[Senate Report 107-83]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 192
107th Congress                                                   Report
                                 SENATE
 1st Session                                                     107-83

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



 
               HEALTH CARE SAFETY NET AMENDMENTS OF 2001

                                _______
                                

                October 11, 2001.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                             together with

                            ADDITIONAL VIEWS

                         [To accompany S. 1533]

    The Committee on Health, Education, Labor, and Pensions, to 
which was referred the bill (S. 1533) to amend the Public 
Health Service Act to reauthorize and strengthen the health 
centers program and the National Health Service Corps, and to 
establish the Healthy Communities Access Program, which will 
help coordinate services for the uninsured and underinsured, 
and for other purposes, having considered the same, reports 
favorably thereon with amendments and recommends that the bill 
do pass.

                                CONTENTS

                                                                   Page
  I. Purpose and summary..............................................1
 II. Background and need for legislation..............................2
III. Committee action................................................12
 IV. Explanation of bill and committee views.........................13
  V. Cost estimate...................................................36
 VI. Application of law to the legislative branch....................36
VII. Regulatory impact statement.....................................36
VIII.Section-by-section analysis.....................................36

 IX. Additional views................................................53
  X. Changes in existing law.........................................56

                         I. Purpose and Summary

    The Health Care Safety Net Amendments of 2001 reauthorizes 
and strengthens the health care centers program; reauthorizes 
the National Health Service Corps; improves and expands rural 
health programs; and establishes the Healthy Communities Access 
Program under the newly created Section 340 of the Public 
Health Service Corps. In doing so, the committee is acting to 
continue, improve, and increase its support for these programs, 
which enable safety net providers in rural and urban areas to 
offer health care services for millions of underserved and 
uninsured people. The programs included in this act are:
    The Consolidated Health Center Program, authorized under 
Section 330 of the Public Health Service Act, supports the 
provision of health care services to the medically 
underserved--meaning those individuals living in rural or urban 
communities that are designated as medically underserved, or 
who are members of a designated medically underserved 
population.
    The Rural Health Outreach, Network Development, and 
Telemedicine grant programs were added to Title III of the 
Public Health Service Act in the last reauthorization of the 
Consolidated Health Centers. These grants were designed to 
assist with the provision of coordinated care in rural areas.
    The National Health Service Corps, authorized under 
Sections 331 through 338 of the Public Health Service Act, 
assists in the delivery of health services in health 
professional shortage areas by providing scholarships and loan 
repayments to eligible clinicians.
    The Healthy Communities Access Program, authorized under 
newly created section 340, provides for the planning, 
developing, and operating expenses incurred while integrating a 
health care delivery system. This system will ensure the 
provision of a broad range of services--including primary, 
secondary, and tertiary services--as well as substance abuse 
treatment and mental health services, in hopes of filling 
identified or documented gaps within an integrated delivery 
system. Furthermore, HCAP encourages greater public-private 
coordination so health providers within a community can 
effectively maximize efforts and resources in caring for the 
medically underserved.

                II. Background and Need for Legislation

    The committee has long supported the work of safety net 
providers in urban and rural areas who dedicate their efforts 
to providing care for those individuals who would otherwise not 
have access to a source of regular health care. Even as data 
show that the number of uninsured Americans has dropped 
slightly to 42.6 million people, existing safety net providers 
continue to grapple with increasing demands for care from the 
uninsured and underinsured in this country.
    At the same time, private market and public efforts to 
control costs are making it increasingly difficult for other 
providers to continue offering care to those without health 
coverage. In addition, thousands of communities across the 
country today continue to experience shortages of accessible, 
cost-effective, preventive and primary health care services 
especially for residents who are unable to pay for care.
    In this light, it is critical that the committee act to 
reauthorize and improve programs that make it possible for 
millions of Americans to access a health care safety net. These 
programs are the Health Centers program, established under 
Section 330 of the Public Health Service Act; the National 
Health Service Corps program, established under Sections 331 
through 338L of the Public Health Service Act; and the rural 
grant programs established under Section 330A of the Public 
Health Service Act. Moreover, the committee has recognized the 
need for support of community-based efforts to integrate 
networks of providers to care for the uninsured, and to do so, 
is authorizing for the first time the new Healthy Communities 
Access Program.

                   CONSOLIDATED HEALTH CENTER PROGRAM

Introduction

    In response to the large number of individuals living in 
medically underserved areas, as well as the growing number of 
special populations lacking access to preventive and primary 
health care services, Congress enacted the Health Center 
programs in the 1960s. For more than 30 years, the Health 
Centers program has effectively and efficiently assured access 
to cost-effective, high quality, preventive and primary care 
services, thereby improving the health status of the Nation's 
underserved and vulnerable populations. These programs were 
designed to empower communities to solve their own local access 
programs and to improve the health status of their underserved 
and vulnerable populations. They do so by building community-
based primary care capacity and by offering case management, 
home visitation, outreach, and other enabling services to 
increase utilization by vulnerable populations and improve the 
effectiveness of the preventive and primary care they offer.
    Health centers have demonstrated their ability to meet 
pressing local health needs while being held accountable for 
meeting national performance standards. The success of the 
Health Centers program can be directly traced to the core 
elements found in Section 330 of the Public Health Service Act, 
as established by this committee. These elements stipulate that 
each Federally-supported health center must:
          Be located in, and serve, a community that is 
        designated as ``medically underserved,'' thus ensuring 
        the proper targeting of Federal resources on areas of 
        greatest need;
          Make its services available to all residents of the 
        community, without regard for ability to pay, and make 
        those services affordable by discounting charges in 
        accordance with family income for otherwise uncovered 
        care to low-income families;
          Provide comprehensive primary health care services, 
        including preventive care (such as regular check-ups 
        and pap smears), care for illness or injury, services 
        that improve both the accessibility of care (such as 
        transportation and translation services) and the 
        effectiveness of care (such as health/nutrition 
        education), and patient case management;
          Be governed by a board of directors, a majority of 
        whose members are active, registered patients of the 
        health center, thus ensuring that the center is 
        responsive to the health care needs of the community it 
        serves.
    When the committee last acted to reauthorize the Health 
Centers program in 1996 (Health Centers Consolidation Act of 
1996, P.L. 104-299), it consolidated four separately targeted 
health center authorities under a single authority, while 
maintaining distinct resources to serve vulnerable 
subpopulations of farm workers, homeless individuals, and 
residents of public housing.
    1. Migrant Health Center.--The Migrant Health Center 
program was established by Congress in 1962 under the Migrant 
Health Act, Public Law 87-692, and reauthorized in 1975 by 
Public Law 94-63. Migrant Health Centers were created to 
provide a broad array of medical and support services to farm 
workers and their families. In addition to primary and 
preventive health care, many of these centers provide 
transportation, outreach, dental, pharmacy, and environmental 
health services. In 1999, a network of 125 migrant health 
centers provided services to approximately 600,000 migrant and 
seasonal farm workers and their families in more than 400 
delivery sites.
    2. Community Health Centers.--Community Health Centers were 
first funded by Congress in the mid-1960s as neighborhood 
health centers. By the early 1970s, approximately 100 
neighborhood health centers had been established under the 
Economic Opportunity Act. These centers were designed to 
provide accessible, personal health services to low-income 
families. Community and consumer participation in the 
organization and ongoing governance of the centers remain 
central elements of the program. Each center is required to 
have a governing board, a majority of the members of which are 
users of the center's services.
    With the phase-out of the Office of Economic Opportunity in 
the early 1970s, the centers supported under this authority 
were transferred to the Public Health Service Act. While 
services were directed to the poor and near poor, the centers 
also provided access to a broader population who could pay all 
or part of the cost of their health care. The Community Health 
Center program, as authorized under Section 330 of the Public 
Health Service Act, was established in 1975 by Public Law 94-
63.
    Over its nearly 30-year history, the Community Health 
Center program developed into a highly successful, cost-
effective, and efficient health program providing services to 
medically underserved populations living in urban and rural 
underserved communities. The program currently serves more than 
8.4 million medically underserved people in more than 2,569 
service delivery sites.
    3. Health Care for the Homeless.--Established under the 
Stewart B. McKinney Homeless Assistance Act of 1987 (P.L. 100-
77), the Health Care for the Homeless program was developed by 
Congress to provide comprehensive, high quality, case-managed, 
preventive and primary health care services, including 
substance abuse services and mental health referrals, for 
homeless individuals at locations accessible to them. In 1992, 
Title VI of the Stewart B. McKinney Homeless Assistance Act was 
amended to include section 340(s), which authorizes additional 
Federal funding to provide outreach and primary health services 
for homeless children.
    The Health Care for the Homeless program played a pivotal 
role in stimulating local collaboration and coordination of 
health and social services. A total of 135 organizations, 
including community health centers, public health departments, 
and other community-based health service providers, currently 
provide care through 1,159 urban and rural delivery sites to 
approximately 600,000 sick and untreated homeless people 
annually.
    4. Health Services for Residents of Public Housing.--The 
Health Services for Residents of Public Housing program was 
established by Congress under the Disadvantaged Minority Health 
Improvement Act of 1990. This legislation focused on the 
disparity in health status of minority populations and placed 
emphasis on the development of delivery models that are 
comprehensive and address the special health problems which 
affect families--especially targeting pregnant women and 
children. Services are provided at public housing complexes or 
at sites either adjacent to or immediately accessible to these 
complexes.
    In 1995, 22 organizations received funding under the 
section 340A authority. These centers provide comprehensive, 
high quality, case-managed, family based preventive and primary 
health care services to approximately 25,000 public housing 
residents at 39 service delivery sites. Currently, 26 
organizations receive funding under the program, and thus 
provide services to approximately 48,000 public housing 
residents at 100 service delivery sites.
    In 2000, more than 9.6 million people were served at health 
centers. Of those, approximately 500,000 were homeless; 600,000 
were migrant and seasonal farm workers; and 55,000 were 
residents of public housing. Also, there were approximately 800 
community health centers and/or migrant and seasonal farm 
worker centers grantees; 130 grantees serving the homeless; and 
20 grantees serving those receiving public housing. Each of the 
grantees may have had more than one site. In total, 
approximately 3000 health center sites exist.

Success of the health center programs

    Since the reauthorization in 1996, the Health Center 
programs have continued to develop and support a significant 
number of highly successful, innovative, preventive, and 
primary health care delivery systems in our Nation's most needy 
inner cities and rural areas. Health centers provide this care 
in a cost-effective manner.
    Health centers also have effectively addressed major public 
health concerns (e.g., violence prevention, teenage pregnancy). 
They have been actively involved with academic health centers 
in providing community-based training of physicians, nurses, 
and other health professionals.
    Health centers are effective in increasing access to 
services in needy communities. In 1998, 10.7 million patients 
were served at health centers--a 4.9 percent increase over 
1997. Of those, 4.4 million patients were uninsured--a 7.26 
percent increase over 1997--and one-third of those uninsured 
individuals were children. Plus, 2.4 million patients are 
enrolled in managed care.
    Furthermore, health centers are effective in improving 
health outcomes, increasing preventive service, improving the 
management of chronic diseases, and reducing avoidable 
hospitalizations. In 1998, the percentage of infants born with 
a low birth weight receiving care from health centers was 7.1 
percent--compared to 7.4 percent for all American infants. 
Given that 57 percent of health center patients belong to a 
minority group with an increased risk for low birth weight 
infants, this particular statistic alludes to the comprehensive 
care that health centers provide.
    According to a recent HRSA survey, women who receive their 
care at health centers are more likely to receive a pap test 
than if they were to receive care elsewhere. This increased 
access to necessary preventive health services also is evident 
for women who are Hispanic and African-American.
    Health center patients are 3.3 times more likely to have 
controlled blood pressure compared to non-health center 
patients. Given that more than 43 million Americans are 
estimated to have high blood pressure--which is a leading risk 
factor for coronary heart disease, congestive heart failure, 
stroke, ruptured aortic aneurysm, renal disease, and 
retinopathy--health centers consistently emphasize care for 
chronically ill individuals.
    Finally, studies comparing health center patients and non-
patients show that health centers provide services at a lower 
cost per ambulatory visit, lower the rate of hospital inpatient 
days, and lower total costs (including decreased inpatient care 
costs).

Reasons for health centers success

    The committee recognizes that these programs have been 
successful because health centers offer integrated, high 
quality, prevention-oriented, case-managed, and family-focused 
primary care services that result in appropriate and cost-
effective use of ambulatory, specialty, and in-patient 
services. Health centers offer primary care for people in all 
life cycles, and a range of health and other social services is 
available on-site or through referrals. The range of services 
includes health promotion, disease prevention, screening, 
educational, outreach, and case management services--which are 
often missing from the traditional delivery of medical services 
but which are particularly needed by high-risk populations 
because of their multiple health problems and the significant 
barriers to access to care that they face.
    Health centers also are staffed with full-time primary care 
providers who are capable of providing culturally competent 
services to diverse populations. More than 6,715 primary care 
physicians, nurse practitioners, physician assistants, and 
certified nurse midwives create the core of health centers 
nationally. Health centers also have been assisted greatly in 
attracting and retaining quality providers through the National 
Health Service Corps.
    In addition, the Health Center programs have enabled 
underserved communities to design and develop their own local 
solutions to their problems of medical underserved. By 
supporting the development and operation of health centers at 
the community level, the health center programs have assured 
that centers are community-responsive and highly accessible. 
Residents and patients play an active role in centers' 
decision-making and planning. By working with local communities 
and State organizations to plan, develop, and determine 
priorities for the allocation of resources, the Health Center 
programs have successfully funded new and expanded programs and 
services in those communities that are most in need. One 
measure of the success of these community-based and governed 
centers is their ability to attract private-pay and privately 
insured individuals and families, as well as those who are 
uninsured or covered by Medicaid. Patient payments and third-
party insurance payments comprise, on average, 15 percent of 
health centers' revenues.
    Several studies over the years have reported favorably on 
the quality and cost-effectiveness of the care offered by 
health centers. Most recently, researchers found that Medicaid 
beneficiaries who receive care at health centers were 
significantly less likely to be hospitalized or to visit 
hospital emergency rooms for ambulatory care sensitive 
conditions than beneficiaries who receive care from other 
providers [Medical Care, Vol. 39, No. 6, June 2001, 551-561]. 
Other recent studies have found that Medicaid patients who 
regularly use health centers receive care of equal or greater 
quality and at significantly less cost than those who use other 
providers--such as HMOs, hospital outpatient units, or private 
physicians. In addition, data collected by the Federal Agency 
for Research on Healthcare Quality (ARHQ) show that health 
center patients are much more likely to have received the care 
they need for their condition (such as mammograms and pap 
smears, or control of blood sugar or blood pressure levels) 
than other similar populations. These findings are consistent 
with those from dozens of previous studies on the cost-
effectiveness and quality of care provided through the health 
center model, and in particular, reflect the health centers' 
demonstrated savings to State Medicaid programs.

Continued need for health centers

    Many Americans continue to lack access to basic preventive 
and primary care services. These individuals are 
disproportionately poor and represent minority communities. 
They lack adequate or any health insurance, and they tend to be 
sicker patients who require more expensive treatment and care. 
The barriers to access to health care services include:
    1. Financial Barriers.--Millions of people lack adequate 
insurance and/or cannot afford to pay for cost-effective, 
preventive and primary care services. According to the Kaiser 
Family Foundation, ``In 1999, 42 million Americans--nearly 18 
percent of the total nonelderly population--were uninsured. The 
number of uninsured has grown by nearly 10 million over the 
past decade. A smaller share of Americans have health insurance 
for themselves and their dependents through their jobs today 
than ten years ago, and even more would be uninsured were it 
not for eligibility expansions and enrollment growth in the 
Medicaid program.'' A significant proportion of these people 
also have incomes under 200 percent of poverty.
    2. Geographic and Capacity Barriers.--Currently, a total of 
71.9 million people live in areas designated by the Federal 
Government as medically underserved--37.7 million in urban 
areas (52 percent) and 34.2 million (48 percent) in rural 
areas. Of these, a total of 43.4 million lack access to a 
primary care provider--22.2 million in urban areas and 21.2 
million in rural areas. Private practice in these underserved 
areas has not been economically viable because of low income, 
and in rural areas, because of low population density. 
Underserved rural and urban areas also tend to lack 
professional backup, facilities, equipment, and organizational 
support. As a result, physicians have not ``diffused'' into 
shortage areas to the degree previously predicted, resulting in 
primary health care practitioner shortages.
    3. Transportation, Culture, and Language Barriers.--Health 
care facilities are often located in areas that are not easily 
accessible to underserved patients. To assure the timely, 
effective receipt of preventive and curative care, the 
availability of transportation and outreach services is 
essential. Even where health services are physically 
accessible, communication and language problems between 
providers and patients, as well as provider insensitivity to 
cultural concerns, may impose barriers to care.
    4. Decline in Charity Care by Non-Safety Net Providers.--
The committee notes that recent studies have found 
substantially lower levels of charity care among physicians and 
hospitals in communities with high managed care enrollment 
(exceeded only by the almost non-existent level of charity care 
among physicians who refuse to participate in managed care), 
resulting in an ``increased burden on an already fragile safety 
net.'' (Cunningham et al, JAMA, November 1999).
    The 3.7 million uninsured people whom Federally-supported 
health centers are able to reach account for only 9 percent of 
the Nation's uninsured. Both the Congress and the President 
have recognized the value of the quality, culturally competent 
care provided by health centers as an ideal model for expanding 
access to care for the uninsured, and they have called for a 
doubling of the capacity of health centers to provide care by 
2006. President Bush declared in his 2001 State of the Union 
address, ``To provide quality care in low-income neighborhoods, 
over the next 5 years we will double the number of people serve 
in community health care centers.''

Health centers programs in a changing health care environment

    Health centers have done an excellent job of adapting to 
the changing health care environment. In 1996, the committee 
permitted the use of grant funds to support the establishment 
of managed care networks and plans. Health centers all across 
the country have taken steps to form networks with other local 
providers and to develop the financial, legal, and business 
acumen necessary to function effectively in managed care. 
Almost three-fourths of all health centers are participating in 
managed care as subcontracting providers to managed care 
plans--serving more than 2 million managed care enrollees.
    As the market continues to change, health centers are 
joining with each other and with other local providers to form 
integrated service networks to coordinate and improve their 
purchasing power and/or to better organize the continuum of 
care, especially for those who are uninsured. These include 
practice management networks designed to improve quality 
through shared expertise (such as centralized pharmaceutical or 
laboratory services, clinical outcomes management, or joint 
management/administrative services); to lower costs through 
shared services (such as unified financial or management 
information systems, or joint purchasing of services or 
supplies); to improve access and availability of health care 
services provided by the health centers participating in the 
network; or to improve the health status of communities by 
establishing community-based programs such as vaccine and 
wellness initiatives. Today, nearly 400 health centers are 
involved in 50-plus local networks across more than 35 States, 
each designed to lower costs and improve care. Separately, some 
250 or more health centers are participating in statewide or 
regional collaboratives designed to significantly improve 
health care management for patients with chronic conditions 
such as asthma, hypertension, diabetes, cardiovascular 
diseases, HIV infections, depression, and environmental health 
conditions. However, many health centers lack the financial 
resources to develop these practice management networks, which 
cannot currently be supported with grant funds under section 
330. The committee supports the continued use of public-private 
partnerships to assist with the provision of health care 
services.
    The committee also heard testimony about health centers' 
substantial need for support for facility construction, 
renovation, and modernization. Approximately 65 percent of all 
health center facilities are more than 10 years old, and 30 
percent are more than 30 years old. A recent survey of health 
centers in 12 States found that approximately two-thirds of 
them currently need to upgrade, expand, or replace their 
current facilities. This situation will need to be remedied to 
meet the intention of Congress to double the capacity of health 
centers over the next 5 years. The committee recognizes that 
health centers have faced difficulties in the past because the 
use of grant funds has been limited in meeting these facility 
needs.

                     NATIONAL HEALTH SERVICE CORPS

    The National Health Service Corps (NHSC) program was 
originally enacted by the Emergency Health Personnel Act of 
1970 to respond to the geographic maldistribution of primary 
care health professionals. The NHSC program, authorized through 
September 2000 under Title III of the Public Health Service 
Act, is comprised of scholarship and loan repayment programs 
that provide education assistance to health professions 
students in return for a period of obligated service in a 
shortage area. The Corps plays a critical role in providing 
care for underserved populations by placing volunteer 
clinicians in urban and rural communities with severe shortages 
of health care providers.
    In 1972, Congress created the Scholarship program to allow 
health professions students to receive support for their 
educational costs in return for service in a designated area. 
In return for each year of scholarship support they receive, 
students agree to provide services for one year with a two-year 
minimum service obligation. In 1987, Congress initiated the 
NHSC Loan Repayment program, under which the Federal Government 
would agree to repay both governmental and commercial loan 
obligations incurred by health professionals for their 
education. In that same year, Congress established a State Loan 
Repayment program. Under this program, if a State establishes a 
loan repayment program similar to the NHSC Loan Repayment 
program, the Department could fund up to 75 percent of the 
total costs through a grant to the State.
    In 1990, Congress reauthorized the NHSC, extending the 
program for 10 years with the enactment of the National Health 
Service Corps Revitalization Amendments of 1990 (P.L. 101-597). 
In reauthorizing the NHSC, Congress made several changes to the 
program, including a strict prioritization of areas of greatest 
shortages for placement of new assignees; requirements to 
include individual assignees' characteristics in making 
placements; improved incentives for recruitment and retention 
of health professionals; increased utilization of nurse 
practitioners, physician assistants, and nurse midwives; and 
renaming of Health Manpower Shortage Areas (HMSAs) to Health 
Professions Shortage Areas (HPSAs). The NHSC authorization 
expired on September 30, 2000.
    During the 1980s, the appropriations for the NHSC 
scholarships fell from $63.4 million in FY1981 to $0 in FY1989 
and FY1990. As a result, the number of physicians and other 
health professionals with scholarship obligations who were 
available for placement fell dramatically. On the other hand, 
funding for the loan repayment program increased in the last 
half of the 1980s. Between 1990 and 1994, Congress increased 
NHSC program funding in response to the growth in the number of 
HPSAs. However, the NHSC is a discretionary program and funding 
dropped to $112.4 million in FY1998. Funding rose slightly to 
$115.3 million in FY 1999, $116.9 million in FY 2000, and $125 
million in FY 2001.
    Currently, 2,376 NHSC clinicians, including physicians, 
dentists, nurse practitioners, physician assistants, nurse 
midwives, and mental and behavioral health professionals 
provide health care services to 3.6 million Americans. The 
committee notes that due to a lack of adequate funding, the 
NHSC has a limited capacity to meet the needs of people living 
in primary care, mental, or dental HPSAs. Indeed, the NHSC 
meets less than 13 percent of the current need for primary care 
clinicians and less than 6 percent of the current need for 
dental and mental/behavioral health services. The committee 
notes that in many cases, the provision of some health care 
services would not be possible without the presence of an NHSC 
assignee, and it further notes that some 15 percent of the 
6,500 clinical providers working at health centers are NHSC 
Scholarship and Loan Repayment recipients. More communities 
apply for placement of Corps providers than are available 
through the program.
    The committee heard testimony that action needs to be taken 
to improve the partnership between health centers and the NHSC. 
Moreover, the capacity of health centers to care for the 
underserved cannot be doubled without the continued growth of 
the NHSC and a strengthening of the relationship between the 
two programs.

        AUTHORIZATION OF THE HEALTHY COMMUNITIES ACCESS PROGRAM

    More than 40 million adults and children are uninsured 
today. When the uninsured seek health care, they often utilize 
a patchwork of unrelated community providers who are willing to 
care for them, including hospitals, community health centers, 
rural health clinics, and a host of other providers. The 
challenges that these providers face in meeting the needs of 
the uninsured leave little leftover resources to devote to 
creating an infrastructure to ensure that care is integrated 
across providers. The Community Access Program (CAP) 
demonstration project, and its evolution into the Healthy 
Communities Access Program (HCAP), addresses the need to 
develop an infrastructure to support coordinated care for the 
uninsured.
    A March 2000 report by the Institute of Medicine (IOM) 
entitled, America's Safety Net: Intact But Endangered, warned 
policy makers about a disturbing threat to safety net providers 
that is jeopardizing access to care for uninsured and 
disadvantaged populations. One of the major recommendations 
that emerged from the IOM's report, was to create a competitive 
grant program to ``help support core safety net providers that 
care for a disproportionate share of uninsured and other 
vulnerable people.'' The IOM proposed a $2.5 billion program 
over 5 years to address the ``challenges of delivering 
coordinated, seamless care for the poor uninsured and other 
vulnerable individuals'' through the core safety net. The IOM 
also reported that the CAP demonstration project was a ``good 
first step'' to addressing its recommendation. (Institute of 
Medicine. March 2000. America's Safety Net: Intact But 
Endangered. 12-14.)
    The CAP demonstration program has provided critical support 
for safety net provider networks that the Healthy Communities 
Access Program (HCAP) will advance even further. In FY 2000, 
Congress launched CAP to provide grants to local consortia of 
hospitals, community health centers, public health departments, 
and nonprofit providers to enhance collaboration and 
integration among them. Through appropriations provided in the 
past two fiscal years--$25 million in FY 2000 and $125 million 
in FY 2001--76 communities across the country have been funded 
and are currently in the middle of improving the level of 
integration among safety net providers. Approximately 50 more 
grants will be awarded this year. These grants are used to 
assist safety net providers in developing a community-wide 
safety net infrastructure, including improved information 
systems, telecommunications, integrated networks, better case 
management, and other collaborative initiatives that have a 
real impact on the quality and efficiency of care provided to 
the uninsured. The Healthy Communities Access Program (HCAP) is 
intended to build on the successes of CAP while adding critical 
disease management components to the grant program.
    The Public Health Subcommittee heard testimony about the 
success of some of the initial CAP grantees. In particular, 
John O'Brien, CEO of the Cambridge Health Alliance and Chair of 
the National Association of Public Hospitals and Health 
Systems, described the exciting initiative undertaken by the 
CAP consortium in Cambridge. The overall goal of the Cambridge 
CAP project is to decrease the number of uninsured and 
underserved in Cambridge, Somerville, and designated 
surrounding communities. They have set an ambitious target of 
enrolling at least 50,000 of the 57,000 uninsured in a 
comprehensive coordinated system of care by the fourth year of 
this project--building upon an already robust partnership 
between the Alliance and more than 50 community partners.
    The Community Lifeline Project of Hennepin County, 
Minnesota, is an excellent example of core safety net providers 
working in collaboration, which includes the local public 
hospital, community health center network, primary care 
association, and public health department. This network is 
using its CAP funding to provide community-based, person-to-
person support in navigating the health delivery system for the 
uninsured. For example, they have enhanced a multi-lingual 
health information and referral phone line; hired a community 
health educator and community health workers to assist 2,208 
individuals applying for available public insurance programs; 
arranged for transportation to clinic appointments for patients 
who might otherwise have been ``no-shows''; placed community 
health workers at the county hospital emergency room and in 
community clinics to provide health education and information 
on the appropriate use of emergency services; and held 15 
community-based health education fairs to further enhance 
outreach to the community.
    As another example, the Erlanger Health System in 
Chattanooga, Tennessee, has assembled a broad coalition of 
public and private resources to serve a 13-county region across 
the States of Tennessee, Georgia, and Alabama. Erlanger is 
utilizing CAP funding to achieve two goals of expanding access 
to primary care and increasing prevention initiatives. With CAP 
funding, they have hired community health representatives 
focusing on three ethnic groups to work with community 
organizations, churches, and community centers. The 
representatives assist patients in appropriately navigating the 
health care delivery and financing system, and they provide 
some case management assistance. Through further collaboration 
with the health department and other community organizations, 
access to health education materials and teaching opportunities 
has been expanded with increased access to preventive medicine 
such as vaccinations. Ultimately, the health status of the 
individual is improved, and they are further empowered to take 
control of the management of their health care throughout the 
continuum of care.
    In addition to the IOM report and CAP demonstration, the 
concept of targeting financial support to community networks of 
safety net providers has been implemented by private sector 
programs. The W. K. Kellogg Foundation's Community Voices 
program, launched in 1998, provides grants to 13 communities 
and supports practical solutions to increasingly severe 
problems. These communities are influencing the process to 
identify best practices in meeting the needs of those who 
receive inadequate or no health services. The Robert Wood 
Johnson Foundation's Communities in Charge grants help broad-
based community consortia design and implement sustainable new 
delivery systems that manage care, promote prevention and early 
intervention, and integrate services. Communities in Charge 
provided grants to 20 communities in 2000, and they continued 
with second phase funding to 14 communities in 2001. These 
programs are models of the consensus needed to fill gaps in 
care to the uninsured. Currently, there is no Federal support 
other than the CAP demonstration program for communities 
wishing to build upon the IOM, Kellogg, and RWJ models by 
integrating the programs and services they already provide into 
a cohesive system of care for uninsured patients.

                         III. Committee Action

    The Health Care Safety Net Amendments of 2001 was brought 
up for markup as an original bill at the Health, Education, 
Labor, and Pensions Executive Session on August 1, 2001. At 
that time, Senator Kennedy offered an amendment in the nature 
of a substitute which included several technical changes to 
clarify the language of the bill, as well as one substantive 
change. The manager's amendment was accepted by unanimous 
consent and the committee allowed for the discussion of further 
amendments.
    Senator Clinton offered an amendment to the initial HCAP 
authorization to amend the underlying bill by altering the 
authorization level from ``such sums'' to ``$125 million.'' 
Some discussion took place about whether the total funding 
would be available for the program. The amendment was accepted 
by voice vote.
    Senator Collins offered an amendment to the NHSC to 
establish a State dental grant program to assist in developing 
innovative approaches to addressing dental workforce issues. 
The amendment was accepted by voice vote.
    Senator Dodd offered an amendment to establish a school-
based health center technical assistance program. After some 
discussion about whether the amendment would alter the CHC 
program, the amendment was accepted by voice vote.
    Senator Enzi offered an amendment to prioritize new rural 
grant applications under the CHC program. After some discussion 
about the need to emphasize the placement of new health centers 
in rural areas and the additional barriers faced by those 
areas, Senator Enzi withdrew his amendment after Senators 
Kennedy and Frist agreed to work to accommodate those concerns.
    Senator Hutchinson (for himself and Senator Collins) 
offered an amendment to provide for part-time demonstration 
authority within the NHSC. The amendment was accepted by voice 
vote.
    Senator Hutchinson also offered an amendment to alter the 
definition of a migrant farm worker to clarify that the migrant 
health centers should also provide services to farm workers who 
migrate year round. The amendment was accepted by voice vote.
    Senator Reed offered an amendment to require the Secretary 
to establish a demonstration program for the inclusion of 
pharmacists and chiropractors in the NHSC. This amendment 
altered the underlying bill which provided for a chiropractor 
demonstration project. After some discussion about the 
necessity of increasing the types of providers included under 
the NHSC, the amendment was accepted by voice vote.
    Senator Roberts offered one amendment that included two 
different grant programs--the mental-behavioral telehealth 
grant program and the grant program for emergency medical 
services in rural areas. The mental-behavioral health 
telehealth grant program is a demonstration project to provide 
mental and behavioral health services to children and elderly 
residents of long term care facilities located in mental health 
professional shortage areas. The rural EMS grant program would 
provide grants to enable the provision of emergency medical 
services in rural areas by recruiting and training medial 
service and volunteer emergency medical service personnel, 
acquiring emergency medical services equipment and personal 
protective equipment, and educating the public. This amendment 
was accepted by voice vote.
    The final bill with all of the amendments was reported 
favorably from the committee by voice vote.

              IV. Explanation of Bill and Committee Views


                   CONSOLIDATED HEALTH CENTER PROGRAM

Introduction

    The committee recognizes that over the past 35 years, 
health centers have proven their durability as a model health 
care program and their resilience in adapting to a dramatically 
changed American healthcare system while maintaining their 
original mission and purpose. The committee bill reauthorizes 
the Health Centers program for another 5 years at an increased 
level of $1.368 billion initially in FY 2002, and it notes the 
broad Congressional support for the Health Centers program. 
This support also has been demonstrated through a bipartisan 
commitment to double the capacity of the program to provide 
health care services to millions of medically underserved 
individuals over a 5-year period. Health centers are a critical 
part of addressing the needs of uninsured and low-income 
populations for care, and by setting an authorized level of 
$1.368 billion for FY 2002 (a 17 percent increase), the 
committee endorses the plan to double the capacity of health 
centers over 5 years.

Definitions

    The term ``health care provider'' used throughout the 
Health Care Safety Net Amendments of 2001 is meant to denote 
both individual clinicians as well as specific points of care 
(hospitals, clinics, public health departments).
    Also, LUIR refers to hospitals with Low Income Utilization 
Rates of 25 percent or more. The committee chose to use this 
standard because it is a commonly accepted measure of the 
amount of care provided to uninsured and Medicaid patients by 
many hospitals.

New and Optional Services Provided by Health Centers

    To assist health centers in better meeting the needs of the 
communities they serve, the committee bill makes slight 
revisions to the required primary health care services that 
health centers must provide and permits health centers to apply 
for grant funds to provide new, additional services. Within 
required services, the committee bill expands the types of 
cancer screenings from breast and cervical cancer screenings to 
all appropriate cancer screening. The committee bill also 
clarifies that referral services include referrals to 
specialists when medically indicated. Case management services 
are expanded to include housing services. The committee notes 
that the uninsured and underserved individuals served by health 
centers often face additional barriers to health care services, 
such as homelessness and poverty. The committee recognizes that 
health centers have always worked to connect their patients to 
appropriate support services that promote and optimize care, 
and the committee reaffirms the vital role that strong linkages 
to housing and social services play in the provision of health 
care services by health centers to the vulnerable populations 
they serve.
    The committee bill also increases the types of additional 
health services for which grant funding may be provided by 
adding behavioral and mental health services, public health 
services, and recuperative care services as services that 
health centers can choose to provide. It is the intent of the 
committee that, so long as sufficient appropriations are 
available, all new start health centers should include mental 
and behavioral health services as part of their service 
package, and that existing health centers be encouraged to 
develop and offer such services. The committee recognizes that 
behavioral, mental health, and substance abuse services are 
important primary health services.
    There are many indicators of the need for these services, 
including surveys of Community Health Centers by the National 
Association of Community Health Centers, the large number of 
HRSA-designated Mental Health Professional Shortage Areas, and 
the Surgeon General's Report on Mental Health, which reveals 
that one out of five adults and children suffer from mental 
illness in a given year. It also indicates that mental health 
problems are particularly acute in underserved areas throughout 
the Nation. Indeed, mental illness was the fifth most common 
reason for a visit to a health center in 1999.
    The committee recognizes that many urban and rural 
communities served by health centers face a range of 
environmental health factors that may adversely affect the 
health of individuals living in those communities and further 
exacerbate chronic conditions, including exposure to lead, 
chemicals, pesticides, and pollution. Health centers can play 
an integral role in addressing these environmental health 
concerns. The committee bill revises the definition of 
``environmental health services'' to permit health centers to 
offer the detection and alleviation of chemical and pesticide 
exposures, the promotion of indoor and outdoor air quality, and 
the detection and remediation of lead exposures. Additionally, 
the committee bill allows the Secretary to make technical 
assistance grants to health centers to assist in the provision 
of environmental health services that are appropriate for the 
individuals and communities they serve.

Public-Private Partnerships

    Health centers have been particularly resourceful in 
developing partnerships with private entities to assist with 
the provision of health care services. Not only do these 
partnerships assist with the referral to specific specialists 
who are not employed by the center, but they also assist with 
the provision of other wraparound services to assist patients 
in accessing the center itself. We encourage health centers to 
continue forming these crucial public-private partnerships.

S-CHIP

    Since the reauthorization of the Consolidated Health 
Centers in 1996 and the National Health Service Corps in 1990, 
an important public program to increase health insurance access 
for children--the State Children's Health Insurance Program (S-
CHIP)--has been instituted. Given that one-third of the 
patients served at health centers are children and are likely 
eligible for S-CHIP, the committee has added provisions in both 
programs to encourage Corps clinicians and health centers to 
form contracts and seek reimbursement from this valuable 
program. Also, pursuing outreach opportunities to enroll people 
in S-CHIP will prove beneficial for both the medically 
underserved and community providers.

