[Senate Report 106-294]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 548
106th Congress                                                   Report
                                 SENATE
 2d Session                                                     106-294

======================================================================



 
                 RYAN WHITE CARE ACT AMENDMENTS OF 2000

                                _______
                                

                  May 15, 2000.--Ordered to be printed

                                _______
                                

   Mr. Jeffords, from the Committee on Health, Education, Labor, and 
                   Pensions, submitted the following

                              R E P O R T

                         [To accompany S. 2311]

    The Committee on Health, Education, Labor, and Pensions, to 
which was referred to the bill (S. 2311) to revise and extend 
the Ryan White CARE Act programs under title XXVI of the Public 
Health Service Act, to improve access to health care and the 
quality of health care under such programs, and to provide for 
the development of increased capacity to provide health care 
and related support services to individuals and families with 
HIV disease, and for other purposes, having considered the 
same, reports favorably thereon with an amendment in the nature 
of a substitute and recommends that the bill (as amended) do 
pass.

                                CONTENTS

                                                                   Page
  I. Summary of the bill..............................................1
 II. Background and need for the legislation..........................6
III. Legislative history and committee action........................12
 IV. Committee views.................................................12
  V. Cost estimate...................................................35
 VI. Regulatory impact statement.....................................39
VII. Application of law to the legislative branch....................39
VIII.Section-by-section anaylsis.....................................39

 IX. Changes in existing law.........................................43

                         I. Summary of the Bill

    The Ryan White CARE Act Amendments of 2000, S. 2311 
reauthorizes title XXVI of the Public Health Service Act to 
ensure that individuals living with HIV and AIDS receive health 
care and related support services. The legislation contains 
authorization for appropriations and programmatic changes to 
ensure the CARE Act programs respond to evolving demographic 
trends in the HIV/AIDS epidemic and advances in treatment and 
care.

1. The current four-title structure of the Ryan White Care Act is 
        maintained

    Title I: Provides emergency relief grants to eligible 
metropolitan areas (EMA's) disproportionately affected by the 
HIV epidemic to provide primary care and HIV-related support 
services to people with HIV and AIDS. One-half of the title I 
funding is distributed by formula; the remaining one-half is 
distributed competitively, based on severity of need criteria.
    Title II: Provides grants to States and territories to 
improve the quality of health care and support services for 
individuals with HIV disease and their families. The funds are 
used: to provide medical support services; to continue 
insurance payments; to provide home care services; and to 
purchase medications necessary for the care of these 
individuals. Funding for title II is distributed by formula.
    Title III(b): Supports early intervention services on an 
outpatient basis--including counseling: testing; referrals; and 
clinical, diagnostic, and other therapeutic services. This 
funding is distributed by competitive grants.
    Title IV: Provides grants for services and access to 
research for children and families. This funding is distributed 
by competitive grants.

2. Planning requirements for titles I and II are augmented to 
        strengthen service planning and priority setting

    States and title I planning councils are directed to 
consider the availability of other funding sources, such as 
Medicaid and the State Children's Health Insurance Program 
(SCHIP); the consideration of capacity development needs to 
ensure accessible and effective service delivery capacity; and 
the phased-in requirement of planning for individuals with HIV 
disease not currently in care. Homeless service providers are 
included in the list of service providers on planning councils 
and State consortia.

3. Grantees of all titles are required to institute quality management 
        programs

    At present, there is no consistent assessment of the 
quality and effectiveness of CARE Act-funded programs. The new 
provisions require grantees to develop systems of quality 
management to assess and improve the quality of primary care 
and support services, and to ensure that medical services 
provided to patients are consistent with the most recent Public 
Health Service (PHS) guidelines for the treatment of HIV 
disease and related opportunistic infections. The Secretary is 
directed to develop appropriate tools and measures to assist 
grantees in the implementation of quality management programs.

4. Organizations that contract with Ryan White grantees under titles I 
        and II must develop and maintain referral relationships with 
        points of entry to the health care system

    Referral relationship between CARE Act grantees and key 
points of entry to the health care system will facilitate 
access to and entry into care and early intervention services 
for persons newly diagnosed with HIV disease, persons unaware 
of their risk for HIV infection, and those knowledgeable of 
their HIV status but not in care.

5. Support services funded through the act are required to be health 
        care related

    In order to ensure that the focus of Ryan White services 
remains on improving health outcomes of people with HIV and 
AIDS, support services funded through the act must facilitate 
or enhance the delivery, continuity, or benefits of health 
services. Appropriate types of support services are more 
clearly outlined and the intent of support services is defined.

6. Early intervention activities are authorized services under titles I 
        and II

    At present, grantees funded under titles I and II cannot 
support early intervention services (EIS) with Ryan White 
funding. S. 2311 authorizes grantees to include certain 
services to support early intervention and provide linkages 
into care among populations at high risk for HIV infection. 
Funding will be limited to only those provider sites serving as 
key points of entry or current Ryan White-funded medical sites. 
Sites must demonstrate that funds for these services supplement 
but do not supplant existing funds, that other funds are 
unavailable, and that EIS will be provided in accordance with 
existing provisions in the act.

7. Grant awards for title I EMA's protected from precipitous declines 
        in funding

    The current hold harmless provision, which expires in the 
year 2000, is modified and extended through 2005. This update 
retains the hold harmless provision but protects EMA's from 
losing more than 2 percent of funding per fiscal year over the 
next 5-year reauthorization period, for a maximum reduction of 
10 percent over 5 years. The intent is to support stability in 
health care capacity and avert rapid shifting of funds.

8. The existing set-asides for infants, children, and women in titles I 
        and II are required to be allocated proportionately according 
        to the percentage that each group represents in the eligible 
        area

    The current set-aside for infants, children, and women in 
titles I and II does not require that a proportional amount be 
spent on each subgroup. Thus, a grantee may spend all of the 
set-aside funding on one group at the expense of another. This 
change reflects the intent of the provision that funds be set 
aside to address the health care needs of each of these 
vulnerable subpopulations.

9. A supplemental grant is created within title II to meet HIV care and 
        support needs in non-EMA areas

    There are a large number of areas within States that do not 
meet the definition of a title I EMA but that nevertheless 
experience significant numbers of people living with AIDS. This 
provision stipulates that these areas, including emerging 
communities defined as cities with between 1000 and 1999 
reported AIDS cases in the most recent 5-year period, be 
allocated 50 percent of new appropriations to address the 
growing need in these areas. States can apply for these 
supplemental awards by describing the severity of need and the 
manner in which funds are to be used.

10. The AIDS Drug Assistance Program is continued with an authorization 
        for medical management services and a supplemental grant for 
        States experiencing shortfalls in program funding

    With this reauthorization, up to 10 percent of AIDS Drug 
Assistance Program (ADAP) funds will be allowed to support 
services that directly encourage, support, and enhance 
adherence with treatment regimens, including medical 
monitoring. A supplemental grant is instituted for those States 
unable to provide full ADAP benefits to individuals living at 
or below 200 percent of the Federal poverty level (FPL).
    The Secretary is authorized to reserve 3 percent of ADAP 
appropriations for this purpose, which shall be awarded to 
those States to be used only for the purchase of therapeutics. 
States are required to match the Federal supplement at a rate 
of 1:4.

11. The minimum title II base award is increased

    The current minimum grants are increased to $200,000 for 
States with fewer nthan 90 living cases of AIDS and to $500,000 
for States with 90 or more living cases of AIDS. These 
increases will improve the base funding available to States for 
the capacity development of health system programs and 
infrastructure. The Federated States of Micronesia and the 
Republic of Palau are included as entities eligible to receive 
title II funds.

12. Capacity development grants allowed under title III

    Within title III, capacity development grants are allowed 
for underserved, low-income urban and low-income rural areas, 
to a maximum of $150,000 over a 3-year period. These grants are 
intended to help grantees expand capacity, preparedness, and 
expertise to deliver primary care, particularly in underserved 
communities where infrastructure for the provision of HIV 
services is inadequate. To accommodate the addition of a new 
grant category, the percentage of appropriations under this 
section that can be used for planning and capacity development 
grants is increased from 1 percent to 5 percent.

13. The administrative cap for the directly funded title III programs 
        is increased

    The administrative cap for TITLE II grants is raised from 
7.5 percent to 10 percent to correspond with the 10 percent cap 
on individual contractors in title I.

14. Rural and underserved areas receive preferential consideration for 
        title III grant funding applications

    Currently, rural and underserved areas are not able to 
compete successfully for planning grants and early intervention 
service grants due to the lack of infrastructure and experience 
with the Ryan White CARE Act programs. This gap in services 
available is increasingly important, as the HIV and AIDS 
epidemic extends into rural communities. A preference for these 
areas will allow program administrators to target capacity 
development and planning grants and the delivery of primary 
care services to rural communities with a growing need for HIV 
services, while not excluding urban areas from consideration 
for future grants nor reducing funding to current grants in 
urban areas.

15. Removes the requirement that title IV grantees enroll a 
        ``significant number'' of patients in research projects

    Title IV provides an important link between women, 
children, and families affected by HIV/AIDS and HIV-related 
clinical research programs. The ``significant number'' 
requirement is deleted here to remove the incentive for 
providers to inappropriately encourage or pressure patients to 
enroll in research programs. To maintain appropriate access to 
research opportunities, providers are required to develop 
better documentation of the linkages between care and research. 
The Secretary of Health and Human Services (HHS), through the 
National Institutes of Health (NIH), is also directed to 
examine the distribution and availability of HIV-related 
clinical programs for purposes of enhancing and expanding 
access to clinical trials.

16. The Secretary is directed to review administrative and program 
        support expenses for title IV, in consultation with grantees

    In order to assure that children, youth, women, and 
families have access to quality HIV-related health and support 
services and research opportunities, the Secretary is directed 
to work with title IV grantees to review expenses related to 
administrative, program support, and direct service-related 
activities.

17. IOM requested to study the Ryan White CARE Act

    The Secretary is required to contract with the Institute of 
Medicine (IOM) to complete a study, within 2 years after the 
enactment of this act, that examines changing trends in the 
HIV/AIDS epidemic and the financing and delivery of primary 
care and support services for low-income, uninsured, and 
underinsured individuals with HIV disease and to make 
recommendation regarding the most effective use of scarce 
Federal resources.
    The purpose of the study would be to examine key factors 
associated with the effective and efficient financing and 
delivery of HIV services (including the quality of services, 
health outcomes, and cost-effectiveness). The committee expects 
that the study would include examination of CARE Act financing 
of services in relation to existing public sector financing 
(e.g., Medicaid, Medicare, State programs) and private health 
coverage; general demographics (race/ethnicity, socioeconomic 
status, age, gender, geographic location) and comorbidities 
(e.g., substance use, mental health issues, homelessness) 
ofindividuals with HIV disease; regional variations in the financing 
and costs of HIV service delivery; the availability and utility of 
health outcomes measures and data for measuring quality of Ryan White-
funded service; and available epidemiological tools and data sets 
necessary for local and national resource planning and allocation 
decisions, including an assessment of implementation of HIV infection 
reporting as it impacts these factors.

              II. Background and Need for the Legislation


                         a. general background

    In March, 1990, Congress enacted the Ryan White CARE Act, 
honoring Ryan White, a young man who taught the Nation to 
respond to the HIV/AIDS epidemic with hope and action rather 
than fear. By spring, 1990, over 128,000 people had been 
diagnosed with AIDS in the United States; 78,000 had died of 
the disease. The CARE Act was reauthorized in 1996, in 
recognition of the fact that the epidemic continued to spread 
and that primary care and support services provided through the 
act were still vitally important to people with HIV and AIDS 
and the health care systems in their communities.
    In testimony before the committee, Sandra Thurman, director 
of the Office of National AIDS Policy, outlined the success of 
the CARE Act since the last reauthorization:

          The CARE Act has helped to: reduce both the frequency 
        and length of expensive inpatient hospitalizations by 
        at least 30 percent; reduce AIDS mortality by 70 
        percent; reduce mother-to-child transmission of HIV by 
        75 percent; and enhance both the length and quality of 
        life for people living with AIDS. Between 1995 and 
        1997, the Nation has seen a 30 percent decline in HIV-
        related hospitalizations--resulting in nearly 1 million 
        fewer HIV-related hospital days. This represents a 
        saving of more than $1 billion--money much more 
        effectively invested in enabling people with HIV to 
        live healthier and more productive lives. These 
        positive outcomes highlight why the Ryan White CARE Act 
        reauthorization is so imperative. We stand at a 
        critical juncture in this pandemic--and we must be sure 
        that the success of the CARE Act does not breed 
        complacency but constructive action. Increasingly, the 
        AIDS epidemic in the United States parallels the 
        pandemic globally--with more and more disenfranchised 
        people caught in the crossfire.

    Today, more than 711,000 cases of AIDS have been reported 
to the Centers for Disease Control and Prevention (CDC). More 
than 420,000 men, women, and children have died as the epidemic 
has spread over the last 20 years, to both new populations and 
new geographic areas. The epidemic continues to grow, touching 
larger numbers of people and more segments of our society. The 
heterosexual transmission rate continues to increase; women, 
teenagers, and minorities are increasingly being affected. Both 
suburban and rural areas of the country are now feeling the 
full impact of the epidemic. Those areas must now confront the 
same social, economic, and personal challenges that the 
original urban epicenters have been facing since 1981.
    The continued expansion of the AIDS epidemic in America is 
a certainty. Yet, diagnosed AIDS cases measure only a portion 
of the problem. The CDC estimates that there are between 
800,000 and 900,0000 people currently living with HIV in the 
United States, with 40,000 new infections annually. In addition 
to new infections and persons living with HIV infection who are 
not in care, individuals in treatment are living longer with 
the disease, increasing demands on the health care system. 
Hundreds of thousands of these Americans will require health 
care services for HIV-related conditions in the future. This 
ongoing crisis will severely challenge the Nation's health care 
system well into the new century.
    While a cure for HIV has eluded scientists, science has 
made significant progress in developing treatments for HIV 
disease since the last reauthorization. Therapies now exist 
that, for many people, can help slow the progression of HIV and 
allow the immune system to recover some of its ability to 
resist opportunistic infections associated with AIDS. These 
therapies, used alone and in combination, have drastically 
reduced the number of deaths from AIDS and the number of new 
AIDS cases over the last 4 years. In addition, prenatal 
administration of AZT and active outreach to and counseling of 
pregnant women have nearly eliminated the perinatal 
transmission of HIV. These developments have resulted in longer 
survival rates for people diagnosed with AIDS and have 
highlighted the importance of and need for early intervention 
and early treatment.
    Public policy must follow the expanding epidemic and 
incorporate the advances in scientific and medical information 
regarding HIV. Effective policy should also address the 
increasing service needs that the epidemic creates and 
integrate the advances in knowledge, understanding, and 
treatment of the disease. With the introduction of potent 
antiretroviral therapies, for example, patient demand for 
financial assistance has increased rapidly, precipitating a 
financial crisis in AIDS drug assistance programs across the 
country. As the epidemic, the affected communities and 
populations, and the medical response continue to change, 
public policy must be flexible enough to meet unexpected 
challenges.
    The Ryan White CARE Act was originally enacted in 1990 in 
response to the need for HIV primary care and support services. 
The major focus of public policy prior to the CARE Act was on 
research, public education, surveillance, and prevention. These 
activities are still a necessary priority and continue to 
receive attention and funding through the National Institutes 
of Health and the Centers for Disease Control and Prevention. 
In contrast, the CARE Act has helped people with HIV and AIDS 
to obtain primary care and support services to save and improve 
their lives. The CARE Act has played a critical role in the 
Nation's response to the AIDS epidemic.
    The public health burden and the economic burden of the 
AIDS epidemic have not been reduced since the CARE Act was 
passed. While the CARE Act has been a lifeline of support to 
many people, need for services continues to grow faster than 
the resources available. In fact, the steady expansion and 
changed demographics of the epidemic and the increasing 
survival rates for people living with AIDS have increased the 
stress on local health care systems in some areas. This strain 
is felt both in urban centers where the epidemic continues to 
rage, and in smaller cities and rural areas, where the epidemic 
is expanding rapidly.
    In response, the committee ordered favorably reported S. 
2311, the Ryan White CARE Act Amendments of 2000. This 
reauthorization provides accessible HIV primary care and 
support services to the increasing number of people who need 
them. Ryan White-funded, community-based, neighborhood health 
clinics and social service agencies have helped alleviate the 
impact on acute care centers, where much of the AIDS care was 
originally provided. Furthermore, the CARE Act provides 
reimbursement for services that went unreimbursed for too long 
and threatened the stability of the Nation's health care 
system. With Federal assistance, Americans who might otherwise 
become ill and burden our already overcrowded hospital 
emergency rooms can remain healthy, working, and productive 
members of our society.

                     b. hiv disease in urban areas

    HIV and AIDS continue to place a heavy burden on the 
citizens and health care systems of the Nation's metropolitan 
areas. Currently, 51 eligible metropolitan areas (EMA's) 
receive title I emergency relief funding, compared to only 16 
when the CARE Act was originally passed. Seventy-five percent 
of the new AIDS diagnoses are reported in the current EMA's. In 
addition, many non-EMA metropolitan areas have AIDS caseloads 
that fall just short of the 2000 caseloads needed for title I 
eligibility. These are the new epicenters where the AIDS 
epidemic is seriously straining the local health care 
infrastructure and negatively affecting the health of whole 
communities. These urban areas must address not only the 
epidemic, but also other co-occurring conditions including 
tuberculosis, homelessness, substance abuse, mental illness, 
and other sexually transmitted diseases (STD's). These 
conditions vastly complicate the treatment of HIV/AIDS and 
necessitate an array of support services to sustain and enhance 
medical care.
    HIV-specific problems and general health care delivery 
issues continue to challenge public health officials. Municipal 
hospitals bear a disproportionate share of the AIDS burden. 
People with HIV disease are drawn to these urban facilities, 
even as other pressures reduce the ability of these facilities 
to respond to the needs of people with HIV. Private hospitals, 
for example, continue to cut back on charity care, and the 
large public hospitals are now forced to care for a growing 
population of AIDS patients and people with HIV as they 
continue to serve the neediest and struggle to maintain 
financial viability.

          c. hiv in rural areas and smaller metropolitan areas

    While the AIDS epidemic continues in urban areas of the 
country, the number of new cases diagnosed in small urban 
centers and suburban and rural areas has reached alarming 
levels. According to the HIV/AIDS surveillance reports 
published by the Centers for Disease Control and Prevention, 
the proportion of all AIDS cases reported in areas with under 
500,000 population has grown to nearly 16 percent, over 111,000 
cases. Of these, 40,000 cases, or 6 percent of cases, were 
reported in rural areas with less than 50,000 in population. As 
the epidemic has expanded into rural, suburban, and small urban 
areas, local health care systems have often been unable to meet 
the growing demand for medical and support services.
    The problems created by HIV disease in rural areas are 
often similar to those experienced in large cities; however, 
these problems are exacerbated by poor health care 
infrastructure and limited experience with HIV/AIDS care. The 
lack of trained primary care providers, absence of long-term 
care facilities, scarcity of resources, and a scattered 
population are additional obstacles that may be faced in 
developing coordinated outpatient services programs. Small 
rural hospitals and other rural providers may not be able to 
provide the highly specialized services often required by some 
persons with HIV disease. When primary care services are 
unavailable, individuals and families must travel long 
distances to receive necessary care. Furthermore, rural health 
care systems must address not only the epidemic, but also other 
co-occurring conditions including homelessness, tuberculosis, 
substance abuse, mental illness, and other STD's.
    In testifying before the committee, Dr. Chris Grace, who 
provides medical services to people with HIV/AIDS in Vermont 
through Ryan White funding, summed up the challenges facing 
rural people with HIV:

          HIV infection is a complex medical, psycho-social, 
        and economic illness. Numerous barriers impede the 
        provision of care to persons with this illness in rural 
        areas. Because of these barriers, patients may not seek 
        health care or may be forced to travel long distances 
        for expert care. Delays in seeking care could increase 
        the risk of complications, hospitalizations, and death. 
        Barriers to accessing HIV health care include: the 
        complexities of HIV care, long travel distances, 
        confidentiality, limited health insurance, limited 
        psychiatric and substance abuse care, [and] limited 
        mass transportation.

    Some States have been able to adapt to the challenges and 
have developed care systems that can better reach the rural and 
suburban populations in need of services. Many States, however, 
struggle to meet the health care needs of rural citizens and 
low-income citizens, and the additional challenges of HIV and 
AIDS have further stressed typically weak rural health care 
systems. The demand and need for assistance in these areas will 
only continue to rise in the coming years.

                d. the epidemic in communities of color

    The AIDS epidemic has dealt a particularly severe blow to 
communities of color which represent 67 percent of new AIDS 
cases reported from June, 1998, to June, 1999. The extent of 
the disproportionate impact of the epidemic on racial and 
ethnic communities can be seen most dramatically when the 
percentage of AIDS cases in specific communities of color is 
compared with their percentage representation in United States 
population census. African-Americans represented 45 percent of 
all AIDS cases but only 12 percent of the United States 
population in 1998. Hispanics represented 20 percent of cases 
and only 13 percent of United States population for the same 
year. When we examine new cases of HIV infection, we find that 
74 percent of new HIV infections through June, 1999, are in 
communities of color. Of these, African-Americans account for 
54 percent of new infections and Hispanics 19 percent. Women 
account for 30 percent of all new HIV infections, and 82 
percent of these new infections are in women of color. HIV 
remains the leading cause of death among African-Americans 
between the ages of 29 and 44, and the third leading cause of 
death among Hispanics in this age group.
    The impact of HIV and AIDS on minority communities is 
compounded in rural and underserved areas, like the rural 
South, where health care infrastructure is limited. The 
existing health care systems are often inaccessible to minority 
populations, resulting in limited or no access to treatment and 
care services. For example, Native Americans and American 
Indians are eligible for Ryan White services through State and 
Federal citizenship and yet often find it difficult to access 
services that are geographically distant or that are poorly 
coordinated with the Indian Health Service provider. These 
limitations translate into a greater disease burden and poorer 
health outcomes in the very communities least able to address 
their health care needs. The need for assistance and services 
to meet the needs of these affected populations has been 
growing rapidly as the epidemic has established itself in 
minority communities across the Nation.

               e. children and families with hiv disease

    HIV is increasingly spread through unprotected heterosexual 
contact. As HIV is spread through unprotected heterosexual sex, 
and through intravenous drug users and their sexual partners, 
entire families can become infected. These families will need a 
full range of HIV health care and support services. As of June, 
1999, nearly 9,000 children had received an AIDS diagnosis. The 
number of cases of AIDS among women has also been steadily 
rising. While women currently represent 17 percent of 
cumulative AIDS cases, the CDC estimates that women make up 30 
percent of all new reported AIDS cases in the last year. Thus, 
as HIV reaches into new communities, the women, children, and 
families are often hit the hardest by this epidemic.
    Many families find that obtaining access to essential 
services can be a complicated and frustrating process. Women 
have the most limited access to health care of any group 
infected with HIV, and they frequently experience difficulty 
advocating effectively for their children. The availability of 
health care and support services for HIV-infected women and 
children ``under one roof'' is critical. Case 
managementservices can exemplify the family-centered services the CARE 
Act can and should provide. The committee heard eloquent testimony, 
from a woman living with HIV, about how CARE Act-funded services have 
helped her maintain her health and care for her children. This 
courageous woman explained how she thought being HIV-positive was a 
death sentence and how her case manager has helped her manage the 
responsibilities of being a parent and being HIV-positive. As she said:

          * * * [W]ere it not for this wonderful bill called 
        Ryan White, Fenway [clinic] could not have been there 
        for me and offered the services that have kept my life 
        going these past 9 years.

