224 
SEC. 404. MEDICAID IN THE TERRITORIES. 
(a) ELIMINATION OF GENERAL MEDICAID FUNDING 
LIMITATIONS (‘‘CAP’’) FOR TERRITORIES.— 
(1) IN GENERAL.—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 ‘‘subsection 
(g)’’ and inserting ‘‘subsections (g) and (h)’’; 
(B) in subsection (g)(2), in the matter pre-
ceding subparagraph (A), by inserting ‘‘and 
subsection (h)’’ after ‘‘paragraphs (3) and (5)’’; 
and 
(C) by adding at the end the following new 
subsection: 
‘‘(h) SUNSET OF MEDICAID FUNDING LIMITATIONS 
FOR PUERTO RICO, THE VIRGIN ISLANDS
OF
THE 
UNITED STATES, GUAM, THE NORTHERN MARIANA IS-
LANDS, AND AMERICAN SAMOA.—Subsections (f) and (g) 
shall not apply to Puerto Rico, the Virgin Islands of the 
United States, Guam, the Northern Mariana Islands, and 
American Samoa beginning with fiscal year 2020.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1902(j) of the Social Security 
Act (42 U.S.C. 1396a(j)) is amended by strik-
ing ‘‘, the limitation in section 1108(f),’’. 
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225 
(B) Section 1903(u) of the Social Security 
Act (42 U.S.C. 1396b(u)) is amended by strik-
ing paragraph (4). 
(C) Section 1323(c)(1) of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 
18043(c)(1)) is amended by striking ‘‘2019’’ 
and inserting ‘‘2018’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this section shall apply beginning with fiscal year 
2021. 
(b) ELIMINATION OF SPECIFIC FEDERAL MEDICAL 
ASSISTANCE PERCENTAGE (FMAP) LIMITATION
FOR 
TERRITORIES.—Section 1905(b) of the Social Security 
Act (42 U.S.C. 1396d(b)) is amended, in clause (2), by 
inserting ‘‘for fiscal years before fiscal year 2020’’ after 
‘‘American Samoa’’. 
(c) APPLICATION OF MEDICAID WAIVER AUTHORITY 
TO ALL OF THE TERRITORIES.— 
(1) IN GENERAL.—Section 1902(j) of the Social 
Security Act (42 U.S.C. 1396a(j)) is amended— 
(A) by striking ‘‘American Samoa and the 
Northern Mariana Islands’’ and inserting 
‘‘Puerto Rico, the Virgin Islands of the United 
States, Guam, the Northern Mariana Islands, 
and American Samoa’’; 
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226 
(B) by striking ‘‘American Samoa or the 
Northern Mariana Islands’’ and inserting 
‘‘Puerto Rico, the Virgin Islands of the United 
States, Guam, the Northern Mariana Islands, 
or American Samoa’’; 
(C) by inserting ‘‘(1)’’ after ‘‘(j)’’; 
(D) by inserting ‘‘except as otherwise pro-
vided in this subsection,’’ after ‘‘Notwith-
standing any other requirement of this title’’; 
and 
(E) by adding at the end the following: 
‘‘(2) The Secretary may not waive under this 
subsection 
the 
requirement 
of 
subsection 
(a)(10)(A)(i)(IX) (relating to coverage of adults for-
merly under foster care) with respect to any terri-
tory.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this section shall apply beginning October 1, 
2021. 
(d) PERMITTING MEDICAID DSH ALLOTMENTS FOR 
TERRITORIES.—Section 1923(f) of the Social Security Act 
(42 U.S.C. 1396r–4) is amended— 
(1) in paragraph (6), by adding at the end the 
following new subparagraph: 
‘‘(C) TERRITORIES.— 
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227 
‘‘(i) FISCAL
YEAR
2020.—For fiscal 
year 2020, the DSH allotment for Puerto 
Rico, the Virgin Islands of the United 
States, Guam, the Northern Mariana Is-
lands, and American Samoa shall bear the 
same ratio to $300,000,000 as the ratio of 
the number of individuals who are low-in-
come or uninsured and residing in such re-
spective territory (as estimated from time 
to time by the Secretary) bears to the 
sums of the number of such individuals re-
siding in all of the territories. 
‘‘(ii) SUBSEQUENT
FISCAL
YEAR.— 
For each subsequent fiscal year, the DSH 
allotment for each such territory is subject 
to an increase in accordance with para-
graph (2).’’; and 
(2) in paragraph (9), by inserting before the pe-
riod at the end the following: ‘‘, and includes, begin-
ning with fiscal year 2021, Puerto Rico, the Virgin 
Islands of the United States, Guam, the Northern 
Mariana Islands, and American Samoa’’. 
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228 
SEC. 405. EXTENSION OF MEDICARE SECONDARY PAYER. 
(a) IN GENERAL.—Section 1862(b)(1)(C) of the So-
cial Security Act (42 U.S.C. 1395y(b)(1)(C)) is amend-
ed— 
(1) in the last sentence, by inserting ‘‘, and be-
fore January 1, 2021’’ after ‘‘prior to such date)’’; 
and 
(2) by adding at the end the following new sen-
tence: ‘‘Effective for items and services furnished on 
or after January 1, 2021 (with respect to periods 
beginning on or after the date that is 42 months 
prior to such date), clauses (i) and (ii) shall be ap-
plied by substituting ‘42-month’ for ‘12-month’ each 
place it appears.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date of enactment of 
this Act. For purposes of determining an individual’s sta-
tus under section 1862(b)(1)(C) of the Social Security Act 
(42 U.S.C. 1395y(b)(1)(C)), as amended by subsection 
(a), an individual who is within the coordinating period 
as of the date of enactment of this Act shall have that 
period extended to the full 42 months described in the last 
sentence of such section, as added by the amendment 
made by subsection (a)(2). 
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229 
SEC. 406. INDIAN DEFINED IN TITLE I OF THE PATIENT 
PROTECTION AND AFFORDABLE CARE ACT. 
(a) DEFINITION OF INDIAN.—Section 1304 of the 
Patient Protection and Affordable Care Act (42 U.S.C. 