Health center services available to all regardless of ability to pay

    The committee notes that health centers have always 
provided their services to all residents of their service 
areas, regardless of the ability of an individual, or of his or 
her family, to pay for such services. Traditionally, health 
centers have limited the provision of services based only on 
the capacities of the health center facility, its personnel, 
and the financial resources available to the health center to 
provide services to residents of the area. The committee is 
adding language to the bill to emphasize this commitment to 
provide services to all, by requiring health centers to provide 
explicit assurances that no patient will be denied health care 
services due to an ability to pay.
    The committee intends that this new requirement will be 
performed in a manner consistent with the operational and 
financial resource limitations of a particular health center to 
provide care within its service area. Accordingly, if a health 
center reaches capacity, it may limit the provision of services 
as long as it does so consistently across all populations 
served and without discriminating against any individual based 
on ability to pay or coverage by public insurance programs.
    Health centers are fully authorized to waive all fees for 
individuals and families below 100 percent of the Federal 
poverty level. Should health centers determine that a nominal 
fee is appropriate for those below Federal poverty level, that 
also would be acceptable provided that no health center should 
ever deny its services for inability to pay.

Meeting facility needs

    The committee finds that addressing the facility needs of 
health centers is the most critical problem that must be solved 
if they are to continue providing care for the underserved of 
this country. The committee recognizes that many health centers 
operate in facilities that desperately need renovation or 
modernization. Also, to expand health center services to new 
communities, many health centers may need to build new 
facilities, renovate, or modernize existing facilities in the 
area where the services will be provided. The committee notes 
that health centers have limited financial capacity to 
undertake needed facility improvements, expansions, or new site 
developments--while simultaneously serving a large and growing 
patient base on slim operating margins.
    The committee bill has provided a variety of options to 
respond to the capital improvement needs of the Nation's health 
centers. First, the committee has restored the Secretary's 
authority in section 330 to make grants to health centers for 
capital projects, which was eliminated in the 1996 
reauthorization. The elimination of this authority has made it 
extremely difficult for health centers to meet facility needs. 
The committee notes that by allowing health centers to use both 
planning/development and operational grant funds for 
construction, modernization, and expansion, the ability of 
health centers to meet the demand for health care services in 
existing and new communities will be greatly enhanced. The 
committee also believes that restoring construction, expansion, 
and modernization authority in section 330 advances the goals 
of the Resolution to Expand Access to Community Health Centers 
(REACH) Initiative sponsored by Senators Bond and Hollings, 
which calls for doubling the capacity of health centers to 
provide care to as many as 10 million more Americans over a 5-
year period.
    The committee understands that, in most cases, grant funds 
will be used to pay part of the costs of facility needs--
particularly in the case of larger facility construction or 
modernization projects. In these situations, health centers 
also will need to secure long-term financing to meet the 
remainder of the costs. No loan, loan guarantee, or grant may 
be made for a project involving the modernization of a building 
unless the project complies with the Davis-Bacon Act and wages 
are paid at locally prevailing rates.
    The committee intends to give the Secretary flexibility to 
support the costs of capital projects, particularly in rural 
areas and blighted urban areas where no existing facilities are 
available for acquisition and modernization. The committee does 
not intend that limited grant dollars for health services be 
redirected to capital projects. In order to conserve grant 
funds, the committee expects health centers to make every 
effort to utilize available commercial financial sources for 
facility acquisition, construction, modernization, and 
expansion needs. To ensure that the vast majority of funds 
appropriated under section 330 are used for patient care, the 
committee has limited the amount of funds that can be used for 
construction, renovation, and modernization of facilities in 
any fiscal year to no more than 5 percent of the total amount 
appropriated under section 330 for that fiscal year.

Loan guarantee

    The committee is concerned that the loan guarantee program, 
which in the past has only provided a guarantee for 80 percent 
of the loan value with waivers for 85 percent and 90 percent 
has been difficult for health centers to utilize due to a 
number of issues. The committee recognizes that most health 
centers, as non-profit organizations dedicated to making health 
care available to the most needy in their communities, have 
little or no financial reserves and would otherwise encounter 
great difficulty securing long-term financing from local 
lending institutions at reasonable interest rates, if at all. 
At the same time, construction costs have soared over the past 
few years, and as a result, the gap between what health centers 
can afford and the cost of capital projects continues to grow. 
For this reason, the committee bill extends the existing 
authority, which currently permits the issuance of loan 
guarantees for managed-care purposes, to include loan 
guarantees for facility construction, modernization, and 
expansion, and for acquisitions of facilities and equipment. 
The committee authorizes the Secretary to issue guarantees for 
up to 90 percent of the principal and interest on loans made to 
health centers for capital projects. Hopefully, this 
legislation will provide the appropriate balance between the 
Government's duty to ensure safe and effective health centers 
and the local investment in the health care infrastructure.

Use of leftover funds

    The committee has been advised that only a small portion of 
funds has been expended as previously appropriated under 
section 330, which were available for loan guarantees for 
health centers for fiscal years 1997 and 1998, under the 
Departments of Labor, Health and Human Services, and Education, 
and Related Agencies Appropriations Acts of 1997 and 1998, 
respectively. These funds were made available for loan 
guarantees under Title XVI of the Public Health Service Act for 
loans made by non-Federal lenders for the construction, 
renovation, and modernization of health center facilities, as 
well as for guarantees for loans to health centers for the 
costs of developing and operating managed care networks or 
plans under section 330. A total of $14 million was 
appropriated for the 2 fiscal years, which under the terms of 
the Federal Credit Reform Act of 1990, allowed the issuance of 
up to $160 million in loan guarantees. Because of difficulties 
in the administration of the loan guarantee program--which the 
committee bill remedies--very little of the $160 million in 
guarantees were actually issued. Indeed, only $21 million in 
guarantees has been spent to date, leaving $139 million 
available. The committee bill makes these funds available until 
expended for loan guarantees under the newly revised Section 
330(d) of the Public Health Service Act.

Solvency study

    The committee recognizes that many health center-owned or 
controlled managed care organizations are concerned about the 
difficulty in meeting State solvency requirements for loans. 
The committee also understands that health centers face many 
financial burdens in trying to deliver health services to the 
underserved, and innovative ways must be found in guaranteeing 
solvency for loans taken by organizations. For that reason, the 
committee requests the Secretary to conduct a study that would 
examine the feasibility, costs, and implementation requirements 
of establishing a program to provide Federal guarantees to 
health center-owned or controlled managed care organizations so 
they could meet State solvency requirements. The Secretary 
shall provide this report to this committee, and other 
appropriate committees, no later than 2 years after the date of 
enactment of this legislation.

Refinancing of loans

    Refinancing of existing loans will enable health centers to 
reduce interest payments or improve loan terms. To be eligible 
to use the loan guarantee authority for refinancing, a health 
center must demonstrate that it would be beneficial to the 
health center and the government. The committee believes that 
these provisions will allow health centers greater access to 
capital with potentially lower interest rates, resulting in 
lower overhead costs and timely completion of capital projects. 
Also, funds previously used for high interest payments will be 
able to be used instead to provide health care services for the 
underserved.

Practice management networks

    Health centers have been quick to respond to the changing 
dynamics of health care delivery by collaborating with each 
other and with other local providers in networks and 
partnerships designed to improve quality and access to care. 
These relationships also achieve efficiencies in care delivery. 
Examples of these networks include clinical collaboratives, 
shared computer information systems, and shared administrative 
and financial support systems. To assist health centers in 
these efforts, the committee bill expands the current authority 
supporting network development and operation under section 330 
by creating a new category of networks called practice 
management networks. Health centers will be able to apply for 
grant support for networks that reduce costs, enhance the 
quality and coordination of health care services, improve the 
availability and access to health care services, and improve 
the health status of communities.
    In developing the practice management networks in this 
reauthorization (in addition to the managed care networks which 
were added in 1996), it became obvious that a more efficient 
payment system for those networks would allow the Secretary to 
directly provide funds to those networks, rather than requiring 
the Secretary to provide funds to each of the entities in the 
network separately. To ensure that the networks and the funds 
provided by the Secretary are still under the control of each 
of the health centers within the network, those networks are 
required to be at least majority owned or majority controlled 
by the health centers, and the health centers make the request 
to the Secretary for the network payment.
    The committee bill permits the Secretary to make grants 
under section 330 to develop and maintain these new practice 
management networks and continue the use of section 330 funds 
for the planning and development of managed care networks. The 
committee bill further clarifies that health centers may 
receive planning and development support for the establishment 
of practice management networks, and that networks which are 
owned and/or controlled by section 330 funded health centers 
may receive limited operational support. Funds may be used to 
purchase or lease equipment (including data and information 
systems) and to provide training and technical assistance that 
will assist in the development and maintenance of these 
networks. To ensure that the majority of section 330 funds are 
used for direct patient care, the committee bill limits funds 
for all network purposes (both practice management networks and 
managed care networks) to no more than 2 percent of funds 
appropriated in a fiscal year. Additionally, the committee 
believes that no construction funds should be allocated to 
practice management networks or managed care networks, but 
should be reserved for individual health centers.

Proportional funding allocation

    The committee restores the statutory funding allocation 
requirement for the Community Health, Migrant, Homeless, and 
Public Housing subauthorities under section 330. The committee 
notes that when the four separate health center programs were 
consolidated under a single section 330 authority in 1996, the 
law included a requirement for allocating funds appropriated 
under section 330 for each of the subauthorities in accordance 
with the proportion of total funding they each had received in 
FY 1996. The committee recognizes that despite the fact that 
this statutory funding allocation requirement expired in 1998, 
the Secretary has continued to adhere to the methodology in 
distributing overall Health Centers program funding among the 
four health center programs subauthorities. Vulnerable 
populations have benefitted from the Secretary's actions 
because the migrant, homeless, and public housing health center 
programs provide specialized care to these populations. These 
programs should be continued and expanded, and restoring the 
original funding allocation methodology to the statute would 
ensure the continued distribution of section 330 funds to farm 
workers, homeless persons, and public housing residents. The 
committee would like to stress the desire to maintain 
appropriate funding levels for each of the programs, and we 
commend the Secretary for continuing to allocate the same 
percentage each fiscal year as was allocated the previous 
years.

Eligibility of farm workers and homeless individuals

    The committee notes that during consolidation of the Health 
Center authorities in 1996, eligibility for services under the 
homeless program of formerly homeless individuals during the 
first 12 months following their transition to permanent housing 
was inadvertently omitted. Also, current authority fails to 
specify homeless youth as eligible for services, even though 
they remain a key homeless population. In addition, current law 
fails to recognize many farm workers as eligible for services 
because they migrate year-round for employment purposes. The 
committee bill provides access to care for these individuals by 
permitting farm workers who move year-round to receive services 
from farm worker health programs. It also provides coverage to 
homeless youth and formerly homeless persons following their 
transition to permanent housing. The committee believes that 
these provisions ensure that the Health Centers program remains 
appropriately targeted to the most vulnerable populations.

Nurse-managed health centers

    Nurse-managed health centers are nationally recognized 
safety-net primary health care providers in urban and rural 
areas. The majority of nurse-run health centers have been 
established by non-profit, university-based schools of nursing 
to meet the needs and interests of community members and to 
prepare qualified graduates with the skills to work in 
medically underserved areas. Many of these health centers were 
originally funded by the U.S. Department of Health and Human 
Services, Health Resources and Services Administration (HRSA), 
Bureau of Health Professions and Division of Nursing. Critical 
goals for the nurse-managed primary care health centers include 
attaining Federally Qualified Health Center status and becoming 
contributing members of the Consolidated Health Centers 
Program.
    Nurse-managed health centers are eligible to receive 
section 330 funding (or to be certified as FQHC look-alikes) in 
accordance with section 330(e)(1)(B), which allows the 
Secretary to fund an entity for which s/he is ``unable to make 
each of the determinations required by subsection (j)(3)'' 
[including the governance requirement under (j)(3)(H)] for up 
to 2 years. The committee encourages HRSA's Bureau of Primary 
Health Care to expedite FQHC certification and, where 
appropriate, provide 330 funding to nurse-managed health 
centers, which were previously and are currently funded by 
HRSA, Bureau of Health Professions, Division of Nursing, and to 
provide technical assistance during this 2-year period to 
enable the nurse-managed health centers to achieve full 
compliance with all 330 requirements, and thus, remain eligible 
for continued health centers funding.

Outreach and services for special populations

    The committee bill contains a new requirement that health 
center boards review all internal outreach plans for specific 
subpopulations in order to ensure community involvement in 
these efforts. However, the committee does not intend that this 
requirement prevent health centers from engaging in outreach 
activities in response to pressing local health needs before 
the health center board is able to review a plan before the 
outreach activities are needed.
    It is the committee's intention that community health 
centers be accorded considerable flexibility in the development 
of their outreach and services plans, in recognition of the 
variations across communities with regard to the prevalence of 
the various subpopulations, the needs of people in those 
subpopulations, the availability of targeted subpopulation 
services, and the availability of resources.
    The committee instructs the Secretary to provide guidance 
to community health centers with regard to the service 
modifications they may wish to consider as they develop their 
subpopulations outreach and services plans. Such modifications 
may include establishment of advisory or focus groups; posting 
of notices of hours of service and fee schedules at locations 
where subpopulations congregate; adjustments in eligibility 
determination processes, appointment systems, and hours of 
service; outstationing of health center staff at emergency 
shelters or other locations where members of subpopulations 
congregate; addition of services for health conditions common 
among people in those subpopulations; in-service training of 
health center staff about subpopulations; establishment of 
referral relationships for case management and supportive 
services with public entities and faith-based organizations; or 
other locally appropriate activities. Further, the committee 
instructs the Secretary to provide guidance to community health 
centers in developing subpopulation outreach and services 
plans.
    Finally, it is the view of the committee that health 
centers should be encouraged to make contractual and 
collaborative arrangements with entities that currently provide 
health and support service outreach to targeted subpopulations, 
including the homeless, migrant and season farmworkers, and 
residents of public housing.

Availability of translation services

    The committee recognizes the critically important role that 
translation services, as well as health care services provided 
in a culturally competent manner, play in ensuring the delivery 
of appropriate health care services to patients with limited 
English proficiency. The committee applauds the efforts of 
health centers to deliver linguistically and culturally 
appropriate care. It recognizes and appreciates that health 
centers serve increasing numbers of patients speaking a variety 
of languages and representing diverse racial and ethnic 
backgrounds. It is acknowledged that it is often the case that 
grants to health centers under section 330 do not adequately 
cover the full costs of providing needed language access 
services to the continually increasing variety of populations 
and languages served by the health center. The committee 
directs the Secretary to work with health centers to enable 
them to provide, to the maximum extent feasible, appropriate 
language access services for all of the patients with limited 
English proficiency. This includes permitting the Secretary to 
award grants to health centers to provide translation and 
interpretation services or to compensate bilingual or 
multilingual staff for language assistance services for 
limited-English proficiency patients. The committee encourages 
the Secretary to keep the grant application process from being 
overly burdensome for the applicants and to allow creativity 
and flexibility in considering the various ways that grantees 
can provide language access through these funds. The committee 
bill authorizes $10 million in FY 2002 for these grants, in 
addition to the amounts authorized for the Health Centers 
program.

Technical assistance for health centers and new starts

    The committee bill revises the current technical assistance 
authority to require the provision of additional information to 
organizations that wish to become health centers and current 
grantees and requires the provision of information on resources 
available to assist entities to meet the health needs of 
communities.

State-wide technical assistance centers for school-based health

    The committee bill authorizes a new program for school-
based health centers that may not be receiving section 330 
funding to create new organizations to fund current programs to 
establish statewide technical assistance centers. These groups 
will coordinate Federal, State, and local health care services 
that contribute to the delivery of school-based health care; 
provide technical support training; and conduct operational and 
administrative support activities for statewide, school-based 
health center networks. The committee authorizes $5 million to 
be appropriated for fiscal year 2002 for these centers.

                              rural health

    The Rural Health Outreach and Network Development Grant 
Programs serve to support innovative health care delivery 
systems, as well as integrated health care networks in rural 
America. Since 1991, more than 2.7 million people in 46 States 
have been served by the Outreach Grant Program through grants 
that total more than $200 million.
    In re-authorizing this program, the committee has made 
changes to the authorizing language to recognize that the Rural 
Health Outreach Service Grants and Network Development grants 
serve different purposes and are administered separately. The 
committee supports the notion that Outreach Services grants are 
focused on improving health care service delivery, while the 
Network Development grants are focused on helping rural 
communities improve their capacity building efforts to 
strengthen the rural health care infrastructure.
    The committee also has added a new program to the Outreach 
authority entitled, ``the Small Health Care Provider Quality 
Improvement Grant Program.'' This program will provide grants 
to small rural health care providers for projects to improve 
quality and enhance how they deliver care to rural communities.
    The Rural Health Outreach program has been essential for 
the delivery of quality health care for millions of individuals 
living in rural underserved areas. Both Outreach Services and 
Network Development programs include requirements for working 
with other organizations and providers to achieve program 
goals. This aids buy-in across rural communities and ensures 
the continued viability of the project after Federal funding is 
complete. The benefit of this requirement has been to foster 
collaborative relationships between privately practicing health 
professionals, hospitals, schools, churches, emergency medical 
service providers, and local health departments.
    The committee is aware that many rural providers have had 
difficulty accessing the capital necessary to expand services, 
form networks, or develop quality improvement programs. The 
three grant programs authorized by this legislation are 
intended to make resources available for these important 
activities.
    The focus of each of these grant programs is on expanding 
access and improving the quality of health care services being 
delivered in rural communities. The committee encourages the 
Secretary to ensure an equitable distribution of funds across 
the States. The committee notes that the nature of rural 
communities varies significantly across the country. Rural 
Montana is different than rural Massachusetts. Consequently, 
the committee encourages the Secretary to provide support for a 
diversity of projects that reflect the varied nature of rural 
populations. The committee also wants to ensure that the 
program can build on existing models that work.
    In designing these grant programs, the committee paid 
particular attention to the need to focus on service delivery. 
Equally important, the committee felt it was essential to 
design these programs to reflect the reality of the communities 
the projects seek to assist. For example, while both the 
Outreach Services and the Network Development grants require 
that the project reach out to other local partners, the Small 
Health Care Provider Quality Improvement grants do not have a 
similar requirement. Instead, applicants for the Small Health 
Care Provider Quality Improvement grants can be either public 
or private for-profit entities. The committee makes this 
distinction because in many small, rural underserved 
communities, the safety net has a much broader definition than 
in non-rural areas, and it is the privately practicing 
physician who represents the most likely applicant. These 
privately practicing physicians represent an important part of 
the health care safety net in the United States. The committee 
wants to acknowledge their important contribution to making 
health care accessible and affordable. The committee is 
confident that the reauthorization and expansion of this 
important program will provide much needed assistance to rural 
underserved communities not previously supported by the 
program.
    Subtitle B of the bill would consolidate various telehealth 
grant programs and establish the Office for the Advancement of 
Telehealth (OAT). The bill also identifies OAT as the office 
that shall administer these telehealth grant programs.
    Telehealth offers great promise for improving access to 
specialized health care services in rural communities. By 
consolidating the grant programs, the committee hopes a more 
coordinated effort will be created to bring telehealth services 
to rural areas while encouraging the creation of a network of 
users for these services.
    The legislation also would support the establishment of 
telehealth resource centers throughout the United States. These 
centers would provide technical assistance to entities 
interested in putting together a telehealth network. 
Furthermore, these Resource Centers would be available to 
demonstrate how telehealth technology can be used effectively 
in rural communities.
    Finally, the committee asks the Secretary to develop a 
definition of frontier areas to ensure that communities which 
are isolated will be served by the programs established by 
Congress--with the highest benefit possible. A new definition 
of frontier is necessary to ensure that resources targeted to 
this area are given to the areas of greatest need. The 
committee strongly urges that the definition be completed 
within one year after the enactment of this legislation.

                 NATIONAL HEALTH SERVICE CORPS PROGRAM

Expanding and strengthening the NHSC

    The committee recognizes the critical role the NHSC plays 
in providing care for underserved populations by placing 
clinicians in urban and rural communities with severe shortages 
of health care providers. Although the NHSC program has proven 
successful in addressing health professional shortages in many 
areas, funding limitations have restricted the program's 
ability to meet its primary goal. The committee notes that 
according to HHS, more than 12,000 physicians (4 times the 
current number of NHSC providers), would be needed to place 
sufficient providers in all health professions shortage areas. 
More than 20,000 physicians (8 times the current number of NHSC 
providers) would be needed to bring all areas of the country to 
the same staffing ratios for providers that are used by both 
managed care organizations and health centers. To increase the 
ability of the NHSC to meet staffing needs in underserved 
areas, the committee bill reauthorizes the National Health 
Service Corps (NHSC) program for 5 years, with the intention 
that the level of funding for the program be doubled over that 
period. For FY 2002, the committee authorizes a 17 percent 
increase to a level of $146.75 million and such sums as may be 
necessary for the following 4 years.

Automatic HPSA designation

    The committee recognizes that the NHSC, the Health Centers, 
and Rural Health Clinics Programs are intended to address the 
same goal: to meet the health care needs of underserved 
populations. Requiring a health center to obtain a Health 
Professional Shortage Area (HPSA) designation, even though each 
health center already serves a ``medically underserved area or 
population,'' creates a bureaucratic hurdle to the placement of 
NHSC personnel at health centers. The committee believes that 
providing automatic HPSA facility status to health centers and 
rural health clinics, thus making them eligible for placement 
of NHSC personnel, will reduce bureaucratic barriers and allow 
coordinated use of Federal resources in meeting the health care 
needs of areas that lack sufficient services.
    To be eligible for an NHSC placement, health centers and 
rural health clinics will receive automatic designation as a 
HPSA for a period of 5 years. After that period, a rural health 
clinic or a health center would be required to demonstrate that 
its HPSA designation complies with the HPSA requirements in 
effect at that time. The committee feels that this provision 
strikes an appropriate balance--it prevents health centers from 
being ``grandfathered'' in without adequately meeting the 
standards needed to receive an NHSC placement, and at the same 
time, it reduces the bureaucratic burden health centers may 
face in retaining their designation. The committee believes 
that this automatic designation process will improve the 
partnerships between health centers, rural health clinics, and 
the NHSC.

Assignment of Corps personnel

    The committee bill revises the law to permit the assignment 
of Corps personnel to for-profit sites, and provides that 
priority in placements will be given to nonprofit and public 
sites. It is the intent of the committee that the Secretary 
carefully examine and limit the instances in which placements 
are made in for-profit sites. Assignments of Corps personnel 
should be made to safety net providers serving a HPSA whenever 
possible and to support their work in caring for the uninsured 
and underserved.
    The committee recognizes that in some rural areas, 
communities may not have particular non-profit or private 
entities who can serve as placement sites for Corps members, 
even though those communities are designated as health 
professional shortage areas. To increase access to clinician 
services in those areas, the committee has allowed for-profit 
sites to be eligible for the program, but restricts such 
inclusion to areas in which lack non-profit or private sites.

Determining priorities for placement of NHSC personnel

    While intended to ensure that all Corps placements were 
made in areas of highest need, the committee believes that the 
current criteria used to determine whether a NHSC site is 
included on the high priority placement list has actually had 
the effect of discriminating against areas of high need and the 
safety net providers serving these areas because the criteria 
severely restricts the Secretary's flexibility to consider 
factors not listed in current law as indicators of need. The 
committee bill repeals these restrictive criteria, giving the 
Secretary flexibility to take into account a broader range of 
documented access barriers in an area or population, such as 
linguistic or cultural isolation, transportation barriers, and 
other factors highly correlated with underservice--including 
the size of the uninsured, elderly, disabled, or minority 
populations. In determining priorities for placement, the 
Secretary may continue to use the criteria previously used--
ratio of health professionals to the number of individuals in 
the area of population served or served by the medical facility 
to be designated, as well as the rate of low birth weight 
births, infant mortality, poverty, and access to primary health 
services. However, the Secretary is no longer limited to the 
use of just these criteria.

Revision of process for determining placement on the priority list

    The committee bill establishes a new process for the 
development of the priority placement list, and HRSA should 
report back to the committee with the new HPSA regulation and 
how it will be implemented. The Secretary is required to 
publish a proposed list of HPSAs and entities that would 
receive priority in NHSC placements, and the relative scores 
and priorities of all entities applying for NHSC placements. 
All entities will have 30 days after the publication of the 
list to provide additional information to the Secretary in 
support of inclusion on the priority list or in support of a 
higher priority determination. After reviewing the information, 
the Secretary is required to publish a final list. Entities 
eligible for NHSC placements shall be notified that they are 
authorized to receive a placement. The Secretary may 
periodically update the final list and add new entities, and if 
the Secretary does so, entities adversely affected by the 
update shall be notified by the Secretary and shall have 30 
days to file an appeal. The committee notes that these new due 
process rights are a central part of many other statutes and 
are important to providing for the development of the priority 
list for the NHSC. This is important in view of the 
consequences of the loss of HPSA designation or priority status 
to areas that had previously been considered high-priority 
shortage areas.

Residencies

    The committee recognizes that obligated physicians who have 
not completed residencies are less prepared to fulfill their 
service obligation, have extremely limited placement 
opportunities, are less successful in competing for site 
assignments, and are having increasing difficulty in obtaining 
hospital admitting privileges. To correct this situation, we 
are amending current law to require physicians to complete a 
full primary care residency program and extend deferment for 
advanced training to include all disciplines eligible for the 
Corps scholarship program. Residency-trained physicians are 
best qualified to deliver a full range of services required by 
underserved communities. Based on data from the Corps loan 
repayment program, there is less difficulty in placing 
clinicians of all disciplines as a result of additional 
training obtained prior to the start of their service 
obligation.

Termination and other contractual changes

    The committee recognizes that the statute of limitations 
applicable to both the scholarship and loan repayment programs 
gives the Federal Government 6 years from the date a debt 
becomes due to file a complaint in District Court. If a 
complaint is not filed within that time, the agency has no 
alternative but to terminate collection efforts and write off 
the debt. Furthermore, the period of absolute non-
dischargeability is currently 5 years. Although the current 
service obligation under the scholarship and loan repayment 
programs is identical, the default provisions are different: 
the unserved obligation penalty under the loan repayment 
program is only $1,000 per month. Also, under the current 
default/termination authority, the scholar who refuses 
scholarship support, in whole or in part, may convert his or 
her service obligation to simply repay the amounts received. 
Therefore, an individual could accept 95 percent of the 
scholarship for a year, refuse 5 percent, and be able to avoid 
the service obligation and the triple payback penalty for that 
year.
    To enhance the Secretary's effectiveness in collecting 
debts from defaulting Corps clinicians, the committee has 
instituted a variety of changes, including eliminating the 
statute of limitations applicable to the program so that the 
Government can continue to pursue debts that are currently 
being written off, increasing the period of non-
dischargeability from 5 to 7 years to give the Government added 
protections against having these debts discharged in 
bankruptcy, and revising the loan repayment default provision 
by increasing the unserved obligation penalty from $1,000 to 
$7,500 per month. The value of the loss of a clinician's 
services to an underserved community (upon default) should be 
roughly equal under both the scholarship and loan repayment 
programs. However, the average loan repayment debt is $57,948, 
while the average scholarship debt is $252,296.
    Furthermore, the committee grants the Secretary authority 
to terminate loan repayment contracts, at the request of 
individuals who find that their loan repayment service is not 
amenable to their needs, provided the individuals return all 
monies awarded in sufficient time to enable the program to 
reobligate those monies to another loan repayment applicant. 
Therefore, the committee has waived the unserved obligation 
penalty otherwise owed by defaults.
    The committee would like to require scholars who refuse 
scholarship support to repay all funds received during a school 
year by the end of that contract/school year. Thus, scholars 
would have an incentive to decline support earlier rather than 
later in the school year. To institute that change, the 
committee has included language to require the refusal of all 
funds received, rather than just part of the funds.

Overall retention rates

    The committee is heartened by recent reports suggesting 
that Corps clinicians serve for several years beyond completion 
of their service commitment. In 1995, approximately 53 percent 
of eligible clinicians continued to provide valuable services 
to underserved communities after their obligation was 
fulfilled. That percentage has steadily grown to 64 percent in 
1996 and 1997, and 1998 data reveal that more than 70 percent 
remain in service. Of these clinicians, approximately 80 
percent remain in service at the site at which they originally 
served. These results vary only slightly by type of clinician. 
Physicians were retained at a rate of 71.2 percent and nurse 
practitioners at a rate of 76.8 percent. Loan repayers report a 
consistently higher rate of retention over scholars. In 1998, 
loan repayers were retained at a rate of 75.5 percent, while 
scholars were retained at a rate of 61 percent. Both rates have 
increased from the 1996 and 1997 levels.

NRSA option

    The Corps aims to provide access to primary health care 
services. The Corps scholarship program provides scholarship 
support to scholars with the intent that they provide health 
care in underserved areas, whereas the National Research 
Service Award program at NIH trains participants in the 
research field to become academic faculty members. When those 
participants begin their research, they are oftentimes not 
available to provide primary health care services to 
underserved communities. Currently, there are 26 Corps scholars 
participating in the NIH program out of the 669 scholars in 
residency training. Therefore, the committee has opted to 
eliminate the provision which allows scholarship recipients to 
fulfill their service obligation by participating in the 
National Research Service Award program.

Repeal of section 334 cost sharing provisions

    The committee bill repeals Section 334 of the Public Health 
Service Act (``Cost Sharing''), which requires that an entity 
to which a member of the NHSC is assigned must reimburse the 
Federal Government for the cost of that NHSC member. The 
committee notes that, in practice, this requirement is waived 
in almost all cases. For example, in 1998, the cost-sharing 
requirement in section 334 was waived in at least 95 percent of 
cases, and the cost of collecting the remaining 5 percent of 
payments exceeded the funds received. The committee recognizes 
that eliminating this provision will relieve the undue burden 
on underserved communities in seeking an NHSC clinician and the 
unnecessary administrative burden on HRSA. The committee 
believes that the dollars saved by eliminating this provision 
can be better used in providing access to care. The committee 
further clarifies that this action is consistent with the 
spirit of the Paperwork Reduction Act and will facilitate 
increased usage of NHSC clinicians by underserved communities.

Charges for services

    After completing their taxpayer-funded medical education, 
many NHSC Scholars request (and HHS often approves) a waiver of 
their NHSC service obligation if they agree to establish a 
``private practice option'' (PPO) in a designated HPSA. Under 
current law, the Scholar is free to practice in virtually any 
HPSA, whereas those who fulfill their service obligation 
through assignment are targeted to high-need HPSAs. Currently, 
these ``private practice option'' clinicians are not subject to 
the requirement that they open their practice to all in the 
community regardless of ability to pay, and in some cases, 
these NHSC-subsidized for-profit practices have been found to 
resist caring for uninsured (and even Medicaid-covered) 
patients and refer them instead to nearby health centers and 
other local safety net providers.
    The committee bill sets out the requirements that entities 
with Corps placements must comply with when providing services. 
These rules apply to all entities with NHSC assignees, as well 
as NHSC members who elect the private practice option (PPO). 
The bill prohibits discrimination in the provision of services 
to an individual because the individual is unable to pay or 
because the individual has coverage under the Medicare, 
Medicaid, or S-CHIP programs. Assignment under Medicare must be 
accepted, and cooperative agreements must be entered into with 
the State agencies administering the Medicaid and S-CHIP 
programs. The local and prevailing rate for services may be 
charged in an amount designed to cover the cost of the entity. 
However, if an individual is unable to pay the fee, the charge 
must be reduced or waived in accordance with a schedule of 
discounts that are based on the individual's ability to pay for 
services.
    The committee reiterates that this provision is included to 
ensure that the NHSC is used to reduce access barriers for 
everyone living in communities lacking health professionals, 
regardless of their income or ability to pay for services. The 
committee directs the Secretary to monitor compliance with this 
requirement by entities with NHSC assignments, as well as 
individuals electing the PPO option to determine whether 
services are being provided to patients regardless of ability 
to pay and without discrimination against individuals with 
coverage under public programs.

Part-time service

    To assist with both recruitment and retention within the 
National Health Service Corps, the committee creates a 
demonstration program to allow NHSC Loan Repayment participants 
to complete their service requirement on a part-time basis on 
written request of the placement site. Participants in the 
part-time program must work at least 16 hours per week and must 
agree to extend their service obligation so that the full 
service obligation is completed. The committee bill includes 
this provision in order to better meet the needs of the 
communities in which NHSC Loan Repayment participants serve and 
to enhance recruitment and retention efforts. In particular, 
the committee recognizes that many small rural communities may 
not have sufficient volume to support a full-time health care 
practitioner. In addition, some sites may not need particular 
types of providers on a full-time basis. The committee believes 
that some practitioners may find part-time service more 
attractive, which in turn could improve both recruitment and 
retention. Not only will this demonstration project provide for 
added flexibility within the program, but the committee hopes 
that it will also assist with the recruitment of women within 
the program.

Set-aside for non-physician primary care practitioners

    In 1990, when the National Health Service Corps was last 
reauthorized, nurse practitioners, certified nurse midwives, 
and physician assistants were not receiving scholarships. 
Instead, they only received loan repayments. To emphasize that 
the Corps was not a physician-only program, the committee 
provided these groups with a 10 percent scholarship set aside. 
However, over the past 10 years, communities have developed an 
overall preference for receiving loan repayment clinicians, 
rather than having scholarship recipients. For example, in the 
2001 placement cycle, there were only 163 vacancy requests for 
nurse practitioners, certified nurse midwives, and physician 
assistants for 150 scholars available for service, while more 
than 30 percent of the loan repayors placed within the 
underserved communities were nurse practitioners, certified 
nurse midwives, or physician assistants.
    Thus, the committee believes that the set-aside for these 
providers should be expanded to include both the scholarship 
and loan repayment portions of the Corps. This decision should 
not be construed to indicate that the committee does not 
support the placement of such groups in underserved areas. In 
fact, we believe quite the opposite--the placement of such 
groups is critical to the success of the Corps. It is an 
indication of the community requests and their changing needs. 
Furthermore, to maintain the incentive for providing 
scholarships to nurse practitioners, certified nurse midwives, 
and physician assistants, those clinicians should be counted 
for both the scholarship set-aside (30 percent of funds) and 
the nursing set aside (10 percent). With this change, the 
committee also hopes that the Secretary will re-evaluate the 
scholarship program and appropriately target it so that the 
scholarships can be given to minorities and individuals with 
financial need, and that the communities with greatest need 
will obtain appropriate clinicians.

Dental health

    Oral and general health are inseparable, and good dental 
care is critical to our overall physical health and well-being. 
While oral health in America has improved dramatically over the 
last 50 years, these improvements have not occurred evenly 
across all sectors of our population, particularly among low-
income individuals and families. Too many Americans today lack 
access to dental care. While there are clinically proven 
techniques to prevent or delay the progression of dental health 
problems (according to the U.S. Surgeon General's report, Oral 
Health in America), an estimated 25 million Americans live in 
areas lacking adequate dental services.
    The Health Care Safety Net Amendments of 2001 therefore 
contain a number of provisions to strengthen the oral health 
care safety net by increasing the dental workforce in our 
Nation's rural and underserved communities. Among other 
provisions, it directs the Secretary to develop and implement a 
plan for increasing the participation of dentists in the 
National Health Service Corps scholarship and loan repayment 
program. It also improves the process for designating dental 
health professional shortage areas and ensures that the 
criteria for making such designations provides a more accurate 
reflection of oral health need, particularly in rural areas. 
Finally, it authorizes $50 million over 5 years for grants to 
States to help them develop innovative dental workforce 
development programs specific to their individual needs to 
improve access to oral health services in designated dental 
health professional shortage areas. This program would be 
administered by the Health Resources and Services 
Administration of the Department of Health and Human Services. 
States receiving Federal funds under this program would have to 
match at least 40 percent of the grant amount.
    Currently, the Corps requires dental schools to sign an 
Educational Partnership Agreement, which in turn provides 
students attending such schools eligibility to compete for the 
NHSC Scholarship Program. The committee urges the Corps to 
discontinue the Educational Partnership Agreement.
    The NHSC should work with dental education institutions, 
dental organizations, and State and local public health 
departments to determine dental site readiness, especially in 
rural and border areas. There are many examples of 
collaborative efforts between dental schools, dental 
organizations, community health centers, and State and local 
health departments that can be expanded via the involvement of 
NHSC participants.
    In its 1994 Appropriations Conference Report, Congress 
directed the NHSC to undertake an ``oral health initiative.'' 
NHSC made a one-time expenditure of $600,000, which developed 
nine new dental sites. The American Dental Education 
Association and the American Dental Association were encouraged 
that the new sites helped to increase oral health care delivery 
to underserved areas and recruitment of additional dentists, as 
well as an increased number of available sites to place oral 
health practitioners. This ``oral health initiative'' should be 
continually evaluated to determine the level of need for 
further site development in health professional shortage areas 
and the appropriate level of funding.

