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S. 3660 - Health Equity and Accountability Act of 2018

Introduced: 2018-11-27
Bill Status: Read twice and referred to the Committee on Finance.
 
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Full Text


115th CONGRESS
2d Session
S. 3660


    To improve the health of minority individuals, and for other purposes.


IN THE SENATE OF THE UNITED STATES

November 27, 2018

    Ms. Hirono (for herself, Ms. Duckworth, Mr. Cardin, Ms. Harris, Mr. Booker, Mr. Merkley, Mr. Kaine, Mr. Blumenthal, Mrs. Gillibrand, and Mr. Brown) introduced the following bill; which was read twice and referred to the Committee on Finance


A BILL

    To improve the health of minority individuals, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. Short title.

This Act may be cited as the “Health Equity and Accountability Act of 2018”.

SEC. 2. Table of contents.

The table of contents of this Act is as follows:


TITLE I—DATA COLLECTION AND REPORTING


TITLE II—CULTURALLY AND LINGUISTICALLY APPROPRIATE HEALTH AND HEALTH CARE


TITLE III—HEALTH WORKFORCE DIVERSITY


TITLE IV—IMPROVING HEALTH CARE ACCESS AND QUALITY

Subtitle A—Expansion of Coverage


Subtitle B—Expansion of Access


Subtitle C—Advancing Health Equity Through Payment and Delivery Reform


Subtitle D—Health Empowerment Zones


Subtitle E—At-Risk community coverage


TITLE V—IMPROVING HEALTH OUTCOMES FOR WOMEN, CHILDREN, AND FAMILIES

Subtitle A—In General


Subtitle B—Pregnancy Screening


TITLE VI—MENTAL HEALTH


TITLE VII—ADDRESSING HIGH IMPACT MINORITY DISEASES

Subtitle A—Cancer


Subtitle B—Viral Hepatitis and Liver Cancer Control and Prevention


Subtitle C—Acquired Bone Marrow Failure Diseases


Subtitle D—Cardiovascular Disease, Chronic Disease, and Other Disease Issues


Subtitle E—HIV/AIDS


Subtitle F—Diabetes


Subtitle G—Lung Disease


Subtitle H—Tuberculosis


Subtitle I—Osteoarthritis and Musculoskeletal Diseases


Subtitle J—Sleep and Circadian Rhythm Disorders


Subtitle K—Sickle Cell Disease Research, Surveillance, Prevention, and Treatment


TITLE VIII—HEALTH INFORMATION TECHNOLOGY


Subtitle A—Reducing Health Disparities Through Health IT


Subtitle B—Modifications To Achieve Parity in Existing Programs


Subtitle C—Additional Research and Studies


Subtitle D— Closing Gaps in Funding To Adopt Certified EHRs


TITLE IX—ACCOUNTABILITY AND EVALUATION


TITLE X—ADDRESSING SOCIAL DETERMINANTS AND IMPROVING ENVIRONMENTAL JUSTICE

Subtitle A—In General


Subtitle B—Gun Violence

SEC. 3. Findings.

The Congress finds as follows:

(1) The population of racial and ethnic minorities is expected to increase over the next few decades, yet racial and ethnic minorities have the poorest health status and face substantial cultural, social, and economic barriers to obtaining quality health care.

(2) Health disparities are a function of not only access to health care, but also the social determinants of health—including the environment, the physical structure of communities, nutrition and food options, educational attainment, employment, race, ethnicity, sex, geography, language preference, immigrant or citizenship status, sexual orientation, gender identity, socioeconomic status, or disability status—that directly and indirectly affect the health, health care, and wellness of individuals and communities.

(3) By 2020, the United States will face a shortage of health care providers and allied health workers. This shortage will disproportionately affect health professional shortage areas where many racial and ethnic minority populations reside.

(4) All efforts to reduce health disparities and barriers to quality health services require better and more consistent data.

(5) A full range of culturally and linguistically appropriate health care and public health services must be available and accessible in every community.

(6) Racial and ethnic minorities and underserved populations must be included early and equitably in health reform innovations.

(7) Efforts to improve minority health have been limited by inadequate resources in funding, staffing, stewardship, and accountability. Targeted investments that are focused on disparities elimination must be made in providing care and services that are community-based, including prevention and policies addressing social determinants of health.

(8) In 2011, the Department of Health and Human Services developed the HHS Action Plan to Reduce Racial and Ethnic Health Disparities and the National Stakeholder Strategy for Achieving Health Equity, which are 2 strategic plans that represent the first coordinated roadmap in the United States to reducing health disparities. These comprehensive plans, along with the National Prevention Strategy issued by the National Prevention Council of the Department of Health and Human Services, Healthy People 2020, and the National Quality Strategy of the Agency for Healthcare Research and Quality, as well as critical resources such as the 2012 National Healthcare Quality and Disparities Reports, will work to increase the number of people in the United States who are healthy at every stage of life.

(9) The Secretary of Health and Human Services has also reviewed and advanced updated clinical guidelines and developed other strategic planning documents to combat health disparities with a high impact on minority populations and to provide high-quality family planning services. Such guidelines and documents include the National HIV/AIDS Strategy, the Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis, and recommendations of the Centers for Disease Control and Prevention and the Office of Population Affairs.

(10) The Patient Protection and Affordable Care Act (Public Law 111–148), as amended by the Health Care and Education Reconciliation Act (Public Law 111–152), represents the biggest advancement for minority health in the 40 years immediately preceding the enactment of this Act.

TITLE IData collection and reporting

SEC. 101. Amendment to the Public Health Service Act.

(a) Purpose.—It is the purpose of the amendment made by this section to promote data collection, analysis, and reporting by race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, and socioeconomic status among federally supported health programs.

(b) Amendment.—Title XXXIV of the Public Health Service Act, as added by titles II and III of this Act, is further amended by inserting after subtitle B the following:

“subtitle CStrengthening data collection, improving data analysis, and expanding data reporting

“SEC. 3431. Health disparity data.

“(a) Requirements.—

“(1) IN GENERAL.—Each health-related program shall—

“(A) require the collection, by the agency or program involved, of data on the race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, and socioeconomic status of each applicant for and recipient of health-related assistance under such program, including—

“(i) using, at a minimum, standards for data collection on race, ethnicity, sex, primary language, sexual orientation, gender identity, socioeconomic status, and disability status as each are developed under section 3101;

“(ii) collecting data for additional population groups if such groups can be aggregated into the race and ethnicity categories outlined by standards developed under section 3101;

“(iii) using, where practicable, the standards developed by the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (formerly known as the ‘Institute of Medicine’) in the 2009 publication, entitled ‘Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement’; and

“(iv) where practicable, collecting such data through self-reporting;

“(B) with respect to the collection of the data described in subparagraph (A), for applicants and recipients who are minors, require communication assistance in speech or writing, and for applicants and recipients who are otherwise legally incapacitated, require that—

“(i) such data be collected from the parent or legal guardian of such an applicant or recipient; and

“(ii) the primary language of the parent or legal guardian of such an applicant or recipient be collected;

“(C) systematically analyze such data using the smallest appropriate units of analysis feasible to detect racial and ethnic disparities, as well as disparities along the lines of primary language, sex, disability status, sexual orientation, gender identity, and socioeconomic status in health and health care, and report the results of such analysis to the Secretary, the Director of the Office for Civil Rights, each agency listed in section 3101(c)(1), the Committee on Health, Education, Labor, and Pensions and the Committee on Finance of the Senate, and the Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives;

“(D) provide such data to the Secretary on at least an annual basis; and

“(E) ensure that the provision of assistance to an applicant or recipient of assistance is not denied or otherwise adversely affected because of the failure of the applicant or recipient to provide race, ethnicity, primary language, sex, sexual orientation, disability status, gender identity, and socioeconomic status data.

“(2) RULES OF CONSTRUCTION.—Nothing in this subsection shall be construed to—

“(A) permit the use of information collected under this subsection in a manner that would adversely affect any individual providing any such information; or

“(B) diminish any requirements, including such requirements in effect on or after the date of enactment of this section, on health care providers to collect data.

“(3) NO COMPELLED DISCLOSURE OF DATA.—This title does not authorize any health care provider, Federal official, or other entity to compel the disclosure of any data collected under this title. The disclosure of any such data by an individual pursuant to this title shall be strictly voluntary.

“(b) Protection of data.—The Secretary shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) are protected—

“(1) under the same privacy protections as the Secretary applies to other health data under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 relating to the privacy of individually identifiable health information and other protections; and

“(2) from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from other inappropriate uses, as defined by the Secretary.

“(c) National plan of the data Council.—The Secretary shall develop and implement a national plan to ensure the collection of data in a culturally and linguistically appropriate manner, to improve the collection, analysis, and reporting of racial, ethnic, sex, primary language, sexual orientation, disability status, gender identity, and socioeconomic status data at the Federal, State, territorial, Tribal, and local levels, including data to be collected under subsection (a), and to ensure that data collection activities carried out under this section are in compliance with standards developed under section 3101. The Data Council of the Department of Health and Human Services, in consultation with the National Committee on Vital Health Statistics, the Office of Minority Health, Office on Women’s Health, and other appropriate public and private entities, shall make recommendations to the Secretary concerning the development, implementation, and revision of the national plan. Such plan shall include recommendations on how to—

“(1) implement subsection (a) while minimizing the cost and administrative burdens of data collection and reporting;

“(2) expand knowledge among Federal agencies, States, territories, Indian Tribes, counties, municipalities, health providers, health plans, and the general public that data collection, analysis, and reporting by race, ethnicity, sex, primary language, sexual orientation, gender identity, socioeconomic status, and disability status is legal and necessary to assure equity and nondiscrimination in the quality of health care services;

“(3) ensure that future patient record systems follow Federal standards promulgated under the Health Information Technology for Economic and Clinical Health Act for the collection and meaningful use of electronic health data on race, ethnicity, sex, primary language, sexual orientation, gender identity, socioeconomic status, and disability status;

“(4) improve health and health care data collection and analysis for more population groups if such groups can be aggregated into the minimum race and ethnicity categories, including exploring the feasibility of enhancing collection efforts in States, counties, and municipalities for racial and ethnic groups that comprise a significant proportion of the population of the State, county, or municipality;

“(5) provide researchers with greater access to racial, ethnic, primary language, sex, sexual orientation, gender identity, socioeconomic status data, and disability status data, subject to all applicable privacy and confidentiality requirements, including HIPAA privacy and security law as defined in section 3009; and

“(6) safeguard and prevent the misuse of data collected under subsection (a).

“(d) Compliance with Standards.—Data collected under subsection (a) shall be obtained, maintained, and presented (including for reporting purposes) in accordance with standards developed under section 3101.

“(e) Analysis of health disparity data.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality and in coordination with the Assistant Secretary for Planning and Evaluation, the Administrator of the Centers for Medicare & Medicaid Services, the Director of the National Center for Health Statistics, and the Director of the National Institutes of Health, shall provide technical assistance to agencies of the Department of Health and Human Services in meeting Federal standards for health disparity data collection and for analysis of racial, ethnic, and other disparities in health and health care in programs conducted or supported by such agencies by—

“(1) identifying appropriate quality assurance mechanisms to monitor for health disparities;

“(2) specifying the clinical, diagnostic, or therapeutic measures which should be monitored;

“(3) developing new quality measures relating to racial and ethnic disparities and their overlap with other disparity factors in health and health care;

“(4) identifying the level at which data analysis should be conducted; and

“(5) sharing data with external organizations for research and quality improvement purposes.

“(f) Definitions.—In this section—

“(1) the term ‘health-related program’ means a program that is operated by the Secretary, or that receives funding or reimbursement, in whole or in part, either directly or indirectly from the Secretary—

“(A) for activities under the Social Security Act for health care services; or

“(B) for providing federal financial assistance for health care, biomedical research, or health services research or for otherwise improving the health of the public;

“(2) the term ‘primary language data’ includes spoken and written primary language data; and

“(3) the term ‘primary language data collection activities’ includes identifying, collecting, storing, tracking, and analyzing primary language data and information on the methods used to meet the language access needs of individuals with limited-English proficiency.

“(g) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3432. Establishing grants for data collection improvement activities.

“(a) In general.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality and in consultation with the Deputy Assistant Secretary for Minority Health, the Director of the National Institutes of Health, the Assistant Secretary for Planning and Evaluation, and the Director of the National Center for Health Statistics, shall establish a technical assistance program under which the Secretary provides grants to eligible entities to assist such entities in complying with section 3431.

“(b) Types of assistance.—A grant provided under this section may be used to—

“(1) enhance or upgrade computer technology that will facilitate collection, analysis, and reporting of racial, ethnic, primary language, sexual orientation, sex, gender identity, socioeconomic status, and disability status data;

“(2) improve methods for health data collection and analysis, including additional population groups if such groups can be aggregated into the race and ethnicity categories outlined by standards developed under section 3101;

“(3) develop mechanisms for submitting collected data subject to any applicable privacy and confidentiality regulations; and

“(4) develop educational programs to inform health plans, health providers, health-related agencies, and the general public that data collection and reporting by race, ethnicity, primary language, sexual orientation, sex, gender identity, disability status, and socioeconomic status are legal and essential for eliminating health and health care disparities.

“(c) Eligible entity.—To be eligible for grants under this section, an entity shall be a State, territory, Indian Tribe, municipality, county, health provider, health care organization, or health plan making a demonstrated effort to bring data collections into compliance with section 3431.

“(d) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3433. Oversampling of underrepresented groups in Federal health surveys.

“(a) National strategy.—

“(1) IN GENERAL.—The Secretary, acting through the Director of the National Center for Health Statistics of the Centers for Disease Control and Prevention, and other agencies within the Department of Health and Human Services as the Secretary determines appropriate, shall develop and implement an ongoing and sustainable national strategy for oversampling underrepresented populations within the categories of race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, and socioeconomic status as determined appropriate by the Secretary in Federal health surveys and program data collections. Such national strategy shall include a strategy for oversampling of Asian Americans, Native Hawaiians, and Pacific Islanders.

“(2) CONSULTATION.—In developing and implementing a national strategy, as described in paragraph (1), not later than 180 days after the date of the enactment of this section, the Secretary shall—

“(A) consult with representatives of community groups, nonprofit organizations, nongovernmental organizations, and government agencies working with underrepresented populations;

“(B) solicit the participation of representatives from other Federal departments and agencies, including subagencies of the Department of Health and Human Services; and

“(C) consult on, and use as models, the 2014 National Health Interview Survey oversample of Native Hawaiian and Pacific Islander populations and the 2017 Behavioral Risk Factor Surveillance System oversample of American Indian and Alaska Native communities.

“(b) Progress report.—Not later than 2 years after the date of the enactment of this section, the Secretary shall submit to the Congress a progress report, which shall include the national strategy described in subsection (a)(1).

“(c) Authorization of appropriations.—To carry out this section, there are authorized to be appropriated such sums as may be necessary for fiscal years 2019 through 2024.”.

SEC. 102. Elimination of prerequisite of direct appropriations for data collection and analysis.

Section 3101 of the Public Health Service Act (42 U.S.C. 300kk) is amended—

(1) by striking subsection (h); and

(2) by redesignating subsection (i) as subsection (h).

SEC. 103. Collection of race and ethnicity data by the Social Security Administration.

Part A of title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is amended by adding at the end the following:

    Collection of race and ethnicity data by the Social Security Administration

“Sec. 1150C. (a) Requirement.—

“(1) IN GENERAL.—The Commissioner of Social Security, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, shall collect data on the race, ethnicity, primary language, and disability status of all applicants for Social Security account numbers or benefits under title II or part A of title XVIII and all individuals with respect to whom the Commissioner maintains records of wages and self-employment income.

“(2) DATA COLLECTION STANDARDS.—In collecting data under paragraph (1), the Commissioner of Social Security shall use standards for data collection on race, ethnicity, primary language, and disability status developed under section 3101 of the Public Health Service Act and, where practicable, the standards developed by the Institute of Medicine in ‘Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement’ (released August 31, 2009).

“(3) DATA FOR ADDITIONAL POPULATION GROUPS.—Where practicable, the information collected by the Commissioner of Social Security under paragraph (1) shall include data for additional population groups if such groups can be aggregated into the race and ethnicity categories outlined by the data collection standards described in paragraph (2).

“(4) COLLECTION OF DATA FOR MINORS AND LEGALLY INCAPACITATED INDIVIDUALS.—With respect to the collection of the data described in paragraph (1) of applicants who are under 18 years of age or otherwise legally incapacitated, the Commissioner of Social Security shall require that—

“(A) such data be collected from the parent or legal guardian of such an applicant; and

“(B) the primary language of the parent or legal guardian of such an applicant or recipient be used in collecting the data.

“(5) ADDITIONAL REQUIREMENTS.—With respect to data collected under paragraph (1), the Commissioner of Social Security shall—

“(A) require that such data be uniformly analyzed and that such analysis be reported at least annually to the Commissioner;

“(B) be responsible for storing the data reported under subparagraph (A);

“(C) ensure transmission to the Centers for Medicare & Medicaid Services and other agencies within the Department of Health and Human Services, as determined appropriate by the Secretary;

“(D) provide such data to the Secretary on at least an annual basis; and

“(E) ensure that the provision of assistance or benefits to an applicant is not denied or otherwise adversely affected because of the failure of the applicant to provide race, ethnicity, primary language, and disability status data.

“(b) Protection of data.—The Commissioner of Social Security shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) is protected—

“(1) under the same privacy protections as the Secretary applies to health data under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (relating to the privacy of individually identifiable health information and other protections); and

“(2) from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from other inappropriate uses, as defined by the Secretary.

“(c) Rule of construction.—Nothing in this section shall be construed to permit the use of information collected under this section in a manner that would adversely affect any individual providing any such information.

“(d) Technical assistance.—The Secretary may, either directly or by grant or contract, provide technical assistance to enable any entity to comply with the requirements of this section or with regulations implementing this section.

“(e) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.”.

SEC. 104. Revision of HIPAA claims standards.

(a) In general.—Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall revise the regulations promulgated under part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.), relating to the collection of data on race, ethnicity, and primary language in a health-related transaction, to require—

(1) the use, at a minimum, of standards for data collection on race, ethnicity, primary language, disability, sex, sexual orientation, gender identity, and socioeconomic status developed under section 3101 of the Public Health Service Act (42 U.S.C. 300kk); and

(2) in consultation with the Office of the National Coordinator for Health Information Technology, the designation of the appropriate racial, ethnic, primary language, disability, sex, and other code sets as required for claims and enrollment data.

(b) Dissemination.—The Secretary of Health and Human Services shall disseminate the new standards developed under subsection (a) to all entities that are subject to the regulations described in such subsection and provide technical assistance with respect to the collection of the data involved.

(c) Compliance.—The Secretary of Health and Human Services shall require that entities comply with the new standards developed under subsection (a) not later than 2 years after the final promulgation of such standards.

SEC. 105. National Center for Health Statistics.

Section 306(n) of the Public Health Service Act (42 U.S.C. 242k(n)) is amended—

(1) in paragraph (1), by striking “2003” and inserting “2022”;

(2) in paragraph (2), in the first sentence, by striking “2003” and inserting “2022”; and

(3) in paragraph (3), by striking “2002” and inserting “2022”.

SEC. 106. Disparities data collected by the Federal Government.

(a) Repository of Government data.—The Secretary of Health and Human Services, in coordination with the departments, agencies, or offices described in subsection (b), shall establish a centralized electronic repository of Government data on factors related to the health and well-being of the population of the United States.

(b) Collection; submission.—Not later than 180 days after the date of the enactment of this Act, and January 31 of each year thereafter, each department, agency, and office of the Federal Government that has collected data on race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, or socioeconomic status during the preceding calendar year shall submit such data to the repository of Government data established under subsection (a).

(c) Analysis; public availability; reporting.—Not later than April 30, 2019, and April 30 of each year thereafter, the Secretary of Health and Human Services, acting through the Assistant Secretary for Planning and Evaluation, the Assistant Secretary for Health, the Director of the Agency for Healthcare Research and Quality, the Director of the National Center for Health Statistics, the Administrator of the Centers for Medicare & Medicaid Services, the Director of the National Institute on Minority Health and Health Disparities, and the Deputy Assistant Secretary for Minority Health, shall—

(1) prepare and make available datasets for public use that relate to disparities in health status, health care access, health care quality, health outcomes, public health, and other areas of health and well-being by factors that include race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, and socioeconomic status;

(2) ensure that these datasets are publicly identified on the repository established under subsection (a) as “disparities” data; and

(3) submit a report to the Congress on the availability and use of such data by public stakeholders.

SEC. 107. Data collection and analysis grants to minority-serving institutions.

(a) Authority.—The Secretary of Health and Human Services, acting through the Director of the National Institute on Minority Health and Health Disparities and the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities to access and analyze racial and ethnic data on disparities in health and health care, and where possible other data on disparities in health and health care, to monitor and report on progress to reduce and eliminate disparities in health and health care.

(b) Eligible entity.—In this section, the term “eligible entity” means an entity that has an accredited public health, health policy, or health services research program and is any of the following:

(1) A part B institution, as defined in section 322 of the Higher Education Act of 1965 (20 U.S.C. 1061).

(2) A Hispanic-serving institution, as defined in section 502 of such Act (20 U.S.C. 1101a).

(3) A Tribal College or University, as defined in section 316 of such Act (20 U.S.C. 1059c).

(4) An Asian American and Native American Pacific Islander-serving institution, as defined in section 371(c) of such Act (20 U.S.C. 1067q(c)).

(c) Authorization of appropriations.—To carry out this section, there are authorized to be appropriated such sums as may be necessary for fiscal years 2019 through 2024.

SEC. 108. Standards for measuring sexual orientation, gender identity, and socioeconomic status in collection of health data.

Section 3101(a) of the Public Health Service Act (42 U.S.C. 300kk(a)) is amended—

(1) in paragraph (1)(A), by inserting “sexual orientation, gender identity, socioeconomic status,” before “and disability status”;

(2) in paragraph (1)(C), by inserting “sexual orientation, gender identity, socioeconomic status,” before “and disability status”; and

(3) in paragraph (2)(B), by inserting “sexual orientation, gender identity, socioeconomic status,” before “and disability status”.

SEC. 109. Safety and effectiveness of drugs with respect to racial and ethnic background.

(a) In general.—Chapter V of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 351 et seq.) is amended by adding after section 505F the following:

“SEC. 505G. Safety and effectiveness of drugs with respect to racial and ethnic background.

“(a) Preapproval studies.—If there is evidence that there may be a disparity on the basis of racial or ethnic background as to the safety or effectiveness of a drug or biological product, then—

“(1)(A) in the case of a drug, the investigations required under section 505(b)(1)(A) shall include adequate and well-controlled investigations of the disparity; or

“(B) in the case of a biological product, the evidence required under section 351(a) of the Public Health Service Act for approval of a biologics license application for the biological product shall include adequate and well-controlled investigations of the disparity; and

“(2) if the investigations described in subparagraph (A) or (B) of paragraph (1) confirm that there is such a disparity, the labeling of the drug or biological product shall include appropriate information about the disparity.

“(b) Postmarket studies.—

“(1) IN GENERAL.—If there is evidence that there may be a disparity on the basis of racial or ethnic background as to the safety or effectiveness of a drug for which there is an approved application under section 505 of this Act or of a biological product for which there is an approved license under section 351 of the Public Health Service Act, the Secretary may by order require the holder of the approved application or license to conduct, by a date specified by the Secretary, postmarket studies to investigate the disparity.

“(2) LABELING.—If the Secretary determines that the postmarket studies confirm that there is a disparity described in paragraph (1), the labeling of the drug or biological product shall include appropriate information about the disparity.

“(3) STUDY DESIGN.—The Secretary may, in an order under paragraph (1), specify all aspects of the design of the postmarket studies required under such paragraph for a drug or biological product, including the number of studies and study participants, and the other demographic characteristics of the study participants.

“(4) MODIFICATIONS OF STUDY DESIGN.—The Secretary may, by order and as necessary, modify any aspect of the design of a postmarket study required in an order under paragraph (1) after issuing such order.

“(5) STUDY RESULTS.—The results from a study required under paragraph (1) shall be submitted to the Secretary as a supplement to the drug application or biologics license application.

“(c) Applications under section 505(j).—

“(1) IN GENERAL.—A drug for which an application has been submitted or approved under section 505(j) shall not be considered ineligible for approval under that section or misbranded under section 502 on the basis that the labeling of the drug omits information relating to a disparity on the basis of racial or ethnic background as to the safety or effectiveness of the drug, whether derived from investigations or studies required under this section or derived from other sources, when the omitted information is protected by patent or by exclusivity under section 505(j)(5)(F).

“(2) LABELING.—Notwithstanding paragraph (1), the Secretary may require that the labeling of a drug approved under section 505(j) that omits information relating to a disparity on the basis of racial or ethnic background as to the safety or effectiveness of the drug include a statement of any appropriate contraindications, warnings, or precautions related to the disparity that the Secretary considers necessary.

