Health Centers Consolidation Act of 1996
PL 104-299 (S.1044), enacted 10/11/1996

110 STAT. 3626 
PUBLIC LAW 104-299—OCT. 11, 1996 
Public Law 104-299 
104th Congress 
An Act 
Oct. 11, 1996 
To amend title III of the Public Health Service Act to consolidate and reauthorize 
[S. 1044] 
provisions relating to health centers, and for other purposes. 
Be it enacted by the Senate and House of Representatives 
of 
Health Centers 
the United States of America in Congress assembled, 
Consolidation Act 
of 1996. 
SECTION 1. SHORT TITLE. 
This Act may be cited as the "Health Centers ConsoUdation 
Act of 1996". 
SEC. 2. CONSOLIDATION AND REAUTHORIZATION OF PROVISIONS. 
Subpart I of part D of title III of the Public Health Service 
Act (42 U.S.C. 254b et seq.) is amended to read as follows: 
"Subpart I—Health Centers 
42 u s e 254b. 
"SEC. 330. HEALTH CENTERS. 
"(a) DEFINITION OF HEALTH CENTER.— 
"(1) IN GENERAL.—For purposes of this section, the term 
'health center' means an entity that serves a population that 
is medically underserved, or a special medically underserved 
population comprised of migratory and seasonal agricultural 
workers, the homeless, and residents of public housing, by 
providing, either through the staff and supporting resources 
of the center or through contracts or cooperative arrange-
ments— 
"(A) required primary health services (as defined in 
subsection (b)(1)); and 
"(B) as may be appropriate for particular centers, addi-
tional health services (as defined in subsection (b)(2)) nec-
essary for the adequate support of the primary health 
services required under subparagraph (A); 
for all residents of the area served by the center (hereafter 
referred to in this section as the 'catchment area'). 
"(2) LIMITATION.—The requirement in paragraph (1) to pro-
vide services for all residents within a catchment area shall 
not apply in the case of a health center receiving a grant 
only under subsection (g), (h), or (i). 
"(b) DEFINITIONS.—For purposes of this section: 
"(1) REQUIRED PRIMARY HEALTH SERVICES.— 
"(A) IN GENERAL.—The term 'required primary health 
services' means— 
"(i) basic health services which, for purposes of 
this section, shall consist o
f
— 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3627 
"(I) health services related to family medicine, 
internal medicine, pediatrics, obstetrics, or gyne-
cology that are furnished by physicians and where 
appropriate, physician assistants, nurse practition-
ers, and nurse mid 
wives; 
"(11) diagnostic laboratory and radiologic serv-
ices; 
"(III) preventive health services, including— 
"(aa) prenatal and perinatal services; 
"(bb) screening for breast and cervical can-
cer; 
"(cc) well-child services; 
"(dd) 
immunizations 
against 
vaccine-
preventable diseases; 
"(ee) screenings for elevated blood lead 
levels, communicable diseases, and cholesterol; 
"(ff) 
pediatric 
eye, 
ear, 
and 
dental 
screenings to determine the need for vision 
and hearing correction and dental care; 
"(gg) voluntary family planning services; 
and 
"(hh) preventive dental services; 
"(IV) emergency medical services; and 
"(V) pharmaceutical services as may be appro-
priate for particular centers; 
"(ii) referrals to providers of medical services and 
other health-related 
services (including 
substance 
abuse and mental health services); 
"(iii) patient case management services (including 
counseling, referral, and follow-up services) and other 
services designed to assist health center patients in 
establishing eligibility for and gaining access to Fed-
eral, State, and local programs that provide or finan-
cially support the provision of medical, social, edu-
cational, or other related services; 
"(iv) services that enable individuals to use the 
services of the health center (including outreach and 
transportation services and, if a substantial number 
of the individuals in the population served by a center 
are of limited English-speaking ability, the services 
of appropriate personnel fluent in the language spoken 
by a predominant number of such individuals); and 
"(v) education of patients and the general popu-
lation served by the health center regarding the avail-
ability and proper use of health services. 
"(B) EXCEPTION.—^With respect to a health center that 
receives a grant only under subsection (g), the Secretary, 
upon a showing of good cause, shall— 
"(i) waive the requirement that the center provide 
all required primary health services under this para-
graph; and 
"(ii) approve, as appropriate, the provision of cer-
tain required primary health services only during cer-
tain periods of the year. 
"(2) ADDITIONAL HEALTH SERVICES.—The term 'additional 
health services' means services that are not included as 
required primary health services and that are appropriate to 
110 STAT. 3628 
PUBLIC LAW 104-299—OCT. 11, 1996 
meet the health needs of the population served by the health 
center involved. Such term may include— 
"(A) environmental health services, including— 
"(i) the detection and alleviation of unhealthful 
conditions associated with water supply; 
"(ii) sewage treatment; 
"(iii) solid waste disposal; 
"(iv) rodent and parasitic infestation; 
"(v) field sanitation; 
"(vi) housing; and 
"(vii) other environmental factors related to health; 
and 
"(B) in the case of health centers receiving grants 
under subsection (g), special occupation-related health serv-
ices for migratory and seasonal agricultural workers, 
including— 
"(i) screening for and control of infectious diseases, 
including parasitic diseases; and 
"(ii) injury prevention programs, including preven-
tion of exposure to unsafe levels of agricultural chemi-
cals including pesticides. 
"(3) MEDICALLY UNDERSERVED POPULATIONS.— 
"(A) IN GENERAL.—The term 'medically underserved 
population' means the population of an urban or rural 
area designated by the Secretary as an area with a shortage 
of personal health services or a population group designated 
by the Secretary as having a shortage of such services. 
"(B) CRITERIA.—In carrying out subparagraph (A), the 
Secretary shall prescribe criteria for determining the spe-
cific shortages of personal health services of an area or 
population group. Such criteria shall— 
"(i) take into account comments received by the 
Secretary from the chief executive officer of a State 
and local officials in a State; and 
"(ii) include factors indicative of the health status 
of a population group or residents of an area, the 
ability of the residents of an area or of a population 
group to pay for health services and their accessibility 
to them, and the availability of health professionals 
to residents of an area or to a population group. 