18024) is amended by adding at the end the following: 
‘‘(f) INDIAN.— 
‘‘(1) IN GENERAL.—In this title, the term ‘In-
dian’ means any individual— 
‘‘(A) described in paragraph (13) or (28) 
of section 4 of the Indian Health Care Improve-
ment Act (25 U.S.C. 1603); 
‘‘(B) who is eligible for health services pro-
vided by the Indian Health Service under sec-
tion 809 of the Indian Health Care Improve-
ment Act (25 U.S.C. 1679); 
‘‘(C) who is of Indian descent and belongs 
to the Indian community served by the local fa-
cilities and program of the Indian Health Serv-
ice; or 
‘‘(D) who is described in paragraph (2). 
‘‘(2) INCLUSIONS.—An individual is described 
in this paragraph if the individual is any of the fol-
lowing: 
‘‘(A) A member of a federally recognized 
Indian Tribe. 
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231 
ing as a California Indian, Eskimo, Aleut, or 
other Alaska Native.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) AFFORDABLE
CHOICES
HEALTH
BENEFIT 
PLANS.—Section 1311(c)(6)(D) of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 
18031(c)(6)(D)) is amended by striking ‘‘(as defined 
in section 4 of the Indian Health Care Improvement 
Act)’’. 
(2) REDUCED COST-SHARING FOR INDIVIDUALS 
ENROLLING IN QUALIFIED HEALTH PLANS.—Section 
1402(d) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18071(d)) is amended— 
(A) in paragraph (1), in the matter pre-
ceding subparagraph (A), by striking ‘‘(as de-
fined in section 4(d) of the Indian Self-Deter-
mination and Education Assistance Act (25 
U.S.C. 450b(d))’’; and 
(B) in paragraph (2), in the matter pre-
ceding subparagraph (A), by striking ‘‘(as so 
defined)’’. 
(3) EXEMPTION
FROM
PENALTY
FOR
NOT 
MAINTAINING
MINIMUM
ESSENTIAL
COVERAGE.— 
Section 5000A(e) of the Internal Revenue Code of 
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232 
1986 is amended by striking paragraph (3) and in-
serting the following: 
‘‘(3) INDIANS.—Any applicable individual who 
is an Indian (as defined in section 1304(f) of the 
Patient Protection and Affordable Care Act).’’. 
SEC. 407. REMOVING MEDICARE BARRIER TO HEALTH 
CARE. 
(a) PART A.—Section 1818(a)(3) of the Social Secu-
rity Act (42 U.S.C. 1395i–2(a)(3)) is amended by striking 
‘‘an alien’’ and all that follows through ‘‘under this sec-
tion’’ and inserting ‘‘an individual who is lawfully present 
in the United States’’. 
(b) PART B.—Section 1836(2) of the Social Security 
Act (42 U.S.C. 1395o(2)) is amended by striking ‘‘an 
alien’’ and all that follows through ‘‘under this part’’ and 
inserting ‘‘an individual who is lawfully present in the 
United States’’. 
SEC. 408. 100 PERCENT FMAP FOR MEDICAL ASSISTANCE 
PROVIDED BY URBAN INDIAN HEALTH CEN-
TERS. 
(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 such Act’’ after ‘‘(as 
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233 
defined in section 4 of the Indian Health Care Improve-
ment 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. 409. 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)), 
as amended by section 408(a), is amended by inserting 
before the period the following: ‘‘, and with respect to 
medical assistance provided to a Native Hawaiian (as de-
fined in section 12(2) of the Native Hawaiian Health Care 
Improvement Act) through a federally qualified health 
center or a Native Hawaiian health care system (as de-
fined in section 12(6) of such Act), whether directly, by 
referral, or under contract or other arrangement between 
such federally qualified health center or Native Hawaiian 
health care system and another health care provider’’. 
(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. 
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234 
SEC. 410. MEDICAID COVERAGE FOR CITIZENS OF FREELY 
ASSOCIATED STATES. 
(a) IN GENERAL.—Section 402(b)(2) of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (8 U.S.C. 1612(b)(2)) is amended by adding at 
the end the following new subparagraph: 
‘‘(G) MEDICAID EXCEPTION FOR CITIZENS 
OF FREELY ASSOCIATED STATES.—With respect 
to eligibility for benefits for the designated Fed-
eral program described in paragraph (3)(C), 
section 401(a) and paragraph (1) shall not 
apply to any individual who lawfully resides in 
1 of the 50 States or the District of Columbia 
in accordance with the Compacts of Free Asso-
ciation between the Government of the United 
States and the Governments of the Federated 
States of Micronesia, the Republic of the Mar-
shall Islands, and the Republic of Palau and 
shall not apply, at the option of the Governors 
of Puerto Rico, the Virgin Islands, Guam, the 
Northern Mariana Islands, or American Samoa, 
respectively, as communicated to the Secretary 
of Health and Human Services in writing, to 
any individual who lawfully resides in the re-
spective territory in accordance with such Com-
pacts.’’. 
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235 
(b) EXCEPTION TO 5-YEAR LIMITED ELIGIBILITY.— 
Section 403(d) of the Personal Responsibility and Work 
Opportunity Reconciliation Act of 1996 (8 U.S.C. 
1613(d)) is amended— 
(1) in paragraph (1), by striking ‘‘or’’ at the 
end; 
(2) in paragraph (2), by striking the period at 
the end and inserting ‘‘; or’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(3) 
an 
individual 
described 
in 
section 
402(b)(2)(G), but only with respect to the des-
ignated Federal program described in section 
402(b)(3)(C).’’. 
(c) DEFINITION
OF QUALIFIED ALIEN.—Section 
431(b) of the Personal Responsibility and Work Oppor-
tunity Reconciliation Act of 1996 (8 U.S.C. 1641(b)) is 
amended— 
(1) in paragraph (6), by striking ‘‘; or’’ at the 
end and inserting a comma; 
(2) in paragraph (7), by striking the period at 
the end and inserting ‘‘, or’’; and 
(3) by adding at the end the following new 
paragraph: 
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236 
‘‘(8) an individual who lawfully resides in the 
United States in accordance with a Compact of Free 
Association referred to in section 402(b)(2)(G), but 
only with respect to the designated Federal program 
described in section 402(b)(3)(C) (relating to the 
Medicaid program).’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section take effect on October 1, 2021. 
