TITLE IV_INFRASTRUCTURE REFORM Subtitle A_Programs to Improve Access To Underserved Areas PART 1_INITIATIVES FOR ACCESS TO HEALTH CARE Subpart A_Eligible Entities SEC. 4001. ELIGIBLE ENTITIES. (a) In General._For purposes of this part, the term ``eligible entities'' means_ (1) covered entities as defined in section 340B(a)(4) of the Public Health Service Act (42 U.S.C. 256b(a)(4)), except that subsection (a)(4)(L)(iii) and (a)(7) of such section shall not apply; (2) school health service sites under title III of this Act; (3) nonprofit hospitals meeting the criteria for public hospitals which are eligible entities under section 340B of the Public Health Service Act, except that subsection (a)(4)(L)(iii) of such section shall not apply, and children's hospitals meeting comparable criteria as determined appropriate by the Secretary; (4) public and private, nonprofit community mental health centers and substance abuse treatment providers receiving funds from the Substance Abuse and Mental Health Services Administration; (5) runaway homeless youth centers or transitional living programs for homeless youth for the provision of health services under the Runaway Homeless Youth Act of 1974 (42 U.S.C. 5701 et seq.); (6) rural referral centers under section 1886(d)(5)(C) of the Social Security Act, except that such eligibility is restricted to the receipt of grants under section 3441; (7) with respect to_ (A) subparts B, C and D, non-profit and public rural health clinics (as defined in section 1861(aa)(2) of the Social Security Act); and (B) loans under subpart C, for-profit rural health clinics; and (8) public or nonprofit entities in nonmetropolitan areas (as defined by the Department of Commerce) in a consortium of community-based providers that includes at least three of the following: (A) community or migrant health centers; (B) local health departments; (C) community mental health centers; (D) nonprofit hospitals; (E) private practice health professionals; (F) rural health clinics; or (F) other publicly funded health or social services agencies; except that such eligibility is restricted to the receipt of grants or contracts under sections 3421(a) and 3461(a). (b) Equitable Distribution._The Secretary shall, in awarding grants, entering into contracts, and making loans under this part, assure an equitable distribution of funds between rural and urban areas. Subpart B_Development of Community Health Groups and Health Care Sites and Services SEC. 4011. GRANTS AND CONTRACTS FOR DEVELOPMENT OF PLANS AND NETWORKS AND THE EXPANSION AND DEVELOPMENT OF HEALTH CARE SITES AND SERVICES. (a) Authority._ (1) In general._The Secretary may make grants to and enter into contracts with eligible entities described in section 4001(a) for_ (A) the development of community health groups whose principal purpose is to provide the standard benefit package under title I in one or more health professional shortage areas or to provide such items and services to a significant number of individuals who are members of a medically underserved population; and (B) the expansion of existing health delivery sites and services and the development of new health delivery sites and services. (2) Consideration by secretary._In awarding grants or contracts under paragraph (1), the Secretary shall give consideration to_ (A) the geographic proximity of the grant applicants and recipients; (B) cultural and language differences existing within the communities to be served under the grants or contracts; and (C) the capacity needs of the communities to be served. (b) Service Area._In making an award under subsection (a), the Secretary shall designate the geographic area with respect to which the community health group involved is to provide health services. (c) Priority._In making awards under subsection (a)(1), the Secretary shall give priority to proposals in which a greater number of eligible entities and other health care providers are participants in the community health group, except in areas such as rural areas, where providers are severely limited in number. (d) Limitation on Awards._The Secretary may not make awards under subsection (a)(1) for more than 5 years to the same community health group. (e) Definitions._For purposes of this subpart: (1) The term ``community health group'' means_ (A) a community health network that_ (i) is a public or nonprofit private consortium of health care providers that principally provides some of the items and services of the standard benefit package to medically underserved populations, and residents of health professional shortage areas; (ii) has an agreement with one or more health plans; and (iii) has a written agreement governing the participation of health care providers in the consortium to which each participating provider is a party; or (B) a community health plan that_ (i) is a public or nonprofit private entity that principally provides all of the items and services of the standard benefit package to medically underserved populations, and residents of health professional shortage areas; (ii) is a participant in one or more health alliances; and (iii) has a written agreement governing the participation of health care providers in the consortium to which each participating provider is a party. (2) The term ``health professional shortage areas'' means health professional shortage areas designated under section 332 of the Public Health Service Act. (3) The term ``medically underserved population'' means a medically underserved population designated under section 330(b)(3) of the Public Health Service Act, populations residing in health professional shortage areas under section 332 of the Public Health Service Act, and populations eligible for premium subsidies and cost sharing reductions based on income under title I. SEC. 4012. CERTAIN USES OF AWARDS. (a) In General._Amounts awarded under section 4011 may be expended for_ (1) the development of a community health group, including entering into contracts between the recipient of the award and health care providers who are to participate in the group; (2) the expansion, development and on-going operation of health delivery sites and services; and (3) activities under paragraphs (1) and (2) which include_ (A) the recruitment, compensation, and training of health professionals and administrative staff; (B) the purchase and upgrading of equipment, supplies, and information systems including telemedicine systems; and (C) the establishment of reserves required for furnishing services on a prepaid or capitated basis, except that eligible entities may use non-cash mechanisms (including bonds, letters of credit and federally guaranteed reinsurance pools) for establishing and maintaining financial reserves. (b) Loans and Grants._The Secretary may provide for payment, in any fiscal year, of not to exceed 10 percent of the amounts appropriated to carry out this subpart to make loans and grants to eligible entities to support the types of activities described in section 4021, subject to the requirements of subpart C, except that, with respect to amounts available for non-federally qualified health center activities, such funds may be used to convert facilities from providers of acute care service to providers of primary, emergency or long-term care. SEC. 4013. APPLICATION. The Secretary may not make an award to an entity under section 4011 until such entity submits and application to the Secretary, in such form and containing such assurances and information as the Secretary determines appropriate, including_ (1) an assessment of the need that the medically underserved population or populations proposed to be served by the applicant have for health services and for enabling services (as defined in section 4031); (2) a description of how the applicant will design the proposed community health plan or practice network (including the service sites involved) for such populations based on the assessment of need; (3) a description of efforts to secure financial and professional assistance and support for the project; and (4) evidence of significant community involvement in the initiation, development and ongoing operation of the project. SEC. 4014. PURPOSES AND CONDITIONS. Grants shall be made under this subpart for the purposes and subject to all of the conditions under which eligible entities otherwise receive funding to provide health services to medically underserved populations under the Public Health Service Act. The Secretary shall prescribe comparable purposes and conditions for eligible entities not receiving funding under the Public Health Service Act. SEC. 4015. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to carry out this subpart, $441,000,000 for fiscal year 1996, $494,000,000 for fiscal year 1997, $360,000,000 for fiscal year 1998, $269,000,000 for fiscal year 1999, $92,000,000 for fiscal year 2000, $55,000,000 for fiscal year 2001, $32,000,000 for fiscal year 2002, and $23,000,000 for each of the fiscal years 2003 and 2004. Subpart C_Capital Cost of Development of Community Health Groups and Other Purposes SEC. 4021. DIRECT LOANS AND GRANTS. (a) In General._The Secretary shall make grants and loans to_ (1) eligible entities (as defined in section 4001(a)); (2) hospitals designated by the Secretary as essential access community hospitals under section 1820(i)(1) of the Social Security Act; or (3) rural primary care hospitals under section 1820(i)(2) of such Act; for the capital costs of developing community health groups (as defined in section 4011(e)) and expanding existing health delivery sites or developing new health delivery sites. (b) Use of Assistance._ (1) In general._The capital costs for which grants and loans made pursuant to subsection (a) may be expended are, subject to paragraphs (2) and (3), the following: (A) The acquisition, modernization, expansion or construction of facilities, or the conversion of unneeded hospital facilities to facilities that will assure or enhance the provision and accessibility of health care and enabling services to medically underserved populations. (B) The purchase of major equipment, including equipment necessary for the support of external and internal information systems. (C) The establishment of reserves required for furnishing services on a prepaid or capitated basis. (D) Such other capital costs as the Secretary may determine are necessary to achieve the objectives of this section. (2) Priorities regarding use of funds._In providing grants and loans under subsection (a) for an entity, the Secretary shall give priority to authorizing the use of amounts for projects for the renovation and modernization of medical facilities necessary to prevent or eliminate safety hazards including asbestos removal, avoid noncompliance with licensure or accreditation standards, or projects to replace obsolete facilities. (3) Limitation._The Secretary may authorize the use of grants and loans under subsection (a) for the construction of new buildings only if the Secretary determines that appropriate facilities are not available through acquiring, modernizing, expanding or converting existing buildings, or that construction new buildings will cost less. (c) Amount of Assistance._ (1) In general._The principal amount of loans under subsection (a) may cover up to 90 percent of the costs involved. (2) Grants._Grants under this subsection may not exceed 75 percent of the costs involved. (d) Interest Subsidies._Amounts provided under this section may be used to provide interest subsidies for loans provided under this section