"(C) LIMITATION.—The Secretary may not designate 
a medically underserved population in a State or terminate 
the designation of such a population unless, prior to such 
designation or termination, the Secretary provides reason-
able notice and opportunity for comment and consults 
with— 
"(i) the chief executive officer of such State; 
"(ii) local officials in such State; and 
"(iii) the organization, if any, which represents 
a majority of health centers in such State. 
"(D) 
PERMISSIBLE DESIGNATION.—The Secretary 
may 
designate a medically underserved population that does 
not meet the criteria established under subparagraph (B) 
if the chief executive officer of the State in which such 
population is located and local officials of such State rec-
ommend the designation of such population based on 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3629 
unusual local conditions which are a barrier to access to 
or the availability of personal health services. 
"(c) PLANNING GRANTS.— 
"(1) IN GENERAL.— 
"(A) CENTERS.—The Secretary may make grants to 
public and nonprofit private entities for projects to plan 
and develop health centers which will serve medically 
underserved populations. A project for which a grant may 
be made under this subsection may include the cost of 
the acquisition and lease of buildings and equipment 
(including the costs of amortizing the principal of, and 
paying the interest on, loans) and shall include— 
"(i) an assessment of the need that the population 
proposed to be served by the health center for which 
the project is undertaken has for required primary 
health services gind additional health services; 
"(ii) the design of a health center program for 
such population based on such assessment; 
"(iii) efforts 
to secure, within 
the 
proposed 
catchment area of such center, financial and profes-
sional assistance and support for the project; 
"(iv) initiation and encouragement of continuing 
community involvement in the development and oper-
ation of the project; and 
"(v) proposed linkages between the center and 
other appropriate provider entities, such as health 
departments, local hospitals, and rural health clinics, 
to provide better coordinated, higher quality, and more 
cost-effective health care services. 
"(B) COMPREHENSIVE SERVICE DELIVERY NETWORKS AND 
PLANS.—The Secretary may make grants to health centers 
that receive assistance under this section to enable the 
centers to plan and develop a network or plan for the 
provision of health services, which may include the provi-
sion of health services on a prepaid basis or through 
another managed care arrangement, to some or to all of 
the individuals which the centers serve. Such a grant may 
only be made for such a center if— 
"(i) the center has received grants under subsection 
(e)(1)(A) for at least 2 consecutive years preceding the 
year of the grant under this subparagraph or has other-
wise demonstrated, as required by the Secretary, that 
such center has been providing primary care services 
for at least the 2 consecutive years immediately preced-
ing such year; and 
"(ii) the center provides assurances satisfactory to 
the Secretary that the provision of such services on 
a prepaid basis, or under another managed care 
arrangement, will not result in the diminution of the 
level or quality of health services provided to the medi-
cally underserved population served prior to the grant 
under this subparagraph. 
Any such grant may include the acquisition and lease 
of buildings and equipment which may include data and 
information systems (including the costs of amortizing the 
principal of, and pa3dng the interest on, loans), and provid-
ing training and technical assistance related to the provi-
110 STAT. 3630 
PUBLIC LAW 104-299—OCT. 11, 1996 
sion of health services on a prepaid basis or under another 
managed care arrangement, and for other purposes that 
promote the development of managed care networks and 
plans. 
"(2) LIMITATION.—Not more than two grants may be made 
under this subsection for the same project, except that upon 
a showing of good cause, the Secretary may make additional 
grant awards. 
"(d) MANAGED CARE LOAN GUARANTEE PROGRAM.— 
"(1) ESTABLISHMENT.— 
"(A) IN GENERAL.—The Secretary shall establish a pro-
gram under which the Secretary may, in accordance with 
this subsection and to the extent that appropriations are 
provided in advance for such program, guarantee the prin-
cipal and interest on loans made by non-Federal lenders 
to health centers funded under this section for the costs 
of developing and operating managed care networks or 
plans. 
"(B) USE OF FUNDS.—Loan funds guaranteed under 
this subsection may be used— 
"(i) to establish reserves for the furnishing of serv-
ices on a pre-paid basis; or 
"(ii) for costs incurred by the center or centers, 
otherwise permitted under this section, as the Sec-
retary determines are necessary to enable a center 
or centers to develop, operate, and own the network 
or plan. 
"(C) PUBLICATION OF GUIDANCE.—Prior to considering 
an application submitted under this subsection, the Sec-
retary shall publish guidelines to provide guidance on the 
implementation of this section. The Secretary shall make 
such guidelines available to the universe of parties affected 
under this subsection, distribute such guidelines to such 
parties upon the request of such parties, and provide a 
copy of such guidelines to the appropriate committees of 
Congress. 
"(2) PROTECTION OF FINANCIAL INTERESTS.— 
"(A) IN GENERAL.—The Secretary may not approve a 
loan guarantee for a project under this subsection unless 
the Secretary determines that— 
"(i) the terms, conditions, security (if any), and 
schedule and amount of repayments with respect to 
the loan are sufficient to protect the financial interests 
of the United States and are otherwise reasonable, 
including a determination that the rate of interest 
does not exceed such percent per annum on the prin-
cipal obligation outstanding as the Secretary deter-
mines to be reasonable, taking into account the range 
of interest rates prevailing in the private market for 
similar loans and the risks assumed by the United 
States, except that the Secretary may not require as 
security any center asset that is, or may be, needed 
by the center or centers involved to provide health 
services; 
"(ii) the loan would not be available on reasonable 
terms and conditions without the guarantee under this 
subsection; and 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3631 
"(iii) amounts appropriated for the program under 
this subsection are sufficient to provide loan guaran-
tees under this subsection. 
"(B) RECOVERY OF PAYMENTS.— 
"(i) IN GENERAL.—The United States shall be enti-
tled to recover from the applicant for a loan guarantee 
under this subsection the amount of any payment made 
pursuant to such guarantee, unless the Secretary for 
good cause waives such right of recovery (subject to 
appropriations remaining available to permit such a 
waiver) and, upon making any such payment, the 
United States shall be subrogated to all of the rights 
of the recipient of the payments with respect to which 
the guarantee was made. Amounts recovered under 
this clause shall be credited as reimbursements to 
the financing account of the program. 
