I 118th CONGRESS 1st Session H. R. 5387 IN THE HOUSE OF REPRESENTATIVES September 12, 2023 Mrs. Chavez-DeRemer (for herself and Ms. Lee of Pennsylvania ) introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committees on Education and the Workforce , and Financial Services , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To improve the provision of health care to unsheltered homeless individuals, and for other purposes.

1. Short title This Act may be cited as the DIRECT Care for the Homeless Act of 2023 or the Delivering Integral, Rehabilitating, Empathetic, Comprehensive and Targeted Care for the Homeless Act of 2023. 2. Definitions (1) The terms eligible city or county and eligible cities and counties refer to cities and counties, as applicable, in the United States that, according to the Department of Housing and Urban Development, have a homeless population of 150 or more per 100,000 residents. (2) The terms homeless and homeless individual have the meanings given to such terms in section 103 of the McKinney-Vento Homeless Assistance Act ( 42 U.S.C. 11302 ). (3) The term street medicine refers to health professionals providing preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals where said individuals live in a non-permanent location on the street or found environment. (4) The term unsheltered means not residing in a permanent residence or shelter. 3. GAO report Not later than the end of fiscal year 2027, the Comptroller General of the United States shall submit to the Congress an interim report assessing the results achieved through this Act and the amendments made by this Act, including— (1) the number of patients who moved into temporary or permanent housing; (2) the number of patients who have established within their respective Continuum of Care awaiting housing placement; (3) patients diagnosed with a substance use disorder and number who received treatment; (4) the number of health care professionals providing care to unsheltered homeless individuals; (5) how efficient and sufficient reimbursements were for provided care, including any difficulties health care professionals experienced in being reimbursed; (6) the number of unique people receiving street medicine services; (7) the number of total patient visits provided by street medicine teams; (8) a report from street medicine providers detailing barriers to accessing non-street medicine primary care healthcare services such as specialty care, medications, and diagnostic studies; and (9) an analysis of participating street medicine providers’ ability to sustain a sufficient amount of street medicine providers to provide adequate care to its unsheltered homeless population, No later than 120 days after enactment of this Act, the Secretary of the Department of Health and Human Services shall promulgate rules for data collection necessary to complete this report, without creating barriers which negatively impact the effective provision of health care. To ensure this, the Secretary shall also create and maintain an online platform through which health care professional participating in the Program may provide feedback on the Program as a whole, and such platform must be open for submissions 24/7. The online platform must be compliant with the Health Insurance Portability and Accountability Act of 1996. 4. Sunset The provisions of this Act and the amendments made by this Act shall cease to be effective at the end of fiscal year 2028. I Street Medicine 101. Street medicine pilot program (a) In general Beginning on the first day of the first fiscal year following the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this section as the Secretary ) shall conduct a pilot program (referred to in this section as the Program ) to provide payments to providers in eligible cities and counties for furnishing medical services to covered individuals. (b) Program requirements (1) Application A street medicine provider seeking participation in the Program shall submit an application to the Secretary, at such time, in such manner, and containing such information, as the Secretary may require. (2) Provider requirements (A) In general In order to participate in the Program, a provider must— (i) be an eligible provider (as defined in subsection (e)(3)); (ii) be enrolled— (I) under section 1886(j) of the Social Security Act ( 42 U.S.C. 1395cc(j) ); or (II) as a participating provider under a State plan (or waiver of such plan) under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ); (iii) be affiliated with a hospital, university, non-profit organization, city government, county government, state government, or private health care practice; (iv) use a qualified electronic health record to document interactions with, and medical services furnished to, covered individuals under the Program; (v) maintain medical malpractice insurance in the State in which such provider is furnishing medical services under the Program; and (vi) in the case of a provider prescribing opioid medication, meet the requirement described in subparagraph (B). (B) Requirement for prescribing opioid medication In the case of a provider prescribing an opioid medication to a covered individual under the Program, such provider shall meet the standards of their respective State. (C) During each visit with a patient, there shall be a prescriber, as defined in (e)(3), present either in person, via telemedicine, or phone call. (3) Documentation requirements (A) In general A provider furnishing medical services under the Program shall document in a qualified electronic health record each interaction with a covered individual, such documentation shall include— (i) the name and date of birth of such individual; (ii) whether the covered individual has, or has history of, a substance use disorder; (iii) the length of time such individual has been homeless, and factors contributing to such individual’s lack of permanent housing; (iv) whether an individual is under the care of a medical provider other than a street medicine team or provider; (v) the contact information, and billing information for such provider; (vi) the credentials of such provider; and (vii) any other information as determined by the Secretary. (B) Rules of construction regarding documentation (i) Nothing in this section shall be construed as requiring a covered individual to provide a permanent address in order to receive medical services under the Program. (ii) Nothing in this section shall be construed as requiring a provider to document, with respect to a covered individual— (I) the