“(d) Definition.—The term ‘evidence that there may be a disparity on the basis of racial or ethnic background as to the safety or effectiveness’, with respect to a drug or biological product, includes—

“(1) evidence that there is a disparity on the basis of racial or ethnic background as to safety or effectiveness of a drug or biological product in the same chemical class as the drug or biological product;

“(2) evidence that there is a disparity on the basis of racial or ethnic background in the way the drug or biological product is metabolized; and

“(3) other evidence as the Secretary may determine appropriate.”.

(b) Enforcement.—Section 502 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 352) is amended by adding at the end the following:

“(ee) If it is a drug and the holder of the approved application under section 505 or license under section 351 of the Public Health Service Act for the drug has failed to complete the investigations or studies, or comply with any other requirement, of section 505G.”.

(c) Drug fees.—Section 736(a)(1)(A)(ii) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 379h(a)(1)(A)(ii)) is amended by inserting after “are not required” the following: “, including postmarket studies required under section 505G”.

SEC. 110. Improving health data regarding Native Hawaiians and other Pacific Islanders.

Part B of title III of the Public Health Service Act (42 U.S.C. 243 et seq.) is amended by inserting after section 317T the following:

“SEC. 317U. Native Hawaiian and other Pacific Islander health data.

“(a) Definitions.—In this section:

“(1) COMMUNITY GROUP.—The term ‘community group’ means a group of NHOPI who are organized at the community level, and may include a church group, social service group, national advocacy organization, or cultural group.

“(2) NONPROFIT, NONGOVERNMENTAL ORGANIZATION.—The term ‘nonprofit, nongovernmental organization’ means a group of NHOPI with a demonstrated history of addressing NHOPI issues, including a NHOPI coalition.

“(3) DESIGNATED ORGANIZATION.—The term ‘designated organization’ means an entity established to represent NHOPI populations and which has statutory responsibilities to provide, or has community support for providing, health care.

“(4) GOVERNMENT REPRESENTATIVES OF NHOPI POPULATIONS.—The term ‘government representatives of NHOPI populations’ means representatives from Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands.

“(5) NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS (NHOPI).—The term ‘Native Hawaiians and Other Pacific Islanders’ or ‘NHOPI’ means people having origins in any of the original peoples of American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaii, the Republic of the Marshall Islands, the Republic of Palau, or any other Pacific Island.

“(6) INSULAR AREA.—The term ‘insular area’ means Guam, the Commonwealth of Northern Mariana Islands, American Samoa, the United States Virgin Islands, the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands.

“(b) National strategy.—

“(1) IN GENERAL.—The Secretary, acting through the Director of the National Center for Health Statistics (referred to in this section as ‘NCHS’) of the Centers for Disease Control and Prevention, and other agencies within the Department of Health and Human Services as the Secretary determines appropriate, shall develop and implement an ongoing and sustainable national strategy for identifying and evaluating the health status and health care needs of NHOPI populations living in the continental United States, Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands.

“(2) CONSULTATION.—In developing and implementing a national strategy, as described in paragraph (1), not later than 180 days after the date of enactment of the Health Equity and Accountability Act of 2018, the Secretary—

“(A) shall consult with representatives of community groups, designated organizations, and nonprofit, nongovernmental organizations and with government representatives of NHOPI populations; and

“(B) may solicit the participation of representatives from other Federal departments.

“(c) Preliminary health survey.—

“(1) IN GENERAL.—The Secretary, acting through the Director of NCHS, shall conduct a preliminary health survey in order to identify the major areas and regions in the continental United States, Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands in which NHOPI people reside.

“(2) CONTENTS.—The health survey described in paragraph (1) shall include health data and any other data the Secretary determines to be—

“(A) useful in determining health status and health care needs; or

“(B) required for developing or implementing a national strategy.

“(3) METHODOLOGY.—Methodology for the health survey described in paragraph (1), including plans for designing questions, implementation, sampling, and analysis, shall be developed in consultation with community groups, designated organizations, nonprofit, nongovernmental organizations, and government representatives of NHOPI populations, as determined by the Secretary.

“(4) TIMEFRAME.—The survey required under this subsection shall be completed not later than 18 months after the date of enactment of the Health Equity and Accountability Act of 2018.

“(d) Progress report.—Not later than 2 years after the date of enactment of the Health Equity and Accountability Act of 2018, the Secretary shall submit to Congress a progress report, which shall include the national strategy described in subsection (b)(1).

“(e) Study and report by the Health and Medicine Division.—

“(1) IN GENERAL.—The Secretary shall enter into an agreement with the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to conduct a study, with input from stakeholders in insular areas, on each of the following:

“(A) The standards and definitions of health care applied to health care systems in insular areas and the appropriateness of such standards and definitions.

“(B) The status and performance of health care systems in insular areas, evaluated based upon standards and definitions, as the Secretary determines appropriate.

“(C) The effectiveness of donor aid in addressing health care needs and priorities in insular areas.

“(D) The progress toward implementation of recommendations of the Committee on Health Care Services in the United States—Associated Pacific Basin that are set forth in the 1998 report entitled ‘Pacific Partnerships for Health: Charting a New Course’.

“(2) REPORT.—An agreement described in paragraph (1) shall require the Health and Medicine Division to submit to the Secretary and to Congress, not later than 2 years after the date of the enactment of the Health Equity and Accountability Act of 2018, a report containing a description of the results of the study conducted under paragraph (1), including the conclusions and recommendations of the Health and Medicine Division for each of the items described in subparagraphs (A) through (D) of such paragraph.

“(f) Authorization of appropriations.—To carry out this section, there are authorized to be appropriated such sums as may be necessary for fiscal years 2019 through 2024.”.

SEC. 111. Clarification of simplified administrative reporting requirement.

Section 11(a) of the Food and Nutrition Act of 2008 (7 U.S.C. 2020(a)) is amended by adding at the end the following:

“(5) SIMPLIFIED ADMINISTRATIVE REPORTING REQUIREMENT.—With respect to any obligation of a State agency to comply with the notification requirement under paragraph (2) of section 421(e) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1631(e)), notwithstanding the requirement to include in that notification the names of the sponsor and the sponsored alien involved, the State agency shall be considered to have complied with the notification requirement if the State agency submits to the Attorney General a report that includes the aggregate number of exceptions granted by the State agency under paragraph (1) of that section.”.

TITLE IICulturally and linguistically appropriate health and health care

SEC. 201. Definitions; findings.

(a) Definitions.—In this title, the definitions in section 3400 of the Public Health Service Act, as added by section 204, shall apply.

(b) Findings.—Congress finds the following:

(1) Effective communication is essential to meaningful access to quality physical and mental health care.

(2) Research indicates that the lack of appropriate language services creates language barriers that result in increased risk of misdiagnosis, ineffective treatment plans, and poor health outcomes for individuals with limited-English proficiency and individuals with communication disabilities such as hearing, vision, or print impairments.

(3) The number of limited-English-speaking residents in the United States who speak English less than very well and, therefore, cannot effectively communicate with health and social service providers continues to increase significantly.

(4) The responsibility to fund language services in the provision of health care and health-care-related services to individuals with limited-English proficiency and individuals with communication disabilities such as hearing, vision, or print impairments is a societal one that cannot fairly be placed solely upon the health care, public health, or social services community.

(5) Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) prohibits discrimination based on the grounds of race, color, or national origin by any entity receiving Federal financial assistance. In order to avoid discrimination on the grounds of national origin, all programs or activities administered by the Federal Government must take adequate steps to ensure that their policies and procedures do not deny or have the effect of denying individuals with limited-English proficiency with equal access to benefits and services for which such persons qualify.

(6) Both the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.) and the Rehabilitation Act of 1973 (29 U.S.C. 701 et seq.) prohibit discrimination on the basis of disability and require the provision of appropriate auxiliary aids and services necessary to ensure effective communication with individuals with disabilities. The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the method of communication used by the individual; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place. A public accommodation should consult with individuals with disabilities whenever possible to determine what type of auxiliary aid is needed to ensure effective communication, but the ultimate decision as to what measures to take rests with the public accommodation, provided that the method chosen results in effective communication. In order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability.

(7) Linguistic diversity in the health care and health-care-related services workforce is important for providing all patients the environment most conducive to positive health outcomes.

(8) All members of the health care and health-care-related services community should continue to educate their staff and constituents about limited-English-proficient and disability communication issues and help them identify resources to improve access to quality care for individuals with limited-English proficiency and individuals with communication disabilities such as hearing, vision, or print impairments.

(9) Access to English as a second language, and sign language instructions, readers, and other auxiliary aids and services, are essential to ensure effective communication and eliminate the language barriers that impede access to health care.

(10) Competent language services in health care settings should be available as a matter of course.

SEC. 202. Improving access to services for individuals with limited-English proficiency.

(a) Purpose.—Consistent with the goals provided in Executive Order 13166 (42 U.S.C. 2000d–1 note; relating to improving access to services for persons with limited-English proficiency), it is the purpose of this section—

(1) to improve Federal agency performance regarding access to federally conducted and federally assisted programs and activities for individuals with limited-English proficiency;

(2) to require each Federal agency to examine the services it provides and develop and implement a system by which individuals with limited-English proficiency can obtain cultural competence and meaningful access to those services consistent with, and without substantially burdening, the fundamental mission of the agency;

(3) to require each Federal agency to ensure that recipients of Federal financial assistance provide cultural competence and meaningful access to applicants and beneficiaries that are individuals with limited-English proficiency;

(4) to ensure that recipients of Federal financial assistance take reasonable steps, consistent with the guidelines set forth in the “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (67 Fed. Reg. 41455 (June 18, 2002))”, to ensure culturally and linguistically appropriate access to their programs and activities by individuals with limited-English proficiency; and

(5) to ensure compliance with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and that health care providers and organizations do not discriminate in the provision of services.

(b) Federally Conducted programs and activities.—

(1) IN GENERAL.—Not later than 120 days after the date of enactment of this Act, each Federal agency providing financial assistance to, or administering, a health program or activity described in section 203(a) shall prepare a plan to improve culturally and linguistically appropriate access to such program or activity with respect to individuals with limited-English proficiency. Not later than 1 year after the date of enactment of this title, each such Federal agency shall ensure that such plan is fully implemented.

(2) PLAN REQUIREMENT.—Each plan under paragraph (1) shall include—

(A) the steps the agency will take to ensure that individuals with limited-English proficiency have access to each health program or activity supported or administered by the agency;

(B) the policies and procedures for identifying, assessing, and meeting the culturally and linguistically appropriate language needs of its beneficiaries that are individuals with limited-English proficiency served by such program or activity;

(C) the steps the agency will take for such program or activity to be culturally and linguistically appropriate by providing a range of language assistance options, notice to individuals with limited-English proficiency of the right to competent language services, periodic training of staff, monitoring and quality assessment of the language services and, in appropriate circumstances, the translation of written materials;

(D) the steps the agency will take to ensure that applications, forms, and other relevant documents for such program or activity are competently translated into the primary language of a client that is an individual with limited-English proficiency where such materials are needed to improve access of such client to such program or activity;

(E) the resources the agency will provide to improve cultural and linguistic appropriateness to assist recipients of Federal funds to improve access to health care related programs and activities for individuals with limited-English proficiency;

(F) the resources the agency will provide to ensure that competent language assistance is provided to patients that are individuals with limited-English proficiency by interpreters or trained bilingual staff; and

(G) the resources the agency will provide to ensure that family, particularly minor children, and friends are not used to provide interpretation services, except as permitted under regulations implementing section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116).

(3) SUBMISSION OF PLAN TO DOJ.—Each agency that is required to prepare a plan under paragraph (1) shall send a copy of such plan to the Attorney General, which shall serve as the central repository of all such plans.

(4) RULE OF CONSTRUCTION.—Paragraph (2)(G) shall not be construed to mean that emergency rooms or similar entities that regularly provide health care services in medical emergencies are exempt from legal or regulatory requirements related to competent interpreter services.

SEC. 203. National standards for culturally and linguistically appropriate services in health care.

(a) Applicability.—This section shall apply to any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or any program or activity that is administered by an executive agency or any entity established under title I of the Patient Protection and Affordable Care Act (or amendments made thereby), as such programs, activities, agencies, and entities are described in section 1557(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18116(a)).

(b) Standards.—Each program or activity described in subsection (a)—

(1) shall implement strategies to recruit, retain, and promote individuals at all levels to maintain a diverse staff and leadership that can provide culturally and linguistically appropriate health care to patient populations of the service area of the program or activity;

(2) shall educate and train governance, leadership, and workforce at all levels and across all disciplines of the program or activity in culturally and linguistically appropriate policies and practices on an ongoing basis;

(3) shall offer and provide language assistance, including trained bilingual staff and interpreter services, to individuals with limited-English proficiency or who have other communication needs, at no cost to the individual at all points of contact, and during all hours of operation, to facilitate timely access to health care services and health-care-related services;

(4) shall for each language group consisting of individuals with limited-English proficiency that constitutes 5 percent or 500 individuals, whichever is less, of the population of persons eligible to be served or likely to be affected or encountered in the service area of the program or activity, make available—

(A) easily understood patient-related materials, including print and multimedia materials, in the language of such language group;

(B) information or notices about termination of benefits in such language; and

(C) signage;

(5) shall develop and implement clear goals, policies, operational plans, and management, accountability, and oversight mechanisms to provide culturally and linguistically appropriate services and infuse them throughout the planning and operations of the program or activity;

(6) shall conduct initial and ongoing organizational assessments of culturally and linguistically appropriate services-related activities and integrate valid linguistic, competence-related National Standards for Culturally and Linguistically Appropriate Services (CLAS) measures into the internal audits, performance improvement programs, patient satisfaction assessments, continuous quality improvement activities, and outcomes-based evaluations of the program or activity and develop ways to standardize the assessments;

(7) shall ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320–2 note), data on an individual required to be collected pursuant to section 3101, including the individual’s alternative format preferences and policy modification needs, are—

(A) collected in health records;

(B) integrated into the management information systems of the program or activity; and

(C) periodically updated;

(8) shall maintain a current demographic, cultural, and epidemiological profile of the community, conduct regular assessments of community health assets and needs, and use the results of such assessments to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area of the program or activity;

(9) shall develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient involvement in designing, implementing, and evaluating policies and practices to ensure culturally and linguistically appropriate service-related activities;

(10) shall ensure that conflict and grievance resolution processes are culturally and linguistically appropriate and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients;

(11) shall regularly make available to the public information about their progress and successful innovations in implementing the standards under this section and provide public notice in their communities about the availability of this information; and

(12) shall, if requested, regularly make available to the head of each Federal entity from which Federal funds are provided, information about the progress and successful innovations of the program or activity in implementing the standards under this section as required by the head of such entity.

(c) Comments accepted through notice and comment rulemaking.—An agency carrying out a program described in subsection (a) shall ensure that comments with respect to such program that are accepted through notice and comment rulemaking be accepted in all languages and may not require such comments to be submitted only in English.

SEC. 204. Culturally and linguistically appropriate health care in the Public Health Service Act.

The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following:

“TITLE XXXIVCULTURALLY AND LINGUISTICALLY APPROPRIATE HEALTH CARE

“SEC. 3400. Definitions.

“(a) In general.—In this title:

“(1) BILINGUAL.—The term ‘bilingual’, with respect to an individual, means a person who has sufficient degree of proficiency in 2 languages.

“(2) CULTURAL.—The term ‘cultural’ means relating to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups, including lesbian, gay, bisexual, transgender, queer, and questioning individuals, and individuals with physical and mental disabilities.

“(3) CULTURALLY AND LINGUISTICALLY APPROPRIATE.—The term ‘culturally and linguistically appropriate’ means being respectful of and responsive to the cultural and linguistic needs of all individuals.

“(4) EFFECTIVE COMMUNICATION.—The term ‘effective communication’ means an exchange of information between the provider of health care or health-care-related services and the recipient of such services who is limited in English proficiency, or has a communication impairment such as a hearing, vision, speaking, or learning impairment, that enables access to, understanding of, and benefit from health care or health-care-related services, and full participation in the development of their treatment plan.

“(5) GRIEVANCE RESOLUTION PROCESS.—The term ‘grievance resolution process’ means all aspects of dispute resolution including filing complaints, grievance and appeal procedures, and court action.

“(6) HEALTH CARE GROUP.—The term ‘health care group’ means a group of physicians organized, at least in part, for the purposes of providing physician services under the Medicaid program under title XIX of the Social Security Act, the State Children's Health Insurance Program under title XXI of such Act, or the Medicare program under title XVIII of such Act and may include a hospital and any other individual or entity furnishing services covered under any such program that is affiliated with the health care group.

“(7) HEALTH CARE SERVICES.—The term ‘health care services’ means services that address physical as well as mental health conditions in all care settings.

“(8) HEALTH-CARE-RELATED SERVICES.—The term ‘health-care-related services’ means human or social services programs or activities that provide access, referrals, or links to health care.

“(9) HEALTH EDUCATOR.—The term ‘health educator’ includes a professional with a baccalaureate degree who is responsible for designing, implementing, and evaluating individual and population health promotion and chronic disease prevention programs.

“(10) INDIAN; INDIAN TRIBE.—The terms ‘Indian’ and ‘Indian Tribe’ have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act.

“(11) INDIVIDUAL WITH A DISABILITY.—The term ‘individual with a disability’ means any individual who has a disability as defined for the purpose of section 504 of the Rehabilitation Act of 1973.

“(12) INDIVIDUAL WITH LIMITED-ENGLISH PROFICIENCY.—The term ‘individual with limited-English proficiency’ means an individual whose primary language for communication is not English and who has a limited ability to read, write, speak, or understand English.

“(13) INTEGRATED HEALTH CARE DELIVERY SYSTEM.—The term ‘integrated health care delivery system’ means an interdisciplinary system that brings together providers from the primary health, mental health, substance use disorder, and related disciplines to improve the health outcomes of an individual. Such providers may include hospitals, health, mental health, or substance use disorder clinics and providers, home health agencies, ambulatory surgery centers, skilled nursing facilities, rehabilitation centers, and employed, independent, or contracted physicians.

“(14) INTERPRETING; INTERPRETATION.—The terms ‘interpreting’ and ‘interpretation’ mean the transmission of a spoken, written, or signed message from one language or format into another, faithfully, accurately, and objectively.

“(15) LANGUAGE ACCESS.—The term ‘language access’ means the provision of language services to an individual with limited-English proficiency or an individual with communication disabilities designed to enhance that individual’s access to, understanding of, or benefit from health care services or health-care-related services.

“(16) LANGUAGE ASSISTANCE SERVICES.—The term ‘language assistance services’ includes—

“(A) oral language assistance, including interpretation in non-English languages provided in-person or remotely by a qualified interpreter for an individual with limited-English proficiency, and the use of qualified bilingual or multilingual staff to communicate directly with individuals with limited-English proficiency;

“(B) written translation, performed by a qualified translator, of written content in paper or electronic form into languages other than English; and

“(C) taglines.

“(17) MINORITY.—

“(A) IN GENERAL.—The terms ‘minority’ and ‘minorities’ refer to individuals from a minority group.

“(B) POPULATIONS.—The term ‘minority’, with respect to populations, refers to racial and ethnic minority groups, members of sexual and gender minority groups, and individuals with a disability.

“(18) MINORITY GROUP.—The term ‘minority group’ has the meaning given the term ‘racial and ethnic minority group’.

“(19) ONSITE INTERPRETATION.—The term ‘onsite interpretation’ means a method of interpreting or interpretation for which the interpreter is in the physical presence of the provider of health care services or health-care-related services and the recipient of such services who is limited in English proficiency or has a communication impairment such as an impairment in hearing, vision, or learning.

“(20) QUALIFIED INTERPRETER FOR AN INDIVIDUAL WITH LIMITED-ENGLISH PROFICIENCY.—The term ‘qualified interpreter for an individual with limited-English proficiency’ means an interpreter who via a remote interpreting service or an on-site appearance—

“(A) adheres to generally accepted interpreter ethics principles, including client confidentiality;

“(B) has demonstrated proficiency in speaking and understanding both spoken English and one or more other spoken languages; and

“(C) is able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such languages and English, using any necessary specialized vocabulary, terminology, and phraseology.

“(21) QUALIFIED TRANSLATOR.—The term ‘qualified translator’ means a translator who—

“(A) adheres to generally accepted translator ethics principles, including client confidentiality;

“(B) has demonstrated proficiency in writing and understanding both written English and one or more other written non-English languages; and

“(C) is able to translate effectively, accurately, and impartially to and from such languages and English, using any necessary specialized vocabulary, terminology, and phraseology.

“(22) RACIAL AND ETHNIC MINORITY GROUP.—The term ‘racial and ethnic minority group’ means Indians and Alaska Natives, African Americans (including Caribbean Blacks, Africans, and other Blacks), Asian Americans, Hispanics (including Latinos), and Native Hawaiians and other Pacific Islanders.

“(23) SEXUAL AND GENDER MINORITY GROUP.—The term ‘sexual and gender minority group’ encompasses lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expression, or reproductive development varies from traditional, societal, cultural, or physiological norms.

“(24) SIGHT TRANSLATION.—The term ‘sight translation’ means the transmission of a written message in one language into a spoken or signed message in another language, or an alternative format in English or another language.

“(25) STATE.—Notwithstanding section 2, the term ‘State’ means each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.

“(26) TELEPHONIC INTERPRETATION.—The term ‘telephonic interpretation’ (also known as ‘over the phone interpretation’ or ‘OPI’) means, with respect to interpretation for an individual with limited-English proficiency, a method of interpretation in which the interpreter is not in the physical presence of the provider of health care services or health-care-related services and such individual receiving such services, but the interpreter is connected via telephone.

“(27) TRANSLATION.—The term ‘translation’ means the transmission of a written message in one language into a written or signed message in another language, and includes translation into another language or alternative format, such as large print font, Braille, audio recording, or CD.

“(28) VIDEO REMOTE INTERPRETING SERVICES.—The term ‘video remote interpreting services’ means the provision, in health care services or health-care-related services, through a qualified interpreter for an individual with limited-English proficiency, of video remote interpreting services that are—

“(A) in real-time, full-motion video, and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication; and

“(B) in a sharply delineated image that is large enough to display.

“(29) VITAL DOCUMENT.—The term ‘vital document’ includes applications for government programs that provide health care services, medical or financial consent forms, financial assistance documents, letters containing important information regarding patient instructions (such as prescriptions, referrals to other providers, and discharge plans) and participation in a program (such as a Medicaid managed care program), notices pertaining to the reduction, denial, or termination of services or benefits, notices of the right to appeal such actions, and notices advising individuals with limited-English proficiency with communication disabilities of the availability of free language services, alternative formats, and other outreach materials.

“(b) Reference.—In any reference in this title to a regulatory provision applicable to a ‘handicapped individual’, the term ‘handicapped individual’ in such provision shall have the same meaning as the term ‘individual with a disability’ as defined in subsection (a).

“subtitle AResources and innovation for culturally and linguistically appropriate health care

“SEC. 3401. Robert T. Matsui Center for Culturally and Linguistically Appropriate Health Care.

“(a) Establishment.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall establish and support a center to be known as the ‘Robert T. Matsui Center for Culturally and Linguistically Appropriate Health Care’ (referred to in this section as the ‘Center’) to carry out each of the following activities:

“(1) INTERPRETATION SERVICES.—The Center shall provide resources via the internet to identify and link health care providers to competent interpreter and translation services.

“(2) TRANSLATION OF WRITTEN MATERIAL.—

“(A) VITAL DOCUMENTS.—The Center shall provide, directly or through contract, vital documents from competent translation services for providers of health care services and health-care-related services at no cost to such providers. Such documents may be submitted for translation into non-English languages. Such translation services shall be provided in a timely and reasonable manner. The quality of such translation services shall be monitored and reported publicly.

“(B) FORMS.—For each form developed or revised by the Secretary that will be used by individuals with limited-English proficiency in health care or health-care-related settings, the Center shall translate the form, at a minimum, into the top 15 non-English languages in the United States according to the most recent data from the American Community Survey or its replacement. The translation shall be completed within 45 days of the Secretary receiving final approval of the form from the Office of Management and Budget.

“(3) TOLL-FREE CUSTOMER SERVICE TELEPHONE NUMBER.—The Center shall provide, through a toll-free number, a customer service line for individuals with limited-English proficiency—

“(A) to obtain information about federally conducted or funded health programs, including the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the State Children's Health Insurance Program under title XXI of such Act;

“(B) to obtain assistance with applying for or accessing these programs and understanding Federal notices written in English; and

“(C) to learn how to access language services.

