327 
period provided under paragraph (1), the coverage 
period under this part shall— 
‘‘(A) begin on the first day of the first 
month in which the individual applies for a de-
termination under section 1899B(b)(2)(A); and 
‘‘(B) remain in effect until such time as 
the Secretary determines the individual no 
longer eligible as determined under section 
1899B(b)(2)(C)(ii).’’. 
(C) CONFORMING
SUNSET
OF
STATE 
AGREEMENTS RELATING TO ENROLLMENT OF 
QUALIFIED MEDICARE BENEFICIARIES.— 
(i) PART A.—Section 1818(g) of the 
Social Security Act (42 U.S.C. 1395i–2(g)) 
is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(3) SUNSET.—This subsection shall not apply on or 
after January 1, 2023.’’. 
(ii) PART B.—Section 1843(h) of the 
Social Security Act (42 U.S.C. 1395v(h)) 
is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(3) SUNSET WITH RESPECT TO QUALIFIED MEDI-
CARE BENEFICIARIES.—This subsection shall not apply 
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328 
with respect to qualified medicare beneficiaries on or after 
January 1, 2023.’’. 
(3) PUBLIC
AWARENESS
CAMPAIGN.—Section 
1144 of the Social Security Act (42 U.S.C. 1320b– 
14) is amended by adding at the end the following 
new subsection: 
‘‘(d) PUBLIC AWARENESS CAMPAIGN.— 
‘‘(1) IN
GENERAL.—The Commissioner shall 
conduct a public awareness campaign to educate 
Medicare beneficiaries on the availability of Medicare 
cost assistance for low-income individuals under sec-
tion 1899B. 
‘‘(2) COORDINATION.—In carrying out such 
public awareness campaign, the Commissioner shall 
coordinate with State health insurance assistance 
programs described in subsection (a)(1)(A) of sec-
tion 119 of the Medicare Improvements for Patients 
and Providers Act of 2008 (42 U.S.C. 1395b–3 
note)), the Administrator of the Administration for 
Community Living, and the Administrator of the 
Centers for Medicare & Medicaid Services. 
‘‘(3) FUNDING.—There are hereby appropriated 
to the Commissioner, out of any funds in the Treas-
ury not otherwise appropriated, $10,000,000 for 
each of fiscal years 2023 through 2025, to provide 
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329 
grants to State health insurance assistance pro-
grams to carry out outreach and education activities 
under the public awareness campaign pursuant to 
this subsection.’’. 
(b) MOVING MEDICARE COST-SHARING BENEFITS 
FROM MEDICAID TO MEDICARE.— 
(1) ENDING
MOST
MEDICARE
COST-SHARING 
BENEFITS UNDER MEDICAID.—Section 1902(a)(10) 
of the Social Security Act (42 U.S.C. 1396a(a)(10)) 
is amended— 
(A) by inserting ‘‘for calendar quarters be-
ginning before January 1, 2023,’’ before ‘‘for 
making’’ each place it appears in clauses (i), 
(iii), and (iv) of subparagraph (E); and 
(B) in the matter following subparagraph 
(G)— 
(i) by inserting ‘‘furnished during cal-
endar quarters beginning before January 
1, 2023’’ after ‘‘(described in section 
1905(p)(3))’’; 
(ii) by striking ‘‘(XV)’’ and inserting 
‘‘, (XV)’’; 
(iii) by striking ‘‘and (XVIII)’’ and in-
serting ‘‘, (XVIII)’’; and 
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330 
(iv) by inserting ‘‘, and (XIX) no 
medical assistance for medicare cost-shar-
ing, other than medical assistance for 
medicare cost-sharing for qualified disabled 
and working individuals described in sec-
tion 1905(s), shall be made available after 
January 1, 2023’’ before the semicolon at 
the end. 
(2) CONFORMING AMENDMENTS.— 
(A) TITLE XIX.— 
(i) Section 1903(i) of such Act (42 
U.S.C. 1396b(i)) is amended— 
(I) in paragraph (26), by striking 
‘‘; and’’ and inserting a semicolon; 
(II) in paragraph (27), by strik-
ing the period at the end and insert-
ing ‘‘; and’’; and 
(III) by inserting after paragraph 
(27) the following new paragraph: 
‘‘(28) with respect to any amount expended for 
medical assistance for medicare cost-sharing (other 
than medical assistance for medicare cost-sharing 
for qualified disabled and working individuals de-
scribed in section 1905(s)) furnished during cal-
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331 
endar quarters beginning on or after January 1, 
2023.’’. 
(ii) Section 1905(a) of such Act (42 
U.S.C. 1396d(a)) is amended, in the first 
sentence, by inserting ‘‘furnished during 
calendar quarters beginning before Janu-
ary 1, 2023’’ after ‘‘medicare cost-shar-
ing’’. 
(iii) Section 1933(g) of such Act (42 
U.S.C. 1396u–3(g)) is amended— 
(I) in paragraph (2)(Q), by strik-
ing ‘‘paragraph (4), for each subse-
quent year’’ and inserting ‘‘para-
graphs (4) and (5), for each subse-
quent year before 2023’’; and 
(II) by adding at the end the fol-
lowing: 
‘‘(5) SUNSET.—No individual shall be selected 
to be a qualifying individual for any calendar year 
or period under this section beginning on or after 
January 1, 2023, and no State allocation shall be 
made for any fiscal year or period under this section 
beginning on or after January 1, 2023.’’. 
(iv) Section 1935(a) of such Act (42 
U.S.C. 1396u–5(a)) is amended— 
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332 
(I) in paragraph (2), by striking 
‘‘make determinations’’ and inserting 
‘‘prior to January 1, 2023, make de-
terminations’’; and 
(II) in paragraph (3), by insert-
ing ‘‘prior to January 1, 2023,’’ be-
fore ‘‘the State shall’’. 
(B) TITLE XI.—Section 1144 of the Social 
Security Act (42 U.S.C. 1320b–14) is amend-
ed— 
(i) in subsection (a)— 
(I) in paragraph (1)(A)— 
(aa) by striking ‘‘sections 
1902(a)(10)(E) and 1933’’ and 
inserting 
‘‘section 
1902(a)(10)(E) and (prior to 
January 1, 2023) section 1933’’; 
(bb) by striking ‘‘for the 
transitional assistance under sec-
tion 1860D–31(f), or’’ and in-
serting a comma; and 
(cc) by inserting ‘‘, or for 
Medicare premium and cost-shar-
ing 
assistance 
under 
section 
1899B (in the case of months be-
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333 
ginning on or after January 1, 
2023)’’ before the semicolon; and 
(II) by striking paragraph (2) 
and inserting the following: 
‘‘(2) CONTENT
OF
NOTICE.—Any notice fur-
nished under paragraph (1) shall state that eligi-
bility for such medical assistance, subsidies, or pro-
gram is conditioned upon meeting the applicable eli-
gibility criteria.’’; 
(ii) in subsection (b)(1)(A)— 
(I) 
by 
striking 
‘‘sections 
1902(a)(10)(E) and 1933’’ and in-
serting ‘‘section 1902(a)(10)(E) and 
(prior to January 1, 2023) section 
1933’’; 
(II) by striking ‘‘for transitional 
assistance under section 1860D–31(f), 
or’’; and 
(III) by inserting ‘‘, or for Medi-
care premium and cost-sharing assist-
ance under section 1899B’’ before the 
semicolon; and 
(iii) in subsection (c)— 
(I) in paragraph (1)(B), by in-
serting ‘‘, and (beginning January 1, 
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334 
2023), provide an application for en-
rollment under the Medicare Savings 
Program’’ before the period; 
(II) in paragraph (2), in the 
paragraph 
header, 
by 
inserting 
‘‘MEDICARE SAVINGS PROGRAM APPLI-
CATION
AND’’ before ‘‘LIS
APPLICA-
TION’’; and 
(III) in paragraph (7), by strik-
ing ‘‘means the program of medical 
assistance’’ 
and 
all 
that 
follows 
through the period and inserting 
‘‘means— 
‘‘(A) prior to January 1, 2023, the pro-
gram of medical assistance for payment of the 
cost of medicare cost-sharing under the Med-
icaid 
program 
pursuant 
to 
sections 
1902(a)(10)(E) and 1933; and 
‘‘(B) beginning January 1, 2023, the pro-
gram for medical assistance for payment of the 
cost of medicare cost-sharing for qualified dis-
abled and working individuals described in sec-
tion 
1905(s) 
pursuant 
to 
section 
1902(a)(10)(E)(ii) and medicare premium and 
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335 
cost-sharing assistance provided under section 
1899B.’’. 
(3) ENSURING THAT MEDICARE COST-SHARING 
BENEFICIARIES
UNDER
MEDICAID
RECEIVE
MEDI-
CARE COST ASSISTANCE.—Not later than June 1, 
2022, the Secretary of Health and Human Services 
and the Commissioner of Social Security shall jointly 
develop and implement a transition plan to ensure 
that all individuals who are eligible for and are re-
ceiving medical assistance for the payment of medi-
care cost-sharing under a State Medicaid program 
pursuant to clauses (i), (iii), and (iv) of section 
1902(a)(10)(E) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(E)) as of December 31, 2022, 
receive Medicare cost assistance under section 
1899B of such Act, as added by subsection (a), as 
of January 1, 2023. 
(c) ENHANCING
PRESCRIPTION
DRUG
AFFORD-
ABILITY BY EXPANDING ACCESS TO ASSISTANCE WITH 
OUT-OF-POCKET COSTS UNDER MEDICARE PART D FOR 
LOW-INCOME SENIORS AND INDIVIDUALS WITH DISABIL-
ITIES.— 
(1) EXPANDING ACCESS.—Section 1860D–14 of 
the Social Security Act (42 U.S.C. 1395w–114) is 
amended— 
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336 
(A) in subsection (a)— 
(i) in the heading, by striking ‘‘150 
PERCENT’’ and inserting ‘‘200 PERCENT’’; 
(ii) in paragraph (1)— 
(I) in the heading, by striking 
‘‘135
PERCENT’’ and inserting ‘‘200 
PERCENT’’; and 
(II) in the matter preceding sub-
paragraph (A)— 
(aa) by striking ‘‘135 per-
cent’’ and inserting ‘‘200 per-
cent’’; and 
(bb) by striking ‘‘and who 
meets the resources requirement 
described in paragraph (3)(D) or 
who is covered under this para-
graph 
under 
paragraph 
(3)(B)(i)’’ and inserting ‘‘or who 
is covered under this paragraph 
under paragraph (3)(B)(v)’’; 
(iii) by striking paragraph (2); 
(iv) in paragraph (3)— 
(I) in subparagraph (A)— 
(aa) in clause (i), by adding 
‘‘and’’ at the end; 
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337 
(bb) in clause (ii)— 
(AA) by striking ‘‘150 
percent’’ and inserting ‘‘200 
percent’’; and 
(BB) by striking ‘‘; 
and’’ at the end and insert-
ing a period; and 
(cc) by striking clause (iii); 
(II) by striking subparagraphs 
(B) and (C) and inserting the fol-
lowing: 
‘‘(B) DETERMINATIONS.—For provisions 
relating to joint determinations with respect to 
eligibility for Medicare cost assistance under 
section 1899B and premium and cost-sharing 
subsidies 
under 
this 
section, 
see 
section 
1899B(b)(2). 
‘‘(C) INCOME DETERMINATIONS.—For pur-
poses of applying this section— 
‘‘(i) in the case of an individual who 
is not treated as a Medicare cost-sharing 
assistance eligible individual and a subsidy 
eligible 
individual 
under 
section 
1899B(b)(2)(D), income shall be deter-
mined in the manner described under sec-
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338 
tion 1612 for purposes of the supplemental 
security income program, except that sup-
port and maintenance furnished in kind 
shall not be counted as income; and 
‘‘(ii) the term ‘poverty line’ has the 
meaning given such term in section 673(2) 
of the Community Services Block Grant 
Act (42 U.S.C. 9902(2)), including any re-
vision required by such section.’’; and 
(III) by striking subparagraphs 
(D), (E), and (G); and 
(v) in paragraph (4), by striking sub-
paragraph (B); and 
(B) in subsection (c)(1), in the second sen-
tence, by striking ‘‘subsections (a)(1)(D) and 
(a)(2)(E)’’ 
and 
inserting 
‘‘subsection 
(a)(1)(D)’’. 
(2) TREATMENT OF REDUCTION OF COST-SHAR-
ING FOR INDIVIDUALS RECEIVING HOME AND COM-
MUNITY
BASED
SERVICES.—Section 
1860D– 
14(a)(1)(D) of the Social Security Act (42 U.S.C. 
1395w–114(a)(1)(D)) is amended— 
(A) by striking ‘‘who would be such an in-
stitutionalized individual or couple, if the full- 
benefit dual eligible individual were not’’; and 
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339 
(B) by striking ‘‘or subsection (c) or (d) of 
section 1915 or under a State plan amendment 
under subsection (i) of such section’’ and in-
serting ‘‘, section 1115A, section 1915, or 
under a State plan amendment’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to plan year 2023 and 
subsequent plan years. 
SEC. 4107. REDUCING COST-SHARING, ALIGNING INCOME 
AND RESOURCE ELIGIBILITY TESTS, SIMPLI-
FYING ENROLLMENT, AND OTHER PROGRAM 
IMPROVEMENTS 
FOR 
LOW-INCOME 
BENE-
FICIARIES. 
(a) INCREASE IN INCOME ELIGIBILITY TO 135 PER-
CENT
OF
FPL FOR
QUALIFIED
MEDICARE
BENE-
FICIARIES.— 
(1) IN GENERAL.—Section 1905(p)(2)(A) of the 
Social Security Act (42 U.S.C. 1396d(p)(2)(A)) is 
amended by striking ‘‘shall be at least the percent 
provided under subparagraph (B) (but not more 
than 100 percent) of the official poverty line’’ and 
all that follows through the period at the end and 
inserting the following: ‘‘shall be— 
‘‘(i) before January 1, 2023, at least 
the percent provided under subparagraph 
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340 
(B) (but not more than 100 percent) of 
the official poverty line (as defined by the 
Office of Management and Budget, and re-
vised annually in accordance with section 
673(2) of the Omnibus Budget Reconcili-
ation Act of 1981) applicable to a family 
of the size involved; and 
‘‘(ii) on or after January 1, 2023, 
equal to 135 percent of the official poverty 
line (as so defined and revised) applicable 
to a family of the size involved.’’. 
(2) NOT
COUNTING
IN-KIND
SUPPORT
AND 
MAINTENANCE AS INCOME.—Section 1905(p)(2)(D) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396d(p)(2)(D)) is amended by adding at the end 
the following new clause: 
‘‘(iii) In determining income under this sub-
section, support and maintenance furnished in kind 
shall not be counted as income.’’. 
(b) INCREASE IN INCOME ELIGIBILITY TO 200 PER-
CENT OF FPL FOR SPECIFIED LOW-INCOME MEDICARE 
BENEFICIARIES.— 
(1) ELIGIBILITY
OF
INDIVIDUALS
WITH
IN-
COMES
BELOW
150
PERCENT
OF
FPL.—Section 
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341 
1902(a)(10)(E) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(E)) is amended— 
(A) by adding ‘‘and’’ at the end of clause 
(ii); 
(B) in clause (iii)— 
(i) by striking ‘‘and 120 percent in 
1995 and years thereafter’’ and inserting 
‘‘120 percent in 1995 and years thereafter 
before 2023, and 200 percent in 2023 and 
years thereafter’’; and 
(ii) by striking ‘‘and’’ at the end; and 
(C) by striking clause (iv). 
(2) REFERENCES.—Section 1905(p)(1) of the 
Social Security Act (42 U.S.C. 1396d(p)(1)) is 
amended by adding at and below subparagraph (C) 
the following flush sentence: 
‘‘The term ‘specified low-income medicare beneficiary’ 
means 
an 
individual 
described 
in 
section 
1902(a)(10)(E)(iii).’’. 
(3) CONFORMING AMENDMENTS.— 
(A) The first sentence of section 1905(b) 
of such Act (42 U.S.C. 1396d(b)) is amended 
by striking ‘‘and section 1933(d)’’. 
(B) Section 1933 of such Act (42 U.S.C. 
1396u–3) is repealed. 
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342 
(c) 100 PERCENT FMAP.—Section 1905 of the So-
cial Security Act (42 U.S.C. 1396d) is amended by adding 
at the end the following new subsection: 
‘‘(jj) INCREASED FMAP FOR EXPANDED MEDICARE 
COST-SHARING POPULATIONS.— 
‘‘(1) IN GENERAL.—Notwithstanding subsection 
(b), with respect to expenditures described in para-
graph (2) the Federal medical assistance percentage 
shall be equal to 100 percent. 
‘‘(2) EXPENDITURES DESCRIBED.—The expend-
itures described in this paragraph are expenditures 
made on or after January 1, 2023, for medical as-
sistance for medicare cost-sharing provided to any 
individual under clause (i), (ii), or (iii) of section 
1902(a)(10)(E) who would not have been eligible for 
medicare cost-sharing under any such clause under 
the income or resource eligibility standards in effect 
on October 1, 2018.’’. 
(d) CONSOLIDATION OF LOW-INCOME SUBSIDY RE-
SOURCE ELIGIBILITY TESTS.— 
(1) IN GENERAL.—Section 1860D–14(a)(3) of 
the Social Security Act (42 U.S.C. 1395w– 
114(a)(3)) is amended— 
(A) by striking subparagraph (D); 
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343 
(B) by redesignating subparagraphs (E) 
through (G) as subparagraphs (D) through (F), 
respectively; and 
(C) in the heading of subparagraph (D), as 
so redesignated, by striking ‘‘ALTERNATIVE’’. 
(2) CLARIFICATION OF CERTAIN RULES RELAT-
ING
TO
INCOME
AND
RESOURCE
DETERMINA-
TIONS.—Section 1860D–14(a)(3) of the Social Secu-
rity Act (42 U.S.C. 1395w–114(a)(3)), as amended 
by paragraph (1), is amended by striking subpara-
graph (F) and inserting the following new subpara-
graphs: 
‘‘(F) RESOURCE
EXCLUSIONS.—In deter-
mining the resources of an individual (and the 
eligible spouse of the individual, if any) under 
section 1613 for purposes of subparagraph 
(D)— 
‘‘(i) no part of the value of any life in-
surance policy shall be taken into account; 
‘‘(ii) no part of the value of any vehi-
cle shall be taken into account; 
‘‘(iii) there shall be excluded an 
amount equal to $1,500 each with respect 
to any individual or eligible spouse of an 
individual who attests that some of the re-
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344 
sources of such individual or spouse will be 
used to meet the burial and related ex-
penses of such individual or spouse; and 
‘‘(iv) no balance in, or benefits re-
ceived under, an employee pension benefit 
plan (as defined in section 3 of the Em-
ployee Retirement Income Security Act of 
1974) shall be taken into account. 
‘‘(G) FAMILY
SIZE.—In determining the 
size of the family of an individual for purposes 
of determining the income eligibility of such in-
dividual under this section, an individual’s fam-
ily shall consist of— 
‘‘(i) the individual; 
‘‘(ii) the individual’s spouse who lives 
in the same household as the individual (if 
any); and 
‘‘(iii) any other individuals who— 
‘‘(I) are related to the individual 
whose income eligibility is in question 
or such individual’s spouse who lives 
in the same household; 
‘‘(II) are living in the same 
household as such individual; and 
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346 
‘‘subparagraph (F)’’ and inserting ‘‘sub-
paragraph (E)’’; and 
(v) in subparagraph (D)(i), in the 
matter preceding subclause (I), by striking 
‘‘subject to the life insurance policy exclu-
sion provided under subparagraph (G)’’ 
and inserting ‘‘subject to the resource ex-
clusions 
provided 
under 
subparagraph 
(F)’’. 
(e) ALIGNMENT
OF LOW-INCOME SUBSIDY
AND 
MEDICARE SAVINGS PROGRAM INCOME AND RESOURCE 
ELIGIBILITY TESTS.— 
(1) APPLICATION
OF
MEDICAID
SPOUSAL
IM-
POVERISHMENT RESOURCE ALLOWANCE TO MSP AND 
LIS RESOURCE ELIGIBILITY.—Section 1905(p)(1)(C) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396d(p)(1)(C)) is amended to read as follows: 
‘‘(C) whose resources (as determined under sec-
tion 1613 for purposes of the supplemental security 
income program subject to the resource exclusions 
under subparagraph (G) of section 1860D–14(a)(3)) 
do not exceed— 
‘‘(i) in the case of an individual with a 
spouse, an amount equal to the sum of the first 
amount specified in subsection (f)(2)(A)(i) of 
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347 
section 1924 (as adjusted under subsection (g) 
of such section) and the amount specified in 
subsection (f)(2)(A)(ii)(II) of such section (as 
so adjusted); or 
‘‘(ii) in the case of an individual who does 
not have a spouse, an amount equal to 1⁄2 of 
the amount described in clause (i).’’. 
(2) 
APPLICATION
TO
QDWIS.—Section 
1905(s)(3) of the Social Security Act (42 U.S.C. 
1396d(s)(3)) is amended to read as follows: 
‘‘(3) whose resources (as determined under sec-
tion 1613 for purposes of the supplemental security 
income program subject to the resource exclusions 
under subparagraph (G) of section 1860D–14(a)(3)) 
do not exceed— 
‘‘(A) in the case of an individual with a 
spouse, the amount in effect for the year under 
clause (i) of subsection (p)(1)(C); and 
‘‘(B) in the case of an individual who does 
not have a spouse, the amount in effect for the 
year under clause (ii) of subsection (p)(1)(C); 
and’’. 