permanent address of such individual; (II) the address of the facility where medical services were furnished to such individual; or (III) the name of contact information of a provider referring such individual to the program. (c) Payment (1) In general To receive payment for a medical service furnished to a covered individual under the Program, a provider shall submit to the Secretary, at such time and in such manner as determined by the Secretary, a claim for such service. (A) No later than 120 days after enactment of this Act, the Secretary shall promulgate rules to establish and maintain a clear process for reimbursements through the Program. (B) No later than 120 days after enactment of this Act, the Secretary shall create and maintain an online platform through which health care professional participating in the Program may provide feedback on the reimbursement process, and such platform must be open for submissions 24/7. The online platform must be compliant with the Health Insurance Portability and Accountability Act of 1996. This platform may be the same as referred to in section 3 of this Act. (2) Payment amount The Secretary shall establish payment amounts for medical services furnished to covered individuals under the Program. Such payment amounts shall be based upon payment amounts established with respect to medical assistance furnished under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ). (3) Prohibition against supervised consumption No payment may be made under this Program with respect to medical services providing supervised drug consumption, as defined in (e)(9). This provision shall not be construed to prohibit States, counties, and cities which operate their own supervised consumption programs from accessing the Program. (d) Direct access (1) Unsheltered homeless individuals may obtain services from any qualified street medicine provider, as defined in this Act, for purposes of the Program. (2) Individuals enrolled in a primary care case management system or Medicaid managed care organization (MCO) shall not be denied freedom of choice of qualified street medicine providers. (3) Prior authorization shall not be required for purposes of an individual receiving care from a street medicine provider. (4) If a patient is a Medicaid or Medicare beneficiary, street medicine providers shall have the authority to refer patients to medically necessary covered services within the proper Making Care Primary (MCP) network, to ensure beneficiaries have access to all medically necessary covered service. (A) The Secretary of the Department of Health and Human Services or Director of the Centers for Medicaid and Medicare Services shall develop rules to ensure street medicine providers have the appropriate referral and authorization mechanisms in place to facilitate access to needed services in the network without requiring authorization by an assigned primary care; and (B) rules to guarantee a clear and accessible process for making such referrals. (5) The Secretary of Health and Human Services or Director of the Centers for Medicaid and Medicare Services shall develop rules to ensure providers operating within the Program shall have appropriate referral and authorization mechanisms for patients who are not insured, or are not Medicaid or Medicare beneficiaries. (6) Delivery network If a patient is a Medicaid or Medicare beneficiary, MCPs must ensure that, they meet the following requirements: (A) Maintains and monitors a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services covered by the Program or patients’ other health care benefits, such as Medicaid or Medicare, ensuring access to patients with limited English proficiency or physical or mental disabilities; (B) provides female patients with direct access to women’s routine and preventive health care services; (C) arranges for patients to receive a second opinion, should the patient elect, at no cost to the patient; and (D) if its network of street medicine providers are unable to provide necessary services, that the MCP is able to adequately and timely cover those services, without cost to the patient exceeding standards costs within the Program or the providers’ network. (e) Funding The Secretary has the authority to allocate existing funds for the Program. (f) Definitions In this Act: (1) Covered individual The term covered individual means an unsheltered homeless individual over the age of zero who resides in an eligible city or county. (2) Eligible city or county; eligible cities and counties The terms eligible city or county and eligible cities and counties refer to cities and counties, as applicable, in the United States that, according to the Department of Housing and Urban Development, have a homeless population of 150 or more per 100,000. (3) Prescriber The term prescriber means a person permitted under State law, or agent of such person, to issue prescriptions for drugs in compliance with applicable requirements established by the Food and Drug Administration. (4) Eligible provider The term eligible provider includes— (A) a physician (as defined in section 1861(r) of the Social Security Act ( 42 U.S.C. 1395(aa)(5)(A) ); (B) a physician assistant or nurse practitioner (as such terms are defined in section 1861(aa)(5)(A) of the Social Security Act ( 42 U.S.C. 1395(aa)(5)(A) ); (C) a behavioral health therapist; (D) a supplier (as defined in section 1861(d) of the Social Security Act ( 42 U.S.C. 1395(d) ); (E) a psychologist (as defined in section 799B(11) of the Public Health Service Act ( 42 U.S.C. 295p(11) ); (F) a physical therapist; (G) occupational therapist; (H) an emergency medical technician responding to a call or case in which health care is administered to an unhoused homeless individual; or (I) any provider as determined by the Secretary. (5) Homeless; homeless individual The term homeless and homeless individual have the meaning given such terms in section 103 of the McKinney-Vento Homeless Assistance Act ( 42 U.S.C. 300jj(13) ). (6) Medical services The term medical services mean the medical care and services described in section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ). (7) Qualified electronic health record The term qualified electronic health record has the meaning given such term in section 3000(13) of the Public Health Service Act ( 42 U.S.C. 300jj(13) ). (8) Street medicine The term street medicine means the direct provision of medical services to unsheltered homeless individuals where such individuals live in a non-permanent location on the street or found