasonable effort to establish and maintain collaborative
relationships with other health care providers in the
catchment area of the center;
``(C) the center will have an ongoing quality improvement
system that includes clinical services and management, and
that maintains the confidentiality of patient records;
``(D) the center will demonstrate its financial
responsibility by the use of such accounting procedures and
other requirements as may be prescribed by the Secretary;
``(E) the center--
``(i) has or will have a contractual or other arrangement
with the agency of the State, in which it provides services,
which administers or supervises the administration of a State
plan approved under title XIX of the Social Security Act for
the payment of all or a part of the center's costs in
providing health services to persons who are eligible for
medical assistance under such a State plan; or
``(ii) has made or will make every reasonable effort to
enter into such an arrangement;
``(F) the center has made or will make and will continue to
make every reasonable effort to collect appropriate
reimbursement for its costs in providing health services to
persons who are entitled to insurance benefits under title
XVIII of the Social Security Act, to medical assistance under
a State plan approved under title XIX of such Act, or to
assistance for medical expenses under any other public
assistance program or private health insurance program;
``(G) the center--
``(i) has prepared a schedule of fees or payments for the
provision of its services consistent with locally prevailing
rates or charges and designed to cover its reasonable costs
of operation and has prepared a corresponding schedule of
discounts to be applied to the payment of such fees or
payments, which discounts are adjusted on the basis of the
patient's ability to pay;
``(ii) has made and will continue to make every reasonable
effort--
``(I) to secure from patients payment for services in
accordance with such schedules; and
``(II) to collect reimbursement for health services to
persons described in subparagraph (F) on the basis of the
full amount of fees and payments for such services without
application of any discount; and
``(iii) has submitted to the Secretary such reports as the
Secretary may require to determine compliance with this
subparagraph;
``(H) the center has established a governing board which
except in the case of an entity operated by an Indian tribe
or tribal or Indian organization under the Indian Self-
Determination Act or an urban Indian organization under the
Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.)--
``(i) is composed of individuals, a majority of whom are
being served by the center and who, as a group, represent the
individuals being served by the center;
``(ii) meets at least once a month, selects the services to
be provided by the center, schedules the hours during which
such services will be provided, approves the center's annual
budget, approves the selection of a director for the center,
and, except in the case of a governing board of a public
center (as defined in the second sentence of this paragraph),
establishes general policies for the center; and
``(iii) in the case of an application for a second or
subsequent grant for a public center, has approved the
application or if the governing body has not approved the
application, the failure of the governing body to approve the
application was unreasonable;
except that, upon a showing of good cause the Secretary shall
waive, for the length of the project period, all or part of
the requirements of this subparagraph in the case of a health
center that receives a grant pursuant to subsection (g), (h),
(i), or (p);
``(I) the center has developed--
``(i) an overall plan and budget that meets the
requirements of the Secretary; and
``(ii) an effective procedure for compiling and reporting
to the Secretary such statistics and other information as the
Secretary may require relating to--
``(I) the costs of its operations;
``(II) the patterns of use of its services;
``(III) the availability, accessibility, and acceptability
of its services; and
``(IV) such other matters relating to operations of the
applicant as the Secretary may require;
``(J) the center will review periodically its catchment
area to--
``(i) ensure that the size of such area is such that the
services to be provided through the center (including any
satellite) are available and accessible to the residents of
the area promptly and as appropriate;
``(ii) ensure that the boundaries of such area conform, to
the extent practicable, to relevant boundaries of political
subdivisions, school districts, and Federal and State health
and social service programs; and
``(iii) ensure that the boundaries of such area eliminate,
to the extent possible, barriers to access to the services of
the center, including barriers resulting from the area's
physical characteristics, its residential patterns, its
economic and social grouping, and available transportation;
``(K) in the case of a center which serves a population
including a substantial proportion of individuals of limited
English-speaking ability, the center has--
``(i) developed a plan and made arrangements responsive to
the needs of such population for providing services to the
extent practicable in the language and cultural context most
appropriate to such individuals; and
``(ii) identified an individual on its staff who is fluent
in both that language and in English and whose
responsibilities shall include providing guidance to such
individuals and to appropriate staff members with respect to
cultural sensitivities and bridging linguistic and cultural
differences; and
[[Page S11120]]
``(L) the center, has developed an ongoing referral
relationship with one or more hospitals.
For purposes of subparagraph (H), the term `public center'
means a health center funded (or to be funded) through a
grant under this section to a public agency.
``(4) Approval of new or expanded service applications.--
The Secretary shall approve applications for grants under
subparagraph (A) or (B) of subsection (e)(1) for health
centers which--
``(A) have not received a previous grant under such
subsection; or
``(B) have applied for such a grant to expand their
services;
in such a manner that the ratio of the medically underserved
populations in rural areas which may be expected to use the
services provided by such centers to the medically
underserved populations in urban areas which may be expected
to use the services provided by such centers is not less than
two to three or greater than three to two.