(3) APPLICATION TO LIS.—Clause (i) of section 
1860D–14(a)(3)(D) of the Social Security Act (42 
U.S.C. 1395w–114(a)(3)(D)), as redesignated and 
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348 
amended by subsection (d)(1), is amended to read as 
follows: 
‘‘(i) IN GENERAL.—The resources re-
quirement of this subparagraph is that an 
individual’s resources (as determined under 
section 1613 for purposes of the supple-
mental security income program subject to 
the resource exclusions provided under 
subparagraph (G)) do not exceed the 
amount in effect for the year under section 
1905(p)(1)(C)(ii).’’. 
(f) ENROLLMENT SIMPLIFICATIONS.— 
(1) APPLICATION
OF
3-MONTH
RETROACTIVE 
ELIGIBILITY TO QMBS.— 
(A) IN GENERAL.—Section 1902(e)(8) of 
the Social Security Act (42 U.S.C. 1396a(e)(8)) 
is amended by striking ‘‘after the end of the 
month in which the determination first occurs’’ 
and inserting ‘‘in or after the third month be-
fore the month in which the individual makes 
application for assistance’’. 
(B) PROCESS
FOR
SUBMITTING
CLAIMS 
DURING RETROACTIVE ELIGIBILITY PERIOD.— 
Section 1902(e)(8) of the Social Security Act 
(42 U.S.C. 1396a(e)(8)) is further amended by 
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349 
adding at the end the following: ‘‘The Secretary 
shall provide for a process under which claims 
for medical assistance under the State plan may 
be submitted for services furnished to such an 
individual during such 3-month period before 
the month in which the individual made appli-
cation for assistance.’’. 
(C) CONFORMING
AMENDMENT.—Section 
1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)) is amended, in the matter preceding 
paragraph (1), by striking ‘‘or, in the case of 
medicare cost-sharing with respect to a quali-
fied medicare beneficiary described in sub-
section (p)(1), if provided after the month in 
which the individual becomes such a bene-
ficiary’’. 
(2) STATE OPTION FOR 12-MONTH CONTINUOUS 
ELIGIBILITY
FOR
SLMBS
AND
QWDIS.—Section 
1902(e)(12) of the Social Security Act (42 U.S.C. 
1396a(e)(12)) is amended— 
(A) by redesignating subparagraphs (A) 
and (B) as clauses (i) and (ii), respectively; 
(B) by inserting ‘‘(A)’’ after ‘‘(12)’’; and 
(C) by adding at the end the following: 
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350 
‘‘(B) At the option of the State, the plan may provide 
that an individual who is determined to be eligible for ben-
efits under a State plan approved under this title under 
any of the following eligibility categories, or who is rede-
termined to be eligible for such benefits under any of such 
categories, shall be considered to meet the eligibility re-
quirements met on the date of application and shall re-
main eligible for those benefits until the end of the 12- 
month period following the date of the determination or 
redetermination of eligibility, except that a State may pro-
vide for such determinations more frequently, but not 
more frequently than once every 6 months for an indi-
vidual: 
‘‘(i) A specified low-income medicare beneficiary 
described in subsection (a)(10)(E)(iii) of this section 
who is determined eligible for medicare cost sharing 
described in section 1905(p)(3)(A)(ii). 
‘‘(ii) A qualified disabled and working indi-
vidual described in section 1905(s) who is deter-
mined eligible for medicare cost-sharing described in 
section 1905(p)(3)(A)(i).’’. 
(3) STATE OPTION TO USE EXPRESS LANE ELI-
GIBILITY FOR THE MEDICARE SAVINGS PROGRAM.— 
Section 1902(e)(13)(A) of the Social Security Act 
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351 
(42 U.S.C. 1396a(e)(13)(A)) is amended by adding 
at the end the following new clause: 
‘‘(iii) STATE OPTION TO EXTEND EXPRESS 
LANE ELIGIBILITY TO OTHER POPULATIONS.— 
‘‘(I) IN GENERAL.—At the option of 
the State, the State may apply the provi-
sions of this paragraph with respect to de-
termining eligibility under this title for an 
eligible individual (as defined in subclause 
(II)). In applying this paragraph in the 
case of a State making such an option, any 
reference in this paragraph to a child with 
respect to this title (other than a reference 
to child health assistance) shall be deemed 
to be a reference to an eligible individual. 
‘‘(II) 
ELIGIBLE
INDIVIDUAL
DE-
FINED.—In this clause, the term ‘eligible 
individual’ means any of the following: 
‘‘(aa) A qualified medicare bene-
ficiary described in section 1905(p)(1) 
for purposes of determining eligibility 
for medicare cost-sharing (as defined 
in section 1905(p)(3)). 
‘‘(bb) A specified low-income 
medicare beneficiary described in sub-
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352 
section (a)(10)(E)(iii) of this section 
for purposes of determining eligibility 
for medicare cost-sharing described in 
section 1905(p)(3)(A)(ii). 
‘‘(cc) A qualified disabled and 
working individual described in sec-
tion 1905(s) for purposes of deter-
mining eligibility for medicare cost- 
sharing 
described 
in 
section 
1905(p)(3)(A)(i).’’. 
(g) MEDICAID TREATMENT OF CERTAIN MEDICARE 
PROVIDERS.—Section 1902(n) of the Social Security Act 
(42 U.S.C. 1396a(n)) is amended by adding at the end 
the following new paragraph: 
‘‘(4) A State plan shall not deny a claim from a pro-
vider or supplier with respect to medicare cost-sharing de-
scribed in subparagraph (B), (C), or (D) of section 
1905(p)(3) for an item or service which is eligible for pay-
ment under title XVIII on the basis that the provider or 
supplier does not have a provider agreement in effect 
under this title or does not otherwise serve all individuals 
entitled to medical assistance under this title. The State 
shall create a mechanism through which provider or sup-
pliers that do not otherwise have provider agreements with 
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353 
the State can bill the State for medicare cost-sharing for 
qualified medicare beneficiaries.’’. 
(h) ELIGIBILITY FOR OTHER PROGRAMS.—Section 
1905(p) of the Social Security Act (42 U.S.C. 1396d(p)) 
is amended by adding at the end the following new para-
graph: 
‘‘(7) Notwithstanding any other provision of law, any 
medical assistance for some or all medicare cost-sharing 
under this title shall not be considered income or resources 
in determining eligibility for, or the amount of assistance 
or benefits provided under, any other public benefit pro-
vided under Federal law or the law of any State or polit-
ical subdivision thereof.’’. 
(i) TREATMENT OF QUALIFIED MEDICARE BENE-
FICIARIES, SPECIFIED LOW-INCOME MEDICARE BENE-
FICIARIES, AND OTHER DUAL ELIGIBLES AS MEDICARE 
BENEFICIARIES.—Section 1862 of the Social Security Act 
(42 U.S.C. 1395y) is amended by adding at the end the 
following new subsection: 
‘‘(p) TREATMENT OF QUALIFIED MEDICARE BENE-
FICIARIES (QMBS), SPECIFIED LOW-INCOME MEDICARE 
BENEFICIARIES (SLMBS), AND OTHER DUAL ELIGI-
BLES.—Nothing in this title shall be construed as author-
izing a provider of services or supplier to discriminate 
(through a private contractual arrangement or otherwise) 
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354 
against an individual who is otherwise entitled to services 
under this title on the basis that the individual is a quali-
fied 
medicare 
beneficiary 
(as 
defined 
in 
section 
1905(p)(1)), a specified low-income medicare beneficiary, 
or is otherwise eligible for medical assistance for medicare 
cost-sharing or other benefits under title XIX.’’. 
(j) ADDITIONAL FUNDING FOR STATE HEALTH IN-
SURANCE ASSISTANCE PROGRAMS.— 
(1) GRANTS.— 
(A) 
IN
GENERAL.—The 
Secretary 
of 
Health and Human Services (in this subsection 
referred to as the ‘‘Secretary’’) shall use 
amounts made available under subparagraph 
(B) to make grants to States for State health 
insurance assistance programs receiving assist-
ance under section 4360 of the Omnibus Budg-
et Reconciliation Act of 1990. 
(B) FUNDING.—For purposes of making 
grants under this subsection, the Secretary 
shall provide for the transfer, from the Federal 
Hospital Insurance Trust Fund under section 
1817 of the Social Security Act (42 U.S.C. 
1395i) and the Federal Supplementary Medical 
Insurance Trust Fund under section 1841 of 
such Act (42 U.S.C. 1395t), in the same pro-
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355 
portion as the Secretary determines under sec-
tion 1853(f) of such Act (42 U.S.C. 1395w– 
23(f)), of $50,000,000 to the Centers for Medi-
care & Medicaid Services Program Management 
Account for each of the fiscal years 2024 
through 2028, to remain available until ex-
pended. 
(2) AMOUNT OF GRANTS.—The amount of a 
grant to a State under this subsection from the total 
amount made available under paragraph (1) shall be 
equal to the sum of the amount allocated to the 
State under paragraph (3)(A) and the amount allo-
cated to the State under subparagraph (3)(B). 
(3) ALLOCATION TO STATES.— 
(A) ALLOCATION BASED ON PERCENTAGE 
OF LOW-INCOME BENEFICIARIES.—The amount 
allocated to a State under this subparagraph 
from 2⁄3 of the total amount made available 
under paragraph (1) shall be based on the num-
ber of individuals who meet the requirement 
under 
subsection 
(a)(3)(A)(ii) 
of 
section 
1860D–14 of the Social Security Act (42 
U.S.C. 1395w–114) but who have not enrolled 
to receive a subsidy under such section 1860D– 
14 relative to the total number of individuals 
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356 
who meet the requirement under such sub-
section (a)(3)(A)(ii) in each State, as estimated 
by the Secretary. 
(B) ALLOCATION BASED ON PERCENTAGE 
OF RURAL BENEFICIARIES.—The amount allo-
cated to a State under this subparagraph from 
1⁄3 of the total amount made available under 
paragraph (1) shall be based on the number of 
part D eligible individuals (as defined in section 
1860D–1(a)(3)(A) of such Act (42 U.S.C. 
1395w–101(a)(3)(A))) residing in a rural area 
relative to the total number of such individuals 
in each State, as estimated by the Secretary. 
(4) PORTION OF GRANT BASED ON PERCENT-
AGE OF LOW-INCOME BENEFICIARIES TO BE USED 
TO PROVIDE OUTREACH TO INDIVIDUALS WHO MAY 
BE
SUBSIDY
ELIGIBLE
INDIVIDUALS
OR
ELIGIBLE 
FOR
THE
MEDICARE
SAVINGS
PROGRAM.—Each 
grant awarded under this subsection with respect to 
amounts allocated under paragraph (3)(A) shall be 
used to provide outreach to individuals who may be 
subsidy eligible individuals (as defined in section 
1860D–14(a)(3)(A) of the Social Security Act (42 
U.S.C. 1395w–114(a)(3)(A))) or eligible for the pro-
gram of medical assistance for payment of the cost 
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357 
of medicare cost-sharing under the Medicaid pro-
gram pursuant to sections 1902(a)(10)(E) and 1933 
of such Act (42 U.S.C. 1396a(a)(10)(E), 1396u–3). 
(k) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments and repeal made by this 
section take effect on January 1, 2023, and, with re-
spect to title XIX of the Social Security Act, apply 
to calendar quarters beginning on or after January 
1, 2023. 
(2) EXCEPTION FOR STATE LEGISLATION.—In 
the case of a State plan for medical assistance under 
title XIX of the Social Security Act which the Sec-
retary of Health and Human Services determines re-
quires State legislation (other than legislation appro-
priating funds) in order for the plan to meet the ad-
ditional requirements imposed by the amendments 
and repeal made by this section, the State plan shall 
not be regarded as failing to comply with the re-
quirements of such title solely on the basis of its 
failure to meet these additional requirements before 
the first day of the first calendar quarter beginning 
after the close of the first regular session of the 
State legislature that begins after the date of the en-
actment of this Act. For purposes of the previous 
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358 
sentence, in the case of a State that has a 2-year 
legislative session, each year of such session shall be 
deemed to be a separate regular session of the State 
legislature. 
SEC. 4108. 100 PERCENT FMAP FOR MEDICAL ASSISTANCE 
PROVIDED BY URBAN INDIAN ORGANIZA-
TIONS. 
(a) IN GENERAL.—The third sentence of section 
1905(b) of the Social Security Act (42 U.S.C. 1396(b)) 
is amended by inserting ‘‘or are received through a pro-
gram operated by an urban Indian organization through 
a grant or contract under title V of the Indian Health 
Care Improvement Act’’ after ‘‘(as defined in section 4 
of the Indian Health Care Improvement Act)’’. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to medical assistance provided on 
or after the date of enactment of this Act. 
SEC. 4109. 100 PERCENT FMAP FOR MEDICAL ASSISTANCE 
PROVIDED TO A NATIVE HAWAIIAN THROUGH 
A FEDERALLY QUALIFIED HEALTH CENTER 
OR A NATIVE HAWAIIAN HEALTH CARE SYS-
TEM UNDER THE MEDICAID PROGRAM. 
(a) IN GENERAL.—The third sentence of section 
1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) 
is amended by striking ‘‘, for such 8 fiscal year quarters’’. 
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359 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to medical assistance provided on 
or after the date of enactment of this Act. 
SEC. 4110. REPEAL OF REQUIREMENT FOR ESTATE RECOV-
ERY UNDER THE MEDICAID PROGRAM. 
Section 1917 of the Social Security Act (42 U.S.C. 
1396p) is amended— 
(1) in subsection (a)— 
(A) by amending paragraph (1) to read as 
follows: 
‘‘(1) No lien may be imposed against the prop-
erty of any individual prior to his death on account 
of medical assistance paid or to be paid on his behalf 
under the State plan, except pursuant to the judg-
ment of a court on account of benefits incorrectly 
paid on behalf of such individual.’’; 
(B) by striking paragraph (2); 
(C) in paragraph (3), by striking ‘‘(1)(B)’’ 
and inserting ‘‘(1)’’; and 
(D) by redesignating paragraph (3) as 
paragraph (2); and 
(2) by amending subsection (b) to read as fol-
lows: 
‘‘(b) ADJUSTMENT OR RECOVERY OF MEDICAL AS-
SISTANCE CORRECTLY PAID UNDER A STATE PLAN.—No 
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adjustment or recovery of any medical assistance correctly 
paid on behalf of an individual under the State plan may 
be made.’’. 
SEC. 4111. ALLOW FOR SUSPENSION OF MEDICARE BENE-
FITS AND PREMIUM LIABILITY FOR INDIVID-
UALS WHO ARE INCARCERATED AND PRO-
VIDE 
A 
SPECIAL 
ENROLLMENT 
PERIOD 
AROUND THE DATE OF RELEASE. 
(a) SPECIAL ENROLLMENT PERIOD FOR INDIVID-
UALS INCARCERATED
AT TIME
OF MEDICARE ELIGI-
BILITY.—Section 1837(i) of the Social Security Act (42 
U.S.C. 1395p(i)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(5)(A) In the case of an individual who— 
‘‘(i) at the time the individual first satis-
fies paragraph (1) or (2) of section 1836(a), is 
incarcerated; or 
‘‘(ii) has elected not to enroll (or to be 
deemed enrolled) under this section during the 
individual’s initial enrollment period; 
there shall be a special enrollment period de-
scribed in subparagraph (B). 
‘‘(B) The special enrollment period re-
ferred to in subparagraph (A) is the 6-month 
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361 
period on the first day after which the indi-
vidual is no longer incarcerated.’’. 
(b) PREMIUM AMOUNT.—Section 1839(b) of the So-
cial Security Act (42 U.S.C. 1395r(b)) is amended— 
(1) by inserting ‘‘(1)’’ after ‘‘(b)’’; 
(2) in paragraph (1), as so redesignated by 
paragraph (1), by striking ‘‘or (l)’’ and inserting 
‘‘(l), or (m)’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(2) In the case of an individual whose coverage pe-
riod includes months in which by reason of custody under 
penal authority coverage is excluded pursuant to section 
1862(a)(3), the premium amount for such months such 
individual is in custody under penal authority shall be 
zero.’’. 
(c) CONFORMING AMENDMENT.—Section 1818(d)(5) 
of the Social Security Act (42 U.S.C. 1395i–2(d)(5)) is 
amended by adding at the end the following: 
‘‘(D) In the case of an individual who is a 
person who is excluded from coverage pursuant 
to section 1862(a)(3) by reason of custody 
under penal authority, the amount of the 
monthly premium for such individual shall be 
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362 
zero for any month in which such individual is 
in custody under penal authority.’’. 
SEC. 4112. FEDERAL EMPLOYEE HEALTH BENEFIT PLANS. 
(a) COVERAGE OF PREGNANCY.—The Director of the 
Office of Personnel Management shall issue such regula-
tions as are necessary to ensure that pregnancy is consid-
ered a change in family status and a qualifying life event 
for an individual who is eligible to enroll, but is not en-
rolled, in a health benefit plan under chapter 89 of title 
5, United States Code. 
(b) EFFECTIVE DATE.—The requirement in para-
graph (1) shall apply with respect to any contract entered 
into under section 8902 of such title beginning 12 months 
after the date of enactment of this Act. 
SEC. 4113. CONTINUATION OF MEDICAID INCOME ELIGI-
BILITY STANDARD FOR PREGNANT INDIVID-
UALS AND INFANTS. 
Section 1902(l)(2)(A) of the Social Security Act (42 
U.S.C. 1396a(l)(2)(A)) is amended— 
(1) in clause (i), by striking ‘‘and not more 
than 185 percent’’; 
(2) in clause (ii)— 
(A) in subclause (I), by striking ‘‘and’’ 
after the comma; 
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363 
(B) in subclause (II), by striking the pe-
riod at the end and inserting ‘‘, and’’; and 
(C) by adding at the end the following: 
‘‘(III) January 1, 2023, is the 
percentage 
provided 
under 
clause 
(v).’’; and 
(3) by adding at the end the following new 
clause: 
‘‘(v) The percentage provided under 
clause (ii) for medical assistance provided 
on or after January 1, 2023, with respect 
to individuals described in subparagraph 
(A) or (B) of paragraph (1) shall not be 
less than— 
‘‘(I) the percentage specified for 
such individuals by the State in an 
amendment to its State plan (whether 
approved or not) as of January 1, 
2014; or 
‘‘(II) if no such percentage is 
specified as of January 1, 2014, the 
percentage established for such indi-
viduals under the State’s authorizing 
legislation or provided for under the 
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364 
State’s appropriations as of that 
date.’’. 
Subtitle C—Expansion of Access 
PART 1—GENERAL PROVISIONS 
SEC. 4201. AMENDMENT TO THE PUBLIC HEALTH SERVICE 
ACT. 
Title XXXIV of the Public Health Service Act, as 
amended by titles I, II, and III of this Act, is further 
amended by inserting after subtitle D the following: 
‘‘Subtitle 
D—Reconstruction 
and 
Improvement Grants for Public 
Health Care Facilities Serving 
Pacific Islanders and the Insu-
lar Areas 
‘‘SEC. 3441. GRANT SUPPORT FOR QUALITY IMPROVEMENT 
INITIATIVES. 
‘‘(a) IN GENERAL.—The Secretary, in collaboration 
with the Administrator of the Health Resources and Serv-
ices Administration, the Director of the Agency for 
Healthcare Research and Quality, and the Administrator 
of the Centers for Medicare & Medicaid Services, shall 
award grants to eligible entities for the conduct of dem-
onstration projects to improve the quality of and access 
to health care. 
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‘‘(b) ELIGIBILITY.—To be eligible to receive a grant 
under subsection (a), an entity shall— 
‘‘(1) be a health center, hospital, health plan, 
health system, community clinic, hospice or palliative 
care provider, or other health entity determined ap-
propriate by the Secretary— 
‘‘(A) that, by legal mandate or explicitly 
adopted mission, provides patients with access 
to services regardless of their ability to pay; 
‘‘(B) that provides care or treatment for a 
substantial number of patients who are unin-
sured, are receiving assistance under a State 
plan under title XIX of the Social Security Act 
(or under a waiver of such plan), or are mem-
bers of vulnerable populations, as determined 
by the Secretary; and 
‘‘(C)(i) with respect to which, not less than 
50 percent of the entity’s patient population is 
made up of racial and ethnic minority groups 
(as defined in section 1707(g)(1)); or 
‘‘(ii) that— 
‘‘(I) serves a disproportionate percent-
age of local patients who are from a racial 
and ethnic minority group, or has a patient 
population at least 50 percent of which is 
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366 
composed 
of 
individuals 
with 
limited 
English proficiency; and 
‘‘(II) provides an assurance that 
amounts received under the grant will be 
used only to support quality improvement 
activities in the racial and ethnic minority 
population served; and 
‘‘(2) prepare and submit to the Secretary an 
application at such time, in such manner, and con-
taining such information as the Secretary may re-
quire. 
‘‘(c) PRIORITY.—In awarding grants under sub-
section (a), the Secretary shall give priority to eligible enti-
ties that— 
‘‘(1) demonstrate an intent to operate as part 
of a health care partnership, network, collaborative, 
coalition, or alliance where each member entity con-
tributes to the design, implementation, and evalua-
tion of the proposed intervention; or 
‘‘(2) intend to use funds to carry out system-
wide changes with respect to health care quality im-
provement, including— 
‘‘(A) improved systems for data collection 
and reporting; 
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‘‘(B) innovative collaborative or similar 
processes; 
‘‘(C) group programs with behavioral or 
self-management interventions; 
‘‘(D) case management services; 
‘‘(E) physician or patient reminder sys-
tems; 
‘‘(F) educational interventions; 
‘‘(G) comprehensive and patient-centric 
health care; 
‘‘(H) creation and distribution of education 
materials on available health care options; or 
‘‘(I) other activities determined appropriate 
by the Secretary. 