where such subsidies are necessary to make a project financial feasible. SEC. 4022. CERTAIN REQUIREMENTS. (a) In General._The Secretary may approve a loan under section 4021 only if_ (1) the Secretary is reasonably satisfied that the applicant for the project for which the loan would be made will be able to make payments of principal and interest thereon when due; and (2) the applicant provides the Secretary with reasonable assurances that there will be available to it such additional funds as may be necessary to complete the project or undertaking with respect to which such loan is requested. (b) Terms and Conditions._Any loan made under section 4021 shall, subject to the Federal Credit Reform Act of 1990, meet such terms and conditions (including provisions for recovery in case of default) as the Secretary, in consultation with the Secretary of the Treasury, determines to be necessary to carry out the purposes of such section while adequately protecting the financial interests of the United States. Terms and conditions for such loans shall include provisions regarding the following: (1) Security. (2) Maturity date. (3) Amount and frequency of installments. (4) Rate of interest, which shall be at a rate comparable to the rate of interest prevailing on the date the loan is made. SEC. 4023. DEFAULTS; APPLICATIONS AND RIGHTS OF RECOVERY. The provisions of section 1602(f) (relating to prevention of defaults), 1621 (relating to applications), and section 1622 (relating to rights of recovery and waivers) of the Public Health Service Act (42 U.S.C. 300q-2(f), 300s-1, and 300s-1a) shall apply with respect to entities receiving loans under this section in the same manner that such sections apply to entities receiving loans under title XVI of the Public Health Service Act. The Secretary shall promulgate regulations necessary to implement this section with respect to loans under this subpart. SEC. 4024. PROVISIONS REGARDING CONSTRUCTION OR EXPANSION OF FACILITIES. (a) Submission of Information._In the case of a project for construction, conversion, expansion or modernization of a facility, the Secretary may provide loans under section 4021 only if the applicant submits to the Secretary the following: (1) A description of the site. (2) Plans and specifications which meet requirements prescribed by the Secretary. (3) Information reasonably demonstrating that title to such site is vested in one or more of the entities filing the application (unless the agreement described in subsection (b)(1) is made). (4) A specification of the type of assistance being requested under section 4021. (b) Agreements._In the case of a project for construction, conversion, expansion or modernization of a facility, the Secretary may provide loans under section 4021 only if the applicant makes the following agreements: (1) Title to such site will be vested in one or more of the entities filing the application (unless the assurance described in subsection (a)(3) has been submitted under such subsection). (2) Adequate financial support will be available for completion of the project and for its maintenance and operation when completed. (3) All laborers and mechanics employed by contractors or subcontractors in the performance of work on a project will be paid wages at rates not less than those prevailing on similar construction in the locality as determined by the Secretary of Labor in accordance with the Act of March 3, 1931 (40 U.S.C. 276a et seq; commonly known as the Davis-Bacon Act), and the Secretary of Labor shall have with respect to such labor standards the authority and functions set forth in Reorganization Plan Numbered 14 of 1950 (15 FR 3176; 5 U.S.C. Appendix) and section 276c of title 40. (4) The facility will be made available to all persons seeking service regardless of their ability to pay. SEC. 4025. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to carry out this subpart, $63,000,000 for fiscal year 1996, $45,000,000 for fiscal year 1997, $40,000,000 for fiscal year 1998, $38,000,000 for fiscal year 1999, $31,000,000 for fiscal year 2000, $18,000,000 for fiscal year 2001, $11,000,000 for fiscal year 2002, and $8,000,000 for each of the fiscal years 2003 and 2004. Subpart D_Enabling Services SEC. 4031. GRANTS AND CONTRACTS FOR ENABLING SERVICES. (a) Authority._ (1) In general._The Secretary may make grants to and enter into contracts with eligible entities described in section 4001(a) to assist such entities in providing the services described in subsection (b) for the purpose of increasing the capacity of individuals to utilize the items and services included in the standard benefits package under title I, and to provide access to essential supplemental services that are not fully reimbursable under title I prior to January 2001. (2) Consideration by secretary._In awarding grants or contracts under paragraph (1), the Secretary shall give consideration to_ (A) the geographic proximity of the grant applicants and recipients; (B) cultural and language differences existing within the communities to be served under the grants or contracts; and (C) the capacity needs of the communities to be served. (b) Enabling Services._Enabling services shall include transportation, community and patient outreach, patient and family education, translation services, case management, home visiting, and such other services as the Secretary determines to be appropriate in carrying out the purpose described in such subsection. (c) Certain Requirements Regarding Project Area._The Secretary may make an award of a grant or contract under subsection (a) only if the applicant involved_ (1) submits to the Secretary_ (A) information demonstrating that the medically underserved populations in the community to be served under the award have a need for enabling services; and (B) a proposed budget for providing such services; (2) the applicant for the award agrees that the medically underserved residents of the community will be consulted with respect to the design and implementation of the project carried out with the award; (3) agrees that the services will not be denied because the individual is unable to pay for such services; and (4) agrees that the applicant will utilize existing resources to the maximum extent practicable. (d) Application for Awards of Assistance._The Secretary may make an award of a grant or contract under subsection (a) only if an application for the award is submitted to the Secretary, the application contains each agreement described in this subpart, and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this subpart. SEC. 4032. AUTHORIZATIONS OF APPROPRIATIONS. (a) In General._For the purpose of carrying out section 4031, there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 1996 through 2004. (b) Relation to Other Funds._The authorizations of appropriations established in subsection (a) are in addition to any other authorizations of appropriations that are available for the purpose described in such subsection. (c) Equitable Distribution._The Secretary shall, in awarding grants, entering into contracts, and making loans under this part, assure an equitable distribution of funds between rural and urban areas. PART 2_DEVELOPMENT OF TELEMEDICINE IN RURAL UNDERSERVED AREAS SEC. 4041. GRANTS FOR DEVELOPMENT OF RURAL TELEMEDICINE. (a) In General._ (1) Grants awarded._The Secretary, acting through the Office of Rural Health Policy, shall award grants to eligible entities that have applications approved under subsection (b) for the purpose of expanding access to health care services for individuals in rural areas through the use of telemedicine. Grants shall be awarded under this section to encourage the initial development of rural telemedicine networks, expand existing networks, link existing networks together, or link such networks to existing fiber optic telecommunications systems. (2) Eligible entity._For purposes of this section, the term ``eligible entity'' includes hospitals and other health care providers in a health care network of community-based providers that includes at least three of the following: (A) Community or migrant health centers. (B) Local health departments. (C) Community mental health centers. (D) Nonprofit hospitals. (E) Private practice health professionals, including rural health clinics. (F) Other publicly funded health or social services agencies. (b) Application._To be eligible to receive a grant under this section an entity shall prepare and submit to the Secretary an application at such time, in such manner and containing such information as the Secretary may require, including the anticipated need for the grant, a description of the use to which the eligible entity would apply any amounts received under such grant, the source and amount of non-Federal funds the entity would pledge for the project, a showing of the long-term viability of the project and evidence of the provider commitment to the network. The applicant should demonstrate the manner in which the project will promote the integration of telemedicine in the community so as to avoid redundancy of technology and achieve economies of scale. (c) Preference._The Secretary shall, in awarding grants under this section, give preference to applicants that_ (1) are health care providers in rural health care networks or providers that propose to form such networks, and the majority of the providers in such a network are located in a medically underserved or health professional shortage areas; (2) can demonstrate broad geographic coverage in the rural areas of the State, or States in which the applicant is located; (3) propose to use Federal funds to develop plans for, or to establish, telemedicine systems that will link rural hospitals and rural health care providers to other hospitals and health care providers; (4) will use the amounts provided under the grant for a range of health care applications and to promote greater efficiency in the use of health care resources; (5) demonstrate the long term viability of projects through use of local matching funds (cash or in-kind); and (6) demonstrate financial, institutional, and community support for the long range viability of the network. (d) Use of Amounts._Amounts received under a grant awarded under this section shall be utilized for the development of telemedicine networks. Such amounts may be used to cover the costs associated with the development of telemedicine networks and the acquisition of telemedicine equipment and modifications or improvements of telecommunications facilities including_ (1) the development and acquisition through lease or purchase of computer hardware and software, audio and visual equipment, computer network equipment, modification or improvements to telecommunications transmission facilities, telecommunications terminal equipments, interactive video equipment, data terminal equipment, and other facilities and equipment that would further the purposes of this section; (2) the provision of technical assistance and instruction for the development and use of such programming equipment or facilities; (3) the development and acquisition of instructional programming; (4) demonstration projects for teaching or training medical students, residents, and other health professions students in rural training sites about the application of telemedicine; (5) transmission costs, maintenance of equipment, and compensation of specialists and referring practitioners; (6) development of projects to use telemedicine to facilitate collaboration between health care providers; or (7) such other uses that are consistent with achieving the purposes of this section as approved by the Secretary. (e) Prohibited Uses._Amounts received under a grant awarded under this section may not be used for any of the following: (1) Expenditures to purchase or lease equipment to the extent the expenditures would exceed more than 60 percent of the total grant funds. (2) Expenditures for indirect costs (as determined by the Secretary) to the extent the expenditures would exceed more than 10 percent of the total grant funds. SEC. 4042. REPORT AND EVALUATION OF TELEMEDICINE. Not later than October 1, 1995, the White House Information Infrastructure Task Force shall prepare and submit to Congress a report that evaluates telemedicine. Such report shall evaluate_ (1) whether telemedicine expands access to health care services; (2) the effectiveness and cost effectiveness of telemedicine services; (3) the quality of telemedicine services delivered; and (4) all Federal activity regarding telemedicine and recommendations for a coordinated Federal strategy to increase access to health care through telemedicine. SEC. 4043. REGULATIONS ON REIMBURSEMENT OF TELEMEDICINE. Not later than July 1, 1996, the Secretary, in consultation with the Director of the Office of Rural Health and the Administrator of the Health Care Financing Administration, shall issue regulations concerning reimbursement for telemedicine services provided under title XVIII of the Social Security Act. SEC. 4044. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to carry out this subpart, $50,000,000 for fiscal year 1996, $51,000,000 for fiscal year 1997, $53,000,000 for fiscal year 1998, $54,000,000 for fiscal year 1999, $55,000,000 for fiscal year 2000, $57,000,000 for fiscal year 2001, $58,000,000 for fiscal year 2002, $60,000,000 for fiscal year 2003, and $61,000,000 for fiscal year 2004. PART 3_ESSENTIAL PUBLIC HEALTH ACTIVITIES SEC. 4051. GRANTS TO STATES FOR ESSENTIAL PUBLIC HEALTH ACTIVITIES. (a) In General._To enable a State to carry out the activities described in subsection (b), the Secretary shall make a grant to a State that submits an application under section 4054 in an amount that bears the same ratio to the amount appropriated for the fiscal year involved as the amounts provided by the Secretary to the State for fiscal year 1981 under the provisions of law referred to in section 1902(a)(2) of the Public Health Service Act (42 U.S.C. 300w-1(a)(2)) bear to the total amount appropriated with respect to such provisions for fiscal year 1981. (b) Essential Public Health Activities._For purposes of subsection (a), the activities described in this subsection are, subject to subsection (c), as follows: (1) Data collection and activities related to population health measurement and outcomes monitoring (including gender differences, ethnic identifiers, and health differences between racial and ethnic groups), and analysis for planning and needs assessment. (2) Activities to protect the environment and to assure the safety of housing, workplaces, food and water, and the public health of communities (including support for poison control centers and preventive health services programs to reduce the prevalence of chronic diseases and to prevent domestic violence, intentional, and unintentional injuries). (3) Investigation and control of adverse health conditions. (4) Public information, community outreach, and education programs to reduce risks to health. (5) Accountability and quality assurance activities, including quality of personal health services and any communities' overall access to health services. (6) Provision of public health laboratory services. (7) Training and education with special emphasis placed on the training of public health professions and occupational health professionals. (8) Leadership, policy development and administration activities. (c) Restrictions on Use of Grant._ (1) In general._A funding agreement for a grant under subsection (a) for a State is that the grant will not be expended_ (A) to provide inpatient services; (B) to make cash payments to intended recipients of health services; (C) to purchase or improve land, purchase, construct, or permanently improve (other than minor remodeling) any building or other facility, or purchase major medical equipment; (D) to satisfy any requirement for the expenditure of non-Federal funds as a condition for the receipt of Federal funds; or (E) to provide financial assistance to any entity other than a public or nonprofit private entity. (2) Limitation on administrative expenses._A funding agreement for a grant under subsection (a) is that the State involved will not expend more than 10 percent of the grant for administrative expenses with respect to the grant. (d) Maintenance of Effort._A funding agreement for a grant under subsection (a) is that the State involved will maintain expenditures of non-Federal amounts for essential public health activities at a level that is not less than the level of such expenditures maintained by the State for the fiscal year preceding the first fiscal year for which the State receives such a grant. SEC. 4052. SUBMISSION OF INFORMATION. The Secretary may make a grant under section 4051 only if the State involved submits to the Secretary the following information: (1) A description of existing deficiencies in the State's public health system (at the State level and the local level), using standards of sufficiency developed by the Secretary. (2) A description of health status measures to be improved within the State (at the State level and the local level) through expanded public health functions. (3) Measurable outcomes and process objectives for improving health status and essential public health activities for which the grant is to be expended. (4) Information regarding each such activity, which_ (A) identifies the amount of State and local funding expended on each such activity for the fiscal year preceding the fiscal year for which the grant is sought; and (B) provides a detailed description of how additional Federal funding will improve each such activity by both the State and local public health agencies. (5) A description of the essential public health activities to be carried out at the local level, and a specification for each such activity of_ (A) the communities in which the activity will be carried out; and (B) the amount of the grant to be expended for the activity in each community so specified. SEC. 4053. REPORTS. A funding agreement for a grant under section 4051 is that the States involved will, not later than the date specified by the Secretary, submit to the Secretary a report describing_ (1) the purposes for which the grant was expended; and (2) describing the extent of progress made by the State in achieving measurable outcomes and process objectives described in section 4052(3). SEC. 4054. APPLICATION FOR GRANT. The Secretary may make a grant under section 4051 only if an application for the grant is submitted to the Secretary, the application contains each agreement described in this part, the application contains the information required in section 4052, and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this part. SEC. 4055. ALLOCATIONS FOR CERTAIN ACTIVITIES. Of the amounts made available under section 4057 for a fiscal year for carrying out this part, the Secretary may reserve not more than 5 percent for carrying out the following activities: (1) Technical assistance with respect to planning, development, and operation of essential public health activities carried out under section 4031, including provision of biostatistical and epidemiological expertise and provision of laboratory expertise. (2) Development and operation of a national information network among State and local health agencies. (3) Program monitoring and evaluation of essential public health activities carried out under section 4051. (4) Development of a unified electronic reporting mechanism to improve the efficiency of administrative management requirements regarding the provision of Federal grants to State public health agencies. SEC. 4056. DEFINITIONS. For purposes of this part: (1) The term ``funding agreement'', with respect to a grant under section 4031 to a State, means that the Secretary may make the grant only if the State makes the agreement involved. (2) The term ``essential public health activities'', with respect to a State, means the activities described in section 4031(b). SEC. 4057. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to carry out this subpart, $284,000,000 for fiscal year 1996, $292,000,000 for fiscal year 1997, $339,000,000 for fiscal year 1998, $383,000,000 for fiscal year 1999, $381,000,000 for fiscal year 2000, $229,000,000 for fiscal year 2001, $133,000,000 for fiscal year 2002, and $95,000,000 for each of the fiscal years 2003 and 2004. SEC. 4058. SINGLE APPLICATION AND UNIFORM REPORTING SYSTEMS FOR ESSENTIAL PUBLIC HEALTH ACTIVITIES OF PUBLIC HEALTH AND PUBLIC HEALTH CATEGORICAL GRANT PROGRAMS ADMINISTERED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION. (a) Single Application._ (1) In general._The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish a single consolidated application to enable States to apply for the Essential Public Health Activities Grants Program and any or all of the Public Health Service Act categorical programs described in subsection (b). (2) Requirements._The application developed under paragraph (1) shall_ (A) be designed so that information collected will be consistent with the requirements of this part including subsection (b); (B) be designed and implemented not later than 1 year after the date of enactment of this Act; and (C) be developed with resources made available under section 4055 (not resources made available for the programs described in subsection (b)). (3) State public health officers._In developing the single consolidated application form to be used under this subsection the Secretary shall consult with Federal, State and local public health agencies. (4) Eligibility._States and local governments that have grants, contracts or cooperative agreements in effect with the Centers for Disease Control and Prevention on the date of enactment of this Act shall be eligible to use a single application under this section to apply for any or all of the Public Health Service Act categorical programs described in subsection (b). (b) Eligible Public Health Service Act Programs._Eligible Public Health Service Act categorical programs described in this subsection are the following: (1) The Preventive Health and Health Services Block Grant under section 1903 of the Public Health Service Act. (2) The Childhood Lead Poisoning Prevention Program under section 317A of the Public Health Service Act. (3) The Sexually Transmitted Diseases Program under section 318 of the Public Health Service Act. (4) The Prevention of Sexually Transmitted Diseases-Related Infertility Program under section 318A of the Public Health Service Act. (5) The Breast and Cervical Cancer Early Detection Program under sections 1501 through 1509 of the Public Health Service Act. (6) The National Program of Cancer Registries under section 399H of the Public Health Service Act. (7) The Injury Control and Prevention Program under sections 391 through 394 of the Public Health Service Act. (8) The preventive health for prostate cancer program under section 317D of the Public Health Service Act. (9) The birth defects data program under section 317C of the Public Health Service Act. (10) Programs under this