S. 641

One Hundred Fourth Congress

of the

United States of America

AT THE SECOND SESSION

Begun and held at the City of Washington on Wednesday,

the third day of January, one thousand nine hundred and ninety-six

An Act

An Act to amend the Public Health Service Act to revise and extend programs

established pursuant to the Ryan White Comprehensive AIDS Resources Emergency Act of 1990.

Be it enacted by the Senate and House of Representatives of

the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘‘Ryan White CARE Act Amendments of 1996’’.

SEC. 2. REFERENCES.

Whenever in this Act an amendment is expressed in terms

of an amendment to a section or other provision, the reference

shall be considered to be made to a section or other provision

of the Public Health Service Act (42 U.S.C. 201 et seq.).

SEC. 3. GENERAL AMENDMENTS.

(a) PROGRAM OF GRANTS.—

(1) NUMBER OF CASES.—Section 2601(a) (42 U.S.C. 300ff–

11) is amended—

(A) by striking ‘‘subject to subsection (b)’’ and inserting

‘‘subject to subsections (b) through (d)’’; and

(B) by striking ‘‘metropolitan area’’ and all that follows

and inserting the following: ‘‘metropolitan area for which

there has been reported to the Director of the Centers

for Disease Control and Prevention a cumulative total of

more than 2,000 cases of acquired immune deficiency syndrome for the most recent period of 5 calendar years for

which such data are available.’’.

(2) OTHER PROVISIONS REGARDING ELIGIBILITY.—Section

2601 (42 U.S.C. 300ff–11) is amended by adding at the end

thereof the following new subsections:

‘‘(c) REQUIREMENTS REGARDING POPULATION.—

‘‘(1) NUMBER OF INDIVIDUALS.—

‘‘(A) IN GENERAL.—Except as provided in subparagraph

(B), the Secretary may not make a grant under this section

for a metropolitan area unless the area has a population

of 500,000 or more individuals.

‘‘(B) LIMITATION.—Subparagraph (A) does not apply

to any metropolitan area that was an eligible area under

this part for fiscal year 1995 or any prior fiscal year.

‘‘(2) GEOGRAPHIC BOUNDARIES.—For purposes of eligibility

under this part, the boundaries of each metropolitan area are
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the boundaries that were in effect for the area for fiscal year

1994.

‘‘(d) CONTINUED STATUS AS ELIGIBLE AREA.—Notwithstanding

any other provision of this section, a metropolitan area that was

an eligible area under this part for fiscal year 1996 is an eligible

area for fiscal year 1997 and each subsequent fiscal year.’’.

(3) CONFORMING AMENDMENT REGARDING DEFINITION OF

ELIGIBLE AREA.—Section 2607(1) (42 U.S.C. 300ff–17(1)) is

amended by striking ‘‘The term’’ and all that follows and inserting the following: ‘‘The term ‘eligible area’ means a metropolitan

area meeting the requirements of section 2601 that are

applicable to the area.’’.

(b) EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED

FOR SERVICES.—

(1) HIV HEALTH SERVICES PLANNING COUNCIL.—Subsection

(b) of section 2602 (42 U.S.C. 300ff–12(b)) is amended—

(A) in paragraph (1)—

(i) by striking ‘‘include’’ and all that follows

through the end thereof, and inserting ‘‘reflect in its

composition the demographics of the epidemic in the

eligible area involved, with particular consideration

given to disproportionately affected and historically

underserved groups and subpopulations.’’; and

(ii) by adding at the end thereof the following

new sentences: ‘‘Nominations for membership on the

council shall be identified through an open process

and candidates shall be selected based on locally delineated and publicized criteria. Such criteria shall

include a conflict-of-interest standard that is in accordance with paragraph (5).’’;

(B) in paragraph (2), by adding at the end thereof

the following new subparagraph:

‘‘(C) CHAIRPERSON.—A planning council may not be

chaired solely by an employee of the grantee.’’;

(C) in paragraph (3)—

(i) in subparagraph (A), by striking ‘‘area;’’ and

inserting ‘‘area, including how best to meet each such

priority and additional factors that a grantee should

consider in allocating funds under a grant based on

the—

‘‘(i) documented needs of the HIV-infected population;

‘‘(ii) cost and outcome effectiveness of proposed

strategies and interventions, to the extent that such

data are reasonably available (either demonstrated or

probable);

‘‘(iii) priorities of the HIV-infected communities for

whom the services are intended; and

‘‘(iv) availability of other governmental and nongovernmental resources;’’;

(ii) by striking ‘‘and’’ at the end of subparagraph

(B);

(iii) by striking the period at the end of subparagraph (C) and inserting ‘‘, and at the discretion of

the planning council, assess the effectiveness, either

directly or through contractual arrangements, of the

services offered in meeting the identified needs;’’; and
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(iv) by adding at the end thereof the following

new subparagraphs:

‘‘(D) participate in the development of the statewide

coordinated statement of need initiated by the State public

health agency responsible for administering grants under

part B; and

‘‘(E) establish methods for obtaining input on community needs and priorities which may include public meetings, conducting focus groups, and convening ad-hoc panels.’’;

(D) by redesignating paragraphs (2) and (3) as paragraphs (3) and (4), respectively;

(E) by inserting after paragraph (1), the following new

paragraph:

‘‘(2) REPRESENTATION.—The HIV health services planning

council shall include representatives of—

‘‘(A) health care providers, including federally qualified

health centers;

‘‘(B) community-based organizations serving affected

populations and AIDS service organizations;

‘‘(C) social service providers;

‘‘(D) mental health and substance abuse providers;

‘‘(E) local public health agencies;

‘‘(F) hospital planning agencies or health care planning

agencies;

‘‘(G) affected communities, including people with HIV

disease or AIDS and historically underserved groups and

subpopulations;

‘‘(H) nonelected community leaders;

‘‘(I) State government (including the State medicaid

agency and the agency administering the program under

part B);

‘‘(J) grantees under subpart II of part C;

‘‘(K) grantees under section 2671, or, if none are operating in the area, representatives of organizations with a

history of serving children, youth, women, and families

living with HIV and operating in the area; and

‘‘(L) grantees under other Federal HIV programs.’’; and

(F) by adding at the end thereof the following:

‘‘(5) CONFLICTS OF INTEREST.—

‘‘(A) IN GENERAL.—The planning council under paragraph (1) may not be directly involved in the administration

of a grant under section 2601(a). With respect to compliance

with the preceding sentence, the planning council may

not designate (or otherwise be involved in the selection

of) particular entities as recipients of any of the amounts

provided in the grant.

‘‘(B) REQUIRED AGREEMENTS.—An individual may serve

on the planning council under paragraph (1) only if the

individual agrees that if the individual has a financial

interest in an entity, if the individual is an employee of

a public or private entity, or if the individual is a member

of a public or private organization, and such entity or

organization is seeking amounts from a grant under section

2601(a), the individual will not, with respect to the purpose

for which the entity seeks such amounts, participate
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(directly or in an advisory capacity) in the process of selecting entities to receive such amounts for such purpose.

‘‘(6) GRIEVANCE PROCEDURES.—A planning council under

paragraph (1) shall develop procedures for addressing grievances with respect to funding under this part, including procedures for submitting grievances that cannot be resolved to

binding arbitration. Such procedures shall be described in the

by-laws of the planning council and be consistent with the

requirements of subsection (c).

‘‘(c) GRIEVANCE PROCEDURES.—

‘‘(1) FEDERAL RESPONSIBILITY.—

‘‘(A) MODELS.—The Secretary shall, through a process

that includes consultations with grantees under this part

and public and private experts in grievance procedures,

arbitration, and mediation, develop model grievance procedures that may be implemented by the planning council

under subsection (b)(1) and grantees under this part. Such

model procedures shall describe the elements that must

be addressed in establishing local grievance procedures

and provide grantees with flexibility in the design of such

local procedures.

‘‘(B) REVIEW.—The Secretary shall review grievance

procedures established by the planning council and

grantees under this part to determine if such procedures

are adequate. In making such a determination, the Secretary shall assess whether such procedures permit legitimate grievances to be filed, evaluated, and resolved at

the local level.

‘‘(2) GRANTEES.—To be eligible to receive funds under this

part, a grantee shall develop grievance procedures that are

determined by the Secretary to be consistent with the model

procedures developed under paragraph (1)(A). Such procedures

shall include a process for submitting grievances to binding

arbitration.’’.

(2) DISTRIBUTION OF GRANTS.—Section 2603 (42 U.S.C.