“(4) HEALTH INFORMATION CLEARINGHOUSE.—

“(A) IN GENERAL.—The Center shall develop and maintain an information clearinghouse to facilitate the provision of language services by providers of health care services and health-care-related services to reduce medical errors, improve medical outcomes, improve cultural competence, reduce health care costs caused by miscommunication with individuals with limited-English proficiency, and reduce or eliminate the duplication of efforts to translate materials. The clearinghouse shall include the information described in subparagraphs (B) through (F) and make such information available on the internet and in print.

“(B) DOCUMENT TEMPLATES.—The Center shall collect and evaluate for accuracy, develop, and make available templates for standard documents that are necessary for patients and consumers to access and make educated decisions about their health care, including templates for each of the following:

“(i) Administrative and legal documents, including—

“(I) intake forms;

“(II) forms related to the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the State Children's Health Insurance Program under title XXI of such Act, including eligibility information for such programs;

“(III) forms informing patients of the compliance and consent requirements pursuant to the regulations under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320–2 note); and

“(IV) documents concerning informed consent, advanced directives, and waivers of rights.

“(ii) Clinical information, such as how to take medications, how to prevent transmission of a contagious disease, and other prevention and treatment instructions.

“(iii) Public health, patient education, and outreach materials, such as immunization notices, health warnings, or screening notices.

“(iv) Additional health or health-care-related materials as determined appropriate by the Director of the Center.

“(C) STRUCTURE OF FORMS.—In operating the clearinghouse, the Center shall—

“(i) ensure that the documents posted in English and non-English languages are culturally and linguistically appropriate;

“(ii) allow public review of the documents before dissemination in order to ensure that the documents are understandable and culturally and linguistically appropriate for the target populations;

“(iii) allow health care providers to customize the documents for their use;

“(iv) facilitate access to these documents;

“(v) provide technical assistance with respect to the access and use of such information; and

“(vi) carry out any other activities the Secretary determines to be useful to fulfill the purposes of the clearinghouse.

“(D) LANGUAGE ASSISTANCE PROGRAMS.—The Center shall provide for the collection and dissemination of information on current examples of language assistance programs and strategies to improve language services for individuals with limited-English proficiency, including case studies using de-identified patient information, program summaries, and program evaluations.

“(E) CULTURALLY AND LINGUISTICALLY APPROPRIATE MATERIALS.—The Center shall provide information relating to culturally and linguistically appropriate health care for minority populations residing in the United States to all health care providers and health-care-related services at no cost. Such information shall include—

“(i) tenets of culturally and linguistically appropriate care;

“(ii) culturally and linguistically appropriate self-assessment tools;

“(iii) culturally and linguistically appropriate training tools;

“(iv) strategic plans to increase cultural and linguistic appropriateness in different types of providers of health care services and health-care-related services, including regional collaborations among health care organizations; and

“(v) culturally and linguistically appropriate information for educators, practitioners, and researchers.

“(F) INFORMATION ABOUT PROGRESS.—The Center shall regularly collect and make publicly available information about the progress of entities receiving grants under section 3402 regarding successful innovations in implementing the obligations under this subsection and provide public notice in the entities’ communities about the availability of this information.

“(b) Director.—The Center shall be headed by a Director who shall be appointed by, and who shall report to, the Director of the Agency for Healthcare Research and Quality.

“(c) Availability of language access.—The Director shall collaborate with the Deputy Assistant Secretary for Minority Health, the Administrator of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration to notify health care providers and health care organizations about the availability of language access services by the Center.

“(d) Education.—The Secretary, directly or through contract, shall undertake a national education campaign to inform providers, individuals with limited-English proficiency, health professionals, graduate schools, and community health centers about—

“(1) Federal and State laws and guidelines governing access to language services;

“(2) the value of using trained interpreters and the risks associated with using family members, friends, minors, and untrained bilingual staff;

“(3) funding sources for developing and implementing language services; and

“(4) promising practices to effectively provide language services.

“(e) Authorization of appropriations.—There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2019 through 2023.

“SEC. 3402. Innovations in culturally and linguistically appropriate health care grants.

“(a) In general.—

“(1) GRANTS.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall award grants to eligible entities to enable such entities to design, implement, and evaluate innovative, cost-effective programs to improve culturally and linguistically appropriate access to health care services for individuals with limited-English proficiency.

“(2) COORDINATION.—The Director of the Agency for Healthcare Research and Quality shall coordinate with, and ensure the participation of, other agencies including the Health Resources and Services Administration, the National Institute on Minority Health and Health Disparities at the National Institutes of Health, and the Office of Minority Health, regarding the design and evaluation of the grants program.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a) an entity shall—

“(1) be—

“(A) a city, county, Indian Tribe, State, or subdivision thereof;

“(B) an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Code;

“(C) a community health, mental health, or substance use disorder center or clinic;

“(D) a solo or group physician practice;

“(E) an integrated health care delivery system;

“(F) a public hospital;

“(G) a health care group, university, or college; or

“(H) any other entity designated by the Secretary; and

“(2) prepare and submit to the Secretary an application, at such time, in such manner, and containing such additional information as the Secretary may reasonably require.

“(c) Use of funds.—An entity shall use funds received through a grant under this section to—

“(1) develop, implement, and evaluate models of providing competent interpretation services through onsite interpretation, telephonic interpretation, or video remote interpreting services;

“(2) implement strategies to recruit, retain, and promote individuals at all levels of the organization to maintain a diverse staff and leadership that can promote and provide language services to patient populations of the service area of the entity;

“(3) develop and maintain a needs assessment that identifies the current demographic, cultural, and epidemiological profile of the community to accurately plan for and implement language services needed in the service area of the entity;

“(4) develop a strategic plan to implement language services;

“(5) develop participatory, collaborative partnerships with communities encompassing the patient populations of individuals with limited-English proficiency served by the grant to gain input in designing and implementing language services;

“(6) develop and implement grievance resolution processes that are culturally and linguistically appropriate and capable of identifying, preventing, and resolving complaints by individuals with limited-English proficiency;

“(7) develop short-term medical and mental health interpretation training courses and incentives for bilingual health care staff who are asked to provide interpretation services in the workplace;

“(8) develop formal training programs, including continued professional development and education programs as well as supervision, for individuals interested in becoming dedicated health care interpreters and culturally and linguistically appropriate providers;

“(9) provide staff language training instruction, which shall include information on the practical limitations of such instruction for nonnative speakers;

“(10) develop policies that address compensation in salary for staff who receive training to become either a staff interpreter or bilingual provider;

“(11) develop other language assistance services as determined appropriate by the Secretary;

“(12) develop, implement, and evaluate models of improving cultural competence, including cultural competence programs for community health workers; and

“(13) ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 and any applicable State privacy laws, data on the individual patient or recipient’s race, ethnicity, and primary language are collected (and periodically updated) in health records and integrated into the organization’s information management systems or any similar system used to store and retrieve data.

“(d) Priority.—In awarding grants under this section, the Secretary shall give priority to entities that primarily engage in providing direct care and that have developed partnerships with community organizations or with agencies with experience in improving language access.

“(e) Evaluation.—

“(1) BY GRANTEES.—An entity that receives a grant under this section shall submit to the Secretary an evaluation that describes, in the manner and to the extent required by the Secretary, the activities carried out with funds received under the grant, and how such activities improved access to health care services and health-care-related services and the quality of health care for individuals with limited-English proficiency. Such evaluation shall be collected and disseminated through the Robert T. Matsui Center for Culturally and Linguistically Appropriate Health Care established under section 3401. The Director of the Agency for Healthcare Research and Quality shall notify grantees of the availability of technical assistance for the evaluation and provide such assistance upon request.

“(2) BY SECRETARY.—The Director of the Agency for Healthcare Research and Quality shall evaluate or arrange with other individuals or organizations to evaluate projects funded under this section.

“(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section, $5,000,000 for each of fiscal years 2019 through 2023.

“SEC. 3403. Research on cultural and language competence.

“(a) In general.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall expand research concerning language access in the provision of health care services.

“(b) Eligibility.—The Director of the Agency for Healthcare Research and Quality may conduct the research described in subsection (a) or enter into contracts with other individuals or organizations to conduct such research.

“(c) Use of funds.—Research conducted under this section shall be designed to do one or more of the following:

“(1) To identify the barriers to mental and behavioral services that are faced by individuals with limited-English proficiency.

“(2) To identify health care providers’ and health administrators’ attitudes, knowledge, and awareness of the barriers to quality health care services that are faced by individuals with limited-English proficiency.

“(3) To identify optimal approaches for delivering language access.

“(4) To identify best practices for data collection, including—

“(A) the collection by providers of health care services and health-care-related services of data on the race, ethnicity, and primary language of recipients of such services, taking into account existing research conducted by the Government or private sector;

“(B) the development and implementation of data collection and reporting systems; and

“(C) effective privacy safeguards for collected data.

“(5) To develop a minimum data collection set for primary language.

“(6) To evaluate the most effective ways in which the Secretary can create or coordinate, and subsidize or otherwise fund, telephonic interpretation services for health care providers, taking into consideration, among other factors, the flexibility necessary for such a system to accommodate variations in—

“(A) provider type;

“(B) languages needed and their frequency of use;

“(C) type of encounter;

“(D) time of encounter, including regular business hours and after hours; and

“(E) location of encounter.

“(d) Authorization of appropriations.—There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2019 through 2023.”.

SEC. 205. Pilot program for improvement and development of State medical interpreting services.

(a) Grants authorized.—The Secretary shall award 1 grant in accordance with this section to each of 3 States (to be selected by the Secretary) to assist each such State in designing, implementing, and evaluating a statewide program to provide onsite interpreter services under the State Medicaid plan.

(b) Grant period.—A grant awarded under this section is authorized for the period of 3 fiscal years beginning on October 1, 2019, and ending on September 30, 2022.

(c) Preference.—In awarding a grant under this section, the Secretary shall give preference to a State—

(1) that has a high proportion of qualified LEP enrollees, as determined by the Secretary;

(2) that has a large number of qualified LEP enrollees, as determined by the Secretary;

(3) that has a high growth rate of the population of individuals with limited-English proficiency, as determined by the Secretary; and

(4) that has a population of qualified LEP enrollees that is linguistically diverse, requiring interpreter services in at least 200 non-English languages.

(d) Use of funds.—A State receiving a grant under this section shall use the grant funds to—

(1) ensure that all health care providers in the State participating in the State Medicaid plan have access to onsite interpreter services, for the purpose of enabling effective communication between such providers and qualified LEP enrollees during the furnishing of items and services and administrative interactions;

(2) establish, expand, procure, or contract for—

(A) a statewide health care information technology system that is designed to achieve efficiencies and economies of scale with respect to onsite interpreter services provided to health care providers in the State participating in the State Medicaid plan; and

(B) an entity to administer such system, the duties of which shall include—

(i) procuring and scheduling interpreter services for qualified LEP enrollees;

(ii) procuring and scheduling interpreter services for individuals with limited-English proficiency seeking to enroll in the State Medicaid plan;

(iii) ensuring that interpreters receive payment for interpreter services rendered under the system; and

(iv) consulting regularly with organizations representing consumers, interpreters, and health care providers; and

(3) develop mechanisms to establish, improve, and strengthen the competency of the medical interpretation workforce that serves qualified LEP enrollees in the State, including a national certification process that is valid, credible, and vendor-neutral.

(e) Application.—To receive a grant under this section, a State shall submit an application at such time and containing such information as the Secretary may require, which shall include the following:

(1) A description of the language access needs of individuals in the State enrolled in the State Medicaid plan.

(2) A description of the extent to which the program will—

(A) use the grant funds for the purposes described in subsection (d);

(B) meet the health care needs of rural populations of the State; and

(C) collect information that accurately tracks the language services requested by consumers as compared to the language services provided by health care providers in the State participating in the State Medicaid plan.

(3) A description of how the program will be evaluated, including a proposal for collaboration with organizations representing interpreters, consumers, and individuals with limited-English proficiency.

(f) Definitions.—In this section:

(1) QUALIFIED LEP ENROLLEE.—The term “qualified LEP enrollee” means an individual—

(A) who is limited-English proficient; and

(B) who is enrolled in a State Medicaid plan.

(2) STATE.—The term “State” has the meaning given the term in section 1101(a)(1) of the Social Security Act (42 U.S.C. 1301(a)(1)), for purposes of title XIX of such Act.

(3) STATE MEDICAID PLAN.—The term “State Medicaid plan” means a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) or a waiver of such a plan.

(4) UNITED STATES.—The term “United States” has the meaning given the term in section 1101(a)(2) of the Social Security Act (42 U.S.C. 1301(a)(2)), for purposes of title XIX of such Act.

(g) Funding.—

(1) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated $5,000,000 to carry out this section.

(2) AVAILABILITY OF FUNDS.—Amounts appropriated pursuant to the authorization in paragraph (1) are authorized to remain available without fiscal year limitation.

(3) INCREASED FEDERAL FINANCIAL PARTICIPATION.—Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)) is amended by inserting “(or, in the case of a State that was awarded a grant under section 203 of the Health Equity and Accountability Act of 2018, 100 percent for each quarter occurring during the grant period specified in subsection (b) of such section)” after “75 percent”.

(h) Limitation.—No Federal funds awarded under this section may be used to provide interpreter services from a location outside the United States.

SEC. 206. Training tomorrow’s doctors for culturally and linguistically appropriate care: graduate medical education.

(a) Direct graduate medical education.—Section 1886(h)(4) of the Social Security Act (42 U.S.C. 1395ww(h)(4)) is amended by adding at the end the following new subparagraph:

“(L) TREATMENT OF CULTURALLY AND LINGUISTICALLY APPROPRIATE TRAINING.—In determining a hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program for education and training in culturally and linguistically appropriate service delivery shall be counted toward the determination of full-time equivalency.”.

(b) Indirect medical education.—Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended—

(1) by redesignating the clause (x) added by section 5505(b) of the Patient Protection and Affordable Care Act as clause (xi); and

(2) by adding at the end the following new clause:

“(xii) The provisions of subparagraph (L) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.”.

(c) Effective date.—The amendments made by subsections (a) and (b) shall apply with respect to payments made to hospitals on or after the date that is one year after the date of the enactment of this Act.

SEC. 207. Federal reimbursement for culturally and linguistically appropriate services under the Medicare, Medicaid, and State Children’s Health Insurance Programs.

(a) Language Access grants for Medicare Providers.—

(1) ESTABLISHMENT.—

(A) IN GENERAL.—Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the Centers for Medicare & Medicaid Services and in consultation with the Center for Medicare and Medicaid Innovation, shall establish a demonstration program under which the Secretary shall award grants to eligible Medicare service providers to improve communication between such providers and Medicare beneficiaries who are English learners, including beneficiaries who live in diverse and underserved communities.

(B) APPLICATION OF INNOVATION RULES.—The demonstration project under subparagraph (A) shall be conducted in a manner that is consistent with the applicable provisions of subsections (b), (c), and (d) of section 1115A of the Social Security Act (42 U.S.C. 1315a).

(C) NUMBER OF GRANTS.—To the extent practicable, the Secretary shall award not less than 24 grants under this subsection.

(D) GRANT PERIOD.—Except as provided under paragraph (2)(D), each grant awarded under this subsection shall be for a 3-year period.

(2) ELIGIBILITY REQUIREMENTS.—To be eligible for a grant under this subsection, an entity must meet the following requirements:

(A) MEDICARE PROVIDER.—The entity must be—

(i) a provider of services under part A of title XVIII of the Social Security Act;

(ii) a provider of services under part B of such title;

(iii) a Medicare Advantage organization offering a Medicare Advantage plan under part C of such title; or

(iv) a PDP sponsor offering a prescription drug plan under part D of such title.

(B) UNDERSERVED COMMUNITIES.—The entity must serve a community that, with respect to necessary language services for improving access and utilization of health care among English learners, is disproportionally underserved.

(C) APPLICATION.—The entity must prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require.

(D) REPORTING.—In the case of a grantee that received a grant under this subsection in a previous year, such grantee is only eligible for continued payments under a grant under this subsection if the grantee met the reporting requirements under paragraph (9) for such year. If a grantee fails to meet the requirement of such paragraph for the first year of a grant, the Secretary may terminate the grant and solicit applications from new grantees to participate in the demonstration program.

(3) DISTRIBUTION.—To the extent feasible, the Secretary shall award—

(A) at least 6 grants to providers of services described in paragraph (2)(A)(i);

(B) at least 6 grants to service providers described in paragraph (2)(A)(ii);

(C) at least 6 grants to organizations described in paragraph (2)(A)(iii); and

(D) at least 6 grants to sponsors described in paragraph (2)(A)(iv).

(4) CONSIDERATIONS IN AWARDING GRANTS.—

(A) VARIATION IN GRANTEES.—In awarding grants under this subsection, the Secretary shall select grantees to ensure the following:

(i) The grantees provide many different types of language services.

(ii) The grantees serve Medicare beneficiaries who speak different languages, and who, as a population, have differing needs for language services.

(iii) The grantees serve Medicare beneficiaries in both urban and rural settings.

(iv) The grantees serve Medicare beneficiaries in at least two geographic regions, as defined by the Secretary.

(v) The grantees serve Medicare beneficiaries in at least two large metropolitan statistical areas with racial, ethnic, sexual, gender, disability, and economically diverse populations.

(B) PRIORITY FOR PARTNERSHIPS WITH COMMUNITY ORGANIZATIONS AND AGENCIES.—In awarding grants under this subsection, the Secretary shall give priority to eligible entities that have a partnership with—

(i) a community organization; or

(ii) a consortia of community organizations, State agencies, and local agencies,

that has experience in providing language services.

(5) USE OF FUNDS FOR COMPETENT LANGUAGE SERVICES.—

(A) IN GENERAL.—Subject to subparagraph (E), a grantee may only use grant funds received under this subsection to pay for the provision of competent language services to Medicare beneficiaries who are English learners.

(B) COMPETENT LANGUAGE SERVICES DEFINED.—For purposes of this subsection, the term “competent language services” means—

(i) interpreter and translation services that—

(I) subject to the exceptions under subparagraph (C)

(aa) if the grantee operates in a State that has statewide health care interpreter standards, meet the State standards currently in effect; or

(bb) if the grantee operates in a State that does not have statewide health care interpreter standards, utilizes competent interpreters who follow the National Council on Interpreting in Health Care’s Code of Ethics and Standards of Practice; and

(II) that, in the case of interpreter services, are provided through—

(aa) onsite interpretation;

(bb) telephonic interpretation; or

(cc) video interpretation; and

(ii) the direct provision of health care or health-care-related services by a competent bilingual health care provider.

(C) EXCEPTIONS.—The requirements of subparagraph (B)(i)(I) do not apply, with respect to interpreter and translation services and a grantee—

(i) in the case of a Medicare beneficiary who is an English learner if—

(I) such beneficiary has been informed, in the beneficiary’s primary language, of the availability of free interpreter and translation services and the beneficiary instead requests that a family member, friend, or other person provide such services; and

(II) the grantee documents such request in the beneficiary’s medical record; or

(ii) in the case of a medical emergency where the delay directly associated with obtaining a competent interpreter or translation services would jeopardize the health of the patient.

Clause (ii) shall not be construed to exempt emergency rooms or similar entities that regularly provide health care services in medical emergencies to patients who are English learners from any applicable legal or regulatory requirements related to providing competent interpreter and translation services without undue delay.

(D) MEDICARE ADVANTAGE ORGANIZATIONS AND PDP SPONSORS.—If a grantee is a Medicare Advantage organization offering a Medicare Advantage plan under part C of title XVIII of the Social Security Act or a PDP sponsor offering a prescription drug plan under part D of such title, such entity must provide at least 50 percent of the grant funds that the entity receives under this subsection directly to the entity’s network providers (including all health providers and pharmacists) for the purpose of providing support for such providers to provide competent language services to Medicare beneficiaries who are English learners.

(E) ADMINISTRATIVE AND REPORTING COSTS.—A grantee may use up to 10 percent of the grant funds to pay for administrative costs associated with the provision of competent language services and for reporting required under paragraph (9).

(6) DETERMINATION OF AMOUNT OF GRANT PAYMENTS.—

(A) IN GENERAL.—Payments to grantees under this subsection shall be calculated based on the estimated numbers of Medicare beneficiaries who are English learners in a grantee’s service area utilizing—

(i) data on the numbers of English learners who speak English less than “very well” from the most recently available data from the Bureau of the Census or other State-based study the Secretary determines likely to yield accurate data regarding the number of such individuals in such service area; or

(ii) data provided by the grantee, if the grantee routinely collects data on the primary language of the Medicare beneficiaries that the grantee serves and the Secretary determines that the data is accurate and shows a greater number of English learners than would be estimated using the data under clause (i).

(B) DISCRETION OF SECRETARY.—Subject to subparagraph (C), the amount of payment made to a grantee under this subsection may be modified annually at the discretion of the Secretary, based on changes in the data under subparagraph (A) with respect to the service area of a grantee for the year.

(C) LIMITATION ON AMOUNT.—The amount of a grant made under this subsection to a grantee may not exceed $500,000 for the period under paragraph (1)(D).

(7) ASSURANCES.—Grantees under this subsection shall, as a condition of receiving a grant under this subsection—

(A) ensure that clinical and support staff receive appropriate ongoing education and training in linguistically appropriate service delivery;

(B) ensure the linguistic competence of bilingual providers;

(C) offer and provide appropriate language services at no additional charge to each patient who is an English learner for all points of contact between the patient and the grantee, in a timely manner during all hours of operation;

(D) notify Medicare beneficiaries of their right to receive language services in their primary language;

(E) post signage in the primary languages commonly used by the patient population in the service area of the organization; and

(F) ensure that—

(i) primary language data are collected for recipients of language services and such data are consistent with standards developed under title XXXIV of the Public Health Service Act, as added by section 202 of this Act, to the extent such standards are available upon the initiation of the demonstration program; and

(ii) consistent with the privacy protections provided under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note), if the recipient of language services is a minor or is incapacitated, primary language data are collected on the parent or legal guardian of such recipient.

(8) NO COST SHARING.—Medicare beneficiaries who are English learners shall not have to pay cost sharing or co-payments for competent language services provided under this demonstration program.

(9) REPORTING REQUIREMENTS FOR GRANTEES.—Not later than the end of each calendar year, a grantee that receives funds under this subsection in such year shall submit to the Secretary a report that includes the following information:

(A) The number of Medicare beneficiaries to whom competent language services are provided.

(B) The primary languages of those Medicare beneficiaries.

(C) The types of language services provided to such beneficiaries.

(D) Whether such language services were provided by employees of the grantee or through a contract with external contractors or agencies.

(E) The types of interpretation services provided to such beneficiaries, and the approximate length of time such service is provided to such beneficiaries.

(F) The costs of providing competent language services.

(G) An account of the training or accreditation of bilingual staff, interpreters, and translators providing services funded by the grant under this subsection.

(10) EVALUATION AND REPORT TO CONGRESS.—Not later than 1 year after the completion of a 3-year grant under this subsection, the Secretary shall conduct an evaluation of the demonstration program under this subsection and shall submit to the Congress a report that includes the following:

(A) An analysis of the patient outcomes and the costs of furnishing care to the Medicare beneficiaries who are English learners participating in the project as compared to such outcomes and costs for such Medicare beneficiaries not participating, based on the data provided under paragraph (9) and any other information available to the Secretary.

(B) The effect of delivering language services on—

(i) Medicare beneficiary access to care and utilization of services;

(ii) the efficiency and cost effectiveness of health care delivery;

(iii) patient satisfaction;

(iv) health outcomes; and

(v) the provision of culturally appropriate services provided to such beneficiaries.

(C) The extent to which bilingual staff, interpreters, and translators providing services under such demonstration were trained or accredited and the nature of accreditation or training needed by type of provider, service, or other category as determined by the Secretary to ensure the provision of high-quality interpretation, translation, or other language services to Medicare beneficiaries if such services are expanded pursuant to section 1115A(c) of the Social Security Act (42 U.S.C. 1315a(c)).

(D) Recommendations, if any, regarding the extension of such project to the entire Medicare Program, subject to the provisions of such section 1115A(c).

(11) APPROPRIATIONS.—There is appropriated to carry out this subsection, in equal parts from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), $16,000,000 for each fiscal year of the demonstration program.

(12) ENGLISH LEARNER DEFINED.—In this subsection, the term “English learner” has the meaning given such term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.

(b) Language assistance services under the Medicare program.—

(1) INCLUSION AS RURAL HEALTH CLINIC SERVICES.—Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—

(A) in subsection (aa)(1)—

(i) in subparagraph (B), by striking “and” at the end;

(ii) by adding “and” at the end of subparagraph (C); and

(iii) by inserting after subparagraph (C) the following new subparagraph:

“(D) language assistance services as defined in subsection (jjj)(1),”; and

(B) by adding at the end the following new subsection:

“Language Assistance Services And Related Terms

“(jjj) (1) The term ‘language assistance services’ means ‘language access’ or ‘language assistance services’ (as those terms are defined in section 3400 of the Public Health Service Act) furnished by a ‘qualified interpreter for an individual with limited-English proficiency’ or a ‘qualified translator’ (as those terms are defined in such section 3400) to an ‘individual with limited English proficiency’ (as defined in such section 3400) or an ‘English learner’ (as defined in paragraph (2)).