Mental and behavioral health

    The committee recognizes that the NHSC is meeting only 6 
percent of the requests from more than 700 Mental (and 
Behavioral) Health Professional Shortage Areas. In fact, many 
more underserved communities need mental and behavioral health 
professionals but have not yet obtained the designation because 
attention to mental and behavioral health needs of the 
underserved is just beginning. Approximately 25 percent of 
people in the United States live in rural communities, and 
approximately 55 percent of those rural residents have no 
access to mental and behavioral health services. The role of 
mental and behavioral health professionals is to complement and 
supplement the work of the physical and oral health 
professionals.
    The committee believes that mental and behavioral health 
professionals are essential to an effective, integrated, and 
seamless system of primary health care provided to underserved 
communities, and they should be afforded the opportunity to 
participate in both the National Health Service Corps 
Scholarship and Loan Repayment Programs.

Locum tenens

    The committee appreciated previous efforts to provide for 
temporary relief of health care providers through a locum 
tenens program within the National Health Service Corps. The 
temporary relief not only assists with retention by reducing 
clinician burnout, but also allows clinicians to attend 
professional meetings and gain up-to-date information about 
health care delivery. Therefore, we strongly urge that the 
Secretary to re-institute this program and continue to 
encourage health professionals who are not part of the National 
Health Service Corps to be a part of this program.

One percent set aside

    The committee is concerned that the health care safety net 
programs are not being properly evaluated, even though 1 
percent of the total appropriations are allocated for 
evaluation, according to Section 301 of the Public Health 
Service Act. Because the committee values these programs, we 
hope that efforts will be made to more thoroughly evaluate the 
effectiveness and efficiencies of these vital programs. In 
particular, the committee is heartened by the Administration's 
hard work to redefine the health professional shortage areas, 
and we hope that this work will continue until appropriate 
regulations are in place.
    Further, the committee also requests that no later than 6 
months after the date of the enactment of the Health Care 
Safety Net Amendments of 2001, the Secretary commence a study 
of the existing primary, oral, and mental and behavioral health 
care delivery systems in health professional shortage areas. 
The purpose of this study would be to identify the unmet health 
care needs of the underserved communities, including rural 
areas, the vulnerable populations living in health professional 
shortage areas, and the manner in which such needs may be met. 
Furthermore, after this study has been conducted, we request 
that the Secretary prepare a report that includes the findings 
of this study and makes recommendations for programmatic policy 
changes in the National Health Service Corps deemed most 
appropriate to the unique requirements of these communities and 
their diverse populations, as well as those most effective in 
eliminating the identified need for additional health care 
services in health professional shortages areas.

Chiropractic/pharmacist demonstration project

    Section 317 of the bill authorizes the establishment of a 
demonstration project to provide for the participation of 
doctors of Chiropractic and Pharmacists in the Loan Repayment 
Program contained in section 338B of the bill.
    It is the intent of the committee in approving this 
demonstration project that participation be broad-based and 
comprehensive, and that the Secretary ensure that the scope of 
the demonstration project reaches to all regions of the 
country. However, it is up to individual communities to decide 
if they would like to participate in the demonstration project. 
Furthermore, the committee intends that the Secretary shall 
include a substantial number of representatives from the major 
chiropractic health professions organizations, including the 
Association of Chiropractic Colleges and the American 
Chiropractic Association; and from the major pharmacist 
professional organizations, including the American Association 
of Colleges of Pharmacy and other appropriate pharmacy groups, 
in providing input, advice, and counsel to the Secretary and 
his staff regarding the development, implementation, and 
oversight of the demonstration project.
    In evaluating the demonstration project for chiropractors 
and pharmacists, the appropriate number of clinicians to be 
included within the demonstration should include a sufficient 
number to determine the effectiveness of the program, taking 
into account the relative unmet needs in the health 
professional shortage areas documenting physical, oral, or 
mental and behavioral health needs.
    In addition to the reports required under this section, the 
committee expects to receive periodic written reports, 
describing in detail the development and implementation of this 
section, including the input provided from the chiropractic and 
pharmacists groups referenced in this report.

                   HEALTHY COMMUNITIES ACCESS PROGRAM

    The committee bill establishes a new Health Communities 
Access Program (HCAP) in Section 340 of the Public Health 
Service Act. HCAP is designed as a grant program established 
for the purpose of improving access to health services for the 
uninsured and underinsured through better integration of health 
services within communities.
    Safety net infrastructure needs vary from community to 
community, and a Federally directed solution should be flexible 
enough to address the varying needs of each community. The 
committee recognizes that reality, and hopes HCAP will allow 
communities to propose innovative solutions tailored to their 
unique solutions.

Participation of core safety net providers in HCAP consortia

    The committee wants to ensure that the relatively small 
amount of Federal HCAP grant funding is allocated in the most 
effective manner possible so that it can reach the maximum 
number of uninsured and underserved individuals. For this 
reason, the committee bill establishes a requirement that any 
HCAP consortium include the four main groups in a community, if 
they exist within that community, that provide health services 
to the uninsured and underserved: community health centers, 
private health care providers, hospitals with LIURs of 25 
percent or more, and public health departments.
    All four groups must participate in a consortium to be 
eligible for a grant, unless one of the groups does not exist 
in the community, declines or refuses to participate, or places 
unreasonable conditions on their participation. By involving 
all of these groups equally in the makeup of the consortium, it 
is the committee's intent that the members of a consortium work 
cooperatively to coordinate health care services across a 
community and improve access to those services. The committee 
expressly encourages consortiums to be inclusive in 
representing interested organizations within the consortium.
    The committee does not intend to designate any specific 
organization or entity as a priority recipient of HCAP grant 
funds. The committee hopes this legislation will encourage a 
variety of innovative models for integrating health services 
for the uninsured. Public and nonprofit providers are 
encouraged to apply cooperatively as eligible entities, and 
according to the will of the community.
    It is the intent of the committee that each of the four 
aforementioned provider groups be represented in a community's 
decision-making structure. Hopefully, this will strike a 
balance between providing communities flexibility in organizing 
their decision-making processes for the consortium and ensuring 
fair representation of all the provider groups involved in the 
consortium. The committee in no way intends to undercut the 
critical role played by all safety net providers in a 
community--both public and nonprofit--in providing integrated 
care to the uninsured and underserved.
    The committee believes that this program's success will in 
part be measured on its ability to encourage widespread 
participation among community providers of health care. The new 
HCAP program is an important step in assisting communities as 
they innovate to improve access to health care services for 
underserved populations.

Fifteen percent direct services limitation

    The committee bill limits the use of HCAP funding for 
direct patient care and services to no more than 15 percent of 
each grant. This program is intended to provide support for the 
development of the infrastructure necessary to support 
integration among safety net providers of care to the 
uninsured. It is not intended to primarily support the care 
itself, as successful Federal programs such as community health 
centers, Ryan White, maternal and child health, and others have 
been established to provide direct services. These other 
sources of funding, however, are targeted to particular types 
of providers or particular types of treatment. Without HCAP, no 
Federal program provides assistance that cuts across these 
targeted programs to ensure integration among providers. For 
example, HCAP can be used to connect direct care providers by 
getting specialty and hospital care for uninsured patients of 
community health center and Ryan White providers. The committee 
believes that HCAP funding can have the greatest impact on 
local integration if it is used as seed funding for 
infrastructure to enable the coordination of care to the 
uninsured.

Continuation funding for CAP grantees

    As noted above, HCAP is based on the Community Access 
Program (CAP) demonstration project that was launched in FY 
2000. Seventy-six communities have received funding through 
CAP, and the committee understands that approximately 50 more 
communities will be awarded grants before the end of FY 2001. 
Because of the exciting early results from these experiments of 
community integration, the committee believes that these 
initiatives should be supported and continued. For that reason, 
the committee voted to authorize HCAP at $125 million for FY 
2002. Although the ultimate goal of the program is for local 
programs to be self-sustaining, the committee recognizes that 
1-year Federal funding, in most cases, is insufficient to 
accomplish the intended purposes of the grant. Therefore, the 
committee supports the use of a portion of the appropriations 
provided for HCAP to award continuation funding for FY 2000 and 
FY 2001 CAP grantees.

Leveraging local support through HCAP grants

    Through current models for HCAP, communities have been 
successful in leveraging local support to complement the 
initial Federal investment. In fact, the CAP demonstration 
project requires that applicants demonstrate sustainability. 
Many coalition partners in CAP collaborative groups have 
provided resources to support their efforts--some through 
matching donations and others through in-kind contributions. 
The Secretary should encourage all of these approaches and 
efforts--both to enhance current Federal support and to sustain 
programs once such support expires.

Computer decision support services

    The committee is supportive of the inclusion of computer 
decision support services in the provision of coordinated 
health care within HCAP. Computer decision support services 
assist the clinician in applying new information to patient 
care through the analysis of patient-specific clinical 
variables. Many of these systems are used to enhance diagnostic 
efforts and provide extensive differential diagnoses based on 
clinical information entered by the clinician. Other forms of 
clinical decision support systems, including antibiotic 
management programs and anticoagulation dosing calculators, 
seek to prevent medical errors and improve patient safety.

                          rural health clinics

    The Rural Health Clinics (RHC) program was authorized by 
Public Law 95-210. Currently, more than 3,000 Federally 
certified Rural Health Clinics are located throughout the 
United States. These clinics are primary care facilities 
located in rural communities that are designated as a medically 
underserved area, health professional shortage area, or 
underserved area designated by the State's governor. RHCs 
utilize a team approach to health care delivery. Every clinic 
must be staffed by at least one physician--full-time or part-
time--who serves as the clinic's medical director, at least one 
physician assistant, nurse practitioner, or nurse midwife.
    By virtue of being an RHC, these facilities received 
special Medicare and Medicaid payments. However, unlike 
Federally qualified health centers, RHCs receive no Federal 
payments to care for uninsured or underinsured.
    The committee believes that RHCs and the providers that 
work in these facilities are an integral part of the rural 
health care safety net. However, barriers exist that inhibit 
the ability of RHCs to deliver care to uninsured or 
underinsured individuals in their service areas. They also 
realize barriers to maintaining adequate amounts of staff for 
the provision of these services. Therefore, the committee has 
opted to provide certain exceptions to RHCs if they are willing 
to otherwise comply with the requirements of section 334.
    Current Federal law waives the Medicare deductible when 
individuals eligible for Medicare obtain that care at a 
Federally qualified health center. No similar waiver is in 
place when a Medicare beneficiary obtains care at a Rural 
Health Clinic. The committee believes that a similar waiver 
should exist for low-income Medicare beneficiaries when they 
obtain care at a Federally certified Rural Health Clinic that 
is otherwise eligible for Corps placement. Therefore, the 
committee has included language that would waive the Medicare 
deductible for individuals who qualify for subsidized services 
under the Public Health Services Act for those clinics. 
Therefore, low-income Medicare beneficiaries living in rural 
underserved areas served by Rural Health Clinics otherwise 
eligible for placement of a Corps member would have the same 
ability to obtain health care as low-income Medicare 
beneficiaries living in areas served by Federally qualified 
health centers.
    The committee also is proposing to clarify the language 
regarding the ability of Rural Health Clinics to offer a 
sliding fee scale for low-income beneficiaries if they would 
otherwise be eligible for placement of a Corps member. Under 
current law, health care providers are prohibited from offering 
a cash inducement to individuals to encourage that individual 
to obtain health care under a Federal health care program. This 
is commonly referred to as the ``anti-kickback'' statute. Many 
RHCs have expressed concern that this means that clinics cannot 
offer a sliding fee scale for their low-income patients under 
one of the requirements of section 334.
    The law does provide a safe harbor for Federally qualified 
health centers that waive the coinsurance for low-income 
Medicare beneficiaries. The committee would extend that waiver 
authority to Rural Health Clinics so that clinics would not be 
in violation of the anti-kickback statute if the clinic waived 
the Medicare co-pay for individuals who qualify for subsidized 
services under the Public Health Service Act. As with the 
deductible provision, this would insure that low-income 
individuals residing in rural areas served by Rural Health 
Clinics who would otherwise be eligible for Corps placement 
could have the same opportunities to get the Medicare co-pay 
waived, as would low-income individuals residing in areas 
served by Federally qualified health centers.
    The committee does not intend to amend the Social Security 
Act for all RHCs, but only for those who are willing to comply 
with Section 334 of the Public Health Service Act and who would 
otherwise be eligible for Corps placement (i.e., be located in 
a HPSA).

                            V. Cost Estimate

    Due to time constraints, the Congressional Budget Office 
estimate was not included in the report. When received by the 
committee, it will appear in the Congressional Record at a 
later time.

            VI. Application of Law to the Legislative Branch

    The Health Care Safety Net Amendments of 2001 reauthorizes 
and amends the Public Health Service Act to strengthen the 
health care centers program, continue the National Health 
Service Corps, improve and expand rural programs, and establish 
the Health Communities Access Program under the newly created 
Section 340 of the Public Health Service Act. As such, the 
committee finds that the legislation has no application to the 
legislative branch.

                    VII. Regulatory Impact Statement

    The committee has determined that there will be minimal 
increase in the regulatory burden as a direct result of this 
bill. This legislation will increase access to medical services 
in underserved areas through the strengthening of Health 
Centers programs, the reauthorization of the National Health 
Service Corps, and the expansion of rural health programs. 
Also, the implementation of the Healthy Communities Access 
Program will provide for a more effective and coordinated use 
of community resources in providing health services to the 
uninsured and underserved.

                   VIII. Section-by-Section Analysis

    Note on References: Except as otherwise specified, as used 
in the summary--
          ``The Act'' means the Public Health Service (PHS) 
        Act, and references to provisions of law are provisions 
        of the PHS Act;
          ``Corps'' means the National Health Service Corps;
          ``Health centers'' means the Consolidated Health 
        Centers, which includes community health centers, 
        migratory health centers, health centers for the 
        homeless, and public housing health centers; and
          ``Secretary'' means the Secretary of Health and Human 
        Services.
    Section 1. Short Title; Table of Contents.
    Section 1(a) cites this Act as the ``Health Care Safety Net 
Amendments of 2001.''
    Section 1(b) sets forth the table of contents for this Act.

         TITLE I--CONSOLIDATED HEALTH CENTER PROGRAM AMENDMENTS

    Section 101, Health Centers, includes various amendments to 
the Consolidated Health Centers Program, Section 330 of the PHS 
Act.
    Section 330(b)(1) is amended to change the requirement for 
health centers to provide screening for breast and cervical 
cancer to a requirement to provide appropriate cancer 
screening. When making referrals to providers of medical 
services, health centers are required to provide specialty 
referrals when medically indicated. Health centers are required 
to assist patients in establishing eligibility for and gaining 
access to Federal, State, and local programs that provide or 
financially support housing services.
    Section 330(b)(2) is amended to include as additional 
environmental health services that may be provided by a health 
center: (1) the detection and alleviation of chemical and 
pesticide exposures; (2) the promotion of indoor and outdoor 
air quality; and (3) the detection and remediation of lead 
exposures.
    Section 330(b)(2) is amended to include behavioral and 
mental health and substance abuse services as well as 
recuperative care services and public health care services as 
additional services which may be provided by health centers as 
appropriate to meet the needs of the population served by the 
center.
    Section 330(c)(1)(A) is amended to allow health centers to 
use funds for planning grants to lease, modernize, and expand 
existing buildings, construct new buildings, and purchase and 
lease equipment (including the costs of amortizing the 
principal of, and paying the interest on, loans for buildings 
and equipment).
    Section 330(c)(1)(B) is amended to change the name of the 
section from ``Comprehensive Service Delivery Networks and 
Plans'' to ``Managed Care Networks and Plans.''
    A new section 330(c)(1)(C) allows the Secretary to make 
grants to a new category of networks--practice management 
networks, networks which will enable the centers to reduce 
costs, improve access to and the availability of health care 
services, enhance the quality and coordination of health care 
services, or improve the health status of communities. For 
these networks, health centers may use funds to purchase or 
lease equipment, which may include data and information 
systems, to provide training and technical assistance related 
to the provision of health services on a prepaid basis, and to 
develop practice management or managed care networks or plans.
    Section 330(d)(1) is amended to change the name of the 
``Managed Care Loan Guarantee Program'' to the ``Loan Guarantee 
Program''. Section 330(d)(1)(A) is amended to provide a 
guarantee for up to 90% of the principal and interest on loans 
made by non-Federal lenders to health centers for the costs of 
the managed care and practice management networks, including 
the costs of acquiring, leasing, or modernizing existing 
buildings, constructing new buildings or purchasing or leasing 
equipment.
    Section 330(d)(1)(B) is amended to allow funds to be used 
for the refinancing of existing loans, provided that the 
Secretary determines that the financing will result in more 
favorable terms and will be beneficial to both the health 
center and the government.
    Section 330(d)(1) is further amended by adding a subsection 
(D) to allow funds appropriated under fiscal years 1997 and 
1998 for the loan guarantee program to be available until 
expended.
    Section 330(d)(1) is further amended to add a new 
subsection (E) to allow guarantees to be made directly to 
managed care plans or networks if the health center requests 
and if the networks or plans are at least majority owned and/or 
majority controlled (as applicable) by the health centers.
    Section 330(d)(1) is amended by adding a subsection (F) to 
apply the requirement of the Federal Credit Reform Act to 
refinanced loans.
    Section 330(e)(1) is amended by adding a new subsection (C) 
to allow the Secretary to make operating grants directly to 
managed care plans and networks if the health center requests 
and if the networks or plans are at least majority owned and/or 
majority controlled (as applicable) by the health centers. 
Operating grants may be used for acquiring, leasing, 
modernizing, and expanding buildings, constructing buildings, 
and purchasing or leasing equipment (including the costs of 
amortizing principal and paying interest on loans for buildings 
and equipment), and training.
    Section 330(e)(4)(B) limits the amount of operating grants 
that can be allocated to the managed care networks or plans to 
not more than 2 percent the total amount appropriated for these 
grants in a fiscal year.
    Section 330(g) is amended to clarify that grants are 
available to assist with environmental services for seasonal 
agricultural workers.
    Section 330(h)(4) is amended to include homeless youth as 
eligible populations to be served under the Consolidated Health 
Centers Program. This subsection is further amended to provide 
that homeless centers can continue to provide services for up 
to 12 months after an individual is no longer homeless. This 
subsection is also amended to include risk reduction, 
outpatient treatment and rehabilitation as appropriate 
substance abuse services.
    Redesignated section 330(l) is amended to require centers 
to have contracts with the State agency administering the State 
Children's Health Insurance Program (in addition to Medicaid) 
for payment of the costs of services provided to persons 
eligible under that program. This redesignated subsection is 
further amended to require that centers assure that no patient 
will be denied health services due to an individual's inability 
to pay for such services and will assure that any fees or 
payments required by the center will be reduced or waived for 
such situations. A health center's governing board is required 
to review any internal outreach plans for specific 
subpopulations served by the center.
    A new section 330(j) is added to authorize the Secretary to 
make grants to health centers to identify and detect 
environmental factors and conditions and to provide services to 
reduce the disease burden related to environmental factors and 
exposure of populations to such factors, and alleviate 
environmental conditions that affect the health of individuals 
and communities served by health centers.
    A new section 330(k) is added to authorize the Secretary to 
award linguistic access grants to eligible health centers to 
provide translation, interpretation, and other such services 
for clients with limited English speaking sufficiency. 
Appropriations are authorized for such grants in the amount of 
$10 million for FY 2002 and such sums as may be necessary for 
each of the fiscal years 2003 through 2006.
    Redesignated section 330(s) is amended to add a requirement 
that in the case of a project involving the modernization of a 
building that the application contain reasonable assurances 
that the prevailing rate in the locality be paid to all 
laborers and contractors on the project in accordance with the 
Davis-Bacon Act.
    Redesignated section 330(m) is rewritten to require the 
Secretary to establish a program to provide technical and other 
assistance to health centers. Services may include necessary 
technical and nonfinancial assistance, including fiscal and 
program management assistance, training in fiscal and program 
management, operational and administrative support, and the 
provision of information to the entities on available resources 
and how those resources can best meet the community health 
needs.
    Redesignated section 330(t) is amended to authorize, for 
the Consolidated Health Centers Program, appropriations of 
$1.369 billion for fiscal year 2002 and such sums as necessary 
for fiscal years 2003 through 2006. In awarding grants, the 
Secretary, for FY 2002 and each of the following fiscal years, 
must ensure that the proportion of total amounts made available 
to health centers for migrants, homeless, and public housing 
residents is equal to the proportions made available for these 
groups in FY 2001. Funds for building construction, expansion 
or renovation are restricted to not more than 5 percent of the 
total amount of funds appropriated in a year.

                         TITLE II--RURAL HEALTH


 Subtitle A--Rural Health Care Services Outreach, Rural Health Network 
 Development, and Small Health Care Provider Quality Improvement Grant 
                                Programs

    Section 201, Grant Programs, amends Section 330A of the Act 
to specifically separate the rural health grants from the 
telehealth grants and to create a small health care provider 
quality improvement grant program.
    New sections 330A (a) through (d) describe the purpose of 
program, define terms, and outline general administration of 
the program. Under this program, grants would be available for 
expanded delivery of health care services in rural areas, for 
the planning and implementation of integrated health care 
networks in rural areas, and for planning and implementation of 
small health care provider quality improvement activities. The 
program would be administered by the Director of the Office of 
the Office of Rural Health Policy of the Health Resources and 
Services Administration (HRSA).
    Section 330A(e) authorizes the Director of the Office of 
Rural Health Policy of HRSA to award grants to eligible 
entities to promote rural health care services outreach by 
expanding the delivery of health care services to include new 
and enhanced services in rural areas. The grants may be awarded 
for periods of not more than 3 years. Eligible grantees must be 
a rural public or rural nonprofit private entity and represent 
a consortium of 3 or more health care providers.
    Section 330A(f) authorizes the Director to award rural 
health network development grants to eligible entities to 
promote, through planning and implementation, the development 
of integrated health care networks that have combined the 
functions of network entities in order to achieve efficiencies, 
expand access, and to strengthen the rural health care system 
as a whole. Grants for implementation activities may be awarded 
for 3-year periods and grants for planning activities may be 
awarded for one-year periods. Eligible grantees must be a rural 
public or rural nonprofit private entity and represent a 
consortium of 3 or more health care providers.
    Section 330A(g) authorizes the Director to award grants to 
eligible entities to provide for the planning and 
implementation of small health care provider quality 
improvement activities. Grants are limited to periods of 1 to 3 
years. The Director must award not less than 50 percent of 
available funds to providers located in and serving rural 
areas. Eligible grantees must be a rural public or rural 
nonprofit private health care provider or provider of health 
care services, such as a rural health clinic or another rural 
provider or network of small rural providers identified by the 
Secretary as a key source of local care.
    Section 330A(h) prohibits rural health grant monies from 
being used to build or acquire real property, or for 
construction (other than for minor renovations relating to the 
installation of equipment). The Secretary must coordinate with 
similar grant programs to maximize the effect of public 
dollars. Preference must be given to applicants that: (1) are 
located in health professional shortage areas or medically 
underserved communities, or serve medically underserved 
populations; or (2) propose to develop projects with a focus on 
primary care, and wellness and prevention strategies.
    Section 330A(i) requires the Secretary to report to the 
appropriate congressional committees, not later than September 
30, 2005, on the progress and accomplishments of the grant 
programs.
    Section 330A(j) authorizes for these rural health grants 
appropriations of $40 million for FY2002 and such sums as 
necessary for each of the fiscal years 2003 through 2006.

               Subtitle B--Telehealth Grant Consolidation

    Section 211 cites this subtitle as the ``Telehealth Grant 
Consolidation Act of 2001''.
    Section 212 amends the Act to add new section 330I to 
establish telehealth network and telehealth resource centers 
grant programs. (Similar authority exists in current law, 
section 330A.)
    New sections 330I(a) through (c) define terms and outline 
administration of the program. An Office for the Advancement of 
Telehealth, headed by a Director would be established in HRSA. 
The Secretary would be required to establish telehealth network 
and telehealth resource centers grants programs.
    Section 330I(d)(1) authorizes the Director to make 
telehealth network grants to eligible entities for projects to 
demonstrate how telehealth technologies can be used through 
telehealth networks in rural areas, frontier communities, and 
medically underserved areas, and for medically underserved 
populations, to: (1) expand access to, coordinate, and improve 
the quality of health services; (2) improve and expand the 
training of health care providers; and (3) expand and improve 
the quality of health information.
    Section 330I(d)(2) authorizes the Director to award grants 
to eligible entities for projects to demonstrate how telehealth 
technologies can be used in the above-mentioned areas to 
establish telehealth resource centers.
    Section 330I(e) limits both grants to periods of not more 
than 4 years.
    Section 330I(f) defines an eligible grantee as a nonprofit 
entity. Grantees for telehealth networks must also provide 
services through a network of at least two entities, one of 
which must be a community-based provider.
    Section 330I(g) specifies requirements for applications.
    Section 330I(h) specifies terms and conditions of grants.
    Section 330I(i) specifies that the Secretary must give 
preference to an entity that meets one of the requirements 
specified for organization, services, coordination, network, 
connectivitity, and integration. The Secretary must give 
preference to telehealth resource center grantees that meet at 
least one of the requirements specified for: success in the 
provision of services, a record of collaborating and sharing 
expertise, and a record of providing a broad range of 
telehealth services.
    Section 330I(j) requires the Director to ensure that grants 
are equitably distributed among the geographical regions of the 
U.S. The Director must also ensure that not less than 50 
percent of grant awards are made to projects in rural areas and 
that the total amount for such projects are not less than the 
total amount awarded for such projects under existing 330A in 
FY2001.
    Section 330I(k) specifies that grants may be used for 
salaries, equipment, and operating or other costs such as 
education.
    Section 330I(l) specifies uses for which grants may not be 
used, including acquiring real property, for purchase or lease 
of equipment to the extent such expenditures would exceed 40 
percent of total grant funds, and certain other equipment.
    Section 330I(m) requires that grantees collaborate with 
other telehealth entities that receive Federal or State 
assistance.
    Section 330I(n) requires the Director to coordinate with 
similar grant programs to maximize the effect of public 
dollars.
    Section 330I(o) requires the Secretary to carry out 
outreach activities on the grant programs.
    Section 330I(p) expresses the sense of the Congress that 
States should develop reciprocity agreements so that licensed 
telehealth providers can conduct consultations under the 
various State laws.
    Section 330I(q) requires the Secretary to report to the 
appropriate congressional committees, not later than September 
30, 2005, on the progress and accomplishments of the grant 
programs.
    Section 330I(r) requires the Secretary to issue regulations 
that define frontier area, based on factors that include 
population density, travel distance and travel time to the 
nearest medical facility, and other factors as appropriate.
    Section 330I(s) authorizes appropriations of: (1) $40 
million for telehealth network grants for FY2002 and such sums 
as necessary for each of the fiscal years 2003 through 2006; 
and (2) $20 million for telehealth resource center grants for 
FY2002 and such sums as necessary for each of the fiscal years 
2003 through 2006.
    Section 212 adds a new section 330J to authorize the 
Secretary to establish and carry out telehomecare demonstration 
projects.
    New section 330J(a) and (b) define terms and require the 
Secretary, not later than 9 months after enactment, to 
establish a telehomecare demonstration project.
    Section 330J(c) requires the Secretary to make not more 
than five grants to eligible certified home care providers, 
individually or as part of a network of home health agencies, 
for the provision of telehomecare to improve patient care, 
prevent heath care complications, improve patient outcomes, and 
achieve efficiencies in the delivery of care to patients who 
reside in rural areas.
    Section 330J(d) requires that grants be limited to periods 
of 3 years.
    Section 330J(e) requires that grant applications contain 
information as specified by the Secretary.
    Section 330J(f) provides that the funds must be used for 
objectives that include: (1) improving access to care for home 
care patients served by home health care agencies, improving 
quality and patient satisfaction, and reducing costs through 
direct telecommunications with information networks; (2) 
developing effective care management practices and training for 
home care registered nurses; and (3) developing training 
curricula for health care professionals, particularly 
registered nurses, serving home care agencies in the use of 
telecommunications.
    Section 330J(g) specifies that this section should not be 
construed as superseding or modifying Medicare law.
    Section 330J(h) requires the Secretary, not later than 6 
months after the last grant period, to report to Congress on 
results from the demonstration project.
    Section 330J(i) authorizes for this section appropriations 
of such sums as necessary for each of fiscal years 2002 through 
2006.

    Subtitle C--Mental Health Services Telehealth Program and Rural 
  Emergency Medical Service Training and Equipment Assistance Program

    Section 221 adds new section 330K, Rural Emergency Medical 
Service Training and Equipment Assistance Program.
    New section 330K(a) requires the Secretary to award grants 
to eligible entities to provide improved emergency medical 
services in rural areas.
    Section 330K(b) requires that eligible grantees be a State 
emergency medical office, a State emergency medical services 
association, a State office of rural health, a local government 
entity, a State or local ambulance provider, or any other 
entity determined appropriate by the Secretary.
    Section 330K(c) requires that grant funds be used for 
emergency medical service squads that are located in, or that 
serve residents of, a nonmetropolitan statistical area, an area 
designated as a rural area, or a rural census tract of a 
metropolitan statistical area to recruit and train personnel, 
acquire emergency medical services equipment, and educate the 
public on emergency preparedness topics.
    Section 330K(d) requires that the Secretary, in awarding 
grants, give preference to applications that reflect a 
collaborative effort by 2 or more specified entities and that 
intend to use funds for certain activities.
    Section 330K(e) requires grantees to contribute from other 
public or private sources an amount equal to 25% of the Federal 
grant.
    Section 330K(f) states that emergency medical services: (1) 
means resources used by qualified public or private nonprofit 
entities to deliver medical care outside of a medical facility 
under emergency conditions that occur as a result of the 
patient's condition or as a result of a natural disaster or 
similar situation; and (2) includes services delivered by 
compensated or volunteer providers, licensed or certified 
providers recognized by the State involved, a registered nurse, 
a physician assistant, or a physician that provides services 
similar to those provided by such an emergency medical services 
provider.
    Section 330K(g) authorizes appropriations of such sums as 
may be necessary for each of the fiscal years 2002 through 2006 
for these grants. The Secretary may not use more than 10% of 
appropriations for any year for administrative expenses for 
carrying out this program.
    Section 221 adds new section 330L concerning mental health 
services delivered via telehealth.
    New section 330L(a) and (b) define terms and require the 
Secretary, acting through the Director of the Office for the 
Advancement of Telehealth, to award grants to eligible entities 
for demonstration projects to provide mental health services to 
special populations as delivered remotely by qualified mental 
health professionals using telehealth and for the provision of 
education regarding mental illness as delivered remotely by 
qualified mental health professionals and qualified mental 
health education professionals using telehealth.
    Section 330L(c) provides that each grant recipient must 
receive not less than $1,200,000 under the grant and cannot use 
more than 40 percent of grant funds for equipment.
    Section 330L(d) requires that grants be used to provide 
mental health services, education, and collaboration with local 
public health authorities. Grants may also be used for 
equipment, and other enumerated purposes.
    Section 330L(e) requires the Secretary to ensure that 
grants are equitably distributed among all regions of the U.S.
    Section 330L(f) requires that applications for grants 
conform to information specified by the Secretary.
    Section 330L(g) requires a report to the appropriate 
congressional committees, not later than 4 years after the date 
of enactment of this Act, on an evaluation of grant activities.
    Section 330L(h) authorizes appropriations of $20 million 
for FY2002 and such sums as may be necessary for fiscal years 
2003 through 2006 for these grants.

            Subtitle D--School-Based Health Center Networks

    Section 231 adds to the Act new section 330M concerning 
school-based health center networks.
    New section 330M(a) defines an eligible entity as a 
nonprofit organization that has experience working with low-
income communities, schools, families, and school-based health 
centers.
    Section 330M(b) and (c) require the Secretary to award 
grants for the establishment of statewide technical assistance 
centers to coordinate local, State, and Federal health care 
services that contribute to the delivery of school-based health 
care for medically underserved individuals and to conduct other 
support activities for school-based health center networks, to 
maximize operational effectiveness and efficiency and to 
provide technical support training.
    Section 330M(d) requires applications to contain 
information specified by the Secretary.
    Section 330M(e) authorizes appropriations of $5 million for 
FY2002 and such sums as necessary for subsequent fiscal years.

            TITLE III--NATIONAL HEALTH SERVICE CORPS PROGRAM


           Section 301. National Health Service Corps (Corps)

    Section 301(a) amends Section 331(a) of the Act to define 
``behavioral and mental health professionals'' as health 
service psychologists, licensed clinical social workers, 
licensed professional counselors, marriage and family 
therapists, psychiatric nurse specialists, and psychiatrists.
    Section 331(a) of the Act is further amended to define 
``graduate program of behavioral and mental health'' as a 
program that trains behavioral and mental health professionals.
    Section 331(b) of the Act is revised to include schools at 
which graduate programs of behavioral and mental health are 
offered as among those at which the Secretary may conduct 
recruiting programs for the Corps, Scholarship Program and the 
Loan Repayment Program.
    Section 331(b) is further revised to include behavioral and 
mental health professionals, among those who may participate in 
fellowship programs to enable them to gain exposure to and 
expertise in the delivery of primary health services in health 
professional shortage areas.
    Section 331(c) is revised to allow the Secretary to 
reimburse an applicant for actual and reasonable expenses 
incurred for the travel of one family member to accompany the 
applicant to visit an eligible site to which the applicant may 
be assigned (in addition to travel expenses for the applicant 
himself/herself). If an individual enters into a contract for 
obligated service under the Scholarship Program or the Loan 
Repayment Program, the Secretary may reimburse the individual 
for all or part of actual and reasonable expenses incurred in 
relocating the individual and the individual's family to the 
eligible site. The Secretary may to establish a maximum total 
amount that an individual may be reimbursed for relocation 
expenses.
    Section 301(b) adds a new section 331(i) in which the 
Secretary is authorized to carry out demonstration projects so 
that individuals who are obligated to a period of service under 
the Loan Repayment Program may receive waivers to satisfy the 
requirement for providing clinical service at a selected entity 
on a less than full-time basis. Waivers could be provided only 
under certain conditions, including requirements that the 
Secretary determine that less than full-time service would be 
appropriate for the area, that service be for no less than 16 
hours per week, and that the period of obligated service be 
extended so that total time of service would be equal to full-
time. In evaluating a demonstration project in which Corps 
members satisfy requirement for obligated service through less 
than full-time service the Secretary would be required to 
examine the effect of multidisciplinary teams.

     Section 302. Designation of Health Professional Shortage Areas

    Section 302(a) amends section 332(a) (dealing with the 
designation of Health Professional Shortage Areas) to require 
that all Federally qualified health centers and rural health 
clinics (as defined in Medicare law) that meet cost-sharing 
requirements for the Corps be automatically designated as 
having a health professional shortage. Not later than 5 years 
after the date of enactment of this Act, and every 5 years 
thereafter, each such health center or rural health clinic is 
required to demonstrate that it meets the requirements for 
designation as specified in Federal regulations.
    Section 332(a) is further amended to include in the list of 
populations that the Secretary may designate as a health 
manpower shortage area, seasonal agricultural workers and 
migratory agricultural workers and residents of public housing.
    Section 332(b) is amended to repeal as requirements for the 
Secretary's special consideration in designating health 
professional shortage areas the following explicit indicators 
of need: infant mortality, access to health services, health 
status, and ability to pay for health services.
    Section 332(c)(2)(B) is amended to add a requirement that 
the Secretary, when determining whether to designate a health 
professional shortage area, consider the extent to which a 
population that is entitled to have payment made for services 
under the State Children's Health Insurance Program (S-CHIP), 
in addition to Medicare and Medicaid, cannot obtain such 
services because of suspension of physicians under this 
program.
    Section 302(b) requires the Secretary to report to the 
House Energy and Commerce and Senate Health, Education, Labor, 
and Pensions Committees if the Secretary issues a regulation 
that revises the definition of a health professional shortage 
area or the standards for prioritizing areas that receive 
assignments of Corps personnel.
    Section 302(c) requires the Secretary, in consultation with 
specific health professionals and public health officials, to 
develop and implement a plan to increase the level of 
participation by dentists and dental hygienists in the 
Scholarship Program and the Loan Repayment Program.
    Section 302(d) directs the Administrator of HRSA, to revise 
criteria for designating dental health professional shortage 
areas, in consultation with specific health professional groups 
and public health officials in order to provide a more accurate 
reflection of oral health care needs, particularly in rural 
areas.
    Section 302(d) adds a new section 332(i) to require the 
Administrator of HRSA to disseminate information about the 
designation criteria to the Governor of each State; the 
representative of any area, population group or facility 
selected by a Governor to receive such information; the 
representative of any area, population group or facility that 
requests such information; and the representative of any area, 
population group, or facility determined by the Administrator 
as likely to meet the criteria for designation.

