[Senate Report 104-186]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 279
104th Congress                                                   Report
                                 SENATE

 1st Session                                                    104-186
_______________________________________________________________________


 
                HEALTH CENTERS CONSOLIDATION ACT OF 1995

                                _______


               December 15, 1995.--Ordered to be printed

_______________________________________________________________________


   Mrs. Kassebaum, from the Committee on Labor and Human Resources, 
                        submitted the following

                              R E P O R T

                         [To accompany S. 1044]

    The Committee on Labor and Human Resources, to which was 
referred the 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, having 
considered the same, reports favorably thereon with amendments 
and recommends that the bill as amended do pass.

                                CONTENTS

                                                                   Page
  I. Purpose and summary..............................................1
 II. Background and need for the legislation..........................2
III. Legislative history and committee action.........................7
 IV. Committee views..................................................7
  V. Cost estimate...................................................11
 VI. Regulatory impact statement.....................................15
VII. Section-by-section analysis.....................................16
VIII.Changes in existing law.........................................23


                         I. Purpose and Summary

    As reported by the Committee on Labor and Human Resources, 
S. 1044 consolidates, streamlines, and reauthorizes the four 
Federal health center programs under one authority, Section 330 
of the Public Health Service Act. This authority will support 
the continued development and operation of local, community-
based systems of health care to address the needs of medically 
underserved communities and vulnerable populations. The health 
center programs to be consolidated in this new authority 
include the:
          Migrant Health Center program, authorized under 
        Section 329 of the Public Health Service Act, which 
        supports the provision of services to migrant and 
        seasonal farmworkers and their families.
          Community Health Center program, authorized under 
        Section 330 of the Public Health Service Act, which 
        supports the provision of services to medically 
        underserved populations living in urban and rural 
        underserved communities.
          Health Care for the Homeless program, authorized 
        under Section 340 of the Public Health Service Act, 
        which supports the provision of services to homeless 
        individuals and children in locations accessible to 
        them.
          Health Services for Residents of Public Housing 
        program, authorized under Section 340A of the Public 
        Health Service Act, which supports the provision of 
        services to residents of public housing.
    Under a new Section 330A of the Public Health Service Act, 
the bill also authorizes the ``Rural Health Outreach, Network 
Development, and Telemedicine Grant Program.'' This program 
consolidates two rural health demonstration grant programs, the 
Rural Health Outreach program and the Rural Telemedicine grant 
program, and focuses the consolidated program on the 
development of coordinated, integrated health care delivery 
systems in rural areas.

              II. Background and Need for the Legislation

    In response to the large number of individuals living in 
medically underserved areas, as well as the growing number of 
special populations lacking access to preventive and primary 
health care services, Congress enacted the health center 
programs beginning in the 1960s. These programs were designed 
to empower communities to solve their own local access programs 
and to improve the health status of their underserved and 
vulnerable populations by building community-based primary care 
capacity and by offering case management, home visiting, 
outreach and other enabling services.
    Currently, the health center programs support over 700 
organizations and 2,200 service delivery sites, providing 
services to over 8 million underserved and uninsured people.
    There are currently four federally funded health center 
programs.
    Migrant Health Center.--The Migrant Health Center program 
was established by Congress in 1962 under the Migrant Health 
Act, Public Law 87-692, and authorized in its current form in 
1975 by Public Law 94-63. Migrant Health Centers were created 
to provide a broad array of medical and support services to 
farmworkers employed on a seasonal basis and their families. In 
addition to primary and preventive health care, many of these 
centers provide transportation, outreach, dental, 
pharmaceutical, and environmental health services.
    Currently, a network of 122 migrant health centers provides 
services to approximately 600,000 migrant and seasonal 
farmworkers and their families in over 390 service delivery 
sites.
    Community Health Centers.--Community Health Centers were 
first funded by Congress in the mid-1960s as neighborhood 
health centers. By the early 1970s, about 100 neighborhood 
health centers had been established under the Economic 
Opportunity act. These centers were designed to provide 
accessible, dignified personal health services to low-income 
families. Community and consumer participation in the 
organization and ongoing governance of the centers was and 
remains a central element of the program. Each center is 
required to have a governing board, a majority of the members 
of which are users of the center's services.
    With the phase-out of the Office of Economic Opportunity in 
the early 1970s, the centers supported under this authority 
were transferred to the Public Health Service. While services 
were directed to the poor and near poor, the centers also 
provided access to a broader population who could pay all or 
part of the cost of their health care. The Community Health 
Center program, as authorized under section 330 of the Public 
Health Service Act, was established in 1975 by Public Law 94-
63.
    Over its nearly 30-year history, the Community Health 
Center program has developed into a highly successful, cost-
effective and efficient health program. The program currently 
serves over 7 million medically underserved people in over 
1,600 service delivery sites.
    Health Care for the Homeless.--Established under the 
Stewart B. McKinney Homeless Assistance Act of 1987, P.L. 100-
77, the Health Care for the Homeless program was developed by 
Congress to provide comprehensive, high quality, case-managed 
preventive and primary health care services--including 
substance abuse services and mental health referrals for 
homeless individuals--at locations accessible to them. In 1992, 
Title VI of the Stewart B. McKinney Homeless Assistance Act was 
amended to include section 340(s), which authorizes additional 
Federal funding to provide outreach and primary health services 
for homeless children.
    The Health Care for the Homeless program has played a 
pivotal role in stimulating local collaboration and 
coordination of health and social services. A total of 119 
organizations, including community health centers, public 
health departments, and other community-based health service 
providers, currently receive Health Care for the Homeless 
funding. Services are provided at nearly 500 delivery sites in 
both urban and rural areas.
    The Health Care for the Homeless programs provide services 
to approximately 420,000 sick and untreated homeless people 
annually. While most of these are single adults, 4 out of every 
10 people served are family members or run-away youth.
    Health Services for Residents of Public Housing.--The 
Health Services for Residents of Public Housing program was 
established by Congress under the Disadvantaged Minority Health 
Improvement Act of 1990. This legislation focused on the 
disparity in health status of minority populations and placed 
emphasis on the development of delivery models that are 
comprehensive in nature and address the special health problems 
which affect families, especially pregnant women and children.
    Services are provided at public housing complexes or at 
sites either adjacent to or immediately accessible to these 
complexes.
    Currently, there are 22 organizations receiving funding 
under the section 340A authority. These centers provide 
comprehensive, high quality, case-managed, family based 
preventive and primary health care services to approximately 
25,000 public housing residents at 39 service delivery sites.

                 success of the health center programs

    The health center programs have developed and supported a 
significant number of highly successful, innovative preventive 
and primary health care delivery systems in our Nation's most 
needy inner-cities and underserved rural areas. In reviewing 
evaluations of the health center programs, the committee found 
that health centers have reduced infant mortality rates by 10 
to 40 percent in underserved communities, improved the use of 
prenatal care, reduced the incidence of low birthweight and 
increased immunization rates. Health centers have also 
effectively addressed major public health concerns (e.g., 
violence prevention, teenage pregnancy) and have been actively 
involved with Academic Health Centers in providing community-
based training of physicians, nurses, and other health 
professionals.
    When examining studies of the quality of care received in 
health centers, the committee found that nationally, health 
centers have a 96 percent patient satisfaction rate and 97 
percent of their patients would recommend the center to friends 
or family. A recent study in the Journal of the American 
Medical Association found that the care provided in health 
centers was equal to or better than that provided by other 
types of Medicaid providers when rated on 21 different quality 
measures.
    In reviewing evaluations of the impact of health centers on 
the use of other services and on costs, the committee found 
that health centers lower costs otherwise borne publicly 
through Medicaid or State and local taxes. In California, 
health center patients had 33 percent lower total Medicaid 
costs and 27 percent lower hospital costs (controlling for 
maternity). In New York, health center patients had 22 to 30 
percent lower total Medicaid costs and 41 percent lower 
inpatient costs; diabetics and asthmatics who were regular 
health center patients had 62 percent and 44 percent lower 
inpatient costs, respectively. In Maryland, health center 
patients had lower total Medicaid costs and fewer 
hospitalizations than patients who used hospital outpatient 
departments or emergency rooms.

                   reasons for health center success

    The committee recognizes that these programs have been 
successful because health centers offer high quality, 
prevention-oriented, case-managed, family focused primary care 
services that result in appropriate and cost-effective use of 
ambulatory, specialty and in-patient services. Primary care is 
offered for all life cycles, and a range of health and other 
social services is available on-site or through referrals. The 
range of services includes health promotion, disease 
prevention, screening and educational, outreach, and case 
management services which are often missing from the 
traditional delivery of medical services but which are 
particularly needed by high-risk populations because of their 
multiple health problems and the significant barriers to access 
to care that they face.
    Health centers are also staffed with full-time primary care 
providers who are capable of providing culturally competent 
services to diverse populations. Over 4,000 primary care 
physicians and an additional 1,750 nurse practitioners, 
physician assistants and nurse midwives are the core of the 
health centers nationally. Health centers have also been 
assisted greatly in attracting and retaining quality providers 
by the National Health Service Corps.
    In addition, the health center programs have enabled 
underserved communities to design and develop their own local 
solutions to their problems of medical underservice. By 
supporting the development and operation of health centers at 
the community level, the health center programs have assured 
that centers are community-responsive and highly accessible. 
Residents and patients play an active role in centers' 
decision-making and planning. By working with local communities 
and State organizations to plan, develop and determine 
priorities for the allocation of resources, the health center 
programs have successfully funded new and expanded programs and 
services in those communities across the country that are most 
in need. One measure of the success of these community-based 
and governed centers is their ability to attract private-pay 
and privately insured individuals and families as well as those 
who are uninsured or covered by Medicaid. Patient payments and 
third-party insurance payments comprise, on average, 15 percent 
of health centers' revenues.

                   Continued Need For Health Centers

    Many Americans continue to lack access to basic preventive 
and primary care services. These individuals are 
disproportionately poor and minority, they lack adequate or do 
not have any health insurance, and they tend to be sicker 
patients who require more expensive treatment and care. The 
barriers to access to health care services include:
    Financial Barriers.--Millions of people lack adequate 
insurance and/or cannot afford to pay for cost-effective 
preventive and primary care services. An estimated 43 million 
Americans (18.7 percent of the nonelderly population) will be 
without health insurance coverage for some period of time in 
1995, 1 million more than in 1994. A significant proportion of 
these people also have incomes under 200 percent of poverty.
    Geographic and Capacity Barriers.--Currently, a total of 
71.9 million people live in areas designated by the Federal 
Government as medically underserved--37.7 million in urban 
areas (52 percent) and 34.2 million (48 percent) in rural 
areas. Of these, a total of 43.4 million lack access to primary 
care provider--22.2 million in urban areas and 21.2 million in 
rural areas.
    Private practice in these underserved areas has not been 
economically viable because of low income and, in rural areas, 
low population density. Underserved rural and urban areas also 
tend to lack professional backup, facilities, equipment and 
organizational support. As a result, physicians have not 
``diffused'' into shortage areas to the degree previously 
predicted, resulting in primary health care practitioner 
shortages.
    Transportation, Culture, and Language Barriers.--Health 
Care facilities are often located in areas that are not easily 
accessible to underserved patients. To assure the timely, 
effective receipt of preventive as well as curative care, the 
availability of transportation and outreach services is 
essential. Even where health services are physically 
accessible, communication and language problems between 
providers and patients, as well as provider insensitivity to 
cultural concerns, may impose barriers to care.

        Health Centers and the Changing Health Care Environment

    A movement toward managed care is a dominant trend within 
the health care industry and the States in particular. From 
testimony presented to the committee at a May 4, 1995, hearing, 
the committee learned that health centers across the country 
are being affected by the rapid changes in the health care 
marketplace.
    As a result, many health centers have had to make major 
adjustments in their management and strategic decision making. 
In order to assure that they can continue to serve underserved, 
high-risk patients, centers have had to negotiate with State 
Medicaid agencies and Health Maintenance Organizations (HMO's) 
to assure that they are included in both mandated and voluntary 
Medicaid managed care programs.
    As they make the transition to managed care arrangements, 
health centers have needed and will continue to need assistance 
in several areas, including contract review, strategic 
planning, network development, rate setting, clinical 
management, marketing, and development of management 
information systems.
    Health centers are also responding to managed care's 
penetration of Medicaid and private-sector markets by forming 
provider networks for the more efficient, cost-effective 
delivery of coordinated health care services. These networks 
take several forms. They may be horizontal linkages with other 
primary care providers or vertical linkages with primary care 
providers and other providers of care in a community, such as 
inpatient and specialty care providers, for example. 
Horizontally integrated networks may develop into vertically 
integrated networks, and individual centers may participate in 
more than one type of network.
    According to the latest information available to the 
committee, there are 140 networks in the developmental stage 
and 7 which are now operating. These networks currently include 
several hundred participants in addition to health centers. 
Among the participants are nonfederally supported Federally 
Qualified Health Centers, Rural Health Clinics, local health 
departments, other primary care providers, specialty practice 
groups, academic medical centers, and hospitals.
    At the present time, health centers make a significant 
contribution to managed care. As of December 1994, 25 percent 
of health centers were under contract with an HMO or State 
Medicaid agency to cover some of their patients. In 1994, a 
total of 566,000 health center patients were managed care 
enrollees.
    As an increasing number of health centers have become 
involved in managed care, the committee has also learned that 
HMO's are increasingly recognizing the advantages of 
contracting with health center programs. Specifically, HMO's 
reported in a recent study by Lewin-VHI that health centers' 
cost performance is equal to or better than private providers 
in managed care networks. The HMO's also reported that these 
health centers were high-quality providers with a unique 
capability to provide enabling services to underserved 
populations and noted that health centers were often the sole 
providers of health care services in geographically isolated or 
economically depressed areas.

             III. Legislative History and Committee Action

    S. 1044 was introduced on July 17, 1995, by Senators 
Kassebaum, Kennedy, Jeffords, Pell, and Simon. The bill was 
referred to the Committee on Labor and Human Resources, which 
held a hearing to consider the legislation on May 4, 1995.
    In the executive session of the Committee on Labor and 
Human Resources held on Thursday, July 20, 1995, S. 1044 was 
brought up for consideration. It was amended to increase the 
authorization level for the consolidated health center programs 
from $756,000,000 to $756,518,000. It was also amended to 
require that during a 3-year transitional period, migrant, 
homeless, and health services for residents of public housing 
programs would receive funding in relative proportion to the 
funding these programs received in fiscal year 1995. Under the 
amendment, in fiscal years 1997 and 1998, funding for these 
programs could vary by up to 10 percent relative to the funding 
the programs received in fiscal year 1996. The bill was then 
unanimously ordered reported.