"(ii) MODIFICATION OF TERMS AND CONDITIONS.— 
To the extent permitted by clause (iii) and subject 
to the requirements of section 504(e) of the Credit 
Reform Act of 1990 (2 U.S.C. 661c(e)), any terms and 
conditions applicable to a loan guarantee under this 
subsection (including terms and conditions imposed 
under clause (iv)) may be modified or waived by the 
Secretary to the extent the Secretary determines it 
to be consistent with the financial interest of the 
United States. 
"(iii) 
INCONTESTABILITY.—Any 
loan 
guarantee 
made by the Secretary under this subsection shall 
be incontestable— 
"(I) in the hands of an applicant on whose 
behalf such guarantee is made unless the applicant 
engaged in fraud or misrepresentation in securing 
such guarantee; and 
"(II) as to any person (or successor in interest) 
who makes or contracts to make a loan to such 
applicant in reliance thereon unless such person 
(or successor in interest) engaged in fraud or mis-
representation in making or contracting to make 
such loan. 
"(iv) FURTHER TERMS AND CONDITIONS.—Guaran-
tees of loans under this subsection shall be subject 
to such further terms and conditions as the Secretary 
determines to be necessary to assure that the purposes 
of this section will be achieved. 
"(3) LOAN ORIGINATION FEES.— 
"(A) IN GENERAL.—The Secretary shall collect a loan 
origination fee with respect to loans to be guaranteed under 
this subsection, except as provided in subparagraph (C). 
"(B) AMOUNT.—The amount of a loan origination fee 
collected by the Secretary under subparagraph (A) shall 
be equal to the estimated long term cost of the loan guaran-
tees involved to the Federal Government 
(excluding 
administrative costs), calculated on a net present value 
basis, after taking into account any appropriations that 
may be made for the purpose of offsetting such costs, 
and in accordance with the criteria used to award loan 
guarantees under this subsection. 
110 STAT. 3632 
PUBLIC LAW 104-299—OCT. 11, 1996 
"(C) WAIVER.—The Secretary may waive the loan origi-
nation fee for a health center applicant who demonstrates 
to the Secretary that the applicant will be unable to meet 
the conditions of the loan if the applicant incurs the addi-
tional cost of the fee. 
"(4) DEFAULTS.— 
"(A) IN GENERAL.—Subject to the requirements of the 
Credit Reform Act of 1990 (2 U.S.C. 661 et seq.), the 
Secretary may take such action as may be necessary to 
prevent a default on a loan guaranteed under this sub-
section, including the waiver of regulatory conditions, defer-
ral of loan payments, renegotiation of loans, and the 
expenditure of ftinds for technical and consultative assist-
ance, for the temporary pa3anent of the interest Eind prin-
cipal on such a loan, and for other purposes. Any such 
expenditure made under the preceding sentence on behalf 
of a health center or centers shall be made under such 
terms and conditions as the Secretary shall prescribe, 
including the implementation of such organizational, oper-
ational, and financial reforms as the Secretary determines 
are appropriate and the disclosure of such financial or 
other information as the Secretary may require to deter-
mine the extent of the implementation of such reforms. 
"(B) FORECLOSURE.—The Secretary may take such 
action, consistent with State law respecting foreclosure 
procedures and, with respect to reserves required for fur-
nishing services on a prepaid basis, subject to the consent 
of the affected States, as the Secretary determines appro-
priate to protect the interest of the United States in the 
event of a default on a loan guaranteed under this sub-
section, except that the Secretary may only foreclose on 
assets offered as security (if any) in accordance with para-
graph (2)(A)(i). 
"(5) LIMITATION.—Not more than one loan guarantee may 
be made under this subsection for the same network or plan, 
except that upon a showing of good cause the Secretary may 
make additional loan guarantees. 
"(6) ANNUAL REPORT.—Not later than April 1, 1998, and 
each April 1 thereafter, the Secretary shall prepare and submit 
to the appropriate committees of Congress a report concerning 
loam^ guarantees provided under this subsection. Such report 
shall include— 
"(A) a description of the number, amount, and use 
of funds received under each loan guarantee provided under 
this subsection; 
"(B) a description of any defaults with respect to such 
loans and an analysis of the reasons for such defaults, 
if any; and 
"(C) a description of the steps that may have been 
taken by the Secretary to assist an entity in avoiding 
such a default. 
Reports. 
"(7) PROGRAM EVALUATION.—Not later than June 30, 1999, 
the Secretary shall prepare and submit to the appropriate 
committees of Congress a report containing an evaluation of 
the program authorized under this subsection. Such evaluation 
shall include a recommendation with respect to whether or 
not the loan guarantee program under this subsection should 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3633 
be continued and, if so, any modifications that should be made 
to such program. 
"(8) 
AUTHORIZATION 
OF 
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection such 
sums as may be necessary. 
"(e) OPERATING GRANTS.— 
"(1) AUTHORITY.— 
"(A) IN GENERAL.—The Secretary may make grants 
for the costs of the operation of pubhc and nonprofit private 
health centers that provide health services to medically 
underserved populations. 
"(B) ENTITIES THAT FAIL TO MEET CERTAIN REQUIRE-
MENTS.—The Secretary may make grants, for a period of 
not to exceed 2 years, for the costs of the operation of 
public and nonprofit private entities which provide health 
services to medically underserved populations but with 
respect to which the Secretary is unable to make each 
of the determinations required by subsection 0)(3). 
"(2) USE OF FUNDS.—The costs for which a grant may 
be made under subparagraph (A) or (B) of paragraph (1) may 
include the costs of acquiring and leasing buildings and equip-
ment (including the costs of amortizing the principal of, and 
paying interest on, loans), and the costs of providing training 
related to the provision of required primary health services 
and additional health services and to the management of health 
center programs. 
"(3) CONSTRUCTION.—The Secretary may award grants 
which may be used to pay the costs associated with expanding 
and modernizing existing buildings or constructing new build-
ings (including the costs of amortizing the principal of, and 
pa3n[ng the interest on, loans) for projects approved prior to 
October 1, 1996. 
"(4) LIMITATION.—Not more than two greints may be made 
under subparagraph (B) of paragraph (1) for the same entity. 
"(5) AMOUNT.— 
"(A) IN GENERAL.—The amount of any grant made in 
any fiscal year under paragraph (1) to a health center 
shall be determined by the Secretary, but may not exceed 
the amount by which the costs of operation of the center 
in such fiscal year exceed the total o
f
— 
"(i) State, local, and other operational funding pro-
vided to the center; and 
"(ii) 
the 
fees, 
premiums, 
and 
third-party 
reimbursements, which the center may reasonably be 
expected to receive for its operations in such fiscal 
year. 
