[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)).
* * * * * * *