                          IV. Committee Views

    The committee finds that the health center programs have a 
strong history of providing a much-needed, cost-effective, 
high-quality ``medical home'' for millions of individuals who 
would otherwise lack access to comprehensive primary and 
preventive health care services. As the number of uninsured 
individuals and families continues to increase and as the 
Nation's health care system is undergoing significant changes, 
federally funded health center programs continue to merit 
strong Federal support to ensure that the most vulnerable 
individuals have access to high-quality, affordable, community-
based primary and preventive health care services.
    In developing the reauthorization of the health center 
programs under one new health center authority, the committee 
recognized that the migrant health center, community health 
center, health care for the homeless and health services for 
residents of public housing programs all share a number of 
important characteristics and requirements. All of the 
consolidated programs are community-based, organized systems of 
preventive and primary care delivery for medically underserved 
populations. Although some of these programs are targeted to 
specific populations, most are, in fact, jointly funded 
projects that assure access to the whole community, as well as 
its special underserved populations.
    As a logical progression in the development of these 
programs, the committee feels it is now appropriate to 
consolidate these programs into one new health center 
authority. This consolidation maintains the commitment of 
Congress and the health centers to medically underserved and 
special underserved populations, but frees these programs from 
unnecessary and burdensome requirements. In particular, the 
proposed authority will:
          Assure continued Federal support for health centers 
        while consolidating the funding previously requested 
        under separate community health center, migrant health 
        center, health care for the homeless, and public 
        housing primary care authorities of the Public Health 
        Service Act;
          make grants more flexible, simpler, streamlined and 
        less burdensome for communities receiving health center 
        awards; and
          reduce the number of grants and the Federal 
        administrative costs associated with administering the 
        program.
    In proposing the consolidated health center authority, the 
committee recognizes the PHS's successful efforts in the past 2 
years to develop and implement a single grant application for 
all health center applicants. Through this streamlining effort, 
the Public Health Service has been able to eliminate 
duplicative instructions, requirements, and applications for 
hundreds of health centers. In addition, the committee 
recognizes the Public Health Service's current efforts to 
develop a single, uniform data system to reduce and eliminate 
duplicative reporting and data requirements.

               Special Medically Underserved Populations

    The committee bill consolidates the health center 
authorities currently under Sections 329, 330, 340 and 340A of 
the Public Health Service Act. The committee wishes to clarify 
that the consolidation authorizes grants both to centers that 
serve all residents of a catchment area and to centers that 
serve one or more special medically underserved populations, 
i.e., migratory and seasonal agricultural workers, the 
homeless, and residents of public housing.

                    Required Primary Health Services

    The bill revises the current law list of required primary 
health services to streamline and update that list. It is the 
intent of the committee that health centers maintain the same 
services provided under the current health center programs. 
These services have proven to be highly effective in promoting 
and assuring the health of underserved populations.
    The list of required primary health services also serves to 
highlight the critical role that enabling services such as 
outreach, transportation and translation as well as other 
services such as patient case management and patient education 
play in the delivery of primary health services to underserved 
populations. Such services are essential to health centers' 
efforts to reduce the barriers to care experienced by many of 
our Nation's underserved populations.

                         Home Visiting Services

    The committee was encouraged to learn during our May 4 
hearing that a number of health centers have initiated home 
visiting services by nurses and trained volunteers as part of 
their outreach, prevention, and infant mortality and morbidity 
reduction efforts. The committee notes that in its 1988 report 
to Congress, ``Death Before Life: The Tragedy of Infant 
Mortality,'' the National Commission to Prevent Infant 
Mortality strongly recommended home visiting program as an 
effective strategy for reducing infant mortality and morbidity. 
The committee encourages health centers to consider initiating 
or expanding home visiting services as part of their outreach, 
prevention, and infant mortality reduction programs.

                            Dental Services

    The committee notes that a 1993 report by the Oral Health 
Coordinating Committee of the U.S. Public Health Service found 
that the dental needs of low-income and minority population are 
increasing significantly. In response to this growing need, the 
committee has added pediatric dental screenings as a required 
primary health preventive service and encourages health 
centers, as resources are available, to initiate or expand 
dental care for the populations they serve.

          Networks, Including Managed Care Networks and Plans

    The committee recognizes the need, in our nation's changing 
health care delivery system, for health centers to form or 
participate in networks with other health care providers and 
entities, including managed care networks and plans. The 
committee bill authorizes the Secretary to award grants to 
health centers for planning and developing such networks and 
plans.
    The bill does not establish rigid criteria by which the 
Secretary would judge health centers' network development 
proposals. Given the significant diversity of circumstances in 
urban and rural communities, it is the committee's belief that 
no one type or model for a network arrangement be prescribed. 
The committee envisions a continuum of networks, from informal 
linkages of centers and other providers to fully integrated 
managed care networks. In addition, because of the challenges 
facing health centers in participating in networks with other 
providers and in retaining health care providers in underserved 
areas, the committee encourages the Secretary to review current 
policies, such as policies relating to the contracting of 
physicians, which may act as a barrier to health center 
participation in various integrated service networks.
    The committee also wishes to note that applicants for 
health center planning grants would be required under this bill 
to include in their planning grant application proposed 
linkages between the center and other appropriate provider 
entities in their communities, such as local health 
departments, hospitals, and rural health clinics. The committee 
believes that such linkages are essential to the provision of 
coordinated care and to the avoidance of the costly duplication 
of health care services.

                         Use of Nongrant funds

    The committee is advised that a majority of health center 
funding is from sources other than the Federal grant, such as 
funding from State and local sources, patient fees, and third-
party reimbursements. Under current policy, most of the 
restrictions and requirements which apply to the health 
centers' use of Federal funding, including Federal cost 
principles, also apply to the centers' use of their nongrant 
funding.
    The committee understands that some of these restrictions 
and requirements impede health centers' ability to respond to 
changes in the needs and size of the population it serves and 
to compete on an equal footing in an increasingly competitive 
and rapidly changing health care marketplace. Further, these 
restrictions sometimes conflict with requirements of other 
funding sources. Relieving centers from the requirements for 
prior Federal approval for things like equipment purchases and 
procurement and property standards will allow health centers to 
respond quickly to critical business opportunities in the 
competitive marketplace.
    The committee has therefore included in the bill provisions 
to clarify that, although the level of nongrant funding 
available to a health center for an approved project would 
continue to be considered by the Secretary in computing the 
amount of the Federal grant, the restrictions that apply to a 
center's use of Federal grant funds under the Federal cost 
principles and the procurement and property standards would no 
longer apply to the center's use of nongrant funds. The bill 
also continues to require that nongrant funds be spent in a 
manner consistent with the objectives of the project or program 
and continues to require health centers to undergo an 
independent annual audit which includes a review of the 
entity's use of project-related nongrant funds.

        Special Consideration for Sparsely Populated Rural Areas

    Recognizing that the delivery of health care services in 
sparsely populated rural areas poses unique challenges, the 
committee bill directs the Secretary to give special 
consideration to these challenges in evaluating ``new start'' 
grant applications from entities proposing to serve these 
areas. Sparsely populated rural areas, for example, are often 
characterized by significant shortages of health professionals 
and high percentages of elderly individuals in their 
populations, but they may not have high incidences of infant 
mortality or poverty.
    The committee bill also provides the Secretary with the 
authority to waive statutory requirements relating to the full 
scope of required services and the governing board structure 
for new centers upon a showing of good cause by a particular 
health center serving a sparsely populated rural area. In 
providing the authority to waive the statutory requirement that 
centers provide the full scope of required health services, the 
committee recognizes that it may not be feasible or financially 
viable for health centers located in sparsely populated rural 
areas to offer the full range of required primary health 
services.
    While the committee continues to believe that the 
requirement for consumer-directed governance of health centers 
is vital to the continued success of the health center 
programs, the committee recognizes that some programs which are 
being consolidated in the bill have not historically required 
community governance, and in certain instances, compliance with 
such requirements may not be realistic.
    The committee wishes to underscore that it expects that 
requests for waivers will not be automatically granted, but 
rather will be evaluated carefully and limited to cases in 
which good cause has clearly been demonstrated.

  Rural Health Outreach, Network Development, and Telemedicine Grant 
                                Program

    The committee believes, based on expert testimony given at 
the May 14, 1995, hearing, that the development of integrated 
health care provider networks is key to preserving and 
strengthening access to community-based health care services in 
rural areas. Provider networks offer a number of advantages: 
they can work to ensure that a continuum of health care 
services is available, reduce the duplication of services, 
produce savings in administrative and other costs through 
shared services and an enhanced ability to negotiate in the 
health care market place, and recruit and utilize health 
professionals more effectively and efficiently.
    Accordingly, the committee bill consolidates and gives 
specific statutory authorization under a new section 330A of 
the Public Health Service Act to two current demonstration 
programs being administered by the Federal Office of Rural 
Health Policy, the Rural Health Outreach program and a rural 
telemedicine grant program.
    It is the committee's intention that the consolidated 
program provide incentives and support to rural communities and 
the health care providers serving those communities to form 
local and regional integrated health care delivery systems and 
experiment with the potential of telemedicine to strengthen the 
quality and accessibility of care in rural areas.
    The committee intends that these networks become self-
sustaining and that the Secretary take into account the 
potential of the networks to become self-sustaining in 
evaluating grant applications. Under provisions of the bill, a 
network's eligibility to receiving funding would be limited to 
3 years.
    The committee believes it is very important that the States 
be involved in assisting those communities which wish to 
develop networks to ensure that the grants will meet the 
priority health care needs of the State. The bill accordingly 
requires that grant applicants consult with the State office of 
rural health or other appropriate State entity in preparing and 
submitting the grant application.

                            V. Cost Estimate

                                     U.S. Congress,
                               Congressional Budget Office,
                                  Washington, DC, December 7, 1995.
Hon. Nancy Landon Kassebaum,
Chairman, Committee on Labor and Human Resources,
U.S. Senate, Washington, DC.
    Dear Madam Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1044, the Health 
Centers Consolidation Act of 1995, as ordered reported by the 
Senate Committee on Labor and Human Resources on July 20, 1995.
    This bill would not affect direct spending or receipts and 
thus would not be subject to pay-as-you-go procedures under 
section 252 of the Balanced Budget and Emergency Deficit 
Control Act of 1985.
    If you wish further details on this estimate, we will be 
pleased to provide them.
            Sincerely,
                                                   June E. O'Neill.

               congressional budget office cost estimate

    1. Bill number: S. 1044.
    2. Bill title: Health Centers Consolidation Act of 1995.
    3. Bill status: As ordered reported by the Senate Committee 
on Labor and Human Resources on July 20, 1995.
    4. Bill purpose: S. 1044 would reauthorize, consolidate, 
and streamline the four federal health center programs. It 
would also authorize funding of grants for a rural health 
services outreach program that is currently a demonstration 
program.
    5. Estimated cost to the Federal Government: Most of the 
spending that would occur under S. 1004 would be subject to the 
availability of appropriated funds. For the purposes of this 
estimate, CBO assumes that all funds authorized by the bill for 
the 1996-2000 period will be appropriated. For fiscal year 
1996, the additional costs represent funding above the levels 
provided in the continuing resolutions through December 15, 
1995. Estimated outlays are based on historical spending 
patterns of existing programs administered by the Health 
Resources and Services Administration (HRSA).
    The bill would authorize $756.5 million for 1996 for 
federal health centers and such sums as necessary for 1997 
through 2000. The rural health outreach grant program would be 
authorized at $36 million in 1996 and such sums as necessary 
for 1997 through 2000. The following table summarizes the 
estimated authorizations and outlays that would result from S. 
1044 under two different sets of assumptions. The first set of 
assumptions adjusts the estimated amounts for projected 
inflation after 1995. The second set of assumptions makes no 
allowance for projected inflation.

----------------------------------------------------------------------------------------------------------------
                                                                   1995    1996    1997    1998    1999    2000 
----------------------------------------------------------------------------------------------------------------
Spending under current law:                                                                                     
    Budget authority............................................     790     185  ......  ......  ......  ......
    Estimated outlays...........................................     769     497     163      20       0       0
                                                                                                                
                  With adjustment of inflation                                                                  
                                                                                                                
Proposed changes:                                                                                               
    Budget authority............................................  ......     607     820     849     879     910
    Estimated outlays...........................................  ......     291     643     811     860     891
Projected spending under S. 1044:                                                                               
    Budget authority............................................     790     793     820     849     879     910
    Estimated outlays...........................................     769     789     805     831     860     891
                                                                                                                
                Without adjustment for inflation                                                                
                                                                                                                
Proposed changes:                                                                                               
    Budget authority............................................  ......     607     793     793     793     793
    Estimated outlays...........................................  ......     291     629     772     793     793
Projected spending under S. 1044:                                                                               
    Budget authority............................................     790     793     793     793     793     793
    Estimated outlays...........................................     769     789     792     793     793     793
----------------------------------------------------------------------------------------------------------------

    The costs of this bill fall within budget function 550.
    6. Basis of the estimate: S. 1044 would consolidate the 
four existing Federal health center programs under a new 
authority. The programs that would be incorporated into this 
new authority are the Migrant Health Center program, the 
Community Health Center program, the Health Care for the 
Homeless program, and the Health Service for Residents of 
Public Housing program. The bill would also authorize funding 
for the rural health outreach demonstration program operated by 
the Office of Rural Health.