‘‘(d) USE OF FUNDS.—An entity shall use amounts 
received under a grant under subsection (a) to support 
the implementation and evaluation of health care quality 
improvement activities or minority health and health care 
disparity reduction activities that include— 
‘‘(1) with respect to health care systems, activi-
ties relating to improving— 
‘‘(A) patient safety; 
‘‘(B) timeliness of care; 
‘‘(C) effectiveness of care; 
‘‘(D) efficiency of care; 
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‘‘(E) patient centeredness; 
‘‘(F) health information technology; 
‘‘(G) accessibility and availability of infor-
mation on health care; 
‘‘(H) comprehensiveness of health care; 
and 
‘‘(I) patient involvement and choice in 
health care; and 
‘‘(2) with respect to patients, activities relating 
to— 
‘‘(A) staying healthy; 
‘‘(B) getting well, mentally and physically; 
‘‘(C) living effectively with illness or dis-
ability; 
‘‘(D) preparing for end of life and ensuring 
that end-of-life care is accessible and available, 
as well as coping with end-of-life issues; and 
‘‘(E) shared decision making. 
‘‘(e) COMMON DATA SYSTEMS.—The Secretary shall 
provide financial and other technical assistance to grant-
ees under this section for the development of common data 
systems. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section 
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such sums as may be necessary for each of fiscal years 
2023 through 2030. 
‘‘SEC. 3442. CENTERS OF EXCELLENCE. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Administrator of the Health Resources and Services 
Administration, shall designate centers of excellence at 
public hospitals, and other health systems serving large 
numbers of minority patients, that— 
‘‘(1) 
meet 
the 
requirements 
of 
section 
3441(b)(1); 
‘‘(2) demonstrate excellence in providing care to 
minority populations; and 
‘‘(3) demonstrate excellence in reducing dispari-
ties in health and health care. 
‘‘(b) REQUIREMENTS.—A hospital or health system 
that serves as a center of excellence under subsection (a) 
shall— 
‘‘(1) design, implement, and evaluate programs 
and policies relating to the delivery of care in ra-
cially, ethnically, and linguistically diverse popu-
lations; 
‘‘(2) provide training and technical assistance 
to other hospitals and health systems relating to the 
provision of high-quality health care to minority pop-
ulations; and 
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‘‘(3) develop activities for graduate or con-
tinuing medical education that institutionalize a 
focus on cultural competence training for health care 
providers. 
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section, 
such sums as may be necessary for each of fiscal years 
2023 through 2030. 
‘‘SEC. 3443. RECONSTRUCTION AND IMPROVEMENT GRANTS 
FOR PUBLIC HEALTH CARE FACILITIES SERV-
ING PACIFIC ISLANDERS AND THE INSULAR 
AREAS. 
‘‘(a) IN GENERAL.—The Secretary shall provide di-
rect financial assistance to designated health care pro-
viders and community health centers in American Samoa, 
Guam, the Commonwealth of the Northern Mariana Is-
lands, the United States Virgin Islands, Puerto Rico, and 
Hawaii for the purposes of reconstructing and improving 
health care facilities and services in a culturally competent 
and sustainable manner. 
‘‘(b) ELIGIBILITY.—To be eligible to receive direct fi-
nancial assistance under subsection (a), an entity shall be 
a public health facility or community health center located 
in American Samoa, Guam, the Commonwealth of the 
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Northern Mariana Islands, the United States Virgin Is-
lands, Puerto Rico, or Hawaii that— 
‘‘(1) is owned or operated by— 
‘‘(A) the Government of American Samoa, 
Guam, the Commonwealth of the Northern 
Mariana Islands, the United States Virgin Is-
lands, Puerto Rico, or Hawaii or a unit of local 
government; or 
‘‘(B) a nonprofit organization; and 
‘‘(2)(A) provides care or treatment for a sub-
stantial number of patients who are uninsured, are 
receiving assistance under title XVIII of the Social 
Security Act or under a State plan under title XIX 
of such Act (or under a waiver of such plan), or are 
members of a vulnerable population, as determined 
by the Secretary; or 
‘‘(B) serves a disproportionate percentage of 
local patients that are from a racial and ethnic mi-
nority group. 
‘‘(c) REPORT.—Not later than 180 days after the 
date of enactment of this title and annually thereafter, the 
Secretary shall submit to the Congress and the President 
a report that includes an assessment of health resources 
and facilities serving populations in American Samoa, 
Guam, the Commonwealth of the Northern Mariana Is-
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lands, the United States Virgin Islands, Puerto Rico, and 
Hawaii. In preparing such report, the Secretary shall— 
‘‘(1) consult with and obtain information on all 
health care facilities needs from the entities receiv-
ing direct financial assistance under subsection (a); 
‘‘(2) include all amounts of Federal assistance 
received by each such entity in the preceding fiscal 
year; 
‘‘(3) review the total unmet needs of health care 
facilities serving American Samoa, Guam, the Com-
monwealth of the Northern Mariana Islands, the 
United States Virgin Islands, Puerto Rico, and Ha-
waii, including needs for renovation and expansion 
of existing facilities; 
‘‘(4) include a strategic plan for addressing the 
needs of each such population identified in the re-
port; and 
‘‘(5) evaluate the effectiveness of the care pro-
vided by measuring patient outcomes and cost meas-
ures. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as necessary 
to carry out this section.’’. 
SEC. 4202. BORDER HEALTH GRANTS. 
(a) DEFINITIONS.—In this section: 
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(1) BORDER AREA.—The term ‘‘border area’’ 
means the United States-Mexico Border Area, as de-
fined in section 8 of the United States-Mexico Bor-
der Health Commission Act (22 U.S.C. 290n–6). 
(2) ELIGIBLE ENTITY.—The term ‘‘eligible enti-
ty’’ means an entity that is located in the border 
area and is any of the following: 
(A) A State, local government, or Tribal 
government. 
(B) A public institution of higher edu-
cation. 
(C) A nonprofit health organization. 
(D) A community health center. 
(E) A community clinic that is a health 
center receiving assistance under section 330 of 
the Public Health Service Act (42 U.S.C. 
254b). 
(F) A nonprofit organization serving immi-
grants. 
(b) AUTHORIZATION.—From funds appropriated pur-
suant to subsection (f), the Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’), acting through the United States members of the 
United States-Mexico Border Health Commission, shall 
award grants to eligible entities to address priorities and 
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374 
recommendations to improve the health of border area 
residents that are established by— 
(1) the United States members of the United 
States-Mexico Border Health Commission; 
(2) the State border health offices; and 
(3) the Secretary. 
(c) APPLICATION.—An eligible entity that desires a 
grant under subsection (b) shall submit an application to 
the Secretary at such time, in such manner, and con-
taining such information as the Secretary may require and 
demonstrating the entity’s capacity to provide culturally 
and linguistically appropriate services to border area resi-
dents. 
(d) USE OF FUNDS.—An eligible entity that receives 
a grant under subsection (b) shall use the grant funds 
for— 
(1) programs relating to— 
(A) maternal and child health; 
(B) primary care and preventative health; 
(C) public health and public health infra-
structure; 
(D) musculoskeletal health and obesity; 
(E) health education and promotion; 
(F) oral health; 
(G) mental and behavioral health; 
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(H) substance use disorders; 
(I) health conditions that have a high prev-
alence in the border area; 
(J) medical and health services research; 
(K) workforce training and development; 
(L) community health workers, patient 
navigators, and promotores; 
(M) health care infrastructure problems in 
the border area (including planning and con-
struction grants); 
(N) health disparities in the border area; 
(O) environmental health; 
(P) outreach and enrollment services with 
respect to Federal programs (including pro-
grams authorized under titles XIX and XXI of 
the Social Security Act (42 U.S.C. 1396 et seq.; 
42 U.S.C. 1397aa et seq.)); 
(Q) end-of-life care; and 
(R) addressing social determinants of 
health; and 
(2) other programs determined appropriate by 
the Secretary. 
(e) SUPPLEMENT, NOT SUPPLANT.—Amounts pro-
vided to an eligible entity awarded a grant under sub-
section (b) shall be used to supplement and not supplant 
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other funds available to the eligible entity to carry out the 
activities described in subsection (d). 
(f) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section, 
$200,000,000 for fiscal year 2024, and such sums as may 
be necessary for each succeeding fiscal year. 
SEC. 4203. CRITICAL ACCESS HOSPITAL IMPROVEMENTS. 
(a) ELIMINATION OF ISOLATION TEST FOR COST- 
BASED AMBULANCE REIMBURSEMENT.— 
(1) IN
GENERAL.—Section 1834(l)(8) of the 
Social Security Act (42 U.S.C. 1395m(l)(8)) is 
amended— 
(A) in subparagraph (B)— 
(i) by striking ‘‘owned and’’; and 
(ii) by inserting ‘‘(including when 
such services are provided by the entity 
under an arrangement with the hospital)’’ 
after ‘‘hospital’’; and 
(B) by striking the comma at the end of 
subparagraph (B) and all that follows and in-
serting a period. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to services furnished 
on or after January 1, 2021. 
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377 
(b) PROVISION OF A MORE FLEXIBLE ALTERNATIVE 
TO THE CAH DESIGNATION 25 INPATIENT BED LIMIT 
REQUIREMENT.— 
(1) IN
GENERAL.—Section 1820(c)(2) of the 
Social Security Act (42 U.S.C. 1395i–4(c)(2)) is 
amended— 
(A) in subparagraph (B)(iii), by striking 
‘‘provides not more than’’ and inserting ‘‘sub-
ject to subparagraph (F), provides not more 
than’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(F) ALTERNATIVE TO 25 INPATIENT BED 
LIMIT REQUIREMENT.— 
‘‘(i) IN GENERAL.—A State may elect 
to treat a facility, with respect to the des-
ignation of the facility for a cost-reporting 
period, as satisfying the requirement of 
subparagraph (B)(iii) relating to a max-
imum number of acute care inpatient beds 
if the facility elects, in accordance with a 
method specified by the Secretary and be-
fore the beginning of the cost reporting pe-
riod, to meet the requirement under clause 
(ii). 
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‘‘(ii) ALTERNATE
REQUIREMENT.— 
The requirement under this clause, with 
respect to a facility and a cost-reporting 
period, is that the total number of inpa-
tient bed days described in subparagraph 
(B)(iii) during such period will not exceed 
7,300. For purposes of this subparagraph, 
an individual who is an inpatient in a bed 
in the facility for a single day shall be 
counted as one inpatient bed day. 
‘‘(iii) WITHDRAWAL OF ELECTION.— 
The option described in clause (i) shall not 
apply to a facility for a cost-reporting pe-
riod if the facility (for any two consecutive 
cost-reporting periods during the previous 
5 cost-reporting periods) was treated under 
such option and had a total number of in-
patient bed days for each of such two cost- 
reporting periods that exceeded the num-
ber specified in such clause.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply to cost-reporting peri-
ods beginning on or after the date of the enactment 
of this Act. 
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379 
(c) EXPANDING
THE FUNDING AUTHORITY
FOR 
RENOVATING, CONSTRUCTING, AND EXPANDING CERTAIN 
FACILITIES.—Section 509 of the Indian Health Care Im-
provement Act (25 U.S.C. 1659) is amended— 
(1) by striking ‘‘minor’’ before ‘‘renovations’’; 
and 
(2) by striking ‘‘, to assist’’ and all that follows 
through ‘‘standards’’. 
SEC. 
4204. 
MEDICARE 
REMOTE 
MONITORING 
PILOT 
PROJECTS. 
(a) PILOT PROJECTS.— 
(1) IN
GENERAL.—Not later than 9 months 
after the date of enactment of this Act, the Sec-
retary of Health and Human Services (in this sec-
tion referred to as the ‘‘Secretary’’) shall conduct 
pilot projects under title XVIII of the Social Secu-
rity Act (42 U.S.C. 1395 et seq.) for the purpose of 
providing incentives to home health agencies to uti-
lize home monitoring and communications tech-
nologies that— 
(A) enhance health and health care out-
comes for Medicare beneficiaries; and 
(B) reduce expenditures under such title. 
(2) SITE REQUIREMENTS.— 
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380 
(A) URBAN AND RURAL.—The Secretary 
shall conduct the pilot projects under this sec-
tion in both urban and rural areas. 
(B) SITE IN A SMALL STATE.—The Sec-
retary shall conduct at least 3 of the pilot 
projects in a State with a population of less 
than 1,000,000. 
(3) DEFINITION OF HOME HEALTH AGENCY.— 
In this section, the term ‘‘home health agency’’ has 
the meaning given that term in section 1861(o) of 
the Social Security Act (42 U.S.C. 1395x(o)). 
(b) MEDICARE BENEFICIARIES WITHIN THE SCOPE 
OF PROJECTS.—The Secretary shall specify the criteria 
for identifying those Medicare beneficiaries who shall be 
considered within the scope of the pilot projects under this 
section for purposes of the application of subsection (c) 
and for the assessment of the effectiveness of the home 
health agency in achieving the objectives of this section. 
Such criteria may provide for the inclusion in the projects 
of Medicare beneficiaries who begin receiving home health 
services under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) after the date of the implementation 
of the projects. 
(c) INCENTIVES.— 
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381 
(1) PERFORMANCE
TARGETS.—The Secretary 
shall establish for each home health agency partici-
pating in a pilot project under this section a per-
formance target using one of the following meth-
odologies, as determined appropriate by the Sec-
retary: 
(A) ADJUSTED HISTORICAL PERFORMANCE 
TARGET.—The Secretary shall establish for the 
agency— 
(i) a base expenditure amount equal 
to the average total payments made to the 
agency under parts A and B of title XVIII 
of the Social Security Act (42 U.S.C. 1395 
et seq.) for Medicare beneficiaries deter-
mined to be within the scope of the pilot 
project in a base period determined by the 
Secretary; and 
(ii) an annual per capita expenditure 
target for such beneficiaries, reflecting the 
base expenditure amount adjusted for risk 
and adjusted growth rates. 
(B) COMPARATIVE
PERFORMANCE
TAR-
GET.—The Secretary shall establish for the 
agency a comparative performance target equal 
to the average total payments under such parts 
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382 
A and B during the pilot project for comparable 
individuals in the same geographic area that 
are not determined to be within the scope of the 
pilot project. 
(2) INCENTIVE.—Subject to paragraph (3), the 
Secretary shall pay to each participating home care 
agency an incentive payment for each year under the 
pilot project equal to a portion of the Medicare sav-
ings realized for such year relative to the perform-
ance target under paragraph (1). 
(3) LIMITATION ON EXPENDITURES.—The Sec-
retary shall limit incentive payments under this sec-
tion in order to ensure that the aggregate expendi-
tures under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.) (including incentive pay-
ments under this subsection) do not exceed the 
amount that the Secretary estimates would have 
been expended if the pilot projects under this section 
had not been implemented. 
(d) WAIVER AUTHORITY.—The Secretary may waive 
such provisions of titles XI and XVIII of the Social Secu-
rity Act (42 U.S.C. 1301 et seq.; 42 U.S.C. 1395 et seq.) 
as the Secretary determines to be appropriate for the con-
duct of the pilot projects under this section. 
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383 
(e) REPORT TO CONGRESS.—Not later than 5 years 
after the date that the first pilot project under this section 
is implemented, the Secretary shall submit to Congress a 
report on the pilot projects. Such report shall contain a 
detailed description of issues related to the expansion of 
the projects under subsection (f) and recommendations for 
such legislation and administrative actions as the Sec-
retary considers appropriate. 
(f) EXPANSION.—If the Secretary determines that 
any of the pilot projects under this section enhance health 
outcomes for Medicare beneficiaries and reduce expendi-
tures under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.), the Secretary may initiate com-
parable projects in additional areas. 
(g) INCENTIVE PAYMENTS HAVE NO EFFECT ON 
OTHER MEDICARE PAYMENTS TO AGENCIES.—An incen-
tive payment under this section— 
(1) shall be in addition to the payments that a 
home health agency would otherwise receive under 
title XVIII of the Social Security Act for the provi-
sion of home health services; and 
(2) shall have no effect on the amount of such 
payments. 
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384 
SEC. 4205. COMMUNITY HEALTH CENTER COLLABORATIVE 
ACCESS EXPANSION. 
Section 330(r)(4) of the Public Health Service Act 
(42 U.S.C. 254b(r)(4)) is amended— 
(1) in subparagraph (A), by striking ‘‘primary 
health care services’’ each place it appears and in-
serting ‘‘primary health care and other mental, den-
tal, and physical health services’’; and 
(2) in subparagraph (B)— 
(A) in clause (i), by striking ‘‘and’’ at the 
end; 
(B) in clause (ii), by striking the period at 
the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(iii) in the case of a rural health 
clinic described in such subparagraph— 
‘‘(I) that such clinic provides, to 
the extent possible, enabling services, 
such as transportation and language 
assistance (including translation and 
interpretation); and 
‘‘(II) that the primary health 
care and other services described in 
such subparagraph are subject to full 
reimbursement according to the pro-
spective payment system for Federally 
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385 
qualified health center services under 
section 1834(o) of the Social Security 
Act.’’. 
SEC. 4206. FACILITATING THE PROVISION OF TELEHEALTH 
SERVICES ACROSS STATE LINES. 
(a) IN GENERAL.—For purposes of expediting the 
provision of telehealth services, for which payment is made 
under the Medicare Program, across State lines, the Sec-
retary of Health and Human Services shall, in consulta-
tion with representatives of States, physicians, health care 
practitioners, and patient advocates, encourage and facili-
tate the adoption of provisions allowing for multistate 
practitioner practice across State lines. 
(b) DEFINITIONS.—In subsection (a): 
(1) TELEHEALTH
SERVICE.—The term ‘‘tele-
health service’’ has the meaning given that term in 
subparagraph (F) of section 1834(m)(4) of the So-
cial Security Act (42 U.S.C. 1395m(m)(4)). 
(2) PHYSICIAN, 
PRACTITIONER.—The terms 
‘‘physician’’ and ‘‘practitioner’’ have the meaning 
given those terms in subparagraphs (D) and (E), re-
spectively, of such section. 
(3) MEDICARE PROGRAM.—The term ‘‘Medicare 
Program’’ means the program of health insurance 
administered by the Secretary of Health and Human 
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Services under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.). 
SEC. 4207. SCORING OF PREVENTIVE HEALTH SAVINGS. 
Section 202 of the Congressional Budget and Im-
poundment Control Act of 1974 (2 U.S.C. 602) is amend-
ed by adding at the end the following: 
‘‘(h) SCORING OF PREVENTIVE HEALTH SAVINGS.— 
‘‘(1) DETERMINATION
BY
THE
DIRECTOR.— 
Upon a request by the chairman or ranking minority 
member of the Committee on the Budget of the Sen-
ate, or by the chairman or ranking minority member 
of the Committee on the Budget of the House of 
Representatives, the Director shall determine if a 
proposed measure would result in reductions in 
budget outlays in budgetary outyears through the 
use of preventive health and preventive health serv-
ices. 
‘‘(2) PROJECTIONS.—If the Director determines 
that a measure would result in substantial reduc-
tions in budget outlays as described in paragraph 
(1), the Director— 
‘‘(A) shall include, in any projection pre-
pared by the Director, a description and esti-
mate of the reductions in budget outlays in the 
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387 
budgetary outyears and a description of the 
basis for such conclusions; and 
‘‘(B) may prepare a budget projection that 
includes some or all of the budgetary outyears, 
notwithstanding the time periods for projections 
described in subsection (e) and sections 308, 
402, and 424. 
‘‘(3) DEFINITIONS.—As used in this sub-
section— 
‘‘(A) the term ‘budgetary outyears’ means 
the 2 consecutive 10-year periods beginning 
with the first fiscal year that is 10 years after 
the budget year provided for in the most re-
cently agreed to concurrent resolution on the 
budget; and 
‘‘(B) the term ‘preventive health’ means an 
action that focuses on the health of the public, 
individuals, and defined populations in order to 
protect, promote, and maintain health, wellness, 
and functional ability, and prevent disease, dis-
ability, and premature death that is dem-
onstrated by credible and publicly available epi-
demiological projection models, incorporating 
clinical trials or observational studies in hu-
mans, to avoid future health care costs.’’. 
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SEC. 4208. SENSE OF CONGRESS ON MAINTENANCE OF EF-
FORT PROVISIONS REGARDING CHILDREN’S 
HEALTH. 
It is the sense of the Congress that— 
(1) the maintenance of effort provisions added 
to sections 1902 and 2105(d) of the Social Security 
Act (42 U.S.C. 1396a; 42 U.S.C. 1397ee(d)) by sec-
tions 2001(b) and 2101(b) of the Patient Protection 
and Affordable Care Act were intended to maintain 
the eligibility standards for the Medicaid program 
under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) and Children’s Health Insur-
ance Program under title XXI of such Act (42 
U.S.C. 1397aa et seq.) to protect vulnerable and dis-
abled adults, children, and senior citizens, many of 
whom are also members of communities of color; 
(2) the maintenance of effort provisions for 
children’s coverage have been extended by the Con-
gress through September 30, 2027; 
(3) the maintenance of effort provisions ensure 
the continued success of the Medicaid program and 
Children’s Health Insurance Program and were in-
tended to specifically protect vulnerable and disabled 
children, many of whom are also members of com-
munities of color; and 
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389 
(4) the maintenance of effort provisions must 
be strictly enforced and proposals to weaken or 
waive the maintenance of effort provisions must not 
be considered. 