300ff–13) is amended—

(A) in subsection (a)(2), by striking ‘‘Not later

than—’’ and all that follows through ‘‘the Secretary shall’’

and inserting the following: ‘‘Not later than 60 days after

an appropriation becomes available to carry out this part

for each of the fiscal years 1996 through 2000, the Secretary

shall’’; and

(B) in subsection (b)

(i) in paragraph (1)—

(I) by striking ‘‘and’’ at the end of subparagraph (D);

(II) by striking the period at the end of

subparagraph (E) and inserting a semicolon; and

(III) by adding at the end thereof the following

new subparagraphs:

‘‘(F) demonstrates the inclusiveness of the planning

council membership, with particular emphasis on affected

communities and individuals with HIV disease; and

‘‘(G) demonstrates the manner in which the proposed

services are consistent with the local needs assessment

and the statewide coordinated statement of need.’’; and
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(ii) by redesignating paragraphs (2), (3), and (4)

as paragraphs (3), (4), and (5), respectively; and

(iii) by inserting after paragraph (1), the following

new paragraph:

‘‘(2) DEFINITION.—

‘‘(A) SEVERE NEED.—In determining severe need in

accordance with paragraph (1)(B), the Secretary shall consider the ability of the qualified applicant to expend funds

efficiently and the impact of relevant factors on the cost

and complexity of delivering health care and support services to individuals with HIV disease in the eligible area,

including factors such as—

‘‘(i) sexually transmitted diseases, substance abuse,

tuberculosis, severe mental illness, or other comorbid

factors determined relevant by the Secretary;

‘‘(ii) new or growing subpopulations of individuals

with HIV disease; and

‘‘(iii) homelessness.

‘‘(B) PREVALENCE.—In determining the impact of the

factors described in subparagraph (A), the Secretary shall,

to the extent practicable, use national, quantitative

incidence data that are available for each eligible area.

Not later than 2 years after the date of enactment of

this paragraph, the Secretary shall develop a mechanism

to utilize such data. In the absence of such data, the

Secretary may consider a detailed description and qualitative analysis of severe need, as determined under

subparagraph (A), including any local prevalence data gathered and analyzed by the eligible area.

‘‘(C) PRIORITY.—Subsequent to the development of the

quantitative mechanism described in subparagraph (B), the

Secretary shall phase in, over a 3-year period beginning

in fiscal year 1998, the use of such a mechanism to determine the severe need of an eligible area compared to other

eligible areas and to determine, in part, the amount of

supplemental funds awarded to the eligible area under

this part.’’.

(3) DISTRIBUTION OF FUNDS.— (A) IN GENERAL.—Section 2603(a)(2) (42 U.S.C. 300ff–

13(a)(2)) (as amended by paragraph (2)) is further amended—

(i) by inserting ‘‘, in accordance with paragraph

(3)’’ before the period; and

(ii) by adding at the end thereof the following

new sentences: ‘‘The Secretary shall reserve an additional percentage of the amount appropriated under

section 2677 for a fiscal year for grants under part

A to make grants to eligible areas under section 2601(a)

in accordance with paragraph (4).’’.

(B) INCREASE IN GRANT.—Section 2603(a) (42 U.S.C.

300ff–13(a)) is amended by adding at the end thereof the

following new paragraph:

‘‘(4) INCREASE IN GRANT.—With respect to an eligible area

under section 2601(a), the Secretary shall increase the amount

of a grant under paragraph (2) for a fiscal year to ensure

that such eligible area receives not less than—

‘‘(A) with respect to fiscal year 1996, 100 percent;
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‘‘(B) with respect to fiscal year 1997, 99 percent;

‘‘(C) with respect to fiscal year 1998, 98 percent;

‘‘(D) with respect to fiscal year 1999, 96.5 percent;

and

‘‘(E) with respect to fiscal year 2000, 95 percent;

of the amount allocated for fiscal year 1995 to such entity

under this subsection.’’.

(C) ADDITIONAL REQUIREMENTS FOR GRANTS.—Section

2603 (42 U.S.C. 300ff–13) is amended by adding at the

end thereof the following subsection:

‘‘(c) COMPLIANCE WITH PRIORITIES OF HIV PLANNING COUNCIL.—Notwithstanding any other provision of this part, the Secretary, in carrying out section 2601(a), may not make any grant

under subsection (a) or (b) to an eligible area unless the application

submitted by such area under section 2605 for the grant involved

demonstrates that the grants made under subsections (a) and (b)

to the area for the preceding fiscal year (if any) were expended

in accordance with the priorities applicable to such year that were

established, pursuant to section 2602(b)(3)(A), by the planning council serving the area.’’.

(4) USE OF AMOUNTS.—Section 2604 (42 U.S.C. 300ff–14)

is amended—

(A) in subsection (b)(1)(A)—

(i) by inserting ‘‘, substance abuse treatment and

mental health treatment,’’ after ‘‘case management’’;

and

(ii) by inserting ‘‘which shall include treatment

education and prophylactic treatment for opportunistic

infections,’’ after ‘‘treatment services,’’;

(B) in subsection (b)(2)(A)—

(i) by inserting ‘‘, or private for-profit entities if

such entities are the only available provider of quality

HIV care in the area,’’ after ‘‘nonprofit private entities,’’; and

(ii) by striking ‘‘and homeless health centers’’ and

inserting ‘‘homeless health centers, substance abuse

treatment programs, and mental health programs’’;

(C) by adding at the end of subsection (b), the following

new paragraph:

‘‘(3) PRIORITY FOR WOMEN, INFANTS AND CHILDREN.—For

the purpose of providing health and support services to infants,

children, and women with HIV disease, including treatment

measures to prevent the perinatal transmission of HIV, the

chief elected official of an eligible area, in accordance with

the established priorities of the planning council, shall use,

from the grants made for the area under section 2601(a) for

a fiscal year, not less than the percentage constituted by the

ratio of the population in such area of infants, children, and

women with acquired immune deficiency syndrome to the general population in such area of individuals with such syndrome.’’; and

(C) in subsection (e)—

(i) in the subsection heading, by striking ‘‘AND

PLANNING;

(ii) by striking ‘‘The chief’’ and inserting:

‘‘(1) IN GENERAL.—The chief’’;
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(iii) by striking ‘‘accounting, reporting, and program oversight functions’’;

(iv) by adding at the end thereof the following

new sentence: ‘‘In the case of entities and subcontractors to which such officer allocates amounts received

by the officer under the grant, the officer shall ensure

that, of the aggregate amount so allocated, the total

of the expenditures by such entities for administrative

expenses does not exceed 10 percent (without regard

to whether particular entities expend more than 10

percent for such expenses).’’; and

(v) by adding at the end thereof the following

new paragraphs:

‘‘(2) ADMINISTRATIVE ACTIVITIES.—For the purposes of paragraph (1), amounts may be used for administrative activities

that include—

‘‘(A) routine grant administration and monitoring

activities, including the development of applications for

part A funds, the receipt and disbursal of program funds,

the development and establishment of reimbursement and

accounting systems, the preparation of routine programmatic and financial reports, and compliance with

grant conditions and audit requirements; and

‘‘(B) all activities associated with the grantee’s contract

award procedures, including the development of requests

for proposals, contract proposal review activities, negotiation and awarding of contracts, monitoring of contracts

through telephone consultation, written documentation or

onsite visits, reporting on contracts, and funding reallocation activities.

‘‘(3) SUBCONTRACTOR ADMINISTRATIVE COSTS.—For the purposes of this subsection, subcontractor administrative activities

include—

‘‘(A) usual and recognized overhead, including established indirect rates for agencies;

‘‘(B) management oversight of specific programs funded

under this title; and

‘‘(C) other types of program support such as quality

assurance, quality control, and related activities.’’.

(5) APPLICATION.—Section 2605 (42 U.S.C. 300ff–15) is

amended—

(A) in subsection (a)—

(i) in the matter preceding paragraph (1), by inserting ‘‘, in accordance with subsection (c) regarding a

single application and grant award,’’ after ‘‘application’’;

(ii) in paragraph (1)(B), by striking ‘‘1-year period’’

and all that follows through ‘‘eligible area’’ and inserting ‘‘preceding fiscal year’’;

(iii) in paragraph (4), by striking ‘‘and’’ at the

end thereof;

(iv) in paragraph (5), by striking the period at

the end thereof and inserting ‘‘; and’’; and

(v) by adding at the end thereof the following

new paragraph:

‘‘(6) that the applicant has participated, or will agree to

participate, in the statewide coordinated statement of need
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process where it has been initiated by the State public health

agency responsible for administering grants under part B, and

ensure that the services provided under the comprehensive

plan are consistent with the statewide coordinated statement

of need.’’;

(B) in subsection (b)—

(i) in the subsection heading, by striking ‘‘ADDITIONAL’’; and

(ii) in the matter preceding paragraph (1), by striking ‘‘additional application’’ and inserting ‘‘application,

in accordance with subsection (c) regarding a single

application and grant award,’’; and

(C) by redesignating subsections (c) and (d) as subsections (d) and (e), respectively; and

(D) by inserting after subsection (b), the following new

subsection:

‘‘(c) SINGLE APPLICATION AND GRANT AWARD.—

‘‘(1) APPLICATION.—The Secretary may phase in the use

of a single application that meets the requirements of subsections (a) and (b) of section 2603 with respect to an eligible

area that desires to receive grants under section 2603 for a

fiscal year.

‘‘(2) GRANT AWARD.—The Secretary may phase in the

awarding of a single grant to an eligible area that submits

an approved application under paragraph (1) for a fiscal year.’’.