“(2) The term ‘English learner’ has the meaning given that term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.”.

(2) COVERAGE.—Section 1832(a)(2) of the Social Security Act (42 U.S.C. 1395k(a)(2)) is amended—

(A) by striking “and” at the end of subparagraph (I);

(B) by striking the period at the end of subparagraph (J) and inserting “; and”; and

(C) by adding at the end the following new subparagraph:

“(K) language assistance services (as defined in section 1861(jjj)(1)).”.

(3) PAYMENT.—Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) is amended—

(A) by striking “and” at the end of paragraph (8);

(B) by striking the period at the end of paragraph (9) and inserting “; and”; and

(C) by inserting after paragraph (9) the following new paragraph:

“(10) in the case of language assistance services (as defined in section 1861(jjj)(1)), 100 percent of the reasonable charges for such services, as determined in consultation with the Medicare Payment Advisory Commission.”.

(4) WAIVER OF BUDGET NEUTRALITY.—For the 3-year period beginning on the date of enactment of this section, the budget neutrality provision of section 1848(c)(2)(B)(ii) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)(ii)) shall not apply with respect to language assistance services (as defined in section 1861(jjj)(1) of such Act).

(c) Medicare parts C and D.—

(1) IN GENERAL.—Medicare Advantage plans under part C of title XVIII of the Social Security Act and prescription drug plans under part D of such title shall comply with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) to provide effective language services to enrollees of such plans.

(2) MEDICARE ADVANTAGE PLANS AND PRESCRIPTION DRUG PLANS REPORTING REQUIREMENT.—Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:

“(5) REPORTING REQUIREMENTS RELATING TO EFFECTIVE LANGUAGE SERVICES.—A contract under this part shall require a Medicare Advantage organization (and, through application of section 1860D–12(b)(3)(D), a contract under section 1860D–12 shall require a PDP sponsor) to annually submit (for each year of the contract) a report that contains information on the internal policies and procedures of the organization (or sponsor) related to recruitment and retention efforts directed to workforce diversity and linguistically and culturally appropriate provision of services in each of the following contexts:

“(A) The collection of data in a manner that meets the requirements of title I of the Health Equity and Accountability Act of 2018, regarding the enrollee population.

“(B) Education of staff and contractors who have routine contact with enrollees regarding the various needs of the diverse enrollee population.

“(C) Evaluation of the language services programs and services offered by the organization (or sponsor) with respect to the enrollee population, such as through analysis of complaints or satisfaction survey results.

“(D) Methods by which the plan provides to the Secretary information regarding the ethnic diversity of the enrollee population.

“(E) The periodic provision of educational information to plan enrollees on the language services and programs offered by the organization (or sponsor).”.

(d) Improving language services in Medicaid and CHIP.—

(1) PAYMENTS TO STATES.—Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)), as amended by section 203(g)(3), is further amended by—

(A) striking “75” and inserting “90”;

(B) striking “translation or interpretation services” and inserting “language assistance services”; and

(C) striking “children of families” and inserting “individuals”.

(2) STATE PLAN REQUIREMENTS.—Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking “and (28)” and inserting “(28), and (29)”.

(3) DEFINITION OF MEDICAL ASSISTANCE.—Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended by—

(A) in paragraph (28), by striking “and” at the end;

(B) by redesignating paragraph (29) as paragraph (30); and

(C) by inserting after paragraph (28) the following new paragraph:

“(29) language assistance services, as such term is defined in section 1861(jjj)(1), provided in a timely manner to individuals with limited-English proficiency as defined in section 3400 of the Public Health Service Act; and”.

(4) USE OF DEDUCTIONS AND COST SHARING.—Section 1916(a)(2) of the Social Security Act (42 U.S.C. 1396o(a)(2)) is amended by—

(A) by striking “or” at the end of subparagraph (D);

(B) by striking “; and” at the end of subparagraph (E) and inserting “, or”; and

(C) by adding at the end the following new subparagraph:

“(F) language assistance services described in section 1905(a)(29); and”.

(5) CHIP COVERAGE REQUIREMENTS.—Section 2103 of the Social Security Act (42 U.S.C. 1397cc) is amended—

(A) in subsection (a), in the matter before paragraph (1), by striking “and (7)” and inserting “(7), and (9)”; and

(B) in subsection (c), by adding at the end the following new paragraph:

“(9) LANGUAGE ASSISTANCE SERVICES.—The child health assistance provided to a targeted low-income child shall include coverage of language assistance services, as such term is defined in section 1861(jjj)(1), provided in a timely manner to individuals with limited-English proficiency (as defined in section 3400 of the Public Health Service Act).”; and

(C) in subsection (e)(2)—

(i) in the heading, by striking “preventive” and inserting “certain”; and

(ii) by inserting “or subsection (c)(9)” after “subsection (c)(1)(D)”.

(6) DEFINITION OF CHILD HEALTH ASSISTANCE.—Section 2110(a)(27) of the Social Security Act (42 U.S.C. 1397jj(a)(27)) is amended by striking “translation” and inserting “language assistance services as described in section 2103(c)(9)”.

(7) STATE DATA COLLECTION.—Pursuant to the reporting requirement described in section 2107(b)(1) of the Social Security Act (42 U.S.C. 1397gg(b)(1)), the Secretary of Health and Human Services shall require that States collect data on—

(A) the primary language of individuals receiving child health assistance under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.); and

(B) in the case of such individuals who are minors or incapacitated, the primary language of the individual’s parent or guardian.

(8) CHIP PAYMENTS TO STATES.—Section 2105 of the Social Security Act (42 U.S.C. 1397ee) is amended—

(A) in subsection (a)(1), by striking “75” and inserting “90”; and

(B) in subsection (c)(2)(A), by inserting before the period at the end the following: “, except that expenditures pursuant to clause (iv) of subparagraph (D) of such paragraph shall not count towards this total”.

(e) Funding language assistance services furnished by providers of health care and health-Care-Related services that serve high rates of uninsured LEP individuals.—

(1) PAYMENT OF COSTS.—

(A) IN GENERAL.—Subject to subparagraph (B), the Secretary of Health and Human Services (referred to in this subsection as the “Secretary”) shall make payments (on a quarterly basis) directly to eligible entities to support the provision of language assistance services to English learners in an amount equal to an eligible entity’s eligible costs for providing such services for the quarter.

(B) FUNDING.—Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services such sums as may be necessary for each of fiscal years 2019 through 2023.

(C) RELATION TO MEDICAID DSH.—Payments under this subsection shall not offset or reduce payments under section 1923 of the Social Security Act (42 U.S.C. 1396r–4), nor shall payments under such section be considered when determining uncompensated costs associated with the provision of language assistance services for the purposes of this section.

(2) METHODOLOGY FOR PAYMENT OF CLAIMS.—

(A) IN GENERAL.—The Secretary shall establish a methodology to determine the average per person cost of language assistance services.

(B) DIFFERENT ENTITIES.—In establishing such methodology, the Secretary may establish different methodologies for different types of eligible entities.

(C) NO INDIVIDUAL CLAIMS.—The Secretary may not require eligible entities to submit individual claims for language assistance services for individual patients as a requirement for payment under this subsection.

(3) DATA COLLECTION INSTRUMENT.—For purposes of this subsection, the Secretary shall create a standard data collection instrument that is consistent with any existing reporting requirements by the Secretary or relevant accrediting organizations regarding the number of individuals to whom language access are provided.

(4) GUIDELINES.—Not later than 6 months after the date of enactment of this Act, the Secretary shall establish and distribute guidelines concerning the implementation of this subsection.

(5) REPORTING REQUIREMENTS.—

(A) REPORT TO SECRETARY.—Entities receiving payment under this subsection shall provide the Secretary with a quarterly report on how the entity used such funds. Such report shall contain aggregate (and may not contain individualized) data collected using the instrument under paragraph (3) and shall otherwise be in a form and manner determined by the Secretary.

(B) REPORT TO CONGRESS.—Not later than 2 years after the date of enactment of this Act, and every 2 years thereafter, the Secretary shall submit a report to Congress concerning the implementation of this subsection.

(6) DEFINITIONS.—In this subsection:

(A) ELIGIBLE COSTS.—The term “eligible costs” means, with respect to an eligible entity that provides language assistance services to English learners, the product of—

(i) the average per person cost of language assistance services, determined according to the methodology devised under paragraph (2); and

(ii) the number of English learners who are provided language assistance services by the entity and for whom no reimbursement is available for such services under the amendments made by subsections (a), (b), (c), or (d) or by private health insurance.

(B) ELIGIBLE ENTITY.—The term “eligible entity” means an entity that—

(i) is a Medicaid provider that is—

(I) a physician;

(II) a hospital with a low-income utilization rate (as defined in section 1923(b)(3) of the Social Security Act (42 U.S.C. 1396r–4(b)(3))) of greater than 25 percent; or

(III) a federally qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)));

(ii) not later than 6 months after the date of the enactment of this Act, provides language assistance services to not less than 8 percent of the entity’s total number of patients; and

(iii) prepares and submits an application to the Secretary, at such time, in such manner, and accompanied by such information as the Secretary may require, to ascertain the entity’s eligibility for funding under this subsection.

(C) ENGLISH LEARNER.—The term “English learner” has the meaning given such term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.

(D) LANGUAGE ASSISTANCE SERVICES.—The term “language assistance services” has the meaning given such term in section 1861(jjj)(1) of the Social Security Act, as added by subsection (b).

(f) Application of Civil Rights Act of 1964 and other laws.—Nothing in this section shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) or other laws that protect the civil rights of individuals.

(g) Effective date.—

(1) IN GENERAL.—Except as otherwise provided and subject to paragraph (2), the amendments made by this section shall take effect on January 1, 2019.

(2) EXCEPTION IF STATE LEGISLATION REQUIRED.—In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.

SEC. 208. Increasing understanding of and improving health literacy.

(a) In general.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality with respect to grants under subsection (c)(1) and through the Administrator of the Health Resources and Services Administration with respect to grants under subsection (c)(2), in consultation with the Director of the National Institute on Minority Health and Health Disparities and the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities to improve health care for patient populations that have low functional health literacy.

(b) Eligibility.—To be eligible to receive a grant under subsection (a), an entity shall—

(1) be a hospital, health center or clinic, health plan, or other health entity (including a nonprofit minority health organization or association); and

(2) prepare and submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may reasonably require.

(c) Use of funds.—

(1) AGENCY FOR HEALTHCARE RESEARCH AND QUALITY.—A grant awarded under subsection (a) through the Director of the Agency for Healthcare Research and Quality shall be used—

(A) to define and increase the understanding of health literacy;

(B) to investigate the correlation between low health literacy and health and health care;

(C) to clarify which aspects of health literacy have an effect on health outcomes; and

(D) for any other activity determined appropriate by the Director.

(2) HEALTH RESOURCES AND SERVICES ADMINISTRATION.—A grant awarded under subsection (a) through the Administrator of the Health Resources and Services Administration shall be used to conduct demonstration projects for interventions for patients with low health literacy that may include—

(A) the development of new disease management programs for patients with low health literacy;

(B) the tailoring of disease management programs addressing mental, physical, oral, and behavioral health conditions for patients with low health literacy;

(C) the translation of written health materials for patients with low health literacy;

(D) the identification, implementation, and testing of low health literacy screening tools;

(E) the conduct of educational campaigns for patients and providers about low health literacy; and

(F) other activities determined appropriate by the Administrator.

(d) Definitions.—In this section, the term “low health literacy” means the inability of an individual to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

(e) Authorization of appropriations.—There are authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2019 through 2023.

SEC. 209. Requirements for health programs or activities receiving Federal funds.

(a) Covered entity; covered program or activity.—In this section—

(1) the term “covered entity” means an entity carrying out a covered program or activity; and

(2) the term “covered program or activity” means any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, and any program or activity that is administered by an executive agency or any entity established under title I of the Patient Protection and Affordable Care Act (or amendments made thereby), as such programs, activities, agencies, and entities are described in section 1557(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18116(a)).

(b) Requirements.—A covered entity, in order to ensure the right of individuals with limited-English proficiency to receive access to quality health care through the covered program or activity, shall—

(1) ensure that appropriate clinical and support staff receive ongoing education and training in culturally and linguistically appropriate service delivery;

(2) offer and provide appropriate language assistance services at no additional charge to each patient that is an individual with limited-English proficiency at all points of contact, in a timely manner during all hours of operation;

(3) notify patients of their right to receive language services in their primary language; and

(4) utilize only qualified interpreters for an individual with limited-English proficiency or qualified translators, except as provided in subsection (c).

(c) Exemptions.—The requirements of subsection (b)(4) shall not apply as follows:

(1) When a patient requests the use of family, friends, or other persons untrained in interpretation or translation if each of the following conditions are met:

(A) The interpreter requested by the patient is over the age of 18.

(B) The covered entity informs the patient in the primary language of the patient that he or she has the option of having the entity provide to the patient an interpreter and translation services without charge.

(C) The covered entity informs the patient that the entity may not require an individual with a limited-English proficiency to use a family member or friend as an interpreter.

(D) The covered entity evaluates whether the person the patient wishes to use as an interpreter is competent. If the covered entity has reason to believe that such person is not competent as an interpreter, the entity provides its own interpreter to protect the covered entity from liability if the patient’s interpreter is later found not competent.

(E) If the covered entity has reason to believe that there is a conflict of interest between the interpreter and patient, the covered entity may not use the patient’s interpreter.

(F) The covered entity has the patient sign a waiver, witnessed by at least 1 individual not related to the patient, that includes the information stated in subparagraphs (A) through (E) and is translated into the patient’s primary language.

(2) When a medical emergency exists and the delay directly associated with obtaining competent interpreter or translation services would jeopardize the health of the patient, but only until a competent interpreter or translation service is available.

(d) Rule of construction.—Subsection (c)(2) shall not be construed to mean that emergency rooms or similar entities that regularly provide health care services in medical emergencies are exempt from legal or regulatory requirements related to competent interpreter services.

SEC. 210. Report on Federal efforts to provide culturally and linguistically appropriate health care services.

(a) Report.—Not later than 1 year after the date of enactment of this Act and annually thereafter, the Secretary of Health and Human Services shall enter into a contract with the National Academy of Medicine for the preparation and publication of a report that describes Federal efforts to ensure that all individuals with limited-English proficiency have meaningful access to health care services and health-care-related services that are culturally and linguistically appropriate. Such report shall include—

(1) a description and evaluation of the activities carried out under this Act;

(2) a description and analysis of best practices, model programs, guidelines, and other effective strategies for providing access to culturally and linguistically appropriate health care services;

(3) recommendations on the development and implementation of policies and practices by providers of health care services and health-care-related services for individuals with limited-English proficiency;

(4) recommend guidelines or standards for health literacy and plain language, informed consent, discharge instructions, and written communications, and for improvement of health care access;

(5) a description of the effect of providing language services on quality of health care and access to care; and

(6) a description of the costs associated with or savings related to the provision of language services.

(b) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2023.

SEC. 211. English for speakers of other languages.

(a) Grants authorized.—The Secretary of Education is authorized to provide grants to eligible entities for the provision of English as a second language (in this section referred to “ESL”) instruction and shall determine, after consultation with appropriate stakeholders, the mechanism for administering and distributing such grants.

(b) Eligible entity defined.—In this section, the term “eligible entity” means a State or community-based organization that employs and serves minority populations.

(c) Application.—An eligible entity may apply for a grant under this section by submitting such information as the Secretary of Education may require and in such form and manner as the Secretary may require.

(d) Use of grant.—As a condition of receiving a grant under this section, an eligible entity shall—

(1) develop and implement a plan for assuring the availability of ESL instruction that effectively integrates information about the nature of the United States health care system, how to access care, and any special language skills that may be required for individuals to access and regularly negotiate the system effectively;

(2) develop a plan, including, where appropriate, public-private partnerships, for making ESL instruction progressively available to all individuals seeking instruction; and

(3) maintain current ESL instruction efforts by using funds available under this section to supplement rather than supplant any funds expended for ESL instruction in the State as of January 1, 2019.

(e) Additional duties of the secretary.—The Secretary of Education shall—

(1) collect and publicize annual data on how much Federal, State, and local governments spend on ESL instruction;

(2) collect data from State and local governments to identify the unmet needs of English language learners for appropriate ESL instruction, including—

(A) the preferred written and spoken language of such English language learners;

(B) the extent of waiting lists for ESL instruction, including how many programs maintain waiting lists and, for programs that do not have waiting lists, the reasons why not;

(C) the availability of programs to geographically isolated communities;

(D) the impact of course enrollment policies, including open enrollment, on the availability of ESL instruction;

(E) the number individuals in the State and each participating locality;

(F) the effectiveness of the instruction in meeting the needs of individuals receiving instruction and those needing instruction;

(G) as assessment of the need for programs that integrate job training and ESL instruction, to assist individuals to obtain better jobs; and

(H) the availability of ESL slots by State and locality;

(3) determine the cost and most appropriate methods of making ESL instruction available to all English language learners seeking instruction; and

(4) not later than 1 year after the date of enactment of this Act, issue a report to Congress that assesses the information collected in paragraphs (1), (2), and (3) and makes recommendations on steps that should be taken to progressively realize the goal of making ESL instruction available to all English language learners seeking instruction.

(f) Authorization of Appropriations.—There are authorized to be appropriated to the Secretary of Education $250,000,000 for each of fiscal years 2019 through 2022 to carry out this section.

SEC. 212. Implementation.

(a) General provisions.—

(1) IMMUNITY.—A State shall not be immune under the 11th Amendment to the Constitution of the United States from suit in Federal court for a violation of this title (including an amendment made by this title).

(2) REMEDIES.—In a suit against a State for a violation of this title (including an amendment made by this title), remedies (including remedies both at law and in equity) are available for such a violation to the same extent as such remedies are available for such a violation in a suit against any public or private entity other than a State.

(b) Rule of construction.—Nothing in this title shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) or any other Federal statute.

SEC. 213. Language access services.

(a) Essential benefits.—Section 1302(b)(1) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(b)(1)) is amended by adding at the end the following:

“(K) Language access services, including oral interpretation and written translations.”.

(b) Employer-Sponsored minimum essential coverage.—

(1) IN GENERAL.—Section 36B(c)(2)(C) of the Internal Revenue Code of 1986 is amended by redesignating clauses (iii) and (iv) as clauses (iv) and (v), respectively, and by inserting after clause (ii) the following new clause:

“(iii) COVERAGE MUST INCLUDE LANGUAGE ACCESS AND SERVICES.—Except as provided in clause (iv), an employee shall not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employer-sponsored plan (as defined in section 5000A(f)(2)) and the plan does not provide coverage for language access services, including oral interpretation and written translations.”.

(2) CONFORMING AMENDMENTS.—

(A) Section 36B(c)(2)(C) of such Code is amended by striking “clause (iii)” each place it appears in clauses (i) and (ii) and inserting “clause (iv)”.

(B) Section 36B(c)(2)(C)(iv) of such Code, as redesignated by this subsection, is amended by striking “(i) and (ii)” and inserting “(i), (ii), and (iii)”.

(c) Quality Reporting.—Section 2717(a)(1) of the Public Health Service Act (42 U.S.C. 300gg–17(a)(1)) is amended—

(1) by striking “and” at the end of subparagraph (C);

(2) by striking the period at the end of subparagraph (D) and inserting “; and”; and

(3) by adding at the end the following new subparagraph:

“(E) reduce health disparities through the provision of language access services, including oral interpretation and written translations.”.

(d) Regulations regarding internal claims and appeals and external review processes for health plans and health insurance issuers.—The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services shall amend the regulations in section 54.9815–2719(e) of title 26, Code of Federal Regulations, section 2590.715– 2719(e) of title 29, Code of Federal Regulations, and section 147.136(e) of title 45, Code of Federal Regulations, respectively, to require group health plans and health insurance issuers offering group or individual health insurance coverage to which such sections apply—

(1) to provide oral interpretation services without any threshold requirements;

(2) to provide in the English versions of all notices a statement prominently displayed in not less than 15 non-English languages clearly indicating how to access the language services provided by the plan or issuer; and

(3) with respect to the requirements for providing relevant notices in a culturally and linguistically appropriate manner in the applicable non-English languages, to apply a threshold that 5 percent of the population, or not less than 500 individuals, in the county is literate only in the same non-English language in order for the language to be considered an applicable non-English language.

(e) Data collection and reporting.—The Secretary of Health and Human Services shall—

(1) amend the single streamlined application form developed pursuant to section 1413 of the Patient Protection and Affordable Care Act (42 U.S.C. 18083) to collect the preferred spoken and written language for each household member applying for coverage under a qualified health plan through an Exchange under title I of the Patient Protection and Affordable Care Act;

(2) require navigators, certified application counselors, and other individuals assisting with enrollment to collect and report requests for language assistance; and

(3) require the toll-free telephone hotlines established pursuant to section 1311(d)(4)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(d)(4)(B)) to submit an annual report documenting the number of language assistance requests, the types of languages requested, the range and average wait time for a consumer to speak with an interpreter, and any steps the hotline, and any entity contracting with the Secretary to provide language services, have taken to actively address some of the consumer complaints.

(f) Effective date.—The amendments made by this section shall not apply to plans beginning prior to the date of the enactment of this Act.

TITLE IIIHealth workforce diversity

SEC. 301. Amendment to the Public Health Service Act.

Title XXXIV of the Public Health Service Act, as added by section 204, is amended by adding at the end the following:

“subtitle BDiversifying the Health Care Workplace

“SEC. 3411. National Working Group on Workforce Diversity.

“(a) In general.—The Secretary, acting through the Bureau of Health Workforce of the Health Resources and Services Administration, shall award a grant to an entity determined appropriate by the Secretary for the establishment of a national working group on workforce diversity.

“(b) Representation.—In establishing the national working group under subsection (a):

“(1) The grantee shall ensure that the group has representatives of each of the following:

“(A) The Health Resources and Services Administration.

“(B) The Department of Health and Human Services Data Council.

“(C) The Office of Minority Health of the Department of Health and Human Services.

“(D) The Substance Abuse and Mental Health Services Administration.

“(E) The Bureau of Labor Statistics of the Department of Labor.

“(F) The National Institute on Minority Health and Health Disparities.

“(G) The Agency for Healthcare Research and Quality.

“(H) The Institute of Medicine Study Committee for the 2004 workforce diversity report.

“(I) The Indian Health Service.

“(J) The Department of Education.

“(K) Minority-serving academic institutions.

“(L) Consumer organizations.

“(M) Health professional associations, including those that represent underrepresented minority populations.

“(N) Researchers in the area of health workforce.

“(O) Health workforce accreditation entities.

“(P) Private (including nonprofit) foundations that have sponsored workforce diversity initiatives.

“(Q) Local and State health departments.

“(R) Representatives of community members to be included on admissions committees for health profession schools pursuant to subsection (c)(9).

“(S) National community-based organizations that serve as a national intermediary to their urban affiliate members and have demonstrated capacity to train health care professionals.

“(T) The Veterans Health Administration.

“(U) Other entities determined appropriate by the Secretary.

“(2) The grantee shall ensure that, in addition to the representatives under paragraph (1), the working group has not less than 5 health professions students representing various health profession fields and levels of training.

“(c) Activities.—The working group established under subsection (a) shall convene at least twice each year to complete the following activities:

“(1) Review public and private health workforce diversity initiatives.

“(2) Identify successful health workforce diversity programs and practices.

“(3) Examine challenges relating to the development and implementation of health workforce diversity initiatives.

“(4) Draft a national strategic work plan for health workforce diversity, including recommendations for public and private sector initiatives.

“(5) Develop a framework and methods for the evaluation of current and future health workforce diversity initiatives.

“(6) Develop recommended standards for workforce diversity that could be applicable to all health professions programs and programs funded under this Act.

“(7) Develop guidelines to train health professionals to care for a diverse population.

“(8) Develop a workforce data collection or tracking system to identify where racial and ethnic minority health professionals practice.

“(9) Develop a strategy for the inclusion of community members on admissions committees for health profession schools.

“(10) Help with monitoring and implementation of standards for diversity, equity, and inclusion.

“(11) Other activities determined appropriate by the Secretary.

“(d) Annual report.—Not later than 1 year after the establishment of the working group under subsection (a), and annually thereafter, the working group shall prepare and make available to the general public for comment, an annual report on the activities of the working group. Such report shall include the recommendations of the working group for improving health workforce diversity.

“(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3412. Technical Clearinghouse for Health workforce Diversity.

“(a) In general.—The Secretary, acting through the Deputy Assistant Secretary for Minority Health, and in collaboration with the Bureau of Health Workforce within the Health Resources and Services Administration and the National Institute on Minority Health and Health Disparities, shall establish a technical clearinghouse on health workforce diversity within the Office of Minority Health and coordinate current and future clearinghouses related to health workforce diversity.