part. (11) Other relevant programs as determined appropriate by the Secretary. (c) Allocation of Funds._In awarding grants to States and local governments under a single application under this section, the Secretary shall delineate to each grantee the amounts to be dedicated to each of the programs described in subsection (b) and ensure that funding allotments for each of such programs are consistent with the requirements of Federal law. (d) Uniform Essential Public Health Activities Reporting System._ (1) Development._The Secretary, acting through the Director of the Office of Disease Prevention and Health Promotion and the Director of the Centers for Disease Control and Prevention, in consultation with other relevant Federal and State health agencies with data collection responsibilities, shall develop and implement a Uniform Essential Public Health Activities Reporting System to collect program and fiscal data concerning the programs described in subsection (b). (2) Requirements._The system developed under paragraph (1) shall_ (A) use outcomes consistent with the goals of Healthy People 2000; (B) be designed so that information collected will be consistent with the requirements of this part including subsection (b); (C) be designed and implemented not later than 2 years after the date of enactment of this Act; and (D) be developed with resources made available under section 4055 of this Act (not resources made available for the programs described in subsection (b)). (e) Study._ (1) In general._Within a reasonable period of time after the date of enactment of this Act, the Secretary shall request that the Institute of Medicine conduct a study concerning_ (A) the effects of consolidating any or all of the grant programs administered by the Centers for Disease Control and Prevention and described in subsection (b) into a Essential Public Health Activities Block Grant Program; (B) the development of alternative methods for implementing a block grant program or categorical grant program; and (C) alternative formulas for allocating State grants that incorporate measures of health status, population and degree of poverty. If the Institute of Medicine declines to conduct the study under this paragraph, the Secretary shall make grants to or enter into contracts with a public or nonprofit private entity with relevant expertise for the conduct of such study. (2) Report._Not later than 1 year after the date of the submission of a request under paragraph (1) (or the receipt of a grant or contract under such paragraph), the Institute of Medicine (or the grant or contract recipient) shall prepare and submit to the Secretary and the appropriate committees of Congress a report that contains the results of the study conducted under paragraph (1). (3) Issuance of plan._Not later than 1 year after the date on which the report under paragraph (2) is received by the Secretary and the committees referred to in such paragraph, the Secretary shall issue a plan in response to the report. Such plan shall include recommendations for relevant amendments to the grant programs referred to in paragraph (1) PART 4_RURAL HEALTH PLAN DEMONSTRATION PROJECTS SEC. 4061. RURAL HEALTH PLAN DEMONSTRATION PROJECTS. (a) In General._The Secretary, in consultation with the Secretary of Labor, may establish and implement not more than 3 demonstration projects for the designation of rural health plan areas. To be designated as a rural health plan area under this section, an area must be a rural area (as defined in section 1866(d)(2)(D) of the Social Security Act) or an underserved nonurban area in accordance with other criteria specified by the Secretary. (b) Application._To be eligible to conduct a demonstration project under this section, an entity shall prepare and submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require to ensure that project participants meet the goals described in subsection (d). An application submitted under this section shall_ (1) identify the area in which the demonstration project will be conducted; and (2) provide assurances that the area described in paragraph (1) meets the requirements of subsection (a). (c) Requirements._An entity offering a health plan through a demonstration project under this section shall_ (1) have a recognized, long-standing relationship with the rural community in which the project is being conducted; (2) ensure that the health plan is operated as a certified health plan; (3) ensure that the plan meets the requirements for certified health plans under title I; (4) ensure that the plan offers enrollment_ (A) on an experience-rated basis to experience-rated employees of the plan sponsor; and (B) on a community-rated basis to community-rated individuals in the community rating area in which such plan operates; and (5) meet the requirements of subtitle A of title I. (d) Goals._The goals referred to in this subsection are as follows: (1) To develop a reliable supply of health care providers and rural health service delivery infrastructures with a sound financial footing. (2) To develop a mechanism to begin to provide the benefits of networking found in urban health systems to rural Americans living in rural health plan areas. (e) Duration._The Secretary may revoke the designation of a rural health plan area if the Secretary determines that the entity conducting the project in such area has failed to comply with the requirements of this section. The Secretary may not designate a rural health plan area under this section after December 31, 1999. (f) Evaluations and Reports._ (1) Evaluations._Each entity offering a health plan through a demonstration project under this section shall submit to the Secretary such interim evaluations as the Secretary may require. (2) Report._Not later than 360 days after the date on which the first demonstration project is implemented under this section, and annually thereafter for each year in which a project is being conducted, the Secretary shall submit to Congress a report that evaluates the effectiveness of such projects. Such reports shall include any legislative recommendations determined appropriate by the Secretary. PART 5_MENTAL HEALTH AND SUBSTANCE ABUSE SYSTEM INTEGRATION SEC. 4071. INTEGRATION OF MENTAL HEALTH AND SUBSTANCE ABUSE SYSTEMS. (a) Mental Health Services._Section 1912(b) of the Public Health Service Act (42 U.S.C. 300x-1(b)) is amended by adding at the end thereof the following: ``(13) The plan describes_ ``(A) the impact of changes (including gaps in coverage and access) resulting from the enactment of the Health Reform Act concerning the provision of mental illness services to individuals in both the public and private sectors and, if appropriate to ensure the provision of mental illness services, the measures to be implemented by the State to achieve the integration of the mental illness services of the State and its political subdivisions with the mental illness services provided by health plans; and ``(B) the method of financing mental illness services by source, including medicaid (title XIX of the Social Security Act), Federal block grant funds under this title, Federal categorical funds, State and local revenues, and health plan payments. The measures described in subparagraph (A) may include the development and operation of comprehensive managed mental health programs. To the maximum extent practicable, such measures shall be the same as and coordinated with those to integrate the substance abuse services under section 1921.''. (b) Substance Abuse Services._Section 1932(b)(1) of such Act (42 U.S.C. 300x-32(b)(1)) is amended by strike ``if the plan'' and all that follows and inserting ``if the plan_ ``(A) contains detailed provisions for complying with each funding agreement for a grant under section 1921 that is applicable to the State, including a description of the manner in which the State intends to expend the grant; and ``(B)(i) describes the impact of changes (including gaps in coverage and access) resulting from the enactment of the Health Reform Act concerning the provision of substance abuse services to individuals in both the public and private sectors and, if appropriate to ensure the provision of substance abuse services, the measures to be implemented by the State to achieve the integration of the substance abuse services of the State and its political subdivisions with the substance abuse services provided by health plans; and ``(ii) describes the method of financing substance abuse services by source, including medicaid (title XIX of the Social Security Act), Federal block grant funds under this title, Federal categorical funds, State and local revenues, and health plan payments. The measures described in paragraph (1) may include the development and operation of comprehensive managed substance abuse treatment programs. To the maximum extent practicable, such measures shall be the same as and coordinated with those to integrate the mental illness services under section 1911.''. PART 6_SCHOOL-RELATED HEALTH SERVICES SEC. 4081. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to carry out this subpart, $252,000,000 for fiscal year 1996, $292,000,000 for fiscal year 1997, $359,000,000 for fiscal year 1998, $441,000,000 for fiscal year 1999, $427,000,000 for fiscal year 2000, $256,000,000 for fiscal year 2001, $149,000,000 for fiscal year 2002, and $107,000,000 for each of the fiscal years 2003 and 2004. SEC. 4082. ELIGIBILITY FOR GRANTS. (a) In General._ (1) Planning and development grants._Entities eligible to apply for and receive grants under section 4084 are_ (A) State agencies that apply on behalf of local community partnerships; or (B) local community partnerships in States in which State agencies have not successfully applied. (2) Operational grants._Entities eligible to apply for and receive grants under section 4085 are_ (A) a qualified State as designated under subsection (c) that apply on behalf of local community partnerships; or (B) local community partnerships in States that are not designated under subparagraph (A). (b) Local Community Partnerships._ (1) In general._A local community partnership under subsection (a)(1)(B) and (a)(2)(B) is an entity that, at a minimum includes_ (A) a local health care provider, which may be a local public health department, with experience in delivering services to children and youth or medically underserved populations; (B) local educational agency on behalf of one or more public schools; and (C) one community based organization located in the community to be served that has a history of providing services to at-risk children and youth. (2) Rural communities._In rural communities, local partnerships should seek to include, to the fullest extent practicable, providers and community based organizations with experience in serving the target population. (3) Parent and community participation._An applicant described in subsection (a) shall, to the maximum extent feasible, involve broad-based community participation (including parents of the youth to be served). (c) Qualified State._A qualified State under subsection (a)(2)(A) is a State that, at a minimum_ (1) demonstrates an organizational commitment (including a strategic plan) to providing a broad range of health, health education and support services to at-risk youth; and (2) has a memorandum of understanding or cooperative agreement jointly entered into by the State agencies responsible for health and education regarding the planned delivery of health and support services in school-based or school-linked centers. SEC. 