                        f. the need for s. 2311

    The CARE Act was originally passed in 1990 and reauthorized 
in 1996 to address some of the most pressing problems in health 
services delivery raised by the HIV epidemic. Today, S. 2311 
represents the continuation of that comprehensive approach. The 
necessity of the Ryan White CARE Act programs is clear, as more 
people live longer with this disease and the planning, the 
adequate funding, and the delivery of HIV-related health care 
services rise in importance. Because our Nation's health care 
system was totally unprepared for the magnitude of the AIDS and 
HIV epidemic, the planning, funding, and capacity required to 
mount an appropriate response lagged.
    The Ryan White CARE Act of 1990 was designed and passed 
with near unanimity in the Senate to address those capacity 
shortfalls. Two national commissions recommended and supported 
the principles underlying the CARE Act as the most effective 
means to address the burgeoning needs of people living with 
HIV/AIDS. A recent report from the U.S. General Accounting 
Office (GAO) found that the CARE Act continues to be the most 
effective means of getting care to people with HIV and AIDS 
most in need of assistance. The CARE Act is serving high 
numbers of minorities, the poor, and the uninsured. CARE Act 
providers also see a greater number of women than do other, 
non-Ryan White providers, and at higher rates than the 
representation of women in the AIDS population. This study 
found that the majority of CARE Act funds are used for direct 
medical services, with the remaining funds going to services 
that support medical services, such as case management. CARE 
Act providers were also well within their administrative 
limits. Critically, the GAO found that CARE Act funding has 
been able to respond to changes and evolving trends in the 
epidemic, in particular to meet the demands of rapidly changing 
medical treatments and disease progression. The CARE Act, its 
providers, and its administrators have been successful in 
realizing the goal of getting desperately needed, high-quality 
services to those most in need.
    In considering reauthorization of the CARE Act, the 
committee has received input from a wide variety of sources. 
Dr. David Satcher, Surgeon General of the United States, and 
Sandra Thurman, Director of the White House Office of National 
AIDS Policy, testified before the committee that the structure 
of the CARE Act has worked well over the last 10 years and that 
it provides a solid basis on which to build an effective 
response to the changing epidemic over the next 5 years. 
National AIDS organizations, including the AIDS Action Council, 
the CAEAR Coalition, the National Association of State and 
Territorial AIDS Directors, AIDS Alliance, the National 
Association of People with AIDS, the National Minority AIDS 
Coalition, and National Organizations Responding to AIDS (a 
consortium of 175 organizations) also provided valuable input. 
These groups, as well as mayors; governors; Federal, State, and 
local public health officials; CARE Act-funded service 
providers; and, most important, people living with HIV disease, 
are all in agreement that the CARE Act has been a success and a 
lifeline of support to hundreds of thousands of people.
    The committee heard testimony from individuals and 
organizations which supported the existing, 4-title structure 
of the act, its emphasis and reliance upon local planning and 
decision making, and its flexibility in meeting the needs of 
people living with HIV. They also testified that the need for 
emergency relief remains as urgent today as it was in 1990. 
While the CARE Act has provided a lifeline of support and 
relieved some of the strain, it has not stopped the epidemic 
from dangerously taxing already overburdened health care 
delivery systems.
    The Ryan White CARE Act Amendments of 2000 has preserved 
and improved upon the best aspects of the original CARE Act. At 
the same time, in recognition of the changes that have taken 
place over the last 5 years, the committee has also made some 
necessary alterations. To address the geographic expansion of 
this epidemic, this reauthorization continues the efforts made 
during the last reauthorization to direct resources and 
services to areas that are particularly underserved, including 
rural areas and metropolitan areas with significant AIDS cases 
that are not eligible for title I funding. There is also a new 
focus on strengthening the capacity of rural and minority 
communities to address the epidemic. Furthermore, the ADAP 
program has been strengthened to assist States that are 
struggling to provide medications to all of their needy 
clients. The committee has also sought to strengthen the 
ability of local communities, States, and service organizations 
to reach those communities and populations that have been 
historically most underserved, as well as those that are 
experiencing rapid increases in HIV infection and AIDS case 
counts but that have not been brought into the care system 
developed under Ryan White. The purpose of these changes is to 
ensure a strong system of health care delivery and access to 
therapies commensurate with evolving needs.

             III. Legislative History and Committee Action

    S. 2311 was introduced on March 29, 2000, by Senators 
Jeffords, Kennedy, Frist, Hatch, Dodd, Enzi, Harkin, Mikulski, 
Bingaman, Wellstone, Reed, Biden, and Durbin. The bill was 
referred to the Committee on Health, Education, Labor, and 
Pensions. In the executive session of the committee, held on 
Wednesday, April 12, 2000, S. 2311 was brought up for 
consideration. The bill was unanimously adopted and favorably 
reported to the full Senate.

                          IV. Committee Views


                                 part a

    Through part A of S. 2311, the committee intends that 
emergency relief continue to Eligible Metropolitan Areas 
(EMA's) that have been severely impacted by the HIV epidemic. 
Financial relief to EMA's will ensure that health care 
institutions and providers of essential, health-related, 
supportive services will be able to provide services to 
uninsured and underinsured, low-income individuals affected by 
the AIDS epidemic. The committee recognizes that the impact of 
HIV/AIDS is often exacerbated by other medical and social 
factors such as tuberculosis, sexually transmitted diseases, 
substance abuse, homelessness, and severe mental illness, which 
pose serious obstacles in the treatment of HIV/AIDS. The 
committee also recognizes and affirms in S. 2311 that local 
planning, priority setting, and funding allocation processes 
are effective mechanisms to address the variations in the 
impact of the AIDS epidemic among different communities and 
populations, and that shifting trends in the local epidemic, 
disparities in health care access and outcomes, and the need 
for capacity development within the HIV health care 
infrastructures can best be addressed through a local process.
    The committee acknowledges the need to enhance further 
planning and priority-setting processes within the title I 
program. The committee supports the implementation of quality 
management programs that can assist grantees to better document 
the impact of CARE Act programs and lead to improvements inthe 
quality of care and services provided through Ryan White funding. 
Similarly, the committee believes that requiring CARE Act providers to 
develop appropriate and meaningful relationships with key points of 
entry for HIV-positive individuals into the health care system will 
increase the numbers of people in care. The committee also wants CARE 
Act providers to work actively to bring into and retain in care those 
individuals who are unaware of their HIV status and those who are 
knowledgeable of their status but not receiving services. The guidance 
provided by the committee is intended to support and strengthen the 
advisory capacity of planning councils, the ability of grantees to 
administer CARE Act funds to ensure quality care, and the coordination 
of resources with other payers. The committee reaffirms the Secretary's 
responsibility in providing needed guidance and tools to assist EMA's 
in carrying out their mandate.
    The committee expects that EMAs will provide services to 
American Indian and Native American peoples. Native Americans 
and American Indians are eligible for Ryan White services 
through State and Federal citizenship. The committee supports 
better coordination of Ryan White services for Native Americans 
and American Indians in order that they may realize the full 
potential of HIV/AIDS-related primary care and support services 
provided through CARE Act funding.
    These modifications will support closing the gap in 
disparities of access to HIV services and HIV-related health 
outcomes and improve planning, allocation, coordination, and 
quality management activities. Furthermore, these changes 
support capacity development to reach underserved populations 
and provide EMA's with the skills and resources to address the 
challenges of a shifting HIV/AIDS epidemic.

I. Section 2602. Administration and Planning Council

            Housing and homeless service providers
    The committee endorses the planning council mechanism, 
including its advisory structure and duties, in its 
effectiveness in carrying out the responsibilities of 
reflecting and representing the local HIV/AIDS epidemic. The 
committee provides for the inclusion of housing and homeless 
service providers within the category of ``social service 
providers'' to acknowledge the importance of housing and 
homeless support services to treatment adherence and quality of 
health care, as these impact effective care for HIV disease. It 
is the intent of the committee that the category of housing and 
homeless service providers include grantees receiving Federal, 
State, or local housing and/or homeless funds, including U.S. 
Department of Housing and Urban Development (HUD) McKinney 
Homeless Assistance grant and Housing Opportunities for Persons 
With AIDS (HOPWA) funds. Such participation acknowledges the 
importance of coordination of these processes in meeting 
funders' principal mission of addressing the multiple and 
complex needs of persons with HIV disease.
    The committee recognizes that homeless persons comprise a 
medically underserved population that experiences disparities 
in health services. The prevalence of HIV/AIDS is considerably 
higher among homeless people than in the general population. 
Limited access to medical care severely restricts the access of 
homeless people to HIV/AIDS prevention, risk reduction, 
treatment, and care. Accordingly, the committee construes terms 
used throughout the act, such as ``special population,'' 
``traditionally underserved,'' ``historically underserved,'' 
``disproportionately affected,'' and ``affected subgroup 
experiencing disparities in health services'' to include the 
homeless population.
            Membership considerations
    The committee places importance on the inclusion of 
representation from historically underserved, low-income, urban 
and rural areas and populations within the EMA. Planning 
councils should continue to identify and include in council 
activities specific groups within underserved communities that 
are experiencing increased infections, as documented in State 
and local HIV/AIDS surveillance and needs assessment data. By 
recruiting consumers and organizations that reflect the special 
needs of these populations, such as women, people of color, 
Native Americans, youth, homeless persons, rural residents, and 
uninsured/underinsured persons, the committee believes that the 
planning council will improve its ability to plan, prioritize, 
and allocate funds in a more reflective and informed manner. 
Other populations, such as persons with co-occurring 
conditions--defined as other coexisting diseases or 
environmental factors--should have representation on planning 
councils to ensure that planning council processes address the 
difficulties related to health disparities and access to and 
adherence with HIV treatment. Where applicable, such membership 
should include representatives from other titles of the CARE 
Act in order to ensure that the membership processes adequately 
reflect the demographics of the local epidemic.
            Funding allocations based on HIV/AIDS demographics
    The reauthorization bill reflects the committee position 
that priority setting and funding allocation decisions should 
be based on the size and demographic characteristics of the 
populations with HIV disease in the eligible area. Planning, 
priority setting, and funding allocation processes must take 
into account shifts in the local HIV/AIDS epidemic, existing 
health HIV-related disparities, and resulting negative health 
outcomes.
    The bill further requests that the Secretary work with 
title I grant recipients and providers to establish 
epidemiologic measures and tools for use by EMA's in 
identifying the number of individuals with HIV infection, 
especially those who are not in care. The committee recognizes 
the difficulty grantees may experience in identifying persons 
with HIV infection not in care. The committee does not require 
EMA's to establish priorities for the allocation of funds for 
persons not in care, until the Secretary is able to provide 
such advice and technical assistance. EMA's should continue 
such efforts as they have developed in this area for 
establishing priorities of funds for this population. The 
committee is aware that many EMA's do not have HIV reporting in 
place and may be further disadvantaged in implementing the 
requirements under this section, even with the additional tools 
and measures provided by the Secretary. The committee strongly 
encourages that the means to report the incidence of HIV be in 
place as soon as possible, and the Secretary should take these 
differences into account in implementing these requirements. 
The committee expects that those grantees already considering 
people not in care should continue to do so, adopting where 
relevant the methods developed by the Secretary.
            Capacity development
    The committee recognizes the need for capacity development 
planning, in order to assist local communities in developing 
HIV primary care services and effective provider networks. Such 
capacity development should target the structural, 
administrative, and financial management systems that enhance 
the ability of underserved communities to respond to the need 
for HIV primary health care, particularly in those underserved 
and minority communities where infrastructure for the provision 
of HIV services is inadequate. Capacity development includes: 
(1) activities that establish and enhance core management 
functions (for example, accounting and information systems, 
planning, and evaluation); (2) establishment and enhancement of 
program development functions (for example, personnel and staff 
competencies and HIV primary care network development); and (3) 
addition of new services (for example, the purchase of 
equipment and minor upgrading of facilities). The committee 
does not intend funds to be used for construction or 
significant remodeling of facilities.
    The committee intends that these capacity development 
services meet the criteria of expanding thecapacity, 
preparedness, and expertise of grantees to deliver HIV-related primary 
care and health-related supportive services to underserved populations. 
Planning councils should prioritize HIV primary care services and 
network infrastructure development through their needs assessment and 
planning process. The committee recognizes that strengthening capacity 
must be done in a local context.
            Comprehensive plan
    The comprehensive service delivery plan is an effective way 
to demonstrate the organization and delivery of CARE Act 
services based upon the planning, priority setting, and funding 
allocations processes conducted by the planning council. The 
intent of the legislation is also to have the additional 
factors reflected in the plan. Those factors include 
disparities in access to medical and health-related support 
services by specific subpopulations; the needs of persons with 
HIV not in care; capacity development needs; and quality of HIV 
primary care and health-related supportive services. Both the 
planning process and the resulting plan should include the 
participation of, and address the needs of, populations and 
subpopulations living with HIV and AIDS.
    The committee also realizes that, in the planning process, 
planning councils may not currently utilize information 
regarding the types of specialized services needed to bring 
vulnerable subpopulations into care and to retain them in care. 
The specific needs of populations or subgroups identified--such 
as communities of color, persons who are underinsured or 
uninsured, women, persons with co-occurring conditions, youth, 
homeless persons, or persons who live in rural areas within the 
eligible area--should be specifically addressed. To the extent 
that these populations are underserved in the eligible area, 
the Secretary should assist the planning councils in 
identifying the information needed to plan and prioritize 
resources for these populations.

II. Section 2603. Types and distribution of grants

            Formula funding allocation--hold harmless
    The committee intends to continue to extend the hold 
harmless provision to ensure that the amount of a formula grant 
will not be less than 98 percent of the amount the eligible 
area received for the previous fiscal year. An eligible area 
will be allowed to lose no more than 2 percent annually of its 
formula grant, for a maximum of 10 percent over the 5-year 
reauthorization period. The hold harmless provision reflects 
the committee's concern that essential primary care and support 
services are not compromised by short-term fluctuations in AIDS 
case counts.

III. Section 2604. Use of amounts

            Support service required to be health care related
    The committee wishes to stress the primary importance of 
CARE Act funds in meeting the health care needs of persons and 
families with HIV disease. The reauthorization language 
requires support services provided through CARE Act funds to be 
health care related. EMA's should ensure that support services 
meet the objective of increasing access to health care and 
ongoing adherence with primary care needs. The committee 
reaffirms the critical relationship between support service 
provision and positive health outcomes. The committee does not 
establish the level of documentation required to meet this 
objective and expects the Secretary to provide additional 
guidance to EMA's regarding the assessment of relationships 
between health and related supportive services in achieving 
improved access to and stability in health care access.
            Early intervention services
    The reauthorization language authorizes early intervention 
services as eligible services under part A under certain 
limited circumstances. The committee intends to allow grantees 
to provide certain early intervention services, such as HIV 
counseling, testing, and referral services, to individuals at 
high risk for HIV infection in accordance with planning council 
priority setting and funding allocation processes. The language 
references the specified early intervention services under part 
C, section 2651(b)(2), and the provision of certain counseling 
services under section 2662 of the CARE Act. In addition, the 
language describes the types of organizations that may provide 
early intervention services as those that provide other HIV-
related services through parts A or C, or are key points of 
access to the health care system for individuals at high risk 
for HIV.
    This provision is solely for the purpose of expanding the 
scope of primary care services to include HIV testing, 
counseling, and referral. The committee recognizes the 
importance of early intervention services in increasing direct 
access to medical services through established relations with a 
broad network of health care entry points and HIV medical 
providers that serve as critical entry points for medical 
services for uninsured, and underinsured, low-income, and rural 
communities. The committee specifically intends that funds not 
be used for HIV surveillance functions or primary prevention, 
including those activities that are supported through the 
Centers for Disease Control and Prevention (CDC). Further, the 
committee intends that such services need to be provided 
according to guidelines established by the CDC and according to 
the laws and administrative regulations of State and local 
governments. The committee expects that the Secretary, working 
with grantees and the public health community, will provide 
guidance to establish the appropriate parameters for the use of 
CARE Act funds for these purposes and to coordinate these 
activities with existing early intervention services.
    The bill would allow use of funds for such early 
intervention services only if no other Federal, State, or local 
funds are available for those purposes. The committee 
recognizes that other funding sources exist for these services 
and expects all grantees to seek out and use these funds to the 
extent they are reasonably available.
            Women, infants, and children set-aside
    The committee wishes to clarify that the set-aside for 
infants, children, and women with HIV disease be allocated 
proportionally, based on the percentage of the local HIV-
infected population that each group represents. The committee 
is aware of the rising incidence of HIV in youth and in women 
of color, and it recognizes the unique challenges facing these 
groups regarding access and sustaining primary care and support 
services for HIV and AIDS. The intent of this legislation is to 
increase the availability of primary care and health-related 
supportive services for each of these groups. The committee 
wishes to emphasize the importance of these increasing trends 
and requests the Secretary to provide guidance to planning 
councils and grantees in planning and providing services to 
these unique populations.
            Quality management program
    The committee recognizes the importance of having CARE Act 
grantees assure that quality services are provided to people 
with HIV and that quality management activities are conducted 
on an ongoing basis. Quality management programs are intended 
to serve grantees in evaluating and improving the quality of 
primary care and health-related supportive services provided 
under this act. The quality management program should 
accomplish a threefold purpose: (1) assist direct service 
medical providers funded through the CARE Act in assuring that 
funded services adhere to established HIV clinical practices 
and Public Health Service (PHS) guidelines; (2) ensure that 
strategies for improvements to quality medical care include 
vital health-related supportive services in achieving 
appropriate access to and adherence with HIV medical care; and 
(3)ensure that available demographic, clinical, and health care 
utilization information is used to monitor the spectrum of HIV-related 
illnesses and trends in the local epidemic.
    The committee expects the Secretary to provide EMA's with 
guidance and technical assistance to establish quality 
management programs with direct medical services providers 
funded through the CARE Act. Such programs are generally 
available and implemented in clinical practice environments. 
The additional guidance and technical assistance provided 
should assist grantees to develop performance measures on 
specific client health outcomes desired, cost-effectiveness of 
services provided by the CARE Act, and health care status 
indicators of overall improvement in the delivery of 
appropriate health care services to individuals with HIV 
disease. The committee expects that EMA's will communicate and 
coordinate CARE Act requirements with other payers to the 
extent possible to ensure consistency in quality management 
activities.
    The Secretary may consider the need for guidance to EMA's 
on what mechanisms should be in place to ensure that medical 
services provided through Ryan White funds, whether directly or 
through contractual agreement, have established procedures and 
protocols in place to monitor and assess quality of care based 
on established PHS guidelines. Where services are provided 
through contractual agreements, the EMA should incorporate into 
the contract the requirement that subcontractors have a quality 
measurement program in place.
    The committee places responsibility on the Secretary to 
ensure that PHS guidelines, as well as broader measures of the 
population characteristics and trends in use in HIV services, 
are communicated to all CARE Act grantees and subgrantees. This 
information, the committee believes, will assist grantees in 
ensuring the highest quality of HIV care among CARE Act 
providers.
    The committee intends that the Secretary provide 
clarification and guidance regarding the distinction between 
use of CARE Act funds for such program expenditures that are 
covered as either planning and evaluation or program support 
costs. It is not the intent of the committee to reassign 
current program support costs or clinical quality programs to 
new cost areas, if they are an integral part of an EMA's 
current quality management efforts. Program support costs are 
described as any expenditure related to the delivering or 
receiving of health services supported by CARE Act funds. As 
applied to the clinical quality programs, these costs include, 
but are not limited to, activities such as chart review, peer-
to-peer review activities, data collection to measure health 
indicators or outcomes, or other types of activities related to 
the development or implementation of a clinical quality 
improvement program. Planning and evaluation costs are related 
to the collection and analysis of system and process indicators 
for purposes of determining the impact and effectiveness of 
funded health-related support services in providing access to 
and support of individuals and communities within the health 
delivery system.
            Medicaid and SCHIP coordination with CARE Act
    The reauthorization language recognizes the availability of 
other health benefit programs, such as the State Medicaid and 
Children's Health Insurance Program (SCHIP). Planning councils 
should consider and coordinate these alternative funding 
sources in planning for Ryan White CARE Act services. 
Furthermore, the committee expects planning councils and 
grantees to account for the needs of all persons with HIV in 
assessing the types and levels of services to be provided 
within a given jurisdiction.
    The committee also recognizes the importance of the 
Statewide Coordinated Statement of Need (SCSN) process in 
coordinating HIV/AIDS care and support activities across the 
State, including areas that fall within EMA's. The SCSN should 
inform and support the activities of the planning council, 
especially in the coordination of funding sources for HIV 
primary care and support services. CARE Act funds should not be 
used to provide items or services for which payment has already 
been made or reasonably can be expected to be made by third-
party payers, including Medicaid, Medicare, SCHIP, and or other 
State or local entitlement programs, prepaid health plans, or 
private insurance. Funds allocated by this Act shall be 
available to supplement services to patients who are Medicaid 
beneficiaries for services not covered by Medicaid. CARE Act 
grantees should ensure that eligible individuals are 
expeditiously enrolled in Medicaid and that CARE Act funds are 
not used to pay for any Medicaid- or SCHIP-covered services for 
Medicaid or SCHIP enrollees. Both the comprehensive plan and 
the statewide coordinated statement of need can assist the 
planning council in coordinating the various Federal, State and 
local funding sources.
            Clarification on use of planning council administrative 
                    costs
    The committee also wishes to clarify what activities are 
allowable under planning council administrative costs. Planning 
council administration funds can be used for training and 
technical assistance activities for planning council members 
regarding internal and external governing and planning 
processes. In addition, planning council administration funds 
can be used to support consumer-related transportation and 
other related expenses that will enable persons with HIV to 
participate fully and contribute as planning council members.
            Grantee health care relationships
    The committee recognizes that many individuals with HIV/
AIDS will pass through key points of entry into the medical 
system without receiving referral to HIV care services. In 
order to identify and refer those individuals to HIV primary 
care and health-related supportive services, and thus improve 
access to care for persons not currently in the system, the 
committee expects grantees to establish relationships with 
entities that often serve as these key points of entry into the 
medical system for populations at high risk for HIV infection. 
Such key points of entry can include, but are not limited to, 
emergency rooms, community health centers, substance treatment 
programs, detoxification centers, mental health treatment 
programs, adult and juvenile detention centers, correctional 
facilities, soup kitchens, sexually transmitted disease 
clinics, HIV counseling and testing sites, homeless shelters, 
and transitional housing and homeless outreach programs.
    In encouraging the development of key points of entry 
relationships, the EMA should: (1) evaluate what beneficial 
relationships are in place and those that are needed to 
strengthen referral of individuals from key points of entry 
into HIV primary care sites; and (2) assist subgrantees in the 
development of these relationships. The committee allows for 
the use of CARE Act funds to support early intervention 
services within such sites to facilitate the identification, 
counseling, and referral of individuals with HIV/AIDS into the 
HIV care system, as defined elsewhere in the report.