"(B) 
PAYMENTS.—Pajnnents 
under 
grants 
under 
subparagraph (A) or (B) of paragraph (1) shall be made 
in advance or by way of reimbursement and in such install-
ments as the Secretary finds necessary and adjustments 
may be made for overpa5anents or underpayments. 
"(C) USE OF NONGRANT FUNDS.—Nongrant 
funds 
described in clauses (i) and (ii) of subparagraph (A), includ-
ing any such funds in excess of those originally expected, 
shall be used as permitted under this section, and may 
be used for such other purposes as are not specifically 
110 STAT. 3634 
PUBLIC LAW 104-299—OCT. 11, 1996 
prohibited under this section if such use furthers the objec-
tives of the project. 
"(f) INFANT MORTALITY GRANTS.— 
"(1) IN GENERAL.—The Secretary may make grants to 
health centers for the purpose of assisting such centers in— 
"(A) providing comprehensive health care and support 
services for the reduction o
f
— 
"(i) the incidence of infant mortality; and 
"(ii) morbidity among children who are less than 
3 years of age; and 
"(B) developing and coordinating service and referral 
arrangements between health centers and other entities 
for the health management of pregnant women and chil-
dren described in subparagraph (A). 
"(2) PRIORITY.—In making grants under this subsection 
the Secretary shall give priority to health centers providing 
services to any medically underserved population among which 
there is a substantial incidence of infant mortality or among 
which there is a significant increase in the incidence of infant 
mortality. 
"(3) REQUIREMENTS.—The Secretary may make a grant 
under this subsection only if the health center involved agrees 
that— 
"(A) the center will coordinate the provision of services 
under the grant to each of the recipients of the services; 
"(B) such services will be continuous for each such 
recipient; 
"(C) the center will provide follow-up services for 
individuals who are referred by the center for services 
described in paragraph (1); 
"(D) the grant will be expended to supplement, and 
not supplant, the expenditures of the center for primary 
health services (including prenatal care) with respect to 
the purpose described in this subsection; and 
"(E) the center will coordinate the provision of services 
with other maternal and child health providers operating 
in the catchment area. 
"(g) MIGRATORY AND SEASONAL AGRICULTURAL WORKERS.— 
"(1) IN GENERAL.—The Secretary may award grants for 
the purposes described in subsections (c), (e), and (f) for the 
planning and delivery of services to a special medically under-
served population comprised o
f
— 
"(A) migratory agricultural workers, seasonal agricul-
tural workers, and members of the families of such migra-
tory and seasonal agricultural workers who are within 
a designated catchment area; and 
"(B) individuals who have previously been migratory 
agricultural workers but who no longer meet the require-
ments of subparagraph (A) of paragraph (3) because of 
age or disability and members of the families of such 
individuals who are within such catchment area. 
"(2) ENVIRONMENTAL CONCERNS.—The Secretary may enter 
into grants or contracts under this subsection with public and 
private entities to— 
"(A) assist the States in the implementation and 
enforcement of acceptable environmental health standards, 
including enforcement of standards for sanitation in migra-
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3635 
tory agricultural worker labor camps, and applicable Fed-
eral and State pesticide control standards; and 
"(B) conduct projects and studies to assist the several 
States and entities which have received grants or contracts 
under this section in the assessment of problems related 
to camp and field sanitation, exposure to unsafe levels 
of agricultural chemicals including pesticides, and other 
environmental health hazards to which migratory agricul-
tural workers and members of their families are exposed. 
"(3) DEFINITIONS.—For purposes of this subsection: 
"(A) MIGRATORY AGRICULTURAL WORKER.—The term 
'migratory agricultural worker' means an individual whose 
principal employment is in agriculture on a seasonal basis, 
who has been so employed within the last 24 months, 
and who establishes for the purposes of such employment 
a temporary abode. 
"(B) SEASONAL AGRICULTURAL WORKER.—The term 'sea-
sonal agricultural worker' means an individual whose prin-
cipal employment is in agriculture on a seasonal basis 
and who is not a migratory agricultural worker. 
"(C) AGRICULTURE.—The term 'agriculture' 
means 
farming in all its branches, including— 
"(i) cultivation and tillage of the soil; 
"(ii) the production, cultivation, growing, and 
harvesting of any commodity grown on, in, or as an 
adjunct to or part of a commodity grown in or on, 
the land; and 
"(iii) any practice (including preparation 
and 
processing for market and delivery to storage or to 
market or to carriers for transportation to market) 
performed by a farmer or on a farm incident to or 
in conjunction with an activity described in clause 
(ii). 
"(h) HOMELESS POPULATION.— 
"(1) IN GENERAL.—The Secretary may award grants for 
the purposes described in subsections (c), (e), and (f) for the 
planning and delivery of services to a special medically under-
served population comprised of homeless individuals, including 
grants for innovative programs that provide outreach and com-
prehensive primary health services to homeless children and 
children at risk of homelessness. 
"(2) REQUIRED SERVICES.—In addition to required primary 
health services (as defined in subsection (b)(1)), an entity that 
receives a grant under this subsection shall be required to 
provide substance abuse services as a condition of such grant. 
"(3) SUPPLEMENT NOT SUPPLANT REQUIREMENT.—A grant 
awarded under this subsection shall be expended to supple-
ment, and not supplant, the expenditures of the health center 
and the value of in kind contributions for the delivery of services 
to the population described in paragraph (1). 
"(4) DEFINITIONS.—For purposes of this section: 
"(A) 
HOMELESS 
INDIVIDUAL.—The term 
'homeless 
individual' means an individual who lacks housing (without 
regard to whether the individual is a member of a family), 
including an individual whose primary residence during 
the night is a supervised public or private facility that 
110 STAT. 3636 
PUBLIC LAW 104-299—OCT. 11, 1996 
provides temporary living accommodations and an individ-
ual who is a resident in transitional housing. 
"(B) SUBSTANCE ABUSE.—The term 'substance abuse' 
has the same meaning given such term in section 534(4). 