Health Centers

    The bill would provide planning and operating grants to 
centers serving medically underserved populations; grants to 
reduce infant mortality; and grants to centers providing 
specialized services to migratory and seasonal agricultural 
workers, the homeless, and residents of public housing. 
Grantees, except those receiving funds to serve migrant and 
seasonal workers, the homeless and residents of public housing, 
would be required to serve all residents of their service area. 
By replacing categorical grant programs (for example, grants 
are made for services either to the homeless or to migrant and 
seasonal workers) with a single program and a single 
application process, the bill would allow grantees to redirect 
their grant funds to meet the changing health care needs of the 
communities they serve.
    In combining the four Federal health center grant programs, 
the bill would retain the major features of each program. For 
example, many of the same medical services required by the 
current grant programs would be retained, although with some 
modifications. Required primary health services would include: 
medical services related to pediatrics, obstetrics, gynecology, 
and internal and family medicine; preventive health services; 
emergency medical services, referrals for medical and health 
services, including substance abuse and mental health services; 
case management; patient education; and outreach, 
transportation and translation services.
    S. 1044 would also authorize health centers to provide 
additional health services beyond the required primary health 
services. These services could include environmental health 
services, such as sewage treatment or solid waste disposal. The 
bill would also require that centers receiving migratory and 
seasonal agricultural worker grants provide such occupation-
related services as injury prevention programs and screening 
for and control of infectious diseases.
    Finally, the bill would permit the Secretary of Health ad 
Human Services to provide technical or nonfinancial assistance 
(for example, program management assistance) to public or 
nonprofit private entities to help them develop plans for, or 
operate as, health centers.
    Planning grants.--This provision would provide funds for 
the planning and development of new health centers to treat the 
medically underserved. Funds could be used for the purchase and 
renovation of existing facilities or the construction of new 
facilities. Grantees would be required to demonstrate ties 
between the center and area hospitals, rural health clinics and 
health departments for the coordination and provision of cost-
effective services. Eligible entities could also obtain 
planning grants for developing managed care networks to serve 
all or some of their patients, provided they demonstrated that 
the provision of prepaid services would not diminish the 
quality of the care rendered.
    Operating grants.--Operating grants would allow health 
centers to purchase and renovate existing facilities, build new 
facilities, repay loans on buildings, or provide training 
related to center management or the provision of the services 
required under S. 1044. The Secretary would determine the 
amount of operating grants, which could not exceed the 
difference between the costs of a center's operations in a 
given year and the total of operational funds that the center 
received from State and local governments and third-party 
reimbursements (including any fees and premiums that the center 
could reasonably be expected to receive during that year).
    The bill would retain many of the requirements that grant 
recipients must meet under current law. For example, grantees 
must have payment arrangements with agencies administering 
State plans under titles XVIII and XIX of the Social Security 
Act, any public assistance programs, and private insurance 
plans. Centers must also prepare a schedule of discounts based 
on patients' ability to pay. Additionally, the centers must 
form governing boards to determine the general policies and 
operations of the centers. A majority of board members must 
represent the individuals served by the center.
    Infant mortality grants.--This provision would consolidate 
the authority currently existing under the four Federal health 
center programs to fund programs to reduce infant mortality. 
The specifications of this provision are essentially the same 
as those in current law.
    Migratory and seasonal workers.--S. 1044 would preserve 
most of the current requirements and features of grants for the 
provision of services to migrant and seasonal workers and their 
families. However, it would remove the requirement that centers 
receiving these grants serve areas where a minimum of 4,000 
migrant and seasonal workers live for at least 2 months of a 
calendar year.
    Homeless populations.--The bill would provide grants to 
centers serving the homeless and offering outreach and primary 
health services to homeless children and children determined to 
be at risk of homelessness. Grantees serving the homeless would 
also be required to provide substance abuse services, in 
addition to the health services required under the bill.
    Residents of public housing.--Grants for the provision of 
health services to residents of public housing, and individuals 
living in areas immediately accessible to public housing, would 
be continued under S. 1044. Recipients would be required to use 
these funds to supplement other existing funding sources. The 
bill would also require that grantees consult with residents in 
preparing their applications and in planning and operating the 
program to be implemented with the grant.
    S. 1044 would authorized $756.5 million for fiscal year 
1996 for these programs, the same amount of funding as in 1995. 
It would authorize such sums as necessary for 1997 through 
2000. Adjusting for inflation, authorization amounts would rise 
to $869 million in 2000.
    The bill specifies that for 1996, the share of funds for 
services to migrant and seasonal workers, the homeless, and 
residents of public housing should be the same as for 1995. In 
1997 through 2000, the bill would allow the proportion of funds 
available under each subsection to change by no more than 10 
percent in each year.

Rural Health Outreach, Network Development, and Telemedicine Grant 
        Program

    S. 1044 would authorize funding for the rural health 
outreach demonstration program operated under the Office of 
Rural Health. Grants administered under this program could be 
used to broaden access to, reduce the cost and improve the 
quality of health care services in rural areas through the 
formation of integrated health care networks. Grant funds could 
be used to plan and establish integrated health care networks, 
and to fund the initial provision of services. According to the 
bill, the Secretary must ensure that at least 50 percent of the 
grant awarded would be used in a rural area or to provide 
services to residents of rural areas.
    Grants could also be used to operate and evaluate 
telemedicine networks and to demonstrate whether these networks 
improve access to care in rural areas. Providers who were 
members of an existing or proposed telemedicine network, or 
consortiums of providers who were members of such networks 
would be eligible. These networks would have to include at 
least two rural health care facilities, and a multispecialty 
entity that provides 24-hour access to specialty care.
    Funding of a network under this provision would not 
continue for more than 3 years. The bill would also require the 
Secretary to continue funding grants, contracts, and 
cooperative arrangements made under current law until the end 
of the grant period, or the term of the contract or cooperative 
agreement.
    For the purposes of this provision, S. 1044 would authorize 
$36 million for 1996 and such sums as necessary for 1997 
through 2000. Accounting for anticipated inflation, estimated 
authorizations would increase to $41 million in 2000.
    7. Estimated cost to State and local governments: S. 1044 
would have a minimal impact upon health centers operated by 
State or local governments, since such centers constitute less 
than 5 percent of the total number of health centers receiving 
grants under this program. The bill would also make some 
changes in how these centers, all voluntary participants in the 
program, are allowed to use their grant funds. In general, 
these changes would provide more flexibility to the centers.
    8. Estimate comparison: None.
    9. Previous estimate: None.
    10. Estimate prepared by: Anne T. Hunt.
    11. Estimate approved by: Paul Van de Water, Assistant 
Director for Budget Analysis.

                    VI. Regulatory Impact Statement

    The committee has determined that this legislation will 
decrease the regulatory burden and administrative costs of 
health centers, enabling them to devote more of their resources 
to patient care.

                    VII. Section-by-Section Analysis

    Section 1 of the bill entitles the act the ``Health Centers 
Consolidation Act of 1995.''
    Section 2 of the bill amends Subpart I of Part D of Title 
III of the Public Health Service Act to consolidate and 
reauthorize current law Sections 329, 330, 340, and 340A of the 
Public Health Service Act into a new ``Section 330. Health 
Centers.''

SEC. 330. HEALTH CENTERS.

    (a) Definition of Health Center.--Section 330(a) defines 
``health center'' as an entity that serves a population that is 
medically underserved, or a special medically underserved 
population comprised of migratory and seasonal agricultural 
workers and their families, the homeless, and residents of 
public housing. To qualify as a ``health center,'' an entity 
must provide primary health services and, as appropriate for a 
particular center, additional health services necessary for the 
adequate support of the required primary health services. These 
services must be provided to all residents in the area served 
by the center, unless the health center receives a grant only 
for the purpose of providing services to migratory and seasonal 
agriculture workers and their families, a homeless population, 
or residents of public housing.
    (b) Definitions.--Subsection (b) of the bill provides 
definitions of ``required primary health services,'' 
``additional services,'' and ``medically underserved 
population.'' The subsection streamlines and rewords the 
current statutory list of required primary health services, but 
maintains the same services.
    The subsection also sets forth the considerations which 
must go into the Secretary of Health and Human Services' 
determination of areas and populations experiencing shortages 
of personal health services. It requires the Secretary to 
consult with State and local officials and with organizations 
representing a majority of health centers in the States, such 
as State primary care associations, if any, in making these 
determinations, and permits the Secretary to designate 
medically underserved populations that may not meet certain 
criteria but that are recommended by the chief executive 
officer of a State.
    The subsection specifies that upon the showing of good 
cause by a center receiving a grant only for the purpose of 
providing services to migratory and seasonal agricultural 
workers, the Secretary shall waive the requirement that the 
center provide all required primary health services and, as 
appropriate, approve the provision of certain required services 
only during certain periods of the year.
    The subsection maintains the current law requirement that 
in designating medically underserved populations, the Secretary 
take into account State and local government officials' 
comments and include factors indicative of the health status of 
a population, the ability of the population to pay for services 
and their accessibility to them, and the availability of health 
professionals. The subsection also maintains the requirement 
that the Secretary provide reasonable notice and opportunity to 
comment and consult with the chief executive officer of a 
State, local officials, and organizations, if any, representing 
a majority of the centers in a State before designating an area 
as medically underserved or terminating that designation.
    Further, subsection (b) maintains the authority of the 
Secretary to designate as medically underserved, those 
populations which would not otherwise meet the criteria for 
such designation but which are recommended for designation by 
the chief executive officer and local officials of the State on 
the basis of unusual local conditions which are a barrier to 
access to or the availability of personal health services.
    (c) Planning Grants.--Subsection (c) of the bill authorizes 
the Secretary to make grants to public and nonprofit private 
entities to plan and develop health centers which will serve 
medically underserved populations. The subsection adds a 
requirement that grant proposals include 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.
    This subsection also authorizes a new type of planning 
grant for the planning and development of comprehensive service 
delivery networks and plans, which may include the provision of 
health services on a prepaid basis or through another managed 
care arrangement. Such grants are contingent upon a center's 
having received operating grants for at least 2 consecutive 
years preceding the year it applies for this type of planning 
grant or otherwise demonstrating to the Secretary that it has 
been providing primary care services for at least 2 consecutive 
years immediately preceding its application.
    (d) Operating Grants.--Subsection (d) of the bill 
authorizes the Secretary to make grants for the costs of 
operation of public or private nonprofit health centers that 
provide health services to medically underserved populations. 
In addition, the subsection authorizes the Secretary to make 
grants, for a period not to exceed 2 years, for the costs of 
the operation of public and private nonprofit 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 of a health center in subsection 
(i)(3) of the bill
    Under this subsection, the operating grant awarded by the 
Secretary may not exceed the amount by which the costs of 
operation of the center exceed the total of State, local, and 
other operational funds provided to the center and the fees, 
premiums, and third-party reimbursements which the center may 
reasonably be expected to receive for its operations.
    The subsection permits the Secretary to make grant payments 
in advance or by way of reimbursement and in such installments 
as the Secretary may find necessary and allows the Secretary to 
make adjustments for overpayments and underpayments.
    The subsection replaces the current law list of allowable 
uses of nongrant funds with the authority for grantees to use 
nongrant funds as permitted under this section and for other 
purposes that are not specifically prohibited under the 
section, if such use furthers the objectives of the project.
    (e) Infant Mortality Grants.--Subsection (e) maintains the 
current law authority of the Secretary to make grants to health 
centers for the purpose of assisting such centers in reducing 
the incidence of infant mortality and morbidity. The subsection 
also maintains the requirement that in making grants, priority 
be given 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.
    (f) Migratory and Seasonal Agricultural Workers.--
Subsection (f) authorizes the Secretary to award grants for the 
planning and delivery of primary health care services to a 
special medically underserved population comprised of migratory 
and seasonal agricultural workers and their family members.
    Consistent with Section 329 of the current Public Health 
Service Act, subsection (f) also authorizes the Secretary to 
enter into grants or contracts with public and private entities 
to address environmental concerns. Grants and contracts will be 
used to assist the States in implementing and enforcing 
acceptable environmental health standards, including standards 
for sanitation in migratory agricultural worker camps and 
standards for pesticide control. Grants and contracts may also 
be used to conduct projects and studies to assist the States 
and other entities in assessing problems related to camp and 
field sanitation, exposure to unsafe levels of agricultural 
chemicals, including pesticides, and other environmental 
hazards to which migratory agricultural workers and members of 
their families may be exposed.
    Subsection (f) defines ``migratory agricultural worker,'' 
``seasonal agricultural workers,'' and ``agriculture,'' 
consistent with the definitions in Section 329 of the current 
Public Health Service Act.
    (g) Homeless Population.--Consistent with Section 340 of 
the current Public Health Service Act, subsection (g) of this 
bill authorizes the Secretary to award grants for the planning 
and delivery of services to a special medically undeserved 
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.
    Also consistent with Section 340 of the current Public 
Health Service Act, in addition to the required primary health 
services for all centers, an entity that receives a grant under 
subsection (g) is required to provide substance abuse services 
as a condition of the grant .
    Subsection (g) of this bill replaces a matching requirement 
under current law with a requirement that grants awarded under 
the subsection must be used 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 homeless 
population.
    Subsection (g) defines ``homeless individual,'' ``substance 
abuse,'' and ``substance abuse services'' consistent with 
definition of these terms in Section 340 of the current Public 
Health Service Act.
    (h) Residents of Public Housing.--Consistent with Section 
340A of the current Public Health Service Act, subsection (h) 
of this bill authorizes the Secretary to award grants for the 
planning and delivery of services to a special medically 
underserved population comprised of residents of public housing 
(as defined in Section 3(b)(1) of the United States Housing Act 
of 1937) and individual living in areas immediately accessible 
to such public housing.
    Subsection (h) replaces a current law matching requirement 
as a condition of eligibility for a grant with a requirement 
that grant funds to be expended to supplement, not supplant, 
the expenditures of the health center and the value of in-kind 
contributions for the delivery of services to the population 
being served.
    Subsection (h) maintains the current law requirement that 
applicants for grants must consult with residents of public 
housing in preparing applications for grants and must provide 
for ongoing consultation with residents regarding the planning 
and administration of the program.
    (i) Applications.--Subsection (i) of the bill sets forth 
general and specific requirements that health centers must meet 
in order to be eligible for a grant.
    In most cases, before making grants to health centers the 
Secretary must determine that the applicant:
          Will make required health services available and 
        accessible;
          Has an ongoing quality improvement system;
          Will demonstrate its financial responsibility;
          Has or will have a contractual arrangement with the 
        State agency that administers the State Medicaid plan;
          Has made and will continue to make every reasonable 
        effort to secure payment for its costs of providing 
        services to persons who are insured through public or 
        private plans;
          Has prepared a schedule of fees and has made and will 
        continue to make every reasonable effort to secure 
        payment;
          Has established a governing board that meets at least 
        once a month and of which individuals being served by 
        the center comprise a majority. However, upon a showing 
        of good cause, the Secretary is required to waive this 
        requirement for centers receiving grants under 
        subsections (f), (g), (h), and (o) of the bill;
          Has developed an overall plan and budget that meets 
        certain requirements and an effective procedure for 
        compiling and reporting certain data to the Secretary;
          Periodically reviews its catchment area to ensure 
        that services are available and accessible;
          Has developed a plan and made arrangements to meet 
        the needs of individuals with limited English-speaking 
        ability, if necessary; and
          Has developed an ongoing referral relationship with 
        one or more hospitals.
    Subsection (i) maintains the current law requirement that 
in approving grant applications for new health center starts, 
the Secretary fund new rural and urban centers proportionally.
    (j) Technical and Other Assistance.--Subsection (j) 
maintains the Secretary's authority under current law to 
provide grants to public or private nonprofit entities to 
assist entities in developing plans for or operating as health 
centers and in meeting program requirements.
    (k) Authorization of Appropriations.--Subsection (k) 
authorizes appropriations of $756,518,000 for fiscal year 1996 
and such sums as may be necessary for each of fiscal years 1997 
through 2000.
    Subsection (k) prohibits the Secretary from expending more 
than 5 percent of the amounts appropriated for a fiscal year on 
grants to centers which do not meet certain governing board 
requirements. Centers funded under the authorities of 
subsections (g) or (h) are not included in the calculation of 
this limitation.
    Subsection (k) stipulates that for fiscal year 1996, the 
amounts made available under each of subsections (f), (g), and 
(h) must be proportional, relative to the fiscal year 1996 
appropriation, to the amounts appropriated in fiscal year 1995 
under the authorities of sections 329, 340, and 340A. For 
fiscal years 1997 and 1998, the proportion of the amounts made 
available under each of subsections (f), (g), and (h) may vary 
as to the proportion of the amounts made available under each 
subsection for the previous fiscal year by no more than plus or 
minus 10 percent.
    The Secretary is required to report annually to the 
appropriate committees of Congress on the distribution of funds 
provided to meet the health care needs of medically underserved 
populations, including migratory and seasonal agricultural 
workers, the homeless, and residents of public housing. The 
report must 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.--Subsection (l) maintains the 
authority of the Secretary to enter into a memorandum of 
agreement with a State, which may include provisions permitting 
the State to (1) analyze the need for primary health services 
for medically underserved populations within the 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; (4) provide technical assistance to health 
centers in the development of clinical practices and fiscal and 
administrative systems; and (5) share information and data 
relevant to the operation of new and existing health centers.
    (m) Records.--Subsection (m) maintains the requirement that 
each entity that receives an operating grant must establish and 
maintain necessary records and must make such records available 
to the Secretary or the Comptroller General of the United 
States, or any of their duly authorized representatives.
    (n) Delegation of Authority.--Subsection (n) maintains the 
authority of the Secretary to delegate authority to administer 
the programs authorized by this section to any office within 
the Public health Service, except that the authority to enter 
into, modify, or issue approvals with respect to grants and 
contracts may be delegated only within the Health Resources and 
Services Administration (HRSA).
    (o) Special Consideration.--Subsection (o) maintains the 
requirement that the Secretary 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 (b) and (i), subsections 
relating to required primary health services and governing 
boards.