                                 part b

    The committee believes that the current structure of part B 
has enabled States to develop HIV- and AIDS-related primary 
care infrastructure in areas of greatest need and increasingly 
in areas where the epidemic is growing. Part B provides an 
effective means for ensuring that CARE Act funds reach all 
populations in need of HIV/AIDS health care services. Changes 
made in the reauthorization language are not intended to 
restrict States' efforts to direct needed resources to specific 
areas. Rather, it is the intent of the committee to provide to 
States that lack sufficient resources an opportunity to reduce 
restrictions on ADAP benefits while holding States responsible 
for an expected level of effort in utilizing available local 
and State resources to meet local needs. In addition, changes 
in the reauthorization address the fact that a number of States 
have emerging communities in need of targeted assistance. These 
communities have significant HIV/AIDS caseloads which, 
nevertheless, do not qualify for emergency assistance under 
part A of the CARE Act. The issue of geographic equitywithin 
the State was one that the committee aimed to address in 
reauthorization. The committee recognizes that States without EMA's 
often have less funding to support the provision of a full array of HIV 
care services than States with a part A grant.
    In establishing the legislative changes for part B, the 
committee also intended to assist States in developing 
planning, priority setting, and funding allocation tools. The 
reauthorization allows States to fund capacity development 
activities to assist areas with extremely limited HIV care 
infrastructure. Additional flexibility is given to States to 
develop quality management programs for the monitoring and 
improvement of CARE Act-funded activities. The committee 
intends that States have adequate time, resources, and guidance 
in implementing these activities. The committee believes that 
an increase in the minimum grants for services available to 
States will help to improve the foundation of care services. 
Specific United States territories were given title II 
eligibility in order to correct oversights in the previous CARE 
Act reauthorization which omitted them from lists of eligible 
entities. It is the committee's belief that these changes will 
enhance States' and territories' ability to distribute CARE Act 
funds to those areas where a disproportionate need exists.
    The committee expects that States funded under Ryan White 
will provide services to American Indian and Native American 
peoples. Native Americans and American Indians are eligible for 
Ryan White services through State and Federal citizenship. The 
committee supports better coordination of Ryan White services 
for Native Americans and American Indians in order that they 
may realize the full potential of HIV/AIDS-related primary care 
and support services provided through CARE Act funding.

I. Section 2612. General use of funds

            Primary purpose of CARE Act services in achieving health 
                    care access
    The committee stresses that the primary purpose of CARE Act 
funds is to address the health care needs of persons and 
families with HIV disease. To support this goal, the 
reauthorization language requires support services funded 
through the CARE Act to be health care related. States should 
assure that eligible supportive services meet the objective of 
increasing access to health care and ongoing adherence with 
primary care needs. The legislation requires States to have a 
mechanism in place to ensure that supportive services provided 
through Ryan White funds, whether directly or through 
contractual agreement, accomplish the objective of increasing 
access to health care and ongoing adherence with primary care 
needs. The committee reaffirms the relationship between support 
service provision and positive health outcomes. The committee 
does not establish the level of documentation required to meet 
this objective and expects the Secretary to provide additional 
guidance to States regarding the assessment of relationships 
between health and related supportive services in achieving 
improved access to and stability in health care access.
            Early intervention services
    The reauthorization language authorizes early intervention 
services as eligible services under part B under certain 
limited circumstances. The committee intends to allow grantees 
to provide certain early intervention services, such as HIV 
counseling, testing, and referral services, to individuals at 
high risk for HIV infection in accordance with statewide 
planning and regional consortia planning activities. The 
language references the specified early intervention services 
under part C, section 2651(b)(2) and the provision of certain 
counseling services under section 2662 of the CARE Act. In 
addition, the language describes the types of organizations 
that may provide early intervention services as those that 
provide other HIV-related services through parts B or C, or are 
points of access to the health care system for individuals at 
high risk for HIV.
    This provision is solely for the purpose of expanding the 
scope of primary care services to include HIV testing, 
counseling, and referral. The committee recognizes the 
importance of early intervention services in increasing direct 
access to medical services through established relations with a 
broad network of health care entry points and HIV medical 
providers that serve as critical entry points for medical 
services for uninsured, and underinsured, low-income, and rural 
communities. The committee specifically intends that funds not 
be used for HIV surveillance functions or primary prevention, 
including those activities which are supported through the 
Centers for Disease Control and Prevention (CDC). Further, the 
committee intends that such services need to be provided 
according to guidelines established by the CDC and according to 
the laws and administrative regulations of State and local 
governments. The committee expects that the Secretary, working 
with grantees and the public health community, will provide 
guidance to establish the appropriate parameters for the use of 
CARE Act funds for these purposes and to coordinate these 
activities with existing early intervention services.
    The bill would allow use of funds for such early 
intervention services only if no other Federal, State, or local 
funds are available for those purposes. The committee intends 
that grantees should demonstrate that CARE Act funds will not 
be used to supplant other funds supporting early intervention 
services. The committee recognizes that other funding sources 
may exist for these services and expects all grantees to seek 
out and use these funds to the extent they are reasonably 
available.

II. Section 2616. Provision of treatments

            Expansion of ADAP to include medical monitoring services
    The primary purpose of medical monitoring services is to 
ensure that individuals with HIV/AIDS gain access to and 
utilize lifesaving therapeutics. The committee expands eligible 
services and expenses under ADAP to include those services that 
support increased access to and adherence with antiretroviral 
therapy, such as treatment adherence counseling, medical 
monitoring, and laboratory testing. Medical monitoring 
activities are essential components of the provision of 
treatments, and States are encouraged to expand their ADAP's to 
include these activities, as they directly relate to 
appropriate use of medications. However, the committee 
explicitly intends that States should not fund these services 
where such funding will reduce the availability of ADAP 
medications on the State formulary or force the State to 
establish more exclusive financial and medical eligibility.
    In order for States to utilize ADAP funds for medical 
monitoring of HIV treatment, the Secretary must ensure that 
eligibility restrictions have been resolved within a given 
State and that the State's formulary covers all essential HIV-
related treatments. The committee expects the Secretary to 
determine the criteria for eligibility, based on the 
characteristics of the ADAP program within the applicant State, 
including the State's ability to maintain current levels of 
effort in its ADAP funding, as well as its ability to continue 
current medical eligibility and poverty level standards in the 
program. A maximum of 10 percent of the ADAP budget can be 
spent on medical monitoring activities under this section. 
However, the committee wishes to emphasize that the primary 
purpose of ADAP funds is in providing antiretroviral 
medications and medications for treatment of diseases 
associated with AIDS topeople living with HIV. The Secretary 
must ensure that States do not supplant funded services supported with 
other Federal and State resources. In addition, the committee believes 
that States should administer funds under this section in a manner that 
is consistent with other ADAP services funded through this section, 
including consistent eligibility criteria, quality management 
activities, and administrative procedures.
            ADAP supplemental fund
    The committee establishes a new supplemental award, funded 
through a 3 percent set aside of the existing authorization for 
the ADAP program, to assist States in expanding access to 
appropriate HIV/AIDS therapeutics to low-income individuals 
with HIV/AIDS. The committee intends for the Secretary to limit 
the use of this new supplemental fund to the purchase of HIV/
AIDS therapeutics. In addition, the committee intends for the 
Secretary to determine the criteria for eligibility, based on 
the characteristics of the ADAP program within the applicant 
State, including the State's ability to remove restrictions on 
eligibility based on current medical conditions or income 
restrictions, specifically limiting eligibility to less than 
200 percent of the Federal poverty level.
    The committee expects the State to continue to maintain 
current levels of effort in its ADAP funding. In addition, the 
committee believes that States should administer supplemental 
awards under this section in a manner that is consistent with 
other ADAP services funded through this section, including 
maintaining existing eligibility criteria, quality management 
activities, and administrative procedures.

III. Section 2617. State application

            Funding allocations based on HIV/AIDS demographics
    The reauthorization bill reflects the committee's opinion 
that priority setting and funding allocation decisions should 
be based on the size and demographic characteristics of the 
populations with HIV disease within the State. Planning, 
priority setting, and funding allocation processes must take 
into account shifts in the local HIV/AIDS epidemic, existing 
HIV-related health disparities, and resulting negative health 
outcomes. The committee intends for ``demographic 
characteristics'' to include housing status, and requests the 
Secretary to encourage and assist States to ascertain the 
housing status of participants in Ryan White-funded programs 
for service delivery, planning, reporting, and quality 
management purposes.
    The reauthorization legislation requires the Secretary to 
work with title II grant recipients and providers to establish 
epidemiologic measures and tools for use by States in 
identifying persons with HIV infection who are not in care. The 
committee recognizes the difficulty States may experience in 
identifying persons with HIV infection who are not in care and 
who may be unknown to any health or social support system. The 
committee does not intend to require States to establish 
priorities for the allocation of funds for persons not in care, 
until the Secretary is able to provide such advice and 
technical assistance. States should continue such efforts as 
they have developed in this area for establishing priorities of 
funds for this population. The committee is aware that many 
States do not have HIV reporting in place and may be further 
disadvantaged in implementing the requirements under this 
section, even with the additional tools and measures provided 
by the Secretary. The committee strongly encourages that the 
means to report the incidence of HIV be in place as soon as 
possible, and that the Secretary should take these differences 
into account in implementing these requirements.
            Capacity development
    The committee recognizes the need for capacity development 
planning, in order to assist States and communities in 
establishing HIV primary care services and effective provider 
networks. Such capacity development should target the 
structural, administrative, and financial management activities 
that can improve the ability of States and underserved 
communities to address the need for HIV primary health care, 
particularly in those underserved and minority communities 
where infrastructure for the provision of HIV services is 
inadequate. Capacity development includes: (1) activities that 
establish and enhance core management functions (for example, 
accounting and information systems, planning, and evaluation); 
(2) establishment and enhancement of program development 
functions (for example, personnel and staff competencies and 
HIV primary care network development); and (3) addition of new 
services (for example, the purchase of equipment and minor 
upgrading of facilities).
    The committee intends that these capacity development 
services meet the criteria of expanding the capacity, 
preparedness, and expertise of grantees to deliver primary care 
and health-related supportive services to individuals with HIV 
in underserved, low-income communities. States should 
prioritize HIV primary care services and network infrastructure 
development based on their needs assessment and planning 
process. The committee recognizes that building capacity must 
be done in a local context.
            Comprehensive plan requirements for CARE Act grant funds
    The comprehensive service delivery plan is an effective way 
to demonstrate the organization and delivery of CARE Act 
services, based upon the planning, priority setting, and 
funding allocations processes conducted by the State. The 
committee intends that additional factors be reflected in the 
plan such as: disparities in access to medical and health-
related support services by specific subpopulations; capacity 
development activities; and quality of HIV primary care and 
health-related supportive services. Upon the development of 
measures by the Secretary, as described above, the needs of 
persons with HIV not in care should be considered in the 
comprehensive plan. Both the planning process and the resulting 
plan should include the participation of, and address the needs 
of, populations and subpopulations living with HIV and AIDS.
    The specific needs of populations or subgroups, such as 
women, people of color, persons who are underinsured or 
uninsured, youth, homeless persons, persons living in rural 
areas, or persons with co-occurring conditions within the State 
need to be specifically addressed. The committee realizes that 
States, in the planning process, may not currently utilize 
information on the types of specialized services needed to 
bring vulnerable subpopulations into care and to retain them in 
care. To the extent that these populations are underserved in 
the State, the Secretary should assist States in planning and 
prioritizing resources for these populations. The committee 
also asks that the Secretary continue to work with planning 
councils to identify positive health outcomes achieved by local 
planning, priority setting, and funding allocation processes in 
meeting the needs of CARE Act-eligible persons.
            Medicaid and SCHIP coordination with the CARE Act
    The reauthorization language also recognizes the 
availability of other health benefit programs, such as the 
State Medicaid and Children's Health Insurance Program (SCHIP). 
The committee is aware of the wide variation between State 
Medicaid programs and the impact of these variations on the 
variability and scope of services for persons with HIV/AIDS. 
The committee expects that all States will have in place strong 
coordinating mechanisms between Ryan White and the State 
Medicaid programs to assure optimal health care for persons 
living with HIV disease. States should ensure thecoordination 
of benefits from the Medicaid and SCHIP programs with those funded 
under the CARE Act. The committee intends for grantees to take into 
account the needs of all persons with HIV and all payers when assessing 
the types and levels of services to be provided within a given 
jurisdiction.
    The committee also recognizes the importance of the 
Statewide Coordinated Statement of Need (SCSN) process in 
coordinating HIV/AIDS care and support activities across the 
State, including areas that fall within EMAs. The SCSN should 
inform and support the State's annual comprehensive plan. 
States should seek the broadest participation of providers, 
Federal and State grant recipients, and consumers through such 
methods as public notices, hearings, or meetings. The committee 
directs the Secretary to instruct States to consult with the 
full range of public and nonprofit entities providing health 
and support services to persons with HIV/AIDS and affected 
communities and populations.
    CARE Act funds should not be used to provide items or 
services for which payment has already been made or reasonably 
can be expected to be made by third-party payers, including 
Medicaid, Medicare, SCHIP, and or other State or local 
entitlement programs, prepaid health plans, or private 
insurance. Funds allocated by this Act shall be available to 
supplement services to patients who are Medicaid beneficiaries 
for services not covered by Medicaid. CARE Act grantees should 
ensure that eligible individuals are expeditiously enrolled in 
Medicaid and that CARE Act funds are not used to pay for any 
Medicaid- or SCHIP-covered services for Medicaid or SCHIP 
enrollees. Both the comprehensive plan and the statewide 
coordinated statement of need can assist the State in 
coordinating the various Federal, State, and local funding 
sources.
            Quality management program
    The committee recognizes the importance of having CARE Act 
grantees ensure that quality services are provided to people 
living with HIV and that the quality management activities are 
conducted on an ongoing basis. The quality management program 
is intended to serve grantees in evaluating and improving the 
quality of primary care and health-related supportive services 
received by persons under this act. The quality management 
program should accomplish a threefold purpose: (1) assist 
direct service medical providers funded through the CARE Act in 
ensuring that funded services adhere to established HIV 
clinical practices and PHS guidelines; (2) ensure that 
strategies for improvements to quality medical care include 
vital health-related supportive services in achieving 
appropriate access to and adherence with HIV medical care; and 
(3) ensure that available demographic, clinical, and health 
care utilization information is used to monitor the spectrum of 
HIV-related illnesses and trends in the local epidemic.
    The committee expects the Secretary to provide States with 
guidance and technical assistance for establishing quality 
management programs. Such programs are generally available and 
implemented in clinical practice environments. The additional 
guidance and technical assistance provided should assist 
grantees to develop performance measures of specific health 
outcomes, service cost-effectiveness, and indicators of health 
care status improvement. The committee hopes that States will 
communicate and coordinate CARE Act requirements with other 
payers to the extent possible to ensure consistency in quality 
management activities.
    The Secretary may consider the need for guidance to States 
on the types of mechanisms used to ensure that medical service 
providers, whether directly or through contractual agreement, 
have procedures and protocols in place to monitor and assess 
the quality of care based on established PHS guidelines. Where 
services are provided through contractual agreements, the 
States should incorporate within the contract the expectation 
that subcontractors have a quality assurance program in place. 
The committee expects that most States have quality management 
systems in place already and that they utilize mechanisms such 
as peer chart reviews or patient prescription pattern 
monitoring.
    The committee places responsibility on the Secretary to 
ensure that PHS guidelines, as well as population 
characteristics and trends in the use of HIV services, are 
communicated to all CARE Act grantees and subgrantees. This 
information, the committee believes, will assist grantees in 
ensuring the highest quality of HIV care among CARE Act 
providers.
    The committee intends that the Secretary provide 
clarification and guidance regarding the distinction between 
use of CARE Act funds for such program expenditures that are 
covered as either planning and evaluation and funds for program 
support costs. It is not the intent of the committee to 
reassign current program support costs or clinical quality 
programs to new cost areas, if they are an integral part of a 
State's current quality management efforts. Program support 
costs are described as any expenditure related to the provision 
of delivering or receiving health services supported by CARE 
Act funds. As applied to the clinical quality programs, these 
costs include, but are not limited to, activities such as chart 
review, peer-to-peer review activities, data collection to 
measure health indicators or outcomes, or other types of 
activities related to the development or implementation of a 
clinical quality improvement program. Planning and evaluation 
costs are related to the collection and analysis of system and 
process indicators for purposes of determining the impact and 
effectiveness of funded health-related support services in 
providing access to and support of individuals and communities 
within the health delivery system.
            Grantee health care relationships
    The committee recognizes that many individuals with HIV/
AIDS will pass through key points of entry into the medical 
system without being referred to HIV care services. In order to 
identify and refer those individuals to HIV primary care and 
health-related supportive services, and thus improve access to 
appropriate care for persons not currently in the system, the 
committee expects States to establish relationships with 
entities that serve as key points of entry into the medical 
system for populations at high risk of HIV infection. Such key 
points of entry can include, but are not limited to, emergency 
rooms, community health centers, substance treatment programs, 
detoxification centers, mental health treatment programs, adult 
and juvenile detention centers, correctional facilities, soup 
kitchens, sexually transmitted disease clinics, HIV counseling 
and testing sites, homeless shelters, and transitional housing 
and homeless outreach programs.
    In encouraging the development of key points of entry 
relationships, the State should: (1) evaluate those beneficial 
relationships which are in place and those which are needed to 
strengthen referral of individuals from key points of entry 
into HIV primary care sites; and (2) provide mechanisms through 
funding, contractual, and other types of agreements to 
strengthen these relationships. In order to ensure the 
effectiveness of the key point of entry process, the committee 
allows for the use of CARE Act funds to support early 
intervention services within such sites to facilitate the 
identification, counseling, and referral of individuals with 
HIV/AIDS into the HIV care system.

IV. Section 2618. Distribution of funds

            Increase in minimum allotment
    The reauthorization bill doubles the existing level for the 
minimum title II base award to $200,000 for States with fewer 
than 90 living cases of AIDS. For States with 90 or more living 
casesof AIDS, the language increases the minimum allotment to 
$500,000. A minimum funding level of $50,000 is also established for 
territories eligible for Title II funding. In doubling the minimum, the 
committee recognizes that territories and States that typically receive 
the minimum grant lack health care infrastructure with which to support 
people with HIV or AIDS. By increasing the minimum base awards for 
states and territories, the committee intends to provide Part B 
grantees, that often do not have other available sources for HIV care 
services, with the ability to develop and improve their local HIV care 
infrastructure. These minimum grants will improve the level of services 
available and provide greater balance in allocation among affected 
areas throughout the Nation.

V. Section 2622. Supplemental grants to emerging communities

    The committee intends in this section to acknowledge the 
challenges faced by many communities with a high burden of HIV 
and AIDS. The reauthorization language establishes a new 
supplemental grant award under part B to assist States in 
providing comprehensive services in areas of the State not 
eligible for grants under part A. The Secretary shall reserve 
50 percent of new appropriations, in excess of appropriations 
in the previous fiscal year, to fund these supplemental grants. 
From these funds, the Secretary shall reserve the greater of $5 
million or 50% fund for use in emerging communities, defined as 
metropolitan areas with an AIDS case count between 1,000 and 
1,999 over the most recent 5 calendar years. The remaining 
supplemental funds shall be awarded to States with demonstrated 
severity of need. The committee expects the Secretary to 
develop criteria that measure severity of need for additional 
assistance in the State (i.e., the overall population size of 
the eligible area and the number of cumulative AIDS cases in 
the area).
    States should facilitate the development of a local 
planning structure in the emerging community to establish 
program priorities and determine funding allocation for the 
eligible area. It is expected that the State will conduct its 
role in a manner that is consistent with consortia role and 
responsibilities, as well as State oversight responsibilities 
relative to these structures.
    The committee intends to supplement the resources available 
to emerging communities to improve services available to the 
population living with AIDS in these areas. Thus, the committee 
believes that the provision of supplemental funds to emerging 
communities and areas with demonstrated need should be met by a 
State's commitment to continue to provide the current level of 
Federal and State funds to the eligible area. Otherwise, the 
efforts to enhance support to these areas would not be 
accomplished.

VI. Section 2611. Set-aside for infants, children, and women

            Women, infants, and children set-aside
    The committee wishes to clarify that the set-aside for 
infants, children, and women with HIV disease be allocated 
proportionally based on the percentage of the local HIV-
infected population that each group represents. The committee 
is aware of the rising incidence of HIV in youth and in women 
of color, and it recognizes the unique challenges facing these 
groups with respect to access and sustaining primary care and 
support services for HIV and AIDS. The intent of this 
legislation is to increase the availability of primary care and 
health-related supportive services for each of these groups. 
The committee emphasizes the importance of these increasing 
trends and requests the Secretary to provide guidance to 
planning councils and grantees in planning and providing 
services to these unique populations.

                                 PART C

    The committee acknowledges the success of part C grants in 
providing community-based primary care settings with direct 
access to vital CARE Act funds. The part C targeted funding 
allows the CARE Act to respond directly to local needs and 
shifts in the HIV/AIDS epidemic. It assists local primary care 
organizations to build or enhance their capacity to deliver HIV 
care in settings that are community based and regularly 
utilized by persons with HIV/AIDS. Part C is also recognized by 
the committee as an optimal mechanism for developing potential 
primary care networks with its ability to award planning grants 
to low-income urban and rural areas in need of developing an 
HIV primary care infrastructure.

