[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4561 Introduced in House (IH)]
103d CONGRESS
2d Session
H. R. 4561
To amend the Public Health Service Act and the Social Security Act to
provide improved and expanded access to comprehensive primary health
care and related services for medically underserved and vulnerable
populations through the establishment of financial support for the
development of community-based health networks and plans, to allow
federally-assisted health centers to expand their capacity and develop
and operate new sites to serve underserved and vulnerable populations,
to provide certain financial and other protections for such networks,
plans, and health centers, and to facilitate the involvement of, and
payment to, entities serving underserved and vulnerable populations in
the training and education of primary care health professionals.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 9, 1994
Mr. Rangel (for himself, Mr. Richardson, Mr. Bonior, Mr. Owens, Mr.
Sanders, Mr. Parker, Mrs. Clayton, Mr. Rush, Mr. Abercrombie, Mrs.
Meek, Mr. Olver, Mr. Dellums, Ms. Velazquez, Mr. Barrett of Wisconsin,
and Mr. Edwards of California) introduced the following bill; which was
referred jointly to the Committees on Energy and Commerce and Ways and
Means
_______________________________________________________________________
A BILL
To amend the Public Health Service Act and the Social Security Act to
provide improved and expanded access to comprehensive primary health
care and related services for medically underserved and vulnerable
populations through the establishment of financial support for the
development of community-based health networks and plans, to allow
federally-assisted health centers to expand their capacity and develop
and operate new sites to serve underserved and vulnerable populations,
to provide certain financial and other protections for such networks,
plans, and health centers, and to facilitate the involvement of, and
payment to, entities serving underserved and vulnerable populations in
the training and education of primary care health professionals.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) Short Title.--This Act may be cited as the ``Access to
Community Health Care Act of 1994''.
(b) Findings.--The Congress finds the following:
(1) Efforts to assure universal coverage for comprehensive
benefits are a vitally important part of achieving effective
national health care reform.
(2) The provision of universal insurance coverage, while
vitally important, will not alone address the critical needs of
the estimated 3 million Americans who are underserved by the
current health care system, and who lack access to the most
basic health services.
(3) Access to, and coordination of, health care is
especially difficult for those Americans who live in
underserved rural and inner-city communities or who are members
of other vulnerable groups, including migratory and seasonal
agricultural workers, persons who are homeless, those with HIV
infection, those who suffer from substance addiction, high-risk
pregnant women, infants and children, immigrants and refugees,
and persons with disabilities.
(4) The consequences of poor access to, and lack of
coordination of, health care among the underserved is evidenced
by elevated infant and childhood illness and mortality rates,
over-utilization of emergency rooms and other inappropriate
providers for primary care services, and hospitalization rates
for preventable conditions that are significantly higher than
the national average.
(5) Efforts to provide increased access to, and coordinate
the delivery of, vital primary health care and related services
for underserved and vulnerable Americans will not only
contribute to improved health status, but will also reduce
unnecessary care and the overall costs of health care.
(6) Essential community providers, such as the community
and migrant health centers, collectively referred to as health
centers, which serve more than 7 million needy Americans,
provide an effective and proven model for extending access to
all underserved and vulnerable Americans.
(7) Support for the development and operation of new and
expanded sites served by the health centers and similar primary
health care providers, is needed to extend access to
comprehensive primary health care services for the millions of
Americans who remain unserved or underserved.
(8) As managed care has achieved recognition as a means of
organizing and paying for health care for many Americans, there
is a need to assure that such arrangements develop in a manner
that is responsive to the needs of underserved people and
communities. Of particular importance is development of
community-based networks of health centers and other essential
community providers that offer high quality care to individuals
and that endeavor to both contain costs and reduce unnecessary
or inappropriate use of high-cost services.
(9) Essential community providers such as health centers
and community-based networks serving such populations must be
afforded certain protections from full financial risk for the
cost of serving such populations and communities. Protections
are needed because underserved populations typically require
more frequent and intensive care, and because reduced use of
higher-cost inpatient, emergency and specialty care will depend
on increased provision of primary care as well as related and
enabling services.
(10) Health centers and community-based networks that
participate in arrangements which produce savings of grant
funds or increased revenues that will be used to further expand
or improve services to medically underserved populations should
be afforded protection from anti-kickback laws.
(11) Health centers, community-based networks and other
essential community providers of comprehensive primary care
services to the underserved provide the most appropriate
locations and conditions for educating and training primary
health care professionals, and should be centrally involved in
such education and training efforts.
SEC. 2. GRANTS FOR THE DEVELOPMENT AND OPERATION OF HEALTH CENTERS AND
COMMUNITY HEALTH NETWORKS AND HEALTH PLANS.
(a) Enabling and Outreach Services.--Section 330(a) of the Public
Health Service Act (42 U.S.C. 254c(a)) is amended--
(1) in paragraph (5), by striking ``and'' at the end;
(2) in paragraph (6), by inserting before ``patient case
management services'' the following: ``the services of outreach
workers and others to determine, or assist in determining, the
eligibility of individuals to receive services and benefits
under Federal, State and local health programs, and to assist
such individuals in enrolling in such programs, and other'';
(3) in paragraph (6), by adding ``and'' after the comma at
the end; and
(4) by inserting after paragraph (6) the following new
paragraph:
``(7) enabling services, defined as services that are not
otherwise described in this subsection, that promote access to
necessary health and other human and social services, and that
increase the capacity of individuals to utilize the items and
services included as covered benefits under Federal, State, and
local health programs,''.