SEC. 3. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND TELEMEDICINE 
                    GRANT PROGRAM.

    Section 3 of the bill amends Subpart I of part D of title 
III of the Public Health Service Act to add a new section, 
330A, entitled the ``Rural Health Outreach, Network 
Development, and Telemedicine Grant Program.''
    (a) Administration.--Subsection (a) establishes that the 
rural health outreach demonstration grant program, currently 
funded under the general authority of Section 301 of the Public 
Health Service Act, will 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.--Subsection (b) authorizes the Secretary, 
acting through the Office of Rural Health Policy, to 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.--Outreach network--To be eligible to 
receive a grant, an entity must be a public or nonprofit 
private entity in a rural area, 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. The entity, in consultation 
with the State office of rural health or other appropriate 
State entity, must prepare and submit to the Secretary an 
application that meets the Secretary's requirements.
    The application must include: a description of the 
activities which the applicant intends to carry out using 
amounts provided under the grant; a plan for continuing the 
project after Federal support is ended; a description of the 
manner in which the activities funded under the grant will meet 
the health care needs of underserved rural populations in the 
State; and 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.
    For-profit entities--This provision clarifies that an 
eligible network may include for-profit entities so long as the 
network grantee is a nonprofit entity.
    Telemedicine networks--This provision establishes the 
eligibility to receive a grant under this section of an entity 
that is a health care provider and a member of an existing or 
proposed telemedicine network or of an entity that is a 
consortium of health care providers that are members of an 
existing or proposed telemedicine network.
    An eligible telemedicine network must, at a minimum, be 
composed of a multispecialty entity that is located in an urban 
or rural area and can provide 24-hour a day access to a range 
of specialty care and 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.--Subsection (d) requires the Secretary, in 
awarding grants, to give preference to applicant networks that 
include:
          (1) a majority of the health care providers 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 in 
        the area or region;
          (3) outpatient mental health providers 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.--Subsection (e) specifies that in 
general, the amounts provided under this section must be used 
for the planning and development of integrated self-sustaining 
health care networks and for the initial provision of services 
and that not less than 50 percent of the grant award must be 
expended in rural areas.
    Subsection (e) further specifies that telemedicine networks 
may not use in excess of 40 percent of the grant amounts to 
purchase or lease and install equipment and in excess of 20 
percent of grant amounts to pay for the indirect costs 
associated with carrying out the purposes of the grant.
    Subsection (e) specifies that telemedicine networks may use 
grant funds to:
          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;
          Provide a baseline of information for a systematic 
        evaluation of telemedicine systems serving rural areas;
          Purchase or lease and install equipment; and
          Operate and evaluate the telemedicine system.
    This subsection prohibits entities receiving telemedicine 
network grants from using grant funds to build or acquire real 
property or purchase or install transmission equipment or for 
construction, except for minor renovations relating to the 
installation of equipment.
    (f) Terms of the Grant.--Subsection (f) specifies that 
funding may not be provided to outreach or telemedicine network 
grantees for more than 3 years.
    (g) Authorization of Appropriations.--This subsection 
authorizes $36,000,000 for fiscal year 1996 and such sums as 
may be necessary for each of fiscal years 1997 through 2000.
    (h) Transition.--This subsection requires the Secretary to 
continue funding for grants or contracts which were entered 
into prior to the establishment of section 330A until the term 
of the grant or contract expires, subject to the availability 
of appropriations.

SEC. 4. TECHNICAL AND CONFORMING AMENDMENTS.

    This section makes technical and conforming amendments to 
the Public Health Service Act and the Social Security Act 
necessitated by the consolidation of the health center 
programs. It clarifies that 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.
    The Secretary is required, after consultation with the 
appropriate committees of Congress, to prepare and submit to 
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 section specifies an effective date of October 1, 1995 
for the act and amendments made by it.

                     VIII. Changes in Existing Law

    In compliance with rule XXVI, paragraph 12, of the Standing 
Rules of the Senate, the following provides a print of the 
statute or the part or section thereof to be amended or 
replaced (existing law proposed to be omitted is enclosed in 
black brackets, new matter is printed in italic, existing law 
in which no change is proposed is shown in roman):