SEC. 4209. PROTECTION OF THE HHS OFFICES OF MINOR-
ITY HEALTH. 
(a) IN GENERAL.—Pursuant to section 1707A of the 
Public Health Service Act (42 U.S.C. 300u–6a), the Of-
fices of Minority Health established within the Centers for 
Disease Control and Prevention, the Health Resources 
and Services Administration, the Substance Abuse and 
Mental Health Services Administration, the Agency for 
Healthcare Research and Quality, the Food and Drug Ad-
ministration, and the Centers for Medicare & Medicaid 
Services, are offices that, regardless of change in the 
structure of the Department of Health and Human Serv-
ices, shall report to the Secretary of Health and Human 
Services. 
(b) SENSE OF CONGRESS.—It is the sense of the 
Congress that the Offices of Minority Health referred to 
in subsection (a) play a critical role in addressing health 
disparities and should be adequately funded and given a 
prominent role in evaluating and establishing health poli-
cies and programs. 
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390 
SEC. 4210. OFFICE OF MINORITY HEALTH IN VETERANS 
HEALTH ADMINISTRATION OF DEPARTMENT 
OF VETERANS AFFAIRS. 
(a) ESTABLISHMENT AND FUNCTIONS.—Subchapter 
I of chapter 73 of title 38, United States Code, is amended 
by inserting after section 7308 the following new section: 
‘‘§ 7308A. Office of Minority Health 
‘‘(a) ESTABLISHMENT.—There is established in the 
Department within the Office of the Under Secretary for 
Health an office to be known as the ‘Office of Minority 
Health’ (in this section referred to as the ‘Office’). 
‘‘(b) HEAD.—The Director of the Office of Minority 
Health shall be the head of the Office. The Director of 
the Office of Minority Health shall be appointed by the 
Under Secretary for Health from among individuals quali-
fied to perform the duties of the position. 
‘‘(c) FUNCTIONS.—The functions of the Office are as 
follows: 
‘‘(1) To establish short-range and long-range 
goals and objectives and coordinate all other activi-
ties within the Veterans Health Administration that 
relate to disease prevention, health promotion, health 
care services delivery, health and health care edu-
cation, health care quality, and health care research 
concerning veterans who are members of a racial or 
ethnic minority group. 
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391 
‘‘(2) To support research, demonstrations, and 
evaluations to test new and innovative models for 
the discharge of activities described in paragraph 
(1). 
‘‘(3) To increase knowledge and understanding 
of health risk factors for veterans who are members 
of a racial or ethnic minority group. 
‘‘(4) To develop mechanisms that support bet-
ter health care information dissemination, education, 
prevention, and services delivery to veterans from 
disadvantaged backgrounds, including veterans who 
are members of a racial or ethnic minority group. 
‘‘(5) To enter into contracts or agreements with 
appropriate public and nonprofit private entities to 
develop and carry out programs to provide bilingual 
or interpretive services to assist veterans who are 
members of a racial or ethnic minority group and 
who lack proficiency in speaking the English lan-
guage in accessing and receiving health care services 
through the Veterans Health Administration. 
‘‘(6) To carry out programs to improve access 
to health care services through the Veterans Health 
Administration for veterans with limited proficiency 
in speaking the English language, including the de-
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392 
velopment and evaluation of demonstration and pilot 
projects for that purpose. 
‘‘(7) To advise the Under Secretary for Health 
on matters relating to the development, implementa-
tion, and evaluation of health professions education 
in decreasing disparities in health care outcomes be-
tween veterans who are members of a racial or eth-
nic minority group and other veterans, including cul-
tural competency as a method of eliminating such 
health disparities. 
‘‘(8) To perform such other functions and du-
ties as the Secretary or the Under Secretary for 
Health considers appropriate. 
‘‘(d) DEFINITIONS.—In this section: 
‘‘(1) The term ‘racial or ethnic minority group’ 
means any of the following: 
‘‘(A) American Indians (including Alaska 
Natives, Eskimos, and Aleuts). 
‘‘(B) Asian Americans. 
‘‘(C) Native Hawaiians and Pacific Island-
ers. 
‘‘(D) Blacks. 
‘‘(E) Hispanics. 
‘‘(2) The term ‘Hispanic’ means individuals 
whose origin is Mexican, Puerto Rican, Cuban, Cen-
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393 
tral or South American, or any other Spanish-speak-
ing country.’’. 
(b) CLERICAL AMENDMENT.—The table of sections 
at the beginning of such subchapter is amended by insert-
ing after the item relating to section 7308 the following 
new item: 
‘‘7308A. Office of Minority Health.’’. 
SEC. 4211. STUDY OF DSH PAYMENTS TO ENSURE HOSPITAL 
ACCESS FOR LOW-INCOME PATIENTS. 
(a) IN GENERAL.—Not later than January 1, 2021, 
the Comptroller General of the United States shall con-
duct a study on how amendments made by the Patient 
Protection and Affordable Care Act (Public Law 111– 
148) and the Health Care and Education Reconciliation 
Act of 2010 (Public Law 111–152) to titles XVIII and 
XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 
42 U.S.C. 1396 et seq.) relating to disproportionate share 
hospital adjustment payments under Medicare and Med-
icaid (and subsequent amendments made with respect to 
such payments) affect the timely access to health care 
services for low-income patients. Such study shall— 
(1) evaluate and examine whether States elect-
ing to make medical assistance available under sec-
tion 1902(a)(10)(A)(i)(VIII) of the Social Security 
Act (42 U.S.C. 1396a(a)(10)(A)(i)(VIII)) (including 
States making such an election through a waiver of 
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the State plan) to individuals described in such sec-
tion mitigate the need for payments to dispropor-
tionate share hospitals under section 1886(d)(5)(F) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(d)(5)(F)) and section 1923 of such Act (42 
U.S.C. 1396r–4), including the impact of such 
States electing to make medical assistance available 
to such individuals on— 
(A) the number of individuals in the 
United States who are without health insurance 
and the distribution of such individuals in rela-
tion to areas primarily served by dispropor-
tionate share hospitals; and 
(B) the low-income utilization rate of such 
hospitals and the resulting fiscal sustainability 
of such hospitals; 
(2) evaluate the appropriate level and distribu-
tion of such payments among such disproportionate 
share hospitals for purposes of— 
(A) sufficiently accounting for the level of 
uncompensated care provided by such hospitals 
to low-income patients; and 
(B) providing timely access to health care 
services for individuals in medically underserved 
areas; and 
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(3) assess, with respect to such disproportionate 
share hospitals— 
(A) the role played by such hospitals in 
providing critical access to emergency, inpa-
tient, and outpatient health services, including 
end-of-life services, as well as the location of 
such hospitals in relation to medically under-
served areas; and 
(B) the extent to which such hospitals sat-
isfy the requirements established for charitable 
hospital organizations under section 501(r) of 
the Internal Revenue Code of 1986 with respect 
to community health needs assessments, finan-
cial assistance policy requirements, limitations 
on charges, and billing and collection require-
ments. 
(b) REPORTS.— 
(1) REPORT
TO
CONGRESS.—Not later than 
180 days after the date on which the study under 
subsection (a) is completed, the Comptroller General 
of the United States shall submit to the Committee 
on Energy and Commerce of the House of Rep-
resentatives and the Committee on Finance of the 
Senate a report that contains— 
(A) the results of the study; 
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(B) recommendations to Congress for any 
legislative changes to the payments to dis-
proportionate share hospitals under section 
1886(d)(5)(F) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(F)) and section 1923 of 
such Act (42 U.S.C. 1396r–4) that are needed 
to ensure access to health services for low-in-
come patients that— 
(i) are based on the number of indi-
viduals without health insurance, the 
amount of uncompensated care provided by 
such hospitals, and the impact of reduced 
payment levels on low-income communities; 
and 
(ii) takes into account any reports 
submitted by the Secretary of the Treas-
ury, in consultation with the Secretary of 
Health and Human Services, to congres-
sional committees regarding the costs in-
curred by charitable hospital organizations 
for charity care, bad debt, nonreimbursed 
expenses for services provided to individ-
uals under the Medicare program under 
title XVIII of the Social Security Act and 
the Medicaid program under title XIX of 
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397 
such Act, and any community benefit ac-
tivities provided by such organizations. 
(2) REPORT TO THE SECRETARY OF HEALTH 
AND HUMAN SERVICES.—Not later than 180 days 
after the date on which the study under subsection 
(a) is completed, the Comptroller General of the 
United States shall submit to the Secretary of 
Health and Human Services a report that con-
tains— 
(A) the results of the study; and 
(B) any recommendations for purposes of 
assisting in the development of the methodology 
for the adjustment of payments to dispropor-
tionate share hospitals, as required under sec-
tion 1886(r) of the Social Security Act (42 
U.S.C. 1395ww(r)) and the reduction of such 
payments under section 1923(f)(7) of such Act 
(42 U.S.C. 1396r–4(f)(7)), taking into account 
the reports referred to in paragraph (1)(B)(ii). 
SEC. 4212. REAUTHORIZATION OF THE NATIVE HAWAIIAN 
HEALTH CARE IMPROVEMENT ACT. 
(a) NATIVE HAWAIIAN HEALTH CARE SYSTEMS.— 
Section 6(h)(1) of the Native Hawaiian Health Care Im-
provement Act (42 U.S.C. 11705(h)(1)) is amended by 
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398 
striking ‘‘may be necessary for fiscal years 1993 through 
2019’’ and inserting ‘‘are necessary’’. 
(b) ADMINISTRATIVE
GRANT
FOR
PAPA
OLA 
LOKAHI.—Section 7(b) of the Native Hawaiian Health 
Care Improvement Act (42 U.S.C. 11706(b)) is amended 
by striking ‘‘may be necessary for fiscal years 1993 
through 2019’’ and inserting ‘‘are necessary’’. 
(c) NATIVE HAWAIIAN HEALTH SCHOLARSHIPS.— 
Section 10(c) of the Native Hawaiian Health Care Im-
provement Act (42 U.S.C. 11709(c)) is amended by strik-
ing ‘‘may be necessary for fiscal years 1993 through 
2019’’ and inserting ‘‘are necessary’’. 
PART 2—RURAL 
SEC. 4221. ESTABLISHMENT OF RURAL COMMUNITY HOS-
PITAL (RCH) PROGRAM. 
(a) IN GENERAL.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x), as amended by the previous 
sections, is amended by adding at the end of the following 
new subsection: 
‘‘Rural Community Hospital; Rural Community Hospital 
Services 
‘‘(lll)(1) The term ‘rural community hospital’ means 
a hospital (as defined in subsection (e)) that— 
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399 
‘‘(A) is located in a rural area (as defined in 
section 1886(d)(2)(D)) or treated as being so lo-
cated pursuant to section 1886(d)(8)(E); 
‘‘(B) subject to paragraph (2), has less than 51 
acute care inpatient beds, as reported in its most re-
cent cost report; 
‘‘(C) makes available 24-hour emergency care 
services; 
‘‘(D) subject to paragraph (3), has a provider 
agreement in effect with the Secretary and is open 
to the public as of January 1, 2010; and 
‘‘(E) applies to the Secretary for such designa-
tion. 
‘‘(2) For purposes of paragraph (1)(B), beds in a 
psychiatric or rehabilitation unit of the hospital which is 
a distinct part of the hospital shall not be counted. 
‘‘(3) Paragraph (1)(D) shall not be construed to pro-
hibit any of the following from qualifying as a rural com-
munity hospital: 
‘‘(A) A replacement facility (as defined by the 
Secretary in regulations in effect on January 1, 
2012) with the same service area (as defined by the 
Secretary in regulations in effect on such date). 
‘‘(B) A facility obtaining a new provider num-
ber pursuant to a change of ownership. 
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400 
‘‘(C) A facility which has a binding written 
agreement with an outside, unrelated party for the 
construction, reconstruction, lease, rental, or financ-
ing of a building as of January 1, 2012. 
‘‘(4) Nothing in this subsection shall be construed as 
prohibiting a critical access hospital from qualifying as a 
rural community hospital if the critical access hospital 
meets the conditions otherwise applicable to hospitals 
under subsection (e) and section 1866. 
‘‘(5) Nothing in this subsection shall be construed as 
prohibiting a rural community hospital participating in 
the demonstration program under section 410A of the 
Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 
2313) from qualifying as a rural community hospital if 
the rural community hospital meets the conditions other-
wise applicable to hospitals under subsection (e) and sec-
tion 1866.’’. 
(b) PAYMENT.— 
(1) INPATIENT
HOSPITAL
SERVICES.—Section 
1814 of the Social Security Act (42 U.S.C. 1395f) 
is amended by adding at the end the following new 
subsection: 
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401 
‘‘Payment for Inpatient Services Furnished in Rural 
Community Hospitals 
‘‘(m) The amount of payment under this part for in-
patient hospital services furnished in a rural community 
hospital, other than such services furnished in a psy-
chiatric or rehabilitation unit of the hospital which is a 
distinct part, is, at the election of the hospital in the appli-
cation referred to in section 1861(lll)(1)(E)— 
‘‘(1) 101 percent of the reasonable costs of pro-
viding such services, without regard to the amount 
of the customary or other charge, or 
‘‘(2) the amount of payment provided for under 
the prospective payment system for inpatient hos-
pital services under section 1886(d).’’. 
(2) OUTPATIENT SERVICES.—Section 1834 of 
such Act (42 U.S.C. 1395m) is amended by adding 
at the end the following new subsection: 
‘‘(z) PAYMENT FOR OUTPATIENT SERVICES FUR-
NISHED
IN
RURAL
COMMUNITY
HOSPITALS.—The 
amount of payment under this part for outpatient services 
furnished in a rural community hospital is, at the election 
of the hospital in the application referred to in section 
1861(lll)(1)(E)— 
‘‘(1) 101 percent of the reasonable costs of pro-
viding such services, without regard to the amount 
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402 
of the customary or other charge and any limitation 
under section 1861(v)(1)(U), or 
‘‘(2) the amount of payment provided for under 
the prospective payment system for covered OPD 
services under section 1833(t).’’. 
(3) EXEMPTION FROM 30-PERCENT REDUCTION 
IN
REIMBURSEMENT
FOR
BAD
DEBT.—Section 
1861(v)(1)(T) 
of 
such 
Act 
(42 
U.S.C. 
1395x(v)(1)(T)) is amended by inserting ‘‘(other 
than for a rural community hospital)’’ after ‘‘In de-
termining such reasonable costs for hospitals’’. 
(c) BENEFICIARY COST-SHARING FOR OUTPATIENT 
SERVICES.—Section 1834(z) of such Act (as added by 
subsection (b)(2)) is amended— 
(1) by redesignating paragraphs (1) and (2) as 
subparagraphs (A) and (B), respectively; 
(2) by inserting ‘‘(1)’’ after ‘‘(z)’’; and 
(3) by adding at the end the following: 
‘‘(2) The amounts of beneficiary cost-sharing for out-
patient services furnished in a rural community hospital 
under this part shall be as follows: 
‘‘(A) For items and services that would have 
been paid under section 1833(t) if furnished by a 
hospital, the amount of cost-sharing determined 
under paragraph (8) of such section. 
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403 
‘‘(B) For items and services that would have 
been paid under section 1833(h) if furnished by a 
provider of services or supplier, no cost-sharing shall 
apply. 
‘‘(C) For all other items and services, the 
amount of cost-sharing that would apply to the item 
or service under the methodology that would be used 
to determine payment for such item or service if pro-
vided by a physician, provider of services, or sup-
plier, as the case may be.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) PART
A
PAYMENT.—Section 1814(b) of 
such Act (42 U.S.C. 1395f(b)) is amended in the 
matter preceding paragraph (1) by inserting ‘‘other 
than inpatient hospital services furnished by a rural 
community hospital,’’ after ‘‘critical access hospital 
services,’’. 
(2) PART
B
PAYMENT.—Section 1833(a) of 
such Act (42 U.S.C. 1395l(a)), as amended by sec-
tion 207(b)(3), is amended— 
(A) by striking ‘‘and’’ at the end of para-
graph (9); 
(B) by striking the period at the end of 
paragraph (10) and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
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404 
‘‘(11) in the case of outpatient services fur-
nished by a rural community hospital, the amounts 
described in section 1834(z).’’. 
(3) TECHNICAL AMENDMENTS.— 
(A) CONSULTATION
WITH
STATE
AGEN-
CIES.—Section 1863 of such Act (42 U.S.C. 
1395z) is amended by striking ‘‘and (dd)(2)’’ 
and inserting ‘‘(dd)(2), and (lll)(1)’’. 
(B) 
PROVIDER
AGREEMENTS.—Section 
1866(a)(2)(A) 
of 
such 
Act 
(42 
U.S.C. 
1395cc(a)(2)(A)) is amended by inserting ‘‘sec-
tion 1834(z)(2),’’ after ‘‘section 1833(b),’’. 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after October 1, 2022. 
SEC. 4222. RURAL HEALTH QUALITY ADVISORY COMMIS-
SION AND DEMONSTRATION PROJECTS. 
(a) RURAL HEALTH QUALITY ADVISORY COMMIS-
SION.— 
(1) 
ESTABLISHMENT.—Not 
later 
than 
months after the date of the enactment of this sec-
tion, the Secretary of Health and Human Services 
(in this section referred to as the ‘‘Secretary’’) shall 
establish a commission to be known as the Rural 
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405 
Health Quality Advisory Commission (in this section 
referred to as the ‘‘Commission’’). 
(2) DUTIES OF COMMISSION.— 
(A) NATIONAL
PLAN.—The Commission 
shall develop, coordinate, and facilitate imple-
mentation of a national plan for rural health 
quality improvement. The national plan shall— 
(i) identify objectives for rural health 
quality improvement; 
(ii) identify strategies to eliminate 
known gaps in rural health system capacity 
and improve rural health quality; and 
(iii) 
provide 
recommendations 
for 
Federal programs to identify opportunities 
for strengthening and aligning policies and 
programs to improve rural health quality. 
(B) 
DEMONSTRATION
PROJECTS.—The 
Commission shall design demonstration projects 
to recommend to the Secretary to test alter-
native models for rural health quality improve-
ment, including with respect to both personal 
and population health. 
(C) MONITORING.—The Commission shall 
monitor progress toward the objectives identi-
fied pursuant to subparagraph (A)(i). 
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406 
(3) MEMBERSHIP.— 
(A) NUMBER.—The Commission shall be 
composed of 11 members appointed by the Sec-
retary. 
(B) SELECTION.—The Secretary shall se-
lect the members of the Commission from 
among individuals with significant rural health 
care and health care quality expertise, including 
expertise in clinical health care, health care 
quality research, end-of-life care, population or 
public health, or purchaser organizations. 
(4) CONTRACTING AUTHORITY.—Subject to the 
availability of funds, the Commission may enter into 
contracts and make other arrangements, as may be 
necessary to carry out the duties described in para-
graph (2). 
(5) STAFF.—Upon the request of the Commis-
sion, the Secretary may detail, on a reimbursable 
basis, any of the personnel of the Office of Rural 
Health Policy of the Health Resources and Services 
Administration, the Agency for Healthcare Research 
and Quality, or the Centers for Medicare & Medicaid 
Services to the Commission to assist in carrying out 
this subsection. 
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407 
(6) REPORTS TO CONGRESS.—Not later than 1 
year after the establishment of the Commission, and 
annually thereafter, the Commission shall submit a 
report to the Congress on rural health quality. Each 
such report shall include the following: 
(A) An inventory of relevant programs and 
recommendations for improved coordination and 
integration of policy and programs. 
(B) An assessment of achievement of the 
objectives identified in the national plan devel-
oped under paragraph (2) and recommenda-
tions for realizing such objectives. 
(C) Recommendations on Federal legisla-
tion, regulations, or administrative policies to 
enhance rural health quality and outcomes. 
(b) RURAL
HEALTH
QUALITY
DEMONSTRATION 
PROJECTS.— 
(1) IN
GENERAL.—Not later than 270 days 
after the date of the enactment of this section, the 
Secretary, in consultation with the Rural Health 
Quality Advisory Commission, the Office of Rural 
Health Policy of the Health Resources and Services 
Administration, the Agency for Healthcare Research 
and Quality, and the Centers for Medicare & Med-
icaid Services, shall make grants to eligible entities 
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for a total of 5 demonstration projects to implement 
and evaluate methods for improving the quality of 
health care in rural communities. Each such dem-
onstration project shall include— 
(A) alternative community models that— 
(i) will achieve greater integration of 
personal and population health services; 
and 
(ii) 
address 
safety, 
effectiveness, 
patient- or community-centeredness, timeli-
ness, efficiency, and equity (the 6 aims 
identified by the National Academy of 
Medicine (formerly known as the ‘‘Institute 
of Medicine’’) in its report entitled ‘‘Cross-
ing the Quality Chasm: A New Health Sys-
tem for the 21st Century’’ released on 
March 1, 2001); 
(B) innovative approaches to the financing 
and delivery of health care services to achieve 
rural health quality and accessibility goals for 
patients; and 
(C) development of quality improvement 
support structures to assist rural health sys-
tems and professionals in the provision of 
health care (such as workforce support struc-
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409 
tures, quality monitoring and reporting, clinical 
care protocols, and information technology ap-
plications). 