“(b) Information and services.—The clearinghouse established under subsection (a) shall offer the following information and services:

“(1) Information on the importance of health workforce diversity.

“(2) Statistical information relating to underrepresented minority representation in health and allied health professions and occupations.

“(3) Model health workforce diversity practices and programs, including integrated models of care.

“(4) Admissions policies that promote health workforce diversity and are in compliance with Federal and State laws.

“(5) Retainment policies that promote completion of health profession degrees for underserved populations.

“(6) Lists of scholarship, loan repayment, and loan cancellation grants as well as fellowship information for underserved populations for health professions schools.

“(7) Foundation and other large organizational initiatives relating to health workforce diversity.

“(c) Consultation.—In carrying out this section, the Secretary shall consult with non-Federal entities which may include minority health professional associations and minority sections of major health professional associations to ensure the adequacy and accuracy of information.

“(d) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3413. Support for Institutions committed to workforce diversity, equity, and inclusion.

“(a) In general.—The Secretary, acting through the Administrator of the Health Resources and Services Administration and the Centers for Disease Control and Prevention, shall award grants to eligible entities that demonstrate a commitment to health workforce diversity.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a), an entity shall—

“(1) be an educational institution or entity that historically produces or trains meaningful numbers of underrepresented minority health professionals, including—

“(A) part B institutions, as defined in section 322 of the Higher Education Act of 1965;

“(B) Hispanic-serving health professions schools;

“(C) Hispanic-serving institutions, as defined in section 502 of such Act;

“(D) Tribal colleges or universities, as defined in section 316 of such Act;

“(E) Asian American and Native American Pacific Islander-serving institutions, as defined in section 371(c) of such Act;

“(F) institutions that have programs to recruit and retain underrepresented minority health professionals, in which a significant number of the enrolled participants are underrepresented minorities;

“(G) health professional associations, which may include underrepresented minority health professional associations; and

“(H) institutions, including national and regional community-based organizations with demonstrated commitment to a diversified workforce—

“(i) located in communities with predominantly underrepresented minority populations;

“(ii) with whom partnerships have been formed for the purpose of increasing workforce diversity; and

“(iii) in which at least 20 percent of the enrolled participants are underrepresented minorities; and

“(2) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—Amounts received under a grant under subsection (a) shall be used to expand existing workforce diversity programs, implement new workforce diversity programs, or evaluate existing or new workforce diversity programs, including with respect to mental health care professions. Such programs shall enhance diversity by considering minority status as part of an individualized consideration of qualifications. Possible activities may include—

“(1) educational outreach programs relating to opportunities in the health professions;

“(2) scholarship, fellowship, grant, loan repayment, and loan cancellation programs;

“(3) postbaccalaureate programs;

“(4) academic enrichment programs, particularly targeting those who would not be competitive for health professions schools;

“(5) supporting workforce diversity in kindergarten through 12th grade and other health pipeline programs;

“(6) mentoring programs;

“(7) internship or rotation programs involving hospitals, health systems, health plans, and other health entities;

“(8) community partnership development for purposes relating to workforce diversity; or

“(9) leadership training.

“(d) Reports.—Not later than 1 year after receiving a grant under this section, and annually for the term of the grant, a grantee shall submit to the Secretary a report that summarizes and evaluates all activities conducted under the grant.

“(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3414. Career development for scientists and researchers.

“(a) In general.—The Secretary, acting through the Director of the National Institutes of Health, the Director of the Centers for Disease Control and Prevention, the Commissioner of Food and Drugs, the Director of the Agency for Healthcare Research and Quality, and the Administrator of the Health Resources and Services Administration, shall award grants that expand existing opportunities for scientists and researchers and promote the inclusion of underrepresented minorities in the health professions.

“(b) Research funding.—The head of each agency listed in subsection (a) shall establish or expand existing programs to provide research funding to scientists and researchers in training. Under such programs, the head of each such entity shall give priority in allocating research funding to support health research in traditionally underserved communities, including underrepresented minority communities, and research classified as community or participatory.

“(c) Data collection.—The head of each agency listed in subsection (a) shall collect data on the number (expressed as an absolute number and a percentage) of underrepresented minority and nonminority applicants who receive and are denied agency funding at every stage of review. Such data shall be reported annually to the Secretary and the appropriate committees of Congress.

“(d) Student loan reimbursement.—The Secretary shall establish a student loan reimbursement program to provide student loan reimbursement assistance to researchers who focus on racial and ethnic disparities in health. The Secretary shall promulgate regulations to define the scope and procedures for the program under this subsection.

“(e) Student loan cancellation.—The Secretary shall establish a student loan cancellation program to provide student loan cancellation assistance to researchers who focus on racial and ethnic disparities in health. Students participating in the program shall make a minimum 5-year commitment to work at an accredited health profession school. The Secretary shall promulgate additional regulations to define the scope and procedures for the program under this subsection.

“(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3415. Career support for nonresearch Health professionals.

“(a) In general.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, the Assistant Secretary for Mental Health and Substance Use, the Administrator of the Health Resources and Services Administration, and the Administrator of the Centers for Medicare & Medicaid Services, shall establish a program to award grants to eligible individuals for career support in nonresearch-related health and wellness professions.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a), an individual shall—

“(1) be a student in a health professions school, a graduate of such a school who is working in a health profession, an individual working in a health or wellness profession (including mental and behavioral health), or a faculty member of such a school; and

“(2) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—An individual shall use amounts received under a grant under this section to—

“(1) support the individual’s health activities or projects that involve underserved communities, including racial and ethnic minority communities;

“(2) support health-related career advancement activities;

“(3) to pay, or as reimbursement for payments of, student loans or training or credentialing costs for individuals who are health professionals and are focused on health issues affecting underserved communities, including racial and ethnic minority communities; and

“(4) to establish and promote leadership training programs to decrease health disparities and to increase cultural competence with the goal of increasing diversity in leadership positions.

“(d) Definition.—In this section, the term ‘career in nonresearch-related health and wellness professions’ means employment or intended employment in the field of public health, health policy, health management, health administration, medicine, nursing, pharmacy, psychology, social work, psychiatry, other mental and behavioral health, allied health, community health, social work, or other fields determined appropriate by the Secretary, other than in a position that involves research.

“(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3416. Research on the effect of workforce Diversity on quality.

“(a) In general.—The Director of the Agency for Healthcare Research and Quality, in collaboration with the Deputy Assistant Secretary for Minority Health and the Director of the National Institute on Minority Health and Health Disparities, shall award grants to eligible entities to expand research on the link between health workforce diversity and quality health care.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a), an entity shall—

“(1) be a clinical, public health, or health services research entity or other entity determined appropriate by the Director; and

“(2) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—Amounts received under a grant awarded under subsection (a) shall be used to support research that investigates the effect of health workforce diversity on—

“(1) language access;

“(2) cultural competence;

“(3) patient satisfaction;

“(4) timeliness of care;

“(5) safety of care;

“(6) effectiveness of care;

“(7) efficiency of care;

“(8) patient outcomes;

“(9) community engagement;

“(10) resource allocation;

“(11) organizational structure;

“(12) compliance of care; or

“(13) other topics determined appropriate by the Director.

“(d) Priority.—In awarding grants under subsection (a), the Director shall give individualized consideration to all relevant aspects of the applicant’s background. Consideration of prior research experience involving the health of underserved communities shall be such a factor.

“(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3417. Health disparities education program.

“(a) Establishment.—The Secretary, acting through the Office of Minority Health, in collaboration with the National Institute on Minority Health and Health Disparities, the Office for Civil Rights, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and other appropriate public and private entities, shall establish and coordinate a health and health care disparities education program to support, develop, and implement educational initiatives and outreach strategies that inform health care professionals and the public about the existence of and methods to reduce racial and ethnic disparities in health and health care.

“(b) Activities.—The Secretary, through the education program established under subsection (a), shall, through the use of public awareness and outreach campaigns targeting the general public and the medical community at large—

“(1) disseminate scientific evidence for the existence and extent of racial and ethnic disparities in health care, including disparities that are not otherwise attributable to known factors such as access to care, patient preferences, or appropriateness of intervention, as described in the 2002 Institute of Medicine Report entitled ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care’, as well as the impact of disparities related to age, disability status, socioeconomic status, sex, gender identity, and sexual orientation on racial and ethnic minorities;

“(2) disseminate new research findings to health care providers and patients to assist them in understanding, reducing, and eliminating health and health care disparities;

“(3) disseminate information about the impact of linguistic and cultural barriers on health care quality and the obligation of health providers who receive Federal financial assistance to ensure that individuals with limited-English proficiency have access to language access services;

“(4) disseminate information about the importance and legality of racial, ethnic, disability status, socioeconomic status, sex, gender identity, and sexual orientation, and primary language data collection, analysis, and reporting;

“(5) design and implement specific educational initiatives to health care providers relating to health and health care disparities;

“(6) assess the impact of the programs established under this section in raising awareness of health and health care disparities and providing information on available resources; and

“(7) design and implement specific educational initiatives to educate the health care workforce relating to unconscious bias.

“(c) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.”.

SEC. 302. Hispanic-serving institutions, historically black colleges and universities, and tribal colleges.

(a) In general.—Part B of title VII of the Public Health Service Act (42 U.S.C. 293 et seq.) is amended by adding at the end the following:

“SEC. 742. Hispanic-serving institutions, historically black colleges and universities, and tribal colleges.

“(a) In general.—The Secretary, acting through the Administrator of the Health Resources and Services Administration and in consultation with the Secretary of Education, shall award grants to hispanic-serving institutions, historically black colleges and universities, Tribal Colleges or Universities, regional community based organizations, and national minority medical associations, for scholarships and counseling services to prepare underrepresented minority individuals to enroll in and graduate from health professional schools and to increase services for underrepresented minority students including—

“(1) mentoring with underrepresented health professionals; and

“(2) providing financial assistance information for continued education and applications to health professional schools.

“(b) Definitions.—In this section:

“(1) HISPANIC SERVING INSTITUTION.—The term ‘hispanic-serving institution’ means an entity that—

“(A) is a school or program for which there is a definition under 799B;

“(B) has an enrollment of full-time equivalent students that is made up of at least 9 percent Hispanic students;

“(C) has been effective in carrying out programs to recruit Hispanic individuals to enroll in and graduate from the school;

“(D) has been effective in recruiting and retaining Hispanic faculty members;

“(E) has a significant number of graduates who are providing health services to medically underserved populations or to individuals in health professional shortage areas; and

“(F) is a Hispanic Center of Excellence in Health Professions Education designated under section 736(d)(2) of the Public Health Service Act (42 U.S.C. 293(d)(2)).

“(2) HISTORICALLY BLACK COLLEGES AND UNIVERSITY.—The term ‘historically black college and university’ has the meaning given the term ‘part B institution’ as defined in section 322 of the Higher Education Act of 1965.

“(3) TRIBAL COLLEGE OR UNIVERSITY.—The term ‘Tribal College or University’ has the meaning given such term in section 316(b) of such Act.

“(c) Certain loan repayment programs.—In carrying out the National Health Service Corps Loan Repayment Program established under subpart III of part D of title III and the loan repayment program under section 317F, the Secretary shall ensure, notwithstanding such subpart or section, that loan repayments of not less than $50,000 per year per person are awarded for repayment of loans incurred for enrollment or participation of underrepresented minority individuals in health professional schools and other health programs described in this section.”.

SEC. 303. Loan repayment program of Centers for Disease Control and Prevention.

Section 317F(c) of the Public Health Service Act (42 U.S.C. 247b–7(c)) is amended—

(1) by striking “and” after “1994,”; and

(2) by inserting before the period at the end the following: “, $750,000 for fiscal year 2019, and such sums as may be necessary for each of the fiscal years 2020 through 2024”.

SEC. 304. Cooperative agreements for online degree programs at schools of public health and schools of allied health.

Part B of title VII of the Public Health Service Act (42 U.S.C. 293 et seq.), as amended by section 302, is further amended by adding at the end the following:

“SEC. 743. Cooperative agreements for online degree programs.

“(a) Cooperative agreements.—The Secretary, acting through the Administrator of the Health Resources and Services Administration, in consultation with the Director of the Centers for Disease Control and Prevention, the Director of the Agency for Healthcare Research and Quality, and the Deputy Assistant Secretary for Minority Health, shall enter into cooperative agreements with schools of public health and schools of allied health to design and implement online degree programs.

“(b) Priority.—In entering into cooperative agreements under this section, the Secretary shall give priority to any school of public health or school of allied health that has an established track record of serving medically underserved communities.

“(c) Requirements.—As a condition of entering into a cooperative agreement with the Secretary under this section, a school of public health or school of allied health shall agree to design and implement an online degree program that meets the following restrictions:

“(1) Enrollment of individuals who have obtained a secondary school diploma or its recognized equivalent.

“(2) Maintaining a significant enrollment of underrepresented minority or disadvantaged students.

“(3) Achieving a high completion rate of enrolled underrepresented minority or disadvantaged students.

“(d) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.”.

SEC. 305. Sense of Congress on the mission of the National Health Care Workforce Commission.

It is the sense of Congress that the National Health Care Workforce Commission established by section 5101 of the Patient Protection and Affordable Care Act (42 U.S.C. 294q) should, in carrying out its assigned duties under that section, give attention to the needs of racial and ethnic minorities, individuals with lower socioeconomic status, individuals with mental, developmental, and physical disabilities, lesbian, gay, bisexual, transgender, queer, and questioning populations, and individuals who are members of multiple minority or special population groups.

SEC. 306. Scholarship and fellowship programs.

Subtitle B of title XXXIV of the Public Health Service Act, as added by section 301, is further amended by inserting after section 3417 the following:

“SEC. 3418. David Satcher Public Health and Health Services Corps.

“(a) In general.—The Director of the Centers for Disease Control and Prevention, in collaboration with the Administrator of the Health Resources and Services Administration and the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities to increase awareness among secondary and postsecondary students of career opportunities in the health professions.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a), an entity shall—

“(1) be a clinical, public health, or health services organization, community-based or nonprofit entity, or other entity determined appropriate by the Director of the Centers for Disease Control and Prevention;

“(2) serve a health professional shortage area, as determined by the Secretary;

“(3) work with students, including those from racial and ethnic minority backgrounds, that have expressed an interest in the health professions; and

“(4) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—Grant awards under subsection (a) shall be used to support internships that will increase awareness among students of non-research-based, career opportunities in the following health professions:

“(1) Medicine.

“(2) Nursing.

“(3) Public health.

“(4) Pharmacy.

“(5) Health administration and management.

“(6) Health policy.

“(7) Psychology.

“(8) Dentistry.

“(9) International health.

“(10) Social work.

“(11) Allied health.

“(12) Psychiatry.

“(13) Hospice care.

“(14) Community health, patient navigation, and peer support.

“(15) Other professions determined appropriate by the Director of the Centers for Disease Control and Prevention.

“(d) Priority.—In awarding grants under subsection (a), the Director of the Centers for Disease Control and Prevention shall give priority to those entities that—

“(1) serve a high proportion of individuals from disadvantaged backgrounds;

“(2) have experience in health disparity elimination programs;

“(3) facilitate the entry of disadvantaged individuals into institutions of higher education; and

“(4) provide counseling or other services designed to assist disadvantaged individuals in successfully completing their education at the postsecondary level.

“(e) Stipends.—

“(1) IN GENERAL.—Subject to paragraph (2), an entity receiving a grant under this section may use the funds made available through such grant to award stipends for educational and living expenses to students participating in the internship supported by the grant.

“(2) LIMITATIONS.—A stipend awarded under paragraph (1) to an individual—

“(A) may not be provided for a period that exceeds 6 months; and

“(B) may not exceed $20 per day for an individual (notwithstanding any other provision of law regarding the amount of a stipend).

“(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3419. Louis Stokes Public Health Scholars Program.

“(a) In general.—The Director of the Centers for Disease Control and Prevention, in collaboration with the Deputy Assistant Secretary for Minority Health, shall award scholarships to eligible individuals under subsection (b) who seek a career in public health.

“(b) Eligibility.—To be eligible to receive a scholarship under subsection (a), an individual shall—

“(1) have interest, knowledge, or skill in public health research or public health practice, or other health professions as determined appropriate by the Director of the Centers for Disease Control and Prevention;

“(2) reside in a health professional shortage area as determined by the Secretary;

“(3) demonstrate promise for becoming a leader in public health;

“(4) secure admission to a 4-year institution of higher education; and

“(5) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—Amounts received under an award under subsection (a) shall be used to support opportunities for students to become public health professionals.

“(d) Priority.—In awarding grants under subsection (a), the Director shall give priority to those students that—

“(1) are from disadvantaged backgrounds;

“(2) have secured admissions to a minority-serving institution; and

“(3) have identified a health professional as a mentor at their school or institution and an academic advisor to assist in the completion of their baccalaureate degree.

“(e) Scholarships.—The Secretary may approve payment of scholarships under this section for such individuals for any period of education in student undergraduate tenure, except that such a scholarship may not be provided to an individual for more than 4 years, and such a scholarship may not exceed $10,000 per academic year for an individual (notwithstanding any other provision of law regarding the amount of a scholarship).

“(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3420. Patsy Mink Health and Gender Research Fellowship Program.

“(a) In general.—The Director of the Centers for Disease Control and Prevention, in collaboration with the Deputy Assistant Secretary for Minority Health, the Assistant Secretary for Mental Health and Substance Use, and the Director of the Indian Health Services, shall award research fellowships to eligible individuals under subsection (b) to conduct research that will examine gender and health disparities and to pursue a career in the health professions.

“(b) Eligibility.—To be eligible to receive a fellowship under subsection (a), an individual shall—

“(1) have experience in health research or public health practice;

“(2) reside in a health professional shortage area as designated by the Secretary under section 332;

“(3) have expressed an interest in the health professions;

“(4) demonstrate promise for becoming a leader in the field of women’s health;

“(5) secure admission to a health professions school or graduate program with an emphasis in gender studies; and

“(6) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—A fellowship awarded under subsection (a) to an eligible individual shall be used to support an opportunity for the individual to become a researcher and advance the research base on the intersection between gender and health.

“(d) Priority.—In awarding fellowships under subsection (a), the Director of the Centers for Disease Control and Prevention shall give priority to those applicants that—

“(1) are from disadvantaged backgrounds; and

“(2) have identified a mentor and academic advisor who will assist in the completion of their graduate or professional degree and have secured a research assistant position with a researcher working in the area of gender and health.

“(e) Fellowships.—The Director of the Centers for Disease Control and Prevention may approve fellowships for individuals under this section for any period of education in the student’s graduate or health profession tenure, except that such a fellowship may not be provided to an individual for more than 3 years, and such a fellowship may not exceed $18,000 per academic year for an individual (notwithstanding any other provision of law regarding the amount of a fellowship).

“(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3420A. Paul David Wellstone International Health Fellowship Program.

“(a) In general.—The Director of the Agency for Healthcare Research and Quality, in collaboration with the Deputy Assistant Secretary for Minority Health, shall award research fellowships to eligible individuals under subsection (b) to advance their understanding of international health.

“(b) Eligibility.—To be eligible to receive a fellowship under subsection (a), an individual shall—

“(1) have educational experience in the field of international health;

“(2) reside in a health professional shortage area as determined by the Secretary;

“(3) demonstrate promise for becoming a leader in the field of international health;

“(4) be a college senior or recent graduate of a 4-year institution of higher education; and

“(5) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—A fellowship awarded under subsection (a) to an eligible individual shall be used to support an opportunity for the individual to become a health professional and to advance the knowledge of the individual about international issues relating to health care access and quality.

“(d) Priority.—In awarding fellowships under subsection (a), the Director shall give priority to eligible individuals that—

“(1) are from a disadvantaged background; and

“(2) have identified a mentor at a health professions school or institution, an academic advisor to assist in the completion of their graduate or professional degree, and an advisor from an international health non-governmental organization, private volunteer organization, or other international institution or program that focuses on increasing health care access and quality for residents in developing countries.

“(e) Fellowships.—A fellowship awarded under this section may not—

“(1) be provided to an eligible individual for more than a period of 6 months;

“(2) be awarded to a graduate of a 4-year institution of higher education that has not been enrolled in such institution for more than 1 year; and

“(3) exceed $4,000 per academic year (notwithstanding any other provision of law regarding the amount of a fellowship).

“(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3420B. Edward R. Roybal Health Scholar Program.

“(a) In general.—The Director of the Agency for Healthcare Research and Quality, the Director of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration, in collaboration with the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities to expose entering graduate students to the health professions.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a), an entity shall—

“(1) be a clinical, public health, or health services organization, community-based, academic, or nonprofit entity, or other entity determined appropriate by the Director of the Agency for Healthcare Research and Quality;

“(2) serve in a health professional shortage area as designated by the Secretary under section 332;

“(3) work with students obtaining a degree in the health professions; and

“(4) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Use of funds.—Amounts received under a grant awarded under subsection (a) shall be used to support opportunities that expose students to non-research-based health professions, including—

“(1) public health policy;

“(2) health care and pharmaceutical policy;

“(3) health care administration and management;

“(4) health economics; and

“(5) other professions determined appropriate by the Director of the Agency for Healthcare Research and Quality, the Director of the Centers for Medicare & Medicaid Services, or the Administrator of the Health Resources and Services Administration.

“(d) Priority.—In awarding grants under subsection (a), the Director of the Agency for Healthcare Research and Quality, the Director of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration, in collaboration with the Deputy Assistant for Secretary for Minority Health, shall give priority to those entities that—

“(1) have experience with health disparity elimination programs;

“(2) facilitate training in the fields described in subsection (c); and

“(3) provide counseling or other services designed to assist students in successfully completing their education at the postsecondary level.

“(e) Stipends.—

“(1) IN GENERAL.—Subject to paragraph (2), an entity receiving a grant under this section may use the funds made available through such grant to award stipends for educational and living expenses to students participating in the opportunities supported by the grant.

“(2) LIMITATIONS.—A stipend awarded under paragraph (1) to an individual—

“(A) may not be provided for a period that exceeds 2 months; and

“(B) may not exceed $100 per day (notwithstanding any other provision of law regarding the amount of a stipend).

“(f) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3420C. Leadership fellowship programs.

“(a) In general.—The Secretary shall award grants to national minority medical or health professional associations to develop leadership fellowship programs for underrepresented health professionals in order to—

“(1) assist such professionals in becoming future leaders in public health and health care delivery institutions; and

“(2) increase diversity in decision-making positions that can improve the health of underserved communities.

“(b) Use of funds.—A leadership fellowship program supported under this section shall—

“(1) focus on training mid-career physicians and health care executives who have documented leadership experience and a commitment to public health services in underserved communities; and

“(2) support Federal public health policy and budget programs, and priorities that impact health equity, through activities such as didactic lectures and leader site visits.

“(c) Period of grants.—The period during which payments are made under a grant awarded under subsection (a) may not exceed 1 year.”.

SEC. 307. McNair Postbaccalaureate Achievement Program.

Section 402E of the Higher Education Act of 1965 (20 U.S.C. 1070a–15) is amended by striking subsection (g) and inserting the following:

“(g) Collaboration in Health profession Diversity training programs.—The Secretary shall coordinate with the Secretary of Health and Human Services to ensure that there is collaboration between the goals of the program under this section and programs of the Health Resources and Services Administration that promote health workforce diversity. The Secretary of Education shall take such measures as may be necessary to encourage students participating in projects assisted under this section to consider health profession careers.

“(h) Funding.—From amounts appropriated pursuant to the authority of section 402A(g), the Secretary shall, to the extent practicable, allocate funds for projects authorized by this section in an amount which is not less than $31,000,000 for each of the fiscal years 2019 through 2025.”.

SEC. 308. Rules for determination of full-time equivalent residents for cost-reporting periods.

(a) DGME determinations.—Section 1886(h)(4) of the Social Security Act (42 U.S.C. 1395ww(h)(4)), as amended by section 204(a), is amended—

(1) in subparagraph (E), by striking “Subject to subparagraphs (J) and (K), such rules” and inserting “Subject to subparagraphs (J), (K), and (M), such rules”;

(2) in subparagraph (J), by striking “Such rules” and inserting “Subject to subparagraph (M), such rules”;

(3) in subparagraph (K), by striking “In determining” and inserting “Subject to subparagraph (M), in determining”; and

(4) by adding at the end the following new subparagraph:

“(M) TREATMENT OF CERTAIN RESIDENTS AND INTERNS.—For purposes of cost-reporting periods beginning on or after October 1, 2019, in determining the hospital’s number of full-time equivalent residents for purposes of this paragraph, all the time spent by an intern or resident in an approved medical residency training program shall be counted toward the determination of full-time equivalency if the hospital—

“(i) is recognized as a subsection (d) hospital;

“(ii) is recognized as a subsection (d) Puerto Rico hospital;

“(iii) is reimbursed under a reimbursement system authorized under section 1814(b)(3); or

“(iv) is a provider-based hospital outpatient department.”.