I. Section 2651. Establishment of program

            Preference for certain areas
    It is the committee's view that the shift in the HIV/AIDS 
epidemic away from the traditional epicenters has not resulted 
in a commensurate shift in CARE Act resources to address the 
needs of rural and underserved communities and populations. The 
reauthorization language establishes a preference in awarding 
title III grants to areas that are rural and underserved. The 
committee intends that this preference be applied by the 
Secretary with new funds. This preference should not be 
construed to deny funding to qualified applicants in 
historically underserved urban communities or new applicants 
that receive assistance under parts A, B, C, or D under 
planning or minority AIDS initiative grants.

II. Section 2654. Miscellaneous provisions

            Planning and development grants
    The committee recognizes the need for planning for capacity 
development in order to assist local communities in 
establishing HIV primary care services and effective provider 
networks. Such capacity development focuses on the structural, 
administrative, and financial management systems activities 
that can improve the ability of underserved communities to 
respond to the HIV primary health care needs, particularly in 
those underserved, low income communities where infrastructure 
for the provision of HIV services is inadequate. Capacity 
development includes: (1) activities that establish and enhance 
core management functions (for example, accounting and 
information systems, planning and evaluation); (2) 
establishment and enhancement of program development functions 
(for example, personnel and staff competencies and HIV primary 
care network development); and (3) addition of new services 
(for example, the purchase of equipment and minor upgrading of 
facilities).
    The committee intends that these capacity development 
services meet the criteria of expanding the capacity, 
preparedness, and expertise of grantees to deliver primary care 
and health-related supportive services to individuals with HIV 
in underserved, low-income communities. Capacity development 
grants, up to a total of $150,000, may be made for a period not 
exceeding 3 years. The Secretary also redesignates the 
percentage available for grants under this section to 5 percent 
of appropriations.

III. Section 2664. Additional required agreements

            Quality management program
    The committee recognizes the importance of requiring CARE 
Act grantees to ensure that quality services are provided to 
people with HIV and that quality management activities are 
conducted on an ongoing basis. The quality management program 
is intended to serve grantees in evaluating and improving the 
quality of primary care and health-related supportive services 
received by persons underthis act. The quality management 
program should accomplish a threefold purpose: (1) assist direct 
service medical providers funded through the CARE Act in ensuring that 
funded services adhere to established HIV clinical practices and PHS 
guidelines; (2) ensure that strategies for improvements to quality 
medical care include vital, health-related supportive services in 
achieving appropriate access to and adherence with HIV medical care; 
and (3) ensure that available demographic, clinical, and health care 
utilization information is used to monitor the spectrum of HIV-related 
illnesses and trends in the local epidemic.
    The committee expects the Secretary to provide grantees 
with guidance and technical assistance to establish quality 
management programs. Such programs are generally available and 
implemented in clinical practice environments. The guidance and 
technical assistance provided should assist grantees to develop 
performance measures on specific client health outcomes, cost-
effectiveness of services, and indicators of health care status 
of the overall delivery of appropriate health care services to 
individuals with HIV disease. The committee hopes that grantees 
will communicate and coordinate CARE Act requirements with 
other payers to the extent possible to ensure consistency in 
quality management activities.
    The Secretary should also consider the need for guidance to 
grantees on what mechanisms should be used to ensure that 
medical service providers, whether directly or through 
contractual agreement, have established procedures and 
protocols in place to monitor and assess quality of care based 
on established PHS guidelines. Where services are provided 
through contractual agreements, the grantee should incorporate 
within the contract the expectation that subcontractors have a 
quality measurement program in place.
    The committee places responsibility on the Secretary to 
ensure that PHS guidelines, as well as broader measures of the 
population characteristics and trends in use in HIV services, 
are communicated to all CARE Act grantees and subgrantees. This 
information, the committee believes, will assist grantees in 
ensuring the highest quality of HIV care among CARE Act 
providers.
    The committee also recognizes that the current act provides 
reference and funding limitations on quality management 
activities and asks the Secretary to provide clarification and 
guidance regarding the distinction between use of CARE Act 
funds for such program expenditures that are covered as either 
planning and evaluation and funds for program support costs. It 
is not the intent of the committee to reassign current program 
support costs or clinical quality programs to new cost areas, 
if they are an integral part of a grantee's current quality 
management efforts.
            Administrative expenses ceiling
    The reauthorization language increases the administrative 
cap for title III grantees from 7.5 to 10 percent to reflect 
consistency with similar caps established in other sections of 
the act.

                                 PART D

    The committee reaffirms its commitment to the provision of 
innovative comprehensive HIV care systems for children, youth, 
and families with or affected by HIV. Grantees funded through 
this section provide or arrange for coordinated HIV services 
for the purpose of supporting or coordinating comprehensive, 
community-based, culturally competent, family- or youth-
centered HIV care systems. The committee acknowledges the 
importance of facilitating the voluntary participation of 
children, youth, and women with HIV disease in qualified 
research clinical protocols. The committee understands the lack 
of access in clinical research activities in many areas of the 
country. The reauthorization language requires that the 
Secretary, acting through the Director of NIH, examine the 
distribution and availability of ongoing and appropriate 
clinical research projects for the purposes of enhancing and 
expanding voluntary access to such projects.

I. Section 2671. Grants for coordinated services and access to research 
        for women, infants, children, and youth

            Removal of significant enrollment requirement
    The committee reemphasizes the importance of providing 
access to and opportunities for participation in clinical 
research for women, infants, children, and youth. At the same 
time, the committee acknowledges that the primary purpose of 
programs under this section is intended to be increased 
enrollment in and access to health care services. Clinical 
research programs are not available in all areas, and yet the 
clinical services provided under the CARE Act provide 
significant benefit to women, infants, children, and youth. The 
committee is concerned that the requirement of significant 
enrollment in clinical research creates an undue pressure on 
grantees to involve clients in research that may not be 
appropriate or beneficial for clients of title IV programs. The 
committee intends that women, infants, and youth have access to 
clinical care and HIV-related support services and that they be 
connected to and enrolled in clinical research where 
appropriate, with no undue influence or pressure from the 
grantee.
            Requirement for an NIH study of clinical research access
    The reauthorization language requires an examination of the 
distribution and availability of ongoing and appropriate 
clinical research projects. While the ``significant 
enrollment'' language is removed, the committee emphasizes that 
the maintenance of the current level of effort to include 
women, infants, youth, and families in research projects is 
important. To the extent that such projects are available, and 
that title IV clients served by grantees meet the research/
trial protocol, these title IV grantees should educate clients 
on the benefits and risks of research and facilitate their 
entry into trials where appropriate. In order to maintain 
coordination of title IV programs with research activities, 
NIH-funded projects should include title IV projects on 
community advisory boards. The Secretary shall direct NIH to 
work with title IV to evaluate current clinical research 
activities available in areas where title IV programs are 
operating. Furthermore, the Secretary shall evaluate access 
issues related to available clinical trials in situations where 
distance to the closest trial is a barrier to participation. 
The committee requires that a report be available for its 
review within 12 months of enactment of the CARE Act 
reauthorization bill.
            Quality management program
    The committee recognizes the importance of having CARE Act 
grantees ensure that quality services are provided to people 
with HIV and that quality management activities are conducted 
on an ongoing basis. The quality management program is intended 
to serve grantees in evaluating and improving the quality of 
primary care and health-related supportive services received by 
persons under this act. The quality management program should 
accomplish a threefold purpose: (1) assist direct service 
medical providers funded through the CARE Act in ensuring that 
funded services adhere to established HIV clinical practices 
and PHS guidelines; (2) ensure that strategies for improvements 
to quality medical care include vital health-related supportive 
services in achieving appropriate access to and adherence with 
HIV medical care; and (3) ensure that available demographic, 
clinical, and healthcare utilization information is used to 
monitor the spectrum of HIV-related illnesses and trends in the local 
epidemic.
    The committee expects the Secretary to provide grantees 
with guidance and technical assistance to establish quality 
management programs with direct medical services providers 
funded through the CARE Act. Such programs are generally 
available and implemented in clinical practice environments. 
The guidance and technical assistance provided should assist 
grantees to develop performance measures on specific client 
health outcomes, cost-effectiveness of services, and indicators 
of health care status indicators in the overall delivery of 
appropriate health care services to individuals with HIV 
disease. The committee expects that grantees will communicate 
and coordinate CARE Act requirements with other payers, to the 
extent possible, to ensure consistency in quality management 
activities.
    The Secretary may consider the need for guidance to 
grantees on what mechanisms should be in place to ensure that 
medical service providers, whether directly or through 
contractual agreement, have established procedures and 
protocols in place to monitor and assess quality of care based 
on established PHS guidelines. Where services are provided 
through contractual agreements, the grantee should incorporate 
within the contract the expectation that subcontractors have a 
quality management program in place.
    The committee places responsibility on the Secretary to 
ensure that PHS guidelines, as well as broader measures of 
population characteristics and trends in the use of HIV 
services, are communicated to all CARE Act grantees and 
subgrantees. This information, the committee believes, will 
assist grantees in ensuring the highest quality of HIV care 
among CARE Act providers.
            Clarification of title IV services
    The committee believes that the primary purpose of title IV 
should be the following: to provide comprehensive family- and 
youth-centered HIV-related care; to support early intervention 
services and linkages to care; to prevent HIV transmission; and 
to facilitate voluntary access to HIV-related research. 
Grantees are to provide, directly or through referral, 
appropriate HIV prevention services in the context of 
comprehensive care for HIV-infected patients, including 
prevention of perinatal HIV transmission; primary HIV 
prevention for HIV-infected clients and their families; 
information or training about universal precautions for 
settings that serve HIV-infected women, infants, children, and 
youth; and early intervention services, including outreach and 
HIV counseling and testing. Funds may not be used for general 
HIV education and primary prevention activities outside the 
context of comprehensive care for HIV-infected patients and 
their families. Furthermore, the committee intends that 
providers of such services should be guided by CDC guidelines.
    Perinatal HIV prevention services may include case finding 
of HIV-positive and high-risk women; voluntary prenatal 
testing; treatment to reduce perinatal transmission; support 
services to help pregnant women adhere to treatment regimens; 
and creation of linkages between HIV care providers and women's 
health providers to ensure that both have state-of-the-art 
knowledge. As appropriate, these services should be carried out 
in conjunction with and supported by the CDC and state 
perinatal prevention programs funded through the CARE Act.
    It is not the intent of the committee to require that each 
grantee under this section provide services to women, infants, 
children, and youth. Rather, based on local epidemiology, 
demographics, and service needs, grantees have the flexibility 
to focus services on one or more of these populations, if 
appropriate. However, if a grantee does not provide services to 
each of these populations, it must provide referrals to other 
appropriate programs.
            Consumer involvement in title IV programs
    The committee expects the Secretary to assist grantees in 
establishing a process to formalize and increase consumer 
involvement in title IV, including consumer involvement in 
title IV program planning, implementation, and evaluation. 
Applicants should plan, implement, and evaluate activities to 
promote meaningful consumer involvement.
            Limitations on administrative expenses
    The reauthorization language also acknowledges the need of 
the Secretary to conduct a review of the administrative, 
program support, and direct service-related activities of 
grantees. The committee intends that this review be conducted 
in consultation with grantees and permit the Secretary to 
determine allowable expenses under these categories and 
implement requirements as necessary.

                                 part F

I. Section 2692. HIV/AIDS communities, schools, and centers

            Addition of schools of dental hygiene as eligible grantees
    The committee acknowledges that, due to the lack of a 
dental school in their locality, a significant percentage of 
States do not receive reimbursement for dental services 
provided to people with HIV and AIDS. The reauthorization 
language expands the category of entities eligible to receive 
dental reimbursement grants to include schools of dental 
hygiene programs accredited by the Commission on Dental 
Accreditation.

II. Section 201. Institute of Medicine study

    The Secretary is required to contract with the Institute of 
Medicine (IOM) to complete a study that examines changing 
trends in the HIV/AIDS epidemic and the financing and delivery 
of primary care and support services for low-income, uninsured, 
and underinsured individuals with HIV disease. The IOM shall 
provide the Secretary with recommendations regarding the most 
effective use of all Federal resources for HIV/AIDS care and 
support services.
    The purpose of the study would be to examine key factors 
associated with the effective and efficient financing and 
delivery of HIV services (including access, the quality of 
services, health outcomes, and cost-effectiveness). The 
committee expects that the study would include examination of 
CARE Act financing of services as well as existing public 
sector financing (e.g., Medicaid, Medicare, and State programs) 
and private health coverage; general demographics (race/
ethnicity, socioeconomic status, age, gender, geographic 
location) and comorbidities (e.g., substance use, mental health 
issues, homelessness) of individuals with HIV disease; regional 
variations in the financing and costs of HIV service delivery; 
and available epidemiological tools and data sets necessary for 
local and national resource planning and allocation decisions, 
including an assessment of implementation of HIV infection 
reporting as it impacts these factors.
    As the epidemiology and medical science surrounding the HIV 
and AIDS epidemic evolve, many significant changes may be in 
store for the financing and provision of HIV/AIDS care and 
support programs. The Secretary is instructed to evaluate the 
availability and utility of health outcomes measures and data 
for measuring quality and effectiveness of Ryan White-funded 
service; the effectiveness and efficiency of service delivery 
through public and private programs, including Medicaid and 
Medicare; the impact of replacing AIDS case counts with HIV 
surveillance data in funding formulas on funding allocation; 
and existing and needed epidemiological data and other 
analytical tools for resource planning and allocation 
decisions. The study will be conducted by the National Academy 
of Sciences/Institute of Medicine to be completed within 21 
months of the reauthorization of the CARE Act.

                            V. Cost Estimate

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, May 10, 2000.
Hon. James M. Jeffords,
Chairman, Committee on Health, Education, Labor, and Pensions, U.S. 
        Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 2311, the Ryan White 
CARE Act Amendments of 2000.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Cyndi 
Dudzinski.
            Sincerely,
                                          Barry B. Anderson
                                    (For Dan L. Crippen, Director).
    Enclosure.

               congressional budget office, cost estimate

S. 2311--Ryan White CARE Act Amendments of 2000

    Summary: S. 2311 would extend expiring provisions and 
authorizations for appropriations in title XXVI of the Public 
Health Services Act, which was created by the Ryan White CARE 
Act (Public Law 101-381). It would amend the provisions under 
that title to increase access to care and require that care to 
be consistent with the guidelines of the Public Health Service. 
It also would create two new grant programs to pay for health 
care services for individuals with HIV or AIDS.
    The Ryan White CARE Act is almost all administered through 
the Health Resources and Services Administration (HRSA); small 
portions are implemented through the Centers for Disease 
Control and Prevention (CDC) and the National Institutes of 
Health (NIH). Assuming appropriations of the necessary amounts, 
CBO estimates that implementing S. 2311 would cost $326 million 
in 2001 and a total of $6.4 billion from 2001 through 2005, 
without adjusting for inflation, and $332 million in 2001 and a 
total of $6.6 billion from 2001 through 2005 if adjustments for 
inflation are included. The legislation would not affect direct 
spending or receipts; therefore, pay-as-you-go procedures would 
not apply.
    S. 2311 contains no private-sector or intergovernmental 
mandates as defined in the Unfunded Mandates Reform Act (UMRA). 
It would authorize funding for local and state governments as 
well as for other public entities that either fund or provide 
services to individuals with HIV or AIDS.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 2311 is shown in Table 1. The costs of 
this legislation fall within budget function 550 (health).

                                      TABLE 1.--BUDGETARY IMPACT OF S. 2311
----------------------------------------------------------------------------------------------------------------
                                                                  By fiscal year, in millions of dollars--
                                                           -----------------------------------------------------
                                                              2000     2001     2002     2003     2004     2005
----------------------------------------------------------------------------------------------------------------
                                        SPENDING SUBJECT TO APPROPRIATION

Spending Under Current Law:
    Budget Authority \1\..................................    1,605        0        0        0        0        0
    Estimated Outlays.....................................    1,376    1,209      248       64    (\2\)        0

                                        Without Adjustments for Inflation

Proposed Changes:
    Estimated Authorization Level.........................        0    1,620    1,620    1,620    1,620    1,620
    Estimated Outlays.....................................        0      326    1,329    1,523    1,588    1,588
Spending Under S. 2311:
    Estimated Authorization Level \1\.....................    1,605    1,620    1,620    1,620    1,620    1,620
    Estimated Outlays.....................................    1,376    1,534    1,577    1,588    1,588    1,588

                                         With Adjustments for Inflation

Proposed Changes:
    Estimated Authorization Level.........................        0    1,649    1,675    1,706    1,736    1,767
    Estimated Outlays.....................................        0      322    1,357    1,578    1,672    1,702
Spending Under S. 2311:
    Estimated Authorization Level \1\.....................    1,605    1,649    1,675    1,706    1,736    1,767
    Estimated Outlays.....................................    1,376    1,540    1,606    1,642    1,672   1,702
----------------------------------------------------------------------------------------------------------------
\1\ The 2000 level is the amount appropriated for that year for title XXVI programs.
\2\ Less than $500,000

    Basis of Estimate: For purposes of this estimate, CBO 
assumes that the bill will be enacted by the end of fiscal year 
2000 and that outlays would follow historical spending rates 
for the authorized activities. Where specified, CBO assumes the 
authorized and estimated amounts would be appropriated. Where 
appropriations of such sums are necessary are authorized, CBO 
based its estimates on the amount spent in the past for the 
activity. Table 1 shows two alternative spending paths: one 
assuming no increase to account for anticipated inflation, and 
one with annual inflation adjustments.
    The authorizations for appropriations for most of the 
programs under the Ryan White CARE Act expire after fiscal year 
2000. S. 2311 reauthorizes those programs for fiscal year 2001 
through 2005. For those provisions, Table 2 show the amount 
appropriated in fiscal year 2000, and the estimated 
appropriation authorized in the bill for fiscal years 2001 
through 2005, with adjustments for inflation.
    In addition to reauthorizing current programs, the bill 
would provide authorizations for three new provisions in the 
Ryan White CARE Act. The estimated appropriation authorized in 
the bill for those provisions with adjustments for inflation is 
also shown in Table 2. A description of the current programs 
that would be reauthorized and the estimate of the new 
provisions in the bill are provided below.
    Part A of title XXVI, (also known as title I of the Ryan 
White CARE Act), provides grants to eligible metropolitan areas 
with substantial levels of individuals with HIV. The funds are 
used for outpatient and ambulatory health care and other 
support services provided by community-based systems to low 
income or under insured people living with HIV/AIDS. Part B 
(title II of the act), provides grants to states and 
territories for medical and other health and social support 
services delivered primarily through consortia of providers of 
HIV services. States must provide matching funds and use a 
certain amount of the funds for services to infants, children, 
women, and families. Part C (title III of the act), awards 
funds to nonprofit community-based programs that provide 
comprehensive primary health care services aimed at preventing 
and or reducing HIV-related morbidity. Part D, (title IV of the 
act), provides funding to improve and expand the primary care 
and support services for children, youth, women, and families. 
It is intended to increase access to comprehensive, 
coordinated, community-based family-centered systems of care 
for infected individuals and their families. part F \1\ funds a 
net work of regional centers that conduct HIV/AIDS education 
and training programs for health care providers, special 
projects of national significance, and reimbursement assistance 
to dental schools for oral health care.
---------------------------------------------------------------------------
    \1\ There has never been an appropriation for Part E, which 
requires the Secretary to make grants to state and local governments to 
assist them in disseminating guidelines to emergency responses 
employees regarding reducing the risk in the workplace of becoming 
infected with AIDS.
---------------------------------------------------------------------------
    Section 106 of S. 2311 would extend indefinitely the 
requirement that 50 percent of appropriated funds for Part A be 
disbursed within 60 days after the appropriation becomes 
available. Those funds are disbursed in the form of formula 
grants. Section 107 would require that each metropolitan area 
that received a formula grant in 2000 also receive formula 
grants in 2001 through 2005 that could not decrease by more 
than 2 percent a year, subject to the amounts appropriated for 
each year. Section 107 would affect the distribution of annual 
appropriations and both sections may affect the rate at which 
such appropriations are spent by increasing the amounts 
disbursed within 60 days of appropriation, but neither would 
increase total federal spending.

   TABLE 2.--TITLE XXVI PROGRAMS: APPROPRIATIONS FOR FISCAL YEAR 2000 AND AMOUNTS AUTHORIZED IN S. 2311, WITH
                                            ADJUSTMENTS FOR INFLATION
----------------------------------------------------------------------------------------------------------------
                                                                  By fiscal year, in millions of dollars--
                                                           -----------------------------------------------------
                                                              2000     2001     2002     2003     2004     2005
----------------------------------------------------------------------------------------------------------------
                                          Programs Administered by HRSA

Reauthorization: \1\
    Part A (Title I of the Ryan White CARE Act) emergency       547      556      566      576      586      597
     relief grants........................................
    Part B (Title II) HIV care............................      824      839      853      868      884      900
    Part C (Title III) early intervention services........      138      141      143      146      149      151
    Part D (Title IV) pediatric AIDS: women, children, and       51       52       53       54       55       56
     youth................................................
    Part F:
        AIDS education and training centers...............       27       27       28       28       29       29
        Dental reimbursements.............................        8        8        8        8        9        9
    Evaluations and reports...............................        0        1        1        1        1        1
New provisions:
    Supplemental grants to States for non-eligible                0        5        5        5        5        5
     metropolitan areas...................................
    Planning and capacity development grants..............        0        6        6        6        6        6
    Studies and reports...................................        0        1        0        0        0        0
                                                           -----------------------------------------------------
      Subtotal............................................    1,595    1,639    1,665    1,696    1,726    1,757

                                          Programs Administered by CDC

HIV-related services for pregnant women and newborns......       10       10       10       10       10       10

                                         Provisions Administered by NIH

New report................................................        0    (\2\)        0        0        0        0
                                                           -----------------------------------------------------
      Total Proposed Changes..............................    1,605    1,649    1,675    1,706    1,736    1,767
----------------------------------------------------------------------------------------------------------------
\1\ The 2000 level is the amount appropriated for that year.
\2\ Less than $500,000.