(b) Services Authorized at Schools and Other Appropriate
Locations.--Section 330(a) of the Public Health Service Act (42 U.S.C.
254c(a)) is amended in
the matter preceding paragraph (1) by striking ``provides--'' and
inserting the following: ``provides, at appropriate locations, which
may include schools and other sites--''.
(c) Community Health Service Networks and Plans.--Section 330 of
the Public Health Service Act (42 U.S.C. 254c) is amended by adding at
the end the following subsection:
``(l)(1) The Secretary may make a grant to one or more community
health centers that receive grants under subsection (d)(l)(A), or to
one or more Federally qualified health centers as defined in section
1861(aa)(4) of the Social Security Act, to support the development of a
community health service network or plan as defined in paragraph (3).
The costs for which a grant may be made under this paragraph include,
but are not limited to--
``(A) costs of developing the network or plan as a
corporate entity, including planning and needs assessment, and
costs of developing appropriate contractual agreements between
the participating providers and the network or plan;
``(B) costs of development of internal management for the
network or plan, as well as costs of development of financial,
legal, clinical, information systems (exclusive of systems that
the Secretary determines are information highways), billing and
reporting systems for the network or plan;
``(C) costs of development of additional sites that will
assure or enhance the provision and accessibility of primary
health care and enabling services to medically underserved
populations, and residents of health professional shortage
areas;
``(D) costs of recruitment, training, compensation of
health professionals and administrative staff;
``(E) costs of acquisition, expansion, modernization of
facilities, conversion of unneeded hospital facilities to
facilities that will assure or enhance the provision and
accessibility of primary health care and enabling services, as
well as construction of new facilities and purchase of major
equipment (including equipment necessary for support of
external and internal information systems);
``(F) reserves required for furnishing services on a
prepaid basis; and
``(G) such other costs as are necessary to assure that the
network or plan will be ready to assume operational status by
the end of the planning and development phase.
``(2) The Secretary may make grants to support the operation of
community health service networks or plans which received support under
paragraph (1) for planning and development and which meet the
requirements of subparagraphs (A) and (B) of paragraph (3). The costs
for which a grant may be made include, but are not limited to, the
costs described in paragraph (1), and the otherwise unreimbursed costs
of furnishing services described in subsection (a) (except for the
costs of inpatient hospital services, extended care facility services
and long-term physical medicine) to medically underserved populations
and residents of health professional shortage areas and other hard-to-
reach populations.
``(3)(A)(i) For purposes of this section, the term `community
health service network' means a consortium of health care providers
that meets the following requirements:
``(I) The consortium is a public or nonprofit private
entity whose principal purpose is, with respect to the items
and services that are described in subsection (a), to provide
all or a portion of such items and services to a significant
number of individuals who are members of a medically
underserved population or populations, residents of health
professional shortage areas and other hard-to-reach populations
in the network service area.
``(II) The participation of health care providers in the
consortium is governed by a written agreement to which each of
the participating providers is a party.
``(ii) For purposes of this section, the term `community health
service plan' means a health plan that meets the following conditions:
``(I) The health plan is a public or nonprofit private
entity, as defined in section 1903(m)(2)(A) of the Social
Security Act, whose principal purpose is, with respect to the
items and services that are described in subsection (a) to
provide all or a portion of the items and services to a
significant number of individuals who are members of a
medically underserved population or populations, residents of
health professional shortage areas in the plan's service area,
and other hard-to-reach populations in the plan's service area.
``(II) The participation of health care providers in the
health plan is governed by a written agreement to which each of
the participating providers is a party.
``(B) A community health service network or plan must--
``(i) be governed by individuals a majority of whom are
registered patients of the network or plan or are
representatives of the entities described in clause (iv)(I), or
a combination of such individuals;
``(ii) assure the provision of services through
participating providers (who may provide services directly or
through contract) in accordance with all requirements of
subsection (e)(3) except subparagraph (G);
``(iii) be reasonable in size to accomplish the objectives
of this section;
``(iv) include as participating providers (unless such
provider(s) decline to participate): (I) at a minimum, all
entities providing health services under grants under this
section or section 329 or 340, and other Federally qualified
health centers certified in accordance with section 1861(aa)(4)
of the Social Security Act in the service area of the plan or
network; (II) a reasonable number and combination (to assure
that services will be comprehensive and accessible) of public
or nonprofit private entities that are entities providing
health services under grants under section 340A, 1001, or title
XXIII, under title V of the Social Security Act, under title V
of the Indian Health Care Improvement Act, and under the Indian
Self-Determination Act; that are rural health clinics certified
in accordance with section 1861(aa)(2) of the Social Security
Act; that are local and State public health agencies; and that
collectively provide primary health and enabling services to
residents of the network or plan service area; and (III) at the
option of the network or plan, any other public or private
entity that provides primary health, enabling services and/or
supplemental health services to the population served by the
network or plan; and
``(v) assure that each participating provider agrees to
provide services regardless of an individual's ability to pay.