(2) ELIGIBLE
ENTITIES.—In this subsection, 
the term ‘‘eligible entity’’ means a consortium 
that— 
(A) shall include— 
(i) at least one health care provider or 
health care delivery system located in a 
rural area; and 
(ii) at least one organization rep-
resenting multiple community stakeholders; 
and 
(B) may include other partners such as 
rural research centers. 
(3) CONSULTATION.—In developing the pro-
gram for awarding grants under this subsection, the 
Secretary shall consult with the Administrator of the 
Agency for Healthcare Research and Quality, rural 
health care providers, rural health care researchers, 
and private and nonprofit groups (including national 
associations) which are undertaking similar efforts. 
(4) EXPEDITED WAIVERS.—The Secretary shall 
expedite the processing of any waiver that— 
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410 
(A) is authorized under title XVIII or XIX 
of the Social Security Act (42 U.S.C. 1395 et 
seq.; 42 U.S.C. 1396 et seq.); and 
(B) is necessary to carry out a demonstra-
tion project under this subsection. 
(5) DEMONSTRATION
PROJECT
SITES.—The 
Secretary shall ensure that the 5 demonstration 
projects funded under this subsection are conducted 
at a variety of sites representing the diversity of 
rural communities in the United States. 
(6) DURATION.—Each demonstration project 
under this subsection shall be for a period of 4 
years. 
(7) INDEPENDENT
EVALUATION.—The Sec-
retary shall enter into an arrangement with an enti-
ty that has experience working directly with rural 
health systems for the conduct of an independent 
evaluation of the program carried out under this 
subsection. 
(8) REPORT.—Not later than 1 year after the 
conclusion of all of the demonstration projects fund-
ed under this subsection, the Secretary shall submit 
a report to the Congress on the results of such 
projects. The report shall include— 
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411 
(A) an evaluation of patient access to care, 
patient outcomes, and an analysis of the cost 
effectiveness of each such project; and 
(B) recommendations on Federal legisla-
tion, regulations, or administrative policies to 
enhance rural health quality and outcomes. 
(c) APPROPRIATION.— 
(1) IN GENERAL.—Out of funds in the Treas-
ury not otherwise appropriated, there are appro-
priated to the Secretary to carry out this section 
$30,000,000 for the period of fiscal years 2023 
through 2027. 
(2) AVAILABILITY.— 
(A) IN
GENERAL.—Funds appropriated 
under paragraph (1) shall remain available for 
expenditure through fiscal year 2027. 
(B) REPORT.—For purposes of carrying 
out subsection (b)(8), funds appropriated under 
paragraph (1) shall remain available for ex-
penditure through fiscal year 2028. 
(3) RESERVATION.—Of the amount appro-
priated under paragraph (1), the Secretary shall re-
serve— 
(A) $5,000,000 to carry out subsection (a); 
and 
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412 
(B) $25,000,000 to carry out subsection 
(b), of which— 
(i) 2 percent shall be for the provision 
of technical assistance to grant recipients; 
and 
(ii) 5 percent shall be for independent 
evaluation under subsection (b)(7). 
SEC. 4223. RURAL HEALTH CARE SERVICES. 
Section 330A of the Public Health Service Act (42 
U.S.C. 254c) is amended to read as follows: 
‘‘SEC. 330A. RURAL HEALTH CARE SERVICES OUTREACH, 
RURAL HEALTH NETWORK DEVELOPMENT, 
DELTA RURAL DISPARITIES AND HEALTH 
SYSTEMS DEVELOPMENT, AND SMALL RURAL 
HEALTH CARE PROVIDER QUALITY IMPROVE-
MENT GRANT PROGRAMS. 
‘‘(a) PURPOSE.—The purpose of this section is to 
provide for grants— 
‘‘(1) under subsection (b), to promote rural 
health care services outreach; 
‘‘(2) under subsection (c), to provide for the 
planning and implementation of integrated health 
care networks in rural areas; 
‘‘(3) under subsection (d), to assist rural com-
munities in the Delta Region to reduce health dis-
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413 
parities and to promote and enhance health system 
development; and 
‘‘(4) under subsection (e), to provide for the 
planning and implementation of small rural health 
care provider quality improvement activities. 
‘‘(b) RURAL HEALTH CARE SERVICES OUTREACH 
GRANTS.— 
‘‘(1) GRANTS.—The Director of the Office of 
Rural Health Policy of the Health Resources and 
Services Administration (referred to in this section 
as the ‘Director’) may award grants to eligible enti-
ties to promote rural health care services outreach 
by expanding the delivery of health care services to 
include new and enhanced services in rural areas. 
The Director may award the grants for periods of 
not more than 3 years. 
‘‘(2) ELIGIBILITY.—To be eligible to receive a 
grant under this subsection for a project, an enti-
ty— 
‘‘(A) shall be a rural public or rural non-
profit private entity, a facility that qualifies as 
a rural health clinic under title XVIII of the 
Social Security Act, a public or nonprofit entity 
existing exclusively to provide services to mi-
grant and seasonal farm workers in rural areas, 
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414 
or a Tribal government whose grant-funded ac-
tivities will be conducted within federally recog-
nized Tribal areas; 
‘‘(B) shall represent a consortium com-
posed of members— 
‘‘(i) that include 3 or more independ-
ently owned health care entities; and 
‘‘(ii) that may be nonprofit or for- 
profit entities; and 
‘‘(C) shall not previously have received a 
grant under this subsection for the same or a 
similar project, unless the entity is proposing to 
expand the scope of the project or the area that 
will be served through the project. 
‘‘(3) APPLICATIONS.—To be eligible to receive a 
grant under this subsection, an eligible entity shall 
prepare and submit to the Director an application at 
such time, in such manner, and containing such in-
formation as the Director may require, including— 
‘‘(A) a description of the project that the 
eligible entity will carry out using the funds 
provided under the grant; 
‘‘(B) a description of the manner in which 
the project funded under the grant will meet 
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415 
the health care needs of rural populations in 
the local community or region to be served; 
‘‘(C) a plan for quantifying how health 
care needs will be met through identification of 
the target population and benchmarks of service 
delivery or health status, such as— 
‘‘(i) quantifiable measurements of 
health and health care status improvement 
for projects focusing on health promotion; 
or 
‘‘(ii) benchmarks of increased access 
to primary and end-of-life care, including 
tracking factors such as the number and 
type of primary and end-of-life care visits, 
identification of a medical home, or other 
general measures of such access; 
‘‘(D) a description of how the local com-
munity or region to be served will be involved 
in the development and ongoing operations of 
the project; 
‘‘(E) a plan for sustaining the project after 
Federal support for the project has ended; 
‘‘(F) a description of how the project will 
be evaluated; 
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416 
‘‘(G) the administrative capacity to submit 
annual performance data electronically as speci-
fied by the Director; and 
‘‘(H) other such information as the Direc-
tor determines to be appropriate. 
‘‘(c) RURAL
HEALTH
NETWORK
DEVELOPMENT 
GRANTS.— 
‘‘(1) GRANTS.— 
‘‘(A) IN
GENERAL.—The Director may 
award rural health network development grants 
to eligible entities to promote, through planning 
and implementation, the development of inte-
grated health care networks that have combined 
the functions of the entities participating in the 
networks in order to— 
‘‘(i) achieve efficiencies and economies 
of scale; 
‘‘(ii) expand access to, coordinate, and 
improve the quality of the health care de-
livery system through development of orga-
nizational efficiencies; 
‘‘(iii) implement health information 
technology to achieve efficiencies, reduce 
medical errors, and improve quality; 
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417 
‘‘(iv) coordinate care and manage 
chronic and terminal illness; and 
‘‘(v) strengthen the rural health care 
system as a whole and across all facets of 
the health care delivery system, including 
end-of-life care, in such a manner as to 
show a quantifiable return on investment 
to the participants in the network. 
‘‘(B) GRANT PERIODS.—The Director may 
award such a rural health network development 
grant— 
‘‘(i) for a period of 3 years for imple-
mentation activities; or 
‘‘(ii) for a period of 1 year for plan-
ning activities to assist in the initial devel-
opment of an integrated health care net-
work, if the proposed participants in the 
network do not have a history of collabo-
rative efforts and a 3-year grant would be 
inappropriate. 
‘‘(2) ELIGIBILITY.—To be eligible to receive a 
grant under this subsection, an entity— 
‘‘(A) shall be a rural public or rural non-
profit private entity, a facility that qualifies as 
a rural health clinic under title XVIII of the 
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418 
Social Security Act, a public or nonprofit entity 
existing exclusively to provide services to mi-
grant and seasonal farm workers in rural areas, 
or a Tribal government whose grant-funded ac-
tivities will be conducted within federally recog-
nized Tribal areas; 
‘‘(B) shall represent a network composed 
of participants— 
‘‘(i) that include 3 or more independ-
ently owned health care entities; and 
‘‘(ii) that may be nonprofit or for- 
profit entities; and 
‘‘(C) shall not previously have received a 
grant under this subsection (other than a 1- 
year grant for planning activities) for the same 
or a similar project. 
‘‘(3) APPLICATIONS.—To be eligible to receive a 
grant under this subsection, an eligible entity, in 
consultation with the appropriate State office of 
rural health or another appropriate State entity, 
shall prepare and submit to the Director an applica-
tion at such time, in such manner, and containing 
such information as the Director may require, in-
cluding— 
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419 
‘‘(A) a description of the project that the 
eligible entity will carry out using the funds 
provided under the grant; 
‘‘(B) an explanation of the reasons why 
Federal assistance is required to carry out the 
project; 
‘‘(C) a description of— 
‘‘(i) the history of collaborative activi-
ties carried out by the participants in the 
network; 
‘‘(ii) the degree to which the partici-
pants are ready to integrate their func-
tions; and 
‘‘(iii) how the local community or re-
gion to be served will benefit from and be 
involved in the activities carried out by the 
network; 
‘‘(D) a description of how the local com-
munity or region to be served will experience in-
creased access to quality health care services 
across the continuum of care as a result of the 
integration activities carried out by the net-
work, including a description of— 
‘‘(i) return on investment for the com-
munity and the network members; and 
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420 
‘‘(ii) other quantifiable performance 
measures that show the benefit of the net-
work activities; 
‘‘(E) a plan for sustaining the project after 
Federal support for the project has ended; 
‘‘(F) a description of how the project will 
be evaluated; 
‘‘(G) the administrative capacity to submit 
annual performance data electronically as speci-
fied by the Director; and 
‘‘(H) other such information as the Direc-
tor determines to be appropriate. 
‘‘(d) DELTA RURAL DISPARITIES AND HEALTH SYS-
TEMS DEVELOPMENT GRANTS.— 
‘‘(1) GRANTS.—The Director may award grants 
to eligible entities to support reduction of health dis-
parities, improve access to health care, and enhance 
rural health system development in the Delta Re-
gion. 
‘‘(2) ELIGIBILITY.—To be eligible to receive a 
grant under this subsection, an entity shall be a 
rural public or rural nonprofit private entity, a facil-
ity that qualifies as a rural health clinic under title 
XVIII of the Social Security Act, a public or non-
profit entity existing exclusively to provide services 
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421 
to migrant and seasonal farm workers in rural 
areas, or a Tribal government whose grant-funded 
activities will be conducted within federally recog-
nized Tribal areas. 
‘‘(3) APPLICATIONS.—To be eligible to receive a 
grant under this subsection, an eligible entity shall 
prepare and submit to the Director an application at 
such time, in such manner, and containing such in-
formation as the Director may require, including— 
‘‘(A) a description of the project that the 
eligible entity will carry out using the funds 
provided under the grant; 
‘‘(B) an explanation of the reasons why 
Federal assistance is required to carry out the 
project; 
‘‘(C) a description of the manner in which 
the project funded under the grant will meet 
the health care needs of the Delta Region; 
‘‘(D) a description of how the local com-
munity or region to be served will experience in-
creased access to quality health care services as 
a result of the activities carried out by the enti-
ty; 
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422 
‘‘(E) a description of how health dispari-
ties will be reduced or the health system will be 
improved; 
‘‘(F) a plan for sustaining the project after 
Federal support for the project has ended; 
‘‘(G) a description of how the project will 
be evaluated including process and outcome 
measures related to the quality of care provided 
or how the health care system improves its per-
formance; 
‘‘(H) a description of how the grantee will 
develop an advisory group made up of rep-
resentatives of the communities to be served to 
provide guidance to the grantee to best meet 
community need; and 
‘‘(I) other such information as the Director 
determines to be appropriate. 
‘‘(e) SMALL RURAL HEALTH CARE PROVIDER QUAL-
ITY IMPROVEMENT GRANTS.— 
‘‘(1) GRANTS.—The Director may award grants 
to provide for the planning and implementation of 
small rural health care provider quality improvement 
activities. The Director may award the grants for 
periods of 1 to 3 years. 
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423 
‘‘(2) ELIGIBILITY.—To be eligible for a grant 
under this subsection, an entity— 
‘‘(A) shall be— 
‘‘(i) a rural public or rural nonprofit 
private health care provider or provider of 
health care services, such as a rural health 
clinic; or 
‘‘(ii) another rural provider or net-
work of small rural providers identified by 
the Director as a key source of local care; 
and 
‘‘(B) shall not previously have received a 
grant under this subsection for the same or a 
similar project. 
‘‘(3) PREFERENCE.—In awarding grants under 
this subsection, the Director shall give preference to 
facilities that qualify as rural health clinics under 
title XVIII of the Social Security Act. 
‘‘(4) APPLICATIONS.—To be eligible to receive a 
grant under this subsection, an eligible entity shall 
prepare and submit to the Director an application at 
such time, in such manner, and containing such in-
formation as the Director may require, including— 
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424 
‘‘(A) a description of the project that the 
eligible entity will carry out using the funds 
provided under the grant; 
‘‘(B) an explanation of the reasons why 
Federal assistance is required to carry out the 
project; 
‘‘(C) a description of the manner in which 
the project funded under the grant will assure 
continuous quality improvement in the provision 
of services by the entity; 
‘‘(D) a description of how the local com-
munity or region to be served will experience in-
creased access to quality health care services as 
a result of the activities carried out by the enti-
ty; 
‘‘(E) a plan for sustaining the project after 
Federal support for the project has ended; 
‘‘(F) a description of how the project will 
be evaluated including process and outcome 
measures related to the quality of care pro-
vided; and 
‘‘(G) other such information as the Direc-
tor determines to be appropriate. 
‘‘(f) GENERAL REQUIREMENTS.— 
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425 
‘‘(1) PROHIBITED USES OF FUNDS.—An entity 
that receives a grant under this section may not use 
funds provided through the grant— 
‘‘(A) to build or acquire real property; or 
‘‘(B) for construction. 
‘‘(2) COORDINATION WITH OTHER AGENCIES.— 
The Director shall coordinate activities carried out 
under grant programs described in this section, to 
the extent practicable, with Federal and State agen-
cies and nonprofit organizations that are operating 
similar grant programs, to maximize the effect of 
public dollars in funding meritorious proposals. 
‘‘(g) REPORT.—Not later than September 30, 2024, 
the Secretary shall prepare and submit to the appropriate 
committees of Congress a report on the progress and ac-
complishments of the grant programs described in sub-
sections (b), (c), (d), and (e). 
‘‘(h) DEFINITION OF DELTA REGION.—In this sec-
tion, the term ‘Delta Region’ has the meaning given to 
the term ‘region’ in section 382A of the Consolidated 
Farm and Rural Development Act (7 U.S.C. 2009aa). 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section 
such sums as may be necessary for each of fiscal years 
2024 through 2027.’’. 
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426 
PART 3—INDIAN COMMUNITIES 
SEC. 4231. ASSISTANT SECRETARY OF THE INDIAN HEALTH 
SERVICE. 
(a) REFERENCES.—Any reference in a law, regula-
tion, document, paper, or other record of the United 
States to the Director of the Indian Health Service shall 
be deemed to be a reference to the Assistant Secretary 
of the Indian Health Service. 
(b) EXECUTIVE SCHEDULE.—Section 5315 of title 5, 
United States Code, is amended in the matter relating to 
the Assistant Secretaries of Health and Human Services 
by striking ‘‘(6)’’ and inserting ‘‘(7), one of whom shall 
be the Assistant Secretary of the Indian Health Service’’. 
(c) CONFORMING AMENDMENT.—Section 5316 of 
title 5, United States Code, is amended by striking ‘‘Direc-
tor, Indian Health Service, Department of Health and 
Human Services.’’. 
SEC. 4232. EXTENSION OF FULL FEDERAL MEDICAL ASSIST-
ANCE 
PERCENTAGE 
TO 
INDIAN 
HEALTH 
CARE PROVIDERS. 
Section 1905 of the Social Security Act (42 U.S.C. 
1396d) is amended— 
(1) in subsection (a), by amending paragraph 
(9) to read as follows: 
‘‘(9) clinic services furnished by or under the 
direction of a physician, without regard to whether 
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the clinic itself is administered by a physician, in-
cluding— 
‘‘(A) such services furnished outside the 
clinic by clinic personnel to an eligible indi-
vidual who does not reside in a permanent 
dwelling or does not have a fixed home or mail-
ing address; and 
‘‘(B) such services furnished outside the 
clinic by any Indian Health Service facility, a 
health program or facility operated by a tribe or 
tribal organization under the Indian Self-Deter-
mination Act (Public Law 93–638), or an 
urban Indian organization receiving funds 
under title V of the Indian Health Care Im-
provement Act;’’; and 
(2) in subsection (b), by inserting after ‘‘Papa 
Ola Lokahi under section 8 of such Act’’ the fol-
lowing: ‘‘; the Federal medical assistance percentage 
shall also be 100 per centum with respect to 
amounts expended as medical assistance for services 
which are received by an Indian Health Service facil-
ity, a health program or facility operated by a tribe 
or tribal organization under the Indian Self-Deter-
mination Act (Public Law 93–638), or an urban In-
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dian organization receiving funds under title V of 
the Indian Health Care Improvement Act’’. 
SEC. 4233. CONFERRING WITH URBAN INDIAN ORGANIZA-
TIONS. 
Section 514(b) of the Indian Health Care Improve-
ment Act (25 U.S.C. 1660d) is amended to read as fol-
lows: 
‘‘(b) REQUIREMENT.—The Secretary shall ensure 
that the Service and the other agencies and offices of the 
Department of Health and Human Services and the De-
partment of Veterans Affairs confer, to the maximum ex-
tent practicable, with urban Indian organizations in car-
rying out— 
‘‘(1) this Act; and 
‘‘(2) other provisions of law relating to Indian 
health care.’’. 
PART 4—PROVIDERS 
SEC. 4241. AVAILABILITY OF NON-ENGLISH LANGUAGE 
SPEAKING PROVIDERS. 
(a) IN GENERAL.—Section 1311(c)(1)(B) of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18031(c)(1)(B)) is amended by inserting before the semi-
colon the following: ‘‘and the ability of such provider to 
provide care in a language other than English either 
through the provider speaking such language or by the 
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429 
provider having a qualified interpreter for an individual 
with limited English proficiency (as defined in section 
3400 of such Act) who speaks such language available 
during office hours’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall not apply to any plan beginning on 
or prior to the date that is 1 year after the date of the 
enactment of this Act. 
SEC. 4242. ACCESS TO ESSENTIAL COMMUNITY PROVIDERS. 
(a) ESSENTIAL COMMUNITY PROVIDERS.—Section 
1311(c)(1)(C) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18031(c)(1)(C)) is amended— 
(1) by inserting ‘‘(i)’’ after ‘‘(C)’’; and 
(2) by adding at the end the following new 
clauses: 
‘‘(ii) not later than January 1, 2023, in-
crease the percentage of essential community 
providers as described in clause (i) included in 
its network by 10 percent annually (based on 
the level in the plan for 2016) until 90 percent 
of all federally qualified health centers and 75 
percent of all other such essential community 
providers in the contract service area are in-net-
work; and 
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‘‘(iii) include at least one essential commu-
nity provider in each of the essential community 
provider 
categories 
described 
in 
section 
156.235(a)(2)(ii)(B) of title 45, Code of Fed-
eral Regulations (as in effect on the date of en-
actment of the Health Equity and Account-
ability Act of 2022), in each county in the serv-
ice area, where available;’’. 
(b) 
REPORTING
REQUIREMENTS.—Section 
1311(e)(3) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18031(e)(3)) is amended by adding at the 
end the following new subparagraph: 
‘‘(E) DATA
ON
ESSENTIAL
COMMUNITY 
PROVIDERS.—The Secretary shall require quali-
fied health plans to submit annually to the Sec-
retary data on the percentage of essential com-
munity providers as described in clause (ii) of 
subsection (c)(1)(C), by county, that contract 
with each qualified health plan offered in that 
county and the percentage of such essential 
community providers, by category as described 
in clause (iii) of such subsection, that contract 
with each qualified health plan offered in that 
county. Such data shall be made available to 
the general public.’’. 
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431 
(c) ESSENTIAL COMMUNITY PROVIDER PROVISIONS 
APPLIED UNDER MEDICARE AND MEDICAID.— 
(1) MEDICARE.—Section 1852(d)(1) of the So-
cial Security Act (42 U.S.C. 1395w–22(d)(1)) is 
amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (D); 
(B) by striking the period at the end of 
subparagraph (E) and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(F) the plan meets the requirements of 
clauses (ii) and (iii) of section 1311(c)(1)(C) of 
the Patient Protection and Affordable Care Act 
(relating to inclusion in networks of essential 
community providers).’’. 