                       PUBLIC HEALTH SERVICE ACT

                      TITLE 42--UNITED STATES CODE

          * * * * * * *

                      Part D--Primary Health Care

                   [Subpart I--Primary Health Centers

                            [MIGRANT HEALTH

    [Sec. 254b. (a) For purposes of this section:
          [(1) The term ``migrant health center'' means an 
        entity which either through its staff and supporting 
        resources or through contracts or cooperative 
        arrangements with other public or private entities 
        provides--
                  [(A) primary health services,
                  [(B) as may be appropriate for particular 
                centers, supplemental health services necessary 
                for the adequate support of primary health 
                services,
                  [(C) referral to providers of supplemental 
                health services and payment, as appropriate and 
                feasible, for their provision of such services,
                  [(D) environmental health services, 
                including, as may be appropriate for particular 
                centers (as determined by the centers), the 
                detection and alleviation of unhealthful 
                conditions associated with water supply, sewage 
                treatment, solid waste disposal, rodent and 
                parasitic infestation, field sanitation, 
                housing, and other environmental factors 
                related to health,
                  [(E) as may be appropriate for particular 
                centers (as determined by the centers), 
                infections and parasitic disease screening and 
                control,
                  [(F) as may be appropriate for particular 
                centers, accident prevention programs, 
                including prevention of excessive pesticide 
                exposure,
                  [(G) information on the availability and 
                proper use of health services and services 
                which promote and facilitate optimal use of 
                health services, including, 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
                  [(H) patient case management services 
                (including outreach, counseling, referral, and 
                follow-up services),
        for migratory agricultural workers, seasonal 
        agricultural workers, and the members of the families 
        of such migratory and seasonal workers, within the area 
        it serves (referred to in this section as a ``catchment 
        area'') and individuals who have previously been 
        migratory agricultural workers but can no longer meet 
        the requirements of paragraph (2) of this subsection 
        because of age or disability and members of their 
        families within the area it serves.
          [(2) 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 twenty-four months, and who 
        establishes for the purposes of such employment a 
        temporary abode.
          [(3) The term ``seasonal agricultural workers'' means 
        an individual whose principal employment is in 
        agriculture on a seasonal basis and who is not a 
        migratory agricultural worker.
          [(4) The term ``agriculture'' means farming in all 
        its branches, including--
                  [(A) cultivation and tillage of the soil,
                  [(B) 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
                  [(C) 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 subparagraphs (B).
          [(5) The term ``high impact area'' means a health 
        service area or other area which has not less than four 
        thousand migratory agricultural workers and seasonal 
        agricultural workers residing within its boundaries for 
        more than two months in any calendar year. In computing 
        the number of workers residing in an area, there shall 
        be included as workers the members of the families of 
        such workers.
          [(6) The term ``primary health services'' means--
                  [(A) services of physicians and, where 
                feasible, services of physicians' assistants 
                and nurse clinicians;
                  [(B) diagnostic laboratory and radiologic 
                services;
                  [(C) preventive health services (including 
                children's eye and ear examinations to 
                determine the need for vision and hearing 
                correction, perinatal services, well child 
                services, immunizations against vaccine-
                preventable diseases, screenings for elevated 
                blood lead levels, and family planning 
                services);
                  [(D) emergency medical services;
                  [(E) transportation services as required for 
                adequate patient care;
                  [(F) preventive dental services; and
                  [(G) pharmaceutical services, as may be 
                appropriate for particular centers.
          [(7) The term ``supplemental health services'' means 
        services which are not included as primary health 
        services and which are--
                  [(A) hospital services;
                  [(B) home health services;
                  [(C) extended care facility services;
                  [(D) rehabilitative services (including 
                physical therapy) and long-term physical 
                medicine;
                  [(E) mental health services;
                  [(F) dental services;
                  [(G) vision services;
                  [(H) allied health services;
                  [(I) therapeutic radiologic services;
                  [(J) public health services (including, for 
                the social and other nonmedical needs which 
                affect health status, counseling, referral for 
                assistance, and followup services);
                  [(K) ambulatory surgical services;
                  [(L) health education services (including 
                nutrition education); and
                  [(M) other services appropriate to meet the 
                health needs of the population served by the 
                migrant health center involved.
    [(b)(1) The Secretary shall assign to high impact areas and 
any other areas (where appropriate) priorities for the 
provision of assistance under this section to projects and 
programs in such areas. The highest priorities for such 
assistance shall be assigned to areas where the Secretary 
determines the greatest need exists.
    [(2) No application for a grant under subsection (c) or (d) 
for a project in an area which has no migratory agricultural 
workers may be approved unless grants have been provided for 
all approved applications under such subsections for projects 
in areas with migratory agricultural workers.
    [(c)(1)(A) The Secretary may, in accordance with the 
priorities assigned under subsection (b)(1), make grants to 
public and nonprofit private entities for projects to plan and 
develop migrant health center which will serve migratory 
agricultural workers, seasonal agricultural workers, and the 
members of the families of such migratory and seasonal workers, 
in high impact areas. A project for which a grant may be made 
under this subparagraph 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 the costs of providing training related to the management 
of migrant health center programs, and shall include--
          [(i) an assessment of the need that the workers (and 
        the members of the families of such workers) proposed 
        to be served by the migrant health center for which the 
        project is undertaken have for primary health services, 
        supplemental health services, and environmental health 
        services;
          [(ii) the design of a migrant health center program 
        for such workers and the members of their families, 
        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; 
        and
          [(iv) initiation and encouragement of continuing 
        community involvement in the development and operation 
        of the project.
    [(B) The Secretary may make grants to or enter into 
contracts with public and nonprofit private entities for 
projects to plan and develop programs in areas in which no 
migrant health center exists and in which not more than four 
thousand migratory agricultural workers and their families 
reside for more than two months--
          [(i) for the provision of emergency care to migratory 
        agricultural workers, seasonal agricultural workers, 
        and the members of families of such migratory and 
        seasonal workers;
          [(ii) for the provision of primary care (as defined 
        in regulations of the Secretary) for such workers and 
        the members of their families;
          [(iii) for the development of arrangements with 
        existing facilities to provide primary health services 
        (not included as primary care as defined under 
        regulations under clause (ii)) to such workers and the 
        members of their families; or
          [(iv) which otherwise improve the health of such 
        workers and their families.
Any such program may include the acquisition, expansion, an 
modernization of existing buildings, construction of new 
buildings, and providing training related to the management of 
programs assisted under this subparagraph.
    [(2) Not more than two grants may be made under paragraph 
(1)(A) for the same project, and if a grant or contract is made 
or entered into under paragraph (1)(A) for a project, no other 
grant or contract under that paragraph may be made or entered 
into for the project.
    [(3) The amount of any grant made under paragraph (1) for 
any project shall be determined by the Secretary.
    [(d)(1)(A)(i) The Secretary may, in accordance with 
priorities assigned under subsection (b)(1), make grants for 
the cost of operation of public and nonprofit private migrant 
health centers in high impact areas.
    [(ii) If the Secretary makes a determination that an area 
is a high impact area, the Secretary may alter the 
determination only after providing to the grantee under 
subclause (i) for the area, and to other interested entities in 
the area, reasonable notice with respect to such determination 
and a reasonable opportunity to offer information with respect 
to such determination.
    [(B) The Secretary may make grants to and enter into 
contracts with public and nonprofit private entities for 
projects for the operation of programs in areas in which no 
migrant health center exists and in which not more than four 
thousand migratory agricultural workers and their families 
reside for more than two months--
          [(i) for the provision of emergency care to migratory 
        agricultural workers, seasonal agricultural workers, 
        and the members of the families of such migratory and 
        seasonal workers;
          [(ii) for the provision of primary care (as defined 
        in regulations of the Secretary) for such workers and 
        the members of their families;
          [(iii) for the development of arrangements with 
        existing facilities to provide primary health services 
        (not included as primary care as defined under 
        regulations under clause (ii)) to such workers and the 
        members of their families; or
          [(iv) which otherwise improve the health of such 
        workers and the members of their families.
Any such program may include the acquisition, expansion, and 
modernization of existing buildings, construction of new 
buildings, and providing training related to the management of 
programs assisted under this subparagraph.
    [(C) The Secretary may make grants to migrant health 
centers to enable the centers to plan and develop the provision 
of health services on a prepaid basis 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 
        subparagraph (A) of this paragraph for at least two 
        consecutive years preceding the year of the grant under 
        this subparagraph;
          [(ii) the governing board of the center (described in 
        subsection (f)(3)(G)) requests, in a manner prescribed 
        by the Secretary, that the center provide health 
        services on a prepaid basis to some or to all of the 
        population which the center serves; and
          [(iii) the center provides assurances satisfactory to 
        the Secretary that the provision of such services on a 
        prepaid basis will not result in the diminution of 
        health services provided by the center to the 
        population the center served prior to grant under this 
        subparagraph.
Any such grant may include the acquisition, expansion, and 
modernization of existing buildings, construction of new 
buildings, and providing training related to the management of 
the provision of health services on a prepaid basis.
    [(2) The costs for which a grant may be made under 
paragraph (1)(A) 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 the interest on, loans); and the costs of repaying 
loans made by the Farmers Home Administration for buildings; 
and the costs for which a grant or contract may be made under 
paragraph (1) may include the costs of providing training 
related to the provision of primary health services, 
supplemental health services, and environmental health 
services, and to the management of migrant health center 
programs.
    [(3) Not more than two grants may be made under paragraph 
(1)(C) for the same entity.
    [(4)(A) The amount of any grant made in any fiscal year 
under subparagraph (A) of 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, 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. In determining the amount of 
such a grant for a center, if the application for the grant 
requests funds for a service described in subparagraph (D) or 
(E) of subsection (a)(1) (other than to the extent the funds 
would be used for the improvement of private property) or a 
supplemental health service described in subparagraph (B), (F), 
(J), or (L) of subsection (a)(7), the Secretary shall include, 
in an amount determined by the Secretary and to the extent 
funds are available under appropriation Acts, funds for such 
service unless the Secretary makes a written finding that such 
service is not needed and provides the applicant with a copy of 
such finding.
    [(B) Payments under grants under subparagraph (A) 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, except that if an any fiscal year the sum of--
          [(i) the total of the amounts described in clauses 
        (i) and (ii) of subparagraph (A) of this paragraph 
        received by a center in such fiscal year, and
          [(ii) the amount of the grant to the center in such 
        fiscal year,
exceeded the costs of the center's operation in such fiscal 
year because the amount received by the center from fees, 
premiums, and third-party reimbursements was greater than 
expected, an adjustment in the amount of the grant to the 
center in the succeeding fiscal year shall be made in such a 
manner that the center shall be entitled to retain the 
additional amount of fees, premiums, and other third party 
reimbursements as the center will use (I) to expand and improve 
its services, (II) to increase the number of persons (eligible 
under subsection (a) to receive services from such a center) it 
is able to serve, (III) to construct, expand, and modernize its 
facilities, (IV) to improve the administration of its service 
programs, and (V) to establish the financial reserve required 
for the furnishing of services on a prepaid basis. Without the 
approval of the Secretary, not more than one-half of such 
retained sum may be used for construction ad modernization of 
its facilities.
    [(C) With respect to amounts described in clauses (i) and 
(ii) of subparagraph (A), the Secretary may not restrict 
expenditures of such amounts by any grantee under paragraph 
(1)(A) for--
          [(i) repair or minor renovation of the physical 
        plant;
          [(ii) establishment of a financial reserve as 
        required for the furnishing of services on a prepaid 
        basis or as needed to cover unanticipated expenses;
          [(iii) interest payments on short-term loans to cover 
        cash shortfalls; or
          [(iv) necessary salary requirements to remain 
        competitive in hiring health care practitioners.
    [(e) The Secretary may enter into contracts with public and 
private entities to--
          [(1) assist the States in the implementation and 
        enforcement of acceptable environmental health 
        standards, including enforcement of standards for 
        sanitation in migrant labor camps and applicable 
        Federal and State pesticide control standards; and
          [(2) 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, 
        pesticide hazards, and other environmental health 
        hazards to which migratory agricultural workers, 
        seasonal agricultural workers, and members of their 
        families are exposed.
                  [(F)(1) No grant may be made under subsection 
                (c) or (d) and no contract may be entered into 
                under subsection (c)(1)(B), (d)(1)(B), or (e) 
                unless an application therefor 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. An application 
                for a grant or contract which will cover the 
                costs of modernizing a building shall include, 
                in addition to other information required by 
                the Secretary--
                          [(A) a description of the site of the 
                        building,
                          [(B) plans and specifications for its 
                        modernization, and
                          [(C) reasonable assurance that all 
                        laborers and mechanics employed by 
                        contractors or subcontractors in the 
                        performance of work on the 
                        modernization of the building will be 
                        paid wages at rates not less than those 
                        prevailing on similar work in the 
                        locality as determined by the Secretary 
                        of Labor in accordance with the Act of 
                        March 3, 1931 (40 U.S.C. 276a-276a-5, 
                        known as the Davis-Bacon Act).
                The Secretary of Labor shall have with respect 
                to the labor standards referred to in 
                subparagraph (C) the authority and functions 
                set forth in Reorganization Plan Numbered 74 of 
                1950 (15 F.R. 3176; 5 U.S.C. Appendix) and 
                section 2 of the Act of June 13, 1934 (40 
                U.S.C. 276c).
                  [(2) An application for a grant under 
                subparagraph (A) of subsection (d)(1) for a 
                migrant health center shall include--
                          [(A) a description of the need in the 
                        center's catchment area for each of the 
                        health services described in 
                        subparagraph (D) and (E) of subsection 
                        (a)(1) and in subparagraphs (B), (F), 
                        (J), and (L) of subsection (a)(7),
                          [(B) if the applicant determines that 
                        any such service is not needed, the 
                        basis for such determination, and
                          [(C) if the applicant does not 
                        request funds for any such service 
                        which the applicant determines is 
                        needed, the reason for not making such 
                        a request.
                In considering an application for a grant under 
                subparagraph (A) of subsection (d)(1), the 
                Secretary may require as a condition to the 
                approval of such application assurance that the 
                applicant will provide any specified health 
                service described in subsection (a) which 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 the 
                applicant.
                  [(3) The Secretary may not approve an 
                application for a grant under subsection 
                (d)(1)(A) unless the Secretary determines that 
                the entity for which the application is 
                submitted is a migrant health center (within 
                the meaning of subsection (a)(1)) and that--
                          [(A) the primary health services of 
                        the center will be available and 
                        accessible in the center's catchment 
                        area promptly, as appropriate, and in a 
                        manner which assures continuity;
                          [(B) the center will have 
                        organizational arrangements, 
                        established in accordance with 
                        regulations of the Secretary, for (i) 
                        an ongoing quality assurance program 
                        (including utilization and peer review 
                        systems) respecting the center's 
                        services, and (ii) maintaining 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 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 he may 
                        require to determine compliance with 
                        this subparagraph;
                          [(G) the center has established a 
                        governing board which (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, and (ii) 
                        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 public center (as defined in the 
                        second sentence of this paragraph), 
                        establishes general policies for the 
                        center; and if the application is for a 
                        second or subsequent grant for a public 
                        center, the governing body of the 
                        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;
                          [(H) the center has developed, in 
                        accordance with regulations of the 
                        Secretary, (i) an overall plan and 
                        budget that meets the requirements of 
                        section 1861(z) of the Social Security 
                        Act, 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, (IV) 
                        such other matters relating to 
                        operations of the applicant as the 
                        Secretary may, by regulation, require, 
                        and (V) expenditures made from any 
                        amount the center was permitted to 
                        retain under subsection (d)(4)(B);
                          [(I) the center will review 
                        periodically its catchment area to (i) 
                        insure 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 residents of the area promptly and 
                        as appropriate, (ii) insure 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) insure that the boundaries of 
                        such area eliminate, to the extent 
                        possible, barriers to access to the 
                        services of the services of the center, 
                        including barriers resulting from the 
                        area's physical characteristics, its 
                        residential patterns, its economic and 
                        social groupings, and available 
                        transportation; and
                          [(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 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.
                For purposes of subparagraph (G) and subsection 
                (h)(4), the term ``public center'' means a 
                migrant health center funded (or to be funded) 
                through a grant under this section to a public 
                agency.
                  [(4) In considering applications for grants 
                and contracts under subsection (c) or 
                (d)(1)(B), the Secretary shall give priority to 
                applications submitted by community-based 
                organizations which are representative of the 
                populations to be served through the projects, 
                programs, or centers to be assisted by such 
                grants or contracts.
                  [(5) The Secretary, in making a grant under 
                this section to a migrant health center for the 
                provision of environmental health services 
                described in subsection (a)(1)(D), may 
                designate a portion of the grant to be expended 
                for improvements to private property for which 
                the written consent of the owner has been 
                obtained and which are necessary to alleviate a 
                hazard to the health of those residing on, or 
                otherwise using, the property and of other 
                persons in the center's catchment area. A 
                center may make such an expenditure for an 
                improvement under a grant only after the 
                Secretary has specifically approved such 
                expenditure and has determined that funds for 
                the improvement are not available from any 
                other source.
                  [(6) Contracts may be entered into under this 
                section without regard to sections 3648 and 
                3709 of the Revised Statutes (31 U.S.C. 529; 1 
                41 U.S.C. 5).
                  [(7) The Secretary may make a grant under 
                subsection (c) or (d) for the construction of 
                new buildings for a migrant health center or a 
                migrant health program 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 source 
                funds, in lieu of the grant, to construct such 
                facilities.
    [(g)(1) The Secretary may provide (either through the 
Department of Health, Education, and Welfare 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 migrant health center 
or to any public or private nonprofit entity to assist it in 
developing plans for, and in operating as, a migrant health 
center, and in meeting the requirements of subsection (f)(2).
    [(2) The Secretary shall make available to each grant 
recipient under this section a list of available Federal and 
non-Federal resources to improve the environmental and 
nutritional status of individuals in the recipient's catchment 
area.
    [(h)(1)(A) For the purposes of subsections (c) through (e), 
there are authorized to be appropriated $48,500,000 for fiscal 
year 1989, such sums as may be necessary for fiscal years 1990 
and 1991, and such sums as may be necessary for each of the 
fiscal years 1992 through 1994.
    [(B) Of the amounts appropriated pursuant to subparagraph 
(A) for a fiscal year, the Secretary may obligate for grants 
and contracts under subsection (c)(1) not more than 2 percent, 
for grants under subsection (d)(1)(C) not more than 5 percent, 
and for contracts under subsection (e) not more than 10 
percent.
    [(2)(A) For the purpose of carrying out subparagraph (B), 
there are authorized to be appropriated $1,500,000 for fiscal 
year 1989, $2,000,000 for fiscal year 1990, $2,500,000 for 
fiscal year 1991, and such sums as may be necessary for each of 
the fiscal years 1992 through 1994.
    [(B) The Secretary may make grants to migrant health 
centers for the purpose of assisting such centers in--
          [(i) 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
          [(ii) developing and coordinating service and 
        referral arrangements between migrant health centers 
        and other entities for the health management of 
        pregnant women and children described in clause (i).
    [(C) In making grants under subparagraph (B), the Secretary 
shall given priority to migrant health centers providing 
services in any catchment area in which there is a substantial 
incidence of infant mortality or in which there is a 
significant increase in the incidence of infant mortality.
    [(D) The Secretary may make a grant under subparagraph (B) 
only if the migrant health center involved agrees to expend the 
grant for the following activities with respect to the purpose 
described in such subparagraph:
          [(i) Primary health services, including prenatal 
        care.
          [(ii) Community education, outreach, and case 
        finding.
          [(iii) Case management services.
          [(iv) Client education, including parenting and child 
        development education.
    [(E) The purposes for which a migrant health center may 
expend a grant under subparagraph (B) include, with respect to 
the purpose described in such subparagraph, substance abuse 
screening, counseling and referral services, and other 
necessary nonmedical support services, including child care, 
translation services, and housing assistance.
    [(F) The Secretary may make a grant under subparagraph (B) 
only if the migrant health center involved agrees that--
          [(i) the center will coordinate the provision of 
        services under the grant to each of the recipients of 
        the services;
          [(ii) such services will be continuous for each such 
        recipient;
          [(iii) the center will provide follow-up services for 
        individuals who are referred by the center for services 
        described in subparagraph (E); and
          [(iv) 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 such subparagraph.
    [(3) 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 (f)(3)) the governing boards of 
which (as described in subsection (f)(3)(G)(ii)) do not 
establish general policies for such centers, an amount which 
exceeds 5 per centum of the funds appropriated under this 
section for that fiscal year.
    [(i) 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 central office of the Health 
Resources and Services Administration.