``(4)(A) No grant may be made under paragraph (1) or (2) unless an
application therefor is submitted to, and approved by, the Secretary.
Such an application shall be submitted in such form and manner and
shall contain such information as the Secretary shall prescribe,
including (i) with respect to applications for planning and development
the information required by subsection (c)(4) and a demonstration of
how the applicant will meet all requirements of paragraph (3) of this
subsection by the end of the period of support under paragraph (1); and
(ii) with respect to applications for operations, the information
required by subsection (e).
``(B) In evaluating applications submitted under paragraph (1), the
Secretary shall consider--
``(i) the extent to which the applicant proposes to provide
or expand the provision of services described in subsection (a)
in a manner which is coordinated and assures accessibility of
service to medically underserved populations and health
professional shortage areas and which will otherwise meet the
requirements of paragraph (3) when the network or plan assumes
operational status;
``(ii) the relative need of the populations and areas
proposed to be served for the services proposed to be provided;
``(iii) whether the proposed network or plan described in
the application is reasonable in size and capacity;
``(iv) whether the proposed network or plan will address
such other needs of the medically underserved population or
populations and health professional shortage areas to be served
as the applicant or the Secretary may identify;
``(v) evidence of State and local support for the network
or plan; and
``(vi) whether the proposed budget to support the network
or plan, is reasonable and justified, taking into account other
sources of support for the proposed network or plan and
considering whether levels of support previously received from
other sources have been maintained.
``(5) No more than two grants may be made for planning and
developing the same network or plan.''.
(d) Flexible Authority.--Section 330 of the Public Health Service
Act, as amended by subsection (c) of this subsection, is amended by
adding at the end the following subsection:
``(m)(1) The Secretary may make grants to public and nonprofit
private entities that meet all of the requirements of subsection (l),
except for paragraph (3)(B)(i) and such other requirements of that
subsection as the Secretary may decide for good cause to waive, for the
purpose of planning, development and operation of health networks and
health plans as the Secretary determines will provide or enhance the
provision and accessibility of the services that are described in
subsection (a) to medically underserved populations and health
professional shortage areas in the service area of the network or plan.
``(2) An application for a planning and development grant must meet
the requirements of clause (i) of subsection (l)(4)(A) and an
application for an operations grant must meet the requirements of
clause (ii) of such subsection.
``(3)(A) In evaluating applications submitted under paragraph (2),
the Secretary will consider the factors described in subsection
(l)(4)(B).
``(B) The Secretary may not approve an application for a grant
under this subsection unless the Secretary determines that the network
or plan will at a minimum assure significant community involvement. For
purposes of this subsection, `significant community involvement' is
demonstrated if the health network, or health plan (i) is governed by a
board of directors, at least one-third of the members of which are
registered patients or representatives of entities described in
subsection (l)(3)(B)(iv)(I), or a combination of such individuals; or
(ii) has established a patient advisory council, composed of
representative registered patients of the network or plan, through
which registered patients are able to directly participate in decisions
that influence the character and implementation of programs of the
network or plan. The Secretary shall give priority to applicants that
meet the requirements of clause (i) over applicants that meet the
requirements of clause (ii).
``(4) No more than two grants may be made for planning and
developing the same health network or health plan.
``(5) The costs for which a grant may be made under this subsection
for planning and development of a health network or health plan may
include the costs described in paragraph (1) of subsection (l), and the
costs for which a grant may be made for operation of such a health
network or health plan may include the costs described in paragraph (2)
of such subsection.''.
(e) Authorization of Appropriations.--(1) Section 330(g)(1)(A) of
the Public Health Service Act (42 U.S.C. 254c(g)(1)(A)) is amended by
striking ``there are authorized'' and all that follows and inserting
the following: ``there are authorized to be appropriated $925,000,000
for fiscal year 1995, $1,425,000,000 for fiscal year 1996,
$1,625,000,000 for fiscal year 1997, $1,725,000,000 for fiscal year
1998, $1,725,000,000 for fiscal year 1999, $1,725,000,000 for fiscal
year 2000, and such sums equal to or greater than $1,725,000,000 as may
be necessary for each of the fiscal years 2001 through 2005. The
preceding sentence constitutes budget authority in advance of
appropriations acts and represents the obligation of the Federal
government to provide funding for payments in the amounts, and for the
fiscal years specified under this section. Such levels shall not be
subject to offset or reprogramming for any reason.''.
(2) Section 330(g)(1) of the Public Health Service Act (42 U.S.C.
254c(g)(1)) is amended by adding at the end the following new
subparagraph:
``(C)(i) For the purpose of making grants for activities authorized
under subsection (m), the Secretary is authorized to expend up to 15
percent of the amounts appropriated under subparagraph (A) for a fiscal
year that are in excess of $625,000,000. The authority of the Secretary
to make grants for such activities is effective for any fiscal year
only to such extent or in such amounts exceeding $625,000,000 as are
provided in appropriation Acts; and (ii) for the purpose of making
grants under subsections (c) and (d), the Secretary shall spend not
less than $625,000,000 each year.''.