SEC. 411. AT-RISK YOUTH MEDICAID PROTECTION. 
(a) IN GENERAL.—Section 1902 of the Social Secu-
rity Act (42 U.S.C. 1396a) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘and’’ at the end of para-
graph (83); 
(B) by striking the period at the end of 
paragraph (84) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (84) the 
following new paragraph: 
‘‘(85) provide that— 
‘‘(A) the State shall not terminate eligi-
bility for medical assistance under a State plan 
for an individual who is an eligible juvenile (as 
defined in subsection (nn)(2)) because the juve-
nile is an inmate of a public institution (as de-
fined in subsection (nn)(3)), but may suspend 
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237 
coverage during the period the juvenile is such 
an inmate; 
‘‘(B) the State shall restore coverage for 
such medical assistance to such an individual 
upon the individual’s release from any such 
public institution, without requiring a new ap-
plication from the individual, unless (and until 
such date as) there is a determination that the 
individual no longer meets the eligibility re-
quirements for such medical assistance; and 
‘‘(C) the State shall process any applica-
tion for medical assistance submitted by, or on 
behalf of, a juvenile who is an inmate of a pub-
lic institution notwithstanding that the juvenile 
is such an inmate.’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(nn) JUVENILE; ELIGIBLE JUVENILE; PUBLIC IN-
STITUTION.—For purposes of subsection (a)(84) and this 
subsection: 
‘‘(1) JUVENILE.—The term ‘juvenile’ means an 
individual who is— 
‘‘(A) under 21 years of age; or 
‘‘(B) 
is 
described 
in 
subsection 
(a)(10)(A)(i)(IX). 
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238 
‘‘(2) ELIGIBLE JUVENILE.—The term ‘eligible 
juvenile’ means a juvenile who is an inmate of a 
public institution and was eligible for medical assist-
ance under the State plan immediately before be-
coming an inmate of such a public institution or who 
becomes eligible for such medical assistance while an 
inmate of a public institution. 
‘‘(3) INMATE OF A PUBLIC INSTITUTION.—The 
term ‘inmate of a public institution’ has the meaning 
given such term for purposes of applying the sub-
division (A) following paragraph (30) of section 
1905(a), taking into account the exception in such 
subdivision for a patient of a medical institution.’’. 
(b) NO CHANGE IN EXCLUSION FROM MEDICAL AS-
SISTANCE
FOR INMATES
OF PUBLIC INSTITUTIONS.— 
Nothing in this section shall be construed as changing the 
exclusion from medical assistance under the subdivision 
(A) following paragraph (30) of section 1905(a) of the So-
cial Security Act (42 U.S.C. 1396d(a)), including any ap-
plicable restrictions on a State submitting claims for Fed-
eral financial participation under title XIX of such Act 
for such assistance. 
(c) NO CHANGE IN CONTINUITY OF ELIGIBILITY BE-
FORE ADJUDICATION OR SENTENCING.—Nothing in this 
section shall be construed to mandate, encourage, or sug-
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239 
gest that a State suspend or terminate coverage for indi-
viduals before they have been adjudicated or sentenced. 
(d) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by subsection (a) 
shall apply to eligibility for medical assistance under 
a State plan under title XIX of the Social Security 
Act of juveniles who become inmates of public insti-
tutions on or after the date that is 1 year after the 
date of the enactment of this Act. 
(2) RULE
FOR
CHANGES
REQUIRING
STATE 
LEGISLATION.—In the case of a State plan for med-
ical assistance under title XIX of the Social Security 
Act which the Secretary of Health and Human Serv-
ices determines requires State legislation (other than 
legislation appropriating funds) in order for the plan 
to meet the additional requirements imposed by the 
amendments made by subsection (a), the State plan 
shall not be regarded as failing to comply with the 
requirements 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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240 
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. 
Subtitle B—Expansion of Access 
SEC. 412. AMENDMENT TO THE PUBLIC HEALTH SERVICE 
ACT. 
Title XXXIV of the Public Health Service Act, as 
amended by titles I, II, III, and IX of this Act, is further 
amended by inserting after subtitle D the following: 
‘‘Subtitle 
E—Reconstruction 
and 
Improvement Grants for Public 
Health Care Facilities Serving 
Pacific Islanders and the Insu-
lar Areas 
‘‘SEC. 3451. 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, or other health en-
tity determined appropriate 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; 
or 
‘‘(ii) that— 
‘‘(I) serves a disproportionate percent-
age of local patients that are from a racial 
and ethnic minority group, or that has a 
patient population, at least 50 percent of 
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242 
which is composed of individuals with lim-
ited 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 applicants 
under subsection (b)(2) 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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243 
‘‘(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; or 
‘‘(G) other activities determined appro-
priate 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; 
‘‘(E) patient centeredness; and 
‘‘(F) health information technology; and 
‘‘(2) with respect to patients, activities relating 
to— 
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244 
‘‘(A) staying healthy; 
‘‘(B) getting well, mentally and physically; 
‘‘(C) living effectively with illness or dis-
ability; 
‘‘(D) coping with end-of-life issues; and 
‘‘(E) shared decisionmaking. 
‘‘(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 
such sums as may be necessary for each of fiscal years 
2021 through 2026. 
‘‘SEC. 3452. 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 
3451(b)(1); 
‘‘(2) demonstrate excellence in providing care to 
minority populations; and 
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‘‘(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 quality health care to minority popu-
lations; and 
‘‘(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 
2021 through 2026. 
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‘‘SEC. 3453. 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 
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 
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‘‘(2)(A) provides care or treatment for a sub-
stantial number of patients who are uninsured, re-
ceiving assistance under title XVIII of the Social Se-
curity Act, or a State plan under title XIX of such 
Act (or under a waiver of such plan), or who 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-
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; 
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‘‘(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. 413. PROTECTING SENSITIVE LOCATIONS. 