                       [community health centers

    [Sec. 254c. (a) For purposes of this section, the term 
``community health center'' means an entity which either 
through its staff and supporting resources or through contracts 
or cooperative arrangements with other public or private 
entities provides--
          [(1) primary health services,
          [(2) as may be appropriate for particular centers, 
        supplemental health services necessary for the adequate 
        support of primary health services,
          [(3) referral to providers of supplemental health 
        services and payment, as appropriate and feasible, for 
        their provision of such services,
          [(4) environmental health services, including, as may 
        be appropriate for particular centers (as determined by 
        the centers), the detection and alleviation of 
        unhealthful conditions associated with water supply, 
        sewage treatment, solid waste disposal, rodent and 
        parasitic infestation, field sanitation, housing, and 
        other environmental factors related to health,
          [(5) information on the availability and proper use 
        of health services and services which promote and 
        facilitate optimal use of health services, including, 
        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
          [(6) patient case management services (including 
        outreach, counseling, referral, and follow-up 
        services),
for all residents of the area it serves (referred to in this 
section as a ``catchment area'').
    [(b) For purposes of this section:
          [(1) The term ``primary health services'' means--
                  [(A) services of physicians and, where 
                feasible, services of physicians' assistants 
                and nurse clinicians;
                  [(B) diagnostic laboratory and radiologic 
                services;
                  [(C) preventive health services (including 
                children's eye and ear examinations to 
                determine the need for vision and hearing 
                correction, perinatal services, well child 
                services, immunizations against vaccine-
                preventable diseases, screenings for elevated 
                blood lead levels, and family planning 
                services);
                  [(D) emergency medical services;
                  [(E) transportation services as required for 
                adequate patient care;
                  [(F) preventive dental services; and
                  [(G) pharmaceutical services, as may be 
                appropriate for particular centers.
          [(2) The term ``supplemental health services'' means 
        services which are not included as primary health 
        services and which are--
                  [(A) hospital services;
                  [(B) home health services;
                  [(C) extended care facility services;
                  [(D) rehabilitative services (including 
                physical therapy) and long-term physical 
                medicine;
                  [(E) mental health services;
                  [(F) dental services;
                  [(G) vision services;
                  [(H) allied health services;
                  [(I) therapeutic radiologic services;
                  [(J) public health services (including, for 
                the social and other nonmedical needs which 
                affect health status, counseling, referral for 
                assistance, and followup services);
                  [(K) ambulatory surgical services;
                  [(L) health education services (including 
                nutrition education); and
                  [(M) other services appropriate to meet the 
                health needs of the medically underserved 
                population served by the community health 
                center involved.
          [(3) 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.
          [(4) In carrying out paragraph (3), the Secretary 
        shall by regulation prescribe criteria for determining 
        the specific shortages of personal health services of 
        an area or population group. Such criteria shall--
                  [(A) take into account comments received by 
                the Secretary from the chief executive officer 
                of a State and local officials in a State; and;
                  [(B) include infant mortality in an area or 
                population group, other 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.
        The Secretary may modify the criteria established in 
        regulations issued under this paragraph only after 
        affording public notice and an opportunity for comment 
        on any such proposed modifications.
          [(5) 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--
                  [(A) the chief executive officer of such 
                State;;
                  [(B) local officials in such State; and
                  [(C) the State organization, if any, which 
                represents a majority of community health 
                centers in such State.
          [(6) The Secretary may designate a medically 
        underserved population that does not meet the criteria 
        established under paragraph (4) 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)(1) The Secretary may make grants to public and 
nonprofit private entities for projects to plan and develop 
community 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 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--
          [(A) an assessment of the need that the population 
        proposed to be served by the community health center 
        for which the project is undertaken has for primary 
        health services, supplemental health services, and 
        environmental health services;
          [(B) the design of a community health center program 
        for such population based on such assessment;
          [(C) efforts to secure, within the proposed catchment 
        area of such center, financial and professional 
        assistance and support for the project; and
          [(D) initiation and encouragement of continuing 
        community involvement in the development and operation 
        of the project.
    [(2) Not more than two grants may be made under this 
subsection for the same project.
    [(3) The amount of any grant made under this subsection for 
any project shall be determined by the Secretary.
    [(d)(1)(A) The Secretary may make grants for the costs of 
operation of public and nonprofit private community health 
centers which serve medically underserved populations.
    [(B) The Secretary may make grants 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 he is unable to make each of the 
determinations required by subsection (e)(3).
    [(C) The Secretary may make grants to community health 
centers to enable the centers to plan and develop the provision 
of health services on a prepaid basis 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 
        subparagraph (A) of this paragraph for at least two 
        consecutive years preceding the year of the grant under 
        this subparagraph;
          [(ii) the governing board of the center (described in 
        subsection (e)(3)(G)) requests, in a manner prescribed 
        by the Secretary, that the center provide health 
        services on a prepaid basis to some or to all of the 
        population which the center serves; and
          [(iii) the center provides assurances satisfactory to 
        the Secretary that the provision of such services on a 
        prepaid basis will not result in the diminution of 
        health services provided by the center to the 
        population the center served prior to the grant under 
        this subparagraph.
Any such grant may include the acquisition, expansion, and 
modernization of existing buildings, construction of new 
buildings, and providing training related to management on the 
provision of health services on a prepaid basis.
    [(2) The costs for which a grant may be made under 
paragraph (1)(A) or (1)(B) 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 
made by the Farmers Home Administration for buildings, and the 
costs of providing training related to the provision of primary 
health services, supplemental health services and environmental 
health services, and to the management of community health 
center programs.
    [(3) Not more than two grants may be made under paragraph 
(1)(B) or (1)(C) for the same entity.
    [(4)(A) The amount of any grant made in any fiscal year 
under paragraph (1) (other than subparagraph (C)) to a 
community 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, 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. In determining the amount of such a grant for a 
        center, if the application for the grant requests funds 
        for a service described in subsection (a)(4) (other 
        than to the extent the funds would be used for the 
        improvement of private property) or a supplemental 
        health service described in subparagraph (B), (F), (L) 
        or (M) of subsection (b)(2), the Secretary shall 
        include, in an amount determined by the Secretary and 
        to the extent funds are available under appropriation 
        Acts, funds for such service unless the Secretary makes 
        a written finding that such service is not needed and 
        provides the applicant with a copy of such finding.
    [(B) 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, except that if in any fiscal year the sum of--
          [(i) the total of the amounts described in clauses 
        (i) and (ii) of subparagraph (A) received by a center 
        in such fiscal year, and
          [(ii) the amount of the grant to the center in such 
        fiscal year,
exceeded the costs of the center's operation in such fiscal 
year because the amount received by the center from fees, 
premiums, and third-party reimbursements was greater than 
expected, an adjustment in the amount of the grant to the 
center in the succeeding fiscal year shall be made in such a 
manner that the center shall be entitled to retain the 
additional amount of fees, premiums, and other third party 
reimbursements as the center will use (I) to expand and improve 
its services, (II) to increase the number of persons (eligible 
to receive services from such a center) it is able to serve, 
(III) to construct, expand, and modernize its facilities, (IV) 
to improve the administration of its service programs, and (V) 
to establish the financial reserve required for the furnishing 
of services on a prepaid basis. Without the approval of the 
Secretary, not more than one-half of such retained sum may be 
used for construction and modernization of its facilities.
    [(C) With respect to amounts described in clauses (i) and 
(ii) of subparagraph (A), the Secretary may not restrict 
expenditures of such amounts by any grantee under paragraph (1) 
for--
          [(i) repair or minor renovation of the physical 
        plant;
          [(ii) establishment of a financial reserve as 
        required for the furnishing of services on a prepaid 
        basis or as needed to cover unanticipated expenses;
          [(iii) interest payments on short-term loans to cover 
        cash shortfalls; or
          [(iv) necessary salary requirements to remain 
        competitive in hiring health care practitioners.
    [(e)(1) No grant may be made under subsection (c) or (d) 
unless an application therefor is submitted to, and approved 
by, the Secretary. Such an applicant shall be submitted in such 
form and manner and shall contain such information as the 
Secretary shall prescribe. An application for a grant which 
will cover the costs of modernizing a building shall include, 
in addition to other information required by the Secretary--
          [(A) a description of the site of the building,
          [(B) plans and specifications for its modernization, 
        and
          [(C) reasonable assurance that all laborers and 
        mechanics employed by contractors or subcontractors in 
        the performance of work on the modernization of the 
        building will be paid wages at rates not less than 
        those prevailing on similar work in the locality as 
        determined by the Secretary of Labor in accordance with 
        the Act of March 3, 1931 (40 U.S.C. 276a to 276a-5, 
        known as the Davis-Bacon Act).
The Secretary of Labor shall have with respect to the labor 
standards referred to in subparagraph (C) the authority and 
functions set forth in Reorganization Plan Numbered 14 of 1950 
(15 FR 3176, 5 U.S.C. Appendix) and section 2 of the Act of 
June 13, 1934 (40 U.S.C. 276c).
      [(2) An application for a grant under subparagraph (A) of 
(B) of subsection (d)(1) for a community health center shall 
include--
          [(A) a description of the need in the center's 
        catchment area for each of the health services 
        described in subsection (a)(4) and in subparagraphs 
        (B), (F), (L), and (M) of subsection (b)(2),
          [(B) if the applicant determines that any such 
        service is not needed, the basis for such 
        determination, and
          [(C) if the applicant does not requires funds for any 
        such service which the applicant determines is needed, 
        the reason for not making such a request.
Such an application shall also include a demonstration by the 
applicant that the area or a population group to be served by 
the applicant has a shortage of personal health services and 
that the center will be located so that it will provide 
services to the greatest number of persons residing in such 
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 service. 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 
applicant assurance that the applicant will provide any 
specified health services described in subsection (a) or (b) 
which 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 by the 
applicant.
    [(3) Except as provided in subsection (d)(1)(B), the 
Secretary may not approve an application for a grant under 
paragraph (1)(A) or (1)(B) of subsection (d) unless the 
Secretary determines that the entity for which the application 
is submitted is a community health center (within the meaning 
of subsection (a)) and that--
          [(A) the primary health services of the center will 
        be available and accessible in the center's catchment 
        area promptly, as appropriate, and in a manner which 
        assures continuity;
          [(B) the center will have organizational 
        arrangements, established in accordance with 
        regulations prescribed by the Secretary, or (i) an 
        ongoing quality assurance program (including 
        utilization and peer systems) respecting the center's 
        services, and (ii) maintaining the confidentially 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 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 he may require to determine compliance with 
        this subparagraph;
          [(G) the center has established a governing board 
        which (i) except in the case of an entity operated by 
        an Indian tribe or tribal or Indian organization under 
        the Indian Self-Determination Act, 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, and (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 if the application is for a second or 
        subsequent grant for a public center, the governing 
        body 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;
          [(H) the center has developed, in accordance with 
        regulations of the Secretary, (i) an overall plan and 
        budget that meets the requirements of section 1861(z) 
        of the Social Security Act, 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, (IV) such other matters 
        relating to operations of the applicant as the 
        Secretary may, by regulation, require, and (V) 
        expenditures made from any amount the center was 
        permitted to retain under subsection (d)(4)(B);
          [(I) the center will review periodically its 
        catchment area to (i) insure 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) insure 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) insure 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, in accordance with regulations 
        prescribed by the Secretary, has developed an ongoing 
        referral relationship with one or more hospitals.
For purposes of subparagraph (G) and subsection (g)(4), the 
term ``public center'' means a community health center funded 
(or to be funded) through a grant under this section to a 
public agency.
    [(4) The Secretary shall approve applications for grants 
under paragraph (1)(A) or (1)(B) of subsection (d) for 
community health centers which--
          [(A) have not received a previous grant under such 
        paragraph, or
          [(B) have applied for such a grant to expand their 
        services, in such a manner that the ratio of the 
        medical underserved populations in rural areas which 
        may be expected to use the services provided by such 
        centers to the medical underserved populations in urban 
        areas which may be expected to use the services 
        provided by such centers is not less than two or three 
        or greater than three to two.
    [(5) The Secretary, in making a grant under this section to 
a community health center for the provision of environmental 
health services described in subsection (a)(4), may designate a 
portion of the grant to be expended for improvements to private 
property for which the written consent of the owner has been 
obtained and which are necessary to alleviate a hazard to the 
health of those residing on, or otherwise using, the property 
and of other persons in the center's catchment area. A center 
may make such an expenditure for an improvement under a grant 
only after the Secretary has specifically approved such 
expenditure and has determined that funds for the improvement 
are not available from any other source.
    [(6) The Secretary may make a grant under subsection (c) or 
(d) for the construction of new buildings for a community 
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.
    [(f)(1) The Secretary may provide (either through the 
Department of Health, Education, and Welfare 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 it in developing plans for, and in 
operating as, a community health center, and in meeting 
requirements of subsection (e)(2).
    [(2) The Secretary shall make available to each grant 
recipient under this section a list of available Federal and 
non-Federal resources to improve the environmental and 
nutritional status of individuals in the recipient's catchment 
area.
    [(g)(1)(A) For the purpose of payments under grants under 
this section, there are authorized to be appropriated 
$440,000,000 for fiscal year 1989, such sums as may be 
necessary for fiscal years 1990 and 1991, and such sums as may 
be necessary for each of the fiscal years 1992 through 1994.
    [(B) The Secretary may not in any fiscal year--
          [(i) expend for grants to serve medically underserved 
        populations designated under subsection (b)(6) an 
        amount which exceeds 5 percent of the funds 
        appropriated under paragraph (1) for that fiscal year; 
        and
          [(ii) expend for grants under subsection (d)(1)(C) an 
        amount which exceeds 5 percent of the funds 
        appropriated under paragraph (1) for that fiscal year.
    [(2)(A) For the purpose of carrying out subparagraph (B), 
there are authorized to be appropriated $25,000,000 for fiscal 
year 1989, $30,000,000 for fiscal year 1990, $35,000,000 for 
fiscal year 1991, and such sums as may be necessary for each of 
the fiscal years 1992 through 1994.
    [(B) The Secretary may make grants to community health 
centers for the purpose of assisting such centers in--
          [(i) 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
          [(ii) developing and coordinating service and 
        referral arrangements between community health centers 
        and other entities for the health management of 
        pregnant women and children described in clause (i).
    [(C) In making grants under subparagraph (B), the Secretary 
shall give priority to community 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.
    [(D) The Secretary may make a grant under subparagraph (B) 
only if the community health center involved agrees to expend 
the grant for the following activities with respect to the 
purpose described in such subparagraph:
          [(i) Primary health services, including prenatal 
        care.
          [(ii) Community education, outreach, and case 
        finding.
          [(iii) Case management services.
          [(iv) Client education, including parenting ad child 
        development education.
    [(E) The purposes for which a community health center may 
expend a grant under subparagraph (B) include, with respect to 
the purpose described in such subparagraph, substance abuse 
screening, counseling and referral services, and other 
necessary nonmedical support services, including child care, 
translation services, and housing assistance.
    [(F) The Secretary may make a grant under subparagraph (B) 
only if the community health center involved agrees that--
          [(i) the center will coordinate the provision of 
        services under the grant to each of the recipients of 
        the services;
          [(ii) such services will be continuous for each such 
        recipient;
          [(iii) the center will provide follow-up services for 
        individuals who are referred by the center for services 
        described in subparagraph (E); and
          [(iv) 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 such subparagraph.
    [(3) 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 (e)(3)) the governing boards of 
which (as described in subsection (e)(3)(G)(ii)) do not 
establish general policies for such centers, an amount which 
exceeds 5 per centum of the funds appropriated under this 
section for that fiscal year.
    [(h) 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 
        community health centers;
          [(3) review and comment upon annual program plans and 
        budgets of community health centers, including comments 
        upon allocations of health care resources in the State;
          [(4) assist community 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 community 
        health centers; and
          [(5) share information and data relevant to the 
        operation of new and existing community health centers.
    [(i)(1) Each entity which receives a grant under subsection 
(d) 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) Each entity which receives a grant under subsection 
(d) 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) 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 therefor. 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) The Secretary may, under appropriate circumstances, 
waive the application of all or part of the requirements of 
this subsection to a community health center.
    [(j) 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 central office of the Health 
Resources and Services Administration.
    [(k) In making grants under this section, the Secretary 
shall give special consideration to the unique needs of 
frontier areas.]

                       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 requirements 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 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 
                help 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 (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) and (B) of paragraph (1) shall 
                be made in advance or by way of reimbursement 
                and in such installations 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.
          (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 applicant 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) of (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
                  (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 
        $756,518,000 for fiscal year 1996, and such sums as may 
        be necessary for each of the fiscal years 1997 through 
        2000.
          (2) Special provisions.--
                  (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. 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.
          (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.
          * * * * * * *

                      TITLE 42--UNITED STATES CODE

          * * * * * * *
    Sec. 233 * * *
          * * * * * * *
    (g) * * *
          * * * * * * *
          (4) An entity described in this paragraph is a public 
        or non-profit private entity receiving Federal funds 
        [under any of the following grant programs:
                  (A) Section 329 (relating to grants for 
                migrant health centers).
                  (B) Section 330 (relating to grants for 
                community health centers).
                  (C) Section 340 (relating to grants for 
                health services for the homeless).
                  (D) Section 340A (relating to grants for 
                health services for residents of public 
                housing).] under section 330.
          * * * * * * *
    Sec. 256c. * * *
          * * * * * * *
          (2) Relevant entities.--The entities referred to in 
        paragraph (1) are entities that provide immunizations 
        against vaccine-preventable diseases [under the 
        programs established in sections 329, 330, 340, and 
        340A.] with assistance provided under section 330.
          * * * * * * *