(6) TECHNICAL ASSISTANCE.—Section 2606 (42 U.S.C. 300ff–

16) is amended—

(A) by striking ‘‘may’’ and inserting ‘‘shall’’;

(B) by inserting after ‘‘technical assistance’’ the following: ‘‘, including assistance from other grantees, contractors

or subcontractors under this title to assist newly eligible

metropolitan areas in the establishment of HIV health

services planning councils and,’’; and

(C) by adding at the end thereof the following new

sentences: ‘‘The Administrator may make planning grants

available to metropolitan areas, in an amount not to exceed

$75,000 for any metropolitan area, projected to be eligible

for funding under section 2601 in the following fiscal year.

Such grant amounts shall be deducted from the first year

formula award to eligible areas accepting such grants. Not

to exceed 1 percent of the amount appropriated for a fiscal

year under section 2677 for grants under part A may

be used to carry out this section.’’.

(c) CARE GRANT PROGRAM.— (1) PRIORITY FOR WOMEN, INFANTS AND CHILDREN.—Section

2611 (42 U.S.C. 300ff–21) is amended—

(A) by striking ‘‘The’’ and inserting ‘‘(a) IN GENERAL.—

The’’; and

(B) by adding at the end thereof the following new

subsection:

‘‘(b) PRIORITY FOR WOMEN, INFANTS AND CHILDREN.—For the

purpose of providing health and support services to infants, children, and women with HIV disease, including treatment measures

to prevent the perinatal transmission of HIV, a State shall use,

of the funds allocated under this part to the State for a fiscal

year, not less than the percentage constituted by the ratio of the

population in the State of infants, children, and women with
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acquired immune deficiency syndrome to the general population

in the State of individuals with such syndrome.’’.

(2) USE OF GRANTS.—Section 2612 (42 U.S.C. 300ff–22)

is amended—

(A) in subsection (a)—

(i) by striking the subsection designation and heading;

(ii) by redesignating paragraphs (1) through (4)

as paragraphs (2) through (5), respectively;

(iii) by inserting the following new paragraph:

‘‘(1) to provide the services described in section 2604(b)(1)

for individuals with HIV disease;’’;

(iv) in paragraph (5) (as so redesignated), by striking ‘‘treatments’’ and all that follows through ‘‘health,’’

and inserting ‘‘therapeutics to treat HIV disease’’; and

(v) by adding at the end thereof the following

flush sentences:

‘‘Services described in paragraph (1) shall be delivered through

consortia designed as described in paragraph (2), where such consortia exist, unless the State demonstrates to the Secretary that delivery of such services would be more effective when other delivery

mechanisms are used. In making a determination regarding the

delivery of services, the State shall consult with appropriate representatives of service providers and recipients of services who

would be affected by such determination, and shall include in its

demonstration to the Secretary the findings of the State regarding

such consultation.’’; and

(B) by striking subsection (b).

(2) HIV CARE CONSORTIA.—Section 2613 (42 U.S.C. 300ff–

23) is amended—

(A) in subsection (a)—

(i) in paragraph (1), by inserting ‘‘(or private forprofit providers or organizations if such entities are

the only available providers of quality HIV care in

the area)’’ after ‘‘nonprofit private,’’; and

(ii) in paragraph (2)(A)—

(I) by inserting ‘‘substance abuse treatment,

mental health treatment,’’ after ‘‘nursing,’’; and

(II) by inserting ‘‘prophylactic treatment for

opportunistic infections, treatment education to

take place in the context of health care delivery,’’

after ‘‘monitoring,’’; and

(B) in subsection (c)—

(i) in subparagraph (C) of paragraph (1), by inserting before ‘‘care’’ ‘‘and youth centered’’; and

(ii) in paragraph (2)—

(I) in clause (ii) of subparagraph (A), by striking ‘‘served; and’’ and inserting ‘‘served;’’;

(II) in subparagraph (B), by striking the period

at the end and inserting ‘‘; and’’; and

(III) by adding after subparagraph (B), the

following new subparagraph:

‘‘(C) grantees under section 2671, or, if none are operating in the area, representatives in the area of organizations

with a history of serving children, youth, women, and families living with HIV.’’.
S. 641—10

(3) PROVISION OF TREATMENTS.—Section 2616 (42 U.S.C.

300ff–26) is amended—

(A) in subsection (a)—

(i) by striking ‘‘may use amounts’’ and inserting

‘‘shall use a portion of the amounts’’;

(ii) by striking ‘‘section 2612(a)(4)’’ and all that

follows through ‘‘prolong life’’ and inserting ‘‘section

2612(a)(5) to provide therapeutics to treat HIV disease’’; and

(iii) by inserting before the period the following:

‘‘, including measures for the prevention and treatment

of opportunistic infections’’;

(B) in subsection (c)—

(i) in paragraph (3), by striking ‘‘and’’ at the end

thereof;

(ii) in paragraph (4), by striking the period and

inserting ‘‘; and’’; and

(iii) by adding at the end thereof the following

new paragraph:

‘‘(5) document the progress made in making therapeutics

described in subsection (a) available to individuals eligible for

assistance under this section.’’; and

(C) by adding at the end thereof the following new

subsection:

‘‘(d) DUTIES OF THE SECRETARY.—In carrying out this section,

the Secretary shall review the current status of State drug

reimbursement programs established under section 2612(2) and

assess barriers to the expanded availability of the treatments

described in subsection (a). The Secretary shall also examine the

extent to which States coordinate with other grantees under this

title to reduce barriers to the expanded availability of the treatments described in subsection (a).’’.

(4) STATE APPLICATION.—Section 2617(b) (42 U.S.C. 300ff–

27(b)) is amended—

(A) in paragraph (2)—

(i) in subparagraph (A), by striking ‘‘and’’ at the

end thereof; and

(ii) by adding at the end thereof the following

new subparagraph:

‘‘(C) a description of how the allocation and utilization

of resources are consistent with the statewide coordinated

statement of need (including traditionally underserved

populations and subpopulations) developed in partnership

with other grantees in the State that receive funding under

this title; and’’;

(B) by redesignating paragraph (3) as paragraph (4);

(C) by inserting after paragraph (2), the following new

paragraph:

‘‘(3) an assurance that the public health agency administering the grant for the State will periodically convene a meeting

of individuals with HIV, representatives of grantees under each

part under this title, providers, and public agency representatives for the purpose of developing a statewide coordinated

statement of need; and’’.

(5) PLANNING, EVALUATION AND ADMINISTRATION.—Section

2618(c) (42 U.S.C. 300ff–28(c)) is amended—

(A) by striking paragraph (1);
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(B) in paragraphs (3) and (4), to read as follows:

‘‘(3) PLANNING AND EVALUATIONS.—Subject to paragraph

(5) and except as provided in paragraph (6), a State may

not use more than 10 percent of amounts received under a

grant awarded under this part for planning and evaluation

activities.

‘‘(4) ADMINISTRATION.—

‘‘(A) IN GENERAL.—Subject to paragraph (5) and except

as provided in paragraph (6), a State may not use more

than 10 percent of amounts received under a grant awarded

under this part for administration. In the case of entities

and subcontractors to which the State allocates amounts

received by the State under the grant (including consortia

under section 2613), the State shall ensure that, of the

aggregate amount so allocated, the total of the expenditures

by such entities for administrative expenses does not exceed

10 percent (without regard to whether particular entities

expend more than 10 percent for such expenses).

‘‘(B) ADMINISTRATIVE ACTIVITIES.—For the purposes of

subparagraph (A), amounts may be used for administrative

activities that include routine grant administration and

monitoring activities.

‘‘(C) SUBCONTRACTOR ADMINISTRATIVE COSTS.—For the

purposes of this paragraph, subcontractor administrative

activities include—

‘‘(i) usual and recognized overhead, including

established indirect rates for agencies;

‘‘(ii) management oversight of specific programs

funded under this title; and

‘‘(iii) other types of program support such as quality assurance, quality control, and related activities.’’;

(C) by redesignating paragraph (5) as paragraph (7);

and

(D) by inserting after paragraph (4), the following new

paragraphs:

‘‘(5) LIMITATION ON USE OF FUNDS.—Except as provided

in paragraph (6), a State may not use more than a total

of 15 percent of amounts received under a grant awarded

under this part for the purposes described in paragraphs (3)

and (4).

‘‘(6) EXCEPTION.—With respect to a State that receives

the minimum allotment under subsection (a)(1) for a fiscal

year, such State, from the amounts received under a grant

awarded under this part for such fiscal year for the activities

described in paragraphs (3) and (4), may, notwithstanding paragraphs (3), (4), and (5), use not more than that amount required

to support one full-time-equivalent employee.’’.

(6) TECHNICAL ASSISTANCE.—Section 2619 (42 U.S.C. 300ff–

29) is amended—

(A) by striking ‘‘may’’ and inserting ‘‘shall’’; and

(B) by inserting before the period the following: ‘‘,

including technical assistance for the development and

implementation of statewide coordinated statements of

need’’.

(7) COORDINATION.—Part B of title XXVI (42 U.S.C. 300ff–

21 et seq.) is amended by adding at the end thereof the following

new section:
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‘‘SEC. 2621. COORDINATION.

‘‘The Secretary shall ensure that the Health Resources and

Services Administration, the Centers for Disease Control and

Prevention, and the Substance Abuse and Mental Health Services

Administration coordinate the planning and implementation of Federal HIV programs in order to facilitate the local development

of a complete continuum of HIV-related services for individuals

with HIV disease and those at risk of such disease. Not later

than October 1, 1996, and biennially thereafter, the Secretary shall

submit to the appropriate committees of the Congress a report

concerning coordination efforts under this title at the Federal, State,

and local levels, including a statement of whether and to what

extent there exist Federal barriers to integrating HIV-related programs.’’.