"(C) SUBSTANCE ABUSE SERVICES.—The term 'substance 
abuse services' includes detoxification and residential treat-
ment for substance abuse provided in settings other than 
hospitals, 
"(i) RESIDENTS OF PUBLIC HOUSING.— 
"(1) IN GENERAL.—The Secretary may award grants for 
the purposes described in subsections (c), (e), and (f) for the 
planning and delivery of services to a special medically under-
served population comprised of residents of public housing (such 
term, for purposes of this subsection, shall have the same 
meaning given such term in section 3(b)(1) of the United States 
Housing Act of 1937) and individuals living in areas imme-
diately accessible to such public housing. 
"(2) SUPPLEMENT NOT SUPPLANT.—A grant awarded under 
this sulDsection shall be expended to supplement, and not sup-
plant, the expenditures of the health center and the value 
of in kind contributions for the delivery of services to the 
population described in paragraph (1). 
"(3) CONSULTATION WITH RESIDENTS.—The Secretary 
may 
not make a grant under paragraph (1) unless, with respect 
to the residents of the public housing involved, the applicant 
for the grant— 
"(A) has consulted with the residents in the preparation 
of the application for the grant; and 
"(B) agrees to provide for ongoing consultation with 
the residents regarding the planning and administration 
of the program carried out with the grant, 
"(j) APPLICATIONS.— 
"(1) SUBMISSION.—No grant may be made under this section 
unless an application therefore is submitted to, and approved 
by, the Secretary. Such an application shall be submitted in 
such form and manner and shall contain such information 
as the Secretary shall prescribe. 
"(2) DESCRIPTION OF NEED.—An application for a grant 
under subparagraph (A) or (B) of subsection (e)(1) for a health 
center shall include— 
"(A) a description of the need for health services in 
the catchment area of the center; 
"(B) a demonstration by the applicant that the area 
or the population group to be served by the applicant 
has a shortage of personal health services; and 
"(C) a demonstration that the center will be located 
so that it will provide services to the greatest number 
of individuals residing in the catchment area or included 
in such population group. 
Such a demonstration shall be made on the basis of the criteria 
prescribed by the Secretary under subsection (b)(3) or on any 
other criteria which the Secretary may prescribe to determine 
if the area or population group to be served by the applicant 
has a shortage of personal health services. In considering an 
application for a grant under subparagraph (A) or (B) of sub-
section (e)(1), the Secretary may require as a condition to 
the approval of such application an assur£ince that the applicant 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3637 
will provide any health service defined under paragraphs (1) 
and (2) of subsection (b) that the Secretary finds is needed 
to meet specific health needs of the area to be served by 
the applicant. Such a finding shall be made in writing and 
a copy shall be provided to the applicant. 
"(3) REQUIREMENTS.—Except as provided in subsection 
(e)(1)(B), the Secretary may not approve an application for 
a grant under subparagraph (A) or (B) of subsection (e)(1) 
unless the Secretary determines that the entity for which the 
application is submitted is a health center (within the meaning 
of subsection (a)) and that— 
"(A) the required primary health services of the center 
will be available and accessible in the catchment area 
of the center promptly, as appropriate, and in a manner 
which assures continuity; 
"(B) the center has made and will continue to make 
every reasonable effort to establish and maintain collabo-
rative relationships with other health care providers in 
the catchment area of the center; 
"(C) the center will have an ongoing quality improve-
ment system that includes clinical services and manage-
ment, and that maintains the confidentiality of patient 
records; 
"(D) the center will demonstrate its financial respon-
sibility by the use of such accounting procedures and other 
requirements as may be prescribed by the Secretary; 
"(E) the center— 
"(i) has or will have a contractual or other arrange-
ment with the agency of the State, in which it provides 
services, which administers or supervises the adminis-
tration of a State plan approved under title XIX of 
the Social Security Act for the payment of all or a 
part of the center's costs in providing health services 
to persons who are eligible for medical assistance under 
such a State plan; or 
"(ii) has made or will make every reasonable effort 
to enter into such an arrangement; 
"(F) the center has made or will make and will continue 
to make every reasonable effort to collect appropriate 
reimbursement for its costs in providing health services 
to persons who are entitled to insurance benefits under 
title XVIII of the Social Security Act, to medical assistance 
under a State plan approved under title XIX of such Act, 
or to assistance for medical expenses under any other public 
assistance program or private health insurance program; 
"(G) the center— 
"(i) has prepared a schedule of fees or pa5mients 
for the provision of its services consistent with locally 
prevailing rates or charges and designed to cover its 
reasonable costs of operation and has prepared a cor-
responding schedule of discounts to be applied to the 
payment of such fees or payments, which discounts 
are adjusted on the basis of the patient's ability to 
pay; 
"(ii) has made and will continue to make every 
reasonable effort— 
110 STAT. 3638 
PUBLIC LAW 104-299—OCT. 11, 1996 
"(I) to secure from patients payment for serv-
ices in accordance with such schedules; and 
"(II) to collect reimbursement for health serv-
ice^ to persons described in subparagraph (F) on 
the basis of the full amount of fees and payments 
for such services without application of any dis-
count; and 
"(iii) has submitted to the Secretary such reports 
as the Secretary may require to determine compliance 
with this subparagraph; 
"(H) the center has established a governing board 
which except in the case of an entity operated by an Indian 
tribe or tribal or Indian organization under the Indian 
Self-Determination Act or an urban Indian organization 
under the Indian Health Care Improvement Act (25 U.S.C. 