4083. PREFERENCES. In making grants under sections 4084 and 4085, the Secretary shall give priority to applicants whose-communities to be served show the most substantial level of need for health services among children and youth. SEC. 4084. PLANNING AND DEVELOPMENT GRANTS. (a) In General._The Secretary may make grants during fiscal years 1996 and 1997 to entities eligible under section 4082 to develop school-based or school-linked health service sites. (b) Use of Funds._Amounts provided under a grant under this section may be used for the following: (1) Planning for the provision of school health services, including_ (A) an assessment of the need for health services among youth in the communities to be served; (B) the health services to be provided and how new services will be integrated with existing services; (C) assessing and planning for the modernization and expansion of existing facilities and equipment to accommodate such services; and (D) an affiliation with relevant health plans. (2) recruitment and training of staff for the administration and delivery of school health services; (3) the establishment of local community partnerships as described in section 4082(b); (4) in the case of States, the development of memorandums of understanding or cooperative agreements for the coordinated delivery of health and support services through school health service sites; and (5) other activities necessary to assume operational status. (c) Application for Grants._To be eligible to receive a grant under this section an entity described in section 4082(a) shall submit an application in a form and manner prescribed by the Secretary. (d) Number of Grants._Not more than one planning grant may be made to a single applicant. A planning grant may not exceed 2 years in duration. (e) Amount Available for Development Grant._The Secretary may award not to exceed_ (1) $150,000 to entities under section 4082(a)(1)(A) and to localities planning for a citywide or countywide school health services delivery system; and (2) $50,000 to entities under section 4082(a)(1)(B). SEC. 4085. GRANTS FOR OPERATION OF SCHOOL HEALTH SERVICES. (a) In general._The Secretary may make grants to eligible entities described in section 4082(a)(2) that submit applications consistent with the requirements of this section, to pay the cost of operating school-based or school-linked health service sites. (b) Use of Grant._Amounts provided under a grant under this section may be used for the following_ (1) health services, including diagnosis and treatment of simple illnesses and minor injuries; (2) preventive health services, including health screenings follow-up health care, mental health, and preventive health education; (3) enabling services, as defined in subsection (l), and other necessary support services; (4) training, recruitment, and compensation of health professionals and other staff necessary for the administration and delivery of school health services; and (5) referral services, including the linkage of individuals to health plans, and community-based health and social service providers. (c) Application for Grant._To be eligible to receive a grant under this section an entity described in section 4082(a)(2) shall submit an application in a form and manner prescribed by the Secretary. In order to receive a grant under this section, an applicant must include in the application the following information_ (1) a description of the services to be furnished by the applicant; (2) the amounts and sources of funding that the applicant will expend, including estimates of the amount of payments the applicant will receive from health plans and other sources; (3) a description of local community partnerships, including parent and community participation; (4) a description of the linkages with other health and social service providers; and (5) such other information as the Secretary determines to be appropriate. (d) Assurances._In order to receive a grant under this section, an applicant must meet the following conditions_ (1) school health service sites will, directly or indirectly, provide a broad range of health services, in accordance with the determinations of the local community partnership, that may include_ (A) diagnosis and treatment of simple illnesses and minor injuries; (B) preventive health services, including health screenings and follow-up health care, mental health and preventive health education; (C) enabling services, as defined in subsection (l); (D) referrals (including referrals regarding mental health and substance abuse) with follow-up to ensure that needed services are received; (2) the applicant provides services recommended by the health provider, in consultation with the local community partnership, and with the approval of the local education agency; (3) the applicant provides the services under this subsection to adolescents, and other school age children and their families as deemed appropriate by the local partnership; (4) the applicant maintains agreements with community-based health care providers with a history of providing services to such populations for the provision of health care services not otherwise provided directly or during the hours when school health services are unavailable; (5) the applicant establishes an affiliation with relevant health plans and will establish reimbursement procedures and will make every reasonable effort to collect appropriate reimbursement for services provided; and (6) the applicant agrees to supplement and not supplant the level of State or local funds under the direct control of the applying State or participating local education or health authority expended for school health services as defined by this Act; (7) services funded under this Act will be coordinated with existing school health services provided at a participating school; and (8) with respect to applicants in rural areas, the assurances required under paragraph (4) shall be fulfilled to the maximum extent possible. (e) State Laws._Notwithstanding any other provision in this part, no school based health clinic may provide services, to any minor, when to do so is a violation of State laws or regulations pertaining to informed consent for medical services to minors. (f) Limitation on Administrative Funds._In the case of a State applying on behalf of local educational partnerships, the applicant may retain not more than 5 percent of grants awarded under this subpart for administrative costs. (g) Duration of Grant._A grant under this section shall be for a period determined appropriate by the Secretary. (h) Amount of Grant._The annual amount of a grant awarded under this section shall not be more than $200,000 per school-based or school-linked health service site. (i) Federal Share._ (1) In general._Subject to paragraph (3), a grant for services awarded under this section may not exceed_ (A) 90 percent of the non-reimbursed cost of the activities to be funded under the program for the first 2 fiscal years for which the program receives assistance under this section; and (B) 75 percent of the non-reimbursed cost of such activities for subsequent years for which the program receives assistance under this section. The remainder of such costs shall be made available as provided in paragraph (2). (2) Form of non-federal share._The non-Federal share required by paragraph (1) may be in cash or in-kind, fairly evaluated, including facilities, equipment, personnel, or services, but may not include amounts provided by the Federal Government. In-kind contributions may include space within a school facilities, school personnel, program use of school transportation systems, outposted health personnel, and extension of health provider medical liability insurance. (3) Waiver._The Secretary may waive the requirements of paragraph (1) for any year in accordance with criteria established by regulation. Such criteria shall include a documented need for the services provided under this section and an inability of the grantee to meet the requirements of paragraph (1) despite a good faith effort. (j) Training and Technical Assistance._Entities that receive assistance under this section may use not to exceed 10 percent of the amount of such assistance to provide staff training and to secure necessary technical assistance. To the maximum extent feasible, technical assistance should be sought through local community-based entities. The limitation contained in this subsection shall apply to individuals employed to assist in obtaining funds under this part. Staff training should include the training of teachers and other school personnel necessary to ensure appropriate referral and utilization of services, and appropriate linkages between class-room activities and services offered. (k) Report and Monitoring._The Secretary will submit to the Committee on Labor and Human Resources in the Senate and the Committee on Energy and Commerce in the House of Representatives a biennial report on the activities funded under this Act, consistent with the ongoing monitoring activities of the Department. Such reports are intended to advise the relevant Committees of the availability and utilization of services, and other relevant information about program activities. (l) Enabling Services._Enabling services shall include transportation, community and patient outreach, patient and family education, translation services, case management, home visiting, and such other services as the Secretary determines to be appropriate in carrying out the purpose described in such subsection. PART 7_ADDITIONAL PROVISIONS REGARDING PUBLIC HEALTH SEC. 4091. COMMUNITY SCHOLARSHIP PROGRAM. Section 338L of the Public Health Service Act (42 U.S.C. 245t) is amended_ (1) in the section heading, by striking ``DEMONSTRATION''; (2) in subsection (a)_ (A) by striking ``for the purpose of carrying out demonstration programs''; and (B) by striking ``health manpower shortage areas'' and inserting ``Federally-designated health professional shortage areas''; (3) in subsection (c)_ (A) by striking ``health manpower shortage areas'' and inserting ``Federally-designated health professional shortage areas'' in the matter preceding paragraph (1); and (B) by striking ``in the health manpower shortage areas in which the community organizations are located,'' and inserting ``in a Federally-designated health professional shortage area that is served by the community organization awarding the scholarship,'' in paragraph (2); (4) in subsection (e)(1), by striking ``health manpower shortage area'' and inserting ``a Federally-designated health professional shortage area''; (5) in subsection (k)(2), by striking ``internal medicine'' and all that follows through the end thereof and inserting ``general internal medicine, general pediatrics, obstetrics and gynecology, dentistry, or mental health, that are provided by physicians or other health professionals.''; and (6) in subsection (l)(1)_ (A) by striking ``1991'' and inserting ``1995''; and (B) by striking $10,000,000'' and all that follows through the end thereof and inserting: ``$5,000,000 for each of the fiscal years 1996 through 1998, and $6,000,000 for ``for each of the fiscal years 1999 through 2004.''. SEC. 4092. PARITY FOR FEDERAL FACILITIES SUPPORTING RESEARCH. Subpart 1 of part E of title IV of the Public Health Service Act is amended by inserting after section 479 (42 U.S.C. 287 et seq.) the following new section: ``SEC. 479A. COLLECTIONS. ``The Secretary may collect health plan payments for patient care costs pursuant to a qualified investigational treatment (as defined in section 1101(7) of the Health Reform Act) that are incurred in Public Health Service Research facilities, for deposit in the General Treasury.''