               Section 303. Assignment of Corps Personnel

    Section 303 amends Section 333(a)(1) of the Act to 
authorize the Secretary to assign Corps members to any public 
or private entity. (Currently, Corps members are assigned to 
only public and non-profit private entities.)
    Section 333(a)(3) adds a requirement that, in approving 
applications for assignments of Corps members, the Secretary 
must give preference to nonprofit or public entities that will 
provide a site to which Corps members may be assigned.
    Section 333(d)(1) of the Act is revised to specifically 
require (rather than allow) the Secretary to provide technical 
assistance to entities that are located in health professional 
shortage areas and desire to apply for the assignment of a 
Corps member.
    Section 333(d)(1) is further amended by adding a new 
provision to authorize the Secretary to provide assistance to 
an entity for developing long-term plans for addressing health 
professional shortages and improving access to health care. The 
section is also amended to require the Secretary to encourage 
those entities receiving technical assistance to communicate 
with other communities and public health groups concerned with 
site development and community needs assessment.

        Section 304. Priorities in Assignment of Corps Personnel

    Section 304 amends Section 333A of the Act to repeal 
requirements that the Secretary consider only certain factors 
for determining priority assignments of Corps personnel to 
health professional shortage areas with the greatest shortages.
    Section 333A(d) is revised to require the Secretary to 
prepare and publish a proposed list of health professional 
shortage areas and entities that would receive priority for the 
assignment of Corps members. In addition to existing 
requirements for information to be included in the list, the 
list must contain relative scores and relative priorities of 
the entities submitting applications for the assignment of 
Corps members. The Secretary must give all entities 30 days 
after the date of publication of the list to provide additional 
data and information in support of being included on the list 
or in support of a higher priority determination, all of which 
the Secretary must consider in preparing the final list.
    Section 333A(d) is further revised to add technical and 
conforming amendments related to the Secretary's notification 
of parties affected by the prioritization of assignments for 
placements of Corps members in health professional shortage 
areas. Entities adversely affected by revisions to the priority 
list would have 30 days to file a written appeal of the 
determination and the Secretary would be required to consider 
the appeal before the list becomes final.
    Section 333A(e) revises current provisions with respect to 
the number of entities offered as assignment choices in the 
scholarship program. By April 1 of each year, the Secretary 
must determine the number of participants in the scholarship 
program who will be available for assignments during the 
program year beginning on July 1 of that calendar year. The 
number of entities designated to receive Corps members for the 
scholarship program must be no less than the number of 
participants available for the year, and not greater than twice 
the number of participants selected for the scholarship 
program.

                       Section 305. Cost Sharing

    Section 305 amends the Act to rewrite section 334 
concerning charges for services by entities using Corps 
members.
    Section 334(a) provides that entities to which a Corps 
member is assigned may not deny health services to individuals 
or discriminate in the provision of services because of 
inability to pay, or because payment for services would be made 
under Medicare, Medicaid, or SCHIP.
    Section 334(b)(1) requires an entity to prepare a schedule 
of fees or payments consistent with locally prevailing rates or 
charges and designed to cover the entity's reasonable costs. 
Entities may also prepare a corresponding schedule of 
discounts, including waivers, of fees and payments. Entities 
must make every reasonable effort to collect from patients fees 
and payments for services.
    Section 334(b)(2) requires an entity to accept assignments 
of beneficiaries under the Medicare program and enter into 
appropriate agreements with the State agency administering the 
Medicaid and SCHIP programs for payment of services under those 
programs. Entities must take reasonable steps to collect 
payments from third-party payers.

               Section 306. Eligibility for Federal Funds

    Section 306 amends Section 335(e)(1)(B) of the Act to 
provide that any hospital found in violation of this subsection 
by refusing admitting privileges to a Corps member would be 
ineligible to receive SCHIP funds (in addition to Medicare and 
Medicaid funds already specified in this provision).

   Section 307. Facilitation of Effective Provision of Corps Services

    Section 307 amends Section 336 of the Act to change 
references to ``health manpower shortage areas'' to ``health 
professional shortage areas''.

              Section 308. Authorization of Appropriations

    Section 308 amends Section 338(a)(1) of the Act to 
authorize such sums as necessary for appropriations for the 
Corps for FY2002 through FY2006. This section also repeals the 
requirement for the Secretary, to the extent practicable, to 
make assignments, other than for obligated service, of 
certified nurse midwives, certified nurse practitioners, or 
physician assistants to shortage areas.

     Section 309. National Health Service Corps Scholarship Program

    Section 309 amends Section 338A(a)(1) of the Act to include 
behavioral and mental health professionals as eligible 
participants under the Corps Scholarship Program.
    Section 338A(d)(1) is amended to require the Secretary, 
with respect to dental school applicants, to consider 
applications from all individuals accepted for enrollment or 
enrolled in any accredited dental school.
    Section 338A(f) is amended to require an individual to 
agree, if pursuing a degree in medicine or osteopathic 
medicine, to complete a residency in a specialty that the 
Secretary determines is consistent with the needs of the Corps.
    Section 338A(i) is repealed. The section required an annual 
report to the Congress on the Corps Scholarship Program.

   Section 310. National Health Service Corps Loan Repayment Program

    Section 310 amends section 338B to include behavioral and 
mental health professionals as eligible participants under the 
Corps Loan Repayment Program.
    Section 338B(i) is repealed. The section requires an annual 
report to the Congress on the Corps Loan Repayment Program.

                     Section 311. Obligated Service

    Section 311 amends section 338C(b) to revise provisions 
that specify dates when obligated service must begin for 
Scholarship recipients. Persons would be notified about their 
obligated service upon completion of training required for the 
degree for which the individual receives the scholarship. 
However, for persons receiving a degree from a school of 
medicine or osteopathy after September 20, 2000, service would 
begin when the individual completes a residency in a specialty 
determined by the Secretary to be consistent with the needs of 
the Corps. The Secretary could also defer obligated service for 
completion of advanced training (including an internship or 
residency).
    Section 338C(e) is repealed. This provision allows Corps 
personnel to fulfill their period of obligation by working as 
researchers at the National Institutes of Health.

                     Section 312. Private Practice

    Section 312 amends section 338D to replace existing 
requirements for a written agreement between the Secretary and 
individuals who fulfill their service obligation through full-
time clinical private practice. Individuals fulfilling a period 
of obligated service in private clinical practice must comply 
with requirements pertaining to cost-sharing (amounts that 
entities charge for services), and additional provisions as the 
Secretary may determine.

 Section 313. Breach of Scholarship Contract or Loan Repayment Contract

    Section 313 amends section 338E(a) to repeal a provision 
requiring individuals to repay amounts to the U.S. government 
for failing to accept payment or instructing the educational 
institution in which he is enrolled not to accept payment of a 
scholarship from the Corps.
    Section 338E(b) is amended to authorize the Secretary to 
terminate a contract with an individual in the Scholarship 
Program if, not later than 30 days before the end of the school 
year, to which the contract pertains, the individual submits a 
written request for such termination and repays all amounts 
paid to or on behalf of the individual.
    Section 338E(c) is amended to revise the amounts that an 
individual must pay when a written contract is breached in 
accordance with the Loan Repayment Program. The Federal 
Government would be entitled to recover: (1) total amounts paid 
on behalf of the individual; (2) an amount equal to the product 
of the number of months of uncompleted obligated service 
multiplied by $7,500; and (3) interest on these amounts at the 
maximum legal prevailing rate. The Secretary may terminate a 
contract if an individual submits a written request for such 
termination, and repays all amounts as required.
    Section 338E(d) is revised to increase the period of years 
from 5 to 7 after which an obligation for payment of damages 
may be released as a result of a discharge of bankruptcy, 
depending on the decision of the bankruptcy court.
    New section 338E(e) provides that, notwithstanding any 
other provision of law, there will be no limitation on the 
period within which suit may be filed, a judgment may be 
enforced, or an action relating to an offset or garnishment, or 
other action, may be initiated or taken by Federal officials 
for the repayment of the amount due.

              Section 314. Authorization of Appropriations

    Section 314 amends section 338H(a) to authorize 
appropriations for the Scholarship Program of $146,250,000 for 
FY2002 and such sums as may be necessary for fiscal years 2003 
through 2006.
    Section 338H(b) requires the Secretary to obligate not less 
than 30 percent of amounts appropriated for scholarships to 
individuals who have not previously received such scholarships.
    Section 338H(c) requires the Secretary to obligate not less 
than 10 percent of amounts appropriated for both scholarships 
and loan repayments for nurse practitioners, nurse midwives, or 
physician assistants.

       Section 315. Grants to States for Loan Repayment Programs

    Section 315 amends section 338I(a) to require the National 
Advisory Council on the National Health Service Corps to advise 
the Administrator of HRSA on the program of grants to States 
for loan repayment programs.
    Section 338I(e) is revised to require States to submit such 
reports to the Secretary on the loan repayment program as 
determined appropriate by the Secretary.
    Section 338I(i) is amended to authorize appropriations of 
$12 million for FY2002 and such sums as may be necessary for 
each of fiscal years 2003 through 2006 for the grants program 
to States for loan repayments.

 Section 316. Demonstration Grants to States for Community Scholarship 
                                Programs

    Section 316 repeals section 338L of the Act which 
authorizes demonstration grants to States for community 
scholarship programs to increase the availability of primary 
health care in urban and rural areas.

                   Section 317. Demonstration Project

    Section 317 adds a new section 338L to authorize the 
Secretary to establish a demonstration project to provide for 
the participation of chiropractic doctors and pharmacists in 
the Corps loan repayment program. The demonstration project 
would be required to have enough participants to properly 
analyze the project's effectiveness. Any providers selected to 
participate in the project could not be considered by the 
Secretary in the designation of a shortage area. States could 
not be required to participate. The Secretary would be required 
to report to specified congressional committees on the 
effectiveness of the demonstration project, how the 
participation of chiropractic doctors and pharmacists in the 
loan repayment program might affect the designation of health 
professional shortage areas; and the feasibility of adding such 
individuals as permanent members of the Corps.

              TITLE IV--HEALTHY COMMUNITIES ACCESS PROGRAM

    Section 401 states that the purpose of this title is to 
provide assistance to communities and to consortia of health 
care providers, to develop or strengthen integrated health care 
delivery systems that coordinate health services for 
individuals who are uninsured or underinsured and to develop or 
strengthen activities related to providing coordinated care for 
such individuals with chronic conditions who are uninsured or 
underinsured.
    Section 402 amends Part D of title III of the Act to add 
new Subpart V--Healthy Communities Access Program (HCAP) to 
establish a new section 340.
    Section 340(a) authorizes the Secretary to award grants to 
eligible entities to assist in the development of integrated 
health care delivery systems to serve communities of 
individuals who are uninsured or who are underinsured: (1) to 
improve the efficiency of, and coordination among, the 
providers providing services; (2) to assist communities in 
developing programs targeted toward preventing and managing 
chronic diseases; and (3) to expand and enhance the services 
provided through such systems.
    Section 340(b) outlines the eligibility requirements for a 
public or nonprofit private entity to receive grants. The 
entity must: (1) represent a consortium whose principal purpose 
is to provide a broad range of coordinated health care services 
for the community defined in the entity's grant application; 
(2) submit to the Secretary an application, containing specific 
information and other information prescribed by the Secretary, 
(3) agree, together with all providers within the consortium, 
to use grant monies awarded under this section to supplement, 
not supplant, any other sources of funding available to cover 
the expenditures (including the value of any in-kind 
contributions) in carrying out the activities for which the 
grant would be awarded; and (4) have or will establish a 
decision-making body that has full and complete authority to 
determine and oversee all consortium activities.
    Section 340(c) requires that the Secretary give priority to 
applicants that demonstrate the extent of unmet need in the 
community for a more coordinated system of care. The Secretary 
may give priority to other applicants that best promote the 
objectives of this section.
    Section 340(d) requires that grantees use the amounts 
provided under this section only for direct expenses associated 
with planning, developing, and operating the greater 
integration of a health care delivery system and direct patient 
care and service expansions to fill identified or documented 
gaps within an integrated delivery system. Not more than 15 
percent of grant funds may be used for the provision of direct 
patient care and services. The Secretary may not use more than 
3 percent of funds appropriated for the section for providing 
technical assistance to grantees, obtaining expert assistance, 
the dissemination of information, evaluations, and other 
related administrative purposes.
    Section 340(e) requires grantees to report to Secretary 
annually on progress in meeting the goals in the grant 
application and additional information as the Secretary may 
require, and to provide for a financial audit of grant funds. 
The Secretary may not renew an annual grant for any entity 
unless the Secretary is satisfied that the consortium 
represented by the entity has made progress in meeting such 
goals.
    Section 340(f) authorizes the Secretary to provide any 
grantee under this section with technical and other 
nonfinancial assistance to meet requirements.
    Section 340(g) requires the Secretary to report, not later 
than September 30, 2005, to the appropriate congressional 
committees on the progress and accomplishments of the grant 
program.
    Section 340(h) authorizes the Secretary to make 
demonstration awards to historically black medical schools to: 
(1) develop patient-based research infrastructure at such 
schools with an affiliation with any providers under this 
section; (2) establish joint and collaborative programs of 
medical research and data collection between such schools and 
such providers; or (3) support the research-related costs of 
patient care, data collection, and academic training resulting 
from such affiliations.
    Section 340(i) authorizes appropriations of $125 million 
for FY2002 and such sums as may be necessary for each of the 
fiscal years 2003 through 2006 for the program.
    Section 403 amends Part D of title III of the Act to add 
new Subpart X--Primary Dental Programs.
    New section 340F defines the term ``designated dental 
health professional shortage area'' to mean an area, population 
group, or facility that is designated by the Secretary as such 
or designated by the applicable State as having a dental health 
professional shortage.
    New section 340G(a) authorizes the Secretary to award 
grants to States to help them develop and implement innovative 
programs to address the dental workforce needs of designated 
dental health professional shortage areas as appropriate to a 
State's needs.
    Section 340G(b) lists the activities for which States may 
use grant funds: loan forgiveness and repayment programs for 
certain dentists; dental recruitment and retention efforts; 
assistance for dentists who participate in the Medicaid program 
to establish or expand practice in a designated dental health 
professional shortage area; establishment or expansion of 
dental residency programs in States without dental schools; 
programs to expand or establish oral health services; placement 
and support of dental students, dental residents, and advanced 
dentistry trainees; and other specified activities.
    Section 340G(c) requires States to apply for grant funds in 
a manner as the Secretary may reasonably require and include 
assurances that the State will meet Federal grant-matching 
requirements.
    Section 340G(d) requires participating States to provide 
matching funds in an amount equal to 40 percent of the Federal 
grant.
    Section 340G(e) requires the Secretary to report to the 
appropriate congressional committees, not later than 5 years 
after enactment of this Act, on whether such grants increased 
access to dental services.
    Section 340G(f) authorizes appropriations of $50 million 
for the 5-fiscal year period beginning with FY2002.

                     TITLE V--RURAL HEALTH CLINICS

    Section 501(a) and (b) exempt rural health clinics with 
Corps assignees from the coinsurance and deductible 
requirements of Medicare.

                            TITLE VI--STUDY

    Section 601 requires the Secretary to study and report to 
the Congress on the ability of DHHS to provide for solvency of 
managed care networks involving health centers receiving 
funding under the Consolidated Health Centers Program of 
section 330. The report would have to be submitted to Congress 
2 years after enactment.

                    TITLE VII--CONFORMING AMENDMENTS

    Section 701(a) and (b) amend the Act to make technical and 
conforming amendments concerning health centers for the 
homeless.

                          IX. ADDITIONAL VIEWS

         inclusion of additional eligible providers in the nhsc

    With regard to the chiropractor demonstration in the 
underlying bill, there were serious issues raised by the 
initial draft relating to both the health professional shortage 
area designation and the application to both the scholarship 
and loan repayment portions of the National Health Service 
Corps. The Health Resources and Services Administration (HRSA) 
has been working to revamp the health professional shortage 
designation for the past few years and is close to completion. 
In that alteration, Congress has pushed HRSA to count each 
eligible provider who is already providing services through the 
National Health Service Corps, rather than just counting 
physicians. Given that there are over 80,000 chiropractors 
providing care within the United States and that many of them 
do practice in underserved areas, the incorporation of 
chiropractors within the Corps; and thus, within the health 
professional shortage area designation, could result in many 
areas being de-designated. As of September 30, 1999, HRSA 
indicated that 12,056 physicians were needed nationwide. If 
chiropractors were included, we would have almost seven times 
the number of providers required. When I examined this issue on 
the state level, I determined that, even if chiropractors were 
only counted as half of a physician, all but four states or 
areas (Mississippi, Alabama, Louisiana and District of 
Columbia) would lose their health professional shortage area 
designation. Without that designation, states would not only be 
ineligible for the Corps, but they would also become ineligible 
for over 20 other programs that are tied to the HRSA 
designation. This change would be disasterous.
    Another concern related to the role of the loan repayment 
and scholarship programs within the Corps program. In any 
demonstration program, the end result is to discover whether or 
not a specific initiative would be beneficial to both the 
community and the health care provider. In the loan repayment 
program, an eligible provider forms an agreement with a 
community regarding the provision of services. Only then the 
government would provide $50,000 in loan repayment (plus a 39% 
allocation for taxes) to the provider in exchange for two years 
of service. For the scholarship recipient, the eligible 
provider would receive a scholarship for his or her education 
and then would be obligated for each year in which the 
scholarship was given or at least two years, whichever is 
greater. If, at the end of the educational period, an eligible 
provider cannot find an appropriate community to pay his or her 
salary, then the provider would be in default and required to 
pay back three times the amount of the scholarship plus 
interest. Rather than potentially put a provider in a 
disasterous position, unable to find a community to support him 
or her, a Corps demonstration program should initially focus on 
the loan repayment program, much like the part-time 
demonstration program amendment sponsored by Senators 
Hutchinson and Collins.
    Thankfully, after an amendment was circulated which would 
strike the demonstration authority altogether, Senators Harkin 
and Reed worked together to address the aforementioned issues 
by specifically stating that these providers would not be 
counted within the health professional shortage area 
designation and limiting the demonstration authority to the 
loan repayment program. Unfortunately, the changes to the 
chiropractic demonstration program did not fully address all of 
the concerns with the program because it did not fully address 
my concerns relating to the spirit of the National Health 
Service Corps.
    The National Health Service Corps was created to assist 
communities in addressing the primary health care needs. Its 
focus has been to assist communities in determining specific 
workforce issues and then providing incentives to health care 
professionals who decide to serve in those communities. We must 
preserve the community-centered, primary health care focus of 
the program. Other programs, such as Titles VII & VIII of the 
Public Health Service Act, are specifically tailored to address 
the needs of the health professional infrastructure.
    During the course of two years of negotiations regarding 
the re-authorization of the Corps, not one community requested 
the inclusion of the chiropractors. Perhaps this lack of 
inclusion is due to the fact that chiropractors are already 
serving in underserved areas. Perhaps there are other reasons 
for not requesting these providers. Whatever the case, the 
focus should be upon the needs of the communities as they 
struggle to address their primary health care needs. Given the 
recent move of the Corps from the Bureau of Primary Health Care 
to the Bureau of Health Professionals, it is crucial that we, 
as Congress, recognize the specific niche of the Corps in 
providing resources for communities, not resources for health 
professionals. We have heard from numerous organizations who 
have voiced concerns about this move and have requested our 
assistance in ensuring that the Corps remains a program 
centered on communities that assists them in providing access 
to the appropriate primary care resources. We wish to send the 
signal that the communities and their requests should be the 
foremost goal of this program.

                       application of davis-bacon

    Legislative History.--Prior to 1988, grant funds for both 
planning and development of health care services for the 
Consolidated Health Center program could be used to support the 
costs of acquisition and modernization of existing buildings. 
At that time, Davis-Bacon provisions (40 U.S.C. Sec. 276a--
276a-7) applied only to the grants awarded to support the costs 
of modernization, defined in regulation as ``the alteration, 
repair, remodeling and/or renovation of a building (including 
the initial equipment thereof and improvements to the 
building's site) which, when completed, will render the 
building suitable for use by the project for which the grant is 
made'' (42 CFR 51c.502(c). However, despite the regulatory 
definition, the scope of modernization is typically regarded as 
``facility renovations which do not modify the exterior walls 
of the facility'' (as noted in the legislative history for the 
1988 amendments).
    In 1988, Section 330 of the Public Health Service Act (42 
U.S.C. Sec. 254c) was amended to permit the use of grant funds 
to support the costs of expansion of existing buildings and the 
construction of new buildings (in addition to the acquisition 
and modernization). However, the Davis-Bacon requirements were 
not expanded; they still only applied to grants to support the 
costs of modernization.
    In 1996, under the Health Center Consolidation Act, the 
general authority to use grant funds to support the costs of 
expansion, modernization and construction was deleted (although 
funds could still be used to support the acquisition and lease 
of buildings and equipment). Grant funds may be used to support 
the cost of expansion, modernization and construction of 
projects approved pre-1996, and Davis-Bacon would apply to such 
projects in the same manner as pre-1996 (i.e., Davis-Bacon 
would apply only to grants to support the costs of 
modernization).
    Policy Statement.--Within this re-authorization, the final 
policy decision was to apply the Davis-Bacon provisions to the 
construction authorities to which it had previously been 
applied prior to 1996, i.e., only to modernization of 
facilities. In fact, the manager's amendment that Senator 
Kennedy proposed, which was accepted unanimously by voice vote, 
did, in fact, only have the Davis-Bacon provisions applied only 
to modernization. Though Senator Kennedy may not be very 
forthcoming with that statement, the Davis-Bacon provisions 
were the major substantive change within the manager's 
amendment. Given that the committee unanimously agreed to 
applying Davis-Bacon only to modernization and that the 
previous legislative history indicates that Davis-Bacon has 
only previously applied to modernization, passing the bill as 
it was reported out of Committee would afford no disruption of 
labor law as it was previously applied to section 330. Any 
further expansion of the Davis-Bacon application would increase 
the difficulty in contracting for construction, modernization, 
and expansion, and increase the overall costs of such 
activities. Therefore, resources should be focused on needed 
health care services and not on expanding Davis-Bacon 
provisions.

                                                        Judd Gregg.

                       X. 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

           *       *       *       *       *       *       *


                      Part D--Primary Health Care

                       Subpart I--Health Centers

SEC. 330. [254B] HEALTH CENTERS.

    (a) Definition of Health Center.--

           *       *       *       *       *       *       *

    (b) Definitions.--For purposes of this section:
          (1) Required primary health services.--

           *       *       *       *       *       *       *

                                          (bb) [screening for 
                                        breast and cervical 
                                        cancer] appropriate 
                                        cancer screening;

           *       *       *       *       *       *       *

                          (ii) referrals to providers of 
                        medical services (including specialty 
                        referral when medically indicated) and 
                        other health-related services 
                        (including substance abuse and mental 
                        health services);
                          (iii) patient case management 
                        services (including counseling, 
                        referral, and follow-up services) and 
                        other services designed to assist 
                        health center patients in establishing 
                        eligibility for and gaining access to 
                        Federal, State, and local programs that 
                        provide or financially support the 
                        provision of medical, social housing, 
                        educational, or other related services;

           *       *       *       *       *       *       *

                  (A) behavioral and mental health and 
                substance abuse services;
                  (B) recuperative care services;
                  (C) public health services;
                  [(A)] (D) environmental health services, 
                including--
                          (i) the detection and alleviation of 
                        unhealthful conditions associated with 
                        water supply;
                          (ii) sewage treatment;
                          (iii) solid waste disposal;
                          (iv) rodent and parasitic 
                        infestation;
                          (v) field sanitation;
                          (vi) housing; [and]
                          (vii) the detection and alleviation 
                        of chemical and pesticide exposures;
                          (viii) the promotion of indoor and 
                        outdoor air quality;
                          (ix) the detection and remediation of 
                        lead exposures; and
                          [(vii)] (x) other environmental 
                        factors related to health,
                  [(B)] (F) in the case of health centers 
                receiving grants under subsection (g), special 
                occupation-related health services for 
                migratory and seasonal agricultural workers, 
                including--
                          (i) screening for and control of 
                        infectious diseases, including 
                        parasitic diseases; and
                          (ii) injury prevention programs, 
                        including prevention of exposure to 
                        unsafe levels of agricultural chemicals 
                        including pesticides.

           *       *       *       *       *       *       *

    (c) Planning Grants.--
          (1) In general.--
                  (A) Centers.-- The Secretary may make grants 
                to public and nonprofit private entities for 
                projects to plan and develop health centers 
                which will serve medically underserved 
                populations. A project for which a grant may be 
                made under this subsection may include the cost 
                of the acquisition [and lease of buildings and 
                equipment (including the costs of amortizing 
                the principal of, and paying the interest on, 
                loans) and shall include--], lease, 
                modernization, and expansion of buildings, the 
                construction of buildings, and the purchase or 
                lease of equipment (including the costs of 
                amortizing the principal of, and paying the 
                interest on, loans for buildings and equipment) 
                and shall include--

           *       *       *       *       *       *       *

                  (B) [Comprehensive service delivery] Managed 
                care networks and plans.--The Secretary may 
                make grants to health centers that receive 
                assistance under this section to enable the 
                centers to plan and develop a [network or plan 
                for the provision of health services, which may 
                include the provision of health services on a 
                prepaid basis or through another managed care 
                arrangement, to some or to all of the 
                individuals which the centers serve.] managed 
                care network or plan. Such a grant may only be 
                made for such a center if--

           *       *       *       *       *       *       *

                [Any such grant may include the acquisition and 
                lease of buildings and equipment which may 
                include data and information systems (including 
                the costs of amortizing the principal of, and 
                paying the interest on, loans), and providing 
                training and technical assistance related to 
                the provision of health services on a prepaid 
                basis or under another managed care 
                arrangement, and for other purposes that 
                promote the development of managed care 
                networks and plans.]
                  (C) Practice management networks.--The 
                Secretary may make grants to health centers 
                that receive assistance under this section to 
                enable the centers to plan and develop practice 
                management networks that will enable the 
                centers to--
                          (i) reduce costs associated with the 
                        provision of health care services;
                          (ii) improve access to, and 
                        availability of, health care services 
                        provided to individuals served by the 
                        centers;
                          (iii) enhance the quality and 
                        coordination of health care services; 
                        or
                          (iv) improve the health status of 
                        communities.
                  (D) Use of funds.--The activities for which a 
                grant may be made under subparagraph (B) or (C) 
                may include the purchase or lease of equipment, 
                which may include data and information systems 
                (including paying for the costs of amortizing 
                the principal of, and paying the interest on, 
                loans for equipment), the provision of training 
                and technical assistance related to the 
                provision of health care services on a prepaid 
                basis or under another managed care 
                arrangement, and other activities that promote 
                the development of practice management or 
                managed care networks and plans.
    (d) [Managed Care Loan Guarantee Program.--] Loan Guarantee 
Program._
          (1) Establishment.--
                  (A) In general.--The Secretary shall 
                establish a program under which the Secretary 
                may, in accordance with this subsection and to 
                the extent that appropriations are provided in 
                advance for such program, guarantee [the 
                principal and interest on loans made by non-
                Federal lenders to health centers funded under 
                this section for the costs of developing and 
                operating management care networks or plans.]  
                up to 90 percent of the principal and interest 
                on loans made by non-Federal lenders to health 
                centers, funded under this section, for the 
                costs of developing and operating managed care 
                networks or plans described in subsection 
                (c)(1)(B), or practice management networks 
                described in subsection (c)(1)(C), and for the 
                costs of acquiring, leasing, modernizing, or 
                expanding buildings, construction of buildings, 
                or purchasing or leasing equipment.
                  (B) Use of funds.--Loan funds guaranteed 
                under this subsection may be used--
                          (i) to establish reserves for the 
                        furnishing of services on a pre-paid 
                        basis [or]
                          (ii) for costs incurred by the center 
                        or centers, otherwise permitted under 
                        this section, as the Secretary 
                        determines are necessary to enable a 
                        center or centers to develop, operate, 
                        and own the network or plan[.];
                          (iii) to refinance an existing loan 
                        (as of the date of refinancing) to the 
                        center or centers, if the Secretary 
                        determines such refinancing will be 
                        beneficial to the health center and the 
                        Federal Government and will result in 
                        more favorable terms.
                  (D) Loan guarantees.--Notwithstanding any 
                other provision of law, the following funds 
                shall be made available until expended for loan 
                guarantees under this subsection:
                          (i) Funds appropriated for fiscal 
                        year 1997 under the Departments of 
                        Labor, Health and Human Services, and 
                        Education, and Related Agencies 
                        Appropriations Act, 1997, which were 
                        made available for loan guarantees for 
                        loans made by non-Federal lenders for 
                        construction, renovation, and 
                        modernization of medical facilities 
                        that are owned and operated by health 
                        centers and for loan guarantees for 
                        loans to health centers for the costs 
                        of developing and operating managed 
                        care networks or plans, and which have 
                        not been expended.
                          (ii) Funds appropriated for fiscal 
                        year 1998 under the Departments of 
                        Labor, Health and Human Services, and 
                        Education, and Related Agencies 
                        Appropriations Act, 1998, which were 
                        made available for loan guarantees for 
                        loans made by non-Federal lenders for 
                        construction, renovation, and 
                        modernization of medical facilities 
                        that are owned or operated by health 
                        centers and for loan guarantees for 
                        loans to health centers under this 
                        subsection (as in effect on the day 
                        before the date of enactment of the 
                        Health Care Safety Net Amendments of 
                        2001), and which have not been 
                        expended.
                  (E) Provision directly to networks or 
                plans.--At the request of health centers 
                receiving assistance under this section, loan 
                guarantees provided under this paragraph may be 
                made directly to networks or plans that are at 
                least majority controlled and, as applicable, 
                at least majority owned by those health 
                centers.
                  (F) Federal credit reform.--The requirements 
                of the Federal Credit Reform Act of 1990 (2 
                U.S.C. 661 et seq.) shall apply with respect to 
                loans refinanced under subparagraph (B)(iii),

           *       *       *       *       *       *       *

          [(6) Annual report.--Not later than April 1, 1998, 
        and each April 1 thereafter, the Secretary shall 
        prepare and submit to the appropriate committees of 
        Congress a report concerning loan guarantees provided 
        under this subsection. Such report shall include--
                  [(A) a description of the number, amount, and 
                use of funds received under each loan guarantee 
                provided under this subsection;
                  [(B) a description of any defaults with 
                respect to such loans and an analysis of the 
                reasons for such defaults, if any; and
                  [(C) a description of the steps that may have 
                been taken by the Secretary to assist an entity 
                in avoiding such a default.
          [(7) Program evaluation.--Not later than June 30, 
        1999, the Secretary shall prepare and submit to the 
        appropriate committees of Congress a report containing 
        an evaluation of the program authorized under this 
        subsection. Such evaluation shall include a 
        recommendation with respect to whether or not the loan 
        guarantee program under this subsection should be 
        continued and, if so, any modifications that should be 
        made to such program.]
          [(8)] (6) Authorization of appropriations.--There are 
        authorized to be appropriated to carry out this 
        subsection such sums as may be necessary.
    (e) Operating Grants.--
          (1) Authority.--
                  (A) In general.-- * * *

           *       *       *       *       *       *       *

                  (B) Entities that fail to meet certain 
                requirements.--The Secretary may make grants, 
                for a period of not to exceed 2 years, for the 
                costs of the operation of public and nonprofit 
                entities which provide health services to 
                medically underserved populations but with 
                respect to which the Secretary is unable to 
                make each of the determinations required by 
                [subsection (j)(3)] subsection (l)(3).
                  (C) Operation of networks and plans.--The 
                Secretary may make grants to health centers 
                that receive assistance under this section, or 
                at the request of the health centers, directly 
                to a network or plan (as described in 
                subparagraphs (B) and (C) of subsection (c)(1)) 
                that is at least majority controlled and, as 
                applicable, at least majority owned by such 
                health centers receiving assistance under this 
                section, for the costs associated with the 
                operation of such network or plan, including 
                the purchase or lease of equipment (including 
                the costs of amortizing the principal of, and 
                paying the interest on, loans for equipment).
          (2) Use of funds.--The costs for which a grant may be 
        made under subparagraph (A) or (B) of paragraph (1) may 
        include the costs of [acquiring and leasing] acquiring, 
        leasing, modernizing, and expanding buildings [and 
        equipment], constructing buildings, and purchasing or 
        leasing equipment (including the costs of amortizing 
        the principal of, and paying interest on, [loans)] 
        loans for buildings and equipment), and the costs of 
        providing training related to the provision of required 
        primary health services and additional health services 
        and to the management of health center programs. The 
        costs for which a grant may be made under paragraph 
        (1)(C) may include the costs of providing such 
        training.
          [(3) Construction.--The Secretary may award grants 
        which may be used to pay the costs associated with 
        expanding and modernizing existing buildings or 
        constructing new buildings (including the costs of 
        amortizing the principal of, and paying the interest 
        on, loans) for projects approved prior to October 1, 
        1996.]

           *       *       *       *       *       *       *

          [(4)] (3) Limitation.--Not more than two grants may 
        be made under subparagraph (B) of paragraph (1) for the 
        same entity.
          [(5)] (4) Amount.--
                  (A) In general.--The amount of any grant made 
                in any fiscal year under subparagraphs (A) and 
                (B) of paragraph (1) to a health center shall 
                be determined by the Secretary, but may not 
                exceed the amount by which the costs of 
                operation of the center in such fiscal year 
                exceed the total of--
                          (i) State, local, and other 
                        operational funding provided to the 
                        center; and
                          (ii) the fees, premiums, and third-
                        party reimbursements, which the center 
                        may reasonably be expected to receive 
                        for its operations in such fiscal year.
                  (B) Networks and plans.--The total amount of 
                grant funds made available for any fiscal year 
                under paragraph (1)(C) and subparagraphs (B) 
                and (C) of subsection (c)(1) to a health center 
                or to a network or plan shall be determined by 
                the Secretary, but may not exceed 2 percent of 
                the total amount appropriated under this 
                section for such fiscal year.
                  [(B)] (C) Payments.--Payments under grants 
                under subparagraph (A) or (B) of paragraph (1) 
                shall be made in advance or by way of 
                reimbursement and in such installments as the 
                Secretary finds necessary and adjustments may 
                be made for overpayments or underpayments.
                   [(C)] (D) Use of nongrant funds.--Nongrant 
                funds described in clauses (i) and (ii) of 
                subparagraph (A), including any such funds in 
                excess of those originally expected, shall be 
                used as permitted under this section, and may 
                be used for such other purposes as are not 
                specifically prohibited under this section if 
                such use furthers the objectives of the 
                project.

           *       *       *       *       *       *       *

    (g) Migratory and Seasonal Agricultural Workers.--
          (1) In general.--

           *       *       *       *       *       *       *

          (2) Environmental concerns.--The Secretary may enter 
        into grants or contracts under this subsection with 
        public and private entities to--
                  (A) assist the States in the implementation 
                and enforcement of acceptable environmental 
                health standards, including enforcement of 
                standards for sanitation in migratory 
                agricultural worker and seasonal agricultural 
                worker labor camps, and applicable Federal and 
                State pesticide control standards; and
                  (B) conduct projects and studies to assist 
                the several States and entities which have 
                received grants or contracts under this section 
                in the assessment of problems related to camp 
                and field sanitation, exposure to unsafe levels 
                of agricultural chemicals including pesticides, 
                and other environmental health hazards to which 
                migratory agricultural workers [and members of 
                their families]  and seasonal agricultural 
                workers, and members of their families, are 
                exposed.
          (3) Definitions.--For purposes of this subsection:
                  (A) Migratory agricultural worker.--The term 
                ``migratory agricultural worker'' means an 
                individual whose principal employment is in 
                agriculture on a seasonal basis, who has been 
                so employed within the last 24 months, and who 
                establishes for the purposes of such employment 
                a temporary abode.