1651 et seq.)— 
"(i) is composed of individuals, a majority of whom 
are being served by the center and who, as a group, 
represent the individuals being served by the center; 
"(ii) meets at least once a month, selects the serv-
ices to be provided by the center, schedules the hours 
during which such services will be provided, approves 
the center's annual budget, approves the selection of 
a director for the center, and, except in the case of 
a governing board of a public center (as defined in 
the second sentence of this paragraph), establishes gen-
eral policies for the center; and 
"(iii) in the case of an application for a second 
or subsequent grant for a public center, has approved 
the application or if the governing body has not 
approved the application, the failure of the governing 
body to approve the application was unreasonable; 
except that, upon a showing of good cause the Secretary 
shall waive, for the length of the project period, all or 
part of the requirements of this subparagraph in the case 
of a health center that receives a grant pursuant to sub-
section (g), (h), (i), or (p); 
"(I) the center has developed— 
"(i) an overall plan and budget that meets the 
requirements of the Secretary; and 
"(ii) an effective procedure for compiling and 
reporting to the Secretary such statistics and other 
information as the Secretary may require relating to— 
"(I) the costs of its operations; 
"(II) the patterns of use of its services; 
"(III) the availability, accessibility, and accept-
ability of its services; and 
"(IV) such other matters relating to operations 
of the applicant as the Secretary may require; 
"(J) the center will review periodically its catchment 
area to— 
"(i) ensure that the size of such area is such that 
the services to be provided through "the center (includ-
ing any satellite) are available and accessible to the 
residents of the area promptly and as appropriate; 
"(ii) ensure that the boundaries of such area con-
form, to the extent practicable, to relevant boundaries 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3639 
of political subdivisions, school districts, and Federal 
and State health and social service programs; and 
"(iii) ensure that the boundaries of such area elimi-
nate, to the extent possible, barriers to access to the 
services of the center, including barriers resulting from 
the area's physical characteristics, its residential pat-
terns, its economic and social grouping, and available 
transportation; 
"(K) in the case of a center which serves a population 
including a substantial proportion of individuals of limited 
English-speaking ability, the center has— 
"(i) developed a plan and made arrangements 
responsive to the needs of such population for providing 
services to the extent practicable in the language and 
cultural context most appropriate to such individuals; 
and 
"(ii) identified an individual on its staff who is 
fluent in both that language and in English and whose 
responsibilities shall include providing guidance to 
such individuals and to appropriate staff members with 
respect to cultural sensitivities and bridging linguistic 
and cultural differences; and 
"(L) the center, has developed an ongoing referral rela-
tionship with one or more hospitals. 
For purposes of subparagraph (H), the term 'public center' 
means a health center funded (or to be funded) through a 
grant under this section to a public agency. 
"(4) 
APPROVAL OF NEW OR EXPANDED SERVICE APPLICA-
TIONS.—The Secretary shall approve applications for grants 
under subparagraph (A) or (B) of subsection (e)(1) for health 
centers which— 
"(A) have not received a previous grant under such 
subsection; or 
"(B) have applied for such a grant to expand their 
services; 
in such a manner that the ratio of the medically underserved 
populations in rural areas which may be expected to use the 
services provided by such centers to the medically underserved 
populations in urban areas which may be expected to use 
the services provided by such centers is not less than two 
to three or greater than three to two. 
"(k) TECHNICAL AND OTHER ASSISTANCE.—The Secretary 
may 
provide (either through the Department of Health and Human 
Services or by grant or contract) all necessary technical and other 
nonfinancial assistance (including fiscal and program management 
assistance and training in such management) to any public or 
private nonprofit entity to assist entities in developing plans for, 
or operating as, health centers, and in meeting the requirements 
of subsection (j)(2). 
"(1) AUTHORIZATION OF APPROPRIATIONS.— 
"(1) IN GENERAL.—For the purpose of carrying out this 
section, in addition to the amounts authorized to be appro-
priated under subsection (d), there are authorized to be appro-
priated $802,124,000 for fiscal year 1997, and such sums as 
may be necessary for each of the fiscal years 1998 through 
2001. 
"(2) SPECIAL PROVISIONS.— 
110 STAT. 3640 
PUBLIC LAW 104-299—OCT. 11, 1996 
"(A) PUBLIC CENTERS.—The Secretary may not expend 
in any fiscal year, for grants under this section to pubhc 
centers (as defined in the second sentence of subsection 
(j)(3)) the governing boards of which (as described in sub-
section (j)(3)(G)(ii)) do not estabhsh general policies for 
such centers, an amount which exceeds 5 percent of the 
amounts appropriated under this section for that fiscal 
year. For purposes of applying the preceding sentence, 
the term 'public centers' shall not include health centers 
that receive grants pursuant to subsection (h) or (i). 
"(B) DISTRIBUTION OF GRANTS.— 
"(i) FISCAL YEAR 1997.—For fiscal year 1997, the 
Secretary, in awarding grants under this section shall 
ensure that the amounts made available under each 
of subsections (g), (h), and (i) in such fiscal year bears 
the same relationship to the total amount appropriated 
for such fiscal year under paragraph (1) as the amounts 
appropriated for fiscal year 1996 under each of sections 
329, 340, and 340A (as such sections existed one day 
prior to the date of enactment of this section) bears 
to the total amount appropriated under sections 329, 
330, 340, and 340A (as such sections existed one day 
prior to the date of enactment of this section) for such 
fiscal year. 
"(ii) FISCAL YEARS 1998 AND 1999.—For each of 
the fiscal years 1998 and 1999, the Secretary, in award-
ing grants under this section shall ensure that the 
proportion of the amounts made available under each 
of subsections (g), (h), and (i) is equal to the proportion 
of amounts made available under each such subsection 
for the previous fiscal year, as such amounts relate 
to the total amounts appropriated for the previous 
fiscal year involved, increased or decreased by not more 
than 10 percent. 
"(3) FUNDING REPORT.—The Secretary shall annually pre-
pare and submit to the appropriate committees of Congress 
a report concerning the distribution of funds under this section 
that are provided to meet the health care needs of medically 
underserved populations, including the homeless, residents of 
public housing, and migratory and seasonal agricultural work-
ers, and the appropriateness of the delivery systems involved 
in responding to the needs of the particular populations. Such 
report shall include an assessment of the relative health care 
access needs of the targeted populations and the rationale 
for any substantial changes in the distribution of funds. 
"(m) MEMORANDUM OF AGREEMENT.—In carrying out this sec-
tion, the Secretary may enter into a memorandum of agreement 
with a State. Such memorandum may include, where appropriate, 
provisions permitting such State to— 
"(1) analyze the need for primary health services for medi-
cally underserved populations within such State; 
"(2) assist in the planning and development of new health 
centers; 
"(3) review and comment upon annual program plans and 
budgets of health centers, including comments upon allocations 
of health care resources in the State; 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3641 
"(4) assist health centers in the development of clinical 
practices and fiscal and administrative systems through a tech-
nical assistance plan which is responsive to the requests of 
health centers; and 
"(5) share information and data relevant to the operation 
of new and existing health centers. 