Section 287 of the Immigration and Nationality Act 
(8 U.S.C. 1357) is amended— 
(1) by striking ‘‘Service’’ each place such term 
appears and inserting ‘‘Department of Homeland 
Security’’; 
(2) by striking ‘‘Attorney General’’ each place 
such term appears and inserting ‘‘Secretary of 
Homeland Security’’; 
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(3) in subsection (f)(1), by striking ‘‘Commis-
sioner’’ and inserting ‘‘Director of U.S. Citizenship 
and Immigration Services’’; 
(4) in subsection (h)— 
(A) by striking ‘‘of the Immigration and 
Nationality Act’’; and 
(B) by striking ‘‘of such Act’’; and 
(5) by adding at the end the following: 
‘‘(i)(1) In this subsection: 
‘‘(A) The term ‘appropriate committees of Con-
gress’ means— 
‘‘(i) the Committee on Homeland Security 
and Governmental Affairs of the Senate; 
‘‘(ii) the Committee on the Judiciary of the 
Senate; 
‘‘(iii) the Committee on Homeland Security 
of the House of Representatives; and 
‘‘(iv) the Committee on the Judiciary of 
the House of Representatives. 
‘‘(B) The term ‘enforcement action’— 
‘‘(i) means an apprehension, arrest, inter-
view, request for identification, search, or sur-
veillance for the purposes of immigration en-
forcement; and 
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‘‘(ii) includes an enforcement action at, or 
focused on, a sensitive location that is part of 
a joint case led by another law enforcement 
agency. 
‘‘(C) The term ‘exigent circumstances’ means a 
situation involving— 
‘‘(i) the imminent risk of death, violence, 
or physical harm to any person or property, in-
cluding a situation implicating terrorism or the 
national security of the United States; 
‘‘(ii) the immediate arrest or pursuit of a 
dangerous felon, terrorist suspect, or other indi-
vidual presenting an imminent danger; or 
‘‘(iii) the imminent risk of destruction of 
evidence that is material to an ongoing criminal 
case. 
‘‘(D) The term ‘prior approval’ means— 
‘‘(i) in the case of officers and agents of 
U.S. Immigration and Customs Enforcement, 
prior written approval to carry out an enforce-
ment action involving a specific individual or in-
dividuals authorized by— 
‘‘(I) the Assistant Director of Oper-
ations, Homeland Security Investigations; 
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‘‘(II) the Executive Associate Direc-
tor, Homeland Security Investigations; 
‘‘(III) the Assistant Director for Field 
Operations, Enforcement and Removal Op-
erations; or 
‘‘(IV) the Executive Associate Direc-
tor for Field Operations, Enforcement and 
Removal Operations; 
‘‘(ii) in the case of officers and agents of 
U.S. Customs and Border Protection, prior 
written approval to carry out an enforcement 
action involving a specific individual or individ-
uals authorized by— 
‘‘(I) a Chief Patrol Agent; 
‘‘(II) the Director of Field Operations; 
‘‘(III) the Director of Air and Marine 
Operations; or 
‘‘(IV) the Internal Affairs Special 
Agent in Charge; and 
‘‘(iii) in the case of other Federal, State, 
or local law enforcement officers, to carry out 
an enforcement action involving a specific indi-
vidual or individuals authorized by— 
‘‘(I) the head of the Federal agency 
carrying out the enforcement action; or 
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‘‘(II) the head of the State or local 
law enforcement agency carrying out the 
enforcement action. 
‘‘(E) The term ‘sensitive location’ includes all of 
the physical space located within 1,000 feet of— 
‘‘(i) any medical treatment or health care 
facility, including any hospital, doctor’s office, 
accredited health clinic, alcohol or drug treat-
ment center, or emergent or urgent care facil-
ity; 
‘‘(ii) any public or private school, including 
any known and licensed day care facility, pre-
school, other early learning program facility, 
primary school, secondary school, postsecondary 
school (including colleges and universities), or 
other institution of learning (including voca-
tional or trade schools); 
‘‘(iii) any scholastic or education-related 
activity or event, including field trips and inter-
scholastic events; 
‘‘(iv) any school bus or school bus stop 
during periods when school children are present 
on the bus or at the stop; 
‘‘(v) any organization or subdivision of 
government that— 
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‘‘(I) assists children, pregnant women, 
victims of crime or abuse, or individuals 
with significant mental or physical disabil-
ities; or 
‘‘(II) provides social services and as-
sistance, including emergency and disaster 
services or assistance with food and nutri-
tion, housing affordability and income or 
other services funded by State or local gov-
ernment, charitable giving, the Special 
Supplemental 
Nutrition 
Program 
for 
Women, Infants, and Children (WIC), 
Supplemental Nutrition Assistance Pro-
gram (SNAP), Temporary Assistance for 
Needy Families (TANF), or the United 
States Housing Act; 
‘‘(vi) any church, synagogue, mosque, or 
other place of worship, including buildings 
rented for the purpose of religious services, re-
treats, counseling, workshops, instruction, and 
education; 
‘‘(vii) any Federal, State, or local court-
house, including the office of an individual’s 
legal counsel or representative, and a probation, 
parole, or supervised release office; 
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‘‘(viii) the site of a funeral, wedding, or 
other religious ceremony or observance; 
‘‘(ix) any public demonstration, such as a 
march, rally, or parade; 
‘‘(x) any domestic violence shelter, rape 
crisis center, supervised visitation center, family 
justice center, or victim services provider; or 
‘‘(xi) any other location specified by the 
Secretary of Homeland Security for purposes of 
this subsection. 
‘‘(2)(A) An enforcement action may not take place 
at, or be focused on, a sensitive location unless— 
‘‘(i) the action involves exigent circumstances; 
and 
‘‘(ii) prior approval for the enforcement action 
was obtained from the appropriate official. 