(2) MEDICAID.—Section 1932(b)(5) of the So-
cial Security Act (42 U.S.C. 1396u–2(b)(5)) is 
amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (A); 
(B) by striking the period at the end of 
subparagraph (B) and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subparagraph: 
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432 
‘‘(C) meets the requirements of clauses (ii) 
and (iii) of section 1311(c)(1)(C) of the Patient 
Protection and Affordable Care Act (relating to 
inclusion in networks of essential community 
providers) with respect to services offered in the 
service area involved.’’. 
SEC. 4243. PROVIDER NETWORK ADEQUACY IN COMMU-
NITIES OF COLOR. 
(a) IN GENERAL.—Section 1311(c)(1)(B) of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18031(c)(1)(B)), as amended by section 4241(a), is fur-
ther amended— 
(1) by inserting ‘‘(i)’’ after ‘‘(B)’’; and 
(2) by adding at the end the following new 
clauses: 
‘‘(ii) meet such network adequacy 
standards as the Secretary may establish 
with regard to— 
‘‘(I) appointment wait time; 
‘‘(II) travel time and distance to 
health care provider facilities and pro-
viders by public and private transit; 
‘‘(III) hours of operation to ac-
commodate individuals who cannot 
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433 
come to provider appointments during 
standard business hours; 
‘‘(IV) availability of health care 
options for patients; and 
‘‘(V) other network adequacy 
standards to ensure that care through 
these plans is accessible to diverse 
communities, 
including 
individuals 
with limited English proficiency as de-
fined in section 3400 of such Act; and 
‘‘(iii) provide coverage for services for 
enrollees through out-of-network providers 
at no additional cost to the enrollees in 
cases where in-network providers are un-
able to comply with the standards estab-
lished under subclause (III) or (IV) of 
clause (ii) for such services and the out-of- 
network providers can deliver such services 
in compliance with such standards.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall not apply to plans beginning on or 
prior to the date that is 1 year after the date of the enact-
ment of the Health Equity and Accountability Act of 
2022. 
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434 
PART 5—DENTAL 
SEC. 4251. IMPROVING ACCESS TO DENTAL CARE. 
(a) REPORTS TO CONGRESS.— 
(1) GAO REPORTS.—Not later than 1 year 
after the date of the enactment of this Act, the 
Comptroller General of the United States shall sub-
mit to Congress— 
(A) a report on the Alaska Dental Health 
Aide Therapists program and the Dental Ther-
apist and Advanced Dental Therapist programs 
in Minnesota, to assess the effectiveness of den-
tal therapists in— 
(i) improving access to timely dental 
care among communities of color; 
(ii) providing high-quality care; 
(iii) providing culturally competent 
care; and 
(iv) providing accessible care to people 
with disabilities; 
(B) a report on State variations in the use 
of dental hygienists and the effectiveness of ex-
panding the scope of practice for dental hygien-
ists in— 
(i) improving access to timely dental 
care among communities of color; 
(ii) providing high-quality care; 
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435 
(iii) providing culturally competent 
care; and 
(iv) providing accessible care to people 
with disabilities; and 
(C) a report on the use of telehealth serv-
ices to enhance services provided by dental hy-
gienists and therapists, including recommenda-
tions for any modifications to the Medicare pro-
gram under title XVIII of the Social Security 
Act and the Medicaid program under title XIX 
of such Act to better provide for telehealth con-
sultations in conjunction with therapists’ and 
hygienists’ care. 
(2) HRSA REPORT
ON
DENTAL
SHORTAGE 
AREAS.—Not later than 1 year after the date of the 
enactment of this Act, the Secretary of Health and 
Human Services, acting through the Administrator 
of the Health Resources and Services Administra-
tion, shall submit to Congress a report which details 
geographic dental access shortages and the pre-
paredness of dental providers to offer culturally and 
linguistically appropriate, affordable, accessible, and 
timely services. 
(b) EXPANSION OF DENTAL HEALTH AID THERA-
PISTS IN TRIBAL AND URBAN INDIAN COMMUNITIES.— 
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436 
Section 119 of the Indian Health Care Improvement Act 
(25 U.S.C. 1616l) is amended— 
(1) in subsection (d)— 
(A) in paragraph (2), to read as follows: 
‘‘(2) REQUIREMENT; EXCLUSION.—Subject to 
paragraphs (3) and (4), in establishing a national 
program under paragraph (1), the Secretary— 
‘‘(A) shall not reduce the amounts pro-
vided for the Community Health Aide Program 
described in subsections (a) and (b); 
‘‘(B) shall exclude dental health aide thera-
pist services from services covered under such 
Program; and 
‘‘(C) shall include urban Indian organiza-
tions.’’; and 
(B) in paragraph (3), by striking ‘‘or tribal 
organization’’ each place it appears and insert-
ing ‘‘, tribal organization, or urban Indian orga-
nization’’; and 
(2) in subsection (e), by striking ‘‘or a tribal or-
ganization’’ and inserting ‘‘a tribal organization, or 
an urban Indian organization’’. 
(c) COVERAGE OF DENTAL SERVICES UNDER THE 
MEDICARE PROGRAM.— 
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437 
(1) COVERAGE.—Section 1861(s)(2) of the So-
cial Security Act (42 U.S.C. 1395x(s)(2)) is amend-
ed— 
(A) in subparagraph (GG), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (HH), by striking the 
period and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(II) dental and oral health services (as defined 
in subsection (mmm));’’. 
(2) DENTAL AND ORAL HEALTH SERVICES DE-
FINED.—Section 1861 of the Social Security Act (42 
U.S.C. 1395x), as amended by previous provisions of 
this Act, is amended by adding at the end the fol-
lowing new subsection: 
‘‘Dental and Oral Health Services 
‘‘(mmm)(1) The term ‘dental and oral health serv-
ices’ means services (as defined by the Secretary) that are 
necessary to prevent disease and promote oral health, re-
store oral structures to health and function, and treat 
emergency conditions, including— 
‘‘(A) routine diagnostic and preventive care 
such as dental cleanings, exams, and x-rays; 
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438 
‘‘(B) basic dental services such as fillings and 
extractions; 
‘‘(C) major dental services such as root canals, 
crowns, and dentures; 
‘‘(D) emergency dental care; and 
‘‘(E) other necessary services related to dental 
and oral health (as defined by the Secretary). 
‘‘(2) For purposes of paragraph (1), such term shall 
include mobile and portable oral health services (as de-
fined by the Secretary) that— 
‘‘(A) are provided for the purpose of over-
coming mobility, transportation, and access barriers 
for individuals; and 
‘‘(B) satisfy the standards and certification re-
quirements established under section 1902(a)(82)(B) 
for the State in which the services are provided.’’. 
(3) PAYMENT
AND
COINSURANCE.—Section 
1833(a)(1) of the Social Security Act (42 U.S.C. 
1395l(a)(1)) is amended— 
(A) by striking ‘‘and’’ before ‘‘(DD)’’; and 
(B) by inserting before the semicolon at 
the end the following: ‘‘and (EE) with respect 
to dental and oral health services (as defined in 
section 1861(mmm)), the amount paid shall be 
(i) in the case of such services that are preven-
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439 
tive, 100 percent of the lesser of the actual 
charge for the services or the amount deter-
mined under the payment basis determined 
under section 1848, and (ii) in the case of all 
other such services, 80 percent of the lesser of 
the actual charge for the services or the amount 
determined under the payment basis determined 
under section 1848’’. 
(4) PAYMENT UNDER PHYSICIAN FEE SCHED-
ULE.—Section 1848(j)(3) of the Social Security Act 
(42 U.S.C. 1395w–4(j)(3)) is amended by inserting 
‘‘, (2)(II),’’ after ‘‘(including administration of the 
health risk assessment)’’. 
(5) DENTURES.—Section 1861(s)(8) of the So-
cial Security Act (42 U.S.C. 1395x(s)(8)) is amend-
ed— 
(A) by striking ‘‘(other than dental)’’ and 
inserting ‘‘(including dentures)’’; and 
(B) by striking ‘‘internal body’’. 
(6) REPEAL
OF
GROUND
FOR
EXCLUSION.— 
Section 1862(a) of the Social Security Act (42 
U.S.C. 1395y) is amended by striking paragraph 
(12). 
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440 
(7) EFFECTIVE DATE.—The amendments made 
by this section shall apply to services furnished on 
or after January 1, 2023. 
(d) REQUIRING COVERAGE OF DENTAL SERVICES 
UNDER THE MEDICAID PROGRAM.— 
(1) MANDATORY COVERAGE.— 
(A) IN GENERAL.— 
(i) 
REQUIREMENT.—Section 
1902(a)(10)(A) of the Social Security Act 
(42 U.S.C. 1396a(a)(10)(A)) is amended 
by inserting ‘‘, (10)’’ after ‘‘(5)’’. 
(ii) EFFECTIVE
DATE.—The amend-
ment made by clause (i) shall apply with 
respect to medical assistance furnished in 
calendar quarters beginning on or after the 
date that is 1 year after the date of the en-
actment of this Act. 
(B) 
BENCHMARK
COVERAGE.—Section 
1937(b)(5) of the Social Security Act (42 
U.S.C. 1396u–7(b)(5)) is amended by striking 
the period and inserting ‘‘, and, beginning with 
the first quarter beginning on or after the date 
of the enactment of the Health Equity and Ac-
countability Act of 2022, coverage of dental and 
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441 
oral health services (as defined in section 
1905(jj)).’’. 
(2) DEFINITION OF SERVICES.—Section 1905 
of the Social Security Act (42 U.S.C. 1396d) is 
amended— 
(A) in subsection (a)(10), by striking ‘‘den-
tal services’’ and inserting ‘‘dental and oral 
health services (as defined in subsection 
(jj)(1))’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(jj) DENTAL AND ORAL HEALTH SERVICES.—(1) 
For purposes of this title, the term ‘dental and oral health 
services’ means services necessary to prevent disease and 
promote oral health, restore oral structures to health and 
function, reduce oral pain, and treat emergency oral condi-
tions. Such term includes the services specified in para-
graph (2). 
‘‘(2) For purposes of paragraph (1), the services 
specified in this paragraph are the following: 
‘‘(A) Routine diagnostic and preventive care 
(such as dental cleanings, exams, and x-rays). 
‘‘(B) Basic dental services (such as fillings and 
extractions) and major dental services (such as root 
canals, crowns, and dentures). 
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442 
‘‘(C) Emergency dental care. 
‘‘(D) Temporomandibular (TMD) and orofacial 
pain disorder treatment. 
‘‘(E) Other necessary services related to dental 
and oral health (as specified by the Secretary). 
‘‘(3) For purposes of paragraph (1), such term shall 
not include dental care or services provided to individuals 
under the age of 21 under subsection (r)(3).’’. 
(3) CONFORMING AMENDMENTS.— 
(A) STATE PLAN REQUIREMENTS.—Section 
1902(a) of the Social Security Act (42 U.S.C. 
1396a(a)) is amended— 
(i) in paragraph (10)(A), in the mat-
ter preceding clause (i), by inserting 
‘‘(10),’’ after ‘‘(5),’’; 
(ii) in paragraph (85), by striking 
‘‘and’’ at the end; 
(iii) in paragraph (86), by striking the 
period at the end and inserting ‘‘; and’’; 
and 
(iv) by inserting after paragraph (86) 
the following: 
‘‘(87) provide for— 
‘‘(A) informing, in writing, all individuals 
who have been determined to be eligible for 
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443 
medical assistance of the availability of oral 
health services (as defined in section 1905(gg)); 
‘‘(B) conducting targeted outreach to preg-
nant women who have been determined to be el-
igible for medical assistance about the avail-
ability of medical assistance for such dental 
services and the importance of receiving dental 
care while pregnant; and 
‘‘(C) establishing and maintaining stand-
ards for and certification of mobile and portable 
oral health services (as described in subsections 
(r)(3)(C) and (jj)(2)(B) of section 1905).’’. 
(B) DEFINITION
OF
MEDICAL
ASSIST-
ANCE.—Section 1905(a)(12) of the Social Secu-
rity Act (42 U.S.C. 1396d(a)(12)) is amended 
by striking ‘‘, dentures,’’. 
(4) MOBILE
AND
PORTABLE
ORAL
HEALTH 
SERVICES UNDER EPSDT.—Section 1905(r)(3) of the 
Social Security Act (42 U.S.C. 1396d(r)(3)) is 
amended— 
(A) in subparagraph (A)(ii), by striking ‘‘; 
and’’ and inserting a semicolon; 
(B) in subparagraph (B), by striking the 
period at the end and inserting ‘‘; and’’; and 
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444 
(C) by adding at the end the following new 
subparagraph: 
‘‘(C) which shall include mobile and port-
able oral health services (as defined by the Sec-
retary) that— 
‘‘(i) are provided for the purpose of 
overcoming mobility, transportation, or ac-
cess barriers for children; and 
‘‘(ii) satisfy the standards and certifi-
cation requirements established under sec-
tion 1902(a)(87)(C) for the State in which 
the services are provided.’’. 
(5) ENHANCED FMAP; MAINTENANCE OF EF-
FORT.— 
(A) MEDICAID.—Section 1905 of the So-
cial Security Act (42 U.S.C. 1396d), as amend-
ed by paragraph (2), is further amended— 
(i) in subsection (b), by striking ‘‘and 
(ii)’’ and inserting ‘‘(ii), and (kk)’’; and 
(ii) by adding at the end of the fol-
lowing new subsection: 
‘‘(kk) INCREASED FMAP FOR EXPENDITURES FOR 
DENTAL AND ORAL HEALTH SERVICES.— 
‘‘(1) IN GENERAL.—The Federal medical assist-
ance percentage with respect to amounts expended 
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445 
by such State for medical assistance consisting of 
dental and oral health services (as defined in sub-
section (jj)) furnished during the first calendar 
quarter beginning on or after the date that is 1 year 
after the date of the enactment of this subsection or 
during any subsequent quarter) to individuals 21 
years of age or older shall be equal to, in the case 
of such services furnished— 
‘‘(A) during the 3-year period beginning on 
the first day of such first calendar year, 100 
percent; 
‘‘(B) during the 1-year period immediately 
following the period described in subparagraph 
(A), 95 percent; 
‘‘(C) during each subsequent 1-year period 
(through the third such subsequent period), the 
percentage specified under this paragraph for 
the preceding 1-year period, reduced by 5 per-
centage points; and 
‘‘(D) during any quarter beginning after 
the 7-year period beginning on the first day de-
scribed in subparagraph (A), 80 percent. 
‘‘(2) NO REDUCTION IN FMAP.—Paragraph (1) 
shall not apply with respect to amounts expended by 
a State if the Federal medical assistance percentage 
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446 
otherwise applicable to such amounts without appli-
cation of such paragraph would be higher than such 
percentage available to such amounts with applica-
tion of such paragraph.’’. 
(6) EXCLUSION
OF
AMOUNTS
ATTRIBUTABLE 
TO INCREASED FMAP FROM TERRITORIAL CAPS.— 
Section 1108 of the Social Security Act (42 U.S.C. 
1308) is amended— 
(A) in subsection (f), in the matter pre-
ceding paragraph (1), by striking ‘‘subsections 
(g), (h), and (i)’’; and 
(B) by adding at the end the following: 
‘‘(i) EXCLUSION FROM CAPS OF AMOUNTS ATTRIB-
UTABLE TO INCREASED FMAP FOR COVERAGE OF DEN-
TAL AND ORAL SERVICES.—Any payment made to a terri-
tory for expenditures for medical assistance that are sub-
ject to an increase in the Federal medical assistance per-
centage applicable to such expenditures under section 
1905(kk) shall not be taken into account for purposes of 
applying payment limits under subsections (f) and (g) to 
the extent that such payment exceeds the amount of the 
payment that would have been made to the territory for 
such expenditures without regard to such section.’’. 
(e) ORAL HEALTH SERVICES
AS
AN ESSENTIAL 
HEALTH BENEFIT.—Section 1302(b) of the Patient Pro-
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447 
tection and Affordable Care Act (42 U.S.C. 18022(b)) is 
amended— 
(1) in paragraph (1)— 
(A) in subparagraph (J), by striking ‘‘oral 
and’’; and 
(B) by adding at the end the following: 
‘‘(K) Oral health services for children and 
adults.’’; and 
(2) by adding at the end the following: 
‘‘(6) ORAL HEALTH SERVICES.—For purposes 
of paragraph (1)(K), the term ‘oral health services’ 
means services (as defined by the Secretary) that 
are necessary to prevent any oral disease and pro-
mote oral health, restore oral structures to health 
and function, and treat emergency oral conditions.’’. 
(f) DEMONSTRATION PROGRAM ON TRAINING AND 
EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE 
PROVIDERS FOR DENTAL HEALTH CARE SERVICES FOR 
VETERANS IN RURAL AND OTHER UNDERSERVED COM-
MUNITIES.— 
(1) DEMONSTRATION PROGRAM AUTHORIZED.— 
The Secretary of Veterans Affairs may carry out a 
demonstration program to establish programs to 
train and employ alternative dental health care pro-
viders in order to increase access to dental health 
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448 
care services for veterans who are entitled to such 
services from the Department of Veterans Affairs 
and reside in rural and other underserved commu-
nities. 
(2) TELEHEALTH.—For purposes of alternative 
dental health care providers and other dental care 
providers who are licensed to provide clinical care, 
dental services provided under the demonstration 
program under this subsection may be administered 
by such providers through telehealth-enabled collabo-
ration and supervision when appropriate and fea-
sible. 
(3) ALTERNATIVE DENTAL HEALTH CARE PRO-
VIDERS DEFINED.—In this subsection, the term ‘‘al-
ternative dental health care providers’’ has the 
meaning given that term in section 340G–1(a)(2) of 
the Public Health Service Act (42 U.S.C. 256g– 
1(a)(2)). 
(4) AUTHORIZATION
OF
APPROPRIATIONS.— 
There are authorized to be appropriated such sums 
as are necessary to carry out the demonstration pro-
gram under this subsection. 
(g) DEMONSTRATION PROGRAM ON TRAINING AND 
EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE 
PROVIDERS FOR DENTAL HEALTH CARE SERVICES FOR 
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449 
MEMBERS OF THE ARMED FORCES AND DEPENDENTS 
LACKING READY ACCESS TO SUCH SERVICES.— 
(1) DEMONSTRATION PROGRAM AUTHORIZED.— 
The Secretary of Defense may carry out a dem-
onstration program to establish programs to train 
and employ alternative dental health care providers 
in order to increase access to dental health care 
services for members of the Armed Forces and their 
dependents who lack ready access to such services, 
including the following: 
(A) Members and dependents who reside in 
rural areas or areas otherwise underserved by 
dental health care providers. 
(B) Members of a reserve component of 
the Armed Forces in active status who are po-
tentially deployable. 
(2) TELEHEALTH.—For purposes of alternative 
dental health care providers and other dental care 
providers who are licensed to provide clinical care, 
dental services provided under the demonstration 
program under this subsection may be administered 
by such providers through telehealth-enabled collabo-
ration and supervision when appropriate and fea-
sible. 
(3) DEFINITIONS.—In this subsection: 
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450 
(A) ACTIVE
STATUS.—The term ‘‘active 
status’’ has the meaning given that term in sec-
tion 101(d) of title 10, United States Code. 
(B) ALTERNATIVE DENTAL HEALTH CARE 
PROVIDERS.—The 
term 
‘‘alternative 
dental 
health care providers’’ has the meaning given 
that term in section 340G–1(a)(2) of the Public 
Health Service Act (42 U.S.C. 256g–1(a)(2)). 
(4) AUTHORIZATION
OF
APPROPRIATIONS.— 
There are authorized to be appropriated such sums 
as are necessary to carry out the demonstration pro-
gram under this subsection. 
(h) DEMONSTRATION PROGRAM ON TRAINING AND 
EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE 
PROVIDERS FOR DENTAL HEALTH CARE SERVICES FOR 
PRISONERS WITHIN THE CUSTODY OF THE BUREAU OF 
PRISONS.— 
(1) DEMONSTRATION PROGRAM AUTHORIZED.— 
The Attorney General, acting through the Director 
of the Bureau of Prisons, may carry out a dem-
onstration program to establish programs to train 
and employ alternative dental health care providers 
in order to increase access to dental health services 
for prisoners within the custody of the Bureau of 
Prisons. 
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(2) TELEHEALTH.—For purposes of alternative 
dental health care providers and other dental care 
providers who are licensed to provide clinical care, 
dental services provided under the demonstration 
program under this subsection may be administered 
by such providers through telehealth-enabled collabo-
ration and supervision when appropriate and fea-
sible. 
(3) ALTERNATIVE DENTAL HEALTH CARE PRO-
VIDERS
DEFINED.—In this subsection and sub-
section (i), the term ‘‘alternative dental health care 
providers’’ has the meaning given that term in sec-
tion 340G–1(a)(2) of the Public Health Service Act 
(42 U.S.C. 256g–1(a)(2)). 
(4) AUTHORIZATION
OF
APPROPRIATIONS.— 
There are authorized to be appropriated such sums 
as are necessary to carry out the demonstration pro-
gram under this subsection. 
(i) DEMONSTRATION PROGRAM ON TRAINING AND 
EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE 
PROVIDERS
FOR
DENTAL
HEALTH
CARE
SERVICES 
UNDER THE INDIAN HEALTH SERVICE.— 
(1) DEMONSTRATION PROGRAM AUTHORIZED.— 
The Secretary of Health and Human Services, act-
ing through the Indian Health Service, may carry 
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out a demonstration program to establish programs 
to train and employ alternative dental health care 
providers in order to help eliminate oral health dis-
parities and increase access to dental services 
through health programs operated by the Indian 
Health Service, Indian tribes, tribal organizations, 
and urban Indian organizations (as the preceding 3 
terms are defined in section 4 of the Indian Health 
Care Improvement Act (25 U.S.C. 1603)). 