``(k) Technical and Other Assistance.--The Secretary may
provide (either through the Department of Health and Human
Services or by grant or contract) all necessary technical and
other nonfinancial assistance (including fiscal and program
management assistance and training in such management) to any
public or private nonprofit entity to assist entities in
developing plans for, or operating as, health centers, and in
meeting the requirements of subsection (j)(2).
``(l) Authorization of Appropriations.--
``(1) In general.--For the purpose of carrying out this
section, in addition to the amounts authorized to be
appropriated under subsection (d), there are authorized to be
appropriated $802,124,000 for fiscal year 1997, and such sums
as may be necessary for each of the fiscal years 1998 through
2001.
``(2) Special provisions.--
``(A) Public centers.--The Secretary may not expend in any
fiscal year, for grants under this section to public centers
(as defined in the second sentence of subsection (j)(3)) the
governing boards of which (as described in subsection
(j)(3)(G)(ii)) do not establish general policies for such
centers, an amount which exceeds 5 percent of the amounts
appropriated under this section for that fiscal year. For
purposes of applying the preceding sentence, the term `public
centers' shall not include health centers that receive grants
pursuant to subsection (h) or (i).
``(B) Distribution of grants.--
``(i) Fiscal year 1997.--For fiscal year 1997, the
Secretary, in awarding grants under this section shall ensure
that the amounts made available under each of subsections
(g), (h), and (i) in such fiscal year bears the same
relationship to the total amount appropriated for such fiscal
year under paragraph (1) as the amounts appropriated for
fiscal year 1996 under each of sections 329, 340, and 340A
(as such sections existed one day prior to the date of
enactment of this section) bears to the total amount
appropriated under sections 329, 330, 340, and 340A (as such
sections existed one day prior to the date of enactment of
this section) for such fiscal year.
``(ii) Fiscal years 1998 and 1999.--For each of the fiscal
years 1998 and 1999, the Secretary, in awarding grants under
this section shall ensure that the proportion of the amounts
made available under each of subsections (g), (h), and (i) is
equal to the proportion of amounts made available under each
such subsection for the previous fiscal year, as such amounts
relate to the total amounts appropriated for the previous
fiscal year involved, increased or decreased by not more than
10 percent.
``(3) Funding report.--The Secretary shall annually prepare
and submit to the appropriate committees of Congress a report
concerning the distribution of funds under this section that
are provided to meet the health care needs of medically
underserved populations, including the homeless, residents of
public housing, and migratory and seasonal agricultural
workers, and the appropriateness of the delivery systems
involved in responding to the needs of the particular
populations. Such report shall include an assessment of the
relative health care access needs of the targeted populations
and the rationale for any substantial changes in the
distribution of funds.
``(m) Memorandum of Agreement.--In carrying out this
section, the Secretary may enter into a memorandum of
agreement with a State. Such memorandum may include, where
appropriate, provisions permitting such State to--
``(1) analyze the need for primary health services for
medically underserved populations within such State;
``(2) assist in the planning and development of new health
centers;
``(3) review and comment upon annual program plans and
budgets of health centers, including comments upon
allocations of health care resources in the State;
``(4) assist health centers in the development of clinical
practices and fiscal and administrative systems through a
technical assistance plan which is responsive to the requests
of health centers; and
``(5) share information and data relevant to the operation
of new and existing health centers.
``(n) Records.--
``(1) In general.--Each entity which receives a grant under
subsection (e) shall establish and maintain such records as
the Secretary shall require.
``(2) Availability.--Each entity which is required to
establish and maintain records under this subsection shall
make such books, documents, papers, and records available to
the Secretary or the Comptroller General of the United
States, or any of their duly authorized representatives, for
examination, copying or mechanical reproduction on or off the
premises of such entity upon a reasonable request therefore.
The Secretary and the Comptroller General of the United
States, or any of their duly authorized representatives,
shall have the authority to conduct such examination,
copying, and reproduction.
``(o) Delegation of Authority.--The Secretary may delegate
the authority to administer the programs authorized by this
section to any office, except that the authority to enter
into, modify, or issue approvals with respect to grants or
contracts may be delegated only within the central office of
the Health Resources and Services Administration.
``(p) Special Consideration.--In making grants under this
section, the Secretary shall give special consideration to
the unique needs of sparsely populated rural areas, including
giving priority in the awarding of grants for new health
centers under subsections (c) and (e), and the granting of
waivers as appropriate and permitted under subsections
(b)(1)(B)(i) and (j)(3)(G).