(f) Funding Preferences.--Section 330(k) of the Public Health
Service Act (42 U.S.C. 254c(k)) is amended--
(1) by inserting ``(1)'' after ``(k)''; and
(2) by adding at the end the following new paragraph:
``(2) In making grants under this section, the Secretary shall give
preference as follows:
``(A) As between an application for a grant under
subsection (l) to plan, develop or operate a community health
service network or plan and an application for a grant under
subsection (m) to plan, develop or operate a health network or
plan serving the same medically underserved population, the
Secretary shall give preference to the applicant that is or
will be a community health service plan or network in
accordance with subsection (l).
``(B) As between two or more applications under subsection
(m) to serve the same medically underserved population,
preference shall be given to applicants that include as
participating providers the greatest number of entities
providing health services under grants under section 329, this
section, and section 340.''
(g) Miscellaneous and Conforming Amendments.--
(1) Section 330(c)(1)(A) of the Public Health Service Act
(42 U.S.C. 254c(c)(1)(A)) is amended by inserting ``enabling
services,'' before ``primary health services,''.
(2) Section 330(c) of the Public Health Service Act (42
U.S.C. 254c(c)) is amended--
(A) in paragraph (1), in the matter preceding
subparagraph (A), by striking ``loans) and shall
include--'' and inserting ``loans).''; and
(B)(i) by transferring subparagraphs (A) through
(D) of paragraph (1) from the current placement of the
subparagraphs;
(ii) by inserting before such subparagraph (A) the
following:
``(4) No grant may be made under paragraph (1) unless an
application therefor is submitted to and approved by, the Secretary.
Such an application shall be submitted in such form and manner and
contain such information as the Secretary may prescribe, and shall
include:''; and
(iii) by adding paragraph (4) (as so designated) at
the end.
(3) Section 330(e)(2) of the Public Health Service Act (42
U.S.C. 254c(e)(2)) is amended--
(A) by striking ``a grant under'' in the matter
preceding subparagraph (A) and all that follows through
``also include a demonstration'' and inserting the
following: ``a grant under subsection (d)(1) shall
include a demonstration''; and
(B) by adding at the end the following sentence:
``An application for a grant under subparagraph (B) of
subsection (d)(1) must demonstrate how the entity will
meet all of the requirements of subsection (e)(3) by
the end of the period of support under that
subsection.''.
(4) Section 330(e)(3) of the Public Health Service Act (42
U.S.C. 254c(e)(3)) is amended in the matter after and below
subparagraph (K) by adding at the end the following sentence:
``The Secretary may not approve an application under subsection
(d)(l)(B) unless the Secretary determines that the entity will
meet all of the requirements of this paragraph by the end of
the period of support under that subsection.''
(5) Section 330(e)(6) of the Public Health Service Act (42
U.S.C. 254c(e)(6)) is amended--
(A) by striking ``(c) or (d)'' and inserting ``(c),
(d), or (l)''; and
(B) by inserting ``, network, or plan'' after
``community health center''.
(6) Section 330(f)(1) of the Public Health Service Act (42
U.S.C. 254c(f)(1)) is amended by striking ``(e)(2)'' and
inserting ``(e)(3)''.
(7) Section 330(i) of the Public Health Service Act (42
U.S.C. 254c(i)) is amended in each of paragraphs (1) and (2) by
striking ``under subsection (d)'' and inserting ``under this
section''.
SEC. 3. ESTABLISHING A PROGRAM OF LOANS AND LOAN GUARANTEES.
(a) Loans and Loan Guarantees.--Subpart I of part D of title III of
the Public Health Service Act (42 U.S.C. 254b et seq.) is amended by
adding at the end the following new section:
``federal loan and loan guarantee program
``Sec. 330A. (a) Loans and Loan Guarantees.--
``(1) From the fund established pursuant to subsection (b),
the Secretary may make loans and guarantee the payment of
principal and interest to Federal and non-Federal lenders for
loans to any public or nonprofit private entity that receives a
grant under sections 329, 330, or 340 for projects for--
``(A) the acquisition, modernization, expansion or
construction of facilities, or the conversion of
unneeded hospital facilities to facilities that will
assure or enhance the provision and accessibility of
primary health care and enabling services to medically
underserved populations;
``(B) the purchase of major equipment, including
equipment necessary for the support of external and
internal information systems;
``(C) the establishment of reserves required for
furnishing services on a prepaid basis; and
``(D) such other capital costs as the Secretary may
determine are necessary to enable the grant recipient
to achieve the objectives of sections 329, 330 or 340,
as applicable.
``(2)(A) In making loans and loan guarantees authorized
under this section, the Secretary shall give preference to
applications of community health centers that have received
grants under section 330(d)(1)(A) and community health service
networks or plans that have received grants under section
330(l).
``(B) Priority shall be given to applications for projects
for the renovation and modernization of medical facilities
necessary to prevent or eliminate safety hazards, avoid
noncompliance with licensure or accreditation standards, or
projects to replace obsolete facilities.
``(C) The Secretary may make loans or loan guarantees for
the construction of new buildings only if the Secretary
determines that appropriate facilities are not available
through acquiring, modernizing, expanding or converting
existing buildings, or that construction of new buildings will
cost less.
``(3) The Secretary may pay, to the holder of a loan under
paragraph (1), for and on behalf of the project for which the
loan was made, amounts sufficient to reduce, up to seventy five
percent the net effective interest rate otherwise payable on
such loan, if the Secretary finds that without such assistance
the project could not be undertaken.