(d) EARLY INTERVENTION SERVICES.— (1) ESTABLISHMENT OF PROGRAM.—Section 2651(b) (42

U.S.C. 300ff–51(b)) is amended—

(A) in paragraph (1), by inserting before the period

the following: ‘‘, and unless the applicant agrees to expend

not less than 50 percent of the grant for such services

that are specified in subparagraphs (B) through (E) of

such paragraph for individuals with HIV disease’’; and

(B) in paragraph (4)—

(i) by striking ‘‘The Secretary’’ and inserting ‘‘(A)

IN GENERAL.—The Secretary’’;

(ii) by inserting ‘‘, or private for-profit entities if

such entities are the only available provider of quality

HIV care in the area,’’ after ‘‘nonprofit private entities’’;

(iii) by realigning the margin of subparagraph (A)

so as to align with the margin of paragraph (3)(A);

and

(iv) by adding at the end thereof the following

new subparagraph:

‘‘(B) OTHER REQUIREMENTS.—Grantees described in—

‘‘(i) paragraphs (1), (2), (5), and (6) of section

2652(a) shall use not less than 50 percent of the

amount of such a grant to provide the services

described in subparagraphs (A), (B), (D), and (E) of

section 2651(b)(2) directly and on-site or at sites where

other primary care services are rendered; and

‘‘(ii) paragraphs (3) and (4) of section 2652(a) shall

ensure the availability of early intervention services

through a system of linkages to community-based primary care providers, and to establish mechanisms for

the referrals described in section 2651(b)(2)(C), and

for follow-up concerning such referrals.’’.

(2) MINIMUM QUALIFICATIONS.—Section 2652(b)(1)(B) (42

U.S.C. 300ff–52(b)(1)(B)) is amended by inserting ‘‘, or a private

for-profit entity if such entity is the only available provider

of quality HIV care in the area,’’ after ‘‘nonprofit private entity’’.

(3) MISCELLANEOUS PROVISIONS.—Section 2654 (42 U.S.C.

300ff–54) is amended by adding at the end thereof the following

new subsection:

‘‘(c) PLANNING AND DEVELOPMENT GRANTS.—

‘‘(1) IN GENERAL.—The Secretary may provide planning

grants, in an amount not to exceed $50,000 for each such

grant, to public and nonprofit private entities for the purpose
S. 641—13

of enabling such entities to provide HIV early intervention

services.

‘‘(2) REQUIREMENT.—The Secretary may only award a grant

to an entity under paragraph (1) if the Secretary determines

that the entity will use such grant to assist the entity in

qualifying for a grant under section 2651.

‘‘(3) PREFERENCE.—In awarding grants under paragraph

(1), the Secretary shall give preference to entities that provide

primary care services in rural or underserved communities.

‘‘(4) LIMITATION.—Not to exceed 1 percent of the amount

appropriated for a fiscal year under section 2655 may be used

to carry out this section.’’.

(4) AUTHORIZATION OF APPROPRIATIONS.—Section 2655 (42

U.S.C. 300ff–55) is amended by striking ‘‘$75,000,000’’ and

all that follows through the end of the section, and inserting

‘‘such sums as may be necessary in each of the fiscal years

1996, 1997, 1998, 1999, and 2000.’’.

(5) REQUIRED AGREEMENTS.—Section 2664(g) (42 U.S.C.

300ff–64(g)) is amended—

(A) in paragraph (2), by striking ‘‘and’’ at the end

thereof;

(B) in paragraph (3)—

(i) by striking ‘‘5 percent’’ and inserting ‘‘7.5 percent including planning and evaluation’’; and

(ii) by striking the period and inserting ‘‘; and’’;

and

(C) by adding at the end thereof the following new

paragraph:

‘‘(4) the applicant will submit evidence that the proposed

program is consistent with the statewide coordinated statement

of need and agree to participate in the ongoing revision of

such statement of need.’’.

(e) DEMONSTRATION GRANTS FOR RESEARCH AND SERVICES FOR

PEDIATRIC PATIENTS.—Section 2671 (42 U.S.C. 300f–71) is amended

to read as follows:

‘‘SEC. 2671. GRANTS FOR COORDINATED SERVICES AND ACCESS TO

RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND

YOUTH.

‘‘(a) IN GENERAL.—The Secretary, acting through the Administrator of the Health Resources and Services Administration and

in consultation with the Director of the National Institutes of

Health, shall make grants to public and nonprofit private entities

that provide primary care (directly or through contracts) for the

following purposes:

‘‘(1) Providing through such entities, in accordance with

this section, opportunities for women, infants, children, and

youth to be voluntary participants in research of potential

clinical benefit to individuals with HIV disease.

‘‘(2) In the case of women, infants, children, and youth

with HIV disease, and the families of such individuals, providing to such individuals—

‘‘(A) health care on an outpatient basis; and

‘‘(B) additional services in accordance with subsection

(d).

‘‘(b) PROVISIONS REGARDING PARTICIPATION IN RESEARCH.—
S. 641—14

‘‘(1) IN GENERAL.—With respect to the projects of research

with which an applicant under subsection (a) is concerned,

the Secretary may make a grant under such subsection to

the applicant only if the following conditions are met:

‘‘(A) The applicant agrees to make reasonable efforts—

‘‘(i) to identify which of the patients of the

applicant are women, infants, children, and youth who

would be appropriate participants in the projects;

‘‘(ii) to carry out clause (i) through the use of

criteria provided for such purpose by the entities that

will be conducting the projects of research; and

‘‘(iii) to offer women, infants, children, and youth

the opportunity to participate in the projects (as appropriate), including the provision of services under subsection (d)(3).

‘‘(B) The applicant agrees that, in the case of the

research-related functions to be carried out by the applicant

pursuant to subsection (a)(1), the applicant will comply

with accepted standards that are applicable to such functions (including accepted standards regarding informed consent and other protections for human subjects).

‘‘(C) For the first and second fiscal years for which

grants under subsection (a) are to be made to the applicant,

the applicant agrees that, not later than the end of the

second fiscal year of receiving such a grant, a significant

number of women, infants, children, and youth who are

patients of the applicant will be participating in the projects

of research.

‘‘(D) Except as provided in paragraph (3) (and paragraph (4), as applicable), for the third and subsequent

fiscal years for which such grants are to be made to the

applicant, the Secretary has determined that a significant

number of such individuals are participating in the projects.

‘‘(2) PROHIBITION.—Receipt of services by a patient shall

not be conditioned upon the consent of the patient to participate

in research.

‘‘(3) SIGNIFICANT PARTICIPATION; CONSIDERATION BY SEC- RETARY OF CERTAIN CIRCUMSTANCES.—In administering the

requirement of paragraph (1)(D), the Secretary shall take into

account circumstances in which a grantee under subsection

(a) is temporarily unable to comply with the requirement for

reasons beyond the control of the grantee, and shall in such

circumstances provide to the grantee a reasonable period of

opportunity in which to reestablish compliance with the requirement.

‘‘(4) SIGNIFICANT PARTICIPATION; TEMPORARY WAIVER FOR

ORIGINAL GRANTEES.—

‘‘(A) IN GENERAL.—In the case of an applicant under

subsection (a) who received a grant under such subsection

for fiscal year 1995, the Secretary may, subject to subparagraph (B), provide to the applicant a waiver of the requirement of paragraph (1)(D) if the Secretary determines that

the applicant is making reasonable progress toward meeting the requirement.

‘‘(B) TERMINATION OF AUTHORITY FOR WAIVERS.—The

Secretary may not provide any waiver under subparagraph

(A) on or after October 1, 1998. Any such waiver provided
S. 641—15

prior to such date terminates on such date, or on such

earlier date as the Secretary may specify.

‘‘(c) PROVISIONS REGARDING CONDUCT OF RESEARCH.—

‘‘(1) IN GENERAL.—With respect to eligibility for a grant

under subsection (a):

‘‘(A) A project of research for which subjects are sought

pursuant to such subsection may be conducted by the

applicant for the grant, or by an entity with which the

applicant has made arrangements for purposes of the grant.

The grant may not be expended for the conduct of any

project of research, except for such research-related functions as are appropriate for providing opportunities under

subsection (a)(1) (including the functions specified in subsection (b)(1)).

‘‘(B) The grant may be made only if the Secretary

makes the following determinations:

‘‘(i) The applicant or other entity (as the case may

be under subparagraph (A)) is appropriately qualified

to conduct the project of research. An entity shall be

considered to be so qualified if any research protocol

of the entity has been recommended for funding under

this Act pursuant to technical and scientific peer

review through the National Institutes of Health.

‘‘(ii) The project of research is being conducted

in accordance with a research protocol to which the

Secretary gives priority regarding the prevention or

treatment of HIV disease in women, infants, children,

or youth, subject to paragraph (2).