    Under section 128, S. 2311 would create a new supplemental 
grant to meet HIV care and support needs in metropolitan areas 
that are not eligible for Part A grants. The Secretary of the 
Department of Health and Human Services would be required to 
reserve the greater of $5 million per year or 25 percent of the 
increase in funding for Part B grants (other than thatearmarked 
for state AIDS drug assistance programs) for these supplemental grants. 
CBO estimates that would increase spending by $5 million per year for a 
total of $25 million over the 2001-2005 period.
    Section 130 of the bill would double the minimum Part B 
base award to $200,000 for states with fewer than 90 living 
cases of AIDS and to $500,000 for states with 90 or more living 
cases of AIDS. It would also add the federated States of 
Micronesia and the Republic of Palau as entities eligible to 
receive Part B funds. As that provision does not create a new 
program or provide additional funding, CBO estimates that it 
would reallocate some of the appropriated money but would not 
change federal spending.
    Under section 142, S. 2311 would create a program of 
capacity development grants to assist public and nonprofit 
private entities in expanding their ability to provide primary 
care services to individuals with HIV disease in underserved 
low-income communities. Under current law, a maximum of 1 
percent of the amount appropriated for Part C can be used for 
planning grants. S. 2311 would increase to 5 percent the 
proportion that could be earmarked for the new capacity 
development grants and the planning grants. CBO estimates that 
provision would increase federal costs by $6 million in fiscal 
year 2001 and by a total of $29 million through 2005.
    S. 2311 would require several studies and reports. The 
Secretary, through the Administrator of HRSA and in 
consultation with grant recipients, would be required to 
conduct a review of administrative and program support costs 
for grants provided under Part D. The results of the study 
would be used to determine the limitations on allowable amounts 
for administrative and program support expenses for fiscal year 
2002. The Secretary would also request that the Institute of 
Medicine complete a study within two years after the enactment 
of this act regarding the appropriate epidemiological measures 
and their relationship to health-related support services for 
certain individuals with HIV. The Secretary would report to the 
appropriate committee of the Congress within 90 days of 
completion. CBO estimates those reports would increase federal 
spending by a total of $1 million over fiscal years 2001 
through 2002.
    The Secretary, through the Director of NIH, would examine 
the distribution and availability of HIV-related clinical 
research programs for women, infants, children, and youth, and 
submit a report to the Congress within 12 months of enactment. 
CBO estimates that completing the report would cost less than 
$500,000.
    Pay-as-you-go considerations: None.
    Estimated impact on state, local, and tribal governments: 
The bill contains no intergovernmental mandates as defined in 
UMRA. Some provisions of the bill would place additional 
conditions of assistance on recipients of funding for HIV and 
AIDS programs, but those requirements would not be 
intergovernmental mandates. The bill would extend 
authorizations of funding for a variety of HIV and AIDS 
programs, and in a few cases would authorize amounts for new 
grant programs. These authorizations total between $1.6 billion 
and $1.8 billion annually over the 2001-2005 period. Over half 
of those amounts would be for HIV care grants to states, and 
about a third would be for emergency relief grants to local 
governments that qualify as eligible metropolitan areas with 
substantial levels of individuals with HIV. Both nonprofit and 
public entities could qualify for grants under the remaining 
authorizations of funding for a variety of services ranging 
from education and training to pediatric and women's services.
    Estimated impact on the private sector: The bill contains 
no private-sector mandates as defined in UMRA.
    Estimate prepared by: Federal Costs: Cyndi Dudzinski; 
Impact on State, Local, and Tribal Governments: Leo Lex; and 
Impact on the Private Sector: Jennifer Bullard.
    Estimate approved by: Peter H. Fontaine, Deputy Assistant 
Director for Budget Analysis.

                    VI. Regulatory Impact Statement

    The committee has determined that there will be only a 
negative increase in the regulatory burden of paperwork as a 
result of this legislation.

             VII. Application of Law to Legislative Branch

    Section 102(b)(3) of Public Law 104-1, the Congressional 
Accountability Act (CAA), requires a description of the 
application of this bill to the legislative branch. S. 2311 
would amend the Ryan White CARE Act of 1990 as amended by the 
Ryan White Care Act Amendments of 1996, which provides grants 
to States, cities, and organizations to make primary care and 
support services available to people living with HIV and AIDS. 
This requirement would not apply to the legislative branch.

                   VIII. Section-by-Section Analysis


Section 1. Short title

    The short title is the ``Ryan White CARE Act Amendments of 
2000''.

Section 2. References

    Specifies that amendments are being made to section XXVI of 
the Public Health Service Act.

Section 3. General amendments

             TITLE I--AMENDMENTS TO HIV HEALTH CARE PROGRAM


       Subtitle A--Amendments to Part A (Emergency Relief Grants)

    Sec. 101. Amends section 2602. Adds homeless service 
providers to planning councils and clarifies responsibilities 
of the planning council, including: the phased in requirement 
of planning for individuals with HIV disease not currently in 
care; the development of priorities for resource allocation 
including the availability of other funding sources such as 
Medicaid and State Children's Health Insurance Program (SCHIP); 
and the consideration of capacity developments needs.
    Sec. 102. Amends sections 2604 and 2605(a). Establishes 
funding limits for quality management programs of the lesser of 
5% of grant or $3 million. Grantee is required to provide for a 
quality management program to ensure that medical services 
provided to patients are consistent with the most recent PHS 
guidelines for the treatment of HIV disease and related 
opportunistic infections and that improvements in the access to 
and quality of medical services are addressed.
    Sec. 103. Amends sections 2604(e)(1) and 2605(a). Includes 
the State Children's Health Insurance Program in the existing 
requirement that grantees be eligible Medicaid providers in 
order to receive grants under the CARE Act. Requires 
organizations receiving subgrants to maintain referral 
relationships with points of entry to the health care system 
for the purpose of facilitating early intervention services for 
persons newly diagnosed with HIV disease and persons 
knowledgeable of their HIV status but not in care.
    Sec. 104. Amends section 2604(b)(1) and 2605(a). Requires 
that support services funded through the Act facilitate or 
enhance the delivery, continuity, or benefits of health 
services. Defines the appropriate types of services to be 
funded by the EMA.
    Sec. 105. Amends sections 2604(b)(1) and 2605(a)(1). Allows 
grantees to include HIV early intervention activities to 
support early diagnosis and provide linkages to care among 
populations at high risk from HIV. Funding to be limited to 
only those provider sites serving as key points of entry or 
current Ryan White funded medical sites. Sites must demonstrate 
that funds for these services supplement but do not supplant 
existing funds and that other funds are unavailable.
    Sec. 106. Amends sections 2603(a)(2). Replaces the 
specified fiscal years (1996 through 2000) regarding the 
expedited distribution requirement for grants under Title I 
with language allowing the expedited distribution of funds to 
continue into the next reauthorization period.
    Sec. 107. Amends section 2603(a)(4). Updates the hold 
harmless provision by providing that current Title I EMAs 
grants be adjusted by no more than an annual 2% per year 
reduction from FY2000 funding, for a maximum of 10% over 5 
years.
    Sec. 108. Amends section 2604(b)(3). Continues existing 
set-aside for infants, children and women but requires that 
funds be allocated proportionately according to the percentage 
that each group represents in the eligible area.

         Subtitle B--Amendments to Part B (Care Grant Program)

    Sec. 121. Amends section 2612 and 2617(b). Continues 
States' priority setting and funding allocation requirements 
and adds new factors, including: the size and demographics of 
the population with HIV disease; capacity development needs; 
and individuals with HIV disease not currently in care (phased 
in during FY 2003).
    Sec. 122. Amends sections 2617(b)(4) and 2618(c)(3). States 
are required to provide for a quality management program to 
ensure that medical services are consistent with the PHS 
guidelines for the treatment of HIV disease and related 
opportunistic infections and that improvements in the access to 
and quality of medical services are addressed. Requires 
Grantees to coordinate Medicaid and SCHIP program funding with 
CARE Act funds to assure optimal use of financial resources. 
Funding limits are established for quality management services, 
with an exception for smaller States that receive $1,500,000 or 
less.
    Sec. 123. Amends section 2617(b)(4). Requires organizations 
receiving subgrants to maintain referral relationships with 
points of entry to the health care system for the purpose of 
facilitating early intervention services for persons newly 
diagnosed with HIV disease and persons knowledgeable of their 
HIV status but not in care.
    Sec. 124. Amends section 3 of Public law 104-146, and PHS 
Act section 2612(a)(1) and 2617(b)(2). Requires that support 
services funded under Title II facilitate or enhance the 
delivery, continuity, or benefits of health services. Defines 
the appropriate types of services to be funded by the States.
    Sec. 125. Amends section 2612(a). Allows grantees to 
include HIV early intervention activities to support early 
diagnosis and provide linkages to care among populations at 
high risk from HIV. Funding to be limited to only those 
provider sites serving as key points of entry or current Ryan 
White funded medical sites. Sites must demonstrate that funds 
for these services supplement but do not supplant existing 
funds and that other funds are unavailable.
    Sec. 126. Amends section 2625(c)(2). Authorization for 
appropriations for these services is amended for FY 2001-2005.
    Sec. 127. Repeals section 2628. Repeals completed IOM 
study.
    Sec. 128. Creates section 2622. Creates a supplemental 
grant to meet HIV care and support needs in non-EMA areas. 
Emerging communities defined as cities with between 1,000 and 
1,999 reported AIDS cases in the most recent five year period, 
receive half of the supplemental assistance. States 
demonstrating needs for assistance receive the remaining funds. 
Funds for this supplemental grant shall be equal to 50% of 
newly appropriated funding for each fiscal year under Part B.
    Sec. 129. Amends section 2616(c). Clarifies the intent of 
funding for treatments and services related to treatments. 
Creates 10% cap for services that encourage, support and 
enhance adherence with treatment regimens, including medical 
monitoring. Creates a supplemental grant to enable States to 
provide assistance to individuals living at or below 200% of 
the FPL. Supplemental funds shall be available to States who 
are unable to provide access to HIV therapeutic regimens to all 
eligible individuals due to the high cost of and severe need 
for these therapeutic regimens within the State. States shall 
match the Federal supplement at a rate of 1:4. The Secretary is 
authorized to reserve 3 percent of ADAP appropriations, which 
shall be used only for the purchase of therapeutics. Adds 
language regarding the use of these funds to supplement and not 
supplant other funding available to provide treatments of the 
type that may be provided under this section.
    Sec. 130. Amends section 2618(b)(1)(A)(i) and 
2618(b)(3)(B). Doubles existing minimum Title II base award to 
$200,000 for States with less than 90 living cases of AIDS and 
to $500,000 for States with 90 or more living cases of AIDS. 
Adds the Federated States of Micronesia and the Republic of 
Palau as entities eligible to receive Title II funds. 
Establishes a minimum funding level of $50,000 for territories 
eligible for Title II funding.
    Sec. 131. Amends section 2611(b). Continues existing set-
aside for infants, children and women but requires that funds 
be allocated proportionately according to the percentage that 
each group represents in the State.

     Subtitle C--Amendments to Part C (Early Intervention Services)

    Sec. 141. Repeals part C of title XXVI and amends section 
2661(a) and 2664. Repeals formula grant program that has never 
been funded.
    Sec. 142. Amends section 2654(c). Creates new capacity 
development grants for underserved low income urban and low 
income rural areas for the purposes of expanding capacity, 
preparedness, and expertise to deliver primary care, up to a 
maximum of $150,000 over a three year period. Increases the 
percentage of appropriations under this section that can be 
used for planning and capacity development grants from 1% to 
5%.
    Sec. 143. Amends section 2655. Amends language to update 
authorization for FY 2001-2005 appropriations.
    Sec. 144. Amends section 2664(g). Increases the 
administrative cap for the directly funded Title III programs 
to 10% from their current level of 7.5% to correspond to the 
similar 10% cap on individual contractors in Title I. Requires 
grantees to implement a quality management program.
    Sec. 145. Amends section 2651. Provision will require HRSA 
to consider preferentially Title III grant-funding applications 
from rural and underserved areas.

         Subtitle D--Amendments to Part D (General Provisions)

    Sec. 151. Amends section 2671 (b), (d), (f), (g), and (j). 
Removes the requirement that Title IV grantees enroll a 
``significant number'' of women and children in research 
projects. Requires better information and education for 
patients concerning the linkages between care and research. 
Requires grantees to implement a quality management program. 
Requires Secretary, through NIH, to examine the distribution 
and availability of HIV-related clinical programs for purposes 
of enhancing and expanding access. Updates authorization for FY 
2001-2005 appropriations.
    Sec. 152. Amends section 2671. Requires the Secretary to 
conduct a review of administrative and program support, in 
consultation with grantees, to determine FY 2002 limitations on 
allowable amounts for administrative and program support 
expenses.
    Sec. 153. Amends section 2674(c). Amends language to update 
authorization for FY 2001-2005 appropriations for evaluation 
and reports under this part.
    Sec. 154. Amends section 2677. Amends language to update 
authorization for FY 2001-2005 appropriations for Part A and 
Part B.

     Subtitle E--Amendments to Part F (Demonstration and Training)

    Sec. 161. Amends section 2692(c) (1) and (2). Amends 
language to update authorization for FY 2001-2005 
appropriations for this part. Allows for dental hygiene 
programs certified by the Commission on Dental Accreditation to 
receive reimbursement for services provided to people with HIV 
and AIDS.

Section 4. Institute of Medicine study

                   Title II--Miscellaneous Provisions

    Sec. 201. Authorizes the Secretary to request that the 
Institute of Medicine complete a study of the financing and 
delivery of primary care and support services for low income, 
uninsured, and under-insured individuals with HIV disease, 
within 21 months after the enactment of this Act.

                      IX. 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

           *       *       *       *       *       *       *



SEC. 2602. ADMINISTRATION AND PLANNING COUNCIL.

    (a) Administration.--
          (1) In general.--* * *

           *       *       *       *       *       *       *

    (b) HIV Health Services Planning Council.--
          (1) Establishment.--* * *
          (2) Representation.--* * *
                  (A) * * *

           *       *       *       *       *       *       *

                  (C) social service providers, including 
                providers of housing and homeless services;

           *       *       *       *       *       *       *

          (4) Duties.--The planning council established or 
        designated under paragraph (1) [shall--
                  [(A) establish priorities for the allocation 
                of funds within the eligible area, including 
                how best to meet each such priority and 
                additional factors that a grantee should 
                consider in allocating funds under a grant 
                based on the--
                          [(i) documented needs of the HIV-
                        infected population;
                          [(ii) cost and outcome effectiveness 
                        of proposed strategies and 
                        interventions, to the extent that such 
                        data are reasonably (either 
                        demonstrated or probable);
                          [(iii) priorities of the HIV-infected 
                        communities for whom the services are 
                        intended; and
                          [(iv) availability of other 
                        governmental and non-governmental 
                        resources;
                  [(B) develop a comprehensive plan for the 
                organization and delivery of health services 
                described in section 2604 that is compatible 
                with any existing State or local plan regarding 
                the provision of health services to individuals 
                with HIV disease;
                  [(C) assess the efficiency of the 
                administrative mechanism in rapidly allocating 
                funds to the areas of greatest need within the 
                eligible area, and at the discretion of the 
                planning council, assess the effectiveness, 
                either directly or through contractual 
                arrangements, of the services offered in 
                meeting the identified needs;
                  [(D) participate in the development of the 
                statewide coordinated statement of need 
                initiated by the State public health agency 
                responsible for administering grants under part 
                B; and
                  [(E) establish methods for obtaining input on 
                community needs and priorities which may 
                include public meetings, conducting focus 
                groups, and convening ad-hoc panels.] shall 
                have the responsibilities specified in 
                subsection (d).
     (d) Duties of Planning Council.--The planning council 
established under subsection (b) shall have the following 
duties:
          (1) Priorities for allocation of funds.--The council 
        shall establish priorities for the allocation of funds 
        within the eligible area, including how best to meet 
        each such priority and additional factors that a 
        grantee should consider in allocating funds under a 
        grant, based on the following factors:
                  (A) The size and demographic characteristics 
                of the population with HIV disease to be 
                served, including, subject to subsection (e), 
                the needs of individuals living with HIV 
                infection who are not receiving HIV-related 
                health services.
                  (B) The documented needs of the population 
                with HIV disease with particular attention 
                being given to disparities in health services 
                among affected subgroups within the eligible 
                area.
                  (C) The demonstrated or probable cost and 
                outcome effectiveness of proposed strategies 
                and interventions, to the extent that data are 
                reasonably available.
                  (D) Priorities of the communities with HIV 
                disease for whom the services are intended.
                  (E) The availability of other governmental 
                and nongovernmental resources, including the 
                State medicaid plan under title XIX of the 
                Social Security Act and the State Children's 
                Health Insurance Program under title XXI of 
                such Act to cover health care costs of eligible 
                individuals and families with HIV disease.
                  (F) Capacity development needs resulting from 
                gaps in the availability of HIV services in 
                historically underserved low-income 
                communities.
          (2) Comprehensive service delivery plan.--The council 
        shall develop a comprehensive plan for the organization 
        and delivery of health and support services described 
        in section 2604. Such plan shall be compatible with any 
        existing State or local plans regarding the provision 
        of such services to individuals with HIV disease.
          (3) Assessment of fund allocation efficiency.--The 
        council shall assess the efficiency of the 
        administrative mechanism in rapidly allocating funds to 
        the areas of greatest need within the eligible area.
          (4) Statewide statement of need.--The council shall 
        participate in the development of the Statewide 
        coordinated statement of need as initiated by the State 
        public health agency responsible for administering 
        grants under part B.
          (5) Coordination with other federal grantees.--The 
        council shall coordinate with Federal grantees 
        providing HIV-related services within the eligible 
        area.
          (6) Community participation.--The council shall 
        establish methods for obtaining input on community 
        needs and priorities which may include public meetings, 
        conducting focus groups, and convening ad-hoc panels.
    (e) Process for Establishing Allocation Priorities.--
          (1) In general.--Not later than 24 months after the 
        date of enactment of the Ryan White CARE Act Amendments 
        of 2000, the Secretary shall--
                  (A) consult with eligible metropolitan areas, 
                affected communities, experts, and other 
                appropriate individuals and entities, to 
                develop epidemiologic measures for establishing 
                the number of individuals living with HIV 
                disease who are not receiving HIV-related 
                health services; and
                  (B) provide advice and technical assistance 
                to planning councils with respect to the 
                process for establishing priorities for the 
                allocation of funds under subsection (d)(1).
          (2) Exception.--Grantees under this part shall not be 
        required to establish priorities for individuals not in 
        care until epidemiologic measures are developed under 
        paragraph (1).

           *       *       *       *       *       *       *


SEC. 2603. TYPE AND DISTRIBUTION OF GRANTS.

    (a) Grants Based on Relative Need of Area.--
          (1) In general.--* * *
          (2) Expedited distribution.--Not later than 60 days 
        after an appropriation becomes available to carry out 
        this part [for each of the fiscal years 1996 through 
        2000] for a fiscal year, the Secretary shall, except in 
        the case of waivers granted under section 2605(c), 
        disburse 50 percent of the amount appropriated under 
        section 2677 for such fiscal year through grants to 
        eligible areas under section 2601(a), in accordance 
        with paragraph (3). The Secretary shall reserve an 
        additional percentage of the amount appropriated under 
        section 2677 for a fiscal year for grants under part A 
        to make grants to eligible areas under section 2601(a) 
        in accordance with paragraph (4).

           *       *       *       *       *       *       *

          [(4) Increase in grant.--With respect to an eligible 
        area under section 2601(a), the Secretary shall 
        increase the amount of a grant under paragraph (2) for 
        a fiscal year to ensure that such eligible area 
        receives not less than--
                  [(A) with respect to fiscal year 1996, 100 
                percent;
                  [(B) with respect to fiscal year 1997, 99 
                percent;
                  [(C) with respect to fiscal year 1998, 98 
                percent;
                  [(D) with respect to fiscal year 1999, 96.5 
                percent; and
                  [(E) with respect to fiscal year 2000, 95 
                percent; of the amount allocated for fiscal 
                year 1995 to such entity under this 
                subsection.]
         (4) Limitation.--With respect to each of fiscal years 
        2001 through 2005, the Secretary shall ensure that the 
        amount of a grant made to an eligible area under 
        paragraph (2) for such a fiscal year is not less than 
        an amount equal to 98 percent of the amount the 
        eligible area received for the fiscal year preceding 
        the year for which the determination is being made.

SEC. 2604. USE OF AMOUNTS.

    (a) Requirements.--* * *

           *       *       *       *       *       *       *

    (b) Primary Purposes.--
          (1) In general.--The chief elected official shall use 
        amounts received under a grant under section 2601 to 
        provide direct financial assistance to entities 
        described in paragraph (2) for the purpose of 
        delivering or enhancing [HIV-related--] HIV-related 
        services, as follows:
                  (A) [outpatient and ambulatory health and 
                support services, including case management, 
                substance abuse treatment] Outpatient health 
                services.--Outpatient and ambulatory health 
                services, including substance abuse treatment, 
                and mental health treatment, and comprehensive 
                treatment services, which shall include 
                treatment education and prophylactic treatment 
                for opportunistic infections, for individuals 
                and families with HIV disease[; and].
                  (B) Outpatient support services.--Outpatient 
                and ambulatory support services (including case 
                management), to the extent that such services 
                facilitate, enhance, support, or sustain the 
                delivery, continuity, benefits of health 
                services for individuals and families with HIV 
                disease.
                  [(B) inpatient case management] (C) Inpatient 
                case management services._Inpatient case 
                management services that prevent unnecessary 
                hospitalization or that expedite discharge, as 
                medically appropriate, from inpatient 
                facilities.

           *       *       *       *       *       *       *

                  (D) Early intervention services.--Early 
                intervention services as described in section 
                2651(b)(2), with follow-through referral, 
                provided for the purpose of facilitating the 
                access of individuals receiving the services to 
                HIV-related health services, but only if the 
                entity providing such services--
                          (i)(I) is receiving funds under 
                        subparagraph (A) or (C); or
                          (II) is an entity constituting a 
                        point of access to services, as 
                        described in section 2605(a)(4), that 
                        maintains a relationship with an entity 
                        described in subclause (I) and that is 
                        serving individuals at elevated risk of 
                        HIV disease;
                          (ii) demonstrates to the satisfaction 
                        of the chief elected official that 
                        Federal, State, or local funds are 
                        inadequate for the early intervention 
                        services the entity will provide with 
                        funds received under this subparagraph; 
                        and
                          (iii) demonstrates to the 
                        satisfaction of the chief elected 
                        official that funds will be utilized 
                        under this subparagraph to supplement 
                        not supplant other funds available for 
                        such services in the year for which 
                        such funds are being utilized.