(2) TELEHEALTH.—For purposes of alternative 
dental health care providers and other dental care 
providers who are licensed to provide clinical care, 
dental services provided under the demonstration 
program under this subsection may be administered 
by such providers through telehealth-enabled collabo-
ration and supervision when appropriate and fea-
sible. 
(3) AUTHORIZATION
OF
APPROPRIATIONS.— 
There are authorized to be appropriated such sums 
as are necessary to carry out the demonstration pro-
gram under this subsection. 
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453 
SEC. 4252. ORAL HEALTH LITERACY AND AWARENESS CAM-
PAIGN. 
The Public Health Service Act is amended by insert-
ing after section 340G–1 of such Act (42 U.S.C. 256g– 
1) the following: 
‘‘SEC. 340G–2. ORAL HEALTH LITERACY AND AWARENESS. 
‘‘(a) CAMPAIGN.—The Secretary, acting through the 
Administrator of the Health Resources and Services Ad-
ministration, shall establish a public education campaign 
(referred to in this subsection as the ‘campaign’) across 
all relevant programs of the Health Resources and Serv-
ices Administration (including the health center program, 
oral health workforce programs, maternal and child health 
programs, the Ryan White HIV/AIDS Program, and rural 
health programs) to increase oral health literacy and 
awareness. 
‘‘(b) STRATEGIES.—In carrying out the campaign, 
the Secretary shall identify oral health literacy and aware-
ness strategies that are evidence-based and focused on oral 
health care education, including education on prevention 
of oral disease such as early childhood and other caries, 
periodontal disease, and oral cancer. 
‘‘(c) FOCUS.—The Secretary shall design the cam-
paign to communicate directly with specific populations, 
including children, pregnant women, parents, the elderly, 
individuals with disabilities, and ethnic and racial minority 
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454 
populations, including Indians, Alaska Natives, and Na-
tive Hawaiians, in a culturally and linguistically appro-
priate manner. 
‘‘(d) OUTCOMES.—In carrying out the campaign, the 
Secretary shall include a process for measuring outcomes 
and effectiveness. 
‘‘(e) REPORT TO CONGRESS.—Not later than 3 years 
after the date of enactment of this section, the Secretary 
shall submit to the Committee on Energy and Commerce 
of the House of Representatives and the Committee on 
Health, Education, Labor, and Pensions of the Senate a 
report on the outcomes and effectiveness of the campaign. 
‘‘(f) AUTHORIZATION
OF
APPROPRIATIONS.—To 
carry out this section, there is authorized to be appro-
priated $750,000 for each of fiscal years 2023 through 
2027.’’. 
Subtitle D—Advancing Health Eq-
uity Through Payment and De-
livery Reform 
SEC. 4301. SENSE OF CONGRESS. 
It is the sense of Congress that— 
(1) the sustainability of the health care system 
in the United States hinges on restructuring how 
health care is paid for, shifting away from paying 
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for the volume of services provided to the value the 
services provide; 
(2) high value care is care that provides higher 
quality care more efficiently, achieving greater 
health improvement and better health outcomes at 
lower cost (per patient and overall); 
(3) a high value health care system must deliver 
timely, accessible, well-coordinated, high-quality, cul-
turally centered, and language-appropriate care to 
everyone; 
(4) eliminating health and health care dispari-
ties and achieving health equity must be central to 
and required in efforts to achieve a high value health 
care system; 
(5) eliminating such disparities and achieving 
such equity will require tailored interventions and 
targeted investments to address inequities in health 
and health care to make sure that health care deliv-
ery and payment efforts are responsive to and inclu-
sive of the needs of communities of color and other 
communities experiencing disparities; and 
(6) new models of value-based payment and 
care delivery should prioritize primary care and con-
sider the holistic needs of and other factors with re-
spect to the patient population, including with re-
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spect to behavioral health, oral health, end-of-life 
care, history of adverse childhood experiences and 
adverse community environments, social deter-
minants of health, social risk factors, unmet social 
needs, and the burden of intergenerational racial 
and other inequities. 
SEC. 4302. CENTERS FOR MEDICARE & MEDICAID SERVICES 
REPORTING AND VALUE-BASED PROGRAMS. 
(a) ADVANCING HEALTH EQUITY IN REPORTING AND 
VALUE-BASED PAYMENT PROGRAMS.— 
(1) IN
GENERAL.—The Administrator of the 
Centers for Medicare & Medicaid Services (in this 
section referred to as the ‘‘Administrator’’) shall re-
quire that a clinician or other professional partici-
pating in any pay-for-reporting or value-based pay-
ment program stratify clinical quality measures by 
disparity variables, including race, ethnicity, sex, pri-
mary language, disability status, sexual orientation, 
gender identity, and socioeconomic status. A clini-
cian or other professional may use existing demo-
graphic data collection fields in certified electronic 
health record technology (as defined in section 
1848(o)(4) of the Social Security Act (42 U.S.C. 
1395w–4(o)(4))) to carry out such data stratifica-
tion under the preceding sentence. Such stratified 
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data will assist clinicians and other professionals in 
the identification of disparities obscured in aggre-
gated data and assist with the provision of interven-
tions that target reducing those disparities. 
(2) CLINICIAN.—In assessing performance in 
any value-based payment program, the Adminis-
trator shall incorporate a clinician or other profes-
sional’s performance in reducing disparities across 
race, ethnicity, sex, primary language, disability sta-
tus, sexual orientation, gender identity, and socio-
economic status. Linking performance payments to 
the reduction of health care disparities across such 
variables will assist in holding clinicians and other 
professionals accountable for providing quality care 
that can lead to decreased health inequities. 
(3) REQUIREMENT OF ADOPTION OF CERT.—All 
entities, clinicians, or other professionals partici-
pating in the Quality Payment Program of the Cen-
ters for Medicare & Medicaid Services shall be re-
quired to adopt 2015 certified electronic health 
record technology (as so defined) as a condition of 
participating in such program. 
(b) QUALITY IMPROVEMENT ACTIVITIES.—The Ad-
ministrator, upon yearly review of the Quality Payment 
Program, shall add quality improvement activities that im-
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plement the Culturally and Linguistically Accessible 
Standards (CLAS) as Improvement Activities under the 
Quality Payment Program. 
SEC. 4303. DEVELOPMENT AND TESTING OF DISPARITY RE-
DUCING DELIVERY AND PAYMENT MODELS. 
(a) IN GENERAL.—The Center for Medicare and 
Medicaid Innovation established under section 1115A of 
the Social Security Act (42 U.S.C. 1315a) (in this section 
referred to as the ‘‘CMI’’) shall establish a dedicated fund 
to identify, test, evaluate, and scale delivery and payment 
models under the applicable titles (as defined in subsection 
(a)(4)(B) of such section) that target health disparities 
among racial and ethnic minorities, including models that 
support high-value nonmedical services that address so-
cially determined barriers to health in all stages of the 
life cycle through end-of-life, including English proficiency 
status, low health and health care literacy, lack of access 
to health care planning, including end-of-life care plan-
ning, case management, transportation, enrollment assist-
ance needs, stable and affordable housing, utility assist-
ance, employment and career development, and nutrition 
and food security which will help to reduce disparities and 
impact the overall cost of care. 
(b) AMENDMENT TO SOCIAL SECURITY ACT.—The 
second sentence of section 1115A(a)(1) of the Social Secu-
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rity Act (42 U.S.C. 1315a(a)(1)) is amended by inserting 
‘‘and improve health equity’’ after ‘‘expenditures’’. 
(c) PILOT PROGRAMS.—The CMI shall prioritize the 
testing of models under such section 1115A that include 
partnerships with entities, including community based or-
ganizations or other nonprofit entities, to help address so-
cially determined barriers to health and health care. 
(d) ALTERNATIVES.—Any model tested by the CMI 
under such 1115A shall include measures to assess and 
track the impact of the model on health disparities, using 
existing measures such as the Healthcare Disparities and 
Cultural Competency Measures endorsed by the entity 
with a contract under section 1890(a) of the Social Secu-
rity Act (42 U.S.C. 1395aaa(a)), and stratified by race, 
ethnicity, English proficiency, gender identity, sexual ori-
entation, and disability status. 
SEC. 4304. DIVERSITY IN CENTERS FOR MEDICARE AND 
MEDICAID CONSULTATION. 
(a) IN GENERAL.—In carrying out the duties under 
this section, the CMI shall consult representatives of rel-
evant Federal agencies, and clinical and analytical experts 
with expertise in medicine and health care management, 
specifically such experts with expertise in— 
(1) the health care needs of minority, rural, and 
underserved populations; and 
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(2) the financial needs of safety net, community 
based, rural, and critical access providers, including 
federally qualified health centers. 
(b) OPEN DOOR FORUMS.—The CMI shall use open 
door forums or other mechanisms to seek external feed-
back from interested parties and incorporate that feedback 
into the development of models. 
SEC. 4305. SUPPORTING SAFETY NET AND COMMUNITY- 
BASED PROVIDERS TO COMPETE IN VALUE- 
BASED PAYMENT SYSTEMS. 
(a) IN GENERAL.—Any pay-for-performance or alter-
native payment model that is developed and tested by the 
Center for Medicare and Medicaid Innovation established 
under section 1115A of the Social Security Act (42 U.S.C. 
1315a), or any other agency of the Department of Health 
and Human Services with respect to the programs under 
titles XVIII, XIX, or XXI of such Act, shall be assessed 
for potential impact on safety net, community based, and 
critical access providers, including Federally qualified 
health centers. 
(b) NEW MODELS.—The rollout of any such models 
shall include training and additional up front resources for 
community based and safety net providers to enable those 
providers to participate in the model. 
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461 
Subtitle E—Health Empowerment 
Zones 
SEC. 4401. DESIGNATION OF HEALTH EMPOWERMENT 
ZONES. 
(a) IN GENERAL.—The Secretary may, at the request 
of an eligible community partnership described in sub-
section (b)(1), designate an eligible area described in sub-
section (b)(2) as a health empowerment zone for the pur-
pose of eligibility for a grant under section 4402. 
(b) ELIGIBILITY CRITERIA.— 
(1) ELIGIBLE
COMMUNITY
PARTNERSHIP.—A 
community partnership is eligible to submit a re-
quest under this section if the partnership— 
(A) demonstrates widespread public sup-
port from key individuals and entities in the eli-
gible area, including members of the target 
community, State and local governments, non-
profit organizations including national and re-
gional intermediaries with demonstrated capac-
ity to serve low-income urban communities, and 
community and industry leaders, for designa-
tion of the eligible area as a health empower-
ment zone; and 
(B) includes representatives of— 
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(i) a broad cross section of stake-
holders and residents from communities in 
the eligible area experiencing dispropor-
tionate disparities in health status and 
health care; and 
(ii) organizations, facilities, and insti-
tutions that have a history of working 
within and serving such communities. 
(2) ELIGIBLE AREA.—An area is eligible to be 
designated as a health empowerment zone under this 
section if one or more communities in the area expe-
rience disproportionate disparities in health status 
and health care. In determining whether a commu-
nity experiences such disparities, the Secretary shall 
consider data collected by the Department of Health 
and Human Services focusing on the following areas: 
(A) Access to affordable, high-quality 
health care services. 
(B) The prevalence of disproportionate 
rates of certain illnesses or diseases including 
the following: 
(i) Arthritis, osteoporosis, chronic 
back conditions, and other musculoskeletal 
diseases. 
(ii) Cancer. 
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(iii) Chronic kidney disease. 
(iv) Diabetes. 
(v) Injury (intentional and uninten-
tional). 
(vi) Violence (intimate and non-
intimate). 
(vii) Maternal and paternal illnesses 
and diseases. 
(viii) Infant mortality. 
(ix) Mental illness and other disabil-
ities. 
(x) Substance use disorder treatment 
and prevention, including underage drink-
ing. 
(xi) Nutrition, obesity, and overweight 
conditions. 
(xii) Heart disease. 
(xiii) Hypertension. 
(xiv) 
Cerebrovascular 
disease 
or 
stroke. 
(xv) Tuberculosis. 
(xvi) HIV/AIDS and other sexually 
transmitted infections. 
(xvii) Viral hepatitis. 
(xviii) Asthma. 
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(xix) Tooth decay and other oral 
health issues. 
(C) Within the community, the historical 
and persistent presence of conditions that have 
been found to contribute to health disparities 
including any such conditions respecting any of 
the following: 
(i) Poverty. 
(ii) Educational status and the quality 
of community schools. 
(iii) Income. 
(iv) Access to high-quality affordable 
health care. 
(v) Work and work environment. 
(vi) Environmental conditions in the 
community, including with respect to clean 
water, clean air, and the presence or ab-
sence of pollutants. 
(vii) Language and English pro-
ficiency. 
(viii) Access to affordable healthy 
food. 
(ix) Access to ethnically and culturally 
diverse health and human service providers 
and practitioners. 
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(x) Access to culturally and linguis-
tically competent health and human serv-
ices and health and human service pro-
viders. 
(xi) Health-supporting infrastructure. 
(xii) Health insurance that is ade-
quate and affordable. 
(xiii) Race, racism, and bigotry (con-
scious and unconscious). 
(xiv) Sexual orientation. 
(xv) Health and health care literacy. 
(xvi) Place of residence (such as 
urban areas, rural areas, and reservations 
of Indian Tribes). 
(xvii) Stress. 
(c) PROCEDURE.— 
(1) REQUEST.—A request under subsection (a) 
shall— 
(A) describe the bounds of the area to be 
designated as a health empowerment zone and 
the process used to select those bounds; 
(B) demonstrate that the partnership sub-
mitting the request is an eligible community 
partnership described in subsection (b)(1); 
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(C) demonstrate that the area is an eligible 
area described in subsection (b)(2); 
(D) include a comprehensive assessment of 
disparities in health status and health care ex-
perience by one or more communities in the 
area; 
(E) set forth— 
(i) a vision and a set of values for the 
area; and 
(ii) a comprehensive and holistic set of 
goals to be achieved in the area through 
designation as a health empowerment zone; 
and 
(F) include a strategic plan and an action 
plan for achieving the goals described in sub-
paragraph (E)(ii). 
(2) APPROVAL.—Not later than 60 days after 
the receipt of a request for designation of an area 
as a health empowerment zone under this section, 
the Secretary shall approve or disapprove the re-
quest. 
(d) MINIMUM NUMBER.—The Secretary— 
(1) shall designate not more than 110 health 
empowerment zones under this section; and 
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467 
(2) of such zones designated under paragraph 
(1), shall designate at least one health empowerment 
zone in each of the several States, the District of 
Columbia, and each territory or possession of the 
United States. 
SEC. 4402. ASSISTANCE TO THOSE SEEKING DESIGNATION. 
At the request of any organization or entity seeking 
to submit a request under section 4401(a), the Secretary 
shall provide technical assistance, and may award a grant, 
to assist such organization or entity— 
(1) to form an eligible community partnership 
described in section 4401(b)(1); 
(2) to complete a health assessment, including 
an assessment of health disparities under section 
4401(c)(1)(D); or 
(3) to prepare and submit a request, including 
a strategic plan, in accordance with section 4401. 
SEC. 4403. BENEFITS OF DESIGNATION. 
(a) PRIORITY.—In awarding a grant under sub-
section (b), a Federal official shall give priority to any ap-
plicant that— 
(1) meets the eligibility criteria for the grant; 
(2) proposes to use the grant for activities in a 
health empowerment zone; and 
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468 
(3) demonstrates that such activities will di-
rectly and significantly further the goals of the stra-
tegic plan approved for such zone under section 
4401. 
(b) GRANTS
FOR INITIAL IMPLEMENTATION
OF 
STRATEGIC PLAN.— 
(1) IN GENERAL.—Upon designating an eligible 
area as a health empowerment zone at the request 
of an eligible community partnership, the Secretary 
shall, subject to the availability of appropriations, 
make a grant to the community partnership for im-
plementation of the strategic plan for such zone. 
(2) GRANT PERIOD.—A grant under paragraph 
(1) for a health empowerment zone shall be for a pe-
riod of 2 years and may be renewed, except that the 
total period of grants under paragraph (1) for such 
zone may not exceed 10 years. 
(3) LIMITATION.—In awarding grants under 
this subsection, the Secretary shall not give less pri-
ority to an applicant or reduce the amount of a 
grant because the Secretary rendered technical as-
sistance or made a grant to the same applicant 
under section 4401. 
(4) REPORTING.—The Secretary shall establish 
metrics for measuring the progress of grantees 
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469 
under this subsection and, based on such metrics, 
require each such grantee to report to the Secretary 
not less than every 6 months on the progress in im-
plementing the strategic plan for the health em-
powerment zone. 
SEC. 4404. DEFINITION OF SECRETARY. 
In this subtitle, the term ‘‘Secretary’’ means the Sec-
retary of Health and Human Services, acting through the 
Administrator of the Health Resources and Services Ad-
ministration and the Deputy Assistant Secretary for Mi-
nority Health, and in cooperation with the Director of the 
Office of Community Services and the Director of the Na-
tional Institute on Minority Health and Health Dispari-
ties. 
SEC. 4405. AUTHORIZATION OF APPROPRIATIONS. 
To carry out this subtitle, there is authorized to be 
appropriated $100,000,000 for fiscal year 2023. 
Subtitle F—Equitable Health Care 
For All 
SEC. 4501. FINDINGS. 
Congress finds the following: 
(1) In 1966, Dr. Martin Luther King, Jr., said 
‘‘Of all the forms of inequality, injustice in health 
care is the most shocking and inhuman because it 
often results in physical death.’’. 
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(2) Inequity in health care remains a persistent 
and devastating reality for many communities, and, 
in particular, communities of color. 
(3) The provision of inequitable health care has 
complex causes, many stemming from systemic in-
equality in access to health care, housing, nutrition, 
economic opportunity, education, and other factors. 
(4) Health care outcomes for Black commu-
nities in particular lag far behind those of the popu-
lation as a whole. 
(5) Dr. Anthony Fauci, Director of the Na-
tional Institute of Allergy and Infectious Diseases, 
said on April 7, 2020, the coronavirus outbreak is 
‘‘shining a bright light’’ on ‘‘unacceptable’’ health 
disparities in the Black community. 
(6) A contributing factor in health disparities is 
explicit and implicit bias in the delivery of health 
care, resulting in inferior care and poorer outcomes 
for some patients on the basis of factors that include 
race, national origin, sex (including sexual orienta-
tion or gender identity), disability, age, and religion. 
(7) The National Academy of Medicine (for-
merly known as the ‘‘Institute of Medicine’’) issued 
a report in 2002 titled ‘‘Unequal Treatment’’, find-
ing that racial and ethnic minorities receive lower- 
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471 
quality health care than Whites do, even when insur-
ance status, income, age, and severity of condition is 
comparable. 
(8) Just as Congress has sought to eliminate 
bias, both explicit and implicit, in employment, hous-
ing, and other parts of our society, the elimination 
of bias and the legacy of structural racism in health 
care is of paramount importance. 
SEC. 4502. DATA COLLECTION AND REPORTING. 
(a) REQUIRED REPORTING.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services, in consultation with the Director 
for Civil Rights and Health Equity, the Director of 
the National Institutes of Health, the Administrator 
of the Centers for Medicare & Medicaid Services, the 
Director of the Agency for Healthcare Research and 
Quality, the Deputy Assistant Secretary for Minority 
Health, and the Director of the Centers for Disease 
Control and Prevention, shall by regulation require 
all health care providers and facilities that are re-
quired under other provisions of law to report data 
on specific health outcomes to the Department of 
Health and Human Services in aggregate form, to 
disaggregate such data by demographic characteris-
tics, including by race, national origin, sex (including 
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472 
sexual orientation and gender identity), disability, 
and age, as well as any other factor that the Sec-
retary of Health and Human Services determines 
would be useful for determining a pattern of provi-
sion of inequitable health care. 
(2) PROPOSED REGULATIONS.—Not later than 
90 days after the date of enactment of this Act, the 
Secretary of Health and Human Services shall issue 
proposed regulations to carry out paragraph (1). 
(b) REPOSITORY.—The Secretary of Health and 
Human Services shall— 
(1) not later than 1 year after the date of en-
actment of this Act, establish a repository of the 
disaggregated data reported pursuant to subsection 
(a); 
(2) subject to paragraph (3), make the data in 
such repository publicly available; and 
(3) ensure that such repository does not contain 
any data that is individually identifiable. 
SEC. 4503. REQUIRING EQUITABLE HEALTH CARE IN THE 
HOSPITAL VALUE-BASED PURCHASING PRO-
GRAM. 
(a) EQUITABLE HEALTH CARE AS VALUE MEASURE-
MENT.—Section 1886(b)(3)(B)(viii) of the Social Security 
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473 
Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended by 
adding at the end the following new subclause: 
‘‘(XIII)(aa) Effective for payments beginning with 
fiscal year 2024, in expanding the number of measures 
under subclause (III), the Secretary shall adopt measures 
that relate to equitable health care furnished by hospitals 
in inpatient settings. 
‘‘(bb) In carrying out this subclause, the Secretary 
shall solicit input and recommendations from individuals 
and groups representing communities of color and other 
protected classes and ensure measures adopted pursuant 
to this subclause account for social determinants of health, 
as defined in section 7(e)(10) of the Equal Health Care 
for All Act. 