``(4) The principal amount of a loan directly made or
guaranteed under this section may, when added to any other
assistance under sections 329, 330, or 340, cover up to one
hundred percent of such costs.
``(5) The cumulative total of the principal of the loans
outstanding at any time with respect to which guarantees have
been issued, or which have been directly made, may not exceed
limitations as may be specified in appropriation Acts.
``(6)(A) The Secretary may not approve a loan guarantee for
a project under this section unless he determines that the
terms, conditions, security (if any), and schedule and amount
of repayments with respect to the loan are sufficient to
protect the financial interests of the United States and are
otherwise reasonable.
``(B) Guarantees of loans under this section shall be
subject to such further terms and conditions as the Secretary
determines to be necessary to assure that the purposes of this
section will be achieved.
``(7)(A) The Secretary may approve a loan under this
section only if--
``(i) the Secretary is reasonably satisfied that
the applicant for the project for which the loan would
be made will be able to make payments of principal and
interest thereon when due, and--
``(ii) the applicant provides the Secretary with
reasonable assurances that there will be available to
it such additional funds as may be necessary to
complete the project or undertaking with respect to
which such loan is requested.
``(B) Any loan made under this section shall (i) have such
security, (ii) have such maturity date, (iii) be repayable in
such installments, (iv) bear interest at a rate comparable to
the rate of interest prevailing on the date the loan is made,
with respect to loans guaranteed under this section, minus any
interest subsidy made in accordance with paragraph (3), and (v)
be subject to such other terms and conditions (including
provisions for recovery in case of default), as the Secretary
determines to be necessary to carry out the purposes of this
section and sections 329, 330 and 340, as applicable, while
adequately protecting the financial interests of the United
States.
``(C) The Secretary may, for good cause but with due regard
to the financial interests of the United States, waive any
right of recovery which he has by reasons of the failure of a
borrower to make payments of principal of and interest on a
loan made under this subsection, except that if such loan is
sold and guaranteed, any such waiver shall have no effect upon
the Secretary's guarantee of timely payment of principal and
interest.
``(b) Loan and Loan Guarantee Fund.--
``(1) There is established in the Treasury a loan and loan
guarantee fund (hereinafter in this subsection referred to as
the `fund') which shall be available as may be specified from
time to time in appropriations Acts to enable the Secretary to
make loans, loan guarantees, payment of interest subsidies and
such other actions as authorized under subsection (a). There
shall also be deposited in the fund amounts received by the
Secretary in connection with loans and loan guarantees under
this section and other property or assets derived by the
Secretary from operations respecting such loans and loan
guarantees, including any money derived from the sale of
assets.
``(2) There are authorized to be appropriated $100,000,000
for each fiscal year through fiscal year 2005 and such
additional amounts as may be necessary to provide the sums
required for the fund. The preceding sentence constitutes
budget authority in advance of appropriations acts and
represents the obligation of the federal government to provide
funding for payments in the amounts and for the fiscal years
authorized under this section.
``(c) Default.--
``(1) The Secretary may take such action as may be
necessary to prevent a default on a loan made or guaranteed
under subsection (a), including the waiver of regulatory
conditions, deferral of loan payments, renegotiation of loans,
and the expenditure of funds for technical and consultative
assistance, for the temporary payment of the interest and
principal on such a loan, and for other purposes.
``(2) The Secretary may take such action, consistent with
State law respecting foreclosure procedures, as the Secretary
deems appropriate to protect the interest of the United States
in the event of a default on a loan made or guaranteed under
subsection (a), including selling real property pledged as
security for such a loan or loan guarantee and for a reasonable
period of time taking possession of, holding, and using real
property pledged as security for such a loan or loan guarantee.
``(d) Applications.--No loan or loan guarantee may be made under
this section unless an application is submitted to and approved by the
Secretary. The application shall be in the form and manner and contain
such information as the Secretary may prescribe, and if the project is
for construction, conversion, expansion or modernization of a facility,
the application shall at a minimum meet the requirements of Section
330(e)(l) of this Act.
``(e) Right of Recovery.--
``(1) If any facility with respect to which a loan or loan
guarantee was made under this section, or with respect to which
a grant was made under sections 329, 330, or 340, for
construction, acquisition, expansion or modernization, shall at
any time within twenty years after completion--
``(A) be sold or transferred to any entity which is
not eligible for assistance under sections 329, 330 or
340 or which is not approved by the Secretary as a
transferee, or
``(B) cease to be a public or nonprofit entity that
is eligible for assistance under sections 329, 330 or
340,
the United States shall be entitled to recover from the
recipient of the grant, loan or loan guarantee, the purchaser
or transferee, the amount of the grant, loan or loan guarantee
plus interest. This right of recovery shall not constitute a
lien on any facility with respect to which funds have been paid
under this section.