           *       *       *       *       *       *       *

          (3) Priority for women, infants and children.--For 
        the purpose of providing health and support services to 
        infants, children, and women with HIV disease, 
        including treatment measures to prevent the perinatal 
        transmission of HIV, the chief elected official of an 
        eligible area, in accordance with the established 
        priorities of the planning council for each population 
        under this subsection, shall use, from the grants made 
        for the area under section 2601(a) for a fiscal year, 
        not less than the percentage constituted by the [ratio 
        of the] ratio of each population in such area of 
        infants, children, and women with acquired immune 
        deficiency syndrome to the general population in such 
        area of individuals with such syndrome.
    (c) Quality Management.--
          (1) Requirement.--The chief elected official of an 
        eligible area the receives a grant under this part 
        shall provide for the establishment of a quality 
        management program to assess the extent to which 
        medical services provided to patients under the grant 
        are consistent with the most recent Public Health 
        Service guidelines for the treatment of HIV disease and 
        related opportunistic infection and to develop 
        strategies for improvements in the access to and 
        quality of medical services.
          (2) Use of funds.--From amounts received under a 
        grant awarded under this part, the chief elected 
        official of an eligible area may use, for activities 
        associated with its quality management program, not 
        more than the lesser of--
                  (A) 5 percent of amounts received under the 
                grant; or
                  (B) $3,000,000.
    [(c)] (d) Limited Expenditures for Personnel Needs.--

           *       *       *       *       *       *       *

    [(d)] (e) Requirement of Status as Medicaid Provider.--
          (1) Provision of service.--Subject to paragraph (2), 
        the Secretary may not make a grant under section 
        2601(a) for the provision of services under this 
        section in a State unless, in the case of any such 
        service that is available pursuant to the State plan 
        approved under title XIX of the Social Security Act and 
        the State Children's Health Insurance Program under 
        title XXI of such Act for the State--

           *       *       *       *       *       *       *

    [(e)] (f) Administration.--

           *       *       *       *       *       *       *

    [(f)] (g) Construction.--* * *

SEC. 2605. APPLICATION.

    (a) In General.--* * *
          (1)(A) that funds received under a grant awarded 
        under this part will be utilized to supplement not 
        supplant State funds made available in the year for 
        which the grant is awarded to provide HIV-related 
        [services to individuals with HIV disease] services as 
        described in section 2604(b)(1);
          (B) that the political subdivisions within the 
        eligible area will maintain the level of expenditures 
        by such political subdivisions for HIV-related 
        [services for individuals with HIV disease] services as 
        described in section 2604(b)(1) at a level that is 
        equal to the level of such expenditures by such 
        political subdivisions for the preceding fiscal year; 
        and

           *       *       *       *       *       *       *

          (3) that the chief elected official of the eligible 
        area will satisfy all requirements under section 
        2604(c);
          (4) that funded entities within the eligible area 
        that receive funds under a grant under section 2601(a) 
        shall maintain appropriate relationships with entities 
        in the area served that constitute key points of access 
        to the health care system for individuals with HIV 
        disease (including emergency rooms, substance abuse 
        treatment programs, detoxification centers, adult and 
        juvenile detention facilities, sexually transmitted 
        disease clinics, HIV counseling and testing sites, 
        mental health programs, and homeless shelters) and 
        other entities under section 2652(a) for the purpose of 
        facilitating early intervention for individuals newly 
        diagnosed with HIV disease and individuals 
        knowledgeable of their status but not in care;
          [(3)] (5) that entities within the eligible area that 
        will receive funds under a grant provided under section 
        2601(a) shall participate in an established HIV 
        community-based continuum of care if such continuum 
        exists within the eligible area;
          [(4)] (6) that funds received under a grant awarded 
        under this part will not be utilized to make payments 
        for any item or service to the extent that payment has 
        been made, or can reasonably be expected to be made, 
        with respect to that item or service--

           *       *       *       *       *       *       *

          [(5)] (7) to the maximum extent practicable, that--
                  (A) * * *

           *       *       *       *       *       *       *

                  (C) a program of outreach will be provided to 
                low-in-come individuals with HIV-disease to 
                inform such individuals of such services; [and]
          [(6)] (8) that the applicant has participated, or 
        will agree to participate, in the statewide coordinated 
        statement of need process where it has been initiated 
        by the State public health agency responsible for 
        administering grants under part B, and ensure that the 
        services provided under the comprehensive plan are 
        consistent with the statewide coordinated statement of 
        need[.]; and
           (9) that the eligible area has procedures in place 
        to ensure that services provided with funds received 
        under this part meet the criteria specified in section 
        2604(b)(1).

           *       *       *       *       *       *       *


                       PART B--CARE GRANT PROGRAM


                  Subpart I--General Grant Provisions


SEC. 2611. [300FF-21] GRANTS.

    (a) In General.--* * *

           *       *       *       *       *       *       *

    (b) Priority for Women, Infants and Children.--For the 
purpose of providing health and support services to infants, 
children, and women with HIV disease, including treatment 
measures to prevent the perinatal transmission of HIV, a State 
shall use for each population under this subsection, of the 
funds allocated under this part to the State for a fiscal year, 
not less than the percentage constituted by the [ratio of the] 
ratio of each population in the State of infants, children, and 
women with acquired immune deficiency syndrome to the general 
population in the State of individuals with such syndrome.

           *       *       *       *       *       *       *


SEC. 2612. GENERAL USE OF GRANTS.

    [A State] (a) In General._A State may use amounts provided 
under grants made under this part--
          (1) to provide the services described in section 
        2604(b)(1) [for individuals with HIV disease], subject 
        to the conditions and limitations that apply under such 
        section;

           *       *       *       *       *       *       *

          (4) to provide assistance to assure the continuity of 
        health insurance coverage for individuals with HIV 
        disease in accordance with section 2615; [and]
          (5) to provide therapeutics to treat HIV disease to 
        individuals with HIV disease in accordance with section 
        2616[.]; and
          (6) to provide, through systems of HIV-related health 
        services provided under paragraphs (1), (2), and (3), 
        early intervention services, as described in section 
        2651(b)(2), with follow-up referral, provided for the 
        purpose of facilitating the access of individuals 
        receiving the services to HIV-related health services, 
        but only if the entity providing such services--
                  (A)(i) is receiving funds under section 
                2612(a)(1); or
                  (ii) is an entity constituting a point of 
                access to services, as described in section 
                2617(b)(4), that maintains a referral 
                relationship with an entity described in clause 
                (i) and that is serving individuals at elevated 
                risk of HIV disease;
                  (B) demonstrates to the State's satisfaction 
                that other Federal, State, or local funds are 
                inadequate for the early intervention services 
                the entity will provide with funds received 
                under this paragraph; and
                  (C) demonstrates to the satisfaction of the 
                State that funds will be utilized under this 
                paragraph to supplement not supplant other 
                funds available for such services in the year 
                for which such funds are being utilized.
    [Services] (b) Delivery of Services.--Services described in 
[paragraph (1)] subsection (a)(1) shall be delivered through 
consortia designed as described in [paragraph (2)] subsection 
(a)(2) and section 2613, where such consortia exist, unless the 
State demonstrates to the Secretary that delivery of such 
services would be more effective when other delivery mechanisms 
are used. In making a determination regarding the delivery of 
services, the State shall consult with appropriate 
representatives of service providers and recipients of services 
who would be affected by such determination, and shall include 
in its demonstration to the Secretary the findings of the State 
regarding such consultation.

SEC. 2616. [300FF-26] PROVISION OF TREATMENTS.

    (a) In General.--* * *

           *       *       *       *       *       *       *

    (c) State Duties.--[In carrying] (1) In general._In 
carrying out this section the State [shall--] shall use funds 
made available under this section to--
          [(1)] (A) determine, in accordance with guidelines 
        issued by the Secretary, which treatments are eligible 
        to be included under the program established under this 
        section;
          [(2)] (B) provide assistance for the purchase of 
        treatments determined to be eligible under paragraph 
        (1), and the provision of such ancillary devices that 
        are essential to administer such treatments;
          [(3)] (C) provide outreach to individuals with HIV 
        disease, and as appropriate to the families of such 
        individuals;
          [(4)] (D) facilitate access to treatments for such 
        individuals; [and]
          [(5)] (E) document the progress made in making 
        therapeutics described in subsection (a) available to 
        individuals eligible for assistance under this 
        section[.]; and
          (F) encourage, support, and enhance adherence to and 
        compliance with treatment regimens, including related 
        medical monitoring.
    (2) Limitations.--
          (A) In general.--No State shall use funds under 
        paragraph (1)(F) unless the limitations on access to 
        HIV/AIDS therapeutic regimens as defined in subsection 
        (e)(2) are eliminated.
          (B) Amount of funding.--No State shall use in excess 
        of 10 percent of the amount set-aside for use under 
        this section in any fiscal year to carry out activities 
        under paragraph (1)(F) unless the State demonstrates to 
        the Secretary that such additional services are 
        essential and in no way diminish access to 
        therapeutics.

           *       *       *       *       *       *       *

    (e) Supplemental Grants for the Provision of Treatments.--
          (1) In general.--From amounts made available under 
        paragraph (5), the Secretary shall award supplemental 
        grants to States determined to be eligible under 
        paragraph (2) to enable such States to increase access 
        to therapeutics to treat HIV disease as provided by the 
        State under subsection (c)(1)(B) for individuals at or 
        below 200 percent of the Federal poverty line.
          (2) Criteria.--The Secretary shall develop criteria 
        for the awarding of grants under paragraph (1) to 
        States that demonstrate a severe need. In determining 
        the criteria for demonstrating State severity of need, 
        the Secretary shall consider eligibility standards and 
        formulary composition.
          (3) State requirement.--The Secretary may not make a 
        grant to a State under this subsection unless the State 
        agrees that--
                  (A) the State will make available (directly 
                or through donations from public or private 
                entities) non-Federal contributions toward the 
                activities to be carried out under the grant in 
                an amount equal to $1 for each $4 of Federal 
                funds provided in the grant; and
                  (B) the State will not impose eligibility 
                requirements for services or scope of benefits 
                limitations under subsection (a) that are more 
                restrictive than such requirements in effect as 
                of January 1, 2000.
          (4) Use and coordination.--Amounts made available 
        under a grant under this subsection shall only be used 
        by the State to provide HIV/AIDS-related medications. 
        The State shall coordinate the use of such amounts with 
        the amounts otherwise provided under this section in 
        order to maximize drug coverage.
          (5) Funding.--
                  (A) Reservation of amount.--The Secretary 
                shall reserve 3 percent of any amount referred 
                to in section 2618(b)(2)(H) that is 
                appropriated for a fiscal year, to carry out 
                this subsection.
                  (B) Minimum amount.--In providing grants 
                under this subsection, the Secretary shall 
                ensure that the amount of a grant to a State 
                under this part is not less than the amount the 
                State received under this part in the previous 
                fiscal year, as a result of grants provided 
                under this subsection.
    (f) Supplement Not Supplant.--Notwithstanding any other 
provision of law, amounts made available under this section 
shall be used to supplement and not supplant other funding 
available to provide treatments of the type that may be 
provided under this section.

           *       *       *       *       *       *       *


SEC. 2617. STATE APPLICATION.

    (a) In General.--* * *
    (b) * * *
          (1) * * *

           *       *       *       *       *       *       *

                  (C) * * *
                          [(i) the number of individuals to be 
                        served with assistance provided under 
                        the grant;]
                          (i) the size and demographic 
                        characteristics of the population with 
                        HIV disease to be served, except that 
                        by not later than October 1, 2002, the 
                        State shall take into account the needs 
                        of individuals not in care, based on 
                        epidemiologic measures developed by the 
                        Secretary in consultation with the 
                        State, affected communities, experts, 
                        and other appropriate individuals (such 
                        State shall not be required to 
                        establish priorities for individuals 
                        not in care until such epidemiologic 
                        measures are developed);

           *       *       *       *       *       *       *

                          (iii) the average cost of providing 
                        each category of HIV-related health 
                        services and the extent to which such 
                        cost is paid by third-party payors; 
                        [and]

           *       *       *       *       *       *       *

                          (v) the availability of other 
                        governmental and non-governmental 
                        resources;
                          (vi) the capacity development needs 
                        resulting in gaps in the provision of 
                        HIV services in historically 
                        underserved low-income and rural low-
                        income communities; and
                          (vii) the efficiency of the 
                        administrative mechanism in rapidly 
                        allocating funds to the areas of 
                        greatest need within the State;
          (2) * * *

           *       *       *       *       *       *       *

                  (B) a description of the manner in which 
                services funded with assistance provided under 
                this part will be coordinated with other 
                available related services for individuals with 
                HIV disease; [and]
                  (C) an assurance that capacity development 
                needs resulting from gaps in the provision of 
                services in underserved low-income and rural 
                low-income communities will be addressed; and
                  (D) with respect to fiscal year 2003 and 
                subsequent fiscal years, assurances that, in 
                the planning and allocation of resources, the 
                State, through systems of HIV-related health 
                services provided under paragraphs (1), (2), 
                and (3) of section 2612(a), will make 
                appropriate provision for the HIV-related 
                health and support service needs of individuals 
                who have been diagnosed with HIV disease but 
                who are not currently receiving such services, 
                based on the epidemiologic measures developed 
                under paragraph (1)(C)(i);
                  (E) an assurance that the State has 
                procedures in place to ensure that services 
                provided with funds received under this section 
                meet the criteria specified in section 
                2604(b)(1)(B); and
                  [(C)] (F) a description of how the allocation 
                and utilization of resources are consistent 
                with the statewide coordinated statement of 
                need (including traditionally underserved 
                populations and subpopulations) developed in 
                partnership with other grantees in the State 
                that receive funding under this title; and

           *       *       *       *       *       *       *

          (4) * * *

           *       *       *       *       *       *       *

                  [(C) the State will provide for periodic 
                independent peer review to assess the quality 
                and appropriateness of health and support 
                services provided by entities that receive 
                funds from the State under this part;]
                  (C) the State will provide for--
                          (i) the establishment of a quality 
                        management program to assess the extent 
                        to which medical services provided to 
                        patients under the grant are consistent 
                        with the most recent Public Health 
                        Service guidelines for the treatment of 
                        HIV disease and related opportunistic 
                        infections and to develop strategies 
                        for improvements in the access to and 
                        quality of medical services; and
                          (ii) a periodic review (such as 
                        through an independent peer review) to 
                        assess the quality and appropriateness 
                        of HIV-related health and support 
                        services provided by entities that 
                        receive funds from the State under this 
                        part;

           *       *       *       *       *       *       *

                  (E) an assurance that the State, through 
                systems of HIV-related health services provided 
                under paragraphs (1), (2), and (3) of section 
                2612(a), has considered strategies for working 
                with providers to make optimal use of financial 
                assistance under the State medicaid plan under 
                title XIX of the Social Security Act, the State 
                Children's Health Insurance Program under title 
                XXI of such Act, and other Federal grantees 
                that provide HIV-related services, to maximize 
                access to quality HIV-related health and 
                support services;
                  [(E)] (F) the State will maintain HIV-related 
                activities at a level that is equal to not less 
                than level of such expenditures by the State 
                for the 1-year period preceding the fiscal year 
                for which the State is applying to receive a 
                grant under this part; [and,]
                  [(F)] (G) the State will ensure that grant 
                funds are not utilized to make payments for any 
                item or service to the extent that payment has 
                been made, or can reasonably be expected to be 
                made, with respect to that item or service--
                          (i) under any State compensation 
                        program, under an insurance policy, or 
                        under any Federal or State health 
                        benefits program; or
                          (ii) by an entity that provides 
                        health services on a prepaid basis[.]; 
                        and
                  (H) that funded entities maintain appropriate 
                relationships with entities in the area served 
                that constitute key points of access to the 
                health care system for individuals with HIV 
                disease (including emergency rooms, substance 
                abuse treatment programs, detoxification 
                centers, adult and juvenile detention 
                facilities, sexually transmitted disease 
                clinics, HIV counseling and testing sites, 
                mental health programs, and homeless shelters), 
                and other entities under section 2652(a), for 
                the purpose of facilitating early intervention 
                for individuals newly diagnosed with HIV 
                disease and individuals knowledgeable of their 
                status but not in care.

           *       *       *       *       *       *       *


SEC. 2618. [300FF-28] DISTRIBUTION OF FUNDS.

    (b) Amount of Grant to State.--
          (1) Minimum allotment.--* * *

           *       *       *       *       *       *       *

                          (i)(I) with respect to a State or 
                        District that has less than 90 living 
                        cases of acquired immune deficiency 
                        syndrome, as determined under paragraph 
                        (2)(D), [$100,000] $200,000; or
                          (II) with respect to a State or 
                        District that has 90 or more living 
                        cases of acquired immune deficiency 
                        syndrome, as determined under paragraph 
                        (2)(D), [$250,000] $250,000;

           *       *       *       *       *       *       *

          (3) Definitions.--As used in this subsection--
                  (A) * * *

           *       *       *       *       *       *       *

                  (B) the term ``territory of the United 
                States'' means, American Samoa, the 
                Commonwealth of the Northern Mariana Islands, 
                [and the Republic of the Marshall Islands] the 
                Republic of the Marshall Islands, the Federated 
                States of Micronesia, and the Republic of 
                Palau.

           *       *       *       *       *       *       *

    (c) Allocation of Assistance by States.--

           *       *       *       *       *       *       *

          (3) Planning and evaluations.--Subject to paragraph 
        (5) and except as provided in paragraph (6), a State 
        may not use more than 10 percent of amounts received 
        under a grant awarded under this part for planning and 
        evaluation activities, including not more than 
        $3,000,000 for all activities associated with its 
        quality management program.

           *       *       *       *       *       *       *

          [(6) Exception.--With respect to a State that 
        received the minimum allotment under subsection (a)(1) 
        for a fiscal year such State, from the amounts received 
        under a grant awarded under this part for such fiscal 
        year for the activities described in paragraphs (3) and 
        (4), may, notwithstanding paragraphs (3), (4), and (5), 
        use not more than that amount required to support one 
        full-time-equivalent employee.]
          (6) Exception for quality management.--
        Notwithstanding paragraph (5), a State whose grant 
        under this part for a fiscal year does not exceed 
        $1,500,000 may use not to exceed 20 percent of the 
        amount of the grant for the purposes described in 
        paragraphs (3) and (4) if--
                  (A) that portion of the amount that may be 
                used for such purposes in excess of 15 percent 
                of the grant is used for its quality management 
                program; and
                  (B) the State submits and the Secretary 
                approves a plan (in such form and containing 
                such information as the Secretary may 
                prescribe) for use of funds for its quality 
                management program.

           *       *       *       *       *       *       *


SEC. 2622. SUPPLEMENTAL GRANTS.

     (a) In General.--The Secretary shall award supplemental 
grants to States determined to be eligible under subsection (b) 
to enable such States to provide comprehensive services of the 
type described in section 2612(a) to supplement the services 
otherwise provided by the State under a grant under this 
subpart in emerging communities within the State that are not 
eligible toreceive grants under part A.
    (b) Eligibility.--To be eligible to receive a supplemental 
grant under subsection (a) a State shall--
          (1) be eligible to receive a grant under this 
        subpart; and
          (2) demonstrate the existence in the State of an 
        emerging community as defined in subsection (d)(1).
    (c) Reporting Requirements.--A State that desires a grant 
under this section shall, as part of the State application 
submitted under section 2617, submit a detailed description of 
the manner in which the State will use amounts received under 
the grant and of the severity of need. Such description shall 
include--
          (1) a report concerning the dissemination of 
        supplemental funds under this section and the plan for 
        the utilization of such funds in the emerging 
        community;
          (2) a demonstration of the existing commitment of 
        local resources, both financial and in-kind;
          (3) a demonstration that the State will maintain HIV-
        related activities at a level that is equal to not less 
        than the level of such activities in the State for the 
        1-year period preceding the fiscal year for which the 
        State is applying to receive a grant under this part;
          (4) a demonstration of the ability of the State to 
        utilize such supplemental financial resources in a 
        manner that is immediately responsive and cost 
        effective;
          (5) a demonstration that the resources will be 
        allocated in accordance with the local demographic 
        incidence of AIDS including appropriate allocations for 
        services for infants, children, women, and families 
        with HIV disease;
          (6) a demonstration of the inclusiveness of the 
        planning process, with particular emphasis on affected 
        communities and individuals with HIV disease; and
          (7) a demonstration of the manner in which the 
        proposed services are consistent with local needs 
        assessments and the statewide coordinated statement of 
        need.
    (d) Definition of Emerging Community.--In this section, the 
term ``emerging community'' means a metropolitan area--
          (1) that is not eligible for a grant under part A; 
        and
          (2) for which there has been reported to the Director 
        of the Centers for Disease Control and Prevention a 
        cumulative total of between 500 and 1999 cases of 
        acquired immune deficiency syndrome for the most recent 
        period of 5 calendar years for which such data are 
        available.
    (e) Funding.--
          (1) In general.--Subject to paragraph (2), with 
        respect to each fiscal year beginning with fiscal year 
        2001, the Secretary, to carry out this section, shall 
        utilize--
                  (A) the greater of--
                          (i) 25 percent of the amount 
                        appropriated under 2677 to carry out 
                        part B, excluding the amount 
                        appropriated under section 
                        2618(b)(2)(H), for such fiscal year 
                        that is in excess of the amount 
                        appropriated to carry out such part in 
                        fiscal year preceding the fiscal year 
                        involved; or
                          (ii) $5,000,000;
                to provide funds to States for use in emerging 
                communities with at least 1000, but less than 
                2000, cases of AIDS as reported to and 
                confirmed by the Director of the Centers for 
                Disease Control and Prevention for the five 
                year period preceding the year for which the 
                grant is being awarded; and
                  (B) the greater of--
                          (i) 25 percent of the amount 
                        appropriated under 2677 to carry out 
                        part B, excluding the amount 
                        appropriated under section 
                        2618(b)(2)(H), for such fiscal year 
                        that is in excess of the amount 
                        appropriated to carry out such part in 
                        fiscal year preceding the fiscal year 
                        involved; or
                          (ii) $5,000,000;
                to provide funds to States for use in emerging 
                communities with at least 500, but less than 
                1000, cases of AIDS reported to and confirmed 
                by the Director of the Centers for Disease 
                Control and Prevention for the five year period 
                preceding the year for which the grant is being 
                awarded.
          (2) Trigger of funding.--This section shall be 
        effective only for fiscal years beginning in the first 
        fiscal year in which the amount appropriated under 2677 
        to carry out part B, excluding the amount appropriated 
        under section 2618(b)(2)(H), exceeds by at least 
        $20,000,000 the amount appropriated under 2677 to carry 
        out part B in fiscal year 2000, excluding the amount 
        appropriated under section 2618(b)(2)(H).
          (3) Minimum amount in future years.--Beginning with 
        the first fiscal year in which amounts provided for 
        emerging communities under paragraph (1)(A) equals 
        $5,000,000 and under paragraph (1)(B) equals 
        $5,000,000, the Secretary shall ensure that amounts 
        made available under this section for the types of 
        emerging communities described in each such paragraph 
        in subsequent fiscal years is at least $5,000,000.