environment. (9) Supervised consumption The consumption of schedule I drugs, fentanyl, cocaine, and methamphetamine under the supervision of health care professionals. II Federal Loan Repayment Programs 201. Public health loan repayment programs (a) In general In carrying out programs under the Public Health Service Act ( 42 U.S.C. 201 et seq. ) for loan repayments for health care professionals, the Secretary of Health and Human Services shall include awards to applicants seeking to practice street medicine in eligible cities and counties. (b) National Health Service Corps In assigning members of the National Health Service Corps to health professional shortage areas pursuant to section 333 of the Public Health Service Act ( 42 U.S.C. 254f ) to fulfill a period of obligated service under the National Health Service Corps Loan Repayment Program, the Secretary of Health and Human Services shall assign an appropriate number of Corps members to practice street medicine in eligible cities and counties. (c) Treatment of mobile clinics as HPSAS The Secretary of Health and Human Services shall treat mobile clinics providing street medicine in an eligible city or county as a health professional shortage area eligible for designation under section 332 of the Public Health Service Act ( 42 U.S.C. 254e ). 202. Community service officers (a) In general Public Service Loan Forgiveness (PSLF) Program eligibility shall include individuals who spend at least one year as a community service officer (CSO), including those working less than 30 hours per week, employed by a local law enforcement agency. (b) Section 455(m) of the Higher Education Act of 1965 ( 20 U.S.C. 1087e(m) ) is amended— (1) by striking the period at the end of (3)(B)(ii) and inserting ; or ; (2) by adding at the end of (3)(B) the following: (iii) serving, for a calendar year, full-time or part-time as a community service officer ; and (3) by inserting after subparagraph (B) the following: (C) Community service officers are professionals or paraprofessional law enforcement who do not respond to emergencies, do not carry firearms, and do not have power of arrest; this includes those persons training to be full-time law enforcement. . (c) The Department of Education The Secretary of Education must treat local law enforcement agencies, including those of tribal governments, as qualifying employers as defined in 34 CFR 685.219. (1) No later than 120 days after enactment of this Act, the Secretary of Education must promulgate rules to provide a clear and accessible process for community service officers to apply for loan forgiveness. These rules must ensure that community service officers employed by local law enforcement agencies receive Public Service Loan Forgiveness benefits no later than one year after applying for and being determined eligible for this program. (2) No later than 120 days after enactment of this Act, the Secretary of Education must create and maintain a clear and accessible appeals process for all borrowers who are denied participation in the PSLF Program. The appeals process must meet, but is not limited to, the following requirements: (A) petition for appeal must be submitted through an online program which is clearly displayed on the department website and is accessible to non-English speakers; (B) the Department must provide notice of the appeals process when a borrower initially applies for the PSLF Program; (C) the Department must provide for accessible communication with borowers; (D) the Department must provide the borrower detailed information about which loans did not qualify, which payments did not qualify, and what information is necessary for a successful appeal; (E) borrowers who were denied loan forgiveness prior to enactment of this Act have 180 days to request reconsideration; and (F) for any months in which a borrower postponed monthly payments under a deferment or forbearance and was employed full-time or part-time at a qualifying employer as defined in 34 CFR 685.219 but was in a deferment or forbearance status, the borrower may obtain credit towards forgiveness for those months. III Loan and Interest Pause 301. Student loan and interest pause (a) Section 455(f) of the Higher Education Act of 1965 ( 20 U.S.C. 1087e(f) ) is amended— (1) in paragraph (1), in the matter preceding subparagraph (A), by striking A borrower and inserting Except as provided in paragraph (6), a borrower ; (2) in paragraph (2)(A)— (A) in clause (i), by striking or after the semicolon; (B) by striking the matter following clause (ii); (C) in clause (ii), by striking the comma at the end and inserting ; or ; and (D) by adding at the end the following: (iii) is serving in a medical or residency program which, in part, focuses on the provision of street medicine; ; and (3) by adding at the end the following: (6) Special rule for certain in school deferment Notwithstanding any other provision of this Act, a borrower described in paragraph (2)(A)(ii) shall be eligible for a deferment, during which periodic installments of principal need not be paid and interest shall not accrue on any loan made to the borrower under this part. . IV Improved Standards for Shelters 401. Safe shelters Whereas homeless shelters should always be safe for residents; Whereas a significant number of homeless women report feeling safer spending the night in a car as opposed to a shelter; Whereas approximately thirty-two percent of homeless women report being sexually or physically assaulted each year; Whereas homeless individuals accrue citations for sleeping in their car or parking their car in a certain spot for too long, resulting in criminal records which might prevent an employer from providing them employment; Whereas a significant number of homeless women are unable to afford menstrual products; and Whereas transgender men frequently experience discrimination by being denied necessary menstrual products. 402. Improved standards (a) Section 415 of the McKinney-Vento Homeless Assistance Act ( 42 U.S.C. 1137 ) is amended by adding at the end the following: (c) Emergency shelter requirements No amount provided under this subtitle may be allocated to an emergency shelter unless such emergency shelter— (1) provides menstrual products for each menstruating resident; and (2) maintains a security camera system with no less than two functional security cameras and consideration for residents’ personal privacy. . (b) There shall be no restrictions on the kind of security cameras a shelter may install and maintain to be in compliance with this Act.