``(2) Notwithstanding paragraph (1), the Secretary shall
subordinate or waive the right of recovery and any other
Federal interest that may be derived by virtue of a loan or
loan guarantee under this section, or a grant under sections
329, 330, or 340, to support the construction, acquisition,
modernization, expansion, conversion of a facility or other
capital project authorized under this section, where the
facility is being used as security for a new loan which will
support improvements to the facility, construction of new
primary health care facilities or improvements of health
services described in section 330(a) to medically underserved
populations, or where the facility is being sold in order to
finance the acquisition or construction of another facility
which will be used for the purposes authorized by sections 329,
330 or 340, provided that the Secretary shall obtain an
equivalent right of recovery or interest in the new
facility.''.
SEC. 4. AMENDMENTS TO THE MIGRANT HEALTH CENTERS AND HEALTH CARE FOR
THE HOMELESS PROGRAM AUTHORITIES.
(a) Enabling and Outreach Services.--(1) Section 329(a)(1) of the
Public Health Service Act (42 U.S.C. 254b(a)(1)) is amended--
(A) in the matter preceding subparagraph (A), by striking
``provides--'' and inserting the following: ``provides, at
appropriate locations, which may include schools and other
sites--'';
(B) in subparagraph (H), by inserting before ``patient case
management services'' the following: ``the services of outreach
workers and others to determine, or assist in determining, the
eligibility of individuals to receive services and benefits
under Federal, State and local health programs, and to assist
such individuals in enrolling in such programs, and other'';
(C) in subparagraph (G), by striking ``and'' at the end;
(D) in subparagraph (H), by adding ``and'' after the comma
at the end; and
(E) by inserting after subparagraph (H) the following new
subparagraph:
``(I) enabling services, defined as services that are not
otherwise described in this subsection, that promote access to
necessary health and other human and social services, and that
increase the capacity of individuals to utilize the items and
services that are included as covered benefits under Federal,
State, or local health programs,''.
(2) Section 340(i) of the Public Health Service Act (42 U.S.C.
256(i)) is amended--
(A) in paragraph (1)--
(i) in subparagraph (B), by adding ``and'' after
the semicolon at the end;
(ii) in subparagraph (C), by striking ``; or'' and
inserting a period; and
(iii) by striking subparagraph (D); and
(B) in paragraph (2), by amending the paragraph to read as
follows:
``(2) Any grant may include the acquisition, expansion, or
modernization of existing buildings, and the construction of new
buildings (if the Secretary determines that appropriate facilities are
not available through the acquisition, expansion or modernization of
existing buildings, or that construction of a new building will cost
less).''
(3) Section 340(r)(1) of the Public Health Service Act (42 U.S.C.
256(r)(1)) is amended by inserting before ``and substance abuse
services'' the following: ``, supplemental health services, enabling
services,''.
(4) Section 340(r)(6) of the Public Health Service Act (42 U.S.C.
256(r)(6)) is amended to read as follows:
``(6) The terms `primary health services', `supplemental
health services' and `enabling services', have the meanings
given such terms in section 330.''.
(b) Authorization of Appropriations.--(1) Section 329(h)(1)(A) of
the Public Health Service Act (42 U.S.C. 254b(h)(1)(A)) is amended by
striking ``there are authorized'' and all that follows and inserting
the following: ``there are authorized to be appropriated $100,000,000
for fiscal year 1995, $110,000,000 for fiscal year 1996, $120,000,000
for fiscal year 1997, $130,000,000 for fiscal year 1998, $140,000,000
for fiscal year 1999, $150,000,000 for fiscal year 2000, and such sums
equal to or greater than $150,000,000 as may be necessary for each of
the five fiscal years thereafter. The preceding sentence constitutes
budget authority in advance of appropriations acts and represents the
obligation of the Federal government to provide funding for payments in
the amounts, and for the fiscal years specified under this section.
Such levels shall not be subject to offset or reprogramming for any
reason.''.
(2) Section 340(q)(1) of the Public Health Service Act is amended
by striking ``There are authorized'' and all that follows and inserting
the following: ``There are authorized to be appropriated to carry out
this section $100,000,000 for fiscal year 1995, $110,000,000 for fiscal
year 1996, $120,000,000 for fiscal year 1997, $130,000,000 for fiscal
year 1998, $140,000,000 for fiscal year 1999, $150,000,000 for fiscal
year 2000, and such sums equal to or greater than $150,000,000 as may
be necessary for each of the five fiscal years thereafter. The
preceding sentence constitutes budget authority in advance of
appropriations acts and represents the obligation of the Federal
government to provide funding for payments in the amounts, and for the
fiscal years specified under this section. Such levels shall not be
subject to offset or reprogramming for any reason.''.
SEC. 5. EXPANDING THE NATIONAL HEALTH SERVICE CORPS.
(a) Additional Funding for Corps Programs.--Section 338(a) of the
Public Health Service Act (42 U.S.C. 254k) is amended--
(1) by redesignating paragraph (2) as paragraph (3); and
(2) by inserting after paragraph (1) the following new
paragraph:
``(2)(A) For the purpose of carrying out this paragraph, there are
authorized to be appropriated $50,000,000 for fiscal year 1995,
$100,000,000 for fiscal year 1996, and $200,000,000 for each of the
fiscal years 1997 through 2000. The preceding sentence constitutes
budget authority in advance of appropriations acts and represents the
obligation of the Federal government to provide funding for payments in
the amounts, and for the fiscal years, specified under this section.
Such levels shall not be subject to offset or reprogramming for any
reason.