SEC. 2625. CDC GUIDELINES FOR PREGNANT WOMEN.

    (a) Requirement.--* * *

           *       *       *       *       *       *       *

    (c) Additional Funds Regarding Women and Infants.--
          (1) In general.--* * *

           *       *       *       *       *       *       *

          (2) Funding.--For purposes of carrying out this sub-
        section, there are authorized to be appropriated 
        $10,000,000 for each of the [fiscal years 1996 through 
        2000] fiscal years 2001 through 2005. Amounts made 
        available under section 2677 for carrying out this part 
        are not available for carrying out this section unless 
        otherwise authorized.

           *       *       *       *       *       *       *


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

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

              TITLE XXVI--HIV HEALTH CARE SERVICES PROGRAM

PART A--EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES

           *       *       *       *       *       *       *



  [PART C--EARLY INTERVENTION SERVICES] PART C_EARLY INTERVENTION AND 
                         PRIMARY CARE SERVICES


                 [Subpart I--Formula Grants for States


[SEC. 2641. [300FF-41] ESTABLISHMENT OF PROGRAM.

    [(a) Allotments for States.--For the purposes described in 
subsection (b), the Secretary, acting through the Director of 
the Centers for Disease Control and Prevention and in 
consultation with the Administrator of the Health Resources and 
Services Administration, shall for each of the fiscal years 
1991 through 1995 make an allotment for each State in an amount 
determined in accordance with section 2649. The Secretary shall 
make payments, as grants, to each State from the allotment for 
the State for the fiscal year involved if the Secretary 
approves for the fiscal year an application submitted by the 
State pursuant to section 2665.
    [(b) Purposes of Grants.--
          [(1) In general.--The Secretary may not make a grant 
        under subsection (a) unless the State involved agrees 
        to expend the grant for the purposes of providing, on 
        an outpatient basis, each of the early intervention 
        services specified in paragraph (2) with respect to HIV 
        disease.
          [(2) Specification of early intervention services.--
        The early intervention services referred to in 
        paragraph (1) are--
                  [(A) counseling individuals with respect to 
                HIV disease in accordance with section 2662;
                  [(B) testing individuals with respect to such 
                disease, including tests to confirm the 
                presence of the disease, tests to diagnose the 
                extent of the deficiency in the immune system, 
                and tests to provide information on appropriate 
                therapeutic measures for preventing and 
                treating the deterioration of the immune system 
                and for preventing and treating conditions 
                arising from the disease;
                  [(C) referrals described in paragraph (3);
                  [(D) other clinical and diagnostic services 
                with respect to HIV disease, and periodic 
                medical evaluations of individuals with the 
                disease; and
                  [(E) providing the therapeutic measures 
                described in subparagraph (B).
          [(3) Referrals.--The services referred to in 
        paragraph (2)(C) are referrals of individuals with HIV 
        disease to appropriate providers of health and support 
        services, including, as appropriate--
                  [(A) to entities receiving amounts under part 
                A or B for the provision of such services;
                  [(B) to biomedical research facilities of 
                institutions of higher education that offer 
                experimental treatment for such disease, or to 
                community-based organizations or other entities 
                that provide such treatment; or
                  [(C) to grantees under section 2671, in the 
                case of pregnant women.
          [(4) Requirement of availability of all early 
        intervention services through each grantee.--The 
        Secretary may not make a grant under subsection (a) 
        unless the State involved agrees that each of the early 
        intervention services specified in paragraph (2) will 
        be available through the State. With respect to 
        compliance with such agreement, a State may expend the 
        grant to provide the early intervention services 
        directly, and may expend the grant to enter into 
        agreements with public or nonprofit private entities 
        under which the entities provide the services.
          [(5) Optional services.--A State receiving a grant 
        under subsection (a)--
                  [(A) may expend not more than 5 percent of 
                the grant to provide early intervention 
                services through making grants to hospitals 
                that--
                          [(i) for the most recent fiscal year 
                        for which the data is available, have 
                        admitted--
                                  [(I) not fewer than 250 
                                individuals with acquired 
                                immune deficiency syndrome; or
                                  [(II) a number of such 
                                individuals constituting 20 
                                percent of the number of 
                                inpatients of the hospital 
                                admitted during such period;
                          [(ii) agree to offer and encourage 
                        such services with respect to 
                        inpatients of the hospitals; and
                          [(iii) agree that subsections (c) and 
                        (d) of section 2644 will apply to the 
                        hospitals to the same extent and in the 
                        same manner as such subsections apply 
                        to entities described in such section;
                  [(B) may expend the grant to provide outreach 
                services to individuals who may have HIV 
                disease, or may be at risk of the disease, and 
                who may be unaware of the availability and 
                potential benefits of early treatment of the 
                disease, and to provide outreach services to 
                health care professionals who may be unaware of 
                such availability and potential benefits; and
                  [(C) may, in the case of individuals who seek 
                early intervention services from the grantee, 
                expend the grant--
                          [(i) for case management to provide 
                        coordination in the provision of health 
                        care services to the individuals and to 
                        review the extent of utilization of the 
                        services by the individuals; and
                          [(ii) to provide assistance to the 
                        individuals regarding establishing the 
                        eligibility of the individuals for 
                        financial assistance and services under 
                        Federal, State, or local programs 
                        providing for health services, mental 
                        health services, social services, or 
                        other appropriate services.
          [(6) Allocations.--
                  [(A) Subject to subparagraphs (B) and (C), 
                the Secretary may not make a grant under 
                subsection (a) unless the State involved 
                agrees--
                          [(i) to expend not less than 35 
                        percent of the grant to provide the 
                        early intervention services specified 
                        in subparagraphs (A) through (C) of 
                        paragraph (2); and
                          [(ii) to expend not less than 35 
                        percent of the grant to provide the 
                        early intervention services specified 
                        in subparagraphs (D) and (E) of such 
                        paragraph.
                  [(B) With respect to compliance with the 
                agreement under subparagraph (A), amounts 
                reserved by a State for fiscal year 1991 for 
                purposes of clauses (i) and (ii) of such 
                subparagraph may be expended to provide the 
                services specified in paragraph (5).
                  [(C) The Secretary shall ensure that, of the 
                amounts appropriated under section 2650 for 
                fiscal year 1991, an amount equal to 
                $130,000,000 is expended to provide the early 
                intervention services specified in 
                subparagraphs (A) through (C) of paragraph (2).

[SEC. 2642. [300FF-42] PROVISION OF SERVICES THROUGH MEDICAID 
                    PROVIDERS.

    [(a) In General.--Subject to subsection (b), the Secretary 
may not make a grant under section 2641 to a State unless, in 
the case of any service described in subsection (b) of such 
section that is available pursuant to the State plan approved 
under title XIX of the Social Security Act for the State--
          [(1) the State will provide the service through a 
        State entity, and the State entity has entered into a 
        participation agreement under the State plan and is 
        qualified to receive payments under such plan; or
          [(2) the State will enter into an agreement with a 
        public or nonprofit private entity under which the 
        entity will provide the service, and the entity has 
        entered into such a participation agreement and is 
        qualified to receive such payments.
    [(b) Waiver Regarding Certain Secondary Agreements.--
          [(1) In general.--In the case of an entity making an 
        agreement pursuant to subsection (a)(2) regarding the 
        provision of services, the requirement established in 
        such subsection regarding a participation agreement 
        shall be waived by the Secretary if the entity 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.
          [(2) Acceptance of voluntary donations.--A 
        determination by the Secretary of whether an entity 
        referred to in paragraph (1) meets the criteria for a 
        waiver under such subparagraph shall be made without 
        regard to whether the entity accepts voluntary 
        donations for the purpose of providing services to the 
        public.

[SEC. 2643. [300FF-43] REQUIREMENT OF MATCHING FUNDS.

    [(a) In General.--In the case of any State to which the 
criterion described in subsection (c) applies, the Secretary 
may not make a grant under section 2641 unless the State agrees 
that, with respect to the costs to be incurred by the State in 
carrying out the purpose referred to in such subsection, the 
State will, subject to subsection (b)(2), make available 
(directly or through donations from public or private entities) 
non-Federal contributions toward such costs in an amount equal 
to--
          [(1) for the first fiscal year for which such 
        criterion applies to the State, not less than 16\2/3\ 
        percent of such costs ($1 for each $5 of Federal funds 
        provided in the grant);
          [(2) for any second such fiscal year, not less than 
        20 percent of such costs ($1 for each $4 of Federal 
        funds provided in the grant);
          [(3) for any third such fiscal year, not less than 25 
        percent of such costs ($1 for each $3 of Federal funds 
        provided in the grant); and
          [(4) for any subsequent fiscal year, not less than 
        33\1/3\ percent of such costs ($1 for each $2 of 
        Federal funds provided in the grant).
    [(b) Determination of Amount of Non-Federal Contribution.--
          [(1) In general.--Non-Federal contributions required 
        in subsection (a) may be in cash or in kind, fairly 
        evaluated, including plant, equipment, or services. 
        Amounts provided by the Federal Government, and any 
        portion of any service subsidized by the Federal 
        Government, may not be included in determining the 
        amount of such non-Federal contributions.
          [(2) Inclusion of certain amounts.--
                  [(A) In making a determination of the amount 
                of non-Federal contributions made by a State 
                for purposes of subsection (a), the Secretary 
                shall, subject to subparagraph (B), include any 
                non-Federal contributions provided by the State 
                for HIV-related services, without regard to 
                whether the contributions are made for programs 
                established pursuant to this title.
                  [(B) In making a determination for purposes 
                of subparagraph (A), the Secretary may not 
                include any non-Federal contributions provided 
                by the State as a condition of receiving 
                Federal funds under any program under this 
                title (except for the program established in 
                section 2641) or under other provisions of law.
    [(c) Applicability of Matching Requirement.--
          [(1) Percentage of national number of cases.--
                  [(A) The criterion referred to in subsection 
                (a) is, with respect to a State, that the 
                number of cases of acquired immune deficiency 
                syndrome reported to and confirmed by the 
                Director of the Centers for Disease Control and 
                Prevention for the State for the period 
                described in subparagraph (B) constitutes more 
                than 1 percent of the number of such cases 
                reported to and confirmed by the Director for 
                the United States for such period.
                  [(B) The period referred to in subparagraph 
                (A) is the 2-year period preceding the fiscal 
                year for which the State involved is applying 
                to receive a grant under section 2641.
          [(2) Exemption.--For purposes of paragraph (1), the 
        number of cases of acquired immune deficiency syndrome 
        reported and confirmed for the Commonwealth of Puerto 
        Rico for any fiscal year shall be deemed to be less 
        than 1 percent.
    [(d) Diminished State Contribution.--With respect to a 
State that does not make available the entire amount of the 
non-Federal contribution referred to in subsection (a), the 
State shall continue to be eligible to receive Federal funds 
under a grant under section 2641, except that the Secretary in 
providing Federal funds under the grant shall provide such 
funds (in accordance with the ratios prescribed in paragraph 
(1)) only with respect to the amount of funds contributed by 
such State.

[SEC. 2644. [300FF-44] OFFERING AND ENCOURAGING EARLY INTERVENTION 
                    SERVICES.

    [(a) In General.--The Secretary may not make a grant under 
section 2641 unless, in the case of entities to which the State 
provides amounts form the grant for the provision of early 
intervention services, the State involved agrees that--
          [(1) if the entity is a health care provider that 
        regularly provides treatment for sexually transmitted 
        diseases, the entity will offer and encourage such 
        services with respect to individuals to whom the entity 
        provides such treatment;
          [(2) if the entity is a health care provider that 
        regularly provides treatment for intravenous substance 
        abuse, the entity will offer and encourage such 
        services with respect to individuals to whom the entity 
        provides such treatment;
          [(3) if the entity is a family planning clinic, the 
        entity will offer and encourage such services with 
        respect to individuals to whom the entity provides 
        family planning services and whom the entity has reason 
        to believe has HIV disease; and
          [(4) If the entity is a health care provider that 
        provides treatment for tuberculosis, the entity will 
        offer and encourage such services with respect to 
        individuals to whom the entity provides such treatment.
    [(b) Sufficiency of Amount of Grant.--With respect to 
compliance with the agreement made under subsection (a), an 
entity to which subsection (a) applies may be required to 
offer, encourage, and provide early intervention services only 
to the extent that the amount of the grant is sufficient to pay 
the costs of offering, encouraging, and providing the services.
    [(c) Criteria for Offering and Encouraging.--Subject to 
section 2641(b)(4), an entity to which subsection (a) applies 
is, for purposes of such subsection, offering and encouraging 
early intervention services with respect to the individuals 
involved if the entity--
          [(1) offers such services to the individuals, and 
        encourages the individuals to receive the services, as 
        a regular practice in the course of providing the 
        health care involved; and
          [(2) provides the early intervention services only 
        with the consent of the individuals.

[SEC. 2645. [300FF-45] NOTIFICATION OF CERTAIN INDIVIDUALS RECEIVING 
                    BLOOD TRANSFUSIONS.

    [(a) In General.--The Secretary may not make a grant under 
section 2641 unless the State involved provides assurances 
satisfactory to the Secretary that, with respect to individuals 
in the State receiving, between January 1, 1978, and April 1, 
1985 (inclusive), a transfusion of whole blood or a blood-
clotting factor, the State will provide public education and 
information for the purpose of--
          [(1) encouraging the population of such individuals 
        to receive early intervention services; and
          [(2) informing such population of any health 
        facilities in the geographic area involved that provide 
        such services.
    [(b) Rule of Construction.--An agreement made under sub-
section (a) may not be construed to require that, in carrying 
out the activities described in such subsection, a State 
receiving a grant under section 2641 provide individual 
notifications to the individuals described in such subsection.

[SEC. 2646. [300FF-46] REPORTING AND PARTNER NOTIFICATION.

    [(a) Reporting.--The Secretary may not take a grant under 
section 2641 unless, with respect to testing for HIV disease, 
the State involved provides assurances satisfactory to the 
Secretary that the State will require that any entity carrying 
out such testing confidentially report to the State public 
health officer information sufficient--
          [(1) to perform statistical and epidemiological 
        analyses of the incidence in the State of cases of such 
        disease;
          [(2) to perform statistical and epidemiological 
        analyses of the demographic characteristics of the 
        population of individuals in the State who have the 
        disease; and
          [(3) to assess the adequacy of early intervention 
        services in the State.
    [(b) Partner Notification.--The Secretary may not make a 
grant under section 2641 unless the State involved provides 
assurances satisfactory to the Secretary that the State will 
require that the public health officer of the State, to the 
extent appropriate in the determination of the officer, carry 
out a program of partner notification regarding cases of HIV 
disease.
    [(c) Rules of Construction.--An agreement made under this 
section may not be construed--
          [(1) to require or prohibit any State from providing 
        that identifying information concerning individuals 
        with HIV disease is required to be submitted to the 
        State; or
          [(2) to require any State to establish a requirement 
        that entities other than the public health officer of 
        the State are required to make the notifications 
        referred to in subsection (b).

[SEC. 2647. [300FF-47] REQUIREMENT OF STATE LAW PROTECTION AGAINST 
                    INTENTIONAL TRANSMISSION.

    [(a) In General.--The Secretary may not make a grant under 
section 2641 to a State unless the chief executive officer 
determines that the criminal laws of the State are adequate to 
prosecute any HIV infected individual, subject to the condition 
described in sub-section (b), who--
          [(1) makes a donation of blood, semen, or breast 
        milk, if the individual knows that he or she is 
        infected with HIV and intends, through such donation, 
        to expose another HIV in the event that the donation is 
        utilized;
          [(2) engages in sexual activity if the individual 
        knows that he or she is infected with HIV and intends, 
        through such sexual activity, to expose another to HIV; 
        and
          [(3) injects himself or herself with a hypodermic 
        needle and subsequently provides the needle to another 
        person for purposes of hypodermic injection, if the 
        individual knows that he or she is infected and 
        intends, through the provision of the needle, to expose 
        another to such etiologic agent in the event that the 
        needle is utilized.
    [(b) Consent To Risk of Transmission.--The State laws 
described in subsection (a) need not apply to circumstances 
under which the conduct described in paragraphs (1) through (3) 
of subsection (a) if the individual who is subjected to the 
behavior involved knows that the other individual is infected 
and provides prior informed consent to the activity.
    [(c) State Certification With Respect to Required Laws.--
With respect to complying with subsection (a) as a condition of 
receiving a grant under section 2641, the Secretary may not 
require a State to enact any statute, or to issue any 
regulation, if the chief executive officer of the State 
certifies to the Secretary that the laws of the State are 
adequate. The existence of a criminal law of general 
application, which can be applied to the conduct described in 
paragraphs (1) through (3) of subsection (a), is sufficient for 
compliance with this section.
    [(d) Time Limitations With Respect to Required Laws.--With 
respect to receiving a grant under section 2641, if a State is 
unable to certify compliance with subsection (a), the Secretary 
may make a grant to a State under such section if--
          [(1) for each of the fiscal years 1991 and 1992, the 
        State provides assurances satisfactory to the Secretary 
        that by not later than October 1, 1992, the State will 
        have in place or will establish the prohibitions 
        described in subsection (a); and
          [(2) for fiscal year 1993 and subsequent fiscal 
        years, the State has established such prohibitions.

[SEC. 2648. [300FF-48] TESTING AND OTHER EARLY INTERVENTION SERVICES 
                    FOR STATE PRISONERS.

    [(a) In General.--In addition to grants under section 2641, 
the Secretary may make grants to States for the purpose of 
assisting the States in providing early intervention services 
to individuals sentenced by the State to a term of 
imprisonment. The Secretary may make such a grant only if the 
State involved requires, subject to subsection (d), that--
          [(1) the services be provided to such individuals; 
        and
          [(2) each such individual be informed of the 
        requirements of subsection (c) regarding testing and be 
        informed of the results of such testing of the 
        individual.
    [(b) Requirement of Matching Funds.--
          [(1) In general.--The Secretary may not make a grant 
        under subsection (a) unless the State involved agrees 
        that, with respect to the costs to be incurred by the 
        State in carrying out the purpose described in such 
        subsection, the State will make available (directly or 
        through donations from public or private entities) non-
        Federal contributions toward such costs in an amount 
        equal to--
                  [(A) for the first fiscal year of payments 
                under the grant, not less than $1 for each $2 
                of Federal Funds provided in the grant; and
                  [(B) for any subsequent fiscal year of such 
                payments, not less than $1 for each $1 of 
                Federal funds provided in the grant.
          [(2) Determination of amount of non-federal 
        contribution.--Non-Federal contributions required in 
        paragraph (1) may be in cash or in kind, fairly 
        evaluated, including plant, equipment, or services. 
        Amounts provided by the Federal Government, and 
        services (or portions of services) subsidized by the 
        Federal Government, may not be included in determining 
        the amount of such non-Federal contributions.
    [(c) Testing.--The Secretary may not make a grant under 
sub-section (a) unless--
          [(1) the State involved requires that, subject to 
        subsection (d), any individual sentenced by the State 
        to a term of imprisonment be tested for HIV disease--
                  [(A) upon entering the State penal system; 
                and
                  [(B) during the 30-day period preceding the 
                date on which the individual is released from 
                such system;
          [(2) with respect to informing employees of the penal 
        system of the results of such testing of the 
        individual, the State--
                  [(A) upon the request of any such employee, 
                provides the results to the employee in any 
                case in which the medical officer of the prison 
                determines that there is a reasonable basis for 
                believing that the employee has been exposed by 
                the individual to such disease; and
                  [(B) informs the employees of the 
                availability to the employees of such results 
                under the conditions described in subparagraph 
                (A);
          [(3) with respect to informing the spouse of the 
        individual of the results of such testing of the 
        individual, the State--
                  [(A) upon the request of the spouse, provides 
                such results to the spouse prior to any 
                conjugal visit and provides such results to the 
                spouse during the period described in paragraph 
                (1)(B); and
                  [(B) informs the spouse of the availability 
                to the spouse of such results under the 
                conditions described in subparagraph (A);
          [(4) with respect to such testing upon entering the 
        State penal system of such an individual who has been 
        convicted of rape or aggravated sexual assault, the 
        State--
                  [(A) upon the request of the victim of the 
                rape or assault, provides such results to the 
                victim; and
                  [(B) informs the victim of the availability 
                to the victim of such results; and
          [(5) the State, except as provided in any of 
        paragraphs (2) through (4), maintains the 
        confidentiality of the results of testing for HIV 
        disease in each prison operated by the State or with 
        amounts provided by the State, and makes disclosures of 
        such results only as medically necessary.
    [(d) Determination of Prisons Subject to Requirement.--
          [(1) In general.--The Secretary may not make a grant 
        under subsection (a) unless the State involved agrees 
        that the requirement established in such subsection 
        regarding the provision of early intervention services 
        to inmates will apply only to inmates who are 
        incarcerated in prisons with respect to which the State 
        public health officer, after consultation with the 
        chief State correctional officer, has, on the basis of 
        the criteria described in paragraph (2), determined 
        that the provision of such services is appropriate with 
        respect to the public health and safety.
          [(2) Description of criteria.--The criteria to be 
        considered for purposes of paragraph (1) are--
                  [(A) with respect to the geographic areas in 
                which inmates of the prison involved resided 
                before incarceration in the prison--
                          [(i) the severity of the epidemic of 
                        HIV disease in the areas during the 
                        period in which the inmates resided in 
                        the areas; and
                          [(ii) the incidence, in the areas 
                        during such period, of behavior that 
                        places individuals at significant risk 
                        of developing HIV disease; and
                  [(B) the extent to which medical examinations 
                conducted by the State for inmates of the 
                prison involved indicate that the inmates have 
                engaged in such behavior.
    [(e) Applicability of Provisions Regarding Informed 
Consent, Counseling, and Other Matters.--The Secretary may not 
make a grant under subsection (a) unless the State involved 
agrees that sections 2641(b)(4), 2662, and 2664(c) will apply 
to the provision of early intervention services pursuant to the 
grant in the same manner and to the same extent as such 
sections apply to the provision of such services by grantees 
under section 2641.
    [(f) Requirement of Application.--The Secretary may not 
make a grant under subsection (a) 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 section.
    [(g) Rule of Construction.--With respect to testing inmates 
of State prisons for HIV disease without the consent of the 
inmates, the agreements made under this section may not be 
construed to authorize, prohibit, or require any State to 
conduct such testing, except as provided in subparagraphs (A) 
and (B) of subsection (c)(1).
    [(h) Authorization of Appropriations.--To carry out this 
section, there are authorized to be appropriated such sums as 
may be necessary for each of the fiscal years 1988 through 
1995.

[SEC. 2649. [300FF-49] DETERMINATION OF AMOUNT OF ALLOTMENTS.