           *       *       *       *       *       *       *

    (h) Homeless Population.--
          (1) In general.--The Secretary may award grants for 
        the purposes described in subsections (c), (e), and (f) 
        for the planning and delivery of services to a special 
        medically underserved population comprised of homeless 
        individuals, including grants for innovative programs 
        that provide outreach and comprehensive primary health 
        services to [homeless children and children at risk of 
        homelessness] homeless children and youth and children 
        and youth at risk of homelessness.

           *       *       *       *       *       *       *

          (4) Temporary continued provision of services to 
        certain former homeless individuals.--If any grantee 
        under this subsection has provided services described 
        in this section under the grant to a homeless 
        individual, such grantee may, notwithstanding that the 
        individual is no longer homeless as a result of 
        becoming a resident in permanent housing, expend the 
        grant to continue to provide such services to the 
        individual for not more than 12 months.
          [(4)] (5) Definitions.--For purposes of this section:
                  (A) Homeless individual.--The term ``homeless 
                individual'' means an individual who lacks 
                housing (without regard to whether the 
                individual is a member of a family), including 
                an individual whose primary residence during 
                the night is a supervised public or private 
                facility that provides temporary living 
                accommodations and an individual who is a 
                resident in transitional housing.
                  (B) Substance abuse.--The term ``substance 
                abuse'' has the same meaning given such term in 
                section 534(4).
                  (C) Substance abuse services.--The term 
                ``substance abuse services'' includes 
                detoxification [and residential treatment], 
                risk reduction, outpatient treatment, 
                residential treatment, and rehabilitation for 
                substance abuse provided in settings other than 
                hospitals.

           *       *       *       *       *       *       *

    (j) Environmental Concerns.--The Secretary may make grants 
to health centers for the purpose of assisting such centers in 
identifying and detecting environmental factors and conditions, 
and providing services, including environmental health services 
described in subsection (b)(2)(D), to reduce the disease burden 
related to environmental factors and exposure of populations to 
such factors, and alleviate environmental conditions that 
affect the health of individuals and communities served by 
health centers funded under this section.
    (k) Linguistic Access Grants.--
          (1) In general.--The Secretary may award grants to 
        eligible health centers with a substantial number of 
        clients with limited English speaking proficiency to 
        provide translation, interpretation, and other such 
        services for such clients with limited English speaking 
        proficiency.
          (2) Eligible health center.--In this subsection, the 
        term ``eligible health center'' means an entity that--
                  (A) is a health center as defined under 
                subsection (a); and
                  (B) provides health care services for clients 
                for whom English is a second language.
          (3) Grant amount.--The amount of a grant awarded to a 
        center under this subsection shall be determined by the 
        Administrator. Such determination of such amount shall 
        be based on the number of clients for whom English is a 
        second language that is served by such center, and 
        larger grant amounts shall be awarded to centers 
        serving larger number of such clients.
          (4) Use of funds.--An eligible health center that 
        receives a grant under this subsection may use funds 
        received through such grant to--
                  (A) provide translation, interpretation, and 
                other such services for clients for whom 
                English is a second language, including hiring 
                professional translation and interpretation 
                services; and
                  (B) compensate bilingual or multilingual 
                staff for language assistance services provided 
                by the staff for such clients.
          (5) Application.--An eligible health center desiring 
        a grant under this subsection shall submit an 
        application to the Secretary at such time, in such 
        manner, and containing such information as the 
        Secretary may reasonably require, including--
                  (A) an estimate of the number of clients that 
                the center serves for whom English is a second 
                language;
                  (B) the ratio of the number of clients for 
                whom English is a second language to the total 
                number of clients served by the center; and
                  (C) a description of any language assistance 
                services that the center proposes to provide to 
                aid clients for whom English is second 
                language.
          (6) Authorization of appropriations.--There are 
        authorized to be appropriated to carry out this 
        subsection, in addition to any funds authorized to be 
        appropriated or appropriated for health centers under 
        any other subsection of this section, $10,000,000 for 
        fiscal year 2002, and such sums as may be necessary for 
        each of fiscal years 2003 through 2006.
    [(j)] (l) Applications.--
          (1) Submission.--

           *       *       *       *       *       *       *

                  (E) the center--
                          [(i)] (i)(I) has or will have a 
                        contractual or other arrangement with 
                        the agency of the State, in which it 
                        provides services, which administers or 
                        supervises the administration of a 
                        State plan approved under title XIX of 
                        the Social Security Act for the payment 
                        of all or a part of the center's costs 
                        in providing health services to persons 
                        who are eligible for medical assistance 
                        under such a State [plan; or] plan; and
                          (II) has or will have a contractual 
                        or other arrangement with the State 
                        agency administering the program under 
                        title XXI of such Act (42 U.S.C. 1397aa 
                        et seq.) with respect to individuals 
                        who are State children's health 
                        insurance program beneficiaries; or
                          [(ii) has made or will make every 
                        reasonable effort to enter into such an 
                        arrangement;]
                          (ii) has made or will make every 
                        reasonable effort to enter into 
                        arrangements described in subclauses 
                        (I) and (II) of clause (i);

           *       *       *       *       *       *       *

                  (G) the center--

           *       *       *       *       *       *       *

                          (II) to collect reimbursement for 
                        health services to persons described in 
                        subparagraph (F) on the basis of the 
                        full amount of fees and payments for 
                        such services without application of 
                        any discount; [and]
                          (iii)(I) will assure that no patient 
                        will be denied health care services due 
                        to an individual's inability to pay for 
                        such services; and
                          (II) will assure that any fees or 
                        payments required by the center for 
                        such services will be reduced or waived 
                        to enable the center to fulfill the 
                        assurance described in subclause (I); 
                        and
                          [(iii)] (iv) has submitted to the 
                        Secretary such reports as the Secretary 
                        may require to determine compliance 
                        with this subparagraph;
                  (H) * * *

           *       *       *       *       *       *       *

                          (ii) meets at least once a month, 
                        selects the services to be provided by 
                        the center, schedules the hours during 
                        which such services will be provided, 
                        reviews any internal outreach plans for 
                        specific subpopulations served by the 
                        center, approves the center's annual 
                        budget, approves the selection of a 
                        director for the center, and, except in 
                        the case of a governing board of a 
                        public center (as defined in the second 
                        sentence of this paragraph), 
                        established general policies for the 
                        center; and

           *       *       *       *       *       *       *

                except that, upon a showing of good cause the 
                Secretary shall waive, for the length of the 
                project period, all or part of the requirements 
                of this subparagraph in the case of a health 
                center that receives a grant pursuant to 
                subsection (g), (h), (i), [or (p);] or (q);

           *       *       *       *       *       *       *

                  (K) in the case of a center which serves a 
                population including a substantial proportion 
                of individuals of limited English-speaking 
                ability, the center has--

           *       *       *       *       *       *       *

                          (ii) identified an individual on its 
                        staff who is fluent in both that 
                        language and in English and whose 
                        responsibilities shall include 
                        providing guidance to such individuals 
                        and to appropriate staff members with 
                        respect to cultural sensitivities and 
                        bridging linguistic and cultural 
                        differences; [and]

           *       *       *       *       *       *       *

                  (L) the center, has developed an ongoing 
                referral relationship with one or more 
                hospitals[.]; and
                  (M) in the case of a project involving 
                modernization of a building, the application 
                contains a reasonable assurance that all 
                laborers and mechanics employed by contractors 
                or subcontractors in the performance of work on 
                the modernization of the building described in 
                the application will be paid wages at rates not 
                less than the rates prevailing on similar work 
                in the locality involved as determined by the 
                Secretary of Labor in accordance with the labor 
                standards specified in the Act of March 3, 1931 
                (commonly known as the `Davis-Bacon Act') (46 
                Stat. 1494, chapter 411; 40 U.S.C. 276a et 
                seq.), and the Secretary of Labor shall have 
                with respect to such labor standards and such 
                project the authority and functions set forth 
                in Reorganization Plan No. 14 of 1950 (50 
                U.S.C. App.) and section 2 of the Act of June 
                13, 1934 (48 Stat. 948, chapter 482; 40 U.S.C. 
                276c).
    [(k) Technical and Other Assistance.--The Secretary may 
provide (either through the Department of Health and Human 
Services or by grant or contract) all necessary technical and 
other nonfinancial assistance (including fiscal and program 
management assistance and training in such management) to any 
public or private nonprofit entity to assist entities in 
developing plans for, or operating as, health centers, and in 
meeting the requirements of subsection (j)(2)]
    (m) Technical Assistance.--The Secretary shall establish a 
program through which the Secretary shall provide technical and 
other assistance to eligible entities to assist such entities 
to meet the requirements of subsection (l)(3) in developing 
plans for, or operating, health centers. Services provided 
through the program may include necessary technical and 
nonfinancial assistance, including fiscal and program 
management assistance, training in fiscal and program 
management, operational and administrative support, and the 
provision of information to the entities of the variety of 
resources available under this title and how those resources 
can be best used to meet the health needs of the communities 
served by the entities.
    [(m)] (n) Memorandum of Agreement.--In carrying out this 
section, the Secretary may enter into a memorandum of agreement 
with a State. Such memorandum may include, where appropriate, 
provisions permitting such State to--
    [(n)] (o) Records.--
    [(o)] (p) Delegation of Authority.--The Secretary may 
delegate the authority to administer the programs authorized by 
this section to any office, except that the authority to enter 
into, modify, or issue approvals with respect to grants or 
contracts may be delegated only within the central office of 
the Health Resources and Services Administration.
    [(p)] (q) Special Consideration.--In making grants under 
this section, the Secretary shall give special consideration to 
the unique needs of sparsely populated rural areas, including 
giving priority in the awarding of grants for new health 
centers under subsections (c) and (e), and the granting of 
waivers as appropriate and permitted under subsections 
(b)(1)(B)(i) and [(j)(3)(G)] (l)(3)(G).
    [(q)] (r) Audits.--
          (1) In general.--Each entity which receives a grant 
        under this section shall provide for an independent 
        annual financial audit of any books, accounts, 
        financial records, files, and other papers and property 
        which relate to the disposition or use of the funds 
        received under such grant and such other funds received 
        by or allocated to the project for which such grant was 
        made. For purposes of assuring accurate, current, and 
        complete disclosure of the disposition or use of the 
        funds received, each such audit shall be conducted in 
        accordance with generally accepted accounting 
        principles. Each audit shall evaluate--
    [(l)] (s) Authorization of Appropriations.--
          (1) In general.--For the purpose of carrying out this 
        section, in addition to the amounts authorized to be 
        appropriated under subsection (d), there are authorized 
        to be appropriated [$802,124,000 for fiscal year 1997, 
        and such sums as may be necessary for each of the 
        fiscal years 1998 through 2001] $1,369,000,000 for 
        fiscal year 2002 and such sums as may be necessary for 
        each of the fiscal years 2003 through 2006.
          (2) Special provisions.--
                  (A) Public centers.--The Secretary may not 
                expend in any fiscal year, for grants under 
                this section to public centers (as defined in 
                the second sentence of subsection [(j)(3))] 
                (l)(3)) the governing boards of which (as 
                described in subsection [(j)(3)(G)(ii)] 
                (l)(3)(H)) do not establish general policies 
                for such centers, an amount which exceeds 5 
                percent of the amounts appropriated under this 
                section for that fiscal year. For purposes of 
                applying the preceding sentence, the term 
                ``public centers'' shall not include health 
                centers that receive grants pursuant to 
                subsection (h) or (i).
                  [(B) Distribution of grants.--
                          [(i) Fiscal year 1997.--For fiscal 
                        year 1997, the Secretary, in awarding 
                        grants under this section shall ensure 
                        that the amounts made available under 
                        each of subsections (g), (h), and (i) 
                        in such fiscal year bears the same 
                        relationship to the total amount 
                        appropriated for such fiscal year under 
                        paragraph (1) as the amounts 
                        appropriated for fiscal year 1996 under 
                        each of sections 329, 340, and 340A (as 
                        such sections existed one day prior to 
                        the date of enactment of this section) 
                        bears to the total amount appropriated 
                        under sections 329, 330, 340, and 340A 
                        (as such sections existed one day prior 
                        to the date of enactment of this 
                        section) for such fiscal year.
                          [(ii) Fiscal years 1998 and 1999.--
                        For each of the fiscal years 1998 and 
                        1999, the Secretary, in awarding grants 
                        under this section shall ensure that 
                        the proportion of the amount made 
                        available under each of subsections 
                        (g), (h), and (i) is equal to the 
                        proportion of amounts made available 
                        under each such subsection for the 
                        previous fiscal year, as such amounts 
                        relate to the total amounts 
                        appropriated for the previous fiscal 
                        year involved, increased or decreased 
                        by not more than 10 percent.]
                  (B) Distribution of grants.--For fiscal year 
                2002 and each of the following fiscal years, 
                the Secretary, in awarding grants under this 
                section, shall ensure that the proportion of 
                the amount made available under each of 
                subsections (g), (h), and (i), relative to the 
                total amount appropriated to carry out this 
                section for that fiscal year, is equal to the 
                proportion of the amount made available under 
                that subsection for fiscal year 2001, relative 
                to the total amount appropriated to carry out 
                this section for fiscal year 2001.
          [(3) Funding report.--The Secretary shall annually 
        prepare and submit to the appropriate committees of 
        Congress a report concerning the distribution of funds 
        under this section that are provided to meet the health 
        care needs of medically underserved populations, 
        including the homeless, residents of public housing, 
        and migratory and seasonal agricultural workers, and 
        the appropriateness of the delivery systems involved in 
        responding to the needs of the particular populations. 
        Such report shall include an assessment of the relative 
        health care access needs of the targeted populations 
        and the rationale for any substantial changes in the 
        distribution of funds.]
          (3) Limitation.--The total amount of grant funds made 
        available in any fiscal year under subsections 
        (c)(1)(A) and (e)(2), to support the costs of building 
        construction or building expansion or modernization 
        projects shall not exceed 5 percent of the total amount 
        appropriated to carry out this section for such fiscal 
        year.

           *       *       *       *       *       *       *


[SEC. 330A. [254C] RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND 
                    TELEMEDICINE GRANT PROGRAM.

    [(a) Administration.--The rural health services outreach 
demonstration grant program established under section 301 shall 
be administered by the Office of Rural Health Policy (of the 
Health Resources and Services Administration), in consultation 
with State rural health offices or other appropriate State 
governmental entities.
    [(b) Grants.--Under the program referred to in subsection 
(a), the Secretary, acting through the Director of the Office 
of Rural Health Policy, may award grants to expand access to, 
coordinate, restrain the cost of, and improve the quality of 
essential health care services, including preventive and 
emergency services, through the development of integrated 
health care delivery systems or networks in rural areas and 
regions.
    [(c) Eligible Networks.--
          [(1) Outreach networks.--To be eligible to receive a 
        grant under this section, an entity shall--
                  [(A) be a rural public or nonprofit private 
                entity that is or represents a network or 
                potential network that includes three or more 
                health care providers or other entities that 
                provide or support the delivery of health care 
                services; and
                  [(B) in consultation with the State office of 
                rural health or other appropriate State entity, 
                prepare and submit to the Secretary an 
                application, at such time, in such manner, and 
                containing such information as the Secretary 
                may require, including--
                          [(i) a description of the activities 
                        which the applicant intends to carry 
                        out using amounts provided under the 
                        grant;
                          [(ii) a plan for continuing the 
                        project after Federal support is ended;
                          [(iii) a description of the manner in 
                        which the activities funded under the 
                        grant will meet health care needs of 
                        underserved rural populations within 
                        the State; and
                          [(iv) a description of how the local 
                        community or region to be served by the 
                        network or proposed net-work will be 
                        involved in the development and ongoing 
                        operations of the network.
          [(2) For-profit entities.--An eligible network may 
        include for-profit entities so long as the network 
        grantee is a nonprofit entity.
          [(3) Telemedicine networks.--
                  [(A) In general.--An entity that is a health 
                care provider and a member of an existing or 
                proposed telemedicine network or an entity that 
                is a consortium of health care providers that 
                are members of an existing or proposed 
                telemedicine network shall be eligible for a 
                grant under this section.
                  [(B) Requirement.--A telemedicine network 
                referred to in subparagraph (A) shall, at a 
                minimum, be composed of--
                          [(i) a multispecialty entity that is 
                        located in an urban or rural area, 
                        which can provide 24-hour a day access 
                        to a range of specialty care; and
                          [(ii) at least two rural health care 
                        facilities, which may include rural 
                        hospitals, rural physician offices, 
                        rural health clinics, rural community 
                        health clinics, and rural nursing 
                        homes.
    [(d) Preference.--In awarding grants under this section, 
the Secretary shall give preference to applicant networks that 
include--
          [(1) a majority of the health care providers serving 
        in the area or region to be served by the network;
          [(2) any federally qualified health centers, rural 
        health clinics, and local public health departments 
        serving in the area or region;
          [(3) outpatient mental health providers serving in 
        the area or region; or
          [(4) appropriate social service providers, such as 
        agencies on aging, school systems, and providers under 
        the women, infants, and children program, to improve 
        access to and coordination of health care services.
    [(e) Use of Funds.--
          [(1) In general.--Amounts provided under grants 
        awarded under this section shall be used--
                  [(A) for the planning and development of 
                integrated self-sustaining health care 
                networks; and
                  [(B) for the initial provision of services.
          [(2) Expenditures in rural areas.--
                  [(A) In general.--In awarding a grant under 
                this section, the Secretary shall ensure that 
                not less than 50 percent of the grant award is 
                expended in a rural area or to provide services 
                to residents of rural areas.
                  [(B) Telemedicine networks.--An entity 
                described in subsection (c)(3) may not use in 
                excess of--
                          [(i) 40 percent of the amounts 
                        provided under a grant under this 
                        section to carry out activities under 
                        paragraph (3)(A)(iii); and
                          [(ii) 20 percent of the amounts 
                        provided under a grant under this 
                        section to pay for the indirect costs 
                        associated with carrying out the 
                        purposes of such grant.
          [(3) Telemedicine networks.--
                  [(A) In general.--An entity described in 
                subsection (c)(3), may use amounts provided 
                under a grant under this section to--
                          [(i) demonstrate the use of 
                        telemedicine in facilitating the 
                        development of rural health care 
                        networks and for improving access to 
                        health care services for rural 
                        citizens;
                          [(ii) provide a baseline of 
                        information for a systematic evaluation 
                        of telemedicine systems serving rural 
                        areas;
                          [(iii) purchase or lease and install 
                        equipment; and
                          [(iv) operate the telemedicine system 
                        and evaluate the telemedicine system.
                  [(B) Limitations.--An entity described in 
                subsection (c)(3), may not use amounts provided 
                under a grant under this section--
                          [(i) to build or acquire real 
                        property;
                          [(ii) purchase or install 
                        transmission equipment (such as laying 
                        cable or telephone lines, microwave 
                        towers, satellite dishes, amplifiers, 
                        and digital switching equipment); or
                          [(iii) for construction, except that 
                        such funds may be expended for minor 
                        renovations relating to the 
                        installation of equipment;
    [(f) Term of Grants.--Funding may not be provided to a 
network under this section for in excess of a 3-year period.
    [(g) Authorization of Appropriations.--For the purpose of 
carrying out this section there are authorized to be 
appropriated $36,000,000 for fiscal year 1997, and such sums as 
may be necessary for each of the fiscal years 1998 through 
2001.]

``SEC. 330A. RURAL HEALTH CARE SERVICES OUTREACH, RURAL HEALTH NETWORK 
                    DEVELOPMENT, AND SMALL HEALTH CARE PROVIDER QUALITY 
                    IMPROVEMENT GRANT PROGRAMS.

  (a) Purpose.--The purpose of this section is to provide 
grants for expanded delivery of health care services in rural 
areas, for the planning and implementation of integrated health 
care networks in rural areas, and for the planning and 
implementation of small health care provider quality 
improvement activities.
  (b) Definitions.--
          (1) Director.--The term ``Director'' means the 
        Director specified in subsection (d).
          (2) Federally qualified health center; rural health 
        clinic.--The terms ``Federally qualified health 
        center'' and ``rural health clinic'' have the meanings 
        given the terms in section 1861(aa) of the Social 
        Security Act (42 U.S.C. 1395x(aa)).
          (3) Health professional shortage area.--The term 
        ``health professional shortage area'' means a health 
        professional shortage area designated under section 
        332.
          (4) Medically underserved community.--The term 
        ``medically underserved community'' has the meaning 
        given the term in section 799B.
          (5) Medically underserved population.--The term 
        ``medically underserved population'' has the meaning 
        given the term in section 330(b)(3).
  (c) Program.--The Secretary shall establish, under section 
301, a small health care provider quality improvement grant 
program.
  (d) Administration.--
          (1) Programs.--The rural health care services 
        outreach, rural health network development, and small 
        health care provider quality improvement grant programs 
        established under section 301 shall be administered by 
        the Director of the Office of Rural Health Policy of 
        the Health Resources and Services Administration, in 
        consultation with State offices of rural health or 
        other appropriate State government entities.
          (2) Grants.--
                  (A) In general.--In carrying out the programs 
                described in paragraph (1), the Director may 
                award grants under subsections (e), (f), and 
                (g) to expand access to, coordinate, and 
                improve the quality of essential health care 
                services, and enhance the delivery of health 
                care, in rural areas.
                  (B) Types of grants.--The Director may award 
                the grants--
                          (i) to promote expanded delivery of 
                        health care services in rural areas 
                        under subsection (e);
                          (ii) to provide for the planning and 
                        implementation of integrated health 
                        care networks in rural areas under 
                        subsection (f); and
                          (iii) to provide for the planning and 
                        implementation of small health care 
                        provider quality improvement activities 
                        under subsection (g).
  (e) Rural Health Care Services Outreach Grants.--
          (1) Grants.--The Director may award grants to 
        eligible entities to promote rural health care services 
        outreach by expanding the delivery of health care 
        services to include new and enhanced services in rural 
        areas. The Director may award the grants for periods of 
        not more than 3 years.
          (2) Eligibility.--To be eligible to receive a grant 
        under this subsection for a project, an entity--
                  (A) shall be a rural public or rural 
                nonprofit private entity;
                  (B) shall represent a consortium composed of 
                members--
                          (i) that include 3 or more health 
                        care providers; and
                          (ii) that may be nonprofit or for-
                        profit entities; and
                  (C) shall not previously have received a 
                grant under this subsection for the same or a 
                similar project, unless the entity is proposing 
                to expand the scope of the project or the area 
                that will be served through the project.
          (3) Applications.--To be eligible to receive a grant 
        under this subsection, an eligible entity, in 
        consultation with the appropriate State office of rural 
        health or another appropriate State entity, shall 
        prepare and submit to the Secretary an application, at 
        such time, in such manner, and containing such 
        information as the Secretary may require, including--
                  (A) a description of the project that the 
                eligible entity will carry out using the funds 
                provided under the grant;
                  (B) a description of the manner in which the 
                project funded under the grant will meet the 
                health care needs of rural underserved 
                populations in the local community or region to 
                be served;
                  (C) a description of how the local community 
                or region to be served will be involved in the 
                development and ongoing operations of the 
                project;
                  (D) a plan for sustaining the project after 
                Federal support for the project has ended;
                  (E) a description of how the project will be 
                evaluated; and
                  (F) other such information as the Secretary 
                determines to be appropriate.
  (f) Rural Health Network Development Grants.--
          (1) Grants.--
                  (A) In general.--The Director may award rural 
                health network development grants to eligible 
                entities to promote, through planning and 
                implementation, the development of integrated 
                health care networks that have combined the 
                functions of the entities participating in the 
                networks in order to--
                          (i) achieve efficiencies;
                          (ii) expand access to, coordinate, 
                        and improve the quality of essential 
                        health care services; and
                          (iii) strengthen the rural health 
                        care system as a whole.
                  (B) Grant periods.--The Director may award 
                such a rural health network development grant 
                for implementation activities for a period of 3 
                years. The Director may also award such a rural 
                health network development grant for planning 
                activities for a period of 1 year, to assist in 
                the development of an integrated health care 
                network, if the proposed participants in the 
                network do not have a history of collaborative 
                efforts and a 3-year grant would be 
                inappropriate.
          (2) Eligibility.--To be eligible to receive a grant 
        under this subsection, an entity--
                  (A) shall be a rural public or rural 
                nonprofit private entity;
                  (B) shall represent a network composed of 
                participants--
                          (i) that include 3 or more health 
                        care providers; and
                          (ii) that may be nonprofit or for-
                        profit entities; and
                  (C) shall not previously have received a 
                grant under this subsection (other than a grant 
                for planning activities) for the same or a 
                similar project.
          (3) Applications.--To be eligible to receive a grant 
        under this subsection, an eligible entity, in 
        consultation with the appropriate State office of rural 
        health or another appropriate State entity, shall 
        prepare and submit to the Secretary an application, at 
        such time, in such manner, and containing such 
        information as the Secretary may require, including--
                  (A) a description of the project that the 
                eligible entity will carry out using the funds 
                provided under the grant;
                  (B) an explanation of the reasons why Federal 
                assistance is required to carry out the 
                project;
                  (C) a description of--
                          (i) the history of collaborative 
                        activities carried out by the 
                        participants in the network;
                          (ii) the degree to which the 
                        participants are ready to integrate 
                        their functions; and
                          (iii) how the local community or 
                        region to be served will benefit from 
                        and be involved in the activities 
                        carried out by the network;
                  (D) a description of how the local community 
                or region to be served will experience 
                increased access to quality health care 
                services across the continuum of care as a 
                result of the integration activities carried 
                out by the network;
                  (E) a plan for sustaining the project after 
                Federal support for the project has ended;
                  (F) a description of how the project will be 
                evaluated; and
                  (G) other such information as the Secretary 
                determines to be appropriate.
  (g) Small Health Care Provider Quality Improvement Grants.--
          (1) Grants.--The Director may award grants to provide 
        for the planning and implementation of small health 
        care provider quality improvement activities. The 
        Director may award the grants for periods of 1 to 3 
        years.
          (2) Eligibility.--To be eligible for a grant under 
        this subsection, an entity--
                  (A)(i) shall be a rural public or rural 
                nonprofit private health care provider or 
                provider of health care services, such as a 
                critical access hospital or a rural health 
                clinic; or
                  (ii) shall be another rural provider or 
                network of small rural providers identified by 
                the Secretary as a key source of local care; 
                and
                  (B) shall not previously have received a 
                grant under this subsection for the same or a 
                similar project.
          (3) Applications.--To be eligible to receive a grant 
        under this subsection, an eligible entity, in 
        consultation with the appropriate State office of rural 
        health or another appropriate State entity, such as a 
        hospital association, shall prepare and submit to the 
        Secretary an application, at such time, in such manner, 
        and containing such information as the Secretary may 
        require, including--
                  (A) a description of the project that the 
                eligible entity will carry out using the funds 
                provided under the grant;
                  (B) an explanation of the reasons why Federal 
                assistance is required to carry out the 
                project;
                  (C) a description of the manner in which the 
                project funded under the grant will assure 
                continuous quality improvement in the provision 
                of services by the entity;
                  (D) a description of how the local community 
                or region to be served will experience 
                increased access to quality health care 
                services across the continuum of care as a 
                result of the activities carried out by the 
                entity;
                  (E) a plan for sustaining the project after 
                Federal support for the project has ended;
                  (F) a description of how the project will be 
                evaluated; and
                  (G) other such information as the Secretary 
                determines to be appropriate.
          (4) Expenditures for small health care provider 
        quality improvement grants.--In awarding a grant under 
        this subsection, the Director shall ensure that the 
        funds made available through the grant will be used to 
        provide services to residents of rural areas. The 
        Director shall award not less than 50 percent of the 
        funds made available under this subsection to providers 
        located in and serving rural areas.
  (h) General Requirements.--
          (1) Prohibited uses of funds.--An entity that 
        receives a grant under this section may not use funds 
        provided through the grant--
                  (A) to build or acquire real property; or
                  (B) for construction, except that such funds 
                may be expended for minor renovations relating 
                to the installation of equipment.
          (2) Coordination with other agencies.--The Secretary 
        shall coordinate activities carried out under grant 
        programs described in this section, to the extent 
        practicable, with Federal and State agencies and 
        nonprofit organizations that are operating similar 
        grant programs, to maximize the effect of public 
        dollars in funding meritorious proposals.
          (3) Preference.--In awarding grants under this 
        section, the Secretary shall give preference to 
        entities that--
                  (A) are located in health professional 
                shortage areas or medically underserved 
                communities, or serve medically underserved 
                populations; or
                  (B) propose to develop projects with a focus 
                on primary care, and wellness and prevention 
                strategies.
  (i) Report.--Not later than September 30, 2005, the Secretary 
shall prepare and submit to the appropriate committees of 
Congress a report on the progress and accomplishments of the 
grant programs described in subsections (e), (f), and (g).
  (j) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out this section $40,000,000 for 
fiscal year 2002, and such sums as may be necessary for each of 
fiscal years 2003 through 2006.

SEC. 330I. TELEHEALTH NETWORK AND TELEHEALTH RESOURCE CENTERS GRANT 
                    PROGRAMS.