"(n) RECORDS.— 
"(1) IN GENERAL.—Each entity which receives a grant under 
subsection (e) shall establish and maintain such records as 
the Secretary shall require. 
"(2) AVAILABILITY.—Each entity which is required to estab-
lish and maintain records under this subsection shall make 
such books, documents, papers, and records available to the 
Secretary or the Comptroller General of the United States, 
or any of their duly authorized representatives, for examination, 
copying or mechanical reproduction on or off the premises of 
such entity upon a reasonable request therefore. The Secretary 
and the Comptroller General of the United States, or any 
of their duly authorized representatives, shall have the author-
ity to conduct such examination, cop3dng, and reproduction. 
"(o) DELEGATION OF AUTHORITY.—The Secretary may delegate 
the authority to administer the programs authorized by this section 
to any office, except that the authority to enter into, modify, or 
issue approvals with respect to grants or contracts may be delegated 
only within the central office of the Health Resources and Services 
Administration. 
"(p) SPECIAL CONSIDERATION.—In making grants under this 
section, the Secretary shall give special consideration to the unique 
needs of sparsely populated rural areas, including giving priority 
in the awarding of grants for new health centers under subsections 
(c) and (e), and the granting of waivers as appropriate and permitted 
under subsections (b)(l)(B)(i) and (j)(3)(G). 
"(q) AUDITS.— 
"(1) IN GENERAL.—Each entity which receives a grant under 
this section shall provide for an independent annual financial 
audit of any books, accounts, financial records, files, and other 
papers and property which relate to the disposition or use 
of the funds received under such grant and such other funds 
received by or allocated to the project for which such grant 
was made. For purposes of assuring accurate, current, and 
complete disclosure of the disposition or use of the funds 
received, each such audit shall be conducted in accordance 
with generally accepted accounting principles. Each audit shall 
evaluate— 
"(A) the entity's implementation of the guidelines 
established by the Secretary respecting cost accounting, 
"(B) the processes used by the entity to meet the finan-
cial and program reporting requirements of the Secretary, 
and 
"(C) the billing and collection procedures of the entity 
and the relation of the procedures to its fee schedule and 
schedule of discounts and to the availability of health insur-
ance and public programs to pay for the health services 
it provides. 
A report of each such audit shall be filed with the Secretary 
at such time and in such manner as the Secretary may require. 
110 STAT. 3642 
PUBLIC LAW 104-299—OCT. 11, 1996 
Regulations. 
"(2) RECORDS.—Each entity which receives a grant under 
this section shall establish and maintain such records as the 
Secretary shall by regulation require to facilitate the audit 
required by paragraph (1). The Secretary may specify by regula-
tion the form and manner in which such records shall be 
established and maintained. 
"(3) AVAILABILITY OF RECORDS.—Each entity which is 
required to establish and maintain records or to provide for 
and audit under this subsection shall make such books, docu-
ments, papers, and records available to the Secretary or the 
Comptroller General of the United States, or any of their duly 
authorized 
representatives, 
for 
examination, 
copying 
or 
mechanical reproduction on or off the premises of such entity 
upon a reasonable request therefore. The Secretary and the 
Comptroller General of the United States, or any of their duly 
authorized representatives, shall have the authority to conduct 
such examination, cop3n.ng, and reproduction. 
"(4) WAIVER.—The Secretary may, under appropriate cir-
cumstances, waive the application of all or part of the require-
ments of this subsection with respect to an entity.". 
SEC. 
3
. 
RURAL 
HEALTH OUTREACH, 
NETWORK DEVELOPMENT, 
AND 
TELEMEDICINE 
GRANT 
PROGRAM. 
(a) IN GENERAL.—Subpart I of part D of title III of the Public 
Health Service Act (42 U.S.C. 254b et seq.) (as amended by section 
2) is further amended by adding at the end thereof the following 
new section: 
42 use 254c. 
"SEC. 330A. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, 
AND TELEMEDICINE GRANT PROGRAM. 
"(a) ADMINISTRATION.—The rural health services outreach dem-
onstration grant program established under section 301 shall be 
administered by the Office of Rural Health Policy (of the Health 
Resources and Services Administration), in consultation with State 
rural health offices or other appropriate State governmental enti-
ties. 
"(b) GRANTS.—Under the program referred to in subsection 
(a), the Secretary, acting through the Director of the Office of 
Rural Health Policy, may award grants to expand access to, coordi-
nate, restrain the cost of, and improve the quality of essential 
health care services, including preventive and emergency services, 
through the development of integrated health care delivery systems 
or networks in rural areas and regions. 
"(c) ELIGIBLE NETWORKS.— 
"(1) OUTREACH NETWORKS.—To be eligible to receive a grant 
under this section, an entity shall— 
"(A) be a rural public or nonprofit private entity that 
is or represents a network or potential network that 
includes three or more health care providers or other enti-
ties that provide or support the delivery of health care 
services; and 
"(B) in consultation with the State office of rural health 
or other appropriate State entity, prepare and submit to 
the Secretary an application, at such time, in such manner, 
and containing such information as the Secretary may 
require, including— 
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3643 
"(i) a description of the activities which the 
appHcant intends to carry out using amounts provided 
under the grant; 
"(ii) a plan for continuing the project after Federal 
support is ended; 
"(iii) a description of the manner in which the 
activities funded under the grant will meet health 
care needs of underserved rural populations within 
the State; and 
"(iv) a description of how the local community or 
region to be served by the network or proposed network 
will be involved in the development and ongoing oper-
ations of the network. 
"(2) FOR-PROFIT ENTITIES.—^An eligible network may include 
for-profit entities so long as the network grantee is a nonprofit 
entity. 
"(3) TELEMEDICINE NETWORKS.— 
"(A) IN GENERAL.—An entity that is a health care 
provider and a member of an existing or proposed telemedi-
cine network, or an entity that is a consortium of health 
care providers that are members of an existing or proposed 
telemedicine network shall be eligible for a grant under 
this section. 
"(B) REQUIREMENT.—A telemedicine network referred 
to in subparagraph (A) shall, at a minimum, be composed 
of— 
"(i) a multispecialty entity that is located in an 
urban or rural area, which can provide 24-hour a day 
access to a range of specialty care; and 
"(ii) at least two rural health care facilities, which 
may include rural hospitals, rural physician offices, 
rural health clinics, rural community health clinics, 
and rural nursing homes. 