‘‘(B) If an enforcement action is initiated pursuant 
to subparagraph (A) and the exigent circumstances per-
mitting the enforcement action cease, the enforcement ac-
tion shall be discontinued until such exigent circumstances 
reemerge. 
‘‘(C) If an enforcement action is carried out in viola-
tion of this subsection— 
‘‘(i) no information resulting from the enforce-
ment action may be entered into the record or re-
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ceived into evidence in a removal proceeding result-
ing from the enforcement action; and 
‘‘(ii) the alien who is the subject of such re-
moval proceeding may file a motion for the imme-
diate termination of the removal proceeding. 
‘‘(3)(A) This subsection shall apply to any enforce-
ment action by officers or agents of the Department of 
Homeland Security, including— 
‘‘(i) officers or agents of U.S. Immigration and 
Customs Enforcement; 
‘‘(ii) officers or agents of U.S. Customs and 
Border Protection; and 
‘‘(iii) any individual designated to perform im-
migration enforcement functions pursuant to sub-
section (g). 
‘‘(B) While carrying out an enforcement action at a 
sensitive location, officers and agents referred to in sub-
paragraph (A) shall make every effort— 
‘‘(i) to limit the time spent at the sensitive loca-
tion; 
‘‘(ii) to limit the enforcement action at the sen-
sitive location to the person or persons for whom 
prior approval was obtained; and 
‘‘(iii) to conduct themselves discreetly. 
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‘‘(C) If, while carrying out an enforcement action 
that is not initiated at or focused on a sensitive location, 
officers or agents are led to a sensitive location, and no 
exigent circumstance and prior approval with respect to 
the sensitive location exists, such officers or agents shall— 
‘‘(i) cease before taking any further enforce-
ment action; 
‘‘(ii) conduct themselves in a discreet manner; 
‘‘(iii) maintain surveillance; and 
‘‘(iv) immediately consult their supervisor in 
order to determine whether such enforcement action 
should be discontinued. 
‘‘(D) The limitations under this paragraph shall not 
apply to the transportation of an individual apprehended 
at or near a land or sea border to a hospital or health 
care provider for the purpose of providing medical care 
to such individual. 
‘‘(4)(A) Each official specified in subparagraph (B) 
shall ensure that the employees under his or her super-
vision receive annual training on compliance with— 
‘‘(i) the requirements under this subsection in 
enforcement actions at or focused on sensitive loca-
tions and enforcement actions that lead officers or 
agents to a sensitive location; and 
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‘‘(ii) the requirements under section 239 of this 
Act and section 384 of the Illegal Immigration Re-
form and Immigrant Responsibility Act of 1996 (8 
U.S.C. 1367). 
‘‘(B) The officials specified in this subparagraph 
are— 
‘‘(i) the Chief Counsel of U.S. Immigration and 
Customs Enforcement; 
‘‘(ii) the Field Office Directors of U.S. Immi-
gration and Customs Enforcement; 
‘‘(iii) each Special Agent in Charge of U.S. Im-
migration and Customs Enforcement; 
‘‘(iv) each Chief Patrol Agent of U.S. Customs 
and Border Protection; 
‘‘(v) the Director of Field Operations of U.S. 
Customs and Border Protection; 
‘‘(vi) the Director of Air and Marine Operations 
of U.S. Customs and Border Protection; 
‘‘(vii) the Internal Affairs Special Agent in 
Charge of U.S. Customs and Border Protection; and 
‘‘(viii) the chief law enforcement officer of each 
State or local law enforcement agency that enters 
into a written agreement with the Department of 
Homeland Security pursuant to subsection (g). 
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‘‘(5) The Secretary of Homeland Security shall mod-
ify the Notice to Appear form (I–862)— 
‘‘(A) to provide the subjects of an enforcement 
action with information, written in plain language, 
summarizing the restrictions against enforcement 
actions at sensitive locations set forth in this sub-
section and the remedies available to the alien if 
such action violates such restrictions; 
‘‘(B) so that the information described in sub-
paragraph (A) is accessible to individuals with lim-
ited English proficiency; and 
‘‘(C) so that subjects of an enforcement action 
are not permitted to verify that the officers or 
agents that carried out such action complied with 
the restrictions set forth in this subsection. 
‘‘(6)(A) The Director of U.S. Immigration and Cus-
toms Enforcement and the Commissioner of U.S. Customs 
and Border Protection shall each submit an annual report 
to the appropriate committees of Congress that includes 
the information set forth in subparagraph (B) with respect 
to the respective agency. 
‘‘(B) Each report submitted under subparagraph (A) 
shall include, with respect to the submitting agency during 
the reporting period— 
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‘‘(i) the number of enforcement actions that 
were carried out at, or focused on, a sensitive loca-
tion; 
‘‘(ii) the number of enforcement actions in 
which officers or agents were subsequently led to a 
sensitive location; and 
‘‘(iii) for each enforcement action described in 
clause (i) or (ii)— 
‘‘(I) the date on which it occurred; 
‘‘(II) the specific site, city, county, and 
State in which it occurred; 
‘‘(III) the components of the agency in-
volved in the enforcement action; 
‘‘(IV) a description of the enforcement ac-
tion, including the nature of the criminal activ-
ity of its intended target; 
‘‘(V) the number of individuals, if any, ar-
rested or taken into custody; 
‘‘(VI) the number of collateral arrests, if 
any, and the reasons for each such arrest; 
‘‘(VII) a certification whether the location 
administrator was contacted before, during, or 
after the enforcement action; and 
‘‘(VIII) the percentage of all of the staff 
members and supervisors reporting to the offi-
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cials listed in paragraph (4)(B) who completed 
the training required under paragraph (4)(A). 
‘‘(7) Nothing in the subsection may be construed— 
‘‘(A) to affect the authority of Federal, State, 
or local law enforcement agencies— 
‘‘(i) to enforce generally applicable Federal 
or State criminal laws unrelated to immigra-
tion; or 
‘‘(ii) to protect residents from imminent 
threats to public safety; or 
‘‘(B) to limit or override the protections pro-
vided in— 
‘‘(i) section 239; or 
‘‘(ii) section 384 of the Illegal Immigration 
Reform and Immigrant Responsibility Act of 
1996 (8 U.S.C. 1367).’’. 