‘‘(2) LIST OF RESEARCH PROTOCOLS.—

‘‘(A) IN GENERAL.—From among the research protocols

described in paragraph (1)(B)(ii), the Secretary shall establish a list of research protocols that are appropriate for

purposes of subsection (a)(1). Such list shall be established

only after consultation with public and private entities

that conduct such research, and with providers of services

under subsection (a) and recipients of such services.

‘‘(B) DISCRETION OF SECRETARY.—The Secretary may

authorize the use, for purposes of subsection (a)(1), of a

research protocol that is not included on the list under

subparagraph (A). The Secretary may waive the requirement specified in paragraph (1)(B)(ii) in such circumstances

as the Secretary determines to be appropriate.

‘‘(d) ADDITIONAL SERVICES FOR PATIENTS AND FAMILIES.—A

grant under subsection (a) may be made only if the applicant

for the grant agrees as follows:

‘‘(1) The applicant will provide for the case management

of the patient involved and the family of the patient.

‘‘(2) The applicant will provide for the patient and the

family of the patient—

‘‘(A) referrals for inpatient hospital services, treatment

for substance abuse, and mental health services; and

‘‘(B) referrals for other social and support services,

as appropriate.

‘‘(3) The applicant will provide the patient and the family

of the patient with such transportation, child care, and other

incidental services as may be necessary to enable the patient
S. 641—16

and the family to participate in the program established by

the applicant pursuant to such subsection.

‘‘(e) COORDINATION WITH OTHER ENTITIES.—A grant under subsection (a) may be made only if the applicant for the grant agrees

as follows:

‘‘(1) The applicant will coordinate activities under the grant

with other providers of health care services under this Act,

and under title V of the Social Security Act.

‘‘(2) The applicant will participate in the statewide coordinated statement of need under part B (where it has been

initiated by the public health agency responsible for administering grants under part B) and in revisions of such statement.

‘‘(f) APPLICATION.—A grant under subsection (a) may be made

only if an application for the grant is submitted to the Secretary

and the application is in such form, is made in such manner,

and contains such agreements, assurances, and information as the

Secretary determines to be necessary to carry out this section.

‘‘(g) COORDINATION WITH NATIONAL INSTITUTES OF HEALTH.—

The Secretary shall develop and implement a plan that provides

for the coordination of the activities of the National Institutes

of Health with the activities carried out under this section. In

carrying out the preceding sentence, the Secretary shall ensure

that projects of research conducted or supported by such Institutes

are made aware of applicants and grantees under subsection (a),

shall require that the projects, as appropriate, enter into arrangements for purposes of such subsection, and shall require that each

project entering into such an arrangement inform the applicant

or grantee under such subsection of the needs of the project for

the participation of women, infants, children, and youth.

‘‘(h) ANNUAL REVIEW OF PROGRAMS; EVALUATIONS.— ‘‘(1) REVIEW REGARDING ACCESS TO AND PARTICIPATION IN

PROGRAMS.—With respect to a grant under subsection (a) for

an entity for a fiscal year, the Secretary shall, not later than

180 days after the end of the fiscal year, provide for the conduct

and completion of a review of the operation during the year

of the program carried out under such subsection by the entity.

The purpose of such review shall be the development of recommendations, as appropriate, for improvements in the following:

‘‘(A) Procedures used by the entity to allocate

opportunities and services under subsection (a) among

patients of the entity who are women, infants, children,

or youth.

‘‘(B) Other procedures or policies of the entity regarding

the participation of such individuals in such program.

‘‘(2) EVALUATIONS.—The Secretary shall, directly or through

contracts with public and private entities, provide for evaluations of programs carried out pursuant to subsection (a).

‘‘(i) TRAINING AND TECHNICAL ASSISTANCE.—Of the amounts

appropriated under subsection (j) for a fiscal year, the Secretary

may use not more than five percent to provide, directly or through

contracts with public and private entities (which may include

grantees under subsection (a)), training and technical assistance

to assist applicants and grantees under subsection (a) in complying

with the requirements of this section.

‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of

carrying out this section, there are authorized to be appropriated
S. 641—17

such sums as may be necessary for each of the fiscal years 1996

through 2000.’’.

(f) EVALUATIONS AND REPORTS.—Section 2674 (42 U.S.C. 300ff–

74) is amended—

(1) in subsection (b)—

(A) in the matter preceding paragraph (1), by striking

‘‘not later than 1 year’’ and all that follows through ‘‘title,’’

and inserting the following: ‘‘not later than October 1,

1996,’’;

(B) by striking paragraphs (1) through (3) and inserting

the following paragraph:

‘‘(1) evaluating the programs carried out under this title;

and’’; and

(C) by redesignating paragraph (4) as paragraph (2);

and

(2) by adding at the end the following subsection:

‘‘(d) ALLOCATION OF FUNDS.—The Secretary shall carry out

this section with amounts available under section 241. Such

amounts are in addition to any other amounts that are available

to the Secretary for such purpose.’’.

(g) DEMONSTRATION AND TRAINING.—

(1) IN GENERAL.—Title XXVI is amended by adding at

the end, the following new part:

‘‘PART F—DEMONSTRATION AND TRAINING

‘‘Subpart I—Special Projects of National

Significance

‘‘SEC. 2691. SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE.

‘‘(a) IN GENERAL.—Of the amount appropriated under each

of parts A, B, C, and D of this title for each fiscal year, the

Secretary shall use the greater of $20,000,000 or 3 percent of

such amount appropriated under each such part, but not to exceed

$25,000,000, to administer a special projects of national significance

program to award direct grants to public and nonprofit private

entities including community-based organizations to fund special

programs for the care and treatment of individuals with HIV disease.

‘‘(b) GRANTS.—The Secretary shall award grants under subsection (a) based on—

‘‘(1) the need to assess the effectiveness of a particular

model for the care and treatment of individuals with HIV

disease;

‘‘(2) the innovative nature of the proposed activity; and

‘‘(3) the potential replicability of the proposed activity in

other similar localities or nationally.

‘‘(c) SPECIAL PROJECTS.—Special projects of national significance

shall include the development and assessment of innovative service

delivery models that are designed to—

‘‘(1) address the needs of special populations;

‘‘(2) assist in the development of essential community-based

service delivery infrastructure; and

‘‘(3) ensure the ongoing availability of services for Native

American communities to enable such communities to care

for Native Americans with HIV disease.
S. 641—18

‘‘(d) SPECIAL POPULATIONS.—Special projects of national significance may include the delivery of HIV health care and support

services to traditionally underserved populations including—

‘‘(1) individuals and families with HIV disease living in

rural communities;

‘‘(2) adolescents with HIV disease;

‘‘(3) Indian individuals and families with HIV disease;

‘‘(4) homeless individuals and families with HIV disease;

‘‘(5) hemophiliacs with HIV disease; and

‘‘(6) incarcerated individuals with HIV disease.

‘‘(e) SERVICE DEVELOPMENT GRANTS.—Special projects of

national significance may include the development of model

approaches to delivering HIV care and support services including—

‘‘(1) programs that support family-based care networks and

programs that build organizational capacity critical to the delivery of care in minority communities;

‘‘(2) programs designed to prepare AIDS service organizations and grantees under this title for operation within the

changing health care environment; and

‘‘(3) programs designed to integrate the delivery of mental

health and substance abuse treatment with HIV services.

‘‘(f) COORDINATION.—The Secretary may not make a grant

under this section unless the applicant submits evidence that the

proposed program is consistent with the statewide coordinated

statement of need, and the applicant agrees to participate in the

ongoing revision process of such statement of need.

‘‘(g) REPLICATION.—The Secretary shall make information

concerning successful models developed under this part available

to grantees under this title for the purpose of coordination, replication, and integration. To facilitate efforts under this subsection,

the Secretary may provide for peer-based technical assistance from

grantees funded under this part.’’.

(2) REPEAL.—Subsection (a) of section 2618 (42 U.S.C.

300ff–28(a)) is repealed.

(h) HIV/AIDS COMMUNITIES, SCHOOLS, CENTERS.— (1) NEW PART.—Part F of title XXVI (as added by subsection

(e)) is further amended by adding at the end, the following

new subpart:

‘‘Subpart II—AIDS Education and Training

Centers

‘‘SEC. 2692. HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTERS.’’.

(2) AMENDMENTS.—Section 776 (42 U.S.C. 294n) is amended—

(A) by striking the section heading; and

(B) in subsection (a)(1)—

(i) by striking subparagraphs (B) and (C);

(ii) by redesignating subparagraphs (A) and (D)

as subparagraphs (B) and (C), respectively;

(iii) by inserting before subparagraph (B) (as so

redesignated) the following new subparagraph:

‘‘(A) training health personnel, including practitioners

in title XXVI programs and other community providers,

in the diagnosis, treatment, and prevention of HIV infection

and disease, including the prevention of the perinatal trans-
S. 641—19

mission of the disease and including measures for the

prevention and treatment of opportunistic infections;’’; and

(iv) in subparagraph (B) (as so redesignated) by

adding ‘‘and’’ after the semicolon.

(3) TRANSFER.—Section 776 (42 U.S.C. 294n) (as amended

by paragraph (2)) is amended by transferring such section

to section 2692 (as added by paragraph (1)).