                      TITLE 42--UNITED STATES CODE

          * * * * * * *

              [Subpart V--Health Services for the Homeless

    [Sec. 256. Grant Program for Certain Health Services for 
the Homeless.--
    [(a) Establishment.--
          [(1) The Secretary, acting through the Administrator 
        of the Health Resources and Services Administration, 
        shall make grants for the purpose of enabling grantees, 
        directly or through contracts, to provide for the 
        delivery of health services to homeless individuals.
          [(2) In carrying out the program established in 
        paragraph (1), the Administrator shall consult with the 
        Director of the National Institute on Alcohol Abuse and 
        Alcoholism and with the Director of the National 
        Institute of Mental Health.
    [(b) Minimum Qualifications of Grantees.--(1) Subject to 
paragraph (2), the Secretary may not make a grant under 
subsection (a) to an applicant unless--
          [(A) the applicant is a public or nonprofit private 
        entity;
          [(B) the applicant has the capacity to effectively 
        administer a grant under subsection (a); and
          [(C) in the case of any health service that is 
        covered in the State plan approved under title XIX of 
        the Social Security Act for the State involved--
                  [(i) the applicant for the grant will provide 
                the health service directly, and the applicant 
                has entered into a participation agreement 
                under the State plan and is qualified to 
                receive payments under such plan; or
                  [(ii) the applicant for the grant will enter 
                into an agreement with an organization under 
                which the organization will provide the health 
                service, and the organization has entered into 
                such a participation agreement and is qualified 
                to receive such payments.
    [(2)(A) In the case of an organization making an agreement 
under paragraph (1)(C)(ii) regarding the provision of health 
services under subsection (a), the requirement established in 
such paragraph regarding a participation agreement shall be 
waived by the Secretary if the organization does not, in 
providing health care services, impose a charge or accept 
reimbursement available from any third-party payor, including 
reimbursement under any insurance policy or under any Federal 
or State health benefits program.
    [(B) A determination by the Secretary of whether an 
organization referred to in subparagraph (A) meets the criteria 
for a waiver under such subparagraph shall be made without 
regard to whether the organization accepts voluntary donations 
regarding the provision of services to the public.
    [(c) Preferences in Making Grants.--The Secretary shall, in 
making grants under subsection (a), give preference to 
qualified applicants that--
          [(1)(A) are experienced in the direct delivery of 
        primary health services to homeless individuals or 
        medically underserved populations; or
          [(B) are experienced in the treatment of substance 
        abuse in homeless individuals of medically underserved 
        populations; and
          [(2) agree to provide for health services to homeless 
        individuals through both public entities and private 
        organizations.
    [(d) Requirement of Submission of Application Containing 
Certain Agreements.--(1) The Secretary may not make a grant 
under subsection (a) to an applicant unless the applicant has 
submitted to the Secretary an application for the grant 
containing agreements in accordance with--
          [(A) subsection (e)(1)(A)(ii), relating to the 
        provision of matching funds;
          [(B) subsection (f), relating to the provision of 
        certain health services;
          [(C) subsection (i), relating to restrictions on the 
        use of funds;
          [(D) subsection (j), relating to a limitation on 
        charges for services;
          [(E) subsection (k), relating to the administration 
        of grants; and
          [(F) subsection (l), relating to a limitation on 
        administrative expenses.
    [(2) An application required in paragraph (1) shall, with 
respect to agreements required to be contained in the 
application, provide assurances of compliance satisfactory to 
the Secretary and shall otherwise be in such form, be made in 
such manner, and contain such information in addition to 
information required in paragraph (1) as the Secretary 
determines to be necessary to carry out this section.
    [(e) Requirement of Provision of Matching Funds.--(1)(A) 
The Secretary may not make a grant under subsection (a) to an 
applicant--
          [(i) in an amount exceeding 75 percent of the costs 
        of providing health services for the first fiscal year 
        of payments under the grant and 662/3 percent of the 
        costs of providing such services for any subsequent 
        fiscal year of payments under the grant; and
          [(ii) unless the applicant agrees that the applicant 
        will make available, directly or through donations to 
        the applicant, non-Federal contributions toward such 
        costs in an amount equal to not less than $1 (in cash 
        or in kind under subparagraph (B)) for each $3 of 
        Federal funds provided for the first fiscal year of 
        payments under the grant and not less than $1 (in cash 
        or in kind under such subparagraph) for each $2 of 
        Federal funds provided for any subsequent fiscal year 
        of payments under the grant.
    [(B)(i) Non-Federal contributions required in subparagraph 
(A) may be in cash or in kind, fairly evaluated, including 
plant, equipment, or services. Amounts provided by the Federal 
Government, or services assisted or subsidized to any 
significant extent by the Federal Government, may not be 
included in determining the amount of such non-Federal 
contributions.
          [(ii) Such determination may not include any cash or 
        in-kind contributions that, prior to February 26, 1987, 
        were made available by any public or private entity for 
        the purpose of assisting homeless individuals 
        (including assistance other than the provision of 
        health services).
    [(2) The Secretary may waive the requirement established in 
paragraph (1)(A) if the applicant involved is a nonprofit 
private entity and the Secretary determines that it is not 
feasible for the applicant to comply with such requirement.
    [(f) Requirement of Provision of Certain Health Services.--
The Secretary may not make a grant under subsection (a) to an 
applicant unless the applicant agrees that the applicant will, 
directly or through contract--
          [(1) provide health services at locations accessible 
        to homeless individuals;
          [(2) provide to homeless individuals, at all hours, 
        emergency health services;
          [(3) refer homeless individuals as appropriate to 
        medical facilities for necessary hospital services;
          [(4) refer for mental health services homeless 
        individuals who are mentally ill to entities that 
        provide such services, unless the applicant will 
        provide such services pursuant to subsection (g);
          [(5) provide outreach services to inform homeless 
        individuals of the availability of health services; and
          [(6) aid homeless individuals in establishing 
        eligibility for assistance, and in obtaining services, 
        under entitlement programs.
    [(g) Optional Provision of Certain Services.--A grantee 
under subsection (a) may expend amounts received pursuant to 
such subsection for the purpose of providing to homeless 
individuals mental health services, dental services (including 
dentures), services with respect to vision, and podiatry 
services.
    [(h) Temporary Continued Provision of Services to Certain 
Former Homeless Individuals.--If any grantee under subsection 
(a) has provided services described in subsection (f) or (g) to 
a homeless individual, any such grantee may, notwithstanding 
that the individual is no longer homeless as a result of 
becoming a resident in permanent housing, expend the grant to 
continue to provide such services to the individual for not 
more than 12 months.
    [(i) Restrictions on Use of Grant Funds.--(1) The Secretary 
may not except as provided in paragraph (2) make a grant under 
subsection (a) to an applicant unless the applicant agrees that 
amount received pursuant to such subsection will not, directly 
or through contract, be expended--
          [(A) for any purpose other than the purposes 
        described in subsections (a) and (g);
          [(B) to provide inpatient services, except with 
        respect to residential treatment for substance abuse 
        provided in settings other than hospitals;
          [(C) to make cash payments to intended recipients of 
        health services or mental health services; or
          [(D) to purchase or improve real property (other than 
        minor remodeling of existing improvements to real 
        property) or to purchase major medical equipment.
    [(2) If the Secretary finds that the purpose described in 
subsection (a) cannot otherwise be carried out, the Secretary 
may, with respect to an otherwise qualified applicant, waive 
the restriction established in paragraph (1)(D).
    [(j) Limitation on Charges for Services.--The Secretary may 
not make a grant under subsection (a) to an applicant unless 
the applicant agrees that, whether health services are provided 
directly or through contract--
          [(1) health services under the grant will be provided 
        without regard to ability to pay the health services; 
        and
          [(2) if a charge is imposed for the delivery of 
        health services, such charge--
                  [(A) will be made according to a schedule of 
                charges that is made available to the public;
                  [(B) will not be imposed on any homeless 
                individual with an income less than the 
                official poverty level; and
                  [(C) will be adjusted to reflect the income 
                and resources of the homeless individual 
                involved.
    [(k) Requirements With Respect to Administration.--The 
Secretary may not make a grant under subsection (a) to an 
applicant unless the applicant--
          [(1) agrees to establish such procedures for fiscal 
        control and fund accounting as may be necessary to 
        ensure proper disbursement and accounting with respect 
        to the grant;
          [(2) agrees to establish an ongoing program of 
        quality assurance with respect to the health services 
        provided under the grant;
          [(3) agrees to ensure the confidentiality of records 
        maintained on homeless individuals receiving health 
        services under the grant;
          [(4) with respect to providing health services to any 
        population of homeless individuals a substantial 
        portion of which has a limited ability to speak the 
        English language--
                  [(A) has developed and has the ability to 
                carry out a reasonable plan to provide health 
                services under the grant through individuals 
                who are able to communicate with the population 
                involved in the language and cultural context 
                that is most appropriate; and
                  [(B) has designated at least one individual, 
                fluent in both English and the appropriate 
                language, to assist in carrying out the plan; 
                and
          [(5) agrees to submit to the Secretary an annual 
        report that describes the utilization and costs of 
        health services provided under the grant and that 
        provides such other information as the Secretary 
        determines to be appropriate.
    [(l) Limitation on Administrative Expenses of Grantee.--The 
Secretary may not make a grant under subsection (a) to an 
applicant unless the applicant agrees that the applicant will 
not expend more than 10 percent of amounts received pursuant to 
such subsection for the purpose of administering the grant.
    [(m) Use of Grant Funds for Referrals to Certain Advocacy 
Systems.--A grantee under subsection (a) may, with respect to 
title I of the Protection and Advocacy for Mentally Ill 
Individuals Act of 1986, expend amounts received under 
subsection (a) for the purpose of referring homeless 
individuals who are chronically mentally ill, and who are 
eligible under such Act, to systems that provide advocacy 
services under such Act.
    [(n) Use of Self-Help Organizations.--Any grantee under 
subsection (a) may provide health services through contracts 
with nonprofit self-help organizations that--
          [(1) are established and managed by current and 
        former recipients of mental health services, or 
        substance abuse services, who have been homeless 
        individuals; and
          [(2) with respect to the provision of health services 
        described in subsection (b)(3), are organizations 
        qualified under subparagraph (B) of such subsection.
    [(o) Technical Assistance.--(1) The Secretary may, without 
charge to any grantee under subsection (a), provide technical 
assistance to any such grantee with respect to the planning, 
development, and operation of programs to carry out the purpose 
described in such subsection. The Secretary may provide such 
technical assistance directly, through contract, or through 
grants.
          [(2) Of the amounts appropriated pursuant to 
        subsection (q)(1) for a fiscal year, the Secretary may 
        expend not more than $2,000,000 for the purpose of 
        carrying out paragraph (1).
    [(p) Annual Reports by Secretary.--Not later than January 
10 of each year, the Secretary shall submit to the Congress a 
report describing the utilization and costs of health services 
provided under subsection (a) during the immediate preceding 
fiscal year.
    [(q) Funding.--(1) There are authorized to be appropriated 
to carry out this section $70,000,000 for fiscal year 1991, 
$80,000,000 for fiscal year 1992, and such sums as may be 
necessary for each of the fiscal years 1993 and 1994.
    [(2) Amounts received by a grantee pursuant to subsection 
(a) remaining unobligated at the end of the fiscal year in 
which the amounts were received shall remain available to the 
grantee during the succeeding fiscal year for the purpose 
described in such subsection.
    [(r) Definitions.--For purposes of this section:
          [(1) The term ``health services'' means primary 
        health services and substance abuse services.
          [(2) 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.
          [(3) The term ``medically underserved population'' 
        has the meaning given such term in section 330(b)(3).
          [(4) The term ``official poverty level'' means the 
        nonfarm income official poverty line defined by the 
        Office of Management and Budget and revised annually in 
        accordance with section 673(2) of the Omnibus Budget 
        Reconciliation Act of 1981.
          [(5) The term ``organization'' includes individuals, 
        corporations, partnerships, companies, and 
        associations.
          [(6) The term ``primary health services'' has the 
        meaning given such term in section 330(b)(1).
          [(7) The term ``substance abuse'' has the meaning 
        given such term in section 536(4). So in original. 
        Probably should be ``section 534(4)''. See the 
        amendments made by section 511 of Public Law 101-645 
        (104 Stat. 4726).
          [(8) The term ``substance abuse services'' includes 
        detoxification and residential treatment for substance 
        abuse provided in settings other than hospitals.
    [(s) Grants Regarding Outreach and Primary Health Services 
for Homeless Children.--
          [(1) The Secretary may make grants to entities 
        specified in paragraph (2) for the purpose of enabling 
        the entities, directly or through contracts, to carry 
        out demonstration programs--
                  [(A) to provide comprehensive primary health 
                services to homeless children and to children 
                at imminent risk of homelessness, including 
                such services provided through mobile medical 
                units;
                  [(B) to provide referrals for the provision 
                of appropriate health services, social 
                services, and education services to children 
                receiving services under subparagraph (A) 
                (including referrals regarding hospitals, the 
                programs of sections 329 and 330, the program 
                of the Head Start Act (and other programs 
                providing education services), and programs 
                regarding the prevention and treatment of child 
                abuse); and
                  [(C) to provide outreach services to identify 
                children who are homeless and to inform the 
                parents (or other guardians) of the children of 
                the availability of services from the grantees 
                and from the entities or programs specified in 
                subparagraph (B).
          [(2) The entities referred to in paragraph (1) are--
                  [(A) grantees under subsection (a), and other 
                public and nonprofit private entities (other 
                than children's hospitals) that provide primary 
                health services, and substance abuse services, 
                to a substantial number of homeless 
                individuals; and
                  [(B) public and nonprofit private children's 
                hospitals that provide primary health services 
                to a substantial number of individuals.
          [(3)(A) The Secretary may not make a grant under 
        paragraph (1) to a hospital unless the hospital agrees, 
        with respect to the costs of providing services under 
        such paragraph, to make available (directly or through 
        donations from public or private entities) non-Federal 
        contributions toward such costs in an amount that is 
        not less than $1 for each $1 of Federal funds provided 
        in the grant.
          [(B) Non-Federal contributions required in 
        subparagraph (A) may be in cash or in kind, fairly 
        evaluated, including plant, equipment, or services. 
        Amounts provided by the Federal Government, or services 
        assisted or subsidized to any significant extent by the 
        Federal Government, may not be included in determining 
        the amount of such non-Federal contributions.
          [(4) The Secretary may not make a grant under 
        paragraph (1) unless the applicant for the grant agrees 
        that subsections (b)(3), (h), (i), and (j) will apply 
        to the grant to the same extent and in the same manner 
        as such subsections apply to any grant under subsection 
        (a). For purposes of subsection (i)(1)(D) (including as 
        applied to this subsection by the preceding sentence), 
        mobile medical units shall be considered to be major 
        medical equipment.
          [(5) The Secretary may not make a grant under 
        paragraph (1) unless the applicant for the grant agrees 
        to collect such data as the Secretary determines to be 
        necessary for assessing the efficacy of services 
        provided under paragraph (1) to homeless children.
          [(6) The Secretary may not make a grant under 
        paragraph (1) unless an application for the grant is 
        submitted to the Secretary and the application is in 
        such form, is made in such manner, and contains such 
        agreements, assurances, and information as the 
        Secretary determines to be necessary to carry out this 
        subsection.
          [(7) In making grants under paragraph (1), the 
        Secretary shall take into account the needs of homeless 
        children in rural areas.
          [(8) For the purpose of carrying out this subsection, 
        there is authorized to be appropriated $5,000,000 for 
        each of the fiscal years 1991 through 1993.
    [(t) Infant Mortality and Morbidity.--
          [1) In general.--The Secretary may make grants to 
        grantees under subsection (a) for the purpose of 
        assisting such grantees 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 such grantees and 
                other entities for the health management of 
                pregnant women and children described in 
                subparagraph (A).
          [(2) Required activities.--The Secretary may make a 
        grant under paragraph (1) only if the applicant 
        involved agrees to expend the grant for the following 
        activities with respect to the purpose described in 
        such paragraph:
                  [(A) Primary health services, including 
                prenatal care.
                  [(B) Community education, outreach, and case 
                finding.
                  [(C) Case management services.
                  [(D) Client education, including parenting 
                and child development education.
          [(3) Certain authorized activities.--The purposes for 
        which a grant under paragraph (1) may be expended 
        include, with respect to the purpose described in such 
        paragraph, substance abuse screening, counseling and 
        referral services, and other necessary nonmedical 
        support services, including child care, translation 
        services, and housing assistance.
          [(4) Certain requirements regarding provision of 
        services.--The Secretary may make a grant under 
        paragraph (1) only if the applicant involved agrees 
        that--
                  [(A) the applicant 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 applicant will provide follow-up 
                services for individuals who are referred by 
                the applicant for services described in 
                paragraph (3); and
                  [(D) the grant will be expended to 
                supplement, and not supplant, the expenditures 
                of the applicant for primary health services 
                (including prenatal care) with respect to the 
                purpose described in paragraph (1).
          [(5) Application for grant.--The Secretary may make a 
        grant under paragraph (1) only if an application for 
        the grant is submitted to the Secretary and the 
        application is in such form, is made in such manner, 
        and contains such agreements, assurances, and 
        information as the Secretary determines to be necessary 
        to carry out this subsection.
          [(6) Authorization of appropriations.--For the 
        purpose of carrying out this subsection, there are 
        authorized to be appropriated such sums as may be 
        necessary for each of the fiscal years 1993 and 1994.

