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[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.''.

                                 <all>

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