(b) IME determinations.—Section 1886(d)(5)(B)(xi) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(xi)), as redesignated by section 204(b), is amended—

(1) in subclause (II), by striking “In determining” and inserting “Subject to subclause (IV), in determining”;

(2) in subclause (III), by striking “In determining” and inserting “Subject to subclause (IV), in determining”; and

(3) by inserting after subclause (III) the following new subclause:

“(IV) For purposes of cost-reporting periods beginning on or after October 1, 2019, the provisions of subparagraph (M) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.”.

SEC. 309. Developing and implementing strategies for local health equity.

(a) Grants.—The Secretary of Health and Human Services, acting jointly with the Secretary of Education and the Secretary of Labor, shall make grants to institutions of higher education for the purposes of—

(1) in accordance with subsection (b), developing capacity—

(A) to build an evidence base for successful strategies for increasing local health equity; and

(B) to serve as national models of driving local health equity;

(2) in accordance with subsection (c), developing a strategic partnership with the community in which the institution is located; and

(3) collecting data on, and periodically evaluating, the effectiveness of the institution’s programs funded through this section to enable the institution to adapt accordingly for maximum efficiency and success.

(b) Developing capacity for increasing local health equity.—As a condition on receipt of a grant under subsection (a), an institution of higher education shall agree to use the grant to build an evidence base for successful strategies for increasing local health equity, and to serve as a national model of driving local health equity, by supporting—

(1) resources to strengthen institutional metrics and capacity to execute institution-wide health workforce goals that can serve as models for increasing health equity in communities across the United States;

(2) collaborations among a cohort of institutions in implementing systemic change, partnership development, and programmatic efforts supportive of health equity goals across disciplines and populations; and

(3) enhanced or newly developed data systems and research infrastructure capable of informing current and future workforce efforts and building a foundation for a broader research agenda targeting urban health disparities.

(c) Strategic partnerships.—As a condition on receipt of a grant under subsection (a), an institution of higher education shall agree to use the grant to develop a strategic partnership with the community in which the institution is located for the purposes of—

(1) strengthening connections between the institution and the community—

(A) to improve evaluation of and address the community’s health and health workforce needs; and

(B) to engage the community in health workforce development;

(2) developing, enhancing, or accelerating innovative undergraduate and graduate programs in the biomedical sciences and health professions; and

(3) strengthening pipeline programs in the biomedical sciences and health professions, including by developing partnerships between institutions of higher education and elementary schools and secondary schools to recruit the next generation of health professionals earlier in the pipeline to a health care career.

SEC. 310. Loan forgiveness for mental and behavioral health social workers.

Section 455 of the Higher Education Act of 1965 (20 U.S.C. 1087e) is amended by adding at the end the following:

“(r) Repayment plan for mental and behavioral health social workers.—

“(1) IN GENERAL.—The Secretary shall cancel the balance of interest and principal due, in accordance with paragraph (2), on any eligible Federal Direct Loan not in default for a borrower who—

“(A) has made 120 monthly payments on the eligible Federal Direct Loan after October 1, 2016, pursuant to any one or a combination of the following—

“(i) payments under an income-based repayment plan under section 493C;

“(ii) payments under a standard repayment plan under subsection (d)(1)(A), based on a 10-year repayment period;

“(iii) monthly payments under a repayment plan under subsection (d)(1) or (g) of not less than the monthly amount calculated under subsection (d)(1)(A), based on a 10-year repayment period; or

“(iv) payments under an income contingent repayment plan under subsection (d)(1)(D); and

“(B)(i) is employed as a mental health or behavioral health social worker, as defined by the Secretary by regulation, at the time of such forgiveness; and

“(ii) has been employed as such a mental health or behavioral health social worker during the period in which the borrower makes each of the 120 payments as described in subparagraph (A).

“(2) LOAN CANCELLATION AMOUNT.—After the conclusion of the employment period described in paragraph (1), the Secretary shall cancel the obligation to repay the balance of principal and interest due as of the time of such cancellation, on the eligible Federal Direct Loans made to the borrower under this part.

“(3) INELIGIBILITY FOR DOUBLE BENEFITS.—No borrower may, for the same employment as a mental health or behavioral health social worker, receive a reduction of loan obligations under both this subsection and subsection (m), 428J, 428K, 428L, or 460.

“(4) DEFINITION OF ELIGIBLE FEDERAL DIRECT LOAN.—In this subsection, the term ‘eligible Federal Direct Loan’ means a Federal Direct Stafford Loan, Federal Direct PLUS Loan, Federal Direct Unsubsidized Stafford Loan, or a Federal Direct Consolidation Loan.”.

SEC. 311. Health Professions Workforce Fund.

(a) Establishment.—There is established in the Health Resources and Services Administration of the Department of Health and Human Services a Health Professions Workforce Fund to provide for expanded and sustained national investment in the health professions and nursing workforce development programs under title VII and title VIII of the Public Health Service Act (42 U.S.C. 292 et seq; 42 U.S.C. 296 et seq).

(b) Funding.—

(1) IN GENERAL.—There is authorized to be appropriated, and there is appropriated, out of any monies in the Treasury not otherwise appropriated, to the Health Professions Workforce Fund—

(A) $355,000,000 for fiscal year 2019;

(B) $375,000,000 for fiscal year 2020;

(C) $392,000,000 for fiscal year 2021;

(D) $412,000,000 for fiscal year 2022;

(E) $432,000,000 for fiscal year 2023;

(F) $454,000,000 for fiscal year 2024;

(G) $476,000,000 for fiscal year 2025;

(H) $500,000,000 for fiscal year 2026;

(I) $525,000,000 for fiscal year 2027; and

(J) $552,000,000 for fiscal year 2028.

(2) HEALTH PROFESSIONS EDUCATION PROGRAMS.—For the purpose of carrying out health professions education programs authorized under title VII of the Public Health Service Act, in addition to any other amounts authorized to be appropriated for such purpose, there is authorized to be appropriated out of any monies in the Health Professions Workforce Fund, the following:

(A) $240,000,000 for fiscal year 2019.

(B) $253,000,000 for fiscal year 2020.

(C) $265,000,000 for fiscal year 2021.

(D) $278,000,000 for fiscal year 2022.

(E) $292,000,000 for fiscal year 2023.

(F) $307,000,000 for fiscal year 2024.

(G) $322,000,000 for fiscal year 2025.

(H) $338,000,000 for fiscal year 2026.

(I) $355,000,000 for fiscal year 2027.

(J) $373,000,000 for fiscal year 2028.

(3) NURSING WORKFORCE DEVELOPMENT PROGRAMS.—For the purpose of carrying out nursing workforce development programs authorized under Title VIII of the Public Health Service Act, in addition to any other amounts authorized to be appropriated for such purpose, there is authorized to be appropriated out of any monies in the Health Professions Workforce Fund, the following:

(A) $115,000,000 for fiscal year 2019.

(B) $122,000,000 for fiscal year 2020.

(C) $127,000,000 for fiscal year 2021.

(D) $134,000,000 for fiscal year 2022.

(E) $140,000,000 for fiscal year 2023.

(F) $147,000,000 for fiscal year 2024.

(G) $154,000,000 for fiscal year 2025.

(H) $162,000,000 for fiscal year 2026.

(I) $170,000,000 for fiscal year 2027.

(J) $179,000,000 for fiscal year 2028.

SEC. 312. Findings; sense of Congress relating to graduate medical education.

(a) Findings.—Congress finds the following:

(1) Projections by the Association of American Medical Colleges and other expert entities, such as the Health Resources and Services Administration, have indicated a nationwide shortage of up to 104,900 physicians, split evenly between primary care and specialists, by 2030.

(2) Primarily due to the growing and aging population, over the next decade, physician demand is expected to grow up to 17 percent.

(3) The United States Census Bureau estimates that the United States population will grow from 321 million in 2015 to 347 million in 2025. Further, the number of Medicare beneficiaries is estimated to increase from 47,800,000 in 2015 to approximately 66,000,000 in 2025.

(4) Approximately 36 percent of practicing physicians are over the age of 55 and are likely to retire within the next decade.

(5) A nationwide physician shortage will result in many people in the United States waiting longer and traveling farther for health care; seeking nonemergent care in emergency departments; and delaying treatment until their health care needs become more serious, complex, and costly.

(6) Changing demographics (such as an aging population), new health care delivery models (such as medical homes), and other factors (such as disaster preparedness) are contributing to a shortage of both generalist and specialist physicians.

(7) These shortages will have the most severe impact on vulnerable and underserved populations, including racial and ethnic minorities and the approximately 20 percent of people in the United States who live in rural or inner-city locations designated as health professional shortage areas.

(8) The health care utilization equity model of the Association of American Medical Colleges estimates that if racial and ethnic minorities and individuals from rural areas utilized health care in a similar way to their Caucasian counterparts living in metropolitan areas, the physician shortage would require an additional 96,000 physicians.

(9) To address the physician shortage, medical education and training need to be accessible for students and physicians from all backgrounds. International graduates play an important role in health care in the United States, representing roughly 25 percent of the health care workforce. Immigration pathways like student, exchange-visitor, and employment visas, and programs like the National Interest Waiver and Conrad 30 J–1 Visa Waiver, help improve health access across the United States.

(10) United States medical school enrollment will grow by 30 percent from 2018 to 2019 to help reduce the shortage of quality physicians in the United States.

(11) An increase in United States medical school graduates must be accompanied by an increase of 4,000 graduate medical education training positions each year.

(12) Graduate medical education programs and teaching hospitals provide venues in which the next generation of physicians learns to work collaboratively with other physicians and health professionals, adopt more efficient care delivery models (such as care coordination and medical homes), incorporate health information technology and electronic health records in every aspect of their work, apply new methods of assuring quality and safety, and participate in groundbreaking clinical and public health research.

(13) The Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) (having more beneficiaries than any other health care program), supports its “fair share” of the costs associated with graduate medical education.

(14) In general, the level of support of graduate medical education by the Medicare program has been capped since 1997 and has not been increased to support the expansion of graduate medical education programs needed to avert the projected physician shortage or to accommodate the increase in United States medical school graduates.

(b) Sense of Congress.—It is the sense of Congress that eliminating the limit of the number of residency positions that receive some level of Medicare support under section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), also referred to as the Medical graduate medical education cap, is critical to—

(1) ensuring an appropriate supply of physicians to meet the health care needs in the United States;

(2) facilitating equitable access for all who seek health care; and

(3) mitigating disparities in health and health care.

SEC. 313. Career support for skilled, internationally educated health professionals.

(a) Findings.—Congress finds the following:

(1) According to the Association of Schools and Programs of Public Health, projections indicate a nationwide shortage of up to 250,000 public health workers needed by 2020.

(2) Similar trends are projected for other health professions indicating shortages across disciplines, including within the fields of nursing (500,000 by 2025), dentistry (15,000 by 2025), pharmacy (38,000 by 2030), mental and behavioral health, primary care (46,000 by 2025), and community and allied health.

(3) A nationwide health workforce shortage will result in serious health threats and more severe and costly health care needs, due to, in part, a delayed response to food-borne outbreaks, emerging infectious diseases, natural disasters, fewer cancer screenings, and delayed treatment.

(4) Vulnerable and underserved populations and health professional shortage areas will be most severely impacted by the health workforce shortage.

(5) According to the Migration Policy Institute, more than 2,000,000 college-educated immigrants in the United States today are unemployed or underemployed in low- or semi-skilled jobs that fail to draw on their education and expertise.

(6) Approximately 2 out of every 5 internationally educated immigrants are unemployed or underemployed.

(7) According to the Drexel University Center for Labor Markets and Policy, underemployment for internationally educated immigrant women is 28 percent higher than for their male counterparts.

(8) According to the Drexel University Center for Labor Markets and Policy, the mean annual earnings of underemployed immigrants were $32,000, or 43 percent less than United States born college graduates employed in the college labor market.

(9) According to Upwardly Global and the Welcome Back Initiative, with proper guidance and support, underemployed skilled immigrants typically increase their income by 215 percent to 900 percent.

(10) According to the Brookings Institution and the Partnership for a New American Economy, immigrants working in the health workforce are, on average, better educated than United States-born workers in the health workforce.

(b) Grants to eligible entities.—

(1) AUTHORITY TO PROVIDE GRANTS.—The Secretary of Health and Human Services, acting through the Bureau of Health Workforce within the Health Resources and Services Administration, the National Institute on Minority Health and Health Disparities, or the Office of Minority Health (in this section referred to as the “Secretary”), may award grants to eligible entities to carry out activities described in subsection (c).

(2) ELIGIBILITY.—To be eligible to receive a grant under this section, an entity shall—

(A) be a clinical, public health, or health services organization, a community-based or nonprofit entity, an academic institution, a faith-based organization, a State, county, or local government, an area health education center, or another entity determined appropriate by the Secretary; and

(B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

(c) Authorized activities.—A grant awarded under this section shall be used—

(1) to provide services to assist unemployed and underemployed skilled immigrants, residing in the United States, who have legal, permanent work authorization and who are internationally educated health professionals, enter into the health workforce of the United States with employment matching their health professional skills and education, and advance in employment to positions that better match their health professional education and expertise;

(2) to provide training opportunities to reduce barriers to entry and advancement in the health workforce for skilled, internationally educated immigrants;

(3) to educate employers regarding the abilities and capacities of internationally educated health professionals;

(4) to assist in the evaluation of foreign credentials;

(5) to support preceptorships for international medical graduates in hospital primary care training; and

(6) to facilitate access to contextualized and accelerated courses on English as a second language.

TITLE IVImproving Health Care Access and Quality

subtitle AExpansion of Coverage

SEC. 401. Amendment to the Public Health Service Act.

Title XXXIV of the Public Health Service Act, as amended by titles I, II, III, and IX of this Act, is further amended by inserting after subtitle D the following:

“subtitle EReconstruction and Improvement Grants for Public Health Care Facilities Serving Pacific Islanders and the Insular Areas

“SEC. 3451. Grant support for quality improvement initiatives.

“(a) In general.—The Secretary, in collaboration with the Administrator of the Health Resources and Services Administration, the Director of the Agency for Healthcare Research and Quality, and the Administrator of the Centers for Medicare & Medicaid Services, shall award grants to eligible entities for the conduct of demonstration projects to improve the quality of and access to health care.

“(b) Eligibility.—To be eligible to receive a grant under subsection (a), an entity shall—

“(1) be a health center, hospital, health plan, health system, community clinic, or other health entity determined appropriate by the Secretary—

“(A) that, by legal mandate or explicitly adopted mission, provides patients with access to services regardless of their ability to pay;

“(B) that provides care or treatment for a substantial number of patients who are uninsured, are receiving assistance under a State plan under title XIX of the Social Security Act (or under a waiver of such plan), or are members of vulnerable populations, as determined by the Secretary; and

“(C)(i) with respect to which, not less than 50 percent of the entity’s patient population is made up of racial and ethnic minority groups; or

“(ii) that—

“(I) serves a disproportionate percentage of local patients that are from a racial and ethnic minority group, or that has a patient population, at least 50 percent of which is composed of individuals with limited-English proficiency; and

“(II) provides an assurance that amounts received under the grant will be used only to support quality improvement activities in the racial and ethnic minority population served; and

“(2) prepare and submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

“(c) Priority.—In awarding grants under subsection (a), the Secretary shall give priority to applicants under subsection (b)(2) that—

“(1) demonstrate an intent to operate as part of a health care partnership, network, collaborative, coalition, or alliance where each member entity contributes to the design, implementation, and evaluation of the proposed intervention; or

“(2) intend to use funds to carry out systemwide changes with respect to health care quality improvement, including—

“(A) improved systems for data collection and reporting;

“(B) innovative collaborative or similar processes;

“(C) group programs with behavioral or self-management interventions;

“(D) case management services;

“(E) physician or patient reminder systems;

“(F) educational interventions; or

“(G) other activities determined appropriate by the Secretary.

“(d) Use of funds.—An entity shall use amounts received under a grant under subsection (a) to support the implementation and evaluation of health care quality improvement activities or minority health and health care disparity reduction activities that include—

“(1) with respect to health care systems, activities relating to improving—

“(A) patient safety;

“(B) timeliness of care;

“(C) effectiveness of care;

“(D) efficiency of care;

“(E) patient centeredness; and

“(F) health information technology; and

“(2) with respect to patients, activities relating to—

“(A) staying healthy;

“(B) getting well, mentally and physically;

“(C) living effectively with illness or disability;

“(D) coping with end-of-life issues; and

“(E) shared decisionmaking.

“(e) Common data systems.—The Secretary shall provide financial and other technical assistance to grantees under this section for the development of common data systems.

“(f) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3452. Centers of excellence.

“(a) In general.—The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall designate centers of excellence at public hospitals, and other health systems serving large numbers of minority patients, that—

“(1) meet the requirements of section 3451(b)(1);

“(2) demonstrate excellence in providing care to minority populations; and

“(3) demonstrate excellence in reducing disparities in health and health care.

“(b) Requirements.—A hospital or health system that serves as a center of excellence under subsection (a) shall—

“(1) design, implement, and evaluate programs and policies relating to the delivery of care in racially, ethnically, and linguistically diverse populations;

“(2) provide training and technical assistance to other hospitals and health systems relating to the provision of quality health care to minority populations; and

“(3) develop activities for graduate or continuing medical education that institutionalize a focus on cultural competence training for health care providers.

“(c) Authorization of appropriations.—There are authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2019 through 2024.

“SEC. 3453. Reconstruction and improvement grants for Public Health care facilities serving Pacific Islanders and the insular areas.

“(a) In general.—The Secretary shall provide direct financial assistance to designated health care providers and community health centers in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, and Hawaii for the purposes of reconstructing and improving health care facilities and services in a culturally competent and sustainable manner.

“(b) Eligibility.—To be eligible to receive direct financial assistance under subsection (a), an entity shall be a public health facility or community health center located in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, or Hawaii that—

“(1) is owned or operated by—

“(A) the Government of American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, or Hawaii or a unit of local government; or

“(B) a nonprofit organization; and

“(2)(A) provides care or treatment for a substantial number of patients who are uninsured, receiving assistance under title XVIII of the Social Security Act, or a State plan under title XIX of such Act (or under a waiver of such plan), or who are members of a vulnerable population, as determined by the Secretary; or

“(B) serves a disproportionate percentage of local patients that are from a racial and ethnic minority group.

“(c) Report.—Not later than 180 days after the date of enactment of this title and annually thereafter, the Secretary shall submit to the Congress and the President a report that includes an assessment of health resources and facilities serving populations in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, and Hawaii. In preparing such report, the Secretary shall—

“(1) consult with and obtain information on all health care facilities needs from the entities receiving direct financial assistance under subsection (a);

“(2) include all amounts of Federal assistance received by each such entity in the preceding fiscal year;

“(3) review the total unmet needs of health care facilities serving American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, and Hawaii, including needs for renovation and expansion of existing facilities;

“(4) include a strategic plan for addressing the needs of each such population identified in the report; and

“(5) evaluate the effectiveness of the care provided by measuring patient outcomes and cost measures.

“(d) Authorization of appropriations.—There are authorized to be appropriated such sums as necessary to carry out this section.”.

SEC. 402. Removing citizenship and immigration barriers to access to affordable health care under ACA.

(a) In general.—

(1) PREMIUM TAX CREDITS.—Section 36B of the Internal Revenue Code of 1986 is amended—

(A) in subsection (c)(1)(B)—

(i) by amending the heading to read as follows: “Special rule for certain individuals ineligible for Medicaid due to status”, and

(ii) in clause (ii), by striking “lawfully present in the United States, but” and inserting “who”, and

(B) by striking subsection (e).

(2) COST-SHARING REDUCTIONS.—Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended by striking subsection (e).

(3) BASIC HEALTH PROGRAM ELIGIBILITY.—Section 1331(e)(1)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18051(e)(1)(B)) is amended by striking “lawfully present in the United States”.

(4) RESTRICTIONS ON FEDERAL PAYMENTS.—Section 1412 of the Patient Protection and Affordable Care Act (42 U.S.C. 18082) is amended by striking subsection (d).

(5) REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.—Section 5000A(d) of the Internal Revenue Code of 1986 is amended by striking paragraph (3) and by redesignating paragraph (4) as paragraph (3).

(b) Conforming amendments.—

(1) Section 1411(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18081(a)) is amended by striking paragraph (1) and redesignating paragraphs (2), (3), and (4) as paragraphs (1), (2), and (3), respectively.

(2) Section 1312(f) of the Patient Protection and Affordable Care Act (42 U.S.C. 18032(f)) is amended—

(A) in the heading, by striking “; access limited to citizens and lawful residents”; and

(B) by striking paragraph (3).

SEC. 403. Study on the uninsured.

(a) In general.—The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall—

(1) conduct a study, in accordance with the standards under section 3101 of the Public Health Service Act (42 U.S.C. 300kk), on the demographic characteristics of the population of individuals who do not have health insurance coverage or oral health coverage; and

(2) predict, based on such study, the demographic characteristics of the population of individuals who would remain without health insurance coverage after the end of any annual open enrollment or any special enrollment period or upon enactment and implementation of any legislative changes to the Patient Protection and Affordable Care Act (Public Law 111–148) that affect the number of persons eligible for coverage.

(b) Reporting requirements.—

(1) IN GENERAL.—Not later than 12 months after the date of the enactment of this Act, the Secretary shall submit to the Congress the results of the study under subsection (a)(1) and the prediction made under subsection (a)(2).

(2) REPORTING OF DEMOGRAPHIC CHARACTERISTICS.—The Secretary shall—

(A) report the demographic characteristics under paragraphs (1) and (2) of subsection (a) on the basis of racial and ethnic group, and shall stratify the reporting on each racial and ethnic group by other demographic characteristics that can impact access to health insurance coverage, such as sexual orientation, gender identity, primary language, disability status, sex, socioeconomic status, age group, and citizenship and immigration status, in a manner consistent with title I of this Act, including the amendments made by such title; and

(B) not use such report to engage in or anticipate any deportation or immigration related enforcement action by any entity, including the Department of Homeland Security.

SEC. 404. Medicaid in the territories.

(a) Elimination of general Medicaid funding limitations (“cap”) for territories.—

(1) IN GENERAL.—Section 1108 of the Social Security Act (42 U.S.C. 1308) is amended—

(A) in subsection (f), in the matter before paragraph (1), by striking “subsection (g)” and inserting “subsections (g) and (h)”;

(B) in subsection (g)(2), in the matter before subparagraph (A), by inserting “and subsection (h)” after “paragraphs (3) and (5)”; and

(C) by adding at the end the following new subsection:

“(h) Sunset of Medicaid funding limitations for Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa.—Subsections (f) and (g) shall not apply to Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa beginning with fiscal year 2019.”.

(2) CONFORMING AMENDMENTS.—

(A) Section 1902(j) of the Social Security Act (42 U.S.C. 1396a(j)) is amended by striking “, the limitation in section 1108(f),”.

(B) Section 1903(u) of the Social Security Act (42 U.S.C. 1396b(u)) is amended by striking paragraph (4).

(C) Section 1323(c)(1) of the Patient Protection and Affordable Care Act (42 U.S.C. 18043(c)(1)) is amended by striking “2019” and inserting “2018”.

(3) EFFECTIVE DATE.—The amendments made by this section shall apply beginning with fiscal year 2019.

(b) Elimination of specific Federal medical assistance percentage (FMAP) limitation for territories.—Section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended, in clause (2), by inserting “for fiscal years before fiscal year 2019” after “American Samoa”.

SEC. 405. Extension of Medicare secondary payer.

(a) In general.—Section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)) is amended—

(1) in the last sentence, by inserting “, and before January 1, 2019” after “prior to such date)”; and

(2) by adding at the end the following new sentence: “Effective for items and services furnished on or after January 1, 2019 (with respect to periods beginning on or after the date that is 42 months prior to such date), clauses (i) and (ii) shall be applied by substituting ‘42-month’ for ‘12-month’ each place it appears.”.

(b) Effective date.—The amendments made by this section shall take effect on the date of enactment of this Act. For purposes of determining an individual’s status under section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)), as amended by subsection (a), an individual who is within the coordinating period as of the date of enactment of this Act shall have that period extended to the full 42 months described in the last sentence of such section, as added by the amendment made by subsection (a)(2).

SEC. 406. Border health grants.

(a) Definitions.—In this section:

(1) BORDER AREA.—The term “border area” means the United States-Mexico Border Area, as defined in section 8 of the United States-Mexico Border Health Commission Act (22 U.S.C. 290n–6).

(2) ELIGIBLE ENTITY.—The term “eligible entity” means an entity that is located in the border area and is any of the following:

(A) A State, local government, or Tribal government.

(B) Public institution of higher education.

(C) Nonprofit health organization.

(D) Community health center.

(E) Community clinic that is a health center receiving assistance under section 330 of the Public Health Service Act (42 U.S.C. 254b).