  (a) Definitions.--In this section:
          (1) Director; office.--The terms ``Director'' and 
        ``Office'' mean the Director and Office specified in 
        subsection (c).
          (2) Federally qualified health center and rural 
        health clinic.--The term ``Federally qualified health 
        center'' and ``rural health clinic'' have the meanings 
        given the terms in section 1861(aa) of the Social 
        Security Act (42 U.S.C. 1395x(aa)).
          (3) Frontier community.--The term ``frontier 
        community'' shall have the meaning given the term in 
        regulations issued under subsection (r).
          (4) Medically underserved area.--The term ``medically 
        underserved area'' has the meaning given the term 
        ``medically underserved community'' in section 799B.
          (5) Medically underserved population.--The term 
        ``medically underserved population'' has the meaning 
        given the term in section 330(b)(3).
          (6) Telehealth services.--The term ``telehealth 
        services'' means services provided through telehealth 
        technologies.
          (7) Telehealth technologies.--The term ``telehealth 
        technologies'' means technologies relating to the use 
        of electronic information, and telecommunications 
        technologies, to support and promote, at a distance, 
        health care, patient and professional health-related 
        education, health administration, and public health.
  (b) Programs.--The Secretary shall establish, under section 
301, telehealth network and telehealth resource centers grant 
programs.
  (c) Administration.--
          (1) Establishment.--There is established in the 
        Health and Resources and Services Administration an 
        Office for the Advancement of Telehealth. The Office 
        shall be headed by a Director.
          (2) Duties.--The telehealth network and telehealth 
        resource centers grant programs established under 
        section 301 shall be administered by the Director, in 
        consultation with the State offices of rural health, 
        State offices concerning primary care, or other 
        appropriate State government entities.
  (d) Grants.--
          (1) Telehealth network grants.--The Director may, in 
        carrying out the telehealth network grant program 
        referred to in subsection (b), award grants to eligible 
        entities for projects to demonstrate how telehealth 
        technologies can be used through telehealth networks in 
        rural areas, frontier communities, and medically 
        underserved areas, and for medically underserved 
        populations, to--
                  (A) expand access to, coordinate, and improve 
                the quality of health care services;
                  (B) improve and expand the training of health 
                care providers; and
                  (C) expand and improve the quality of health 
                information available to health care providers, 
                and patients and their families, for 
                decisionmaking.
          (2) Telehealth resource centers grants.--The Director 
        may, in carrying out the telehealth resource centers 
        grant program referred to in subsection (b), award 
        grants to eligible entities for projects to demonstrate 
        how telehealth technologies can be used in the areas 
        and communities, and for the populations, described in 
        paragraph (1), to establish telehealth resource 
        centers.
  (e) Grant Periods.--The Director may award grants under this 
section for periods of not more than 4 years.
  (f) Eligible Entities.--
          (1) Telehealth network grants.--
                  (A) Grant recipient.--To be eligible to 
                receive a grant under subsection (d)(1), an 
                entity shall be a nonprofit entity.
                  (B) Telehealth networks.--
                          (i) In general.--To be eligible to 
                        receive a grant under subsection 
                        (d)(1), an entity shall demonstrate 
                        that the entity will provide services 
                        through a telehealth network.
                          (ii) Nature of entities.--Each entity 
                        participating in the telehealth network 
                        may be a nonprofit or for-profit 
                        entity.
                          (iii) Composition of network.--The 
                        telehealth network shall include at 
                        least 2 of the following entities (at 
                        least 1 of which shall be a community-
                        based health care provider):
                                  (I) Community or migrant 
                                health centers or other 
                                Federally qualified health 
                                centers.
                                  (II) Health care providers, 
                                including pharmacists, in 
                                private practice.
                                  (III) Entities operating 
                                clinics, including rural health 
                                clinics.
                                  (IV) Local health 
                                departments.
                                  (V) Nonprofit hospitals, 
                                including community access 
                                hospitals.
                                  (VI) Other publicly funded 
                                health or social service 
                                agencies.
                                  (VII) Long-term care 
                                providers.
                                  (VIII) Providers of health 
                                care services in the home.
                                  (IX) Providers of outpatient 
                                mental health services and 
                                entities operating outpatient 
                                mental health facilities.
                                  (X) Local or regional 
                                emergency health care 
                                providers.
                                  (XI) Institutions of higher 
                                education.
                                  (XII) Entities operating 
                                dental clinics.
          (2) Telehealth resource centers grants.--To be 
        eligible to receive a grant under subsection (d)(2), an 
        entity shall be a nonprofit entity.
  (g) Applications.--To be eligible to receive a grant under 
subsection (d), an eligible entity, in consultation with the 
appropriate State office of rural health or another appropriate 
State entity, shall prepare and submit to the Secretary an 
application, at such time, in such manner, and containing such 
information as the Secretary may require, including--
          (1) a description of the project that the eligible 
        entity will carry out using the funds provided under 
        the grant;
          (2) a description of the manner in which the project 
        funded under the grant will meet the health care needs 
        of rural or other populations to be served through the 
        project, or improve the access to services of, and the 
        quality of the services received by, those populations;
          (3) evidence of local support for the project, and a 
        description of how the areas, communities, or 
        populations to be served will be involved in the 
        development and ongoing operations of the project;
          (4) a plan for sustaining the project after Federal 
        support for the project has ended;
          (5) information on the source and amount of non-
        Federal funds that the entity will provide for the 
        project;
          (6) information demonstrating the long-term viability 
        of the project, and other evidence of institutional 
        commitment of the entity to the project;
          (7) in the case of an application for a project 
        involving a telehealth network, information 
        demonstrating how the project will promote the 
        integration of telehealth technologies into the 
        operations of health care providers, to avoid 
        redundancy, and improve access to and the quality of 
        care; and
          (8) other such information as the Secretary 
        determines to be appropriate.
  (h) Terms; Conditions; Maximum Amount of Assistance.--The 
Secretary shall establish the terms and conditions of each 
grant program described in subsection (b) and the maximum 
amount of a grant to be awarded to an individual recipient for 
each fiscal year under this section. The Secretary shall 
publish, in a publication of the Health Resources and Services 
Administration, notice of the application requirements for each 
grant program described in subsection (b) for each fiscal year.
  (i) Preferences.--
          (1) Telehealth networks.--In awarding grants under 
        subsection (d)(1) for projects involving telehealth 
        networks, the Secretary shall give preference to an 
        eligible entity that meets at least 1 of the following 
        requirements:
                  (A) Organization.--The eligible entity is a 
                rural community-based organization or another 
                community-based organization.
                  (B) Services.--The eligible entity proposes 
                to use Federal funds made available through 
                such a grant to develop plans for, or to 
                establish, telehealth networks that provide 
                mental health, public health, long-term care, 
                home care, preventive, or case management 
                services.
                  (C) Coordination.--The eligible entity 
                demonstrates how the project to be carried out 
                under the grant will be coordinated with other 
                relevant federally funded projects in the 
                areas, communities, and populations to be 
                served through the grant.
                  (D) Network.--The eligible entity 
                demonstrates that the project involves a 
                telehealth network that includes an entity 
                that--
                          (i) provides clinical health care 
                        services, or educational services for 
                        health care providers and for patients 
                        or their families; and
                          (ii) is--
                                  (I) a public school;
                                  (II) a public library;
                                  (III) an institution of 
                                higher education; or
                                  (IV) a local government 
                                entity.
                  (E) Connectivity.--The eligible entity 
                proposes a project that promotes local 
                connectivity within areas, communities, or 
                populations to be served through the project.
                  (F) Integration.--The eligible entity 
                demonstrates that health care information has 
                been integrated into the project.
          (2) Telehealth resource centers.--In awarding grants 
        under subsection (d)(2) for projects involving 
        telehealth resource centers, the Secretary shall give 
        preference to an eligible entity that meets at least 1 
        of the following requirements:
                  (A) Provision of services.--The eligible 
                entity has a record of success in the provision 
                of telehealth services to medically underserved 
                areas or medically underserved populations.
                  (B) Collaboration and sharing of expertise.--
                The eligible entity has a demonstrated record 
                of collaborating and sharing expertise with 
                providers of telehealth services at the 
                national, regional, State, and local levels.
                  (C) Broad range of telehealth services.--The 
                eligible entity has a record of providing a 
                broad range of telehealth services, which may 
                include--
                          (i) a variety of clinical specialty 
                        services;
                          (ii) patient or family education;
                          (iii) health care professional 
                        education; and
                          (iv) rural residency support 
                        programs.
  (j) Distribution of Funds.--
          (1) In general.--In awarding grants under this 
        section, the Director shall ensure, to the greatest 
        extent possible, that such grants are equitably 
        distributed among the geographical regions of the 
        United States.
          (2) Telehealth networks.--In awarding grants under 
        subsection (d)(1) for a fiscal year, the Director shall 
        ensure that--
                  (A) not less than 50 percent of the funds 
                awarded shall be awarded for projects in rural 
                areas; and
                  (B) the total amount of funds awarded for 
                such projects for that fiscal year shall be not 
                less than the total amount of funds awarded for 
                such projects for fiscal year 2001 under 
                section 330A (as in effect on the day before 
                the date of enactment of the Health Care Safety 
                Net Amendments of 2001).
  (k) Use of Funds.--
          (1) Telehealth network program.--The recipient of a 
        grant under subsection (d)(1) may use funds received 
        through such grant for salaries, equipment, and 
        operating or other costs, including the cost of--
                  (A) developing and delivering clinical 
                telehealth services that enhance access to 
                community-based health care services in rural 
                areas, frontier communities, or medically 
                underserved areas, or for medically underserved 
                populations;
                  (B) developing and acquiring, through lease 
                or purchase, computer hardware and software, 
                audio and video equipment, computer network 
                equipment, interactive equipment, data terminal 
                equipment, and other equipment that furthers 
                the objectives of the telehealth network grant 
                program;
                  (C)(i) developing and providing distance 
                education, in a manner that enhances access to 
                care in rural areas, frontier communities, or 
                medically underserved areas, or for medically 
                underserved populations; or
                  (ii) mentoring, precepting, or supervising 
                health care providers and students seeking to 
                become health care providers, in a manner that 
                enhances access to care in the areas and 
                communities, or for the populations, described 
                in clause (i);
                  (D) developing and acquiring instructional 
                programming;
                  (E)(i) providing for transmission of medical 
                data, and maintenance of equipment; and
                  (ii) providing for compensation (including 
                travel expenses) of specialists, and referring 
                health care providers, who are providing 
                telehealth services through the telehealth 
                network, if no third party payment is available 
                for the telehealth services delivered through 
                the telehealth network;
                  (F) developing projects to use telehealth 
                technology to facilitate collaboration between 
                health care providers;
                  (G) collecting and analyzing usage statistics 
                and data to document the cost-effectiveness of 
                the telehealth services; and
                  (H) carrying out such other activities as are 
                consistent with achieving the objectives of 
                this section, as determined by the Secretary.
          (2) Telehealth resource centers.--The recipient of a 
        grant under subsection (d)(2) may use funds received 
        through such grant for salaries, equipment, and 
        operating or other costs for--
                  (A) providing technical assistance, training, 
                and support, and providing for travel expenses, 
                for health care providers and a range of health 
                care entities that provide or will provide 
                telehealth services;
                  (B) disseminating information and research 
                findings related to telehealth services;
                  (C) promoting effective collaboration among 
                telehealth resource centers and the Office;
                  (D) conducting evaluations to determine the 
                best utilization of telehealth technologies to 
                meet health care needs;
                  (E) promoting the integration of the 
                technologies used in clinical information 
                systems with other telehealth technologies;
                  (F) fostering the use of telehealth 
                technologies to provide health care information 
                and education for health care providers and 
                consumers in a more effective manner; and
                  (G) implementing special projects or studies 
                under the direction of the Office.
  (l) Prohibited Uses of Funds.--An entity that receives a 
grant under this section may not use funds made available 
through the grant--
          (1) to acquire real property;
          (2) for expenditures to purchase or lease equipment, 
        to the extent that the expenditures would exceed 40 
        percent of the total grant funds;
          (3) in the case of a project involving a telehealth 
        network, to purchase or install transmission equipment 
        (such as laying cable or telephone lines, or purchasing 
        or installing microwave towers, satellite dishes, 
        amplifiers, or digital switching equipment), except on 
        the premises of an entity participating in the 
        telehealth network;
          (4) to pay for any equipment or transmission costs 
        not directly related to the purposes for which the 
        grant is awarded;
          (5) to purchase or install general purpose voice 
        telephone systems;
          (6) for construction, except that such funds may be 
        expended for minor renovations relating to the 
        installation of equipment; or
          (7) for expenditures for indirect costs (as 
        determined by the Secretary), to the extent that the 
        expenditures would exceed 20 percent of the total grant 
        funds.
  (m) Collaboration.--In providing services under this section, 
an eligible entity shall collaborate, if feasible, with 
entities that--
          (1)(A) are private or public organizations, that 
        receive Federal or State assistance; or
          (B) are public or private entities that operate 
        centers, or carry out programs, that receive Federal or 
        State assistance; and
          (2) provide telehealth services or related 
        activities.
  (n) Coordination With Other Agencies.--The Secretary shall 
coordinate activities carried out under grant programs 
described in subsection (b), to the extent practicable, with 
Federal and State agencies and nonprofit organizations that are 
operating similar programs, to maximize the effect of public 
dollars in funding meritorious proposals.
  (o) Outreach Activities.--The Secretary shall establish and 
implement procedures to carry out outreach activities to advise 
potential end users of telehealth services in rural areas, 
frontier communities, medically underserved areas, and 
medically underserved populations in each State about the grant 
programs described in subsection (b).
  (p) Telehealth.--It is the sense of Congress that, for 
purposes of this section, States should develop reciprocity 
agreements so that a provider of services under this section 
who is a licensed or otherwise authorized health care provider 
under the law of 1 or more States, and who, through telehealth 
technology, consults with a licensed or otherwise authorized 
health care provider in another State, is exempt, with respect 
to such consultation, from any State law of the other State 
that prohibits such consultation on the basis that the first 
health care provider is not a licensed or authorized health 
care provider under the law of that State.
  (q) Report.--Not later than September 30, 2005, the Secretary 
shall prepare and submit to the appropriate committees of 
Congress a report on the progress and accomplishments of the 
grant programs described in subsection (b).
  (r) Regulations.--The Secretary shall issue regulations 
specifying, for purposes of this section, a definition of the 
term ``frontier area''. The definition shall be based on 
factors that include population density, travel distance in 
miles to the nearest medical facility, travel time in minutes 
to the nearest medical facility, and such other factors as the 
Secretary determines to be appropriate. The Secretary shall 
develop the definition in consultation with the Director of the 
Bureau of the Census and the Administrator of the Economic 
Research Service of the Department of Agriculture.
  (s) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out this section--
          (1) for grants under subsection (d)(1), $40,000,000 
        for fiscal year 2002, and such sums as may be necessary 
        for each of fiscal years 2003 through 2006; and
          (2) for grants under subsection (d)(2), $20,000,000 
        for fiscal year 2002, and such sums as may be necessary 
        for each of fiscal years 2003 through 2006.

SEC. 330J. TELEHOMECARE DEMONSTRATION PROJECT.

  (a) Definitions.--In this section:
          (1) Distant site.--The term ``distant site'' means a 
        site at which a certified home care provider is located 
        at the time at which a health care service (including a 
        health care item) is provided through a 
        telecommunications system.
          (2) Telehomecare.--The term ``telehomecare'' means 
        the provision of health care services through 
        technology relating to the use of electronic 
        information, or through telemedicine or 
        telecommunication technology, to support and promote, 
        at a distant site, the monitoring and management of 
        home health care services for a resident of a rural 
        area.
  (b) Establishment.--Not later than 9 months after the date of 
enactment of the Health Care Safety Net Amendments of 2001, the 
Secretary shall establish and carry out a telehomecare 
demonstration project.
  (c) Grants.--In carrying out the demonstration project 
referred to in subsection (b), the Secretary shall make not 
more than 5 grants to eligible certified home care providers, 
individually or as part of a network of home health agencies, 
for the provision of telehomecare to improve patient care, 
prevent health care complications, improve patient outcomes, 
and achieve efficiencies in the delivery of care to patients 
who reside in rural areas.
  (d) Periods.--The Secretary shall make the grants for periods 
of not more than 3 years.
  (e) Applications.--To be eligible to receive a grant under 
this section, a certified home care provider shall submit an 
application to the Secretary at such time, in such manner, and 
containing such information as the Secretary may require.
  (f) Use of Funds.--A provider that receives a grant under 
this section shall use the funds made available through the 
grant to carry out objectives that include--
          (1) improving access to care for home care patients 
        served by home health care agencies, improving the 
        quality of that care, increasing patient satisfaction 
        with that care, and reducing the cost of that care 
        through direct telecommunications links that connect 
        the provider with information networks;
          (2) developing effective care management practices 
        and educational curricula to train home care registered 
        nurses and increase their general level of competency 
        through that training; and
          (3) developing curricula to train health care 
        professionals, particularly registered nurses, serving 
        home care agencies in the use of telecommunications.
  (g) Coverage.--Nothing in this section shall be construed to 
supersede or modify the provisions relating to exclusion of 
coverage under section 1862(a) of the Social Security Act (42 
U.S.C 1395y(a)), or the provisions relating to the amount 
payable to a home health agency under section 1895 of that Act 
(42 U.S.C. 1395fff).
  (h) Report.--
          (1) Interim report.--The Secretary shall submit to 
        Congress an interim report describing the results of 
        the demonstration project.
          (2) Final report.--Not later than 6 months after the 
        end of the last grant period for a grant made under 
        this section, the Secretary shall submit to Congress a 
        final report--
                  (A) describing the results of the 
                demonstration project; and
                  (B) including an evaluation of the impact of 
                the use of telehomecare, including telemedicine 
                and telecommunications, on--
                          (i) access to care for home care 
                        patients; and
                          (ii) the quality of, patient 
                        satisfaction with, and the cost of, 
                        that care.
  (i) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out this section such sums as may be 
necessary for each of fiscal years 2002 through 2006.

SEC. 330K. RURAL EMERGENCY MEDICAL SERVICE TRAINING AND EQUIPMENT 
                    ASSISTANCE PROGRAM.

  (a) Grants.--The Secretary, acting through the Administrator 
of the Health Resources and Services Administration (referred 
to in this section as the ``Secretary'') shall award grants to 
eligible entities to enable such entities to provide for 
improved emergency medical services in rural areas.
  (b) Eligibility.--To be eligible to receive a grant under 
this section, an entity shall--
          (1) be--
                  (A) a State emergency medical services 
                office;
                  (B) a State emergency medical services 
                association;
                  (C) a State office of rural health;
                  (D) a local government entity;
                  (E) a State or local ambulance provider; or
                  (F) any other entity determined appropriate 
                by the Secretary; and
          (2) prepare and submit to the Secretary an 
        application at such time, in such manner, and 
        containing such information as the Secretary may 
        require, that includes--
                  (A) a description of the activities to be 
                carried out under the grant; and
                  (B) an assurance that the eligible entity 
                will comply with the matching requirement of 
                subsection (e).
  (c) Use of Funds.--An entity shall use amounts received under 
a grant made under subsection (a), either directly or through 
grants to emergency medical service squads that are located in, 
or that serve residents of, a nonmetropolitan statistical area, 
an area designated as a rural area by any law or regulation of 
a State, or a rural census tract of a metropolitan statistical 
area (as determined under the most recent Goldsmith 
Modification, originally published in a notice of availability 
of funds in the Federal Register on February 27, 1992, 57 Fed. 
Reg. 6725), to--
          (1) recruit emergency medical service personnel;
          (2) recruit volunteer emergency medical service 
        personnel;
          (3) train emergency medical service personnel in 
        emergency response, injury prevention, safety 
        awareness, and other topics relevant to the delivery of 
        emergency medical services;
          (4) fund specific training to meet Federal or State 
        certification requirements;
          (5) develop new ways to educate emergency health care 
        providers through the use of technology-enhanced 
        educational methods (such as distance learning);
          (6) acquire emergency medical services equipment, 
        including cardiac defibrillators;
          (7) acquire personal protective equipment for 
        emergency medical services personnel as required by the 
        Occupational Safety and Health Administration; and
          (8) educate the public concerning cardiopulmonary 
        resuscitation, first aid, injury prevention, safety 
        awareness, illness prevention, and other related 
        emergency preparedness topics.
  (d) Preference.--In awarding grants under this section the 
Secretary shall give preference to--
          (1) applications that reflect a collaborative effort 
        by 2 or more of the entities described in subparagraphs 
        (A) through (F) of subsection (b)(1); and
          (2) applications submitted by entities that intend to 
        use amounts provided under the grant to fund activities 
        described in any of paragraphs (1) through (5) of 
        subsection (c).
  (e) Matching Requirement.--The Secretary may not award a 
grant under this section to an entity unless the entity agrees 
that the entity will make available (directly or through 
contributions from other public or private entities) non-
Federal contributions toward the activities to be carried out 
under the grant in an amount equal to 25 percent of the amount 
received under the grant.
  (f) Emergency Medical Services.--In this section, the term 
``emergency medical services''--
          (1) means resources used by a qualified public or 
        private nonprofit entity, or by any other entity 
        recognized as qualified by the State involved, to 
        deliver medical care outside of a medical facility 
        under emergency conditions that occur--
                  (A) as a result of the condition of the 
                patient; or
                  (B) as a result of a natural disaster or 
                similar situation; and
          (2) includes services delivered by an emergency 
        medical services provider (either compensated or 
        volunteer) or other provider recognized by the State 
        involved that is licensed or certified by the State as 
        an emergency medical technician or its equivalent (as 
        determined by the State), a registered nurse, a 
        physician assistant, or a physician that provides 
        services similar to services provided by such an 
        emergency medical services provider.
  (g) Authorization of Appropriations.--
          (1) In general.--There are authorized to be 
        appropriated to carry out this section such sums as may 
        be necessary for each of fiscal years 2002 through 
        2006.
          (2) Administrative costs.--The Secretary may use not 
        more than 10 percent of the amount appropriated under 
        paragraph (1) for a fiscal year for the administrative 
        expenses of carrying out this section.

SEC. 330L. MENTAL HEALTH SERVICES DELIVERED VIA TELEHEALTH.

  (a) Definitions.--In this section:
          (1) Eligible entity.--The term ``eligible entity'' 
        means a public or nonprofit private telehealth provider 
        network that offers services that include mental health 
        services provided by qualified mental health providers.
          (2) Qualified mental health education 
        professionals.--The term ``qualified mental health 
        education professionals'' refers to teachers, community 
        mental health professionals, nurses, and other entities 
        as determined by the Secretary who have additional 
        training in the delivery of information on mental 
        illness to children and adolescents or who have 
        additional training in the delivery of information on 
        mental illness to the elderly.
          (3) Qualified mental health professionals.--The term 
        ``qualified mental health professionals'' refers to 
        providers of mental health services reimbursed under 
        the medicare program carried out under title XVIII of 
        the Social Security Act (42 U.S.C. 1395 et seq.) who 
        have additional training in the treatment of mental 
        illness in children and adolescents or who have 
        additional training in the treatment of mental illness 
        in the elderly.
          (4) Special populations.--The term ``special 
        populations'' refers to the following 2 distinct 
        groups:
                  (A) Children and adolescents located in 
                public elementary and public secondary schools 
                in mental health underserved rural areas or in 
                mental health underserved urban areas.
                  (B) Elderly individuals located in long-term 
                care facilities in mental health underserved 
                rural areas.
          (5) Telehealth.--The term ``telehealth'' means the 
        use of electronic information and telecommunications 
        technologies to support long distance clinical health 
        care, patient and professional health-related 
        education, public health, and health administration.
  (b) Program Authorized.--
          (1) In general.--The Secretary, acting through the 
        Director of the Office for the Advancement of 
        Telehealth of the Health Resources and Services 
        Administration, shall award grants to eligible entities 
        to establish demonstration projects for the provision 
        of mental health services to special populations as 
        delivered remotely by qualified mental health 
        professionals using telehealth and for the provision of 
        education regarding mental illness as delivered 
        remotely by qualified mental health professionals and 
        qualified mental health education professionals using 
        telehealth.
          (2) Populations served.--The Secretary shall award 
        the grants under paragraph (1) in a manner that 
        distributes the grants so as to serve equitably the 
        populations described in subparagraphs (A) and (B) of 
        subsection (a)(4).
  (c) Amount.--Each entity that receives a grant under 
subsection (b) shall receive not less than $1,200,000 under the 
grant, and shall use not more than 40 percent of the grant 
funds for equipment.
  (d) Use of Funds.--
          (1) In general.--An eligible entity that receives a 
        grant under this section shall use the grant funds--
                  (A) for the populations described in 
                subsection (a)(4)(A)--
                          (i) to provide mental health 
                        services, including diagnosis and 
                        treatment of mental illness, in public 
                        elementary and public secondary schools 
                        as delivered remotely by qualified 
                        mental health professionals using 
                        telehealth;
                          (ii) to provide education regarding 
                        mental illness (including suicide and 
                        violence) in public elementary and 
                        public secondary schools as delivered 
                        remotely by qualified mental health 
                        professionals and qualified mental 
                        health education professionals using 
                        telehealth, including education 
                        regarding early recognition of the 
                        signs and symptoms of mental illness, 
                        and instruction on coping and dealing 
                        with stressful experiences of childhood 
                        and adolescence (such as violence, 
                        social isolation, and depression); and
                          (iii) to collaborate with local 
                        public health entities to provide the 
                        mental health services; and
                  (B) for the populations described in 
                subsection (a)(4)(B)--
                          (i) to provide mental health 
                        services, including diagnosis and 
                        treatment of mental illness, in long-
                        term care facilities as delivered 
                        remotely by qualified mental health 
                        professionals using telehealth;
                          (ii) to provide education regarding 
                        mental illness to primary staff 
                        (including physicians, nurses, and 
                        nursing aides) as delivered remotely by 
                        qualified mental health professionals 
                        and qualified mental health education 
                        professionals using telehealth, 
                        including education regarding early 
                        recognition of the signs and symptoms 
                        of mental illness, and instruction on 
                        coping and dealing with stressful 
                        experiences of old age (such as loss of 
                        physical and cognitive capabilities, 
                        death of loved ones and friends, social 
                        isolation, and depression); and
                          (iii) to collaborate with local 
                        public health entities to provide the 
                        mental health services.
          (2) Other uses.--An eligible entity that receives a 
        grant under this section may also use the grant funds 
        to--
                  (A) acquire telehealth equipment to use in 
                public elementary and public secondary schools 
                and long-term care facilities for the 
                objectives of this section;
                  (B) develop curricula to support activities 
                described in subparagraphs (A)(ii) and (B)(ii) 
                of paragraph (1);
                  (C) pay telecommunications costs; and
                  (D) pay qualified mental health professionals 
                and qualified mental health education 
                professionals on a reasonable cost basis as 
                determined by the Secretary for services 
                rendered.
          (3) Prohibited uses.--An eligible entity that 
        receives a grant under this section shall not use the 
        grant funds to--
                  (A) purchase or install transmission 
                equipment (other than such equipment used by 
                qualified mental health professionals to 
                deliver mental health services using telehealth 
                under the project involved); or
                  (B) build upon or acquire real property 
                (except for minor renovations related to the 
                installation of reimbursable equipment).
  (e) Equitable Distribution.--In awarding grants under this 
section, the Secretary shall ensure, to the greatest extent 
possible, that such grants are equitably distributed among 
geographical regions of the United States.
  (f) Application.--An entity that desires a grant under this 
section shall submit an application to the Secretary at such 
time, in such manner, and containing such information as the 
Secretary determines to be reasonable.
  (g) Report.--Not later than 4 years after the date of 
enactment of the Health Care Safety Net Amendments of 2001, the 
Secretary shall prepare and submit to the appropriate 
committees of Congress a report that shall evaluate activities 
funded with grants under this section.
  (h) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out this section, $20,000,000 for 
fiscal year 2002 and such sums as may be necessary for fiscal 
years 2003 through 2006.

SEC. 330M. SCHOOL-BASED HEALTH CENTER NETWORKS.

  (a) Eligible Entity.--In this section, the term ``eligible 
entity'' means a nonprofit organization, such as a State 
school-based health center association, academic institution, 
or primary care association, that has experience working with 
low-income communities, schools, families, and school-based 
health centers.
  (b) Program Authorized.--The Secretary shall award grants to 
eligible entities to establish statewide technical assistance 
centers and carry out activities described in subsection (c) 
through the centers.
  (c) Use of Funds.--An eligible entity that receives a grant 
under this section may use funds received through such grant 
to--
          (1) establish a statewide technical assistance center 
        that shall coordinate local, State, and Federal health 
        care services, including primary, dental, and 
        behavioral and mental health services, that contribute 
        to the delivery of school-based health care for 
        medically underserved individuals;
          (2) conduct operational and administrative support 
        activities for statewide school-based health center 
        networks to maximize operational effectiveness and 
        efficiency;
          (3) provide technical support training, including 
        training on topics regarding--
                  (A) identifying parent and community 
                interests and priorities;
                  (B) assessing community health needs and 
                resources;
                  (C) implementing accountability and 
                management information systems;
                  (D) integrating school-based health centers 
                with care provided by any other school-linked 
                provider, and with community-based primary and 
                specialty health care systems;
                  (E) securing third party payments through 
                effective billing and collection systems;
                  (F) developing shared services and joint 
                purchasing arrangements across provider 
                networks;
                  (G) linking services with health care 
                services provided by other programs, especially 
                services provided under the medicaid program 
                under title XIX of the Social Security Act (42 
                U.S.C. 1396 et seq.) and the State Children's 
                Health Insurance Program under title XXI of the 
                Social Security Act (42 U.S.C. 1397aa et seq.);
                  (H) contracting with managed care 
                organizations; and
                  (I) assuring and improving clinical quality 
                and improvement; and
          (4) provide to interested communities technical 
        assistance for the planning and implementation of 
        school-based health centers.
  (d) Application.--An eligible entity desiring a grant under 
this section shall submit an application to the Secretary at 
such time, in such manner, and containing such information as 
the Secretary may reasonably require, including--
          (1) a description of the region that will receive 
        service and the potential partners in such region;
          (2) a description of the policy and program 
        environment and the needs of the community that will 
        receive service;
          (3) a 1- to 3-year work plan that describes the goals 
        and objectives of the entity, and any activities that 
        the entity proposes to carry out; and
          (4) a description of the organizational capacity of 
        the entity and its experience in serving the region's 
        school-based health center community.
  (e) Authorization of Appropriations.--There is authorized to 
be appropriated to carry out this section, $5,000,000 for 
fiscal year 2002, and such sums as may be necessary for 
subsequent fiscal years.

           *       *       *       *       *       *       *


             Subpart V--Healthy Communities Access Program

SEC. 340. GRANTS TO STRENGTHEN THE EFFECTIVENESS, EFFICIENCY, AND 
                    COORDINATION OF SERVICES FOR THE UNINSURED AND 
                    UNDERINSURED.

  (a) In General.--The Secretary may award grants to eligible 
entities to assist in the development of integrated health care 
delivery systems to serve communities of individuals who are 
uninsured and individuals who are underinsured--
          (1) to improve the efficiency of, and coordination 
        among, the providers providing services through such 
        systems;
          (2) to assist communities in developing programs 
        targeted toward preventing and managing chronic 
        diseases; and
          (3) to expand and enhance the services provided 
        through such systems.
  (b) Eligible Entities.--To be eligible to receive a grant 
under this section, an entity shall be a public or nonprofit 
entity that--
          (1) represents a consortium--
                  (A) whose principal purpose is to provide a 
                broad range of coordinated health care services 
                for a community defined in the entity's grant 
                application as described in paragraph (2); and
                  (B) that includes a provider (unless such 
                provider does not exist within the community, 
                declines or refuses to participate, or places 
                unreasonable conditions on their participation) 
                that--
                          (i) serves the community; and
                          (ii)(I) is a Federally qualified 
                        health center (as defined in section 
                        1861(aa) of the Social Security Act (42 
                        U.S.C. 1395x(aa)));
                          (II) is a hospital with a low-income 
                        utilization rate (as defined in section 
                        1923(b)(3) of the Social Security Act 
                        (42 U.S.C. 1396r-4(b)(3)), that is 
                        greater than 25 percent;
                          (III) is a public health department; 
                        and
                          (IV) is an interested public or 
                        private sector health care provider or 
                        an organization that has traditionally 
                        served the medically uninsured and 
                        underserved;
          (2) submits to the Secretary an application, in such 
        form and manner as the Secretary shall prescribe, 
        that--
                  (A) defines a community of uninsured and 
                underinsured individuals that consists of all 
                such individuals--
                          (i) in a specified geographical area, 
                        such as a rural area; or
                          (ii) in a specified population within 
                        such an area, such as American Indians, 
                        Native Alaskans, Native Hawaiians, 
                        Hispanics, homeless individuals, 
                        migrant and seasonal farmworkers, 
                        individuals with disabilities, and 
                        public housing residents;
                  (B) identifies the providers who will 
                participate in the consortium's program under 
                the grant, and specifies each provider's 
                contribution to the care of uninsured and 
                underinsured individuals in the community, 
                including the volume of care the provider 
                provides to beneficiaries under the medicare, 
                medicaid, and State child health insurance 
                programs carried out under titles XVIII, XIX, 
                and XXI of the Social Security Act (42 U.S.C. 
                1395 et seq., 1396 et seq., and 1397aa et seq.) 
                and to patients who pay privately for services;
                  (C) describes the activities that the 
                applicant and the consortium propose to perform 
                under the grant to further the objectives of 
                this section;
                  (D) demonstrates the consortium's ability to 
                build on the current system (as of the date of 
                submission of the application) for serving a 
                community of uninsured and underinsured 
                individuals by involving providers who have 
                traditionally provided a significant volume of 
                care for that community;
                  (E) demonstrates the consortium's ability to 
                develop coordinated systems of care that either 
                directly provide or ensure the prompt provision 
                of a broad range of high-quality, accessible 
                services, including, as appropriate, primary, 
                secondary, and tertiary services, as well as 
                substance abuse treatment and mental health 
                services in a manner that assures continuity of 
                care in the community;
                  (F) demonstrates the consortium's ability to 
                create comprehensive programs to address the 
                prevention and management of chronic diseases 
                of high importance within the community, where 
                applicable;
                  (G) provides evidence of community 
                involvement in the development, implementation, 
                and direction of the program that the entity 
                proposes to operate;
                  (H) demonstrates the consortium's ability to 
                ensure that individuals participating in the 
                program are enrolled in public insurance 
                programs for which the individuals are 
                eligible;
                  (I) presents a plan for leveraging other 
                sources of revenue, which may include State and 
                local sources and private grant funds, and 
                integrating current and proposed new funding 
                sources in a way to assure long-term 
                sustainability of the program;
                  (J) describes a plan for evaluation of the 
                activities carried out under the grant, 
                including measurement of progress toward the 
                goals and objectives of the program and the use 
                of evaluation findings to improve program 
                performance;
                  (K) demonstrates fiscal responsibility 
                through the use of appropriate accounting 
                procedures and appropriate management systems;
                  (L) demonstrates the consortium's commitment 
                to serve the community without regard to the 
                ability of an individual or family to pay by 
                arranging for or providing free or reduced 
                charge care for the poor; and
                  (M) includes such other information as the 
                Secretary may prescribe;
          (3) agrees along with each of the participating 
        providers identified under paragraph (2)(B) that each 
        will commit to use grant funds awarded under this 
        section to supplement, not supplant, any other sources 
        of funding (including the value of any in-kind 
        contributions) available to cover the expenditures of 
        the consortium and of the participating providers in 
        carrying out the activities for which the grant would 
        be awarded; and
          (4) has established or will establish before the 
        receipt of any grant under this section, a decision-
        making body that has full and complete authority to 
        determine and oversee all the activities undertaken by 
        the consortium with funds made available through such 
        grant and that includes representation from each of the 
        following providers listed in (b)(1)(B) if they 
        participate in the consortium.
  (c) Priorities.--In awarding grants under this section, the 
Secretary--
          (1) shall accord priority to applicants that 
        demonstrate the extent of unmet need in the community 
        involved for a more coordinated system of care; and
          (2) may accord priority to applicants that best 
        promote the objectives of this section, taking into 
        consideration the extent to which the application 
        involved--
                  (A) identifies a community whose geographical 
                area has a high or increasing percentage of 
                individuals who are uninsured;
                  (B) demonstrates that the applicant has 
                included in its consortium providers, support 
                systems, and programs that have a tradition of 
                serving uninsured individuals and underinsured 
                individuals in the community;
                  (C) shows evidence that the program would 
                expand utilization of preventive and primary 
                care services for uninsured and underinsured 
                individuals and families in the community, 
                including behavioral and mental health 
                services, oral health services, or substance 
                abuse services;
                  (D) proposes a program that would improve 
                coordination between health care providers and 
                appropriate social service providers, including 
                local and regional human services agencies, 
                school systems, and agencies on aging;
                  (E) demonstrates collaboration with State and 
                local governments;
                  (F) demonstrates that the applicant makes use 
                of non-Federal contributions to the greatest 
                extent possible; or
                  (G) demonstrates a likelihood that the 
                proposed program will continue after support 
                under this section ceases.
  (d) Use of Funds.--
          (1) Use by grantees.--
                  (A) In general.--Except as provided in 
                paragraphs (2) and (3), a grantee may use 
                amounts provided under this section only for--
                          (i) direct expenses associated with 
                        planning and developing the greater 
                        integration of a health care delivery 
                        system, and operating the resulting 
                        system, so that the system either 
                        directly provides or ensures the 
                        provision of a broad range of 
                        culturally competent services, as 
                        appropriate, including primary, 
                        secondary, and tertiary services, as 
                        well as substance abuse treatment and 
                        mental health services; and
                          (ii) direct patient care and service 
                        expansions to fill identified or 
                        documented gaps within an integrated 
                        delivery system.
                  (B) Specific uses.--The following are 
                examples of purposes for which a grantee may 
                use grant funds under this section, when such 
                use meets the conditions stated in subparagraph 
                (A):
                          (i) Increases in outreach activities.
                          (ii) Improvements to case management.
                          (iii) Improvements to coordination of 
                        transportation to health care 
                        facilities.
                          (iv) Development of provider networks 
                        and other innovative models to engage 
                        physicians in voluntary efforts to 
                        serve the medically underserved within 
                        a community.
                          (v) Recruitment, training, and 
                        compensation of necessary personnel.
                          (vi) Acquisition of technology, such 
                        as telehealth technologies to increase 
                        access to tertiary care.
                          (vii) Identifying and closing gaps in 
                        health care services being provided.
                          (viii) Improvements to provider 
                        communication, including implementation 
                        of shared information systems or shared 
                        clinical systems.
                          (ix) Development of common processes 
                        for determining eligibility for the 
                        programs provided through the system, 
                        including creating common 
                        identification cards and single sliding 
                        scale discounts.
                          (x) Creation of a triage system to 
                        coordinate referrals and to screen and 
                        route individuals to appropriate 
                        locations of primary, specialty, and 
                        inpatient care.
                          (xi) Development of specific 
                        prevention and disease management tools 
                        and processes, including--
                                  (I) carrying out a protocol 
                                or plan for each individual 
                                patient concerning what needs 
                                to be done, at what intervals, 
                                and by whom, for the patient;
                                  (II) redesigning practices to 
                                incorporate regular patient 
                                contact, collection of critical 
                                data on health and disease 
                                status, and use of strategies 
                                to meet the educational and 
                                psychosocial needs of patients 
                                who may need to make lifestyle 
                                and other changes to manage 
                                their diseases;
                                  (III) the promotion of the 
                                availability of specialized 
                                expertise through the use of--
                                          (aa) teams of 
                                        providers with 
                                        specialized knowledge;
                                          (bb) collaborative 
                                        care arrangements;
                                          (cc) computer 
                                        decision support 
                                        services; or
                                          (dd) telehealth 
                                        technologies.
                                  (IV) providing patient 
                                educational and support tools 
                                that are culturally competent 
                                and meet appropriate health 
                                literacy and literacy 
                                requirements; and
                                  (V) the collection of data 
                                related to patient care and 
                                outcomes.
                          (xii) Translation services.
                          (xiii) Carrying out other activities 
                        that may be appropriate to a community 
                        and that would increase access by the 
                        uninsured to health care, such as 
                        access initiatives for which private 
                        entities provide non-Federal 
                        contributions to supplement the Federal 
                        funds provided through the grants for 
                        the initiatives.
          (2) Direct patient care limitation.--Not more than 15 
        percent of the funds provided under a grant awarded 
        under this section may be used for providing direct 
        patient care and services.
          (3) Reservation of funds for national program 
        purposes.--The Secretary may use not more than 3 
        percent of funds appropriated to carry out this section 
        for providing technical assistance to grantees, 
        obtaining assistance of experts and consultants, 
        holding meetings, development of tools, dissemination 
        of information, evaluation, and carrying out activities 
        that will extend the benefits of a program funded under 
        this section to communities other than the community 
        served by the program funded.
  (e) Grantee Requirements.--
          (1) In general.--A grantee under this section shall--
                  (A) report to the Secretary annually 
                regarding--
                          (i) progress in meeting the goals and 
                        measurable objectives set forth in the 
                        grant application submitted by the 
                        grantee under subsection (b); and
                          (ii) such additional information as 
                        the Secretary may require; and
                  (B) provide for an independent annual 
                financial audit of all records that relate to 
                the disposition of funds received through the 
                grant.
          (2) Progress.--The Secretary may not renew an annual 
        grant under this section for an entity for a fiscal 
        year unless the Secretary is satisfied that the 
        consortium represented by the entity has made 
        reasonable and demonstrable progress in meeting the 
        goals and measurable objectives set forth in the 
        entity's grant application for the preceding fiscal 
        year.
  (f) Technical Assistance.--The Secretary may, either directly 
or by grant or contract, provide any entity that receives a 
grant under this section with technical and other nonfinancial 
assistance necessary to meet the requirements of this section.
  (g) Report.--Not later than September 30, 2005, the Secretary 
shall prepare and submit to the appropriate committees of 
Congress a report on the progress and accomplishments of the 
grant programs described in this section.
  (h) Demonstration Authority.--The Secretary may make 
demonstration awards under this section to historically black 
medical schools for the purposes of--
          (1) developing patient-based research infrastructure 
        at historically black medical schools, which have an 
        affiliation, or affiliations, with any of the providers 
        identified in section (b)(1)(B);
          (2) establishment of joint and collaborative programs 
        of medical research and data collection between 
        historically black medical schools and such providers, 
        whose goal is to improve the health status of medically 
        underserved populations; or
          (3) supporting the research-related costs of patient 
        care, data collection, and academic training resulting 
        from such affiliations.
  (i) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out this section $125,000,000 for 
fiscal year 2002 and such sums as may be necessary for each of 
fiscal years 2003 through 2006.

           *       *       *       *       *       *       *


                   Subpart X--Primary Dental Programs

SEC. 340F. DESIGNATED DENTAL HEALTH PROFESSIONAL SHORTAGE AREA.

  In this subpart, the term ``designated dental health 
professional shortage area'' means an area, population group, 
or facility that is designated by the Secretary as a dental 
health professional shortage area under section 332 or 
designated by the applicable State as having a dental health 
professional shortage.

SEC. 340G. GRANTS FOR INNOVATIVE PROGRAMS.