``(B) The authorizations of appropriations established in
subparagraph (A) are in addition to the authorization of appropriations
in paragraph (1).
``(C) Of the amounts appropriated under subparagraph (A), the
Secretary shall reserve such amounts as may be necessary to ensure
that, of the aggregate number of individuals who are participants in
the Scholarship program under section 338A, or in the Loan Repayment
Program under section 338B, the total number who are being educated as
nurses or are serving as nurses, respectively, is increased to 20
percent.
``(D) Notwithstanding section 333(a)(3) and the priorities stated
in section 333A for approval of applications for the assignment of
Corps members, to the extent that additional funds appropriated
pursuant to subparagraph (A) increases the number of individuals
participating in the Scholarship Program under Section 338A of the
Public Health Service Act and in the Loan Repayment Program under
section 338B of such Act over the number of individuals participating
in such programs in fiscal year 1994, the Secretary shall give
preference in assigning those individuals to applicants that serve a
health professional shortage area and receive grants to provide health
services and enabling services under sections 329, 330 or 340
(including, but not limited to, networks and plans awarded funds under
section 330) and other Federally qualified health centers as defined in
section 1861(aa)(4) of the Social Security Act.''.
SEC. 6. FACILITATING THE PARTICIPATION OF COMMUNITY PROVIDERS IN HEALTH
PROFESSIONS TRAINING.
(a) Preference for Certain Health Professions Program Applicants.--
Section 791(a)(1) of the Public Health Service Act (42 U.S.C.
295j(a)(1)) is amended--
(1) by striking ``or under section 766 or 767,'' and
inserting the following: ``, under section 766 or 767, or under
section 777 or 778, in addition to preferences stated in such
sections,'';
(2)(A) by striking ``(B) during'' and inserting ``(ii)
during''; and
(B) by striking ``(A) has'' and inserting ``(B)(i) has'';
and
(3) by inserting before subparagraph (B) (as redesignated
by paragraph (2) of this subsection) the following new
subparagraph:
``(A) is (or is a co-applicant with) an entity that
receives support under section 329, 330, or 340, or
that is certified as a Federally qualified health
center under section 1861(aa)(4) of the Social Security
Act; and''.
(b) Preference for Certain Nurse Training Program Applicants.--
Section 860(e)(1)(A) of the Public Health Service Act (42 U.S.C. 298b-
7(e)(1)(A)) is amended--
(1) by inserting ``820(b), 820(c),'' before ``821,'';
(2) by inserting ``827,'' before ``830,'';
(3)(A) by striking ``(ii) during'' and inserting ``(II)
during''; and
(B) by striking ``(i) has'' and inserting ``(ii)(I) has'';
and
(4) by inserting before clause (ii) (as redesignated by
paragraph (3) of this subsection) the following new clause:
``(i) is (or is a co-applicant with) an
entity that receives support under section 329,
330, or 340, or that is certified as a
Federally qualified health center under section
1861(aa)(4) of the Social Security Act; and''.
(c) Payment for Direct Costs of Graduate Medical Education.--
Section 1886(h)(4)(E) of the Social Security Act (42 U.S.C.
1395ww(h)(4)(E)) is amended by inserting before the period at the end
the following: ``(or, in the case of activities performed at a
Federally qualified health center described in section 1861(aa)(4), if
the hospital incurs any of the costs for the training program at such
center and reimburses the center for any of the costs of the program
that the center incurs)''.
(d) Payment for Indirect Costs of Graduate Medical Education.--
Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(B)(iv)), as amended by section 13506 of the Omnibus Budget
Reconciliation Act of 1993 (Public Law 103-66; 107 Stat. 579), is
amended--
(1) by striking ``entity receiving a grant'' and all that
follows through ``control of the hospital'' and inserting
``Federally qualified health center described in section
1861(aa)(4)'';
(2) by striking ``all, or substantially all, of the costs''
and inserting ``any of the costs''; and
(3) by striking ``residents)'' and inserting the following:
``residents and reimburses the center for any of the costs of
the program that the center incurs)''.
(e) Clarifying Allowability of Costs.--Section 1833(a)(3) of the
Social Security Act (42 U.S.C. 1395l(a)(3)) is amended by inserting
after ``furnishing such services'' the following: ``(including, without
limitation, all costs associated with participation in an approved
medical residency training program)''.
(f) Effective Date.--The amendments made by subsections (c), (d),
and (e) shall apply to services furnished during cost reporting periods
beginning on or after October 1, 1994.
SEC. 7. PROVIDING SAFEGUARDS FOR RURAL HEALTH CLINICS AND FEDERALLY
QUALIFIED HEALTH CENTERS IN MEDICAID DEMONSTRATIONS.
(a) Section 1115(a)(1) of the Social Security Act (42 U.S.C.
1315(a)(1)) is amended by striking ``or 1902,'' and inserting the
following: ``or 1902 (other than paragraphs (13)(E), (10)(A), and (23)
of section 1902(a) insofar as such paragraphs require provision of,
payment for, and allow freedom of choice to select the provider of, the
care and services described in subparagraphs (B) and (C) of section
1905(a)(2)),''.
(b) Section 1115(a)(2) of the Social Security Act (42 U.S.C.