      [Subpart VI--Health Services for Residents of Public Housing

            [health services for residents of public housing

    [Sec. 256a. (a) Establishment.--
          [(1) The Secretary, acting through the Administrator 
        of the Health Resources and Services Administration, 
        shall make grants for the purpose of enabling grantees, 
        directly or through contracts, to provide to residents 
        of public housing, subject to subsections (e) and (f)--
                  [(A) primary health services, including 
                health screenings; and
                  [(B) health counseling and education 
                services.
          [(2) The Secretary may not make a grant under 
        paragraph (1) unless the applicant for the grant agrees 
        to expend the grant to carry out each of subparagraphs 
        (A) and (B) of such paragraph.
          [(3) In carrying out the program established in 
        paragraph (1), the Administrator shall consult with the 
        Director of the Centers for Disease Control.
    [(b) Minimum Qualifications of Grantees.--
          [(1) Subject to paragraph (2), the Secretary may not 
        make a grant under subsection (a) to an applicant 
        unless--
                  [(A) the applicant is a public or nonprofit 
                private entity;
                  [(B) the applicant has the capacity to 
                effectively administer a grant under subsection 
                (a); and
                  [(C) in the case of any service under this 
                section that is available pursuant to the State 
                plan approved under title XIX of the Social 
                Security Act for the State in which the service 
                will be provided--
                          [(i) the applicant for the grant will 
                        provide the service directly, and the 
                        applicant has entered into a 
                        participation agreement under the State 
                        plan and is qualified to receive 
                        payments under such plan; or
                          [(ii) the applicant for the grant 
                        will enter into an agreement with a 
                        public or nonprofit private 
                        organization under which the 
                        organization will provide the service, 
                        and the organization has entered into 
                        such a participation agreement and is 
                        qualified to receive such payments.
          [(2)(A) In the case of an organization making an 
        agreement pursuant to paragraph (1)(C)(ii) regarding 
        the provision of services under subsection (a), the 
        requirement established in such paragraph regarding a 
        participation agreement shall be waived by the 
        Secretary if the organization does not, in providing 
        services, impose a charge or accept reimbursement 
        available from any third-party payor, including 
        reimbursement under any insurance policy or under any 
        Federal or State health benefits program.
          [(B) A determination by the Secretary of whether an 
        organization referred to in subparagraph (A) meets the 
        criteria for a waiver under such subparagraph shall be 
        made without regard to whether the organization accepts 
        voluntary donations regarding the provision of services 
        to the public.
    [(c) Preferences in Making Grants.--The Secretary shall, in 
making grants under subsection (a), give preference to 
qualified applicants that--
          [(1) are resident management corporations under 
        section 20 of the United States Housing Act of 1937; or
          [(2) are receiving funds under section 330 or 340.
    [(d) Requirement of Matching Funds From Public Grantees.--
          [(1) In the case of a public entity applying for a 
        grant under subsection (a), the Secretary may not make 
        such a grant unless the public entity agrees that, with 
        respect to the costs to be incurred by such entity in 
        carrying out the purpose described in such subsection, 
        the entity will make available non-Federal 
        contributions in cash toward such costs in an amount 
        equal to not less than $1 for each $1 of Federal funds 
        provided in the grant.
          [(2) In determining the amount of non-Federal 
        contributions in cash that a public entity has provided 
        pursuant to paragraph (1), the Secretary may not 
        include any amounts provided to the public entity by 
        the Federal Government.
    [(e) Requirements Regarding Services.--The Secretary may 
not make a grant under subsection (a) to an applicant unless 
the applicant agrees that the applicant will, directly or 
through contract--
          [(1) provide services under this section on the 
        premises of public housing projects or at other 
        locations immediately accessible to residents of public 
        housing;
          [(2) refer such residents, as appropriate, to 
        qualified facilities and practitioners for necessary 
        follow-up services;
          [(3) provide outreach services to inform such 
        residents of the availability of such services; and
          [(4) aid such residents in establishing eligibility 
        for assistance, and in obtaining services, under 
        Federal, State, and local programs providing health 
        services, mental health services, or social services.
    [(f) Optional Provision of Certain Services.--
          [(1) A grantee under subsection (a) may expend the 
        grant--
                  [(A) to train residents of public housing to 
                provide health screenings and to provide 
                educational services; and
                  [(B) to provide health services to 
                individuals who are not residents of public 
                housing.
          [(2) The Secretary may not make a grant under 
        subsection (a) unless the applicant for the grant 
        agrees that if, pursuant to paragraph (1)(B), the 
        applicant provides health services to individuals who 
        are not residents of public housing, the health 
        services will be provided to such individuals under the 
        same terms and conditions as such services are provided 
        to residents of public housing (including all terms and 
        conditions in effect pursuant to this section).
    [(g) Consultation With Residents.--The Secretary may not 
make a grant under subsection (a) unless, with respect to the 
residents of the public housing involved, the applicant for the 
grant--
          [(1) has consulted with the residents in the 
        preparation of the application for the grant; and
          [(2) agrees to provide for ongoing consultation with 
        the residents regarding the planning and administration 
        of the program carried out with the grant.
    [(h) Restrictions on Use of Grant Funds.--
          [(1) The Secretary may not, except as provided in 
        paragraph (2), make a grant under subsection (a) to an 
        applicant unless the applicant agrees that amounts 
        received pursuant to such subsection will not, directly 
        or through contract, be expended--
                  [(A) for any purpose other than the purposes 
                authorized in this section;
                  [(B) to provide inpatient services;
                  [(C) to make cash payments to intended 
                recipients of services under this section; or
                  [(D) to purchase or improve real property 
                (other than minor remodeling of existing 
                improvements to real property) or to purchase 
                major medical equipment or motor vehicles.
          [(2) If the Secretary finds that the purpose 
        described in subsection (a) cannot otherwise be carried 
        out, the Secretary may, with respect to an otherwise 
        qualified applicant, waive the restriction established 
        in paragraph (1)(D).
    [(i) Limitation on Charges for Services.--The Secretary may 
not make a grant under subsection (a) to an applicant unless 
the applicant agrees that, whether the services are provided 
directly or through contract--
          [(1) services under the grant will be provided 
        without regard to ability to pay for the services; and
          [(2) if a charge is imposed for the delivery of the 
        services, such charge--
                  [(A) will be made according to a schedule of 
                charges that is made available to the public;
                  [(B) will not be imposed on any resident of 
                public housing with an income less than the 
                official poverty level; and
                  [(C) will be adjusted to reflect the income 
                and resources of the resident of public housing 
                involved.
    [(j) Requirements Regarding Administration.--The Secretary 
may not make a grant under subsection (a) to an applicant 
unless the applicant--
          [(1) agrees to establish such procedures for fiscal 
        control and fund accounting as may be necessary to 
        ensure proper disbursement and accounting with respect 
        to the grant;
          [(2) agrees to establish an ongoing program of 
        quality assurance with respect to the services provided 
        under the grant;
          [(3) agrees to ensure the confidentiality of records 
        maintained on residents of public housing that are 
        receiving such services;
          [(4) with respect to providing services to any 
        population of such residents a substantial portion of 
        which has a limited ability to speak the English 
        language--
                  [(A) has developed and has the ability to 
                carry out a reasonable plan to provide services 
                under the grant through individuals who are 
                able to communicate with the population 
                involved in the language and cultural context 
                that is most appropriate; and
                  [(B) has designated at least one individual, 
                fluent in both English and the appropriate 
                language, to assist in carrying out the plan; 
                and
          [(5) agrees to submit to the Secretary an annual 
        report that describes the utilization and costs of 
        services provided under the grant and that provides 
        such other information as the Secretary determines to 
        be appropriate.
    [(k) Limitation on Administrative Expenses of Grantee.--The 
Secretary may not make a grant under subsection (a) to an 
applicant unless the applicant agrees that the applicant will 
not expend more than 10 percent of amounts received pursuant to 
such subsection for the purpose of administering the grant.
    [(l) Requirement of Application.--The Secretary may not 
provide financial assistance under subsection (a) unless--
          [(1) an application for the assistance is submitted 
        to the Secretary;
          [(2) with respect to carrying out the purpose for 
        which the assistance is to be provided, the application 
        provides assurances of compliance satisfactory to the 
        Secretary; and
          [(3) the application otherwise is in such form, is 
        made in such manner, and contains such agreements, 
        assurances, and information as the Secretary determines 
        to be necessary to carry out this section.
    [(m) Technical Assistance.--
          [(1) The Secretary may provide technical assistance 
        to applicants and grantees under subsection (a) 
        regarding the planning, development, and operation of 
        programs to carry out the purpose described in such 
        subsection. The Secretary may provide such technical 
        assistance directly, through contracts, or through 
        grants.
          [(2) Any technical assistance provided by the 
        Secretary under paragraph (1) shall be provided without 
        charge to applicants and grantees under subsection (a).
          [(3) Of the amounts appropriated pursuant to 
        subsection (p)(1) for a fiscal year, the Secretary may 
        expend not more than $2,000,000 for the purpose of 
        carrying out paragraph (1).
    [(n) Annual Reports by Secretary.--Not later than January 
10 of each year, the Secretary shall submit to the Congress a 
report describing the utilization and costs of services 
provided under this section during the immediately preceding 
fiscal year.
    [(o) Definitions.--For purposes of this section:
          [(1) The term ``official poverty level'' means the 
        nonfarm income official poverty line defined by the 
        Office of Management and Budget and revised annually in 
        accordance with section 673(2) of the Omnibus Budget 
        Reconciliation Act of 1981.
          [(2) The term ``organization'' includes individuals, 
        corporations, partnerships, companies, and 
        associations.
          [(3) The term ``primary health services'' has the 
        meaning given such term in section 330(b)(1).
          [(4) The term ``public housing'' has the meaning 
        given such term in section 3(b)(1) of the United States 
        Housing Act of 1937.
    [(p) Funding.--
          [(1) For the purpose of carrying out this section, 
        there are authorized to be appropriated $35,000,000 for 
        fiscal year 1991, and such sums as may be necessary for 
        each of the fiscal years 1992 and 1993.
          [(2) Amounts received by a grantee pursuant to 
        subsection (a) remaining unobligated at the end of the 
        fiscal year in which the amounts were received shall 
        remain available to the grantee during the succeeding 
        fiscal year for the purpose described in such 
        subsection.
    [(q) Infant Mortality and Morbidity.--
          [(1) In general.--The Secretary may make grants to 
        grantees under subsection (a) for the purpose of 
        assisting such grantees 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 such grantees and 
                other entities for the health management of 
                pregnant women and children described in 
                subparagraph (A).
          [(2) Required activities.--The Secretary may make a 
        grant under paragraph (1) only if the applicant 
        involved agrees to expend the grant for the following 
        activities with respect to the purpose described in 
        such paragraph:
                  [(A) Primary health services, including 
                prenatal care.
                  [(B) Community education, outreach, and case 
                finding.
                  [(C) Case management services.
                  [(D) Client education, including parenting 
                and child development education.
          [(3) Certain authorized activities.--The purposes for 
        which a grant under paragraph (f) may be expended 
        include, with respect to the purpose described in such 
        paragraph, substance abuse screening, counseling and 
        referral services, and other necessary nonmedical 
        support services, including child care, translation 
        services, and housing assistance.
          [(4) Certain requirements regarding provision of 
        services.--The Secretary may make a grant under 
        paragraph (1) only if the applicant involved agrees 
        that--
                  [(A) the applicant 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 applicant will provide follow-up 
                services for individuals who are referred by 
                the applicant for services described in 
                paragraph (3); and
                  [(D) the grant will be expended to 
                supplement, and not supplant, the expenditures 
                of the applicant for primary health services 
                (including prenatal care) with respect to the 
                purpose described in paragraph (1).
          [(5) Application for grant.--The Secretary may make a 
        grant under paragraph (1) only if an application for 
        the grant is submitted to the Secretary and the 
        application is in such form, is made in such manner, 
        and contains such agreements, assurances, and 
        information as the Secretary determines to be necessary 
        to carry out this subsection.
          [(6) Authorization of appropriations.--For the 
        purpose of carrying out this subsection, there are 
        authorized to be appropriated such sums as may be 
        necessary for each of the fiscal years 1993 and 1994.]
          * * * * * * *
                              ----------                              


                          SOCIAL SECURITY ACT

                      TITLE 42--UNITED STATES CODE

          * * * * * * *
    Sec. 1395x * * *
          * * * * * * *
    (aa) * * *
          * * * * * * *
          (4) * * *
          * * * * * * *
                  (A) * * *
                          (i) is receiving a grant under 
                        [section 329, 330, or 340] section 330 
                        (other than subsection (h) of the 
                        Public Health Service Act, or
                          (ii)(I) * * *
                          (II) meets the requirements to 
                        receive a grant under [section 329, 
                        330, or 340] section 330 (other than 
                        subsection (h)) of such Act, or
          * * * * * * *
    Sec. 1396d. * * *
          * * * * * * *
          (2) * * *
          * * * * * * *
                  (B) * * *
                          (i) is receiving a grant under 
                        section [329, 330, 340, or 340A] 
                        section 330 of the Public Health 
                        Service Act.
                          (ii) * * *
                                  (II) meets the requirements 
                                to receive a grant under 
                                section [329, 330, 340, or 
                                340A] Section 330 of such Act.
          * * * * * * *

                                
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