"(d) PREFERENCE.—In awarding grants under this section, the 
Secretary shall give preference to applicant networks that include— 
"(1) a majority of the health care providers serving in 
the area or region to be served by the network; 
"(2) any federally qualified health centers, rural health 
clinics, and local public health departments serving in the 
area or region; 
"(3) outpatient mental health providers serving in the area 
or region; or 
"(4) appropriate social service providers, such as agencies 
on aging, school systems, and providers under the women, 
infants, and children program, to improve access to and 
coordination of health care services. 
"(e) USE OF FUNDS.— 
"(1) IN GENERAL.—Amounts provided under grants awarded 
under this section shall be used— 
"(A) for the planning and development of integrated 
self-sustaining health care networks; and 
"(B) for the initial provision of services. 
"(2) EXPENDITURES IN RURAL AREAS.— 
"(A) IN GENERAL.—In awarding a grant under this 
section, the Secretary shall ensure that not less than 50 
percent of the grant award is expended in a rural area 
or to provide services to residents of rural areas. 
110 STAT. 3644 
PUBLIC LAW 104-299—OCT. 11, 1996 
"(B) TELEMEDICINE NETWORKS.—^An entity described 
in subsection (c)(3) may not use in excess of— 
"(i) 40 percent of the amounts provided under a 
grant under this section to carry out activities under 
paragraph (3)(A)(iii); and 
"(ii) 20 percent of the amounts provided under 
a grant under this section to pay for the indirect costs 
associated with carrying out the purposes of such 
grant. 
"(3) TELEMEDICINE NETWORKS.— 
"(A) IN GENERAL.—^An entity described in subsection 
(c)(3), may use amounts provided under a grant under 
this section to— 
"(i) demonstrate the use of telemedicine in facihtat-
ing the development of rural health care networks 
and for improving access to health care services for 
rural citizens; 
"(ii) provide a baseline of information for a system-
atic evaluation of telemedicine systems serving rural 
areas; 
"(iii) purchase or lease and install equipment; and 
"(iv) operate the telemedicine system and evaluate 
the telemedicine system. 
"(B) LIMITATIONS.—An entity described in subsection 
(c)(3), may not use amounts provided under a grant under 
this section— 
"(i) to build or acquire real property; 
"(ii) purchase or install transmission equipment 
(such as la3dng cable or telephone lines, microwave 
towers, satellite dishes, amplifiers, and digital switch-
ing equipment); or 
"(iii) for construction, except that such funds may 
be expended for minor renovations relating to the 
installation of equipment; 
"(f) TERM OF GRANTS.—Funding may not be provided to a 
network under this section for in excess of a 3-year period. 
"(g) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section there are authorized to be appropriated 
$36,000,000 for fiscal year 1997, and such sums as may be necessary 
for each of the fiscal years 1998 through 2001.". 
42 use 254b 
(b) TRANSITION.—The Secretary of Health and Human Services 
note. 
shall ensure the continued funding of grants made, or contracts 
or cooperative agreements entered into, under subpart I of part 
D of title III of the Pubhc Health Service Act (42 U.S.C. 254b 
et seq.) (as such subpart existed on the day prior to the date 
of enactment of this Act), until the expiration of the grant period 
or the term of the contract or cooperative agreement. Such funding 
shall be continued under the same terms and conditions as were 
in effect on the date on which the grant, contract or cooperative 
agreement was awarded, subject to the availability of appropria-
tions. 
SEC. 4. TECHNICAL AND CONFORMING AMENDMENTS. 
(a) IN GENERAL.—The Public Health Service Act is amended— 
(1) in section 224(g)(4) (42 U.S.C. 233(g)(4)), by striking 
"under" and all that follows through the end thereof and insert-
ing "under section 330."; 
ed-
PUBLIC LAW 104-299—OCT. 11, 1996 
110 STAT. 3645 
(2) in section 340C(a)(2) (42 U.S.C. 256c) by striking 
"under" and all that follows through the end thereof and insert-
ing "with assistance provided under section 330."; and 
(3) by repealing subparts V and VI of part D of title 
III (42 U.S.C. 256 et seq.). 
(b) SOCIAL SECURITY ACT.—^The Social Security Act is amend-
(1) in clauses (i) and (ii)(I) of section 1861(aa)(4)(A) (42 
U.S.C. 1395x(aa)(4)(A) (i) and (ii)(I)) by striking "section 329, 
330, or 340" and inserting "section 330 (other than subsection 
(h))"; and 
(2) in clauses (i) and (ii)(II) of section 1905(1)(2)(B) (42 
U.S.C. 1396d(l)(2)(B) (i) and (ii)(II)) by striking "section 329, 
330, 340, or 340A" and inserting "section 330". 
(c) REFERENCES.—^Whenever any reference is made in any provi- 
42 USC 254b 
sion of law, regulation, rule, record, or document to a community note. 
health center, migrant health center, public housing health center, 
or homeless health center, such reference shall be considered a 
reference to a health center. 
(d) FTCA CLARIFICATION.—^For purposes of section 224(k)(3) 
of the Public Health Service Act (42 U.S.C. 233(k)(3)), transfers 
from the fund described in such section for fiscal year 1996 shall 
be deemed to have occurred prior to December 31, 1995. 
(e) ADDITIONAL AMENDMENTS.—^After consultation with the 42 use 254b 
appropriate committees of the Congress, the Secretary of Health ^^te. 
and Human Services shall prepare and submit to the Congress 
a legislative proposal in the form of an implementing bill containing 
technical and conforming amendments to reflect the changes made 
by this Act. 
SEC. 5. EFFECTIVE DATE. 
42 USC 233 note. 
This Act and the amendments made by this Act shall become 
effective on October 1, 1997. 
Approved October 11, 1996. 
LEGISLATIVE HISTORY—S. 1044: 
SENATE REPORTS: No. 104-186 (Comm. on Labor and Human Resources). 
CONGRESSIONAL RECORD, Vol. 142 (1996): 
Sept. 20, considered and passed Senate. 
Sept. 27, considered and passed House. 
WEEKLY COMPILATION OF PRESIDENTIAL DOCUMENTS, Vol. 32 (1996): 
Oct. 11, Presidential statement.