    [(a) Minimum Allotment.--Subject to the extent of amounts 
made available in appropriations Acts, the amount of an 
allotment under section 2641(a) for a State for a fiscal year 
shall be the greater of--
          [(1) $100,000 for each of the several States, the 
        District of Columbia, and the Commmonwealth of Puerto 
        Rico, and $50,000 for each of the territories of the 
        United States other than the Commonwealth of Puerto 
        Rico; and
          [(2) an amount determined under subsection (b).
    [(b) Determination Under Formula.--The amount referred to 
in subsection (a)(2) is the product of--
          [(1) an amount equal to the amount appropriated under 
        section 2650 for the fiscal year involved; and
          [(2) a percentage equal to the quotient of--
                  [(A) an amount equal to the number of cases 
                of acquired immune deficiency syndrome reported 
                to and confirmed by the Director of the Centers 
                for Disease Control and Prevention for the 
                State involved for the most recent fiscal year 
                for which such data is available; divided by
                  [(B) an amount equal to the number of cases 
                of acquired immune deficiency syndrome reported 
                to and confirmed by the Director of the Centers 
                for Disease Control and Prevention for the 
                United States for the most recent fiscal year 
                for which such data is available.
    [(c) Certain Allocations by Secretary.--
          [(1) Discretionary grants to certain states.--After 
        determining the amount of an allotment under subsection 
        (a) for a fiscal year, the Secretary shall reduce the 
        amount of the allotment of each State by 10 percent. 
        From the amounts available as a result of such 
        reductions, the Secretary shall, on a discretionary 
        basis, make grants to States receiving allotments for 
        the fiscal year involved. Such grants shall be made 
        subject to each of the agreements and assurances required 
        as a condition of receiving grants under section 2641.
          [(2) Grants to certain political subdivisions.--
                  [(A)(i) In the case of a State containing any 
                political subdivision described in clause (ii), 
                the Secretary shall, subject to subparagraph 
                (B), make a reduction in the amount of the 
                allotment under subsection (a) for the State 
                for each fiscal year in an amount necessary for 
                carrying out subparagraphs (B) and (C) with 
                respect to the political subdivision. Any such 
                reduction shall be in addition to the reduction 
                required in paragraph (1) for the fiscal year 
                involved.
                  [(ii) The political subdivision referred to 
                in clause (i) is any political subdivision that 
                received a cooperative agreement from the 
                Secretary, acting through the Director of the 
                Centers for Disease Control and Prevention, for 
                fiscal year 1990 for programs to provide 
                counseling and testing with respect to acquired 
                immune deficiency syndrome.
                  [(B) In the case of a State described in 
                subparagraph (A), the Secretary shall, from the 
                amounts made available as a result of 
                reductions under such subparagraph, make a 
                grant each fiscal year to each political 
                subdivision described in such subparagraph that 
                exists in the State if the political 
                subdivision involved agrees that the provisions 
                of subparts II and III will apply to the 
                political subdivision to the same extent and in 
                the same manner as such subparts apply to 
                entities receiving grants under section 
                2651(a).
                  [(C) Grants under subparagraph (B) for a 
                fiscal year for a political subdivision shall 
                be provided in an amount equal to the amount 
                received by the political subdivision in fiscal 
                year 1990 under the cooperative agreement 
                described in subparagraph (A).
    [(d) Disposition of Certain Funds Appropriated for 
Allotments.--
          [(1) In general.--Any amounts available pursuant to 
        paragraph (2) shall, in accordance with paragraph (3), 
        be allotted by the Secretary each fiscal year to States 
        receiving payments under section 2641(a) for the fiscal 
        year (other than any State referred to in paragraph 
        (2)(C)). The Secretary shall make payments, as grants, 
        to each such State from any such allotment for the 
        State for the fiscal year involved.
          [(2) Specification of amounts.--The amounts referred 
        to in paragraph (1) are any amounts that are not paid 
        to States under section 2641(a) as a result of--
                  [(A) the failure of any State to submit an 
                application under section 2651;
                  [(B) the failure, in the determination of the 
                Secretary, of any State to prepare the 
                application in compliance with such section or 
                to submit the application within a reasonable 
                period of time; or
                  [(C) any State informing the Secretary that 
                the State does not intend to expend the full 
                amount of the allotment made to the State.
          [(3) Amount of allotment.--The amount of an allotment 
        under paragraph (1) for a State for a fiscal year shall 
        be an amount equal to the product of--
                  [(A) an amount equal to the amount available 
                pursuant to paragraph (2) for the fiscal year 
                involved; and
                  [(B) the percentage determined under 
                subsection (b)(2) for the State.
    [(e) Transition Rules.--
          [(1) For the fiscal years 1991 through 1993, the 
        amount of an allotment under section 2641 shall be the 
        greater of the amount determined under subsection (a) 
        and an amount equal to the amount applicable under 
        paragraph (2) for the fiscal year involved.
          [(2) For purposes of paragraph (1)--
                  [(A) the amount applicable for fiscal year 
                1991 is an amount equal to the amount received 
                by the State involved from the Secretary, 
                acting through the Director of the Centers for 
                Disease Control and Prevention, for fiscal year 
                1990 for the provision of counseling and 
                testing services with respect to HIV;
                  [(B) the amount applicable for fiscal year 
                1992 is 85 percent of the amount specified in 
                subparagraph (A); and
                  [(C) the amount applicable for fiscal year 
                1993 is 70 percent of the amount specified in 
                subparagraph (A).

[SEC. 2649A. [300FF-49A] MISCELLANEOUS PROVISIONS.

    [The Secretary may not make a grant under section 2641 
unless--
          [(1) the State involved submits to the Secretary a 
        comprehensive plan for the organization and delivery of 
        the early intervention services to be funded with the 
        grant that includes a description of the purposes for 
        which the State intends to use such assistance, 
        including--
                  [(A) the services and activities to be 
                provided and an explanation of the manner in 
                which the elements of the program to be 
                implemented by the State with the grant will 
                maximize the quality of early intervention 
                services available to individuals with HIV 
                disease throughout the State; and
                  [(B) a description of the manner in which 
                services funded with the grant will be 
                coordinated with other available related 
                services for individuals with HIV disease; and
          [(2) the State agrees that--
                  [(A) the public health agency administering 
                the grant will conduct public hearings 
                regarding the proposed use and distribution of 
                the grant;
                  [(B) to the maximum extent practicable, early 
                intervention services delivered pursuant to the 
                grant will be provided without regard to the 
                ability of the individual to pay for such 
                services and without regard to the current or 
                past health condition of the individual with 
                HIV disease;
                  [(C) early intervention services under the 
                grant will be provided in settings accessible 
                to low-income individuals with HIV disease; and
                  [(D) outreach to low-income individuals with 
                HIV disease will be provided to inform such 
                individuals of the services available pursuant 
                to the grant.

[SEC. 2650. [300FF-50] AUTHORIZATION OF APPROPRIATIONS.

    [For the purpose of making grants under section 2641, there 
are authorized to be appropriated $230,000,000 for fiscal year 
1991, and such sums as may be necessary for each of the fiscal 
years 1992 through 1995.]

                   Subpart [II] I--Categorical Grants


SEC. 2651. [300FF-51] ESTABLISHMENT OF PROGRAM.

    (a) In General.--* * *

           *       *       *       *       *       *       *

    (d) Preference in Awarding Grants.--In awarding new grants 
under this section, the Secretary shall give preference to 
applicants that will use amounts received under the grant to 
serve areas that are determined to be rural and underserved for 
the purposes of providing health care to individuals infected 
with HIV or diagnosed with AIDS.

SEC. 2652. [300FF-52] MINIMUM QUALIFICATIONS OF GRANTEES.

    (a) In General.--The entities referred to in section 
2651(a) are public entities and nonprofit private entities that 
are--
          [(1) migrant health centers under section 329 or 
        community health centers under section 330;
          [(2) grantees under section 340 (regarding health 
        services for the homeless);]
          (1) health centers under section 330;
          [(3)] (2) grantees under section 1001 (regarding 
        family planning) other than states;
          [(4)] (3) comprehensive hemophilia diagnostic and 
        treatment centers;
          [(5)] (4) Federally-qualified health centers under 
        section 1905(1)(2)(B) of the Social Security Act; or
          [(6)] (5) nonprofit private entities that provide 
        comprehensive primary care services to populations at 
        risk of HIV disease.

           *       *       *       *       *       *       *


SEC. 2654. [300FF-54] MISCELLANEOUS PROVISIONS.

    (a) Services for Individuals With Hemophilia.--* * *

           *       *       *       *       *       *       *

    (c) Planning and Development Grants.--
          [(1) In general.--The Secretary may provide planning 
        grants, in an amount not to exceed $50,000 for each 
        such grant, to public and nonprofit private entities 
        for the purpose of enabling such entities to provide 
        HIV early intervention services.]
          (1) In general.--The Secretary may provide planning 
        and development grants to public and nonprofit private 
        entities for the purpose of--
                  (A) enabling such entities to provide HIV 
                early intervention services; or
                  (B) assisting such entities to expand the 
                capacity, preparedness, and expertise to 
                deliver primary care services to individuals 
                with HIV disease in underserved low-income 
                communities on the condition that the funds are 
                not used to purchase or improve land or to 
                purchase, construct, or permanently improve 
                (other than minor remodeling) any building or 
                other facility.
          (2) Requirement.--The Secretary may only award a 
        grant to an entity under [paragraph (1)] paragraph 
        (1)(A) if the Secretary determines that the entity will 
        use such grant to assist the entity in qualifying for a 
        grant under section 2651.
          (3) Preference.--In awarding grants under [paragraph 
        (1)] paragraph (1)(A), the Secretary shall give 
        preference to entities that provide primary care 
        services in rural or underserved communities.
          (4) Amount and duration of grants.--
                  (A) Early intervention services.--A grant 
                under paragraph (1)(A) may be made in an amount 
                not to exceed $50,000.
                  (B) Capacity development.--
                          (i) Amount.--A grant under paragraph 
                        (1)(B) may be made in an amount not to 
                        exceed $150,000.
                          (ii) Duration.--The total duration of 
                        a grant under paragraph (1)(B), 
                        including any renewal, may not exceed 3 
                        years.
          [(4)] (5) Limitation.--Not to exceed [1 percent] 5 
        percent of the amount appropriated for a fiscal year 
        under section 2655 may be used to carry out this 
        section.

SEC. 2655. [300FF-55] AUTHORIZATION OF APPROPRIATIONS.

    For the purpose of making grants under section 2651, there 
are authorized to be appropriated such sums as may be necessary 
in each of the fiscal years [1996, 1997, 1998, 1999, and 2000] 
2001 through 2005.

                  Subpart [III] II--General Provisions


SEC. 2661. [300FF-61] CONFIDENTIALITY AND INFORMED CONSENT.

    (a) Confidentiality.--The Secretary may not make a grant 
under this part [unless--
          [(1) in the case of any State applying for a grant 
        under section 2641, the State agrees to ensure that 
        information regarding the receipt of early intervention 
        services is maintained confidentially pursuant to law 
        or regulations in a manner not inconsistent with 
        applicable law; and
          [(2) in the case] unless, in the case of any entity 
        applying for a grant under section 2651, the entity 
        agrees to ensure that information regarding the receipt 
        of early intervention services pursuant to the grant is 
        maintained confidentially in a manner not inconsistent 
        with applicable law.

           *       *       *       *       *       *       *


SEC. 2664. [300FF-64] ADDITIONAL REQUIRED AGREEMENTS.

    (a) Reports to Secretary.--* * *

           *       *       *       *       *       *       *

    (e) Requirements Regarding Imposition of Charges for 
Services.--
          (1) In general.--* * *

           *       *       *       *       *       *       *

          (5) Waiver regarding certain secondary agreements.--
        The requirement established in paragraph (1)(B)(i) 
        shall be waived by the Secretary in the case of any 
        entity for whom the Secretary has granted a waiver 
        under section [2642(b) or] 2652(b)(2).
    (f) Relationship to Items and Services Under Other 
Programs.--
          (1) In general.--* * *

           *       *       *       *       *       *       *

          (2) Applicability to certain secondary agreements for 
        provision of services.--An agreement made under 
        paragraph (1) shall not apply in the case of an entity 
        through which a grantee under this part provides early 
        intervention services if the Secretary has provided a 
        waiver under section [2642(b) or] 2652(b)(2) regarding 
        the entity.
    (g) Administration of Grant.--The Secretary may not make a 
grant under this part unless the applicant for the grant agrees 
that--
          (1) * * *

           *       *       *       *       *       *       *

          [(3) the applicant will not expend more than 7.5 
        percent including planning and evaluation of the grant 
        for administrative expenses with respect to the grant; 
        and]
          (3) the applicant will not expend more than 10 
        percent of the grant for costs of administrative 
        activities with respect to the grant;
          (4) the applicant will submit evidence that the 
        proposed program is consistent with the statewide 
        coordinated statement of need and agree to participate 
        in the ongoing revision of such statement of need[.]; 
        and
          (5) the applicant will provide for the establishment 
        of a quality management program to assess the extent to 
        which medical services funded under this title that are 
        provided to patients are consistent with the most 
        recent Public Health Service guidelines for the 
        treatment of HIV disease and related opportunistic 
        infections and that improvements in the access to and 
        quality of medical services are addressed.
    [(h) Construction.--A State may not use amounts received 
under a grant awarded under section 2641 to purchase or improve 
land, or to purchase, construct, or permanently improve (other 
than minor remodeling) any building or other facility, or to 
make cash payments to intended recipients of services.]

           *       *       *       *       *       *       *


                       PART D--GENERAL PROVISIONS


SEC. 2671. [300FF-71] GRANTS FOR COORDINATED SERVICES AND ACCESS TO 
                    RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH.

    (a) In General.--* * *

           *       *       *       *       *       *       *

                  [(C) For the first and second fiscal years 
                for which grants under subsection (a) are to be 
                made to the applicant, the applicant agrees 
                that, not later than the end of the second 
                fiscal year of receiving such a grant, a 
                significant number of women, infants, children, 
                and youth who are patients of the applicant 
                will be participating in the projects of 
                research.
                  [(D) Except as provided in paragraph (3) (and 
                paragraph (4), as applicable), for the third 
                and subsequent fiscal years for which such 
                grants are to be made to the applicant, the 
                Secretary has determined that a significant 
                number of such individuals are participating in 
                the projects.]

           *       *       *       *       *       *       *

          [(3) Significant participation; consideration by 
        secretary of certain circumstances.--In administering 
        the requirement of paragraph (1)(D), the Secretary 
        shall take into account circumstances in which a 
        grantee under subsection (a) is temporarily unable to 
        comply with the requirement for reasons beyond the 
        control of the grantee, and shall in such circumstances 
        provide to the grantee a reasonable period of 
        opportunity in which to reestablish compliance with the 
        requirement.
          [(4) Significant participation; temporary waiver for 
        original grantees.--
                  [(A) In general.--In the case of an applicant 
                under subsection (a) who received a grant under 
                such subsection for fiscal year 1995, the 
                Secretary may, subject to subparagraph (B), 
                provide to the applicant a waiver of the 
                requirement of paragraph (1)(D) if the 
                Secretary determines that the applicant is 
                making reasonable progress toward meeting the 
                requirement.
                  [(B) Termination of authority for waivers.--
                The Secretary may not provide any waiver under 
                subparagraph (A) on or after October 1, 1998. 
                Any such waiver provided prior to such date 
                terminates on such date, or on such earlier 
                date as the Secretary may specify.]

           *       *       *       *       *       *       *

    (d) Additional Services for Patients and Families.--A grant 
under subsection (a) may be made only if the applicant for the 
grant agrees as follows:
          (1) * * *

           *       *       *       *       *       *       *

          (4) The applicant will provide individuals with 
        information and education on opportunities to 
        participate in HIV/AIDS-related clinical research.

           *       *       *       *       *       *       *

    [(f) Application.--] (f) Administration._
          (1) Application.--A grant under subsection (a) may be 
        made only if an application for the grant is submitted 
        to the Secretary and the application is in such form, 
        is made in such manner, and contains such agreements, 
        assurances, and information as the Secretary determines 
        to be necessary to carry out this section.
          (2) Quality management program.--A grantee under this 
        section shall implement a quality management program.
    (g) Coordination With National Institutes of Health.--The 
Secretary shall develop and implement a plan that provides for 
the coordination of the activities carried out under this 
section. In carrying out the preceding sentence, the Secretary 
shall ensure that projects of research conducted or supported 
by such Institutes are made aware of applicants and grantees 
under subsection (a), shall require that the projects, as 
appropriate, enter into arrangements for purposes of such 
subsection and shall require that each project entering into 
such an arrangement inform the applicant or grantee under such 
subsection of the needs of the project for the participation of 
women, infants, children, and youth. The Secretary acting 
through the Director of NIH, shall examine the distribution and 
availability of ongoing and appropriate HIV/AIDs-related 
research projects to existing sites under this section for 
purposes of enhancing and expanding voluntary access to HIV-
related research, especially within communities that are not 
reasonably served by such projects. Not later than 12 months 
after the date of enactment of the Ryan White CARE Act 
Amendments of 2000, the Secretary shall prepare and submit to 
the appropriate committees of Congress a report that describes 
the findings made by the Director and the manner in which the 
conclusions based on those findings can be addressed.

           *       *       *       *       *       *       *

    (i) Limitation on Administration Expenses.--
          (1) Determination by secretary.--Not later than 12 
        months after the date of enactment of the Ryan White 
        CARE Act Amendments of 2000, the Secretary, in 
        consultation with grantees under this part, shall 
        conduct a review of the administrative, program 
        support, and direct service-related activities that are 
        carried out under this part to ensure that eligible 
        individuals have access to quality, HIV-related health 
        and support services and research opportunities under 
        this part, and to support the provision of such 
        services.
          (2) Requirements.--
                  (A) In general.--Not later than 180 days 
                after the expiration of the 12-month period 
                referred to in paragraph (1) the Secretary, in 
                consultation with grantees under this part, 
                shall determine the relationship between the 
                costs of the activities referred to in 
                paragraph (1) and the access of eligible 
                individuals to the services and research 
                opportunities described in such paragraph.
                  (B) Limitation.--After a final determination 
                under subparagraph (A), the Secretary may not 
                make a grant under this part unless the grantee 
                complies with such requirements as may be 
                included in such determination.
    [(i)] (j) Training and Technical Assistance.--Of the 
amounts appropriated under subsection (j) for a fiscal year, 
the Secretary may use not more than five percent to provide, 
directly or through contracts with public and private entities 
(which may include grantees under subsection (a)), training and 
technical assistance to assist applicants and grantees under 
subsection (a) in complying with the requirements of this 
section.
    [(j)] (k) Authorization of Appropriations.--For the purpose 
of carrying out this section, there are authorized to be 
appropriated such sums as may be necessary for each of the 
[fiscal years 1996 through 2000] fiscal years 2001 through 
2005.

SEC. 2674. [300FF-74] EVALUATIONS AND REPORTS.

    (a) Evaluations.--* * *

           *       *       *       *       *       *       *

    (c) Authorization of Appropriations.--There are authorized 
to be appropriated to carry out this section, such sums as may 
be necessary for each of the fiscal years [1991 through 1995] 
2001 through 2005.

           *       *       *       *       *       *       *


[SEC. 2677. [300FF-77] AUTHORIZATION OF APPROPRIATIONS.

    [(a) In General.--Subject to subsection (b), there are 
authorized to be appropriated to make grants under parts A and 
B, such sums as may be necessary for each of the fiscal years 
1996 through 2000.
    [(b) Development of Methodology.--
          [(1) In general.--With respect to each of the fiscal 
        years 1997 through 2000, the Secretary shall develop 
        and implement a methodology for adjusting the 
        percentages allocated to part A and part B to account 
        for grants to new eligible areas under part A and other 
        relevant factors. Not later than July 1, 1996, the 
        Secretary shall prepare and submit to the appropriate 
        committees of Congress a report regarding the findings 
        with respect to the methodology developed under this 
        paragraph.
          [(2) Failure to implement.--If the Secretary 
        determines that such a methodology under paragraph (1) 
        cannot be developed, there are authorized to be 
        appropriated--
                  [(A) such sums as may be necessary to carry 
                out part A for each of the fiscal years 1997 
                through 2000; and
                  [(B) such sums as may be necessary to carry 
                out part B for each of the fiscal years 1997 
                through 2000.]

SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

    There are authorized to be appropriated--
          (1) such sums as may be necessary to carry out part A 
        for each of the fiscal years 2001 through 2005; and
          (2) such sums as may be necessary to carry out part B 
        for each of the fiscal years 2001 through 2005.

           *       *       *       *       *       *       *


            Subpart II--AIDS Education and Training Centers


SEC. 2692. [300FF-11] HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTERS.

    (a) Schools; Centers.--

           *       *       *       *       *       *       *

    (b) Dental Schools.--
          (1) In general.--The Secretary may make grants to 
        assist dental schools and programs described in section 
        [777(b)(4)(B)] 777(b)(4)(B) (as such section existed on 
        the day before the date of enactment of the Health 
        Professions Education Partnerships Act of 1998 (Public 
        Law 105-392)) and dental hygiene programs that are 
        accredited by the Commission on Dental Accreditation 
        with respect to oral health care to patients with HIV 
        disease.
          (2) Application.--Each dental school or program 
        described in section [777(b)(4)(B)] 777(b)(4)(B) (as 
        such section existed on the day before the date of 
        enactment of the Health Professions Education 
        Partnerships Act of 1998 (Public Law 105-392)) may 
        annually submit an application documenting the 
        unreimbursed costs of oral health care provided to 
        patients with HIV disease by that school or hospital 
        during the prior year.

           *       *       *       *       *       *       *

    (c) Authorization of Appropriations.--
          (1) Schools; centers.--For the purpose of grants 
        under subsection (a), there are authorized to be 
        appropriated such sums as may be necessary for each of 
        the [fiscal years 1996 through 2000] fiscal years 2001 
        through 2005.
          (2) Dental schools.--For the purpose of grants under 
        subsection (b), there are authorized to be appropriated 
        such sums as may be necessary for each of the [fiscal 
        years 1996 through 2000] fiscal years 2001 through 
        2005.

           *       *       *       *       *       *       *


                 RYAN WHITE CARE ACT AMENDMENTS OF 1996


                          Public Law 104-146

           *       *       *       *       *       *       *



SEC. 3. GENERAL AMENDMENTS.

    (a) Program of Grants.--
          (1) Number of cases.--* * *

           *       *       *       *       *       *       *

                          (iii) by inserting before paragraph 
                        (2) as so redesignated the following 
                        new paragraph:

           *       *       *       *       *       *       *


                                  
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