1315(a)(2)) is amended by inserting before the period at the end the
following: ``, except that this paragraph shall not provide authority
for the Secretary to waive compliance by a State with the requirements
of paragraph (2)(A)(ix) or (3) of section 1903(m)''.
(c) Section 1915(b) of the Social Security Act (42 U.S.C. 1396n(b))
is amended--
(1) in the matter preceding paragraph (1), by striking
``section 1905(a)(2)(C))'' and inserting ``subparagraphs (B)
and (C) of section 1905(a)(2))''; and
(2) in the matter after and below paragraph (4), by
striking ``section 1905(a)(4)(C)'' and inserting ``paragraphs
(2)(B), (2)(C), and (4)(C) of section 1905(a)''.
(d) Section 1903(m) of the Social Security Act (42 U.S.C. 1396b) is
amended by inserting after paragraph (2) the following new paragraph:
``(3) Notwithstanding sections 1115 and 1915(b), in the event that
a State agency contracts with an entity described in paragraph (2)(A)
or an entity similar to such entity, such State agency, upon receiving
an offer to provide health care services from a rural health clinic or
a Federally qualified health center operating in the same geographic
area as such entity, shall enter into a contract with such clinic or
center for the provision of all health care services referred to in
such offer and, unless the clinic or center elects otherwise, the
payment made by the State to such clinic or center for services
described in subparagraphs (B) and (C) of section 1905(a)(2) to the
individuals proposed to be served in the clinic's or center's offer
shall be made at the rates of payment specified in section
1902(a)(13)(E).''.
SEC. 8. PROVIDING SAFE HARBOR FOR CERTAIN COLLABORATIVE EFFORTS THAT
BENEFIT MEDICALLY UNDERSERVED PERSONS.
(a) Section 1128B(b)(3) of the Social Security Act (42 U.S.C.
1320a-7b(b)(3)) is amended--
(1) in subparagraph (D), by striking ``and'' after the
semicolon at the end;
(2) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following:
``(F) any remuneration paid by or to a recipient or
subrecipient of Federal grant funds under or in connection with
an arrangement for the procurement of goods or services by the
recipient or subrecipient, the referral of patients, or the
lease or purchase of space or equipment, provided that the
following requirements are met:
``(i) The arrangement is in writing and signed by
the parties.
``(ii) The arrangement will result in the savings
of Federal grant funds or increased revenues to the
recipient or subrecipient that will be used to increase
the availability or accessibility of services to a
medically underserved population served by the
recipient or subrecipient or an improvement in the
quality of services to such population; provided that
the recipient or subrecipient may seek a prior
determination from the Public Health Service that this
requirement is met and, if the recipient or
subrecipient does so, Public Health Service approval
shall be conclusive and binding on the Federal
Government.
``(iii) The arrangement will not result in private
inurement to any current employees or members of the
Board of Directors of the recipient or subrecipient, or
to agents of the recipient or subrecipient who were
involved in recommending or negotiating the
arrangement.
``(iv) With respect to an arrangement under which a
recipient or subrecipient is procuring goods or
services, the provider of the goods or services is the
only provider able to supply such goods or services, or
the recipient or subrecipient has engaged in a
competitive process to procure the goods or services
that meets the requirements for competition under
Federal grant awards.
``(v) With respect to an arrangement for a referral
of patients, the arrangement will assure that all
patients covered or affected by the arrangement are
advised that they may request a referral to any person
or entity of their choosing, subject to appropriate
contractual limitations under which the recipient or
subrecipient may operate as a health plan or as a
contract health plan provider and such limitations as
the patient may be under as an enrollee of a health
plan.
``(vi) With respect to an arrangement for a
referral of patients, the arrangement will not
interfere with the discretion of health professionals
to refer patients in a manner they believe will most
appropriately deal with a patient's particular
circumstances, subject to appropriate contractual
limitations under which the recipient or subrecipient
may operate as a health plan or as a contract health
plan provider and such limitations as the patient may
be under as an enrollee of a health plan.
For any arrangement that does not meet the above requirements,
paragraphs (1) and (2) shall not apply when the recipient or
subrecipient of Federal grant funds has applied to the
Secretary for approval of the arrangement and the Secretary,
after consultation with the Department of Health and Human
Services Office of Inspector General, has approved the
arrangement based upon a finding that the arrangement will
produce a substantial benefit to a medically underserved
population that outweighs the arrangement's failure to fully
satisfy all of the above requirements. For any arrangement
existing on the date of enactment of this subparagraph (F)
involving a recipient or subrecipient of Federal grant funds
that does not meet the foregoing requirements and would subject
the recipient or subrecipient to criminal penalties under
paragraphs (1) or (2), the recipient or subrecipient shall be
immune from criminal prosecution under paragraphs (1) or (2),
provided that within six months after enactment of this
subparagraph (F) the arrangement is terminated or amended to
conform to the requirements of this subparagraph (F).
For purposes of this section, a `recipient' shall mean a public or
nonprofit private entity that receives a grant or cooperative agreement
under the Public Health Service Act or title V of this Social Security
Act. For purposes of this section, a `subrecipient' shall mean a public
or nonprofit private entity that performs substantive work under a
grant or cooperative agreement under the Public Health Service Act or
title V of this Act to a recipient.''.
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