SEC. 414. GRANTS FOR RACIAL AND ETHNIC APPROACHES 
TO COMMUNITY HEALTH. 
(a) PURPOSE.—It is the purpose of this section to 
award grants to assist communities in mobilizing and or-
ganizing resources in support of effective and sustainable 
programs that will reduce or eliminate disparities in health 
and health care experienced by racial and ethnic minority 
individuals. 
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(b) AUTHORITY TO AWARD GRANTS.—The Secretary 
of Health and Human Services, acting through the Ad-
ministrator of the Health Resources and Services Admin-
istration (referred to in this section as the ‘‘Secretary’’), 
shall award grants to eligible entities to assist in design-
ing, implementing, and evaluating culturally and linguis-
tically appropriate, science-based, and community-driven 
sustainable strategies to eliminate racial and ethnic health 
and health care disparities. 
(c) ELIGIBLE ENTITIES.—To be eligible to receive a 
grant under this section, an entity shall— 
(1) represent a coalition— 
(A) whose principal purpose is to develop 
and implement interventions to reduce or elimi-
nate a health or health care disparity in a tar-
geted racial or ethnic minority group in the 
community served by the coalition; and 
(B) that includes— 
(i) members selected from among— 
(I) public health departments; 
(II) community-based organiza-
tions; 
(III) university and research or-
ganizations; 
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(IV) Indian tribes or tribal orga-
nizations (as such terms are defined 
in section 4 of the Indian Self-Deter-
mination and Education Assistance 
Act (25 U.S.C. 5304)), the Indian 
Health Service, or any other organiza-
tion that serves Alaska Natives; and 
(V) interested public or private 
health care providers or organizations 
as determined appropriate by the Sec-
retary; and 
(ii) at least 1 member from a commu-
nity-based organization that represents the 
targeted racial or ethnic minority group; 
and 
(2) submit to the Secretary an application at 
such time, in such manner, and containing such in-
formation as the Secretary may require, which shall 
include— 
(A) a description of the targeted racial or 
ethnic populations in the community to be 
served under the grant; 
(B) a description of at least 1 health dis-
parity that exists in the racial or ethnic tar-
geted populations, including health issues such 
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as infant mortality, breast and cervical cancer 
screening and management, musculoskeletal 
diseases and obesity, prostate cancer screening 
and management, cardiovascular disease, diabe-
tes, child and adult immunization levels, oral 
disease, or other health priority areas as des-
ignated by the Secretary; and 
(C) a demonstration of a proven record of 
accomplishment of the coalition members in 
serving and working with the targeted commu-
nity. 
(d) SUSTAINABILITY.—The Secretary shall give pri-
ority to an eligible entity under this section if the entity 
agrees that, with respect to the costs to be incurred by 
the entity in carrying out the activities for which the grant 
was awarded, the entity (and each of the participating 
partners in the coalition represented by the entity) will 
maintain its expenditures of non-Federal funds for such 
activities at a level that is not less than the level of such 
expenditures during the fiscal year immediately preceding 
the first fiscal year for which the grant is awarded. 
(e) NONDUPLICATION.—Any funds provided to an eli-
gible entity through a grant under this section shall— 
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264 
(1) supplement, not supplant, any other Federal 
funds made available to the entity for the purposes 
of this section; and 
(2) not be used to duplicate the activities of any 
other health disparity grant program under this Act, 
including an amendment made by this Act. 
(f) TECHNICAL ASSISTANCE.—The Secretary may, 
either directly or by grant or contract, provide any entity 
that receives a grant under this section with technical and 
other nonfinancial assistance necessary to meet the re-
quirements of this section. 
(g) DISSEMINATION.—The Secretary shall encourage 
and enable eligible entities receiving grants under this sec-
tion to share best practices, evaluation results, and reports 
with communities not affiliated with such entities, by 
using the internet, conferences, and other pertinent infor-
mation regarding the projects funded by this section, in-
cluding through using outreach efforts of the Office of Mi-
nority Health and the Centers for Disease Control and 
Prevention. 
(h) ADMINISTRATIVE
BURDENS.—The Secretary 
shall make every effort to minimize duplicative or unneces-
sary administrative burdens on eligible entities receiving 
grants under this section. 
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(i) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary to carry out this section. 
SEC. 415. BORDER HEALTH GRANTS. 
(a) DEFINITIONS.—In this section: 
(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). 
(b) AUTHORIZATION.—From funds appropriated 
under subsection (f), the Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’), 
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acting through the United States members of the United 
States-Mexico Border Health Commission, shall award 
grants to eligible entities to address priorities and rec-
ommendations to improve the health of border area resi-
dents 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. 
(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; and 
(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.)); 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 
other funds available to the eligible entity to carry out the 
activities described in subsection (d). 
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(f) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section 
$200,000,000 for fiscal year 2021 and such sums as may 
be necessary for each succeeding fiscal year. 
SEC. 416. 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. 
(b) PROVISION OF A MORE FLEXIBLE ALTERNATIVE 
TO THE CAH DESIGNATION 25 INPATIENT BED LIMIT 
REQUIREMENT.— 
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(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). 
‘‘(ii) ALTERNATE
REQUIREMENT.— 
The requirement under this clause, with 
respect to a facility and a cost-reporting 
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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. 
SEC. 417. 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 section 
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205(b)(1), is amended by adding at the end of the fol-
lowing new subsection: 
‘‘Rural Community Hospital; Rural Community Hospital 
Services 
‘‘(kkk)(1) The term ‘rural community hospital’ 
means a hospital (as defined in subsection (e)) that— 
‘‘(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: 
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‘‘(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. 
‘‘(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.— 
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of the hospital in the application referred to in section 
1861(kkk)(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 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(j) of such Act (as added by sub-
section (b)(2)) is amended— 
(1) by redesignating paragraphs (1) and (2) as 
subparagraphs (A) and (B), respectively; 
(2) by inserting ‘‘(1)’’ after ‘‘(j)’’; 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: 
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‘‘(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. 