‘‘(cc) For purposes of this subclause, the term ‘equi-
table health care’ refers to the principle that high-quality 
care should be provided to all individuals and health care 
treatment and services should not vary on account of the 
real or perceived race, national origin, sex (including sex-
ual orientation and gender identity), disability, or age of 
an individual, as well as any other factor that the Sec-
retary determines would be useful for determining a pat-
tern of provision of inequitable health care.’’. 
(b) INCLUSION OF EQUITABLE HEALTH CARE MEAS-
URES.—Section 1886(o)(2)(B) of the Social Security Act 
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474 
(42 U.S.C. 1395ww(o)(2)(B)) is amended by adding at the 
end the following new clause: 
‘‘(iv) 
INCLUSION
OF
EQUITABLE 
HEALTH CARE MEASURES.—Beginning in 
fiscal year 2024, measures selected under 
subparagraph (A) shall include the equi-
table health care measures described in 
subsection (b)(3)(B)(viii)(XIII).’’. 
SEC. 4504. PROVISION OF INEQUITABLE HEALTH CARE AS A 
BASIS FOR PERMISSIVE EXCLUSION FROM 
MEDICARE AND STATE HEALTH CARE PRO-
GRAMS. 
Section 1128(b) of the Social Security Act (42 U.S.C. 
1320a–7(b)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(18) PROVISION
OF
INEQUITABLE
HEALTH 
CARE.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), any health care provider that the 
Secretary determines has engaged in a pattern 
of providing inequitable health care (as defined 
in section 7(e)(7) of the Equal Health Care for 
All Act) on the basis of race, national origin, 
sex (including sexual orientation and gender 
identity), disability, or age of an individual. 
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475 
‘‘(B) EXCEPTION.—For purposes of car-
rying out subparagraph (A), the Secretary shall 
not exclude any health care provider from par-
ticipation in the Medicare program under title 
XVIII of the Social Security Act or the Med-
icaid program under title XIX of such Act if 
the exclusion of such health care provider would 
result in increased difficulty in access to health 
care services for underserved or low-income 
communities.’’. 
SEC. 4505. OFFICE FOR CIVIL RIGHTS AND HEALTH EQUITY 
OF 
THE 
DEPARTMENT 
OF 
HEALTH 
AND 
HUMAN SERVICES. 
(a) NAME OF OFFICE.—Beginning on the date of en-
actment of this Act, the Office for Civil Rights of the De-
partment of Health and Human Services shall be known 
as the ‘‘Office for Civil Rights and Health Equity’’ of the 
Department of Health and Human Services. Any ref-
erence to the Office for Civil Rights of the Department 
of Health and Human Services in any law, regulation, 
map, document, record, or other paper of the United 
States shall be deemed to be a reference to the Office for 
Civil Rights and Health Equity. 
(b) HEAD OF OFFICE.—The head of the Office for 
Civil Rights and Health Equity shall be the Director for 
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476 
Civil Rights and Health Equity, to be appointed by the 
President. Any reference to the Director of the Office for 
Civil Rights of the Department of Health and Human 
Services in any law, regulation, map, document, record, 
or other paper of the United States shall be deemed to 
be a reference to the Director for Civil Rights and Health 
Equity. 
SEC. 4506. PROHIBITING DISCRIMINATION IN HEALTH 
CARE. 
(a) PROHIBITING DISCRIMINATION.— 
(1) IN
GENERAL.—No health care provider 
may, on the basis, in whole or in part, of race, sex 
(including sexual orientation and gender identity), 
disability, age, or religion, subject an individual to 
the provision of inequitable health care. 
(2) NOTICE
OF
PATIENT
RIGHTS.—The Sec-
retary shall provide to each patient a notice of a pa-
tient’s rights under this section. 
(b) ADMINISTRATIVE COMPLAINT AND CONCILIATION 
PROCESS.— 
(1) COMPLAINTS AND ANSWERS.— 
(A) IN
GENERAL.—An aggrieved person 
may, not later than 1 year after an alleged vio-
lation of subsection (a) has occurred or con-
cluded, file a complaint with the Director alleg-
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477 
ing inequitable provision of health care by a 
provider described in subsection (a). 
(B) COMPLAINT.—A complaint submitted 
pursuant to subparagraph (A) shall be in writ-
ing and shall contain such information and be 
in such form as the Director requires. 
(C) OATH
OR
AFFIRMATION.—The com-
plaint and any answer made under this sub-
section shall be made under oath or affirmation, 
and may be reasonably and fairly modified at 
any time. 
(2) RESPONSE TO COMPLAINTS.— 
(A) IN GENERAL.—Upon the filing of a 
complaint under this subsection, the following 
procedures shall apply: 
(i) COMPLAINANT NOTICE.—The Di-
rector shall serve notice upon the com-
plainant acknowledging receipt of such fil-
ing and advising the complainant of the 
time limits and procedures provided under 
this section. 
(ii) RESPONDENT NOTICE.—The Di-
rector shall, not later than 30 days after 
receipt of such filing— 
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478 
(I) serve on the respondent a no-
tice of the complaint, together with a 
copy of the original complaint; and 
(II) advise the respondent of the 
procedural rights and obligations of 
respondents under this section. 
(iii) ANSWER.—The respondent may 
file, not later than 60 days after receipt of 
the notice from the Director, an answer to 
such complaint. 
(iv) INVESTIGATIVE DUTIES.—The Di-
rector shall— 
(I) make an investigation of the 
alleged inequitable provision of health 
care; and 
(II) complete such investigation 
within 180 days (unless it is impracti-
cable to complete such investigation 
within 180 days) after the filing of 
the complaint. 
(B) INVESTIGATIONS.— 
(i) PATTERN
OR
PRACTICE.—In the 
course of investigating the complaint, the 
Director may seek records of care provided 
to patients other than the complainant if 
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479 
necessary to demonstrate or disprove an 
allegation of inequitable provision of health 
care or to determine whether there is a 
pattern or practice of such care. 
(ii) ACCOUNTING FOR SOCIAL DETER-
MINANTS
OF
HEALTH.—In investigating 
the complaint and reaching a determina-
tion on the validity of the complaint, the 
Director shall account for social deter-
minants of health and the effect of such 
social determinants on health care out-
comes. 
(iii) INABILITY TO COMPLETE INVES-
TIGATION.—If the Director is unable to 
complete (or finds it is impracticable to 
complete) the investigation within 180 
days after the filing of the complaint (or, 
if the Secretary takes further action under 
paragraph (6)(B) with respect to a com-
plaint, within 180 days after the com-
mencement of such further action), the Di-
rector shall notify the complainant and re-
spondent in writing of the reasons in-
volved. 
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480 
(iv) REPORT
TO
STATE
LICENSING 
AUTHORITIES.—On concluding each inves-
tigation under this subparagraph, the Di-
rector shall provide to the State licensing 
authorities that were notified under sub-
paragraph (A), information specifying the 
results of the investigation. 
(C) REPORT.— 
(i) FINAL
REPORT.—On completing 
each investigation under this paragraph, 
the Director shall prepare a final investiga-
tive report. 
(ii) MODIFICATION
OF
REPORT.—A 
final report under this subparagraph may 
be modified if additional evidence is later 
discovered. 
(3) CONCILIATION.— 
(A) IN GENERAL.—During the period be-
ginning on the date on which a complaint is 
filed under this subsection and ending on the 
date of final disposition of such complaint (in-
cluding during an investigation under para-
graph (2)(B)), the Director shall, to the extent 
feasible, engage in conciliation with respect to 
such complaint. 
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481 
(B) CONCILIATION
AGREEMENT.—A con-
ciliation agreement arising out of such concilia-
tion shall be an agreement between the re-
spondent and the complainant, and shall be 
subject to approval by the Director. 
(C) RIGHTS
PROTECTED.—The Director 
shall approve a conciliation agreement only if 
the agreement protects the rights of the com-
plainant and other persons similarly situated. 
(D) PUBLICLY AVAILABLE AGREEMENT.— 
(i) IN
GENERAL.—Subject to clause 
(ii), the Secretary shall make available to 
the public a copy of a conciliation agree-
ment entered into pursuant to this sub-
section unless the complainant and re-
spondent otherwise agree, and the Sec-
retary determines, that disclosure is not re-
quired to further the purposes of this sub-
section. 
(ii) 
LIMITATION.—A 
conciliation 
agreement that is made available to the 
public pursuant to clause (i) may not dis-
close individually identifiable health infor-
mation. 
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482 
(4) FAILURE TO COMPLY WITH CONCILIATION 
AGREEMENT.—Whenever the Director has reason-
able cause to believe that a respondent has breached 
a conciliation agreement, the Director shall refer the 
matter to the Attorney General to consider filing a 
civil action to enforce such agreement. 
(5) WRITTEN
CONSENT
FOR
DISCLOSURE
OF 
INFORMATION.—Nothing said or done in the course 
of conciliation under this subsection may be made 
public, or used as evidence in a subsequent pro-
ceeding under this subsection, without the written 
consent of the parties to the conciliation. 
(6) PROMPT JUDICIAL ACTION.— 
(A) IN GENERAL.—If the Director deter-
mines at any time following the filing of a com-
plaint under this subsection that prompt judi-
cial action is necessary to carry out the pur-
poses of this subsection, the Director may rec-
ommend that the Attorney General promptly 
commence a civil action under subsection (d). 
(B) IMMEDIATE SUIT.—If the Director de-
termines at any time following the filing of a 
complaint under this subsection that the public 
interest would be served by allowing the com-
plainant to bring a civil action under subsection 
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483 
(c) in a State or Federal court immediately, the 
Director shall certify that the administrative 
process has concluded and that the complainant 
may file such a suit immediately. 
(7) ANNUAL REPORT.—Not later than 1 year 
after the date of enactment of this Act, and annually 
thereafter, the Director shall make publicly available 
a report detailing the activities of the Office for Civil 
Rights and Health Equity under this subsection, in-
cluding— 
(A) the number of complaints filed and the 
basis on which the complaints were filed; 
(B) the number of investigations under-
taken as a result of such complaints; and 
(C) the disposition of all such investiga-
tions. 
(c) ENFORCEMENT BY PRIVATE PERSONS.— 
(1) IN GENERAL.— 
(A) CIVIL ACTION.— 
(i) IN
SUIT.—A complainant under 
subsection (b) may commence a civil action 
to obtain appropriate relief with respect to 
an alleged violation of subsection (a), or 
for breach of a conciliation agreement 
under subsection (b), in an appropriate 
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484 
district court of the United States or State 
court— 
(I) not sooner than the earliest 
of— 
(aa) the date a conciliation 
agreement is reached under sub-
section (b); 
(bb) the date of a final dis-
position of a complaint under 
subsection (b); or 
(cc) 180 days after the first 
day of the alleged violation; and 
(II) not later than 2 years after 
the final day of the alleged violation. 
(ii) STATUTE OF LIMITATIONS.—The 
computation of such 2-year period shall 
not include any time during which an ad-
ministrative proceeding (including inves-
tigation or conciliation) under subsection 
(b) was pending with respect to a com-
plaint under such subsection. 
(B) BARRING SUIT.—If the Director has 
obtained a conciliation agreement under sub-
section (b) regarding an alleged violation of 
subsection (a), no action may be filed under 
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485 
this paragraph by the complainant involved 
with respect to the alleged violation except for 
the purpose of enforcing the terms of such an 
agreement. 
(2) RELIEF WHICH MAY BE GRANTED.— 
(A) IN GENERAL.—In a civil action under 
paragraph (1), if the court finds that a viola-
tion of subsection (a) or breach of a conciliation 
agreement has occurred, the court may award 
to the plaintiff actual and punitive damages, 
and may grant as relief, as the court deter-
mines to be appropriate, any permanent or tem-
porary injunction, temporary restraining order, 
or other order (including an order enjoining the 
defendant from engaging in a practice violating 
subsection (a) or ordering such affirmative ac-
tion as may be appropriate). 
(B) FEES AND COSTS.—In a civil action 
under paragraph (1), the court, in its discre-
tion, may allow the prevailing party, other than 
the United States, a reasonable attorney’s fee 
and costs. The United States shall be liable for 
such fees and costs to the same extent as a pri-
vate person. 
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486 
(3) INTERVENTION BY ATTORNEY GENERAL.— 
Upon timely application, the Attorney General may 
intervene in a civil action under paragraph (1), if 
the Attorney General certifies that the case is of 
general public importance. 
(d) ENFORCEMENT BY THE ATTORNEY GENERAL.— 
(1) COMMENCEMENT OF ACTIONS.— 
(A) PATTERN OR PRACTICE CASES.—The 
Attorney General may commence a civil action 
in any appropriate district court of the United 
States if the Attorney General has reasonable 
cause to believe that any health care provider 
covered by subsection (a)— 
(i) is engaged in a pattern or practice 
that violates such subsection; or 
(ii) is engaged in a violation of such 
subsection that raises an issue of signifi-
cant public importance. 
(B) CASES BY REFERRAL.—The Director 
may determine, based on a pattern of com-
plaints, a pattern of violations, a review of data 
reported by a health care provider covered by 
subsection (a), or any other means, that there 
is reasonable cause to believe a health care pro-
vider is engaged in a pattern or practice that 
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487 
violates subsection (a). If the Director makes 
such a determination, the Director shall refer 
the related findings to the Attorney General. If 
the Attorney General finds that such reasonable 
cause exists, the Attorney General may com-
mence a civil action in any appropriate district 
court of the United States. 
(2) ENFORCEMENT OF SUBPOENAS.—The At-
torney General, on behalf of the Director, or another 
party at whose request a subpoena is issued under 
this subsection, may enforce such subpoena in ap-
propriate proceedings in the district court of the 
United States for the district in which the person to 
whom the subpoena was addressed resides, was 
served, or transacts business. 
(3) RELIEF WHICH MAY BE GRANTED IN CIVIL 
ACTIONS.— 
(A) IN GENERAL.—In a civil action under 
paragraph (1), the court— 
(i) may award such preventive relief, 
including a permanent or temporary in-
junction, temporary restraining order, or 
other order against the person responsible 
for a violation of subsection (a) as is nec-
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488 
essary to assure the full enjoyment of the 
rights granted by this subsection; 
(ii) may award such other relief as the 
court determines to be appropriate, includ-
ing monetary damages, to aggrieved per-
sons; and 
(iii) may, to vindicate the public inter-
est, assess punitive damages against the 
respondent— 
(I) in an amount not exceeding 
$500,000, for a first violation; and 
(II) in an amount not exceeding 
$1,000,000, for any subsequent viola-
tion. 
(B) FEES AND COSTS.—In a civil action 
under this subsection, the court, in its discre-
tion, may allow the prevailing party, other than 
the United States, a reasonable attorney’s fee 
and costs. The United States shall be liable for 
such fees and costs to the extent provided by 
section 2412 of title 28, United States Code. 
(4) INTERVENTION IN CIVIL ACTIONS.—Upon 
timely application, any person may intervene in a 
civil action commenced by the Attorney General 
under paragraphs (1) and (2) if the action involves 
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489 
an alleged violation of subsection (a) with respect to 
which such person is an aggrieved person (including 
a person who is a complainant under subsection (b)) 
or a conciliation agreement to which such person is 
a party. 
(e) DEFINITIONS.—In this section: 
(1) AGGRIEVED PERSON.—The term ‘‘aggrieved 
person’’ means— 
(A) a person who believes that the person 
was or will be injured in violation of subsection 
(a); or 
(B) the personal representative or estate of 
a deceased person who was injured in violation 
of subsection (a). 
(2) DIRECTOR.—The term ‘‘Director’’ refers to 
the Director for Civil Rights and Health Equity of 
the Department of Health and Human Services. 
(3) DISABILITY.—The term ‘‘disability’’ has the 
meaning given such term in section 3 of the Ameri-
cans with Disabilities Act of 1990 (42 U.S.C. 
12102). 
(4) CONCILIATION.—The term ‘‘conciliation’’ 
means the attempted resolution of issues raised by 
a complaint, or by the investigation of such com-
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490 
plaint, through informal negotiations involving the 
complainant, the respondent, and the Secretary. 
(5) CONCILIATION
AGREEMENT.—The term 
‘‘conciliation agreement’’ means a written agreement 
setting forth the resolution of the issues in concilia-
tion. 
(6) INDIVIDUALLY IDENTIFIABLE HEALTH IN-
FORMATION.—The term ‘‘individually identifiable 
health information’’ means any information, includ-
ing demographic information collected from an indi-
vidual— 
(A) that is created or received by a health 
care provider covered by subsection (a), health 
plan, employer, or health care clearinghouse; 
(B) that relates to the past, present, or fu-
ture physical or mental health or condition of, 
the provision of health care to, or the past, 
present, or future payment for the provision of 
health care to, the individual; and 
(C)(i) that identifies the individual; or 
(ii) with respect to which there is a reason-
able basis to believe that the information can be 
used to identify the individual. 
(7) PROVISION
OF
INEQUITABLE
HEALTH 
CARE.—The term ‘‘provision of inequitable health 
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491 
care’’ means the provision of any health care service, 
by a health care provider in a manner that— 
(A) fails to meet a high-quality care stand-
ard, meaning the health care provider fails to— 
(i) avoid harm to patients as a result 
of the health services that are intended to 
help the patient; 
(ii) provide health services based on 
scientific knowledge to all and to all pa-
tients who benefit; 
(iii) refrain from providing services to 
patients not likely to benefit; 
(iv) provide care that is responsive to 
patient preferences, needs, and values; and 
(v) avoids waits or delays in care; and 
(B) is discriminatory in intent or effect 
based at least in part on a basis specified in 
subsection (a). 
(8) RESPONDENT.—The term ‘‘respondent’’ 
means the person or other entity accused in a com-
plaint of a violation of subsection (a). 
(9) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(10) SOCIAL DETERMINANTS OF HEALTH.—The 
term ‘‘social determinants of health’’ means condi-
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492 
tions in the environments in which individuals live, 
work, attend school, and worship, that affect a wide 
range of health, functioning, and quality-of-life out-
comes and risks. 
(f) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed as repealing or limiting the effect 
of title VI of the Civil Rights Act of 1964 (42 U.S.C. 
2000b et seq.), section 1557 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18116), section 504 of 
the Rehabilitation Act of 1973 (29 U.S.C. 794), or the 
Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.). 
SEC. 4507. FEDERAL HEALTH EQUITY COMMISSION. 
(a) ESTABLISHMENT OF COMMISSION.— 
(1) IN
GENERAL.—There is established the 
Federal Health Equity Commission (in this section 
referred to as the ‘‘Commission’’). 
(2) MEMBERSHIP.— 
(A) IN GENERAL.—The Commission shall 
be composed of— 
(i) 8 voting members appointed under 
subparagraph (B); and 
(ii) the nonvoting, ex officio members 
listed in subparagraph (C). 
(B) VOTING MEMBERS.—Not more than 4 
of the members described in subparagraph 
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493 
(A)(i) shall at any one time be of the same po-
litical party. Such members shall have recog-
nized expertise in and personal experience with 
racial and ethnic health inequities, health care 
needs of vulnerable and marginalized popu-
lations, and health equity as a vehicle for im-
proving health status and health outcomes. 
Such members shall be appointed to the Com-
mission as follows: 
(i) 4 members of the Commission 
shall be appointed by the President. 
(ii) 2 members of the Commission 
shall be appointed by the President pro 
tempore of the Senate, upon the rec-
ommendations of the majority leader and 
the minority leader of the Senate. Each 
member appointed to the Commission 
under this clause shall be appointed from 
a different political party. 
(iii) 2 members of the Commission 
shall be appointed by the Speaker of the 
House of Representatives upon the rec-
ommendations of the majority leader and 
the minority leader of the House of Rep-
resentatives. Each member appointed to 
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494 
the Commission under this clause shall be 
appointed from a different political party. 
(C) EX OFFICIO MEMBER.—The Commis-
sion shall have the following nonvoting, ex offi-
cio members: 
(i) The Director for Civil Rights and 
Health Equity of the Department of 
Health and Human Services. 
(ii) The Deputy Assistant Secretary 
for Minority Health of the Department of 
Health and Human Services. 
(iii) The Director of the National In-
stitute on Minority Health and Health Dis-
parities. 
(iv) The Chairperson of the Advisory 
Committee on Minority Health established 
under section 1707(c) of the Public Health 
Service Act (42 U.S.C. 300u–6(c)). 
(3) TERMS.—The term of office of each mem-
ber appointed under paragraph (2)(B) of the Com-
mission shall be 6 years. 
(4) CHAIRPERSON; VICE CHAIRPERSON.— 
(A) CHAIRPERSON.—The President shall, 
with the concurrence of a majority of the mem-
bers of the Commission appointed under para-
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495 
graph (2)(B), designate a Chairperson from 
among the members of the Commission ap-
pointed under such paragraph. 
(B) VICE CHAIRPERSON.— 
(i) DESIGNATION.—The Speaker of 
the House of Representatives shall, in con-
sultation with the majority leaders and the 
minority leaders of the Senate and the 
House of Representatives and with the 
concurrence of a majority of the members 
of the Commission appointed under para-
graph (2)(B), designate a Vice Chairperson 
from among the members of the Commis-
sion appointed under such paragraph. The 
Vice Chairperson may not be a member of 
the same political party as the Chair-
person. 
(ii) DUTY.—The Vice Chairperson 
shall act in place of the Chairperson in the 
absence of the Chairperson. 
(5) REMOVAL
OF
MEMBERS.—The President 
may remove a member of the Commission only for 
neglect of duty or malfeasance in office. 
(6) QUORUM.—A majority of members of the 
Commission appointed under paragraph (2)(B) shall 
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