(4) AUTHORIZATION OF APPROPRIATIONS.—Section 2692 (as

added by paragraph (1)) is amended by adding at the end

thereof the following new subsection:

‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized

to be appropriated to carry out this section, such sums as may

be necessary for each of the fiscal years 1996 through 2000.’’.

SEC. 4. AMOUNT OF EMERGENCY RELIEF GRANTS.

Paragraph (3) of section 2603(a) (42 U.S.C. 300ff–13(a)(3)) is

amended to read as follows:

‘‘(3) AMOUNT OF GRANT.—

‘‘(A) IN GENERAL.—Subject to the extent of amounts

made available in appropriations Acts, a grant made for

purposes of this paragraph to an eligible area shall be

made in an amount equal to the product of—

‘‘(i) an amount equal to the amount available for

distribution under paragraph (2) for the fiscal year

involved; and

‘‘(ii) the percentage constituted by the ratio of the

distribution factor for the eligible area to the sum

of the respective distribution factors for all eligible

areas.

‘‘(B) DISTRIBUTION FACTOR.—For purposes of subparagraph (A)(ii), the term ‘distribution factor’ means an

amount equal to the estimated number of living cases

of acquired immune deficiency syndrome in the eligible

area involved, as determined under subparagraph (C).

‘‘(C) ESTIMATE OF LIVING CASES.—The amount determined in this subparagraph is an amount equal to the

product of—

‘‘(i) the number of cases of acquired immune deficiency syndrome in the eligible area during each year

in the most recent 120-month period for which data

are available with respect to all eligible areas, as

indicated by the number of such cases reported to

and confirmed by the Director of the Centers for Disease Control and Prevention for each year during such

period; and

‘‘(ii) with respect to—

‘‘(I) the first year during such period, .06;

‘‘(II) the second year during such period, .06;

‘‘(III) the third year during such period, .08;

‘‘(IV) the fourth year during such period, .10;

‘‘(V) the fifth year during such period, .16;

‘‘(VI) the sixth year during such period, .16;

‘‘(VII) the seventh year during such period,

.24;

‘‘(VIII) the eighth year during such period,

.40;
S. 641—20

‘‘(IX) the ninth year during such period, .57;

and

‘‘(X) the tenth year during such period, .88.

The yearly percentage described in subparagraph (ii) shall

be updated biennially by the Secretary, after consultation

with the Centers for Disease Control and Prevention. The

first such update shall occur prior to the determination

of grant awards under this part for fiscal year 1998.

‘‘(D) UNEXPENDED FUNDS.—The Secretary may, in

determining the amount of a grant for a fiscal year under

this paragraph, adjust the grant amount to reflect the

amount of unexpended and uncanceled grant funds remaining at the end of the fiscal year preceding the year for

which the grant determination is to be made. The amount

of any such unexpended funds shall be determined using

the financial status report of the grantee.’’.

SEC. 5. AMOUNT OF CARE GRANTS.

Paragraphs (1) and (2) of section 2618(b) (42 U.S.C. 300ff–

28(b) (1) and (2)) are amended to read as follows:

‘‘(1) MINIMUM ALLOTMENT.—Subject to the extent of

amounts made available under section 2677, the amount of

a grant to be made under this part for—

‘‘(A) each of the several States and the District of

Columbia for a fiscal year shall be the greater of—

‘‘(i)(I) with respect to a State or District that has

less than 90 living cases of acquired immune deficiency

syndrome, as determined under paragraph (2)(D),

$100,000; or

‘‘(II) with respect to a State or District that has

90 or more living cases of acquired immune deficiency

syndrome, as determined under paragraph (2)(D),

$250,000;

‘‘(ii) an amount determined under paragraph (2);

and

‘‘(B) each territory of the United States, as defined

in paragraph (3), shall be an amount determined under

paragraph (2).

‘‘(2) DETERMINATION.—

‘‘(A) FORMULA.—The amount referred to in paragraph

(1)(A)(ii) for a State and paragraph (1)(B) for a territory

of the United States shall be the product of—

‘‘(i) an amount equal to the amount appropriated

under section 2677 for the fiscal year involved for

grants under part B, subject to subparagraph (H); and

‘‘(ii) the percentage constituted by the sum of—

‘‘(I) the product of .80 and the ratio of the

State distribution factor for the State or territory

(as determined under subsection (B)) to the sum

of the respective State distribution factors for all

States or territories; and

‘‘(II) the product of .20 and the ratio of the

non-EMA distribution factor for the State or territory (as determined under subparagraph (C)) to

the sum of the respective distribution factors for

all States or territories.
S. 641—21

‘‘(B) STATE DISTRIBUTION FACTOR.—For purposes of

subparagraph (A)(ii)(I), the term ‘State distribution factor’

means an amount equal to the estimated number of living

cases of acquired immune deficiency syndrome in the

eligible area involved, as determined under subparagraph

(D).

‘‘(C) NON-EMA DISTRIBUTION FACTOR.—For purposes of

subparagraph (A)(ii)(II), the term ‘non-ema distribution factor’ means an amount equal to the sum of—

‘‘(i) the estimated number of living cases of

acquired immune deficiency syndrome in the State or

territory involved, as determined under subparagraph

(D); less

‘‘(ii) the estimated number of living cases of

acquired immune deficiency syndrome in such State

or territory that are within an eligible area (as determined under part A).

‘‘(D) ESTIMATE OF LIVING CASES.—The amount determined in this subparagraph is an amount equal to the

product of—

‘‘(i) the number of cases of acquired immune deficiency syndrome in the State or territory during each

year in the most recent 120-month period for which

data are available with respect to all States and territories, as indicated by the number of such cases

reported to and confirmed by the Director of the Centers for Disease Control and Prevention for each year

during such period; and

‘‘(ii) with respect to each of the first through the

tenth year during such period, the amount referred

to in section 2603(a)(3)(C)(ii).

‘‘(E) PUERTO RICO, VIRGIN ISLANDS, GUAM.—For purposes of subparagraph (D), the cost index for Puerto Rico,

the Virgin Islands, and Guam shall be 1.0.

‘‘(F) UNEXPENDED FUNDS.—The Secretary may, in

determining the amount of a grant for a fiscal year under

this subsection, adjust the grant amount to reflect the

amount of unexpended and uncanceled grant funds remaining at the end of the fiscal year preceding the year for

which the grant determination is to be made. The amount

of any such unexpended funds shall be determined using

the financial status report of the grantee.

‘‘(G) LIMITATION.— ‘‘(i) IN GENERAL.—The Secretary shall ensure that

the amount of a grant awarded to a State or territory

for a fiscal year under this part is equal to not less

than—

‘‘(I) with respect to fiscal year 1996, 100 percent;

‘‘(II) with respect to fiscal year 1997, 99 percent;

‘‘(III) with respect to fiscal year 1998, 98 percent;

‘‘(IV) with respect to fiscal year 1999, 96.5

percent; and

‘‘(V) with respect to fiscal year 2000, 95 percent;
S. 641—22

of the amount such State or territory received for fiscal

year 1995 under this part. In administering this

subparagraph, the Secretary shall, with respect to

States that will receive grants in amounts that exceed

the amounts that such States received under this part

in fiscal year 1995, proportionally reduce such amounts

to ensure compliance with this subparagraph. In making such reductions, the Secretary shall ensure that

no such State receives less than that State received

for fiscal year 1995.

‘‘(ii) RATABLE REDUCTION.—If the amount appropriated under section 2677 and available for allocation

under this part is less than the amount appropriated

and available under this part for fiscal year 1995,

the limitation contained in clause (i) shall be reduced

by a percentage equal to the percentage of the reduction in such amounts appropriated and available.

‘‘(H) APPROPRIATIONS FOR TREATMENT DRUG PRO- GRAM.—With respect to the fiscal year involved, if under

section 2677 an appropriations Act provides an amount

exclusively for carrying out section 2616, the portion of

such amount allocated to a State shall be the product

of—

‘‘(i) 100 percent of such amount; and

‘‘(ii) the percentage constituted by the ratio of the

State distribution factor for the State (as determined

under subparagraph (B)) to the sum of the State distribution factors for all States.’’.

SEC. 6. CONSOLIDATION OF AUTHORIZATIONS OF APPROPRIATIONS.

(a) IN GENERAL.—Part D of title XXVI (42 U.S.C. 300ff–71)

is amended by adding at the end thereof the following new section:

‘‘SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

‘‘(a) IN GENERAL.—Subject to subsection (b), there are authorized to be appropriated to make grants under parts A and B,

such sums as may be necessary for each of the fiscal years 1996

through 2000.

‘‘(b) DEVELOPMENT OF METHODOLOGY.— ‘‘(1) IN GENERAL.—With respect to each of the fiscal years

1997 through 2000, the Secretary shall develop and implement

a methodology for adjusting the percentages allocated to part

A and part B to account for grants to new eligible areas under

part A and other relevant factors. Not later than July 1, 1996,

the Secretary shall prepare and submit to the appropriate

committees of Congress a report regarding the findings with

respect to the methodology developed under this paragraph.

‘‘(2) FAILURE TO IMPLEMENT.—If the Secretary determines

that such a methodology under paragraph (1) cannot be developed, there are authorized to be appropriated—

‘‘(A) such sums as may be necessary to carry out part

A for each of the fiscal years 1997 through 2000; and

‘‘(B) such sums as may be necessary to carry out part

B for each of the fiscal years 1997 through 2000.’’.