‘‘(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 205(b)(3), is amended— 
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(A) in paragraph (2), in the matter before 
subparagraph (A), by striking ‘‘and (I)’’ and in-
serting ‘‘(I), and (K)’’; 
(B) by striking ‘‘and’’ at the end of para-
graph (8); 
(C) by striking the period at the end of 
paragraph (9) and inserting ‘‘; and’’; and 
(D) by adding at the end the following: 
‘‘(10) in the case of outpatient services fur-
nished by a rural community hospital, the amounts 
described in section 1834(j).’’. 
(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 (kkk)(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(j)(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, 2021. 
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SEC. 
418. 
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 outcomes for Medicare 
beneficiaries; and 
(B) reduce expenditures under such title. 
(2) SITE REQUIREMENTS.— 
(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 
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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.— 
(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— 
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(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 
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-
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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. 
(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. 
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(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. 
SEC. 419. RURAL HEALTH QUALITY ADVISORY COMMISSION 
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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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 paragraph (1)(A). 
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(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, 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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(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 Institute of Medicine of 
the National Academy of Sciences in its re-
port entitled ‘‘Crossing the Quality Chasm: 
A New Health System for the 21st Cen-
tury’’ released on March 1, 2001); 
(B) innovative approaches to the financing 
and delivery of health services to achieve rural 
health quality goals; and 
(C) development of quality improvement 
support structures to assist rural health sys-
tems and professionals (such as workforce sup-
port structures, quality monitoring and report-
ing, clinical care protocols, and information 
technology applications). 
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(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— 
(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 
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(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— 
(A) an evaluation of patient access to care, 
patient outcomes, and an analysis of the cost 
effectiveness of each such project; and 
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(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 2021 
through 2025. 
(2) AVAILABILITY.— 
(A) IN
GENERAL.—Funds appropriated 
under paragraph (1) shall remain available for 
expenditure through fiscal year 2025. 
(B) REPORT.—For purposes of carrying 
out subsection (b)(8), funds appropriated under 
paragraph (1) shall remain available for ex-
penditure through fiscal year 2026. 
(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 
(B) $25,000,000 to carry out subsection 
(b), of which— 
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(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. 420. 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-
parities and to promote and enhance health system 
development; and 
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‘‘(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, 
or a Tribal government whose grant-funded ac-
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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 
the health care needs of rural populations in 
the local community or region to be served; 
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‘‘(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 status improvement for projects fo-
cusing on health promotion; or 
‘‘(ii) benchmarks of increased access 
to primary care, including tracking factors 
such as the number and type of primary 
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; 
‘‘(G) the administrative capacity to submit 
annual performance data electronically as speci-
fied by the Director; and 
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‘‘(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; 
‘‘(iv) coordinate care and manage 
chronic illness; and 
‘‘(v) strengthen the rural health care 
system as a whole in such a manner as to 
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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 
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; 
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‘‘(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— 
‘‘(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— 
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‘‘(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 
‘‘(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; 
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297 
‘‘(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 
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 
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298 
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; 
‘‘(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 
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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. 
‘‘(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 
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300 
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— 
‘‘(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; 
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‘‘(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.— 
‘‘(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 
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302 
similar grant programs, to maximize the effect of 
public dollars in funding meritorious proposals. 
‘‘(g) REPORT.—Not later than September 30, 2022, 
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 
$40,000,000 for fiscal year 2021 and such sums as may 
be necessary for each of fiscal years 2022 through 2025.’’. 
SEC. 421. 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)— 
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(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 
qualified health center services under 
section 1834(o) of the Social Security 
Act.’’. 
SEC. 422. 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-
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304 
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 
Services under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.). 
SEC. 423. 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.— 
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‘‘(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 
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. 
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‘‘(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.’’. 
SEC. 424. 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-
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307 
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.) until the American Health 
Benefit Exchanges in the States are fully oper-
ational; 
(2) it is imperative that the maintenance of ef-
fort provisions are enforced to the strict standard in-
tended by the Congress through September 30, 
2027; 
(3) waiving the maintenance of effort provisions 
should not be permitted; 
(4) 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 
adults, children, and senior citizens, many of whom 
are also members of communities of color; and 
(5) the maintenance of effort provisions must 
be strictly enforced and proposals to weaken the 
maintenance of effort provisions must not be consid-
ered. 
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308 
SEC. 425. PROTECTION OF THE HHS OFFICES OF MINORITY 
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 any effort to eliminate or consolidate such 
Offices of Minority Health undermines the progress 
achieved so far. 
SEC. 426. 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 adding at the end the following new section: 
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‘‘§ 7310. 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, and health care research con-
cerning veterans who are members of a racial or eth-
nic minority group. 
‘‘(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. 
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‘‘(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-
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-
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311 
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 other Pacific 
Islanders. 
‘‘(D) Blacks. 
‘‘(E) Hispanics. 
‘‘(2) The term ‘Hispanic’ means individuals 
whose origin is Mexican, Puerto Rican, Cuban, Cen-
tral or South American, or any other Spanish-speak-
ing country.’’. 
(b) CLERICAL AMENDMENT.—The table of sections 
at the beginning of such chapter is amended by inserting 
after the item relating to section 7309A the following new 
item: 
‘‘7310. Office of Minority Health.’’. 
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SEC. 427. 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 
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 
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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 serv-
ices for individuals in medically underserved 
areas; and 
(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, as well as 
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the location of such hospitals in relation to 
medically underserved 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; 
(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 
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315 
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 
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 
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316 
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. 428. 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), 1 of whom shall be 
the Assistant Secretary of the Indian Health Service’’. 
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317 
(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. 429. 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 
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’’. 
SEC. 430. 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. 
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318 
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 
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. 431. 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, 2020, 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 
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319 
percent of all other such essential community 
providers in the contract service area are in-net-
work; and 
‘‘(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 2020) 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 
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320 
with each qualified health plan offered in that 
county. Such data shall be made available to 
the general public.’’. 