. PART 8_NATIONAL HEALTH SERVICE CORPS SEC. 4095. NATIONAL HEALTH SERVICE CORPS. Section 338 of the Public Health Service Act (42 U.S.C. 254k) is amended by adding at the end thereof the following new subsection: ``(c) Of the amounts appropriated under this section, the Secretary shall reserve such amounts as may be necessary to ensure that, 20 percent of the aggregate number of individuals who are participants in the Scholarship Program under section 338A, or in the Loan Repayment Program under section 338B, are being educated or are serving as nurse practitioners, certified nurse midwives, nurse anesthetists or physician assistants. ``(d) Of the amounts appropriate under this section, the Secretary shall reserve such amounts as may be necessary to ensure that 15 percent of the aggregate number of individuals who are participants in the scholarship program under section 338A, or in the Loan Repayment Program under section 338B, are being educated or are serving as dentists, psychiatrists, psychologists, or clinical social workers.''. IVB˙09 IVB˙09 IVB˙09 Subtitle B_Graduate Medical Education PART 1_WORKFORCE PRIORITIES FOR DIRECT GRADUATE MEDICAL EDUCATION SEC. 4101. NATIONAL COMMISSION ON GRADUATE MEDICAL EDUCATION. (a) Establishment._There is established an independent National Commission on Graduate Medical Education (referred to in this section as the ``Commission''). (b) Membership._ (1) Appointment._The Commission shall consist of 13 members appointed by the Director of the Congressional Office of Technology Assessment (referred to in this section as the ``Director'') without regard to the provisions of title 5, United States Code, governing appointments in the competitive service. Members of the Commission shall first be appointed no later than May 1, 1995, for a term of 3 years, except that the Director may provide initially for such shorter terms as will ensure that the terms of no more than 4 members expire in any one year. (2) Expertise._The membership of the Commission shall be composed of individuals with expertise in issues relating to physician training and the national physician workforce. The membership of the Commission shall include, but is not limited to, the following: (A) Consumers of health care services, at least one of whom resides in a rural area. (B) Primary health care physicians who are faculty members of medical schools (including officials of medical schools and executive officers of teaching hospitals) and primary health care physicians who are practicing and are not faculty members of medical schools, at least one of whom resides in a rural area. (C) Non-primary health care specialty physicians who are faculty members of medical schools, non-primary health care specialty physicians who are not faculty members of medical schools, officials of medical schools, and executive officers of teaching hospitals. (D) Officers and employees of health plans, at least one of whom represents a managed care entity. (c) Activities of the Commission._ (1) Legislative proposal on the national health care workforce._ (A) In general._Not later than May 1, 1996, the Commission shall develop a legislative proposal containing the Commission's legislative recommendations on the national health care workforce (as developed under subparagraph (B)). (B) National health care workforce._ (i) In general._The Commission shall monitor the national health care workforce and develop legislative recommendations on_ (I) the composition of residency training positions after considering how such composition and the composition of the physician health care workforce addresses the needs of the health care market for access to health care services, including access in underserved rural and urban areas, economic efficiency, and quality; and (II) a system for distributing funds to the residency positions that are supported by the Graduate Medical Education Trust Fund established under section 9511 of the Internal Revenue Code of 1986 beginning in academic year 1998 that is as decentralized and nonregulatory as possible and that is administered by the Secretary of Health and Human Services (referred to in this section as the ``Secretary''). (ii) Special considerations._In developing its legislative recommendations under clause (i), the Commission shall_ (I) consult with the Secretary, the Council on Graduate Medical Education, the Prospective Payment Assessment Commission, and the Physician Payment Review Commission; (II) consider recommendations of organizations representing health care providers, residency educators, academic health centers, teaching hospitals, health care insurers (including managed care entities), and any other relevant organization; (III) take into account developments in the health care market and the supply of nonphysician health care providers that affect the need for physicians, the physician specialty mix, and physician distribution; (IV) address the special issues of implementation, including issues relating to international medical graduates seeking residency positions in the United States and the impact on health care delivery systems in the States that have relied on the medical residency services of such graduates most; (V) take into account the historical allocation of residency positions funded, the impact on the health care delivery systems that have relied on such positions, the quality of the programs, and the unique missions or special services provided by the programs; (VI) in developing a system for distributing funds out of the Fund_ (aa) consider the direct distribution of all funds through residency programs, through health care training consortia, through teaching hospitals, or through methods that adjust per resident payments by various weighting factors; and (bb) give priority to a system which is as decentralized and nonregulatory as possible while achieving the goals developed under clause (i)(II). (C) Ongoing reports and recommendations to the congress and the secretary._After a legislative proposal developed by the Commission under subparagraph (A) is submitted under section 4102, the Commission shall submit to the Congress and the Secretary annual reports or legislative recommendations on issues which include_ (i) assessments and recommendations, as appropriate, in the following areas: (I) the composition of the physician and non-physician national health care workforce and how such composition addresses the needs of the health care market; (II) sources and uses of funds related to direct and indirect graduate medical education and options for future payment policy, including methods which would create a market to match residents with residency positions; (III) payment distribution methods related to graduate medical education and options for future distribution policy; (IV) per-speciality national average direct graduate medical education payments and direct medical education payment amounts provided by this Act; (V) incentives to encourage health care practitioners to enter primary health care specialty areas and to provide services in underserved areas and options for future policies; (VI) role, composition, distribution, and costs related to international medical graduates in the national health care workforce and options for future policies; and (VII) the funding of academic health centers and teaching hospitals considering changes in the medical market and the unique educational and research missions of such entities; (ii) recommendations for a coordinated policy for the future direction and distribution of grants, demonstration projects, and other funding affecting the health care workforce; and (iii) recommendations and a schedule for topics to be addressed in subsequent reports, based on the findings and recommendations of the Commission described in the previous clauses. (d) Matters Related to Carrying Out Functions._In order to carry out its functions, the Commission shall collect and assess information. In collecting and assessing information, the Commission shall_ (1) utilize existing information (both published and unpublished, where possible) collected and assessed either by the Commission's staff or under other arrangements made in accordance with this section; (2) carry out, or award grants or contracts for, original research and experimentation if existing information is inadequate for the development of useful and valid guidelines by the Commission; (3) adopt procedures allowing any interested parties to submit information with respect to physicians services (including new practices, such as the use of new technologies and treatment modalities) which the Commission shall consider in making reports and recommendations to the Congress and the Secretary; and (4) if existing data bases are insufficient, maintain, develop, or seek to enhance, data bases concerning the supply and distribution of, and postgraduate training programs for, physicians and other primary care providers in the United States. (e) Administrative Issues Related to the Commission._The following provisions of section 1886(e)(6) of the Social Security Act shall apply to the Commission in the same manner as such provisions apply to the Prospective Payment Assessment Commission established under section 1886(e)(2) of such Act: (1) Subparagraph (C) (relating to staffing and administration). (2) Subparagraph (D) (relating to compensation of members). (3) Subparagraph (F) (relating to access to information). (4) Subparagraph (G) (relating to use of funds). (5) Subparagraph (H) (relating to periodic GAO audits). (6) Subparagraph (J) (relating to requests for appropriations). (g) Funding for Commission._There are authorized to be appropriated such sums as may be necessary to carry out the provisions of this section. (h) Conforming Amendment Repealing the Council on Graduate Medical Education._Effective October 1, 1995, section 30 of the Health Professions Extension Amendments of 1992 (Public Law 102-408) is repealed. SEC. 4102. FAST TRACK PROCEDURE FOR CONSIDERATION OF LEGISLATIVE PROPOSAL ON NATIONAL HEALTH CARE WORKFORCE. (a) In General._The legislative proposal of the National Commission on Graduate Medical Education (referred to in this section as the ``Commission'') described in section 4101(c)(1)(A) shall be submitted to Congress in the form of an implementing bill which contains the statutory provisions necessary or appropriate to implement the proposal. Such an implementing bill shall be considered by Congress as described in section 1108. (b) Resubmissions._If an implementing bill submitted under subsection (a) is not approved by Congress or is vetoed by the President (and such veto is not overridden by the Congress), the Commission shall resubmit a new implementing bill not later than 90 days after Congress failed to approve such bill or failed to override the President's veto, and such new implementing bill shall be subject to congressional consideration as provided in subsection (a). PART 2_PAYMENTS FOR OPERATION OF APPROVED PHYSICIAN TRAINING PROGRAMS Subpart A_Payments for Operation of Approved Physician Training Programs SEC. 4111. FEDERAL FORMULA PAYMENTS FOR THE DIRECT COSTS OF THE OPERATION OF APPROVED PHYSICIAN TRAINING PROGRAMS. (a) Requirement on Secretary to Make Payments._In the case of a qualified entity (as defined in subsection (c)) that in accordance with section 4112 submits to the Secretary an