``(q) Audits.--
``(1) In general.--Each entity which receives a grant under
this section shall provide for an independent annual
financial audit of any books, accounts, financial records,
files, and other papers and property which relate to the
disposition or use of the funds received under such grant and
such other funds received by or allocated to the project for
which such grant was made. For purposes of assuring accurate,
current, and complete disclosure of the disposition or use of
the funds received, each such audit shall be conducted in
accordance with generally accepted accounting principles.
Each audit shall evaluate--
``(A) the entity's implementation of the guidelines
established by the Secretary respecting cost accounting,
``(B) the processes used by the entity to meet the
financial and program reporting requirements of the
Secretary, and
``(C) the billing and collection procedures of the entity
and the relation of the procedures to its fee schedule and
schedule of discounts and to the availability of health
insurance and public programs to pay for the health services
it provides.
A report of each such audit shall be filed with the Secretary
at such time and in such manner as the Secretary may require.
``(2) Records.--Each entity which receives a grant under
this section shall establish and maintain such records as the
Secretary shall by regulation require to facilitate the audit
required by paragraph (1). The Secretary may specify by
regulation the form and manner in which such records shall be
established and maintained.
``(3) Availability of records.--Each entity which is
required to establish and maintain records or to provide for
and audit under this subsection shall make such books,
documents, papers, and records available to the Secretary or
the Comptroller General of the United States, or any of their
duly authorized representatives, for examination, copying or
mechanical reproduction on or off the premises of such entity
upon a reasonable request therefore. The Secretary and the
Comptroller General of the United States, or any of their
duly authorized representatives, shall have the authority to
conduct such examination, copying, and reproduction.
``(4) Waiver.--The Secretary may, under appropriate
circumstances, waive the application of all or part of the
requirements of this subsection with respect to an entity.''.
SEC. 3. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND
TELEMEDICINE GRANT PROGRAM.
(a) In General.--Subpart I of part D of title III of the
Public Health Service Act (42 U.S.C. 254b et seq.) (as
amended by section 2) is further amended by adding at the end
thereof the following new section:
``SEC. 330A. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND
TELEMEDICINE GRANT PROGRAM.
``(a) Administration.--The rural health services outreach
demonstration grant program established under section 301
shall be administered by the Office of Rural Health Policy
(of the Health Resources and Services Administration), in
consultation with State rural health offices or other
appropriate State governmental entities.
``(b) Grants.--Under the program referred to in subsection
(a), the Secretary, acting through the Director of the Office
of Rural Health Policy, may award grants to expand access to,
coordinate, restrain the cost of, and improve the quality of
essential health care services, including preventive and
emergency services, through the development of integrated
health care delivery systems or networks in rural areas and
regions.
``(c) Eligible Networks.--
``(1) Outreach networks.--To be eligible to receive a grant
under this section, an entity shall--
``(A) be a rural public or nonprofit private entity that is
or represents a network or potential network that includes
three or more health care providers or other entities that
provide or support the delivery of health care services; and
``(B) in consultation with the State office of rural health
or other appropriate State
[[Page S11121]]
entity, prepare and submit to the Secretary an application,
at such time, in such manner, and containing such information
as the Secretary may require, including--
``(i) a description of the activities which the applicant
intends to carry out using amounts provided under the grant;
``(ii) a plan for continuing the project after Federal
support is ended;
``(iii) a description of the manner in which the activities
funded under the grant will meet health care needs of
underserved rural populations within the State; and
``(iv) a description of how the local community or region
to be served by the network or proposed network will be
involved in the development and ongoing operations of the
network.
``(2) For-profit entities.--An eligible network may include
for-profit entities so long as the network grantee is a
nonprofit entity.
``(3) Telemedicine networks.--
``(A) In general.--An entity that is a health care provider
and a member of an existing or proposed telemedicine network,
or an entity that is a consortium of health care providers
that are members of an existing or proposed telemedicine
network shall be eligible for a grant under this section.
``(B) Requirement.--A telemedicine network referred to in
subparagraph (A) shall, at a minimum, be composed of--
``(i) a multispecialty entity that is located in an urban
or rural area, which can provide 24-hour a day access to a
range of specialty care; and
``(ii) at least two rural health care facilities, which may
include rural hospitals, rural physician offices, rural
health clinics, rural community health clinics, and rural
nursing homes.
``(d) Preference.--In awarding grants under this section,
the Secretary shall give preference to applicant networks
that include--
``(1) a majority of the health care providers serving in
the area or region to be served by the network;
``(2) any federally qualified health centers, rural health
clinics, and local public health departments serving in the
area or region;
``(3) outpatient mental health providers serving in the
area or region; or
``(4) appropriate social service providers, such as
agencies on aging, school systems, and providers under the
women, infants, and children program, to improve access to
and coordination of health care services.