  (a) Grant Program Authorized.--The Secretary, acting through 
the Administrator of the Health Resources and Services 
Administration, is authorized to award grants to States for the 
purpose of helping States develop and implement innovative 
programs to address the dental workforce needs of designated 
dental health professional shortage areas in a manner that is 
appropriate to the States' individual needs.
  (b) State Activities.--A State receiving a grant under 
subsection (a) may use funds received under the grant for--
          (1) loan forgiveness and repayment programs for 
        dentists who--
                  (A) agree to practice in designated dental 
                health professional shortage areas;
                  (B) are dental school graduates who agree to 
                serve as public health dentists for the 
                Federal, State, or local government; and
                  (C) agree to--
                          (i) provide services to patients 
                        regardless of such patients' ability to 
                        pay; and
                          (ii) use a sliding payment scale for 
                        patients who are unable to pay the 
                        total cost of services;
          (2) dental recruitment and retention efforts;
          (3) grants and low-interest or no-interest loans to 
        help dentists who participate in the medicaid program 
        under title XIX of the Social Security Act (42 U.S.C. 
        1396 et seq.) to establish or expand practices in 
        designated dental health professional shortage areas by 
        equipping dental offices or sharing in the overhead 
        costs of such practices;
          (4) the establishment or expansion of dental 
        residency programs in coordination with accredited 
        dental training institutions in States without dental 
        schools;
          (5) programs developed in consultation with State and 
        local dental societies to expand or establish oral 
        health services and facilities in designated dental 
        health professional shortage areas, including services 
        and facilities for children with special needs, such 
        as--
                  (A) the expansion or establishment of a 
                community-based dental facility, free-standing 
                dental clinic, consolidated health center 
                dental facility, school-linked dental facility, 
                or United States dental school-based facility;
                  (B) the establishment of a mobile or portable 
                dental clinic; and
                  (C) the establishment or expansion of private 
                dental services to enhance capacity through 
                additional equipment or additional hours of 
                operation;
          (6) placement and support of dental students, dental 
        residents, and advanced dentistry trainees;
          (7) continuing dental education, including distance-
        based education;
          (8) practice support through teledentistry conducted 
        in accordance with State laws;
          (9) community-based prevention services such as water 
        fluoridation and dental sealant programs;
          (10) coordination with local educational agencies 
        within the State to foster programs that promote 
        children going into oral health or science professions;
          (11) the establishment of faculty recruitment 
        programs at accredited dental training institutions 
        whose mission includes community outreach and service 
        and that have a demonstrated record of serving 
        underserved States;
          (12) the development of a State dental officer 
        position or the augmentation of a State dental office 
        to coordinate oral health and access issues in the 
        State; and
          (13) any other activities determined to be 
        appropriate by the Secretary.
  (c) Application.--
          (1) In general.--Each State desiring a grant under 
        this section shall submit an application to the 
        Secretary at such time, in such manner, and containing 
        such information as the Secretary may reasonably 
        require.
          (2) Assurances.--The application shall include 
        assurances that the State will meet the requirements of 
        subsection (d) and that the State possesses sufficient 
        infrastructure to manage the activities to be funded 
        through the grant and to evaluate and report on the 
        outcomes resulting from such activities.
  (d) Matching Requirement.--The Secretary may not make a grant 
to a State under this section unless that State agrees that, 
with respect to the costs to be incurred by the State in 
carrying out the activities for which the grant was awarded, 
the State will provide non-Federal contributions in an amount 
equal to not less than 40 percent of Federal funds provided 
under the grant. The State may provide the contributions in 
cash or in kind, fairly evaluated, including plant, equipment, 
and services and may provide the contributions from State, 
local, or private sources.
  (e) Report.--Not later than 5 years after the date of 
enactment of the Health Care Safety Net Amendments of 2001, the 
Secretary shall prepare and submit to the appropriate 
committees of Congress a report containing data relating to 
whether grants provided under this section have increased 
access to dental services in designated dental health 
professional shortage areas.
  (f) Authorization of Appropriations.--There is authorized to 
be appropriated to carry out this section, $50,000,000 for the 
5-fiscal year period beginning with fiscal year 2002.

           *       *       *       *       *       *       *


SEC. 1320A-7B. CRIMINAL PENALTIES FOR ACTS INVOLVING FEDERAL HEALTH 
                    CARE PROGRAMS.

           *       *       *       *       *       *       *


    (b) Illegal Remunerations.--
          (1) * * *

           *       *       *       *       *       *       *

          (3) Paragraphs (1) and (2) shall not apply to--
                  (A) * * *
                  (D) a waiver of any coinsurance under part B 
                of subchapter XVIII of this chapter by [a 
                Federally qualified health care center] a rural 
                health clinic (as defined in section 1861(aa)) 
                to which members of the National Health Service 
                Corps are assigned under section 333 of the 
                Public Health Service Act, or a Federally 
                qualified health center (as defined in section 
                1861(aa)) with respect to an individual who 
                qualifies for subsidized services under a 
                provision of the Public Health Service Act;

           *       *       *       *       *       *       *


          defense of certain malpractice and negligence suits

    Sec. 224. (a) * * *

           *       *       *       *       *       *       *

                (G) * * *
                          (i) * * *
                          (ii) This section does not affect any 
                        authority of the entity to purchase 
                        medical malpractice liability insurance 
                        coverage with Federal funds provided to 
                        the entity under section 329, 330, 
                        [340] 330(h), or 340A.

           *       *       *       *       *       *       *

    (k)(1)(A) * * *

           *       *       *       *       *       *       *

    (2) Subject to appropriations, for each fiscal year, the 
Secretary shall establish a fund of an amount equal to the 
amount estimated under paragraph (1) that is attributable to 
entities receiving funds under each of the grant programs 
described in paragraph (4) of subsection (g), but not to exceed 
a total of $10,000,000 for each such fiscal year. 
Appropriations for purposes of this paragraph shall be made 
separate from appropriations made for purposes of sections 329, 
330, [340] 330(h), and 340A.

           *       *       *       *       *       *       *

    (n)(1) Not later than one year after the date of the 
enactment of the Federally Supported Health Centers Assistance 
Act of 1995, the Comptroller General of the United States shall 
submit to the Congress a report on the following:
          (A) * * *

           *       *       *       *       *       *       *

          (C) The value of private sector risk-management 
        services, and the value of risk-management services and 
        procedures required as a condition of receiving a grant 
        under section 329, 330, [340] 330(h), or 340A.

           *       *       *       *       *       *       *


     screenings, referrals, and education regarding lead poisoning

    Sec. 317A. (a) Authority for Grants.--
          (1) In general.-- * * *

           *       *       *       *       *       *       *

          (2) Authority regarding certain entities.--With 
        respect to a geographic area with a need for activities 
        authorized in paragraph (1), in any case in which 
        neither the State nor the political subdivision in 
        which such area is located has applied for a grant 
        under paragraph (1), the Secretary may make a grant 
        under such paragraph to any grantee under section 329, 
        330, [340] 330(h), or 340A for carrying out such 
        activities in the area.

           *       *       *       *       *       *       *


           preventive health services regarding tuberculosis

    Sec. 317E. (a) In General.-- * * *

           *       *       *       *       *       *       *

    (c) Cooperation With Providers of Primary Health 
Services.--The Secretary may make a grant under subsection (a) 
of (b) only if the applicant for the grant agrees that, in 
carrying out activities under the grant, the applicant will 
cooperate with public and nonprofit private providers of 
primary health services or substance abuse services, including 
entities receiving assistance under section 329, 330, [340] 
330(h), or 340A or under title V or XIX.

           *       *       *       *       *       *       *


             infertility and sexually transmitted diseases

    Sec. 318A. (a) In General.-- * * *

           *       *       *       *       *       *       *

    (e) Required Providers Regarding Certain Services.--The 
Secretary may make a grant under subsection (a) only if the 
applicant involved agrees that, in expending the grant to carry 
out activities authorized in subsection (c), the services 
described in paragraphs (1) through (7) of such subsection will 
be provided only through entities that are State or local 
health departments, grantees under section 329, 330, [340] 
330(h), 340A, or 1001, or are other public or nonprofit private 
entities that provide health services to a significant number 
of low-income women.

           *       *       *       *       *       *       *


           designation of health professional shortage areas

    Sec. 332. (a)(1) * * *
    (2) * * *

           *       *       *       *       *       *       *

          (C) such a facility used in connection with the 
        delivery of health services under section 321 (relating 
        to hospitals), 322 (relating to care and treatment of 
        persons under quarantine and others), 323 (relating to 
        care and treatment of Federal prisoners), 324 (relating 
        to examination and treatment of certain Federal 
        employees), 325 (relating to examination of aliens), 
        326 (relating to services to certain Federal 
        employees), 320 (relating to services for persons with 
        Hansen's disease), or [340] 330(h) (relating to the 
        provision of health services to homeless individuals); 
        and

           *       *       *       *       *       *       *


                 breast and cervical cancer information

    Sec. 340D. (a) In General.-- * * *

           *       *       *       *       *       *       *

    (c) Relevant Entities.--The entities specified in this 
subsection are the following:

           *       *       *       *       *       *       *

            (5) Entities receiving assistance under section 
        [340] 330(h) (relating to homeless individuals).

           *       *       *       *       *       *       *


SEC. 799B. DEFINITIONS.

    For purposes of this title:
          (1)(A) * * *

           *       *       *       *       *       *       *

          (6) The term ``medically underserved community'' 
        means an urban or rural area or population that--

           *       *       *       *       *       *       *

                  (B) is eligible to be served by a migrant 
                health center under section 329, a community 
                health center under section 330, a grantee 
                under section [340] 330(h) (relating to 
                homeless individuals), or a grantee under 
                section 340A (relating to residents of public 
                housing);

           *       *       *       *       *       *       *


  limitation on source of funding for health maintenance organizations

    Sec. 1313. No funds appropriated under any provision of 
this Act (except as provided in sections 329, 330, and [340] 
330(h) other than this title may be used--

           *       *       *       *       *       *       *


SEC. 2652. MINIMUM QUALIFICATIONS OF GRANTEES.

    (a) In General.--The entities referred to in section 
2651(a) are public entities and nonprofit private entities that 
are--

           *       *       *       *       *       *       *

          (2) grantees under section [340] 330(h) (regarding 
        health services for the homeless);

           *       *       *       *       *       *       *


SEC. 534. DEFINITIONS.

    For purposes of this part:
          (1) Eligible homeless individual.-- * * *
          (2) Homeless individual.--The term ``homeless 
        individual'' has the meaning given such term in section 
        [340(r)] 330(h)(5).

           *       *       *       *       *       *       *


                     national health service corps

    Sec. 331. (a)(1) * * *

           *       *       *       *       *       *       *

    (3) * * *
          (A) * * *

           *       *       *       *       *       *       *

          (E)(i) The term ``behavioral and mental health 
        professionals'' means health service psychologists, 
        licensed clinical social workers, licensed professional 
        counselors, marriage and family therapists, psychiatric 
        nurse specialists, and psychiatrists.
          (ii) The term ``graduate program of behavioral and 
        mental health'' means a program that trains behavioral 
        and mental health professionals.
    (b)(1) The Secretary may conduct at schools of medicine, 
osteopathic medicine, dentistry, and, as appropriate, nursing 
and other schools of the [health professions] health 
professions, including schools at which graduate programs of 
behavioral and mental health are offered, and at entities which 
train allied health personnel, recruiting programs for the 
Corps, the Scholarship Program, and the Loan Repayment Program. 
Such recruiting programs shall include efforts to recruit 
individuals who will serve in the Corps other than pursuant to 
obligated service under the Scholarship or Loan Repayment 
Program.
    (2) In the case of physicians, dentists, behavioral and 
mental health professionals, certified nurse midwives, 
certified nurse practitioners, and physician assistants who 
have an interest and a commitment to providing primary health 
care, the Secretary may establish fellowship programs to enable 
such health professionals to gain exposure to and expertise in 
the delivery of primary health services in health professional 
shortage areas. To the maximum extent practicable, the 
Secretary shall ensure that any such programs are established 
in conjunction with accredited residency programs, and other 
training programs, regarding such health professions.
    [(c) The Secretary may reimburse applicants for positions 
in the Corps (including individuals considering entering into a 
written agreement pursuant to section 338D) for actual and 
reasonable expenses incurred in traveling to and from their 
places of residence to a health professional shortage area 
(designated under section 332) in which they may be assigned 
for the purpose of evaluating such area with regard to being 
assigned in such area. The Secretary shall not reimburse an 
applicant for more than one such trip.]
  (c)(1) The Secretary may reimburse an applicant for a 
position in the Corps (including an individual considering 
entering into a written agreement pursuant to section 338D) for 
the actual and reasonable expenses incurred in traveling to and 
from the applicant's place of residence to an eligible site to 
which the applicant may be assigned under section 333 for the 
purpose of evaluating such site with regard to being assigned 
at such site. The Secretary may establish a maximum total 
amount that may be paid to an individual as reimbursement for 
such expenses.
  (2) The Secretary may also reimburse the applicant for the 
actual and reasonable expenses incurred for the travel of 1 
family member to accompany the applicant to such site. The 
Secretary may establish a maximum total amount that may be paid 
to an individual as reimbursement for such expenses.
  (3) In the case of an individual who has entered into a 
contract for obligated service under the Scholarship Program or 
under the Loan Repayment Program, the Secretary may reimburse 
such individual for all or part of the actual and reasonable 
expenses incurred in transporting the individual, the 
individual's family, and the family's possessions to the site 
of the individual's assignment under section 333. The Secretary 
may establish a maximum total amount that may be paid to an 
individual as reimbursement for such expenses.
  (i)(1) In carrying out subpart III, the Secretary may, in 
accordance with this subsection, carry out demonstration 
projects in which individuals who have entered into a contract 
for obligated service under the Loan Repayment Program receive 
waivers under which the individuals are authorized to satisfy 
the requirement of obligated service through providing clinical 
service that is not full-time.
  (2) A waiver described in paragraph (1) may be provided by 
the Secretary only if--
          (A) the entity for which the service is to be 
        performed--
                  (i) has been approved under section 333A for 
                assignment of a Corps member; and
                  (ii) has requested in writing assignment of a 
                health professional who would serve less than 
                full time;
          (B) the Secretary has determined that assignment of a 
        health professional who would serve less than full time 
        would be appropriate for the area where the entity is 
        located;
          (C) a Corps member who is required to perform 
        obligated service has agreed in writing to be assigned 
        for less than full-time service to an entity described 
        in subparagraph (A);
          (D) the entity and the Corps member agree in writing 
        that the less than full-time service provided by the 
        Corps member will not be less than 16 hours of clinical 
        service per week;
          (E) the Corps member agrees in writing that the 
        period of obligated service pursuant to section 338B 
        will be extended so that the aggregate amount of less 
        than full-time service performed will equal the amount 
        of service that would be performed through full-time 
        service under section 338C; and
          (F) the Corps member agrees in writing that if the 
        Corps member begins providing less than full-time 
        service but fails to begin or complete the period of 
        obligated service, the method stated in 338E(c) for 
        determining the damages for breach of the individual's 
        written contract will be used after converting periods 
        of obligated service or of service performed into their 
        full-time equivalents.
  (3) In evaluating a demonstration project described in 
paragraph (1), the Secretary shall examine the effect of 
multidisciplinary teams.

           DESIGNATION OF HEALTH PROFESSIONAL SHORTAGE AREAS

    Sec. 332. (a)(1) For purposes of this subpart the term 
``health professional shortage area'' means (A) an area in an 
urban or rural area (which need not conform to the geographic 
boundaries of a political subdivision and which is a rational 
area for the delivery of health services) which the Secretary 
determines has a health manpower shortage, (B) a population 
group which the Secretary determines has such a shortage, or 
(C) a public or nonprofit private medical facility or other 
public facility which the Secretary determines has such a 
shortage. All Federally qualified health centers and rural 
health clinics, as defined in section 1861(aa) of the Social 
Security Act (42 U.S.C. 1395x(aa)), that meet the requirements 
of section 334 shall be automatically designated, on the date 
of enactment of the Health Care Safety Net Amendments of 2001, 
as having such a shortage. Not later than 5 years after such 
date of enactment, and every 5 years thereafter, each such 
center or clinic shall demonstrate that the center or clinic 
meets the applicable requirements of the Federal regulations, 
issued after the date of enactment of this Act, that revise the 
definition of a health professional shortage area for purposes 
of this section. The Secretary shall not remove an area from 
the areas determined to be health professional shortage areas 
under subparagraph (A) of the preceding sentence until the 
Secretary has afforded interested persons and groups in such 
area an opportunity to provide data and information in support 
of the designation as a health professional shortage area or a 
population group described in subparagraph (B) of such sentence 
or a facility described in subparagraph (C) of such sentence, 
and has made a determination on the basis of the data and 
information submitted by such persons and groups and other data 
and information available to the Secretary.

           *       *       *       *       *       *       *

    (3) Homeless individuals (as defined in section [340(r)) 
may be a population group] 330(h)(4)), seasonal agricultural 
workers (as defined in section 330(g)(3)) and migratory 
agricultural workers (as so defined)), and residents of public 
housing (as defined in section 3(b)(1) of the United States 
Housing Act of 1937 (42 U.S.C. 1437a(b)(1))) may be population 
groups under paragraph (1).

           *       *       *       *       *       *       *

    (b) * * *
          (2) Indicators of a need, notwithstanding the supply 
        of health manpower, for health services for the 
        individuals in an area or population group or served by 
        a medical facility or other public facility under 
        consideration for designation.[, with special 
        consideration to indicators of--
                  [(A) infant mortality,
                  [(B) access to health services,
                  [(C) health status, and
                  [(D) ability to pay for health services.]

           *       *       *       *       *       *       *

    (c) * * *
          (2) The extent to which individuals who are (A) 
        residents of the area, members of the population group, 
        or patients in the medical facility or other public 
        facility under consideration for designation, and (B) 
        entitled to have payment made for medical services 
        under title [XVIII or XIX] XVIII, XIX, or XXI of the 
        Social Security Act, cannot obtain such services 
        because of suspension of physicians from the programs 
        under such titles.

           *       *       *       *       *       *       *

    (i) Dissemination.--The Administrator of the Health 
Resources and Services Administration shall disseminate 
information concerning the designation criteria described in 
subsection (b) to--
          (1) the Governor of each State;
          (2) the representative of any area, population group, 
        or facility selected by any such Governor to receive 
        such information;
          (3) the representative of any area, population group, 
        or facility that requests such information; and
          (4) the representative of any area, population group, 
        or facility determined by the Administrator to be 
        likely to meet the criteria described in subsection 
        (b).

                     ASSIGNMENT OF CORPS PERSONNEL

    Sec. 333. (a)(1) The Secretary may assign members of the 
Corps to provide, under regulations promulgated by the 
Secretary, health services in or to a health professional 
shortage area during the assignment period [specified in the 
agreement described in section 334] only if--
          (A) a public or [nonprofit] private entity, which is 
        located or has a demonstrated interest in such area, 
        makes application to the Secretary for such assignment;
          (B) such application has been approved by the 
        Secretary;
          [(C) an agreement has been entered into between the 
        entity which has applied and the Secretary, in 
        accordance with section 334; and]
          (C) the entity agrees to comply with the requirements 
        of section 334; and

           *       *       *       *       *       *       *

    (3) In approving applications for assignment of members of 
the Corps the Secretary shall not discriminate against 
applications from entities which are not receiving Federal 
financial assistance under this Act. In approving such 
applications, the Secretary shall give preference to 
applications in which a nonprofit entity or public entity shall 
provide a site to which Corps members may be assigned.

           *       *       *       *       *       *       *

    (d)(1) The Secretary [may] shall provide technical 
assistance to a public or [nonprofit] private entity which is 
located in a health professional shortage area and which 
desires to make an application under this section for 
assignment of a Corps member to such area. Assistance provided 
under this paragraph may include assistance to an entity in (A) 
analyzing the potential use of health professions personnel in 
defined health services delivery areas by the residents of such 
areas, (B) determining the need for such personnel in such 
areas, (C) determining the extent to which such areas will have 
a financial base to support the practice of such personnel and 
the extent to which additional financial resources are needed 
to adequately support the practice, [and] (D) determining the 
types of inpatient and other health services that should be 
provided by such personnel in such areas[.], and (E) developing 
longterm plans for addressing health professional shortages and 
improving access to health care. The Secretary shall encourage 
entities that receive technical assistance under this paragraph 
to communicate with other communities, State Offices of Rural 
Health, State Primary Care Associations and Offices, and other 
entities concerned with site development and community needs 
assessment.

           *       *       *       *       *       *       *

    (2) The Secretary may provide, to public and [nonprofit] 
private entities which are located in a health professional 
shortage area to which area a Corps member has been assigned, 
technical assistance to assist in the retention of such member 
in such area after the completion of such member's assignment 
to the area.

           *       *       *       *       *       *       *


SEC. 333A. PRIORITIES IN ASSIGNMENT OF CORPS PERSONNEL.

    (a) In General.-- * * *

           *       *       *       *       *       *       *

                  (A) is made regarding the provision of 
                primary health services to a health 
                professional shortage area with the greatest 
                such shortage[, as determined in accordance 
                with subsection (b)]; and

           *       *       *       *       *       *       *

    [(b) Exclusive Factors for Determining Greatest 
Shortages.--In making a determination under subsection 
(a)(1)(A) of the health professional shortage areas with the 
greatest such shortages, the Secretary may consider only the 
following factors:
          [(1) The ratio of available health manpower to the 
        number of individuals in the area or population group 
        involved, or served by the medical facility or other 
        public facility involved.
          [(2) Indicators of need as follows:
                  [(A) The rate of low birthweight births.
                  [(B) The rate of infant mortality.
                  [(C) The rate of poverty.
                  [(D) Access to primary health services, 
                taking into account the distance to such 
                services.]
    [(c)] (b) Establishment of Criteria for Determining 
Priorities.--
          (1) In general.--The Secretary shall establish 
        criteria specifying the manner in which the Secretary 
        makes a determination under subsection (a)(1)(A) of the 
        health professional shortage areas with the greatest 
        such shortages. [Such criteria shall specify the manner 
        in which the factors described in subsection (b) are 
        implemented regarding such a determination.]

           *       *       *       *       *       *       *

    [(d)] (c) Notifications Regarding Priorities.--
          ``(1) Proposed list.--The Secretary shall prepare and 
        publish a proposed list of health professional shortage 
        areas and entities that would receive priority under 
        subsection (a)(1) in the assignment of Corps members. 
        The list shall contain the information described in 
        paragraph (2), and the relative scores and relative 
        priorities of the entities submitting applications 
        under section 333, in a proposed format. All such 
        entities shall have 30 days after the date of 
        publication of the list to provide additional data and 
        information in support of inclusion on the list or in 
        support of a higher priority determination and the 
        Secretary shall reasonably consider such data and 
        information in preparing the final list under paragraph 
        (2).
          [(1)] (2) Preparation of list for applicable 
        period.--For the purpose of carrying out [paragraph 
        (2)] paragraph (3), the Secretary shall [prepare a list 
        of health professional shortage areas] prepare and, as 
        appropriate, update a list of health professional 
        shortage areas and entities that are receiving priority 
        under subsection (a)(1) in the assignment of Corps 
        members [for the period applicable under subsection 
        (f)]. Such list--

           *       *       *       *       *       *       *

          [(2)] (3) Notification of affected parties.--
                  [(A) Not later than 30 days after the 
                preparation of each list under paragraph (1), 
                the Secretary shall notify entities specified 
                for purposes of subparagraph (A) of such 
                paragraph of the fact that the entities have 
                been provided an authorization to receive 
                assignments of Corps members in the event that 
                Corps members are available for the 
                assignments.
                  [(B) In the case of individuals with respect 
                to whom a period of obligated service under the 
                Scholarship Program will begin during the 
                period under subsection (f) for which a list 
                under paragraph (1) is prepared, the Secretary 
                shall, not later than 30 days after the 
                preparation of each such list, provide to such 
                individuals the names of each of the entities 
                specified for purposes of paragraph (1)(B)(i) 
                that is appropriate to the medical speciality 
                of the individuals.]
          (3) Notification of affected parties.--
                  (A) Entities.--Not later than 30 days after 
                the Secretary has added to a list under 
                paragraph (2) an entity specified as described 
                in subparagraph (A) of such paragraph, the 
                Secretary shall notify such entity that the 
                entity has been provided an authorization to 
                receive assignments of Corps members in the 
                event that Corps members are available for the 
                assignments.
                  (B) Individuals.--In the case of an 
                individual obligated to provide service under 
                the Scholarship Program, not later than 3 
                months before the date described in section 
                338C(b)(5), the Secretary shall provide to such 
                individual the names of each of the entities 
                specified as described in paragraph (2)(B)(i) 
                that is appropriate for the individual's 
                medical specialty and discipline.
          [(3) Revisions in list.--If the Secretary makes a 
        revision in a list under paragraph (1) during the 
        period under subsection (f) to which the list is 
        applicable, and the revision alters the status of an 
        entity with respect to the list, the Secretary shall 
        notify the entity of the effect on the entity of the 
        revision. Such notification shall be provided not later 
        than 30 days after the date on which the revision is 
        made.]
          (4) Revisions.--If the Secretary proposes to make a 
        revision in the list under paragraph (2), and the 
        revision would adversely alter the status of an entity 
        with respect to the list, the Secretary shall notify 
        the entity of the revision. Any entity adversely 
        affected by such a revision shall be notified in 
        writing by the Secretary of the reasons for the 
        revision and shall have 30 days to file a written 
        appeal of the determination involved which shall be 
        reasonably considered by the Secretary before the 
        revision to the list becomes final. The revision to the 
        list shall be effective with respect to assignment of 
        Corps members beginning on the date that the revision 
        becomes final.
  [(e) Limitation on Number of Entities Offered as Assignment 
Choices in Scholarship Program.--
          [(1) Determination of available corps members.--The 
        Secretary shall determine the number of participants in 
        the Scholarship Program who are available for 
        assignments under section 333 for the period applicable 
        under subsection (f).
          [(2) Availability of 500 or fewer members.--If the 
        number of participants for purposes of paragraph (1) is 
        less than 500, the Secretary shall limit the number of 
        entities specified under subsection (d)(1)(B)(i) to the 
        lesser of--
                  [(A) 500 such entities; and
                  [(B) a number of such entities constituting 
                300 percent of the number of such participants 
                available for assignment under section 333.
          [(3) Availability of more than 500 members.--If the 
        number of participants for purposes of paragraph (1) is 
        equal to or greater than 500, the Secretary shall 
        determine the number of entities to be specified under 
        subsection (d)(1)(B)(i), subject to ensuring that 
        assignments of such participants are made to 500 
        entities that serve health professional shortage areas 
        that have chronic difficulty in recruiting and 
        retaining health professionals to provide primary 
        health services.
          [(4) Adjustment in base number.--The number 500, as 
        used for purposes of paragraphs (2) and (3), may by 
        regulation be adjusted by the Secretary to a greater or 
        a lesser number.]
  [(e)] (d) Limitation on Number of Entities Offered as 
Assignment Choices in Scholarship Program.--
          (1) Determination of available corps members.--By 
        April 1 of each calendar year, the Secretary shall 
        determine the number of participants in the Scholarship 
        Program who will be available for assignments under 
        section 333 during the program year beginning on July 1 
        of that calendar year.
          (2) Determination of number of entities.--At all 
        times during a program year, the number of entities 
        specified under subsection (c)(2)(B)(i) shall be--
                  (A) not less than the number of participants 
                determined with respect to that program year 
                under paragraph (1); and
                  (B) not greater than twice the number of 
                participants determined with respect to that 
                program year under paragraph (1).
    [(f) Applicable Period Regarding Priorities.--
          [(1) In general.--With respect to determinations 
        under subsection (a)(1) of the applications that are to 
        be given priority regarding the assignment of Corps 
        members, the Secretary shall make such a determination 
        not less than once each fiscal year. The first 
        determination shall be made not later than July 1 of 
        the year preceding the year in which the period of 
        obligated service begins. If the Secretary revises the 
        determination before July 1 of the following year, the 
        revised determination shall be applicable with respect 
        to assignments of Corps members made during the period 
        beginning on the date of the issuance of the revised 
        determination and ending on July 1 of such year.
          [(2) Date certain for preparation of notification 
        list.--A list under subsection (d)(1) shall be prepared 
        for each of the periods described in paragraph (1). 
        Each such list shall be prepared not later than the 
        date on which a determination of priorities under such 
        paragraph is required to be made for the period 
        involved.
    [Sec. 334. (a) The Secretary shall require, as a condition 
to the approval of an application under section 333 for the 
assignment of a member of the Corps, that the entity which 
submitted the application enter into an agreement for a 
specific assignment period (not to exceed 4 years) with the 
Secretary under which--
          [(1) the entity shall be responsible for charging, in 
        accordance with subsection (d), for health services 
        provided by Corps members assigned to the entity;
          [(2) the entity shall take such action as may be 
        reasonable for the collection of payments for such 
        health services, including, if a Federal agency, an 
        agency of a State or local government, or other third 
        party would be responsible for all or part of the cost 
        of such health services if it had not been provided by 
        Corps members under this subpart, the collection, on a 
        fee-for-service or other basis, from such agency or 
        third party, the portion of such cost for which it 
        would be so responsible (and in determining the amount 
        of such cost which such agency or third party would be 
        responsible, the health services provided by Corps 
        members shall be considered as being provided by 
        private practitioners);
          [(3) the entity, if not a small health center, shall 
        pay to the United States, as prescribed by the 
        Secretary in each calendar quarter (or other period as 
        may be specified in the agreement) during which any 
        Corps member is assigned to such entity, the sum of--
                  [(A) an amount calculated by the Secretary to 
                reflect the average salary (including amounts 
                paid in accordance with section 331(d)) and 
                allowances of comparable Corps members for a 
                calendar quarter (or other period);
                  [(B) that portion of an amount calculated by 
                the Secretary to reflect the average amount 
                paid under the Scholarship Program or the Loan 
                Repayment Program to or on behalf of comparable 
                Corps members that bears the same ratio to the 
                calculated amount as the number of days of 
                service provided by the member during that 
                quarter (or other period) bears to the number 
                of days in his period of obligated service 
                under the Scholarship Program or the Loan 
                Repayment Program; and
                  [(C) if such entity received a loan under 
                section 335(c) or a grant under section 
                333(d)(2), an amount which bears the same ratio 
                to the amount of such loan or grant as the 
                number of days in such quarter (or other 
                period) during which any Corps members were 
                assigned to the entity bears to the number of 
                days in the assignment period after such entity 
                received such loan or grant;
          [(4) the entity, if a small health center, shall pay 
        to the United States, in each calendar quarter (or 
        other period as may be specified in the agreement) 
        during which any Corps members is assigned to such 
        entity, an amount determined by the Secretary in 
        accordance with subsection (f); and
          [(5) the entity shall prepare and submit to the 
        Secretary an annual report, in such form and manner, as 
        the Secretary may require.
    [(b)(1) The Secretary may waive in whole or in part, on a 
prospective or retrospective basis, the application of the 
requirement of subsection (a)(3) for an entity which is not a 
small health center if he determines that the entity is 
financially unable to meet such requirement of if he determines 
that compliance with such requirement would unreasonably limit 
the ability of the entity to provide for the adequate support 
of the provision of health services by Corps members.
    [(2) The Secretary may waive in whole or in part, on a 
prospective or retrospective basis, the application of the 
requirement of subsection (a)(3) for any entity which is not a 
small health center and which is located in a health 
professional shortage area in which a significant percentage of 
the individuals are elderly, living in poverty, or have other 
characteristics which indicate an inability to repay, in whole 
or in part, the amounts required in subsection (a)(3).
    [(3) In the event that the Secretary grants a waiver under 
paragraph (1) or (2), and does not, pursuant to paragraph (5), 
require payment by the entity in the amount described in 
subsection (f)(1) the entity shall be required to use the total 
amount of funds collected by such entity in accordance with 
subsection (a)(2) for the improvement of the capability of such 
entity to deliver health services to the individuals in, or 
served by, the health professional shortage area.
    [(4) In determining whether to grant a waiver under 
paragraph (1) or (2), the Secretary shall not discriminate 
against a public entity.
    [(5)(A) If the Secretary determines that an entity which is 
not a small health center is eligible for a waiver under 
paragraph (1) or (2), the Secretary may waive the application 
of subsection (a)(3) for such entity and require such entity to 
make payment in an amount equal to the amount described in 
subsection (f)(1) that would be payable by such entity if such 
entity were a small health center.
    [(B) The Secretary may waive in whole or in part, on a 
prospective or retrospective basis, the application of the 
requirement of subparagraph (A) for any entity if the Secretary 
determines that the entity is financially unable to meet such 
requirement or that compliance with such requirement would 
unreasonably limit the ability of the entity to provide for the 
adequate support of the provision of health services by Corps 
members. Funds which would be paid to the United States but for 
a waiver under this subparagraph shall be used by an entity 
to--
          [(i) expand or improve its provision of health 
        services;
          [(ii) increase the number of individuals served;
          [(iii) renovate or modernize facilities for its 
        provision of health services;
          [(iv) improve the administration of its health 
        service programs; or
          [(v) to establish a financial reserve to assure its 
        ability to continue providing health services.
    [(c) The excess (if any) of the amount of funds collected 
by an entity which is not a small health center in accordance 
with subsection (a)(2) over the amount paid to the United 
States in accordance with subsection (a)(3) or subsection 
(b)(5)(A) shall be used by the entity to expand and improve the 
provision of health services to the individuals in the health 
professional shortage area for which the entity submitted an 
application or to recruit and retain health manpower to provide 
health services for such individuals.
    [(d) Any person who receives health services provided by a 
Corps member under this subpart shall be charged for such 
services on a fee-for-service or other basis, at a rate 
approved by the Secretary, pursuant to regulations. Such rate 
shall be computed in such a way as to permit the recovery of 
the value of such services, except that if such person is 
determined under regulations of the Secretary to be unable to 
pay such charge, the Secretary shall provide for the furnishing 
of such services at a reduced rate or without charge.
    [(e) Funds received by the Secretary under an agreement 
entered into under this section shall be deposited in the 
Treasury as miscellaneous receipts and shall be disregarded in 
determining the amounts of appropriations to be requested and 
the amounts to be made available from appropriations made under 
section 338 to carry out sections 331 through 335 and section 
337.
    [(f)(1) An entity which is a small health center shall pay 
to the United States, as prescribed by the Secretary in each 
calendar quarter (or other period as may be specified in the 
agreement) during which any Corps member is assigned to such 
entity, an amount equal to the amount (prorated for a calendar 
quarter or other period) by which the revenues that the center 
may reasonably expect to receive during an annual period for 
the provision of health services exceeds the costs that the 
center may reasonably expect to incur in the provision of such 
services, except that the amount that an entity shall pay to 
the United States under this paragraph shall not exceed the 
amount such entity would pay to the United States under 
paragraph (3) of subsection (a) if such paragraph applied to 
such entity.
    [(2)(A) To determined for purposes of paragraph (1) the 
revenues and costs which an entity that is a small health 
center may reasonably be expected to receive and incur in an 
annual period for the provision of health services, the entity 
shall submit to the Secretary before the beginning of such 
period a proposed budget which--
          [(i) describes the primary and supplemental health 
        services (as defined in section 330) which are needed 
        by the area the entity serves in such period; and
          [(ii) states the revenues and costs which the entity 
        expects to receive and incur in providing such health 
        services in such period.
    [(B) From the submission under subparagraph (A) and other 
information available to the Secretary, the Secretary shall 
determine--
          [(i) the primary and supplemental health services (as 
        defined in section 330) needed in the area the entity 
        serves;
          [(ii) the fees, premiums, third party reimbursements, 
        and other revenues the entity making the submission may 
        reasonably expect to receive from the provision of such 
        services; and
          [(iii) the costs which the entity may reasonably 
        expect to incur in providing such services.
The revenues and costs determined by the Secretary shall be the 
revenues and costs used in making the determination under 
paragraph (1).
    [(C)(i) A determination under subparagraph (B) regarding 
the revenues and costs of an entity in an annual period shall 
be made by the Secretary utilizing criteria specific to the 
entity and shall be made without regard to whether the entity 
is making progress toward collecting sufficient revenues to 
provide an adequate level of primary health services without 
the assignment of Corps members.
    [(ii) In making a determination referred to in clause (i)--
          [(I) the Secretary may consider whether the proposed 
        budget submitted under subparagraph (A) provides a 
        reasonable estimate regarding the revenues and costs of 
        the entity; and
          [(II) may not consider the reasonableness of the 
        amount of revenues collected, or the amount of costs 
        incurred by the entity, except to the extent necessary 
        to ensure that the entity is operating in good faith 
        and is operating efficiently with respect to fiscal 
        matters within the control of the entity.
    [(iii) A determination of whether an entity is eligible for 
a waiver under paragraph (3) shall be made by the Secretary 
without regard to the revenues and costs determined by the 
Secretary under subparagraph (B).
    [(iv) A determination of whether an entity is a small 
health center shall be made by the Secretary without regard to 
the revenues and costs determined by the Secretary under 
subparagraph (B).
    [(3) The Secretary may waive in whole or in part, on a 
prospective or retrospective basis, the application of 
paragraph (1) for an entity which is a small health center if 
the Secretary determines that the entity needs all or part of 
the amounts otherwise payable under such paragraph to--
          [(A) expand or improve its provision of health 
        services;
          [(B) increase the number of individuals served;
          [(C) renovate or modernize facilities for its 
        provision of health services;
          [(D) improve the administration of its health service 
        programs; or
          [(E) establish a financial reserve to assure its 
        ability to continue providing health services.
    [(4) The excess (if any) of the amount of funds collected 
by an entity which is a small health center in accordance with 
subsection (a)(2) over the amount paid to the United States in 
accordance with paragraph (1) of this subsection shall be used 
by the center for the purposes set out in subparagraph (A) 
through (E) of paragraph (3) of this subsection or to recruit 
and retain health manpower to provide health services to the 
individuals in the health professional shortage area for which 
the entity submitted an application.
    [(5) For purposes of this section, the term ``small health 
center'' means an entity other than--
          [(A) a hospital (or part of a hospital);
          [(B) a public entity; or
          [(C) an entity that is receiving a grant under 
        section 329 or section 330, except that such term 
        includes an entity whose grant is less than the total 
        of the amounts, calculated on an annual basis, 
        specified in subparagraphs (A) and (B) of subsection 
        (a)(3).]