(b) Authorization.—From funds appropriated under subsection (f), the Secretary of Health and Human Services (in this section referred to as the “Secretary”), acting through the United States members of the United States-Mexico Border Health Commission, shall award grants to eligible entities to address priorities and recommendations to improve the health of border area residents that are established by—

(1) the United States members of the United States-Mexico Border Health Commission;

(2) the State border health offices; and

(3) the Secretary.

(c) Application.—An eligible entity that desires a grant under subsection (b) shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.

(d) Use of funds.—An eligible entity that receives a grant under subsection (b) shall use the grant funds for—

(1) programs relating to—

(A) maternal and child health;

(B) primary care and preventative health;

(C) public health and public health infrastructure;

(D) musculoskeletal health and obesity;

(E) health education and promotion;

(F) oral health;

(G) mental and behavioral health;

(H) substance use disorders;

(I) health conditions that have a high prevalence in the border area;

(J) medical and health services research;

(K) workforce training and development;

(L) community health workers, patient navigators, and promotoras;

(M) health care infrastructure problems in the border area (including planning and construction grants);

(N) health disparities in the border area;

(O) environmental health; and

(P) outreach and enrollment services with respect to Federal programs (including programs authorized under titles XIX and XXI of the Social Security Act (42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.)); and

(2) other programs determined appropriate by the Secretary.

(e) Supplement, not supplant.—Amounts provided to an eligible entity awarded a grant under subsection (b) shall be used to supplement and not supplant other funds available to the eligible entity to carry out the activities described in subsection (d).

(f) Authorization of appropriations.—There are authorized to be appropriated to carry out this section, $200,000,000 for fiscal year 2019, and such sums as may be necessary for each succeeding fiscal year.

SEC. 407. Removing Medicare barrier to health care.

(a) Part A.—Section 1818(a)(3) of the Social Security Act (42 U.S.C. 1395i–2(a)(3)) is amended by striking “an alien” and all that follows through “under this section” and inserting “an individual who is lawfully present in the United States”.

(b) Part B.—Section 1836(2) of the Social Security Act (42 U.S.C. 1395o(2)) is amended by striking “an alien” and all that follows through “under this part” and inserting “an individual who is lawfully present in the United States”.

SEC. 408. 100 percent FMAP for medical assistance provided by urban Indian health centers.

(a) In general.—The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396(b)) is amended by inserting “or are received through a program operated by an urban Indian organization through a grant or contract under title V of such Act” after “(as defined in section 4 of the Indian Health Care Improvement Act)”.

(b) Effective date.—The amendment made by this section shall apply to medical assistance provided on or after the date of enactment of this Act.

SEC. 409. 100 percent FMAP for medical assistance provided to a Native Hawaiian through a federally qualified health center or a Native Hawaiian health care system under the Medicaid program.

(a) In general.—The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)), as amended by section 408(a), is amended by inserting before the period the following: “, and with respect to medical assistance provided to a Native Hawaiian (as defined in section 12(2) of the Native Hawaiian Health Care Improvement Act) through a federally qualified health center or a Native Hawaiian health care system (as defined in section 12(6) of such Act), whether directly, by referral, or under contract or other arrangement between such federally qualified health center or Native Hawaiian health care system and another health care provider”.

(b) Effective date.—The amendment made by this section shall apply to medical assistance provided on or after the date of enactment of this Act.

subtitle BExpansion of Access

SEC. 410. Protecting sensitive locations.

Section 287 of the Immigration and Nationality Act (8 U.S.C. 1357) is amended—

(1) by striking “Service” each place such term appears and inserting “Department of Homeland Security”;

(2) by striking “Attorney General” each place such term appears and inserting “Secretary of Homeland Security”;

(3) in subsection (f)(1), by striking “Commissioner” and inserting “Director of U.S. Citizenship and Immigration Services”;

(4) in subsection (h)—

(A) by striking “of the Immigration and Nationality Act”; and

(B) by striking “of such Act”; and

(5) by adding at the end the following:

“(i)(1) In this subsection:

“(A) The term ‘appropriate committees of Congress’ means—

“(i) the Committee on Homeland Security and Governmental Affairs of the Senate;

“(ii) the Committee on the Judiciary of the Senate;

“(iii) the Committee on Homeland Security of the House of Representatives; and

“(iv) the Committee on the Judiciary of the House of Representatives.

“(B) The term ‘enforcement action’—

“(i) means an apprehension, arrest, interview, request for identification, search, or surveillance for the purposes of immigration enforcement; and

“(ii) includes an enforcement action at, or focused on, a sensitive location that is part of a joint case led by another law enforcement agency.

“(C) The term ‘exigent circumstances’ means a situation involving—

“(i) the imminent risk of death, violence, or physical harm to any person or property, including a situation implicating terrorism or the national security of the United States;

“(ii) the immediate arrest or pursuit of a dangerous felon, terrorist suspect, or other individual presenting an imminent danger; or

“(iii) the imminent risk of destruction of evidence that is material to an ongoing criminal case.

“(D) The term ‘prior approval’ means—

“(i) in the case of officers and agents of U.S. Immigration and Customs Enforcement, prior written approval to carry out an enforcement action involving a specific individual or individuals authorized by—

“(I) the Assistant Director of Operations, Homeland Security Investigations;

“(II) the Executive Associate Director, Homeland Security Investigations;

“(III) the Assistant Director for Field Operations, Enforcement and Removal Operations; or

“(IV) the Executive Associate Director for Field Operations, Enforcement and Removal Operations;

“(ii) in the case of officers and agents of U.S. Customs and Border Protection, prior written approval to carry out an enforcement action involving a specific individual or individuals authorized by—

“(I) a Chief Patrol Agent;

“(II) the Director of Field Operations;

“(III) the Director of Air and Marine Operations; or

“(IV) the Internal Affairs Special Agent in Charge; and

“(iii) in the case of other Federal, State, or local law enforcement officers, to carry out an enforcement action involving a specific individual or individuals authorized by—

“(I) the head of the Federal agency carrying out the enforcement action; or

“(II) the head of the State or local law enforcement agency carrying out the enforcement action.

“(E) The term ‘sensitive location’ includes all of the physical space located within 1,000 feet of—

“(i) any medical treatment or health care facility, including any hospital, doctor’s office, accredited health clinic, alcohol or drug treatment center, or emergent or urgent care facility;

“(ii) any public or private school, including any known and licensed day care facility, preschool, other early learning program facility, primary school, secondary school, postsecondary school (including colleges and universities), or other institution of learning (including vocational or trade schools);

“(iii) any scholastic or education-related activity or event, including field trips and interscholastic events;

“(iv) any school bus or school bus stop during periods when school children are present on the bus or at the stop;

“(v) any organization that—

“(I) assists children, pregnant women, victims of crime or abuse, or individuals with significant mental or physical disabilities; or

“(II) provides disaster or emergency social services and assistance;

“(vi) any church, synagogue, mosque, or other place of worship, including buildings rented for the purpose of religious services, retreats, counseling, workshops, instruction, and education;

“(vii) any Federal, State, or local courthouse, including the office of an individual’s legal counsel or representative, and a probation, parole, or supervised release office;

“(viii) the site of a funeral, wedding, or other religious ceremony or observance;

“(ix) any public demonstration, such as a march, rally, or parade;

“(x) any domestic violence shelter, rape crisis center, supervised visitation center, family justice center, or victim services provider; or

“(xi) any other location specified by the Secretary of Homeland Security for purposes of this subsection.

“(2)(A) An enforcement action may not take place at, or be focused on, a sensitive location unless—

“(i) the action involves exigent circumstances; and

“(ii) prior approval for the enforcement action was obtained from the appropriate official.

“(B) If an enforcement action is initiated pursuant to subparagraph (A) and the exigent circumstances permitting the enforcement action cease, the enforcement action shall be discontinued until such exigent circumstances reemerge.

“(C) If an enforcement action is carried out in violation of this subsection—

“(i) no information resulting from the enforcement action may be entered into the record or received into evidence in a removal proceeding resulting from the enforcement action; and

“(ii) the alien who is the subject of such removal proceeding may file a motion for the immediate termination of the removal proceeding.

“(3)(A) This subsection shall apply to any enforcement action by officers or agents of the Department of Homeland Security, including—

“(i) officers or agents of U.S. Immigration and Customs Enforcement;

“(ii) officers or agents of U.S. Customs and Border Protection; and

“(iii) any individual designated to perform immigration enforcement functions pursuant to subsection (g).

“(B) While carrying out an enforcement action at a sensitive location, officers and agents referred to in subparagraph (A) shall make every effort—

“(i) to limit the time spent at the sensitive location;

“(ii) to limit the enforcement action at the sensitive location to the person or persons for whom prior approval was obtained; and

“(iii) to conduct themselves discreetly.

“(C) If, while carrying out an enforcement action that is not initiated at or focused on a sensitive location, officers or agents are led to a sensitive location, and no exigent circumstance and prior approval with respect to the sensitive location exists, such officers or agents shall—

“(i) cease before taking any further enforcement action;

“(ii) conduct themselves in a discreet manner;

“(iii) maintain surveillance; and

“(iv) immediately consult their supervisor in order to determine whether such enforcement action should be discontinued.

“(D) The limitations under this paragraph shall not apply to the transportation of an individual apprehended at or near a land or sea border to a hospital or health care provider for the purpose of providing medical care to such individual.

“(4)(A) Each official specified in subparagraph (B) shall ensure that the employees under his or her supervision receive annual training on compliance with—

“(i) the requirements under this subsection in enforcement actions at or focused on sensitive locations and enforcement actions that lead officers or agents to a sensitive location; and

“(ii) the requirements under section 239 of this Act and section 384 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (8 U.S.C. 1367).

“(B) The officials specified in this subparagraph are—

“(i) the Chief Counsel of U.S. Immigration and Customs Enforcement;

“(ii) the Field Office Directors of U.S. Immigration and Customs Enforcement;

“(iii) each Special Agent in Charge of U.S. Immigration and Customs Enforcement;

“(iv) each Chief Patrol Agent of U.S. Customs and Border Protection;

“(v) the Director of Field Operations of U.S. Customs and Border Protection;

“(vi) the Director of Air and Marine Operations of U.S. Customs and Border Protection;

“(vii) the Internal Affairs Special Agent in Charge of U.S. Customs and Border Protection; and

“(viii) the chief law enforcement officer of each State or local law enforcement agency that enters into a written agreement with the Department of Homeland Security pursuant to subsection (g).

“(5) The Secretary of Homeland Security shall modify the Notice to Appear form (I–862)—

“(A) to provide the subjects of an enforcement action with information, written in plain language, summarizing the restrictions against enforcement actions at sensitive locations set forth in this subsection and the remedies available to the alien if such action violates such restrictions;

“(B) so that the information described in subparagraph (A) is accessible to individuals with limited-English proficiency; and

“(C) so that subjects of an enforcement action are not permitted to verify that the officers or agents that carried out such action complied with the restrictions set forth in this subsection.

“(6)(A) The Director of U.S. Immigration and Customs Enforcement and the Commissioner of U.S. Customs and Border Protection shall each submit an annual report to the appropriate committees of Congress that includes the information set forth in subparagraph (B) with respect to the respective agency.

“(B) Each report submitted under subparagraph (A) shall include, with respect to the submitting agency during the reporting period—

“(i) the number of enforcement actions that were carried out at, or focused on, a sensitive location;

“(ii) the number of enforcement actions in which officers or agents were subsequently led to a sensitive location; and

“(iii) for each enforcement action described in clause (i) or (ii)—

“(I) the date on which it occurred;

“(II) the specific site, city, county, and State in which it occurred;

“(III) the components of the agency involved in the enforcement action;

“(IV) a description of the enforcement action, including the nature of the criminal activity of its intended target;

“(V) the number of individuals, if any, arrested or taken into custody;

“(VI) the number of collateral arrests, if any, and the reasons for each such arrest;

“(VII) a certification whether the location administrator was contacted before, during, or after the enforcement action; and

“(VIII) the percentage of all of the staff members and supervisors reporting to the officials listed in paragraph (4)(B) who completed the training required under paragraph (4)(A).

“(7) Nothing in the subsection may be construed—

“(A) to affect the authority of Federal, State, or local law enforcement agencies—

“(i) to enforce generally applicable Federal or State criminal laws unrelated to immigration; or

“(ii) to protect residents from imminent threats to public safety; or

“(B) to limit or override the protections provided in—

“(i) section 239; or

“(ii) section 384 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (8 U.S.C. 1367).”.

SEC. 411. Grants for racial and ethnic approaches to community health.

(a) Purpose.—It is the purpose of this section to award grants to assist communities in mobilizing and organizing resources in support of effective and sustainable programs that will reduce or eliminate disparities in health and health care experienced by racial and ethnic minority individuals.

(b) Authority To Award Grants.—The Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration (referred to in this section as the “Secretary”), shall award grants to eligible entities to assist in designing, implementing, and evaluating culturally and linguistically appropriate, science-based, and community-driven sustainable strategies to eliminate racial and ethnic health and health care disparities.

(c) Eligible Entities.—To be eligible to receive a grant under this section, an entity shall—

(1) represent a coalition—

(A) whose principal purpose is to develop and implement interventions to reduce or eliminate a health or health care disparity in a targeted racial or ethnic minority group in the community served by the coalition; and

(B) that includes—

(i) members selected from among—

(I) public health departments;

(II) community-based organizations;

(III) university and research organizations;

(IV) Indian tribes or tribal organizations (as such terms are defined in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304)), the Indian Health Service, or any other organization that serves Alaska Natives; and

(V) interested public or private health care providers or organizations as determined appropriate by the Secretary; and

(ii) at least 1 member from a community-based organization that represents the targeted racial or ethnic minority group; and

(2) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, which shall include—

(A) a description of the targeted racial or ethnic populations in the community to be served under the grant;

(B) a description of at least 1 health disparity that exists in the racial or ethnic targeted populations, including health issues such as infant mortality, breast and cervical cancer screening and management, musculoskeletal diseases and obesity, prostate cancer screening and management, cardiovascular disease, diabetes, child and adult immunization levels, oral disease, or other health priority areas as designated by the Secretary; and

(C) a demonstration of a proven record of accomplishment of the coalition members in serving and working with the targeted community.

(d) Sustainability.—The Secretary shall give priority to an eligible entity under this section if the entity agrees that, with respect to the costs to be incurred by the entity in carrying out the activities for which the grant was awarded, the entity (and each of the participating partners in the coalition represented by the entity) will maintain its expenditures of non-Federal funds for such activities at a level that is not less than the level of such expenditures during the fiscal year immediately preceding the first fiscal year for which the grant is awarded.

(e) Nonduplication.—Any funds provided to an eligible entity through a grant under this section shall—

(1) supplement, not supplant, any other Federal funds made available to the entity for the purposes of this section; and

(2) not be used to duplicate the activities of any other health disparity grant program under this Act, including an amendment made by this Act.

(f) Technical Assistance.—The Secretary may, either directly or by grant or contract, provide any entity that receives a grant under this section with technical and other nonfinancial assistance necessary to meet the requirements of this section.

(g) Dissemination.—The Secretary shall encourage and enable eligible entities receiving grants under this section to share best practices, evaluation results, and reports with communities not affiliated with such entities, by using the Internet, conferences, and other pertinent information regarding the projects funded by this section, including through using outreach efforts of the Office of Minority Health and the Centers for Disease Control and Prevention.

(h) Administrative Burdens.—The Secretary shall make every effort to minimize duplicative or unnecessary administrative burdens on eligible entities receiving grants under this section.

(i) Authorization of appropriations.—There are authorized to be appropriated such sums as may be necessary to carry out this section.

SEC. 412. Critical access hospital improvements.

(a) Elimination of isolation test for cost-Based ambulance reimbursement.—

(1) IN GENERAL.—Section 1834(l)(8) of the Social Security Act (42 U.S.C. 1395m(l)(8)) is amended—

(A) in subparagraph (B)—

(i) by striking “owned and”; and

(ii) by inserting “(including when such services are provided by the entity under an arrangement with the hospital)” after “hospital”; and

(B) by striking the comma at the end of subparagraph (B) and all that follows and inserting a period.

(2) EFFECTIVE DATE.—The amendments made by this subsection shall apply to services furnished on or after January 1, 2019.

(b) Provision of a more flexible alternative to the CAH designation 25 inpatient bed limit requirement.—

(1) IN GENERAL.—Section 1820(c)(2) of the Social Security Act (42 U.S.C. 1395i–4(c)(2)) is amended—

(A) in subparagraph (B)(iii), by striking “provides not more than” and inserting “subject to subparagraph (F), provides not more than”; and

(B) by adding at the end the following new subparagraph:

“(F) ALTERNATIVE TO 25 INPATIENT BED LIMIT REQUIREMENT.—

“(i) IN GENERAL.—A State may elect to treat a facility, with respect to the designation of the facility for a cost-reporting period, as satisfying the requirement of subparagraph (B)(iii) relating to a maximum number of acute care inpatient beds if the facility elects, in accordance with a method specified by the Secretary and before the beginning of the cost reporting period, to meet the requirement under clause (ii).

“(ii) ALTERNATE REQUIREMENT.—The requirement under this clause, with respect to a facility and a cost-reporting period, is that the total number of inpatient bed days described in subparagraph (B)(iii) during such period will not exceed 7,300. For purposes of this subparagraph, an individual who is an inpatient in a bed in the facility for a single day shall be counted as one inpatient bed day.

“(iii) WITHDRAWAL OF ELECTION.—The option described in clause (i) shall not apply to a facility for a cost-reporting period if the facility (for any two consecutive cost-reporting periods during the previous 5 cost-reporting periods) was treated under such option and had a total number of inpatient bed days for each of such two cost-reporting periods that exceeded the number specified in such clause.”.

(2) EFFECTIVE DATE.—The amendments made by paragraph (1) shall apply to cost-reporting periods beginning on or after the date of the enactment of this Act.

SEC. 413. Establishment of Rural Community Hospital (RCH) Program.

(a) In general.—Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 205(b)(1), is amended by adding at the end of the following new subsection:

“Rural Community Hospital; Rural Community Hospital Services

“(kkk) (1) The term ‘rural community hospital’ means a hospital (as defined in subsection (e)) that—

“(A) is located in a rural area (as defined in section 1886(d)(2)(D)) or treated as being so located pursuant to section 1886(d)(8)(E);

“(B) subject to paragraph (2), has less than 51 acute care inpatient beds, as reported in its most recent cost report;

“(C) makes available 24-hour emergency care services;

“(D) subject to paragraph (3), has a provider agreement in effect with the Secretary and is open to the public as of January 1, 2010; and

“(E) applies to the Secretary for such designation.

“(2) For purposes of paragraph (1)(B), beds in a psychiatric or rehabilitation unit of the hospital which is a distinct part of the hospital shall not be counted.

“(3) Paragraph (1)(D) shall not be construed to prohibit any of the following from qualifying as a rural community hospital:

“(A) A replacement facility (as defined by the Secretary in regulations in effect on January 1, 2012) with the same service area (as defined by the Secretary in regulations in effect on such date).

“(B) A facility obtaining a new provider number pursuant to a change of ownership.

“(C) A facility which has a binding written agreement with an outside, unrelated party for the construction, reconstruction, lease, rental, or financing of a building as of January 1, 2012.

“(4) Nothing in this subsection shall be construed as prohibiting a critical access hospital from qualifying as a rural community hospital if the critical access hospital meets the conditions otherwise applicable to hospitals under subsection (e) and section 1866.

“(5) Nothing in this subsection shall be construed as prohibiting a rural community hospital participating in the demonstration program under section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2313) from qualifying as a rural community hospital if the rural community hospital meets the conditions otherwise applicable to hospitals under subsection (e) and section 1866.”.

(b) Payment.—

(1) INPATIENT HOSPITAL SERVICES.—Section 1814 of the Social Security Act (42 U.S.C. 1395f) is amended by adding at the end the following new subsection:

“Payment For Inpatient Services Furnished In Rural Community Hospitals

“(m) The amount of payment under this part for inpatient hospital services furnished in a rural community hospital, other than such services furnished in a psychiatric or rehabilitation unit of the hospital which is a distinct part, is, at the election of the hospital in the application referred to in section 1861(kkk)(1)(E)—

“(1) 101 percent of the reasonable costs of providing such services, without regard to the amount of the customary or other charge, or

“(2) the amount of payment provided for under the prospective payment system for inpatient hospital services under section 1886(d).”.

(2) OUTPATIENT SERVICES.—Section 1834 of such Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

“(w) Payment for outpatient services furnished in rural community hospitals.—The amount of payment under this part for outpatient services furnished in a rural community hospital is, at the election of the hospital in the application referred to in section 1861(kkk)(1)(E)—

“(1) 101 percent of the reasonable costs of providing such services, without regard to the amount of the customary or other charge and any limitation under section 1861(v)(1)(U), or

“(2) the amount of payment provided for under the prospective payment system for covered OPD services under section 1833(t).”.

(3) EXEMPTION FROM 30-PERCENT REDUCTION IN REIMBURSEMENT FOR BAD DEBT.—Section 1861(v)(1)(T) of such Act (42 U.S.C. 1395x(v)(1)(T)) is amended by inserting “(other than for a rural community hospital)” after “In determining such reasonable costs for hospitals”.

(c) Beneficiary cost-Sharing for outpatient services.—Section 1834(w) of such Act (as added by subsection (b)(2)) is amended—

(1) by redesignating paragraphs (1) and (2) as subparagraphs (A) and (B), respectively;

(2) by inserting “(1)” after “(w)”; and

(3) by adding at the end the following:

“(2) The amounts of beneficiary cost-sharing for outpatient services furnished in a rural community hospital under this part shall be as follows:

“(A) For items and services that would have been paid under section 1833(t) if furnished by a hospital, the amount of cost-sharing determined under paragraph (8) of such section.

“(B) For items and services that would have been paid under section 1833(h) if furnished by a provider of services or supplier, no cost-sharing shall apply.

“(C) For all other items and services, the amount of cost-sharing that would apply to the item or service under the methodology that would be used to determine payment for such item or service if provided by a physician, provider of services, or supplier, as the case may be.”.

(d) Conforming amendments.—

(1) PART A PAYMENT.—Section 1814(b) of such Act (42 U.S.C. 1395f(b)) is amended in the matter preceding paragraph (1) by inserting “other than inpatient hospital services furnished by a rural community hospital,” after “critical access hospital services,”.

(2) PART B PAYMENT.—Section 1833(a) of such Act (42 U.S.C. 1395l(a)), as amended by section 205(b)(3), is amended—

(A) in paragraph (2), in the matter before subparagraph (A), by striking “and (I)” and inserting “(I), and (K)”;

(B) by striking “and” at the end of paragraph (9);

(C) by striking the period at the end of paragraph (10) and inserting “; and”; and

(D) by adding at the end the following:

“(11) in the case of outpatient services furnished by a rural community hospital, the amounts described in section 1834(w).”.

(3) TECHNICAL AMENDMENTS.—

(A) CONSULTATION WITH STATE AGENCIES.—Section 1863 of such Act (42 U.S.C. 1395z) is amended by striking “and (dd)(2)” and inserting “(dd)(2), and (kkk)(1)”.

(B) PROVIDER AGREEMENTS.—Section 1866(a)(2)(A) of such Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by inserting “section 1834(w)(2),” after “section 1833(b),”.

(e) Effective date.—The amendments made by this section shall apply to items and services furnished on or after October 1, 2019.

SEC. 414. Medicare remote monitoring pilot projects.

(a) Pilot projects.—

(1) IN GENERAL.—Not later than 9 months after the date of enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall conduct pilot projects under title XVIII of the Social Security Act for the purpose of providing incentives to home health agencies to utilize home monitoring and communications technologies that—

(A) enhance health outcomes for Medicare beneficiaries; and

(B) reduce expenditures under such title.

(2) SITE REQUIREMENTS.—

(A) URBAN AND RURAL.—The Secretary shall conduct the pilot projects under this section in both urban and rural areas.

(B) SITE IN A SMALL STATE.—The Secretary shall conduct at least 3 of the pilot projects in a State with a population of less than 1,000,000.

(3) DEFINITION OF HOME HEALTH AGENCY.—In this section, the term “home health agency” has the meaning given that term in section 1861(o) of the Social Security Act (42 U.S.C. 1395x(o)).

(b) Medicare beneficiaries within the scope of projects.—The Secretary shall specify the criteria for identifying those Medicare beneficiaries who shall be considered within the scope of the pilot projects under this section for purposes of the application of subsection (c) and for the assessment of the effectiveness of the home health agency in achieving the objectives of this section. Such criteria may provide for the inclusion in the projects of Medicare beneficiaries who begin receiving home health services under title XVIII of the Social Security Act after the date of the implementation of the projects.