``(e) Use of Funds.--
``(1) In general.--Amounts provided under grants awarded
under this section shall be used--
``(A) for the planning and development of integrated self-
sustaining health care networks; and
``(B) for the initial provision of services.
``(2) Expenditures in rural areas.--
``(A) In general.--In awarding a grant under this section,
the Secretary shall ensure that not less than 50 percent of
the grant award is expended in a rural area or to provide
services to residents of rural areas.
``(B) Telemedicine networks.--An entity described in
subsection (c)(3) may not use in excess of--
``(i) 40 percent of the amounts provided under a grant
under this section to carry out activities under paragraph
(3)(A)(iii); and
``(ii) 20 percent of the amounts provided under a grant
under this section to pay for the indirect costs associated
with carrying out the purposes of such grant.
``(3) Telemedicine networks.--
``(A) In general.--An entity described in subsection
(c)(3), may use amounts provided under a grant under this
section to--
``(i) demonstrate the use of telemedicine in facilitating
the development of rural health care networks and for
improving access to health care services for rural citizens;
``(ii) provide a baseline of information for a systematic
evaluation of telemedicine systems serving rural areas;
``(iii) purchase or lease and install equipment; and
``(iv) operate the telemedicine system and evaluate the
telemedicine system.
``(B) Limitations.--An entity described in subsection
(c)(3), may not use amounts provided under a grant under this
section--
``(i) to build or acquire real property;
``(ii) purchase or install transmission equipment (such as
laying cable or telephone lines, microwave towers, satellite
dishes, amplifiers, and digital switching equipment); or
``(iii) for construction, except that such funds may be
expended for minor renovations relating to the installation
of equipment;
``(f) Term of Grants.--Funding may not be provided to a
network under this section for in excess of a 3-year period.
``(g) Authorization of Appropriations.--For the purpose of
carrying out this section there are authorized to be
appropriated $36,000,000 for fiscal year 1997, and such sums
as may be necessary for each of the fiscal years 1998 through
2001.''.
(b) Transition.--The Secretary of Health and Human Services
shall ensure the continued funding of grants made, or
contracts or cooperative agreements entered into, under
subpart I of part D of title III of the Public Health Service
Act (42 U.S.C. 254b et seq.) (as such subpart existed on the
day prior to the date of enactment of this Act), until the
expiration of the grant period or the term of the contract or
cooperative agreement. Such funding shall be continued under
the same terms and conditions as were in effect on the date
on which the grant, contract or cooperative agreement was
awarded, subject to the availability of appropriations.
SEC. 4. TECHNICAL AND CONFORMING AMENDMENTS.
(a) In General.--The Public Health Service Act is amended--
(1) in section 224(g)(4) (42 U.S.C. 233(g)(4)), by striking
``under'' and all that follows through the end thereof and
inserting ``under section 330.'';
(2) in section 340C(a)(2) (42 U.S.C. 256c) by striking
``under'' and all that follows through the end thereof and
inserting ``with assistance provided under section 330.'';
and
(3) by repealing subparts V and VI of part D of title III
(42 U.S.C. 256 et seq.).
(b) Social Security Act.--The Social Security Act is
amended--
(1) in clauses (i) and (ii)(I) of section 1861(aa)(4)(A)
(42 U.S.C. 1395x(aa)(4)(A)(i) and (ii)(I)) by striking
``section 329, 330, or 340'' and inserting ``section 330
(other than subsection (h))''; and
(2) in clauses (i) and (ii)(II) of section 1905(l)(2)(B)
(42 U.S.C. 1396d(l)(2)(B)(i) and (ii)(II)) by striking
``section 329, 330, 340, or 340A'' and inserting ``section
330''.
(c) References.--Whenever any reference is made in any
provision of law, regulation, rule, record, or document to a
community health center, migrant health center, public
housing health center, or homeless health center, such
reference shall be considered a reference to a health center.
(d) FTCA Clarification.--For purposes of section 224(k)(3)
of the Public Health Service Act (42 U.S.C. 233(k)(3)),
transfers from the fund described in such section for fiscal
year 1996 shall be deemed to have occurred prior to December
31, 1995.
(e) Additional Amendments.--After consultation with the
appropriate committees of the Congress, the Secretary of
Health and Human Services shall prepare and submit to the
Congress a legislative proposal in the form of an
implementing bill containing technical and conforming
amendments to reflect the changes made by this Act.
SEC. 5. EFFECTIVE DATE.
This Act and the amendments made by this Act shall become
effective on October 1, 1997.
Mr. DORGAN. Mr. President, I wonder if the Senator from Mississippi
will yield?
Mr. LOTT. I will be glad to yield.
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