(b) REPEALS.—Sections 2608 and 2620 (42 U.S.C. 300ff–18 and

300ff–30) are repealed.

(c) CONFORMING AMENDMENTS.—Title XXVI is amended—

(1) in section 2603 (42 U.S.C. 300ff–13)—
S. 641—23

(A) in subsection (a)(2), by striking ‘‘2608’’ and inserting ‘‘2677’’; and

(B) in subsection (b)(1), by striking ‘‘2608’’ and inserting ‘‘2677’’;

(2) in section 2605(c)(1) (42 U.S.C. 300ff–15(c)(1)) is amended by striking ‘‘2608’’ and inserting ‘‘2677’’; and

(3) in section 2618 (42 U.S.C. 300ff–28)—

(A) in subsection (a)(1), is amended by striking ‘‘2620’’

and inserting ‘‘2677’’; and

(B) in subsection (b)(1), is amended by striking ‘‘2620’’

and inserting ‘‘2677’’.

SEC. 7. PERINATAL TRANSMISSION OF HIV DISEASE.

(a) FINDINGS.—The Congress finds as follows:

(1) Research studies and statewide clinical experiences

have demonstrated that administration of anti-retroviral medication during pregnancy can significantly reduce the transmission of the human immunodeficiency virus (commonly

known as HIV) from an infected mother to her baby.

(2) The Centers for Disease Control and Prevention have

recommended that all pregnant women receive HIV counseling;

voluntary, confidential HIV testing; and appropriate medical

treatment (including anti-retroviral therapy) and support services.

(3) The provision of such testing without access to such

counseling, treatment, and services will not improve the health

of the woman or the child.

(4) The provision of such counseling, testing, treatment,

and services can reduce the number of pediatric cases of

acquired immune deficiency syndrome, can improve access to

and provision of medical care for the woman, and can provide

opportunities for counseling to reduce transmission among

adults, and from mother to child.

(5) The provision of such counseling, testing, treatment,

and services can reduce the overall cost of pediatric cases

of acquired immune deficiency syndrome.

(6) The cancellation or limitation of health insurance or

other health coverage on the basis of HIV status should be

impermissible under applicable law. Such cancellation or limitation could result in disincentives for appropriate counseling,

testing, treatment, and services.

(7) For the reasons specified in paragraphs (1) through

(6)—

(A) routine HIV counseling and voluntary testing of

pregnant women should become the standard of care; and

(B) the relevant medical organizations as well as public

health officials should issue guidelines making such counseling and testing the standard of care.

(b) ADDITIONAL REQUIREMENTS FOR GRANTS.—Part B of title

XXVI (42 U.S.C. 300ff–21 et seq.) is amended—

(1) by inserting after the part heading the following:

‘‘Subpart I—General Grant Provisions’’;

(2) in section 2611(a), by adding at the end the following

sentence: ‘‘The authority of the Secretary to provide grants

under part B is subject to section 2626(e)(2) (relating to the

decrease in perinatal transmission of HIV disease).’’; and
S. 641—24

(3) by adding at the end thereof the following new subpart:

‘‘Subpart II—Provisions Concerning Pregnancy

and Perinatal Transmission of HIV

‘‘SEC. 2625. CDC GUIDELINES FOR PREGNANT WOMEN.

‘‘(a) REQUIREMENT.—Notwithstanding any other provision of

law, a State shall, not later than 120 days after the date of enactment of this subpart, certify to the Secretary that such State has

in effect regulations or measures to adopt the guidelines issued

by the Centers for Disease Control and Prevention concerning recommendations for human immunodeficiency virus counseling and

voluntary testing for pregnant women.

‘‘(b) NONCOMPLIANCE.—If a State does not provide the certification required under subsection (a) within the 120-day period

described in such subsection, such State shall not be eligible to

receive assistance for HIV counseling and testing under this section

until such certification is provided.

‘‘(c) ADDITIONAL FUNDS REGARDING WOMEN AND INFANTS.—

‘‘(1) IN GENERAL.—If a State provides the certification

required in subsection (a) and is receiving funds under part

B for a fiscal year, the Secretary may (from the amounts

available pursuant to paragraph (2)) make a grant to the State

for the fiscal year for the following purposes:

‘‘(A) Making available to pregnant women appropriate

counseling on HIV disease.

‘‘(B) Making available outreach efforts to pregnant

women at high risk of HIV who are not currently receiving

prenatal care.

‘‘(C) Making available to such women voluntary HIV

testing for such disease.

‘‘(D) Offsetting other State costs associated with the

implementation of this section and subsections (a) and

(b) of section 2626.

‘‘(E) Offsetting State costs associated with the

implementation of mandatory newborn testing in accordance with this title or at an earlier date than is required

by this title.

‘‘(2) FUNDING.—For purposes of carrying out this sub- section, there are authorized to be appropriated $10,000,000

for each of the fiscal years 1996 through 2000. Amounts made

available under section 2677 for carrying out this part are

not available for carrying out this section unless otherwise

authorized.

‘‘(3) PRIORITY.—In awarding grants under this subsection

the Secretary shall give priority to States that have the greatest

proportion of HIV seroprevalance among child bearing women

using the most recent data available as determined by the

Centers for Disease Control and Prevention.

‘‘SEC. 2626. PERINATAL TRANSMISSION OF HIV DISEASE; CONTINGENT

REQUIREMENT REGARDING STATE GRANTS UNDER THIS

PART.

‘‘(a) ANNUAL DETERMINATION OF REPORTED CASES.—A State

shall annually determine the rate of reported cases of AIDS as

a result of perinatal transmission among residents of the State.
S. 641—25

‘‘(b) CAUSES OF PERINATAL TRANSMISSION.—In determining the

rate under subsection (a), a State shall also determine the possible

causes of perinatal transmission. Such causes may include—

‘‘(1) the inadequate provision within the State of prenatal

counseling and testing in accordance with the guidelines issued

by the Centers for Disease Control and Prevention;

‘‘(2) the inadequate provision or utilization within the State

of appropriate therapy or failure of such therapy to reduce

perinatal transmission of HIV, including—

‘‘(A) that therapy is not available, accessible or offered

to mothers; or

‘‘(B) that available therapy is offered but not accepted

by mothers; or

‘‘(3) other factors (which may include the lack of prenatal

care) determined relevant by the State.

‘‘(c) CDC REPORTING SYSTEM.—Not later than 4 months after

the date of enactment of this subpart, the Director of the Centers

for Disease Control and Prevention shall develop and implement

a system to be used by States to comply with the requirements

of subsections (a) and (b). The Director shall issue guidelines to

ensure that the data collected is statistically valid.

‘‘(d) DETERMINATION BY SECRETARY.—Not later than 180 days

after the expiration of the 18-month period beginning on the date

on which the system is implemented under subsection (c), the

Secretary shall publish in the Federal Register a determination

of whether it has become a routine practice in the provision of

health care in the United States to carry out each of the activities

described in paragraphs (1) through (5) of section 2627. In making

the determination, the Secretary shall consult with the States and

with other public or private entities that have knowledge or expertise relevant to the determination.

‘‘(e) CONTINGENT APPLICABILITY.— ‘‘(1) IN GENERAL.—If the determination published in the

Federal Register under subsection (d) is that (for purposes

of such subsection) the activities involved have become routine

practices, paragraph (2) shall apply on and after the expiration

of the 18-month period beginning on the date on which the

determination is so published.

‘‘(2) REQUIREMENT.—Subject to subsection (f), the Secretary

shall not make a grant under part B to a State unless the

State meets not less than one of the following requirements:

‘‘(A) A 50 percent reduction (or a comparable measure

for States with less than 10 cases) in the rate of new

cases of AIDS (recognizing that AIDS is a suboptimal proxy

for tracking HIV in infants and was selected because such

data is universally available) as a result of perinatal transmission as compared to the rate of such cases reported

in 1993 (a State may use HIV data if such data is available).

‘‘(B) At least 95 percent of women in the State who

have received at least two prenatal visits (consultations)

prior to 34 weeks gestation with a health care provider

or provider group have been tested for the human

immunodeficiency virus.

‘‘(C) The State has in effect, in statute or through

regulations, the requirements specified in paragraphs (1)

through (5) of section 2627.
S. 641—26

‘‘(f) LIMITATION REGARDING AVAILABILITY OF FUNDS.—With

respect to an activity described in any of paragraphs (1) through

(5) of section 2627, the requirements established by a State under

this section apply for purposes of this section only to the extent

that the following sources of funds are available for carrying out

the activity:

‘‘(1) Federal funds provided to the State in grants under

part B or under section 2625, or through other Federal sources

under which payments for routine HIV testing, counseling or

treatment are an eligible use.

‘‘(2) Funds that the State or private entities have elected

to provide, including through entering into contracts under

which health benefits are provided. This section does not

require any entity to expend non-Federal funds.

‘‘SEC. 2627. TESTING OF PREGNANT WOMEN AND NEWBORN INFANTS.

‘‘An activity or requirement described in this section is any

of the following:

‘‘(1) In the case of newborn infants who are born in the

State and whose biological mothers have not undergone prenatal testing for HIV disease, that each such infant undergo

testing for such disease.