(c) Incentives.—

(1) PERFORMANCE TARGETS.—The Secretary shall establish for each home health agency participating in a pilot project under this section a performance target using one of the following methodologies, as determined appropriate by the Secretary:

(A) ADJUSTED HISTORICAL PERFORMANCE TARGET.—The Secretary shall establish for the agency—

(i) a base expenditure amount equal to the average total payments made to the agency under parts A and B of title XVIII of the Social Security Act for Medicare beneficiaries determined to be within the scope of the pilot project in a base period determined by the Secretary; and

(ii) an annual per capita expenditure target for such beneficiaries, reflecting the base expenditure amount adjusted for risk and adjusted growth rates.

(B) COMPARATIVE PERFORMANCE TARGET.—The Secretary shall establish for the agency a comparative performance target equal to the average total payments under such parts A and B during the pilot project for comparable individuals in the same geographic area that are not determined to be within the scope of the pilot project.

(2) INCENTIVE.—Subject to paragraph (3), the Secretary shall pay to each participating home care agency an incentive payment for each year under the pilot project equal to a portion of the Medicare savings realized for such year relative to the performance target under paragraph (1).

(3) LIMITATION ON EXPENDITURES.—The Secretary shall limit incentive payments under this section in order to ensure that the aggregate expenditures under title XVIII of the Social Security Act (including incentive payments under this subsection) do not exceed the amount that the Secretary estimates would have been expended if the pilot projects under this section had not been implemented.

(d) Waiver authority.—The Secretary may waive such provisions of titles XI and XVIII of the Social Security Act as the Secretary determines to be appropriate for the conduct of the pilot projects under this section.

(e) Report to Congress.—Not later than 5 years after the date that the first pilot project under this section is implemented, the Secretary shall submit to Congress a report on the pilot projects. Such report shall contain a detailed description of issues related to the expansion of the projects under subsection (f) and recommendations for such legislation and administrative actions as the Secretary considers appropriate.

(f) Expansion.—If the Secretary determines that any of the pilot projects under this section enhance health outcomes for Medicare beneficiaries and reduce expenditures under title XVIII of the Social Security Act, the Secretary may initiate comparable projects in additional areas.

(g) Incentive payments have no effect on other Medicare payments to agencies.—An incentive payment under this section—

(1) shall be in addition to the payments that a home health agency would otherwise receive under title XVIII of the Social Security Act for the provision of home health services; and

(2) shall have no effect on the amount of such payments.

SEC. 415. Rural health quality advisory commission and demonstration projects.

(a) Rural Health Quality Advisory Commission.—

(1) ESTABLISHMENT.—Not later than 6 months after the date of the enactment of this section, the Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall establish a commission to be known as the Rural Health Quality Advisory Commission (in this section referred to as the “Commission”).

(2) DUTIES OF COMMISSION.—

(A) NATIONAL PLAN.—The Commission shall develop, coordinate, and facilitate implementation of a national plan for rural health quality improvement. The national plan shall—

(i) identify objectives for rural health quality improvement;

(ii) identify strategies to eliminate known gaps in rural health system capacity and improve rural health quality; and

(iii) provide recommendations for Federal programs to identify opportunities for strengthening and aligning policies and programs to improve rural health quality.

(B) DEMONSTRATION PROJECTS.—The Commission shall design demonstration projects to recommend to the Secretary to test alternative models for rural health quality improvement, including with respect to both personal and population health.

(C) MONITORING.—The Commission shall monitor progress toward the objectives identified pursuant to paragraph (1)(A).

(3) MEMBERSHIP.—

(A) NUMBER.—The Commission shall be composed of 11 members appointed by the Secretary.

(B) SELECTION.—The Secretary shall select the members of the Commission from among individuals with significant rural health care and health care quality expertise, including expertise in clinical health care, health care quality research, population or public health, or purchaser organizations.

(4) CONTRACTING AUTHORITY.—Subject to the availability of funds, the Commission may enter into contracts and make other arrangements, as may be necessary to carry out the duties described in paragraph (2).

(5) STAFF.—Upon the request of the Commission, the Secretary may detail, on a reimbursable basis, any of the personnel of the Office of Rural Health Policy of the Health Resources and Services Administration, the Agency for Healthcare Quality and Research, or the Centers for Medicare & Medicaid Services to the Commission to assist in carrying out this subsection.

(6) REPORTS TO CONGRESS.—Not later than 1 year after the establishment of the Commission, and annually thereafter, the Commission shall submit a report to the Congress on rural health quality. Each such report shall include the following:

(A) An inventory of relevant programs and recommendations for improved coordination and integration of policy and programs.

(B) An assessment of achievement of the objectives identified in the national plan developed under paragraph (2) and recommendations for realizing such objectives.

(C) Recommendations on Federal legislation, regulations, or administrative policies to enhance rural health quality and outcomes.

(b) Rural Health Quality Demonstration Projects.—

(1) IN GENERAL.—Not later than 270 days after the date of the enactment of this section, the Secretary, in consultation with the Rural Health Quality Advisory Commission, the Office of Rural Health Policy of the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services, shall make grants to eligible entities for a total of 5 demonstration projects to implement and evaluate methods for improving the quality of health care in rural communities. Each such demonstration project shall include—

(A) alternative community models that—

(i) will achieve greater integration of personal and population health services; and

(ii) address safety, effectiveness, patient- or community-centeredness, timeliness, efficiency, and equity (the 6 aims identified by the Institute of Medicine of the National Academy of Sciences in its report entitled “Crossing the Quality Chasm: A New Health System for the 21st Century” released on March 1, 2001);

(B) innovative approaches to the financing and delivery of health services to achieve rural health quality goals; and

(C) development of quality improvement support structures to assist rural health systems and professionals (such as workforce support structures, quality monitoring and reporting, clinical care protocols, and information technology applications).

(2) ELIGIBLE ENTITIES.—In this subsection, the term “eligible entity” means a consortium that—

(A) shall include—

(i) at least one health care provider or health care delivery system located in a rural area; and

(ii) at least one organization representing multiple community stakeholders; and

(B) may include other partners such as rural research centers.

(3) CONSULTATION.—In developing the program for awarding grants under this subsection, the Secretary shall consult with the Administrator of the Agency for Healthcare Research and Quality, rural health care providers, rural health care researchers, and private and nonprofit groups (including national associations) which are undertaking similar efforts.

(4) EXPEDITED WAIVERS.—The Secretary shall expedite the processing of any waiver that—

(A) is authorized under title XVIII or XIX of the Social Security Act (42 U.S.C. 1395 et seq.); and

(B) is necessary to carry out a demonstration project under this subsection.

(5) DEMONSTRATION PROJECT SITES.—The Secretary shall ensure that the 5 demonstration projects funded under this subsection are conducted at a variety of sites representing the diversity of rural communities in the United States.

(6) DURATION.—Each demonstration project under this subsection shall be for a period of 4 years.

(7) INDEPENDENT EVALUATION.—The Secretary shall enter into an arrangement with an entity that has experience working directly with rural health systems for the conduct of an independent evaluation of the program carried out under this subsection.

(8) REPORT.—Not later than 1 year after the conclusion of all of the demonstration projects funded under this subsection, the Secretary shall submit a report to the Congress on the results of such projects. The report shall include—

(A) an evaluation of patient access to care, patient outcomes, and an analysis of the cost effectiveness of each such project; and

(B) recommendations on Federal legislation, regulations, or administrative policies to enhance rural health quality and outcomes.

(c) Appropriation.—

(1) IN GENERAL.—Out of funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary to carry out this section $30,000,000 for the period of fiscal years 2019 through 2023.

(2) AVAILABILITY.—

(A) IN GENERAL.—Funds appropriated under paragraph (1) shall remain available for expenditure through fiscal year 2023.

(B) REPORT.—For purposes of carrying out subsection (b)(8), funds appropriated under paragraph (1) shall remain available for expenditure through fiscal year 2024.

(3) RESERVATION.—Of the amount appropriated under paragraph (1), the Secretary shall reserve—

(A) $5,000,000 to carry out subsection (a); and

(B) $25,000,000 to carry out subsection (b), of which—

(i) 2 percent shall be for the provision of technical assistance to grant recipients; and

(ii) 5 percent shall be for independent evaluation under subsection (b)(7).

SEC. 416. Rural health care services.

Section 330A of the Public Health Service Act (42 U.S.C. 254c) is amended to read as follows:

“SEC. 330A. Rural health care services outreach, rural health network development, Delta rural disparities and health systems development, and small rural health care provider quality improvement grant programs.

“(a) Purpose.—The purpose of this section is to provide for grants—

“(1) under subsection (b), to promote rural health care services outreach;

“(2) under subsection (c), to provide for the planning and implementation of integrated health care networks in rural areas;

“(3) under subsection (d), to assist rural communities in the Delta Region to reduce health disparities and to promote and enhance health system development; and

“(4) under subsection (e), to provide for the planning and implementation of small rural health care provider quality improvement activities.

“(b) Rural health care services outreach grants.—

“(1) GRANTS.—The Director of the Office of Rural Health Policy of the Health Resources and Services Administration (referred to in this section as the ‘Director’) may award grants to eligible entities to promote rural health care services outreach by expanding the delivery of health care services to include new and enhanced services in rural areas. The Director may award the grants for periods of not more than 3 years.

“(2) ELIGIBILITY.—To be eligible to receive a grant under this subsection for a project, an entity—

“(A) shall be a rural public or rural nonprofit private entity, a facility that qualifies as a rural health clinic under title XVIII of the Social Security Act, a public or nonprofit entity existing exclusively to provide services to migrant and seasonal farm workers in rural areas, or a Tribal government whose grant-funded activities will be conducted within federally recognized Tribal areas;

“(B) shall represent a consortium composed of members—

“(i) that include 3 or more independently owned health care entities; and

“(ii) that may be nonprofit or for-profit entities; and

“(C) shall not previously have received a grant under this subsection for the same or a similar project, unless the entity is proposing to expand the scope of the project or the area that will be served through the project.

“(3) APPLICATIONS.—To be eligible to receive a grant under this subsection, an eligible entity shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

“(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

“(B) a description of the manner in which the project funded under the grant will meet the health care needs of rural populations in the local community or region to be served;

“(C) a plan for quantifying how health care needs will be met through identification of the target population and benchmarks of service delivery or health status, such as—

“(i) quantifiable measurements of health status improvement for projects focusing on health promotion; or

“(ii) benchmarks of increased access to primary care, including tracking factors such as the number and type of primary care visits, identification of a medical home, or other general measures of such access;

“(D) a description of how the local community or region to be served will be involved in the development and ongoing operations of the project;

“(E) a plan for sustaining the project after Federal support for the project has ended;

“(F) a description of how the project will be evaluated;

“(G) the administrative capacity to submit annual performance data electronically as specified by the Director; and

“(H) other such information as the Director determines to be appropriate.

“(c) Rural health network development grants.—

“(1) GRANTS.—

“(A) IN GENERAL.—The Director may award rural health network development grants to eligible entities to promote, through planning and implementation, the development of integrated health care networks that have combined the functions of the entities participating in the networks in order to—

“(i) achieve efficiencies and economies of scale;

“(ii) expand access to, coordinate, and improve the quality of the health care delivery system through development of organizational efficiencies;

“(iii) implement health information technology to achieve efficiencies, reduce medical errors, and improve quality;

“(iv) coordinate care and manage chronic illness; and

“(v) strengthen the rural health care system as a whole in such a manner as to show a quantifiable return on investment to the participants in the network.

“(B) GRANT PERIODS.—The Director may award such a rural health network development grant—

“(i) for a period of 3 years for implementation activities; or

“(ii) for a period of 1 year for planning activities to assist in the initial development of an integrated health care network, if the proposed participants in the network do not have a history of collaborative efforts and a 3-year grant would be inappropriate.

“(2) ELIGIBILITY.—To be eligible to receive a grant under this subsection, an entity—

“(A) shall be a rural public or rural nonprofit private entity, a facility that qualifies as a rural health clinic under title XVIII of the Social Security Act, a public or nonprofit entity existing exclusively to provide services to migrant and seasonal farm workers in rural areas, or a Tribal government whose grant-funded activities will be conducted within federally recognized Tribal areas;

“(B) shall represent a network composed of participants—

“(i) that include 3 or more independently owned health care entities; and

“(ii) that may be nonprofit or for-profit entities; and

“(C) shall not previously have received a grant under this subsection (other than a 1-year grant for planning activities) for the same or a similar project.

“(3) APPLICATIONS.—To be eligible to receive a grant under this subsection, an eligible entity, in consultation with the appropriate State office of rural health or another appropriate State entity, shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

“(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

“(B) an explanation of the reasons why Federal assistance is required to carry out the project;

“(C) a description of—

“(i) the history of collaborative activities carried out by the participants in the network;

“(ii) the degree to which the participants are ready to integrate their functions; and

“(iii) how the local community or region to be served will benefit from and be involved in the activities carried out by the network;

“(D) a description of how the local community or region to be served will experience increased access to quality health care services across the continuum of care as a result of the integration activities carried out by the network, including a description of—

“(i) return on investment for the community and the network members; and

“(ii) other quantifiable performance measures that show the benefit of the network activities;

“(E) a plan for sustaining the project after Federal support for the project has ended;

“(F) a description of how the project will be evaluated;

“(G) the administrative capacity to submit annual performance data electronically as specified by the Director; and

“(H) other such information as the Director determines to be appropriate.

“(d) Delta rural disparities and health systems development grants.—

“(1) GRANTS.—The Director may award grants to eligible entities to support reduction of health disparities, improve access to health care, and enhance rural health system development in the Delta Region.

“(2) ELIGIBILITY.—To be eligible to receive a grant under this subsection, an entity shall be a rural public or rural nonprofit private entity, a facility that qualifies as a rural health clinic under title XVIII of the Social Security Act, a public or nonprofit entity existing exclusively to provide services to migrant and seasonal farm workers in rural areas, or a Tribal government whose grant-funded activities will be conducted within federally recognized Tribal areas.

“(3) APPLICATIONS.—To be eligible to receive a grant under this subsection, an eligible entity shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

“(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

“(B) an explanation of the reasons why Federal assistance is required to carry out the project;

“(C) a description of the manner in which the project funded under the grant will meet the health care needs of the Delta Region;

“(D) a description of how the local community or region to be served will experience increased access to quality health care services as a result of the activities carried out by the entity;

“(E) a description of how health disparities will be reduced or the health system will be improved;

“(F) a plan for sustaining the project after Federal support for the project has ended;

“(G) a description of how the project will be evaluated including process and outcome measures related to the quality of care provided or how the health care system improves its performance;

“(H) a description of how the grantee will develop an advisory group made up of representatives of the communities to be served to provide guidance to the grantee to best meet community need; and

“(I) other such information as the Director determines to be appropriate.

“(e) Small rural health care provider quality improvement grants.—

“(1) GRANTS.—The Director may award grants to provide for the planning and implementation of small rural health care provider quality improvement activities. The Director may award the grants for periods of 1 to 3 years.

“(2) ELIGIBILITY.—To be eligible for a grant under this subsection, an entity—

“(A) shall be—

“(i) a rural public or rural nonprofit private health care provider or provider of health care services, such as a rural health clinic; or

“(ii) another rural provider or network of small rural providers identified by the Director as a key source of local care; and

“(B) shall not previously have received a grant under this subsection for the same or a similar project.

“(3) PREFERENCE.—In awarding grants under this subsection, the Director shall give preference to facilities that qualify as rural health clinics under title XVIII of the Social Security Act.

“(4) APPLICATIONS.—To be eligible to receive a grant under this subsection, an eligible entity shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

“(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

“(B) an explanation of the reasons why Federal assistance is required to carry out the project;

“(C) a description of the manner in which the project funded under the grant will assure continuous quality improvement in the provision of services by the entity;

“(D) a description of how the local community or region to be served will experience increased access to quality health care services as a result of the activities carried out by the entity;

“(E) a plan for sustaining the project after Federal support for the project has ended;

“(F) a description of how the project will be evaluated including process and outcome measures related to the quality of care provided; and

“(G) other such information as the Director determines to be appropriate.

“(f) General requirements.—

“(1) PROHIBITED USES OF FUNDS.—An entity that receives a grant under this section may not use funds provided through the grant—

“(A) to build or acquire real property; or

“(B) for construction.

“(2) COORDINATION WITH OTHER AGENCIES.—The Director shall coordinate activities carried out under grant programs described in this section, to the extent practicable, with Federal and State agencies and nonprofit organizations that are operating similar grant programs, to maximize the effect of public dollars in funding meritorious proposals.

“(g) Report.—Not later than September 30, 2020, the Secretary shall prepare and submit to the appropriate committees of Congress a report on the progress and accomplishments of the grant programs described in subsections (b), (c), (d), and (e).

“(h) Definition of Delta Region.—In this section, the term ‘Delta Region’ has the meaning given to the term ‘region’ in section 382A of the Consolidated Farm and Rural Development Act (7 U.S.C. 2009aa).

“(i) Authorization of appropriations.—There are authorized to be appropriated to carry out this section $40,000,000 for fiscal year 2019, and such sums as may be necessary for each of fiscal years 2020 through 2023.”.

SEC. 417. Community health center collaborative access expansion.

Section 330(r)(4) of the Public Health Service Act (42 U.S.C. 254b(r)(4)) is amended—

(1) in subparagraph (A), by striking “primary health care services” each place it appears and inserting “primary health care and other mental, dental, and physical health services”; and

(2) in subparagraph (B)—

(A) in clause (i), by striking “; and” and inserting “;”;

(B) in clause (ii), by striking the period and inserting “; and”; and

(C) by adding at the end the following:

“(iii) in the case of a rural health clinic described in such subparagraph—

“(I) that such clinic provides, to the extent possible, enabling services, such as transportation and language assistance (including translation and interpretation); and

“(II) that the primary health care and other services described in such subparagraph are subject to full reimbursement according to the prospective payment system for Federally qualified health center services under section 1834(o) of the Social Security Act.”.

SEC. 418. Facilitating the provision of telehealth services across State lines.

(a) In general.—For purposes of expediting the provision of telehealth services, for which payment is made under the Medicare Program, across State lines, the Secretary of Health and Human Services shall, in consultation with representatives of States, physicians, health care practitioners, and patient advocates, encourage and facilitate the adoption of provisions allowing for multistate practitioner practice across State lines.

(b) Definitions.—In subsection (a):

(1) TELEHEALTH SERVICE.—The term “telehealth service” has the meaning given that term in subparagraph (F) of section 1834(m)(4) of the Social Security Act (42 U.S.C. 1395m(m)(4)).

(2) PHYSICIAN, PRACTITIONER.—The terms “physician” and “practitioner” have the meaning given those terms in subparagraphs (D) and (E), respectively, of such section.

(3) MEDICARE PROGRAM.—The term “Medicare Program” means the program of health insurance administered by the Secretary of Health and Human Services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

SEC. 419. Scoring of preventive health savings.

Section 202 of the Congressional Budget and Impoundment Control Act of 1974 (2 U.S.C. 602) is amended by adding at the end the following:

“(h) Scoring of preventive health savings.—

“(1) DETERMINATION BY THE DIRECTOR.—Upon a request by the chairman or ranking minority member of the Committee on the Budget of the Senate, or by the chairman or ranking minority member of the Committee on the Budget of the House of Representatives, the Director shall determine if a proposed measure would result in reductions in budget outlays in budgetary outyears through the use of preventive health and preventive health services.

“(2) PROJECTIONS.—If the Director determines that a measure would result in substantial reductions in budget outlays as described in paragraph (1), the Director—

“(A) shall include, in any projection prepared by the Director, a description and estimate of the reductions in budget outlays in the budgetary outyears and a description of the basis for such conclusions; and

“(B) may prepare a budget projection that includes some or all of the budgetary outyears, notwithstanding the time periods for projections described in subsection (e) and sections 308, 402, and 424.

“(3) DEFINITIONS.—As used in this subsection—

“(A) the term ‘budgetary outyears’ means the 2 consecutive 10-year periods beginning with the first fiscal year that is 10 years after the budget year provided for in the most recently agreed to concurrent resolution on the budget; and

“(B) the term ‘preventive health’ means an action that focuses on the health of the public, individuals, and defined populations in order to protect, promote, and maintain health, wellness, and functional ability, and prevent disease, disability, and premature death that is demonstrated by credible and publicly available epidemiological projection models, incorporating clinical trials or observational studies in humans, to avoid future health care costs.”.

SEC. 420. Sense of Congress on Maintenance of Effort Provisions Regarding Children’s Health.

It is the sense of the Congress that—

(1) the maintenance of effort provisions added to sections 1902 and 2105(d) of the Social Security Act by sections 2001(b) and 2101(b) of the Patient Protection and Affordable Care Act were intended to maintain the eligibility standards for the Medicaid program under title XIX of the Social Security Act and Children’s Health Insurance Program under title XXI of such Act until the American Health Benefit Exchanges in the States are fully operational;

(2) it is imperative that the maintenance of effort provisions are enforced to the strict standard intended by the Congress through September 30, 2027;

(3) waiving the maintenance of effort provisions should not be permitted;

(4) the maintenance of effort provisions ensure the continued success of the Medicaid program and Children’s Health Insurance Program and were intended to specifically protect vulnerable and disabled adults, children, and senior citizens, many of whom are also members of communities of color; and

(5) the maintenance of effort provisions must be strictly enforced and proposals to weaken the maintenance of effort provisions must not be considered.

SEC. 421. Repeal of requirement for documentation evidencing citizenship or nationality under the Medicaid program.

(a) Repeal.—Subsections (i)(22) and (x) of section 1903 of the Social Security Act (42 U.S.C. 1396b) are each repealed.

(b) Conforming amendments.—

(1) Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended—

(A) by amending paragraph (46) of subsection (a) to read as follows:

“(46) provide that information is requested and exchanged for purposes of income and eligibility verification in accordance with a State system which meets the requirements of section 1137 of this Act;”;

(B) in subsection (e)(13)(A)(i)—

(i) in the matter preceding subclause (I), by striking “sections 1902(a)(46)(B) and 1137(d)” and inserting “section 1137(d)”; and

(ii) in subclause (IV), by striking “1902(a)(46)(B) or”; and

(C) by striking subsection (ee).

(2) Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended—

(A) in subsection (i), by redesignating paragraphs (23) through (26) as paragraphs (22) through (25), respectively; and

(B) by redesignating subsections (y) and (z) as subsections (x) and (y), respectively.

(3) Subsection (c) of section 6036 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396b note) is repealed.

(c) Effective date.—The repeals and amendments made by this section shall take effect as if included in the enactment of the Deficit Reduction Act of 2005.

SEC. 422. Protection of the HHS Offices of Minority Health.

(a) In general.—Pursuant to section 1707A of the Public Health Service Act (42 U.S.C. 300u–6a), the Offices of Minority Health established within the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, the Agency for Healthcare Research and Quality, the Food and Drug Administration, and the Centers for Medicare & Medicaid Services, are offices that, regardless of change in the structure of the Department of Health and Human Services, shall report to the Secretary of Health and Human Services.

(b) Sense of Congress.—It is the sense of the Congress that any effort to eliminate or consolidate such Offices of Minority Health undermines the progress achieved so far.

SEC. 423. Office of Minority Health in Veterans Health Administration of Department of Veterans Affairs.

(a) Establishment and functions.—Subchapter I of chapter 73 of title 38, United States Code, is amended by adding at the end the following new section:

§ 7310. Office of Minority Health

“(a) Establishment.—There is established in the Department within the Office of the Under Secretary for Health an office to be known as the ‘Office of Minority Health’ (in this section referred to as the ‘Office’).

“(b) Head.—The Director of the Office of Minority Health shall be the head of the Office. The Director of the Office of Minority Health shall be appointed by the Under Secretary for Health from among individuals qualified to perform the duties of the position.

“(c) Functions.—The functions of the Office are as follows:

“(1) To establish short-range and long-range goals and objectives and coordinate all other activities within the Veterans Health Administration that relate to disease prevention, health promotion, health care services delivery, and health care research concerning veterans who are members of a racial or ethnic minority group.

“(2) To support research, demonstrations, and evaluations to test new and innovative models for the discharge of activities described in paragraph (1).

“(3) To increase knowledge and understanding of health risk factors for veterans who are members of a racial or ethnic minority group.

“(4) To develop mechanisms that support better health care information dissemination, education, prevention, and services delivery to veterans from disadvantaged backgrounds, including veterans who are members of a racial or ethnic minority group.

“(5) To enter into contracts or agreements with appropriate public and nonprofit private entities to develop and carry out programs to provide bilingual or interpretive services to assist veterans who are members of a racial or ethnic minority group and who lack proficiency in speaking the English language in accessing and receiving health care services through the Veterans Health Administration.

“(6) To carry out programs to improve access to health care services through the Veterans Health Administration for veterans with limited proficiency in speaking the English language, including the development and evaluation of demonstration and pilot projects for that purpose.

“(7) To advise the Under Secretary for Health on matters relating to the development, implementation, and evaluation of health professions education in decreasing disparities in