SEC. 334. CHARGES FOR SERVICES BY ENTITIES USING CORPS MEMBERS.

  (a) Availability of Services Regardless of Ability To Pay or 
Payment Source.--An entity to which a Corps member is assigned 
shall not deny requested health care services, and shall not 
discriminate in the provision of services to an individual--
          (1) because the individual is unable to pay for the 
        services; or
          (2) because payment for the services would be made 
        under--
                  (A) the medicare program under title XVIII of 
                the Social Security Act (42 U.S.C. 1395 et 
                seq.);
                  (B) the medicaid program under title XIX of 
                such Act (42 U.S.C. 1396 et seq.); or
                  (C) the State children's health insurance 
                program under title XXI of such Act (42 U.S.C. 
                1397aa et seq.).
  (b) Charges for Services.--The following rules shall apply to 
charges for health care services provided by an entity to which 
a Corps member is assigned:
          (1) In general.--
                  (A) Schedule of fees or payments.--Except as 
                provided in paragraph (2), the entity shall 
                prepare a schedule of fees or payments for the 
                entity's services, consistent with locally 
                prevailing rates or charges and designed to 
                cover the entity's reasonable cost of 
                operation.
                  (B) Schedule of discounts.--Except as 
                provided in paragraph (2), the entity shall 
                prepare a corresponding schedule of discounts 
                (including, in appropriate cases, waivers) to 
                be applied to such fees or payments. In 
                preparing the schedule, the entity shall adjust 
                the discounts on the basis of a patient's 
                ability to pay.
                  (C) Use of schedules.--The entity shall make 
                every reasonable effort to secure from patients 
                fees and payments for services in accordance 
                with such schedules, and fees or payments shall 
                be sufficiently discounted in accordance with 
                the schedule described in subparagraph (B).
          (2) Services to beneficiaries of federal and 
        federally assisted programs.--In the case of health 
        care services furnished to an individual who is a 
        beneficiary of a program listed in subsection (a)(2), 
        the entity--
                  (A) shall accept an assignment pursuant to 
                section 1842(b)(3)(B)(ii) of the Social 
                Security Act (42 U.S.C. 1395u(b)(3)(B)(ii)) 
                with respect to an individual who is a 
                beneficiary under the medicare program; and
                  (B) shall enter into an appropriate agreement 
                with--
                          (i) the State agency administering 
                        the program under title XIX of such Act 
                        with respect to an individual who is a 
                        beneficiary under the medicaid program; 
                        and
                          (ii) the State agency administering 
                        the program under title XXI of such Act 
                        with respect to an individual who is a 
                        beneficiary under the State children's 
                        health insurance program.
          (3) Collection of payments.--The entity shall take 
        reasonable and appropriate steps to collect all 
        payments due for health care services provided by the 
        entity, including payments from any third party 
        (including a Federal, State, or local government agency 
        and any other third party) that is responsible for part 
        or all of the charge for such services.

             provision of health services by corps members

    Sec. 335. (a) * * *

           *       *       *       *       *       *       *

    (e)(1)(A) * * *
    (B) Any hospital which is found by the Secretary, after 
notice and an opportunity for a hearing on the record, to have 
violated this subsection shall upon such finding cease, for a 
period to be determined by the Secretary, to receive and to be 
eligible to receive any Federal funds under this Act or under 
titles [XVIII or XIX] XVIII, XIX, or XXI of the Social Security 
Act.

           *       *       *       *       *       *       *


SEC. 336. FACILITATION OF EFFECTIVE PROVISION OF CORPS SERVICES.

    (a) Consideration of Individual Characteristics of Members 
in Making Assignments.-- * * *

           *       *       *       *       *       *       *

    (c) Grants Regarding Preparation of Students for 
Practice.-- With respect to individuals who have entered into 
contracts for obligated service under the Scholarship or Loan 
Repayment Program, the Secretary may make grants to, and enter 
into contracts with, public and nonprofit private entities 
(including health professions schools) for the conduct of 
programs designed to prepare such individuals for the effective 
provision of primary health services in the [health manpower] 
health professional shortage areas to which the individuals are 
assigned.

           *       *       *       *       *       *       *

    (f) Determinations Regarding Effective Service.--In 
carrying out subsection (a) and sections 338A(d) and 338B(d), 
the Secretary shall carry out activities to determine--
          (1) the characteristics of physicians, dentists, and 
        other health professionals who are more likely to 
        remain in practice in [health manpower] health 
        professional shortage areas after the completion of the 
        period of service in the Corps;

           *       *       *       *       *       *       *


                             annual reports

    Sec. 336A. The Secretary shall submit an annual report to 
Congress, and shall include in such report with respect to the 
previous calendar year--

           *       *       *       *       *       *       *

          (8) the amount charged during such year for health 
        services provided by Corps members, the amount which 
        collected in such year by entities in accordance with 
        [agreements under] section 334, and the amount which 
        was paid to the Secretary in such year under such 
        agreements.

           *       *       *       *       *       *       *


                     authorization of appropriation

    Sec. 338. (a)[(1) For] For the purpose of carrying out this 
subpart, there are authorized to be appropriated such sums as 
may be necessary for each of the fiscal years [1991 through 
2000] 2002 through 2006.
    [(2) In the case of individuals who serve in the Corps 
other than pursuant to obligated service under the Scholarship 
or Loan Repayment Program, the Secretary each fiscal year 
shall, to the extent practicable, make assignments under 
section 333 of such individuals who are certified nurse 
midwives, certified nurse practitioners, or physician 
assistants.]

           *       *       *       *       *       *       *


      Subpart III--Scholarship Program and Loan Repayment Program


           National Health Service Corps Scholarship Program

    Sec. 338A. (a) * * *
          (1) an adequate supply of physicians, dentists, 
        behavioral and mental health professionals, certified 
        nurse midwives, certified nurse practitioners, and 
        physician assistants; and

           *       *       *       *       *       *       *

    (b) To be eligible to participate in the Scholarship 
Program, an individual must--
          (1) be accepted for enrollement, or be enrolled, as a 
        full-time student (A) in an accredited (as determined 
        by the Secretary) educational institution in a State 
        and (B) in a course of study or program, offered by 
        such institution and approved by the Secretary, leading 
        to a degree in medicine, osteopathic medicine, 
        dentistry, or other health profession, or an 
        appropriate degree from a graduate program of 
        behavioral and mental health;

           *       *       *       *       *       *       *

    (c)(1) In disseminating application forms and contract 
forms to individuals desiring to participate in the Scholarship 
Program, the Secretary shall include with such forms--
          (A) a fair summary of the rights and liabilities of 
        an individual whose application is approved (and whose 
        contract is accepted) by the Secretary, including in 
        the summary a clear explanation of the damages to which 
        the United States is entitled under section [338D] 338E 
        in the case of the individual's breach of the contract; 
        and
          (B) the Secretary, in considering applications from 
        individuals accepted for enrollment or enrolled in 
        dental school, shall consider applications from all 
        individuals accepted for enrollment or enrolled in any 
        accredited dental school in a State; and
          [(B)] (C) information respecting meeting a service 
        obligation through private practice under an agreement 
        under section [338C] 338D and such other information as 
        may be necessary for the individual to understand the 
        individual's prospective participation in the 
        Scholarship Program and service in the Corps, including 
        a statement of all factors considered in approving 
        applications for participation in the Program and in 
        making assignments for participants in the Program.

           *       *       *       *       *       *       *

    (f) The written contract (referred to in this subpart) 
between the Secretary and an individual shall contain--
          (1) an agreement that--
                  (A) * * *
                  (B) * * *

           *       *       *       *       *       *       *

                          (iii) while enrolled in such course 
                        of study, to maintain an acceptable 
                        level of academic standing (as 
                        determined under regulations of the 
                        Secretary by the educational 
                        institution offering such course of 
                        study); [and]
                           (iv) if pursuing a degree from a 
                        school of medicine or osteopathic 
                        medicine, to complete a residency in a 
                        specialty that the Secretary determines 
                        is consistent with the needs of the 
                        Corps; and
                          [(iv)] (v) to serve for a time period 
                        (hereinafter in the subpart referred to 
                        as the ``period of obligated service'') 
                        equal to--

           *       *       *       *       *       *       *

          (3) a statement of the damages to which the United 
        States is entitled, under section [338D] 338E for the 
        individual's breach of the contract; and

           *       *       *       *       *       *       *

    [(i) Not later than March 1 of each year, the Secretary 
shall submit to the Congress a report providing, with respect 
to the preceding fiscal year--
          [(1) the number, and type of health profession 
        training, of students receiving scholarships under the 
        Scholarship Program;
          [(2) the educational institutions at which such 
        students are receiving their training;
          [(3) the number of applications filed under this 
        section in the school year beginning in such year and 
        in prior school years;
          [(4) the amount of scholarship payments made for each 
        of tuition, stipends, and other expenses, in the 
        aggregate and at each educational institution for the 
        school year beginning in such year and for prior school 
        years;
          [(5)(A) the number, and type of health professions 
        training, of individuals who have breached the contract 
        under subsection (f) through any of the actions 
        specified in subsection (a) or (b) of section 338E; and
          [(B) with respect to such individuals--
                  [(i) the educational institutions with 
                respect to which payments have been made or 
                were to be made under the contract;
                  [(ii) the amounts for which the individuals 
                are liable to the United States under section 
                338E;
                  [(iii) the extent of payment by the 
                individuals of such amounts; and
                  [(iv) if known, the basis for the decision of 
                the individuals to breach the contract under 
                subsection (f); and
          [(6) the effectiveness of the Secretary in recruiting 
        health professionals to participate in the Scholarship 
        Program, and in encouraging and assisting such 
        professionals with respect to providing primary health 
        services to health professional shortage areas after 
        the completion of the period of obligated service under 
        such Program.]

SEC. 338B. NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM.

    (a) Establishment.-- * * *
          (1) an adequate supply of physicians, dentists, 
        behavioral and mental health professionals, certified 
        nurse midwives, certified nurse practitioners, and 
        physician assistants; and
          (2) if needed by the Corps, and adequate supply of 
        other health professionals [(including mental health 
        professionals)].
    (b) Eligibility.--To be eligible to participate in the Loan 
Repayment Program, an individual must--
          (1)[(A) must have a degree in medicine, osteopathic 
        medicine, dentistry, or other health profession, or be 
        certified as a nurse midwife, nurse practitioner, or 
        physician assistant;](A) have a degree in medicine, 
        osteopathic medicine, dentistry, or another health 
        profession, or an appropriate degree from a graduate 
        program of behavior and mental health, or be certified 
        as a nurse midwife, nurse practitioner, or physician 
        assistant;

           *       *       *       *       *       *       *

    (e) Approval Required for Participation.--
          [(1) In general.--]An individual becomes a 
        participant in the Loan Repayment Program only upon the 
        Secretary and the individual entering into a written 
        contract described in subsection (f).

           *       *       *       *       *       *       *

    [(i) Reports.--Not later than March 1 of each year, the 
Secretary shall submit to the Congress a report providing, with 
respect to the preceding fiscal year--
          [(1) the total amount of loan payments made under the 
        Loan Repayment Program;
          [(2) the number of applications filed under this 
        section;
          [(3) the number, and type of health profession 
        training, of individuals receiving loan repayments 
        under such Program;
          [(4) the educational institution at which such 
        individuals received their training;
          [(5) the total amount of the indebtedness of such 
        individuals for educational loans as of the date on 
        which the individuals become participants in such 
        Program;
          [(6) the number of years of obligated service 
        specified for such individuals in the initial contracts 
        under subsection (f), and, in the case of individuals 
        whose period of such service has been completed, the 
        total number of years for which the individuals served 
        in the Corps (including any extensions made for 
        purposes of paragraph (2) of such subsection);
          [(7)(A) the number, and type of health professions 
        training, of such individuals who have breached the 
        contract under subsection (f) through any of the 
        actions specified in subsection (a) or (b) of section 
        338E; and
          [(B) with respect to such individuals--
                  [(i) the educational institutions with 
                respect to which payments have been made or 
                were to be made under contract;
                  [(ii) the amounts for which the individuals 
                are liable to the United States under section 
                338E;
                  [(iii) the extent of payment by the 
                individuals of such amounts; and
                  [(iv) if known, the basis for the decision of 
                the individuals to breach the contract under 
                subsection (f); and
          [(8) the effectiveness of the Secretary in recruiting 
        health professionals to participate in the Loan 
        Repayment Program, and in encouraging and assisting 
        such professionals with respect to providing primary 
        health services to health professional shortage areas 
        after the completion of the period of obligated service 
        under such Program.

                           Obligated Service

    Sec. 338C. (a) * * *
    (b)(1) If an individual is required under subsection (a) to 
provide service as specified in [section 338A(f)(1)(B)(iv)] 
section 338A(f)(1)(B)(v) or 338B(f)(1)(B)(iv) (hereinafter in 
this subsection referred to as ``obligated service''), the 
Secretary shall, not later than ninety days before the date 
described in paragraph (5), determine if the individual shall 
provide such service--

           *       *       *       *       *       *       *

    [(5)(A) In the case of the Scholarship Program, with 
respect to an individual receiving a degree from a school of 
medicine, osteopathic medicine, dentistry, veterinary medicine, 
optometry, podiatry, or pharmacy, the date referred to in 
paragraphs (1) through (4) shall be the date on which the 
individual completes the training required for such degree, 
except that--
          [(i) at the request of such an individual with whom 
        the Secretary has entered into a contract under section 
        338A prior to October 1, 1985, the Secretary shall 
        defer such date until the end of the period of time 
        (not to exceed the number of years specified in 
        subparagraph (B) or such greater period as the 
        Secretary, consistent with the needs of the Corps, may 
        authorize) required for the individual to complete an 
        internship, residency, or other advanced clinical 
        training; and
          [(ii) at the request of such an individual with whom 
        the Secretary has entered into a contract under section 
        338A on or after October 1, 1985, the Secretary may 
        defer such date in accordance with clause (i).
    [(B)(i) In the case of the Scholarship Program, with 
respect to an individual receiving a degree from a school of 
medicine, osteopathic medicine, or dentistry, the number of 
years referred to in subparagraph (A)(i) shall be 3 years.
    [(ii) In the case of the Scholarship Program, with respect 
to an individual receiving a degree from a school of veterinary 
medicine, optometry, podiatry, or pharmacy, the number of years 
referred to in subparagraph (A)(i) shall be 1 year.]
    (5)(A) In the case of the Scholarship Program, the date 
referred to in paragraphs (1) through (4) shall be the date on 
which the individual completes the training required for the 
degree for which the individual receives the scholarship, 
except that--
          (i) for an individual receiving such a degree after 
        September 30, 2000, from a school of medicine or 
        osteopathic medicine, such date shall be the date the 
        individual completes a residency in a specialty that 
        the Secretary determines is consistent with the needs 
        of the Corps; and
          (ii) at the request of an individual, the Secretary 
        may, consistent with the needs of the Corps, defer such 
        date until the end of a period of time required for the 
        individual to complete advanced training (including an 
        internship or residency).
    [(C)] (B) No period of internship, residency, or other 
advanced clinical training shall be counted toward satisfying a 
period of obligated service under this subpart.
    [(D) In the case of the Scholarship Program, with respect 
to an individual receiving a degree from an institution other 
than a school referred to in subparagraph (A), the date 
referred to in paragraphs (1) through (4) shall be the date on 
which the individual completes the academic training of the 
individual leading to such degree.]
    [(E)] (C) In the case of the loan repayment program, if an 
individual is required to provide obligated service under such 
Program, the date referred to in paragraphs (1) through (4)--
          (i) shall be the date determined under [subparagraph 
        (A), (B), or (D)] subparagraph (A) in the case of an 
        individual who is enrolled in the final year of a 
        course of study;

           *       *       *       *       *       *       *

    [(e) Notwithstanding any other provision of this title, 
service of an individual under a National Research Service 
Award awarded under subparagraph (A) or (B) of section 
472(a)(1) \1\ shall be counted against the period of obligated 
service which the individual is required to perform under the 
Scholarship Program or under section 225 as in effect on 
September 30, 1977.]

                            PRIVATE PRACTICE

    Sec. 338D. (a) * * *
    [(b) The written agreement described in subsection (a) 
shall--
          [(1) provide that during the period of private 
        practice by an individual pursuant to the agreement--
                  [(A) any person who receives health services 
                provided by the individual in connection with 
                such practice will be charged for such services 
                at the usual and customary rate prevailing in 
                the area in which such services are provided, 
                except that if such person is unable to pay 
                such charge, such person shall be charged at a 
                reduced rate or not charged any fee; and
                  [(B) the individual in providing health 
                services in connection with such practice (i) 
                shall not discriminate against any person on 
                the basis of such person's ability to pay for 
                such services or because payment for the health 
                services provided to such person will be made 
                under the insurance program established under 
                part A or B of title XVIII of the Social 
                Security Act or under a State plan for medical 
                assistance approved under title XIX of such 
                Act, and (ii) shall agree to accept an 
                assignment under section 1842(b)(3)(B)(ii) of 
                such Act for all services for which payment may 
                be made under part B of title XVIII of such Act 
                and enter into an appropriate agreement with 
                the State agency which administers the State 
                plan for medical assistance under title XIX of 
                such Act to provide services to individuals 
                entitled to medical assistance under the plan; 
                and
          [(2) contain such additional provisions as the 
        Secretary may require to carry out the purposes of this 
        section.
[For purposes of paragraph (1)(A), the Secretary shall by 
regulation prescribe the method for determining a person's 
ability to pay a charge for health services and the method of 
determining the amount (if any) to be charged such person based 
on such ability. The Secretary shall take such action as may be 
appropriate to ensure that the conditions of the written 
agreement prescribed by this subsection are adhered to.]
    (b)(1) The written agreement described in subsection (a) 
shall--
          (A) provide that, during the period of private 
        practice by an individual pursuant to the agreement, 
        the individual shall comply with the requirements of 
        section 334 that apply to entities; and
          (B) contain such additional provisions as the 
        Secretary may require to carry out the objectives of 
        this section.
    (2) The Secretary shall take such action as may be 
appropriate to ensure that the conditions of the written 
agreement prescribed by this subsection are adhered to.

           *       *       *       *       *       *       *


       breach of scholarship contract or loan repayment contract

    Sec. 338E. [254o] (a)(1) An individual who has entered into 
a written contract with the Secretary under section 338A and 
who--
          (A) fails to maintain an acceptable level of academic 
        standing in the educational institution in which he is 
        enrolled (such level determined by the educational 
        institution under regulations of the Secretary)[,];
          (B) is dismissed from such educational institution 
        for disciplinary reasons[,]; or
          (C) voluntarily terminates the training in such an 
        educational institution for which he is provided a 
        scholarship under such contract, before the completion 
        of such training, [or]
          [(D) fails to accept payment, or instructs the 
        educational institution in which he is enrolled not to 
        accept payment, in whole or in part, of a scholarship 
        under such contract,]
in lieu of any service obligation arising under such contract, 
shall be liable to the United States for the amount which has 
been paid to him, or on his behalf, under the contract.

           *       *       *       *       *       *       *

    (b)(1)(A) Except as provided in paragraph (2), if (for any 
reason not specified in subsection (a) or section [338F(d)] 
338G(d) an individual breaches his written contract by failing 
[either] to begin such individual's service obligation under 
section 338A in accordance with section 338C or [338D or] 338D, 
to complete such service obligation, or to complete a required 
residency as specified in section 338A(f)(1)(B)(iv), the United 
States shall be entitled to recover from the individual an 
amount determined in accordance with the formula

                         A=3(t-s/t)


in which ``A'' is the amount the United States is entitled to 
recover, ``'' is the sum of the amounts paid under 
this subpart to or on behalf of the individual and the interest 
on such amounts which would be payable if at the time the 
amounts were paid they were loans bearing interest at the 
maximum legal prevailing rate, as determined by the Treasurer 
of the United States; ``t'' is the total number of months in 
the individual's period of obligated service; and ``s'' is the 
number of months of such period served by him in accordance 
with section 338C or a written agreement under section 338D.

           *       *       *       *       *       *       *

    (3) The Secretary may terminate a contract with an 
individual under section 338A if, not later than 30 days before 
the end of the school year to which the contract pertains, the 
individual--
          (A) submits a written request for such termination; 
        and
          (B) repays all amounts paid to, or on behalf of, the 
        individual under section 338A(g).

           *       *       *       *       *       *       *

    (c)(1) If (for any reason not specified in subsection (a) 
or section [338F(d)] 338G(d)) an individual breaches the 
written contract of the individual under section 338B by 
failing either to begin such individual's service obligation in 
accordance with section 338C or 338D or to complete such 
service obligation, the United States shall be entitled to 
recover from the individual an amount equal to the sum of--
          [(A) in the case of a contract for a 2-year period of 
        obligated service--
                  [(i) the total of the amounts paid by the 
                United States under section 338B(g)(2) on 
                behalf of the individual for any period of 
                obligated service; and
                  [(ii) an amount equal to the unserved 
                obligation penalty;
          [(B) in the case of a contract for a period of 
        obligated service of greater than 2 years, and the 
        breach occurs before the end of the first 2 years of 
        such period--
                  [(i) the total of the amounts paid by the 
                United States under section 338B(g)(2) on 
                behalf of the individual for any period of 
                obligated service; and
                  [(ii) an amount equal to the unserved 
                obligation penalty; and
          [(C) in the case of a contract for a period of 
        obligated service of greater than 2 years, and the 
        breach occurs after the first 2 years of such period--
                  [(i) the total of the amounts paid by the 
                United States under section 338B(g)(2) on 
                behalf of the individual for any period of 
                obligated service not served; and
                  [(ii) if the individual breaching the 
                contract failed to give the Secretary notice, 
                that the individual intends to take action 
                which constitutes a breach of the contract, at 
                least 1 year (or such shorter period of time as 
                the Secretary determines is adequate for 
                finding a replacement prior to the breach, 
                $10,000.]
          (A) the total of the amounts paid by the United 
        States under section 338B(g) on behalf of the 
        individual for any period of obligated service not 
        served;
          (B) an amount equal to the product of the number of 
        months of obligated service that were not completed by 
        the individual, multiplied by $7,500; and
          (C) the interest on the amounts described in 
        subparagraphs (A) and (B), at the maximum legal 
        prevailing rate, as determined by the Treasurer of the 
        United States, from the date of the breach.
    [(2) For purposes of paragraph (1), the term ``unserved 
obligation penalty'' means the amount equal to the product of 
the number of months of obligated service that were not 
completed by an individual, multiplied by $1,000, except that 
in any case in which the individual fails to serve 1 year, the 
unserved obligation penalty shall be equal to the full period 
of obligated service multiplied by $1,000.
    [(3) The Secretary may waive, in whole or in part, the 
rights of the United States to recover amounts under this 
section in any case of extreme hardship or other good cause 
shown, as determined by the Secretary.]
    (2) The Secretary may terminate a contract with an 
individual under section 338B if, not later than 45 days before 
the end of the fiscal year in which the contract was entered 
into, the individual--
          (A) submits a written request for such termination; 
        and
          (B) repays all amounts paid on behalf of the 
        individual under section 338b(g).
    [(4)] (3) Damages that the United States is entitled to 
recover shall be paid in accordance with subsection (b)(1)(B).
    (d)(1) * * *

           *       *       *       *       *       *       *

    (3)(A) Any obligation of an individual under the 
Scholarship Program (or a contract thereunder) or the Loan 
Repayment Program (or a contract thereunder) for payment of 
damages may be released by a discharge in bankruptcy under 
title 11 of the United States Code [only if such discharge is 
granted after the expiration of the five year period]  only if 
such discharge is granted after the expiration of the 7-year 
period beginning on the first date that payment of such damages 
is required, and only if the bankruptcy court finds that 
nondischarge of the obligation would be unconscionable.

           *       *       *       *       *       *       *

    (e) Notwithstanding any other provision of Federal or State 
law, there shall be no limitation on the period within which 
suit may be filed, a judgment may be enforced, or an action 
relating to an offset or garnishment, or other action, may be 
initiated or taken by the Secretary, the Attorney General, or 
the head of another Federal agency, as the case may be, for the 
repayment of the amount due from an individual under this 
section.

           *       *       *       *       *       *       *


[SEC. 338H. REPORT AND AUTHORIZATION OF APPROPRIATIONS.

    [(a) Report.--The secretary shall report on march 1 of each 
year to the Committee on Labor and Human Resources of the 
Senate, the Committee on Energy and Commerce of the House of 
Representatives, and the Committees on Appropriations of the 
Senate and the House of Representatives on--
          [(1) the number of providers of health care who will 
        be needed for the Corps during the 5 fiscal years 
        beginning after the date the report is filed; and
          [(2) the number--
                  [(A) of scholarships the Secretary proposes 
                to provide under the Scholarship program during 
                such 5 fiscal years;
                  [(B) of individuals for whom the Secretary 
                proposes to make loan repayments under the Loan 
                Repayment Program during such 5 fiscal years; 
                and
                  [(C) of individuals who have no obligation 
                under section 338C and who the Secretary 
                proposes to have as members of the Corps during 
                such 5 fiscal years,
in order to provide such number of health care providers.
    [(b) Funding.--
          [(1) Authorization of appropriations.--For the 
        purpose of carrying out this subpart, there are 
        authorized to be appropriated $63,900,000 for fiscal 
        year 1991, and such sums as may be necessary for each 
        of the fiscal years 1992 through 2000.
          [(2) Reservation of amounts.--
                  [(A) Scholarships for new participants.--Of 
                the amounts appropriated under paragraph (1) 
                for a fiscal year, the Secretary shall obligate 
                not less than 30 percent for the purpose of 
                providing contracts for scholarships under this 
                subpart to individuals who have not previously 
                received such scholarships.
                  [(B) Scholarships for first-year study in 
                certain fields.--With respect to certification 
                as a nurse practitioner, nurse midwife, or 
                physician assistant, the Secretary shall, of 
                the amounts appropriated under paragraph (1) 
                for a fiscal year, obligate not less than 10 
                percent for the purpose of providing contracts 
                for scholarships under this subpart to 
                individuals who are entering the first year of 
                study in a course of study or program described 
                in subsection 338A(b)(1)(B) that leads to such 
                a certification. Amounts obligated under this 
                subparagraph shall be in addition to amounts 
                obligated under subparagraph (A).]

``SEC. 338H. AUTHORIZATION OF APPROPRIATIONS.

  ``(a) Authorization of Appropriations.--For the purposes of 
carrying out this subpart, there are authorized to be 
appropriated $146,250,000 for fiscal year 2002, and such sums 
as may be necessary for each of fiscal years 2003 through 2006.
  ``(b) Scholarships for New Participants.--Of the amounts 
appropriated under subsection (a) for a fiscal year, the 
Secretary shall obligate not less than 30 percent for the 
purpose of providing contracts for scholarships under this 
subpart to individuals who have not previously received such 
scholarships.
  ``(c) Scholarships and Loan Repayments.--With respect to 
certification as a nurse practitioner, nurse midwife, or 
physician assistant, the Secretary shall, from amounts 
appropriated under subsection (a) for a fiscal year, obligate 
not less than a total of 10 percent for contracts for both 
scholarships under the Scholarship Program under section 338A 
and loan repayments under the Loan Repayment Program under 
section 338B to individuals who are entering the first year of 
a course of study or program described in section 338A(b)(1)(B) 
that leads to such a certification or individuals who are 
eligible for the loan repayment program as specified in section 
338B(b) for a loan related to such certification.

SEC. 338I. GRANTS TO STATES FOR LOAN REPAYMENT PROGRAMS.

    (a) In General.--
          [(1) Authority for grants.--The Secretary, acting 
        through the Administrator of the Health Resources and 
        Services Administration, may make grants to States for 
        the purpose of assisting the States in operating 
        programs described in paragraph (2) in order to provide 
        for the increased availability of primary health 
        services in health professional shortage areas.]
          (1) Authority for grants.--The Secretary, acting 
        through the Administrator of the Health Resources and 
        Services Administration, may make grants to States for 
        the purpose of assisting the States in operating 
        programs described in paragraph (2) in order to provide 
        for the increased availability of primary health care 
        services in health professional shortage areas. The 
        National Advisory Council established under section 337 
        shall advise the Administrator regarding the program 
        under this section.

           *       *       *       *       *       *       *

    (e) Reports.--The Secretary may not make a grant under 
subsection (a) unless the State involved agrees--
          [(1) to submit to the Secretary reports providing the 
        same types of information regarding the program 
        operated pursuant to such subsection as reports 
        submitted pursuant to subsection (i) of section 338B 
        provide regarding the Loan Repayment Program under such 
        section; and]
          (1) to submit to the Secretary such reports regarding 
        the States loan repayment program, as are determined to 
        be appropriate by the Secretary; and

           *       *       *       *       *       *       *

    (i) Authorization of Appropriations.--
         [(1) In general.--For the purpose of making grants 
        under subsection (a), there is authorized to be 
        appropriated $10,000,000 for each of the fiscal years 
        1991 through 1995, and such sums as may be necessary 
        for each of the fiscal years 1998 through 2002.]
          (1) In general.--For the purpose of making grants 
        under subsection (a), there are authorized to be 
        appropriated $12,000,000 for fiscal year 2002 and such 
        sums as may be necessary for each of fiscal years 2003 
        through 2006.

           *       *       *       *       *       *       *

    [Section 338L is repealed.]

SEC. 338L. DEMONSTRATION PROJECT.

    (a) Program Authorized.--The Secretary shall establish a 
demonstration project to provide for the participation of 
individuals who are chiropractic doctors or pharmacists in the 
Loan Repayment Program described in section 338B.
    (b) Procedure.--An individual that receives assistance 
under this section with regard to the program described in 
section 338B shall comply with all rules and requirements 
described in such section (other than subparagraphs (A) and (B) 
of section 338B(b)(1)) in order to receive assistance under 
this section.
    (c) Limitations.--The demonstration project described in 
this section shall provide for the participation of individuals 
who shall provide services in rural and urban areas, and shall 
also provide for the participation of enough individuals to 
allow the Secretary to properly analyze the effectiveness of 
such project.
    (d) Designations.--The demonstration project described in 
this section, and any providers who are selected to participate 
in such project, shall not be considered by the Secretary in 
the designation of a health professional shortage area under 
section 332 during fiscal years 2002 through 2004.
    (e) Rule of Construction.--This section shall not be 
construed to require any State to participate in the project 
described in this section.
    (f) Report.--
          (1) In general.--The Secretary shall prepare and 
        submit a report describing the information described in 
        paragraph (2) to--
                  (A) the Committee on Health, Education, 
                Labor, and Pensions of the Senate;
                  (B) the Subcommittee on Labor, Health and 
                Human Services, and Education of the Committee 
                on Appropriations of the Senate;
                  (C) the Committee on Energy and Commerce of 
                the House of Representatives; and
                  (D) the Subcommittee on Labor, Health and 
                Human Services, and Education of the Committee 
                on Appropriations of the House of 
                Representatives.
          (2) Content.--The report described in paragraph (1) 
        shall detail--
                  (A) the manner in which the demonstration 
                project described in this section has affected 
                access to primary care services, patient 
                satisfaction, quality of care, and health care 
                services provided for traditionally underserved 
                populations;
                  (B) how the participation of chiropractic 
                doctors and pharmacists in the Loan Repayment 
                Program might affect the designation of health 
                professional shortage areas; and
                  (C) the feasibility of adding chiropractic 
                doctors and pharmacists as permanent members of 
                the National Health Service Corps.
    (g) Authorization of Appropriations.--There are authorized 
to be appropriated to carry out this section, such sums as may 
be necessary for fiscal years 2002 through 2004.

           *       *       *       *       *       *       *


                          SOCIAL SECURITY ACT


                          PAYMENTS OF BENEFITS

    Sec. 1833. (a) * * *

           *       *       *       *       *       *       *

    (b) Before applying subsection (a) with respect to expenses 
incurred by an individual during any calendar year, the total 
amount of the expenses incurred by such individual during such 
year (which would, except for this subsection, constitute 
incurred expenses from which benefits payable under subsection 
(a) are determinable) shall be reduced by a deductible of $75 
for calendar years before 1991 and $100 for 1991 and subsequent 
years; except that (1) such total amount shall not include 
expenses incurred for items and services described in section 
1681(s)(10(A), (2) such deductible shall not apply with respect 
to home health services (other than a covered osteoporosis drug 
(as defined in section 1861(kk)), (3) such deductible shall not 
apply with respect to clinical diagnostic laboratory tests for 
which payment is made under this part (A) under subsection 
(a)(1)(D)(i) or (a)(2)(D)(i) on an assignment-related basis, or 
to a provider having an agreement under section 1866, or (B) 
the basis of a negotiated rate determined under subsection 
(h)(6), (4) [such deductible shall not apply to Federally 
qualified health center services.] such deductible shall not 
apply to rural health clinic services made available through a 
rural health clinic to which members of the National Health 
Service Corps are assigned under section 333 of the Public 
Health Service Act, provided to an individual who qualifies for 
subsidized services under the Public Health Service Act or 
Federally qualified health center services. The total amount of 
the expenses incurred by an individual as determined under the 
preceding sentence shall, after the reduction specified in such 
sentence, be further reduced by an amount equal to the expenses 
incurred for the first three pints of whole blood (or 
equivalent quantities of packed red blood cells, ad defined 
under regulations) furnished to the individual during the 
calendar year, except that such deductible for such blood shall 
in accordance with regulations be appropriately reduced to the 
extent that there has been a replacement of such blood (or 
equivalent quantities of packed red blood cells, as so 
defined); and for such purposes blood (or equivalent quantities 
of packed red blood cells, as so defined) furnished such 
individual shall be deemed replaced when the institution or 
other person furnishing such blood (or such equivalent 
quantities of packed red blood cells, as so defined) is given 
one pint of blood for each pint of blood (or equivalent 
quantities of packed red blood cells, as so defined) furnished 
such individual with respect to which a deduction is made under 
this sentence. The deductible under the previous sentence for 
blood or blood cells furnished an individual in a year shall be 
reduced to the extent that a deductible has been imposed under 
section 1813(a)(2) to blood or blood cells furnished the 
individual in the year, (5) such deductible shall not apply 
with respect to screening mammography (as described in section 
1861(jj)), and (6) such deductible shall not apply with respect 
to screening pap smear and screening pelvic exam (as described 
invsection 1861(nn)).

           *       *       *       *       *       *       *


                                
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