application for calendar year 1997 or any subsequent calendar year, the Secretary shall make payments for such year to the qualified entity for the purpose specified in subsection (b). The Secretary shall make the payments in an amount determined in accordance with section 4113, and may administer the payments as a contract, grant, or cooperative agreement. (b) Payments for Operation of Approved Physician Training Programs._The purpose of payments under subsection (a) is to assist a qualified entity with the direct costs of operation of an approved physician training program. (c) Definitions._For purposes of this subpart: (1) Approved physician training program._The term ``approved physician training program'', with respect to the medical specialty involved, means a residency or other postgraduate program that trains physicians and meets the following conditions: (A) Participation in the program may be counted toward certification in the medical specialty as determined under the applicable standards of the American Board of Medical Specialties or the Council on Postdoctoral Training of the American Osteopathic Association. (B) The program is accredited by the Accreditation Council on Graduate Medical Education, or approved by the Council on Postdoctoral Training of the American Osteopathic Association. (2) Qualified entity._The term ``qualified entity'' means_ (A) a qualified health care training consortium (as defined in paragraph (3)); or (B) any other entity which incurs the cost of operating an approved physician training program. (3) Qualified health care training consortium._The term ``qualified health care training consortium'' means a health care training consortium (as defined in section 1886(j)(5) of the Social Security Act (as added by section 4115)) that meets the requirements of section 1886(j)(2) of such Act. SEC. 4112. APPLICATION FOR PAYMENTS. For purposes of section 4111(a), an application for payments under such section for a calendar year is in accordance with this section if_ (1) the qualified entity submits the application not later than the date specified by the Secretary; and (2) the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this subpart. SEC. 4113. AVAILABILITY OF FUNDS FOR PAYMENTS; ANNUAL AMOUNT OF PAYMENTS. (a) Graduate Medical Education Trust Fund._The following amounts shall be available for a calendar year for making payments under section 4111 from the Graduate Medical Education Trust Fund established under section 9551 of the Internal Revenue Code of 1986: (1) In the case of calendar year 1997, $4,300,000,000. (2) In the case of calendar year 1998, $4,820,000,000. (3) In the case of calendar year 1999, $5,440,000,000. (4) In the case of each of calendar years 2000 and 2001, $5,910,000,000. (5) In the case of each subsequent calendar year, the amount specified in paragraph (4) increased by the product of such amount and the percentage increase in the consumer price index (as defined in subsection (e)(1)) for such year. (b) Amount of Payments for Individual Eligible Entities._ (1) In general._Payment amounts with respect to any physician training program made on such program's behalf to the qualified entity with which the physician training program participates under this section shall be equal to the product of the number of full time equivalent training participants in the program, and the per resident amount for the training program. (2) Per resident amount._ (A) In general._Except as provided under subparagraph (B), the per resident amount for a training program shall be equal to_ (i) with respect to_ (I) the first calendar year during which the program receives payment under subsection (a), 90 percent; (II) the second calendar year during which the program receives payment under subsection (a), 80 percent; (III) the third calendar year during which the program receives payment under subsection (a), 70 percent; (IV) the fourth calendar year during which the program receives payment under subsection (a), 60 percent; and (V) the fifth and subsequent calendar year during which the program receives payment under subsection (a), 50 percent; of the approved FTE resident amount that would have been determined under section 1886(h)(2)(D) of the Social Security Act (42 U.S.C. 1395ww(h)(2)(D)) for the hospital operating such approved physician training program for a cost reporting period beginning in such calendar year if the amendments made by section 4114 of the Health Reform Act had not been made; and (ii) with respect to_ (I) the first calendar year during which the program receives payment under subsection (a), 10 percent; (II) the second calendar year during which the program receives payment under subsection (a), 20 percent; (III) the third calendar year during which the program receives payment under subsection (a), 30 percent; (IV) the fourth calendar year during which the program receives payment under subsection (a), 40 percent; and (V) the fifth and subsequent calendar years during which the program receives payment under subsection (a), 50 percent; of the geographically adjusted national average per resident amount. (B) Minimum per resident amount._Notwithstanding the provisions of subparagraph (A), the per resident amount for a training program shall not be less than 75 percent of the geographically adjusted national average per resident amount determined in accordance with subparagraph (A)(ii). (C) No historic payment basis._For purposes of subparagraph (A)(i), the Secretary shall determine the appropriate per resident amount applicable to a qualified entity that_ (i) has an approved physician training program that sponsored or is affiliated with more than one hospital that had a per resident amount determined under section 1886(h) of the Social Security Act which reflects the average per resident amounts under such section for such hospitals; or (ii) is an institution that did not have a per resident amount determined under such section for cost reporting periods beginning before 1996 which reflects the national average per resident amount. (3) Adjustment factor._Payments under this section shall be subject to an adjustment factor, as determined by the Secretary, so that total payments in any year will not exceed the amounts specified in subsection (a) and as provided in subsection (d). (4) Additional provisions regarding national average cost._ (A) Determination of national average cost._The Secretary shall in accordance with clause (ii) of paragraph (2)(A) determine, for academic year 1992˙091993, an amount equal to the geographically adjusted national average per resident amount described in such clause with respect to training a participant in an approved physician training program. The national average applicable under such clause for a calendar year for such programs is, subject to subparagraph (B), the amount determined under the preceding sentence increased by the amount necessary to offset the effects of inflation occurring since academic year 1992˙091993, as determined through use of the consumer price index. (B) Geographic adjustment._The national average determined under subparagraph (A) and applicable to a calendar year shall, in the case of the qualified entity involved, be adjusted by a factor to reflect regional differences in the applicable wage and wage-related costs. (c) Determination of Full-Time-Equivalent Training Participants._ (1) In general._Except as otherwise provided in this subsection, in determining the number of full-time equivalent training participants in approved physician training programs under subsection (b)(1), paragraphs (4) and (5) of section 1886(h) of the Social Security Act (as in effect on the day before the date of the enactment of this Act) shall apply. (2) Substitution of certain definitions._For purposes of paragraph (1), in applying paragraph (5) of section 1886(h) of the Social Security Act, the Secretary shall_ (A) substitute the definition of the term ``consumer price index'' under subsection (e)(1) for the definition of such term under section 1886(h)(5)(B) of such Act; and (B) substitute the definition of the term ``initial training period'' under subsection (e)(2) for the definition of ``initial residency period'' under section 1886(h)(5)(F) of such Act. (3) Rules._The Secretary shall establish rules for the computation of the number of full-time-equivalent training participants in approved physician training programs in accordance with paragraph (1). (4) Counting time spent in outpatient settings._The rules established by the Secretary shall provide that only time spent in activities relating to patient care shall be counted and that all the time so spent by a training participant under an approved physician training program shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed. (d) Limitation._Subject to subsection (a), if the amount available from the Graduate Medical Education Trust Fund established under section 9551 of the Internal Revenue Code of 1986 for a calendar year is insufficient for providing each qualified entity with the amount of payments determined under subsection (b) for the entity for such year, the Secretary shall make such pro rata reductions in the amounts so determined as may be necessary to ensure that the total of payments made under section 4111 for such year equals the amount specified under subsection (a). (e) Definitions._For purposes of this subpart: (1) Consumer price index._The term ``consumer price index'' means the Consumer Price Index for All Urban Consumers (U.S. city average). (2) Initial training period._The term ``initial training period'' means the period of time required for board eligibility, except that_ (A) except as provided in subparagraph (B), in no case shall the initial period of participation exceed an aggregate period of formal training of more than 5 years for any individual, and (B) a period, of not more than 2 years, during which an individual is in a_ (i) residency or fellowship program in geriatric medicine, preventive medicine, or adolescent medicine, or (ii) a fellowship program in family medicine, general internal medicine or general pediatrics, which provides training for a faculty position in family medicine, general internal medicine or general pediatrics, shall be treated as part of the initial training participation period, but shall not be counted against any limitation on the initial training period. The initial training period shall be determined, with respect to a training participant, as of the time the training participant enters any approved physician training program. SEC. 4114. TERMINATION OF MEDICAL EDUCATION PAYMENTS. (a) In General._Section 1886(h) (42 U.S.C. 1395ww(h)) is amended by adding at the end the following new paragraph: ``(6) Termination of payments attributable to costs of training physicians._Notwithstanding any other provision of this section or section 1861(v), no payment may be made under this title for direct graduate medical education costs attributable to an approved medical residency training program for any cost reporting period (or portion thereof) beginning on or after January 1, 1997.''. (b) Prohibition Against Recognition of Costs of Training Physicians._Section 1861(v)(1) (42 U.S.C. 1395x(v)(1)), as amended by section 3212(b), is amended by adding at the end the following new subparagraph: ``(U) Such regulations shall not include any provision for specific recognition of the costs of graduate medical education for hospitals for any cost reporting period (or portion thereof) beginning on or after January 1, 1997. Nothing in the previous sentence shall be construed to affect in any way payments to hospitals for the costs of any approved educational activities that are not described in such sentence.''