(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); 
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321 
(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: 
‘‘(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. 432. 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 428(a), is further 
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; 
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‘‘(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 
come to provider appointments during 
standard business hours; and 
‘‘(IV) 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-
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323 
ment of the Health Equity and Accountability Act of 
2020.’’. 
SEC. 433. 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; and 
(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— 
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324 
(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; and 
(C) the reports shall also explain how tele-
health service is used to enhance services pro-
vided by dental hygienists and therapists and 
shall recommend any modifications in Medicare 
and Medicaid to better provide for telehealth 
consultations 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. 
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325 
(b) EXPANSION OF DENTAL HEALTH AID THERA-
PISTS IN TRIBAL COMMUNITIES.—Section 119(d) of the 
Indian Health Care Improvement Act (25 U.S.C. 
1616l(d)) is amended— 
(1) in paragraph (2), by striking ‘‘Subject to’’ 
and all that follows and inserting ‘‘Subject to para-
graph (3), in establishing a national program under 
paragraph (1), the Secretary shall not reduce the 
amounts provided for the Community Health Aide 
Program described in subsections (a) and (b).’’; 
(2) by striking paragraph (3); and 
(3) by redesignating paragraph (4) as para-
graph (3). 
(c) COVERAGE OF DENTAL SERVICES UNDER THE 
MEDICARE PROGRAM.— 
(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 adding 
‘‘and’’ after the semicolon at the end; and 
(C) by adding at the end the following new 
subparagraph: 
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326 
‘‘(II) oral health services (as defined in sub-
section (kkk));’’. 
(2) ORAL HEALTH SERVICES DEFINED.—Sec-
tion 1861 of the Social Security Act (42 U.S.C. 
1395x), as amended by sections 205(b) and 413(a), 
is amended by adding at the end the following new 
subsection: 
‘‘Oral Health Services 
‘‘(kkk)(1) The term ‘oral health services’ means serv-
ices (as defined by the Secretary) that are necessary to 
prevent disease and promote oral health, restore oral 
structures to health and function, and treat emergency 
conditions. 
‘‘(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— 
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(A) by striking ‘‘and’’ before ‘‘(CC)’’; and 
(B) by inserting before the semicolon at 
the end the following: ‘‘, and (DD) with respect 
to oral health services (as defined in section 
1861(kkk)), the amount paid shall be (i) in the 
case of such services that are preventive, 100 
percent of the lesser of the actual charge for 
the services or the amount determined under 
the payment basis determined under section 
1848, and (ii) in the case of all other such serv-
ices, 80 percent of the lesser of the actual 
charge for the services or the amount deter-
mined 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 ‘‘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’’. 
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328 
(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). 
(7) EFFECTIVE DATE.—The amendments made 
by this section shall apply to services furnished on 
or after January 1, 2021. 
(d) COVERAGE OF DENTAL SERVICES UNDER THE 
MEDICAID PROGRAM.— 
(1) IN GENERAL.—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 ‘‘oral health services 
(as defined in subsection (ff)(1))’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(ff)(1) Subject to paragraphs (2) and (3), for pur-
poses of this title, the term ‘oral health services’ means 
services (as defined by the Secretary) that are necessary 
to prevent disease and promote oral health, restore oral 
structures to health and function, and treat emergency 
conditions. These services shall include, in the case of 
pregnant or postpartum women, such services as are nec-
essary to address oral health conditions that exist or are 
exacerbated by pregnancy or childbirth or which, if left 
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untreated, could adversely affect fetal or child develop-
ment. 
‘‘(2) For purposes of paragraph (1), such term shall 
include— 
‘‘(A) dentures; and 
‘‘(B) mobile and portable oral health services 
(as defined by the Secretary) that— 
‘‘(i) are provided for the purpose of over-
coming mobility, transportation, and access bar-
riers for individuals; and 
‘‘(ii) satisfy the standards and certification 
requirements 
established 
under 
section 
1902(a)(84)(C) for the State in which the serv-
ices are provided. 
‘‘(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).’’. 
(2) 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),’’; 
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(ii) in paragraph (82), by striking 
‘‘and’’ at the end; 
(iii) in paragraph (83), by striking the 
period at the end and inserting ‘‘; and’’; 
and 
(iv) by inserting after paragraph (83) 
the following: 
‘‘(84) provide for— 
‘‘(A) informing, in writing, all individuals 
who have been determined to be eligible for 
medical assistance of the availability of oral 
health services (as defined in section 1905(ff)); 
‘‘(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 (ff)(2)(B) of section 1905).’’. 
(B) DEFINITION
OF
MEDICAL
ASSIST-
ANCE.—Section 1905(a)(12) of the Social Secu-
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rity Act (42 U.S.C. 1396d(a)(12)) is amended 
by striking ‘‘, dentures,’’. 
(3) 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 
(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)(82)(C) for the State in which 
the services are provided.’’. 
(e) ORAL HEALTH SERVICES
AS
AN ESSENTIAL 
HEALTH BENEFIT.—Section 1302(b) of the Patient Pro-
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332 
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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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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334 
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 the National Guard and 
Reserves in active status who are potentially 
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. 
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335 
(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. 
(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. 
(2) TELEHEALTH.—For purposes of alternative 
dental health care providers and other dental care 
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336 
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 
out a demonstration program to establish programs 
to train and employ alternative dental health care 
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337 
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. 
SEC. 434. PROVIDING FOR A SPECIAL ENROLLMENT PE-
RIOD FOR PREGNANT INDIVIDUALS. 
(a) 
PUBLIC
HEALTH
SERVICE
ACT.—Section 
2702(b)(2) of the Public Health Service Act (42 U.S.C. 
300gg–1(b)(2)) is amended by inserting ‘‘including a spe-
cial enrollment period for pregnant individuals, beginning 
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State’s appropriations as of that 
date.’’. 
Subtitle C—Advancing Health Eq-
uity Through Payment and De-
livery Reform 
SEC. 441. 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 
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 disparities and achieving 
health equity must be central to efforts to achieve a 
high-value health care system; 
(5) eliminating such disparities and achieving 
such equity will require tailored interventions and 
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