‘‘(2) That the results of such testing of a newborn infant

be promptly disclosed in accordance with the following, as

applicable to the infant involved:

‘‘(A) To the biological mother of the infant (without

regard to whether she is the legal guardian of the infant).

‘‘(B) If the State is the legal guardian of the infant:

‘‘(i) To the appropriate official of the State agency

with responsibility for the care of the infant.

‘‘(ii) To the appropriate official of each authorized

agency providing assistance in the placement of the

infant.

‘‘(iii) If the authorized agency is giving significant

consideration to approving an individual as a foster

parent of the infant, to the prospective foster parent.

‘‘(iv) If the authorized agency is giving significant

consideration to approving an individual as an adoptive

parent of the infant, to the prospective adoptive parent.

‘‘(C) If neither the biological mother nor the State

is the legal guardian of the infant, to another legal guardian

of the infant.

‘‘(D) To the child’s health care provider.

‘‘(3) That, in the case of prenatal testing for HIV disease

that is conducted in the State, the results of such testing

be promptly disclosed to the pregnant woman involved.

‘‘(4) That, in disclosing the test results to an individual

under paragraph (2) or (3), appropriate counseling on the

human immunodeficiency virus be made available to the

individual (except in the case of a disclosure to an official

of a State or an authorized agency).

‘‘(5) With respect to State insurance laws, that such laws

require—

‘‘(A) that, if health insurance is in effect for an individual, the insurer involved may not (without the consent

of the individual) discontinue the insurance, or alter the

terms of the insurance (except as provided in subparagraph
S. 641—27

(C)), solely on the basis that the individual is infected

with HIV disease or solely on the basis that the individual

has been tested for the disease or its manifestation;

‘‘(B) that subparagraph (A) does not apply to an individual who, in applying for the health insurance involved,

knowingly misrepresented the HIV status of the individual;

and

‘‘(C) that subparagraph (A) does not apply to any

reasonable alteration in the terms of health insurance for

an individual with HIV disease that would have been made

if the individual had a serious disease other than HIV

disease.

For purposes of this subparagraph, a statute or regulation

shall be deemed to regulate insurance for purposes of this

paragraph only to the extent that such statute or regulation

is treated as regulating insurance for purposes of section

514(b)(2) of the Employee Retirement Income Security Act of

1974.

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

‘‘(a) IN GENERAL.—The Secretary shall request that the

Institute of Medicine of the National Academy of Sciences conduct

an evaluation of the extent to which State efforts have been effective

in reducing the perinatal transmission of the human immuno

deficiency virus, and an analysis of the existing barriers to the

further reduction in such transmission.

‘‘(b) REPORT TO CONGRESS.—The Secretary shall ensure that,

not later than 2 years after the date of enactment of this section,

the evaluation and analysis described in subsection (a) is completed

and a report summarizing the results of such evaluation and analysis is prepared by the Institute of Medicine and submitted to the

appropriate committees of Congress together with the recommendations of the Institute.

‘‘SEC. 2629. STATE HIV TESTING PROGRAMS ESTABLISHED PRIOR TO

OR AFTER ENACTMENT.

‘‘Nothing in this subpart shall be construed to disqualify a

State from receiving grants under this title if such State has established at any time prior to or after the date of enactment of

this subpart a program of mandatory HIV testing.’’.

SEC. 8. SPOUSAL NOTIFICATION.

(a) IN GENERAL.—The Secretary of Health and Human Services

shall not make a grant under part B of title XXVI of the Public

Health Service Act (42 U.S.C. 300ff–21 et seq.) to any State unless

such State takes administrative or legislative action to require

that a good faith effort be made to notify a spouse of a known

HIV-infected patient that such spouse may have been exposed to

the human immunodeficiency virus and should seek testing.

(b) DEFINITIONS.—For purposes of this section:

(1) SPOUSE.—The term ‘‘spouse’’ means any individual who

is the marriage partner of an HIV-infected patient, or who

has been the marriage partner of that patient at any time

within the 10-year period prior to the diagnosis of HIV infection.

(2) HIV-INFECTED PATIENT.—The term ‘‘HIV-infected

patient’’ means any individual who has been diagnosed to be

infected with the human immunodeficiency virus.
S. 641—28

(3) STATE.—The term ‘‘State’’ means any of the 50 States,

the District of Columbia, or any territory of the United States.

SEC. 9. OPTIONAL PARTICIPATION OF FEDERAL EMPLOYEES IN AIDS

TRAINING PROGRAMS.

(a) IN GENERAL.—Notwithstanding any other provision of law,

a Federal employee may not be required to attend or participate

in an AIDS or HIV training program if such employee refuses

to consent to such attendance or participation, except for training

necessary to protect the health and safety of the Federal employee

and the individuals served by such employees. An employer may

not retaliate in any manner against such an employee because

of the refusal of such employee to consent to such attendance

or participation.

(b) DEFINITION.—As used in subsection (a), the term ‘‘Federal

employee’’ has the same meaning given the term ‘‘employee’’ in

section 2105 of title 5, United States Code, and such term shall

include members of the armed forces.

SEC. 10. PROHIBITION ON PROMOTION OF CERTAIN ACTIVITIES.

Part D of title XXVI of the Public Health Service Act (42

U.S.C. 300ff–71) as amended by section 6, is further amended

by adding at the end thereof the following new section:

‘‘SEC. 2678. PROHIBITION ON PROMOTION OF CERTAIN ACTIVITIES.

‘‘None of the funds authorized under this title shall be used

to fund AIDS programs, or to develop materials, designed to promote

or encourage, directly, intravenous drug use or sexual activity,

whether homosexual or heterosexual. Funds authorized under this

title may be used to provide medical treatment and support services

for individuals with HIV.’’.

SEC. 11. LIMITATION ON APPROPRIATIONS.

Notwithstanding any other provision of law, the total amounts

of Federal funds expended in any fiscal year for AIDS and HIV

activities may not exceed the total amounts expended in such fiscal

year for activities related to cancer.

SEC. 12. ADDITIONAL PROVISIONS.

(a) DEFINITIONS.—Section 2676(4) (42 U.S.C. 300ff–76(4)) is

amended by inserting ‘‘funeral-service practitioners,’’ after ‘‘emergency medical technicians,’’.

(b) MISCELLANEOUS AMENDMENT.—Section 1201(a) (42 U.S.C.

300d(a)) is amended in the matter preceding paragraph (1) by

striking ‘‘The Secretary,’’ and all that follows through ‘‘shall,’’ and

inserting ‘‘The Secretary shall,’’.

(c) TECHNICAL CORRECTIONS.—Title XXVI (42 U.S.C. 300ff–

11 et seq.) is amended—

(1) in section 2601(a), by inserting ‘‘section’’ before ‘‘2604’’;

(2) in section 2603(b)(4)(B), by striking ‘‘an expedited

grants’’ and inserting ‘‘an expedited grant’’;

(3) in section 2617(b)(3)(B)(iv), by inserting ‘‘section’’ before

‘‘2615’’;

(4) in section 2647—

(A) in subsection (a)(1), by inserting ‘‘to’’ before ‘‘HIV’’;

(B) in subsection (c), by striking ‘‘section 2601’’ and

inserting ‘‘section 2641’’; and

(C) in subsection (d)—
S. 641—29

(i) in the matter preceding paragraph (1), by striking ‘‘section 2601’’ and inserting ‘‘section 2641’’; and

(ii) in paragraph (1), by striking ‘‘has in place’’

and inserting ‘‘will have in place’’;

(5) in section 2648—

(A) by converting the heading for the section to boldface

type; and

(B) by redesignating the second subsection (g) as subsection (h);

(6) in section 2649—

(A) in subsection (b)(1), by striking ‘‘subsection (a) of’’;

and

(B) in subsection (c)(1), by striking ‘‘this subsection’’

and inserting ‘‘subsection’’;

(7) in section 2651—

(A) in subsection (b)(3)(B), by striking ‘‘facility’’ and

inserting ‘‘facilities’’; and

(B) in subsection (c), by striking ‘‘exist’’ and inserting

‘‘exists’’;

(8) in section 2676—

(A) in paragraph (2), by striking ‘‘section’’ and all that

follows through ‘‘by the’’ and inserting ‘‘section 2686 by

the’’; and

(B) in paragraph (10), by striking ‘‘673(a)’’ and inserting ‘‘673(2)’’;

(9) in part E, by converting the headings for subparts

I and II to Roman typeface; and

(10) in section 2684(b), in the matter preceding paragraph

(1), by striking ‘‘section 2682(d)(2)’’ and inserting ‘‘section

2683(d)(2)’’.

SEC. 13. EFFECTIVE DATE.

(a) IN GENERAL.—Except as provided in subsection (b), this

Act, and the amendments made by this Act, shall become effective

on October 1, 1996.

(b) EXCEPTION.—The amendments made by sections 3(a), 5,

6, and 7 of this Act to sections 2601(c), 2601(d), 2603(a), 2618(b),

2626, 2677, and 2691 of the Public Health Service Act, shall become

effective on the date of enactment of this Act.

Speaker of the House of Representatives.

Vice President of the United States and

President of the Senate.