. Subpart B_Interim Graduate Medical Education Consortium Program SEC. 4115. GRADUATE MEDICAL EDUCATION CONSORTIUM PROGRAM. Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is amended by adding at the end the following new subsection: ``(j) Consortium Program._ ``(1) In general._The Secretary shall provide for the establishment and operation of health care training consortia (as defined in paragraph (5)(B)) which are located in a State (or a region of a State) or are multi-State consortia (which may be regions of various States) for the purpose of receiving funds otherwise available for direct graduate medical education costs under subsection (h). ``(2) Requirements on consortia._ ``(A) In general._A health care training consortium shall meet the following requirements: ``(i) Administration._A health care training consortium shall establish an administrative structure that reflects the membership of the consortium. The Secretary shall monitor the administrative structure of each consortium receiving payments under this subsection to ensure that each member has adequate representation within such structure. ``(ii) Use of funds._ ``(I) In general._The members of a health care training consortium shall collectively determine a plan for how funds received by the consortium under this subsection will be used to better satisfy local and regional workforce needs and the educational quality of the approved physician training programs. ``(II) Resident site of training._With respect to payments made by a health care training consortium to support the training of residents, the consortium shall provide that the funds received by the consortium under this subsection are provided to the entity incurring the costs for the operation of an approved physician training program. (iii) Fiscal agent._A health care training consortium shall designate a fiscal agent to be responsible and accountable for_ (I) the consortium's performance; (II) coordinating the consortium's activities; (III) distributing all funds received by the consortium under this subsection based on the plan approved by the consortium under clause (ii); and (IV) submitting all documentation required by the Secretary regarding the requirements of this subpart. ``(B) Primary care training requirement._For an academic year, the Secretary shall ensure that each health care training consortium is operated with the intent of increasing the consortium's percentage of residents in primary care (as defined in paragraph (5)(C)). ``(3) Applications._ ``(A) In general._Each health care training consortium desiring to receive funds under this subsection shall prepare and submit to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require. ``(B) Approval of applications._A consortium that submits an application under subparagraph (A) may begin an operation under this subsection_ ``(i) upon approval of such application by the Secretary; or ``(ii) at the end of the 60-day period beginning on the date such application is submitted, unless the Secretary denies the application during such period. ``(4) Funding._ ``(A) Allocation of gme funds._For each year a consortium operates under this subsection the Secretary shall pay to such consortium an amount equal to the total amount available to hospitals that are members of the consortium under subsection (h). The consortium shall designate, subject to approval by the Secretary, a teaching hospital for each resident assigned to the consortium which the Secretary shall use to calculate the consortium's payment amount under such subsection. ``(B) Use of funds._Each consortium that receives a payment under subparagraph (A) may use such funds for the establishment and operation of the consortium. ``(5) Definitions._For purposes of this subsection: ``(A) Ambulatory training sites._The term `ambulatory training sites' includes health maintenance organizations, federally qualified health centers, community health centers, migrant health centers, rural health clinics, nursing homes, hospice, and other community-based providers, including private practices. ``(B) Health care training consortium._The term `health care training consortium' means an entity which includes partnerships of academic health centers, teaching hospitals, ambulatory training sites, or one or more schools of allopathic or osteopathic medicine. ``(C) Primary care._The term `primary care' means family practice, general internal medicine, geriatric medicine, general pediatrics, and obstetrics and gynecology.''. PART 3_INDIRECT GRADUATE MEDICAL EDUCATION SEC. 4121. FUNDING UNDER MEDICARE FOR TRAINING IN NONHOSPITAL-OWNED FACILITIES. (a) In General._Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended to read as follows: ``(iv) In determining such adjustment, the Secretary shall_ ``(I) count interns and residents assigned to any patient service environment which is part of the hospital's approved medical residency training program (as defined in subsection (h)(5)(A)); and ``(II) count interns and residents providing services at any entity receiving a grant under section 330 of the Public Health Service Act that is under the ownership or control of a hospital (if the hospital incurs all, or substantially all, of the costs of the services furnished by such interns and residents), as part of the calculation of the full-time-equivalent number of interns and residents.''. (b) Adjustment of Indirect Teaching Adjustment Factor to Achieve Budget Neutrality._Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following new clause: ``(v) The Secretary shall reduce all payments under this subparagraph by such percentage as the Secretary determines necessary so that, beginning on the date of the enactment of the Health Reform Act, the amendments made by section 4121(a) of such Act would not result in expenditures under this subparagraph that exceed the amount of such expenditures that would have been made if such amendments had not been made.''. PART 4_STUDY ON HEALTH PROFESSIONS SCHOOLS PAYMENTS SEC. 4131. STUDY ON HEALTH PROFESSIONS SCHOOLS PAYMENTS. (a) Study._Not later than January 1, 1997, the Secretary shall arrange for an independent study and report to be completed, by the Institute of Medicine or other similar entity, concerning the need for, purpose of, amount of, and allocation method for, medical school funding, public health school funding, graduate nurse education funding, physician assistant school funding, and dental school funding. In conducting the study, the entity conducting the study shall consider the impact of changes in the medical market and the impact of health reform on undergraduate medical education, undergraduate and graduate public health education, physician assistant education, graduate nurse education, and undergraduate dental education. (b) Authorization of Appropriations._For fiscal years 1996 and 1997, there is authorized to be appropriated from the Graduate Medical Education Trust Fund established under section 9551 of the Internal Revenue Code of 1986 such sums as may be necessary to carry out the purposes of this section. PART 5_MISCELLANEOUS PROVISION SEC. 4141. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH RESPECT TO INTERNATIONAL MEDICAL GRADUATES. (a) Waiver._Section 212(e) of the Immigration and Nationality Act (8 U.S.C. 1182(e)) is amended_ (1) in the first proviso by inserting ``(or, in the case of an alien described in clause (iii), pursuant to the request of an interested State agency)'' after ``interested United States Government agency''; and (2) by inserting after ``public interest'' the following: ``except that in the case of a waiver requested by an interested State agency the waiver shall be subject to the requirements of section 214(k)''. (b) Restrictions on Waiver._Section 214 of such Act (8 U.S.C. 1184) is amended by adding at the end the following: ``(k)(1) In the case of a request by an interested State agency for a waiver of the two-year foreign residence requirement under section 212(e) with respect to an alien described in clause (iii) of that section, the Attorney General shall not grant such waiver unless_ ``(A) in the case of an alien who is otherwise contractually obligated to return to a foreign country the Director of such country furnishes a statement in writing that it has no objection to such waiver; ``(B) the alien demonstrates a bona fide offer of full-time employment at a health facility and agrees to begin employment at such facility within 90 days of receiving such waiver and agrees to continue to work in accordance with paragraph (2) at the health care facility in which the alien is employed for a total of not less than 3 years (unless the Attorney General determines that extenuating circumstances such as the closure of the facility or hardship to the alien would justify a lesser period of time); ``(C) the alien agrees to practice medicine in accordance with paragraph (2) for a total of not less than 3 years only in the geographic area or areas which are designated by the Secretary of Health and Human Services as having a shortage of health care professionals; and ``(D) the grant of such waiver would not cause the number of waivers allotted for that State for that fiscal year to exceed twenty. ``(2) Whenever an interested State agency requests the waiver of the two-year residence requirement under section 212(e) with respect to an alien described in clause (iii) of that section, the Attorney General shall change the status of the alien to that of an alien described in section 101(a)(15)(H)(b). ``(3) If an alien whose status was changed under paragraph (2) demonstrates that the alien has worked for a period of 5 years in a health professional shortage area, then the Attorney General may approve a petition filed on the alien's behalf by the health care facility in which the alien is employed seeking change of the alien's status to that of a special immigrant described in section 101(a)(27)(L). ``(4) Notwithstanding any other provision of this subsection, the two-year foreign residence requirement under section 212(e) shall apply with respect to an alien described in clause (iii) of that section, who has not otherwise been accorded status under section 101(a)(27)(L), if at any time the alien practices medicine in an area other than an area described in paragraph (1)(C).''. (c) Special Immigrant Status._Section 101(a)(27) of such Act is amended by adding at the end the following new subparagraph: ``(L) immigrants whose status have been changed from that of an alien described in paragraph (15)(H)(b) pursuant to section 214(k)(2), except that not more than 500 immigrants may be admitted in any fiscal year under this subparagraph.''. (d) Grounds for Deportation._Section 241(a) of such Act (8 U.S.C. 1251(a)) is amended by adding at the end the following new subparagraph: ``(I) Failure to maintain employment as a health care professional._Any alien described in section 212(e)(iii) who fails to maintain employment in accordance with subparagraphs (B) and (C) of section 212(k)(1).''. (e) Effective Date._The amendments made by this section shall apply to aliens admitted to the United States under section 101(a)(15)(J) of the Immigration and Nationality Act, or acquiring such status after admission to the United States, before, on, or after the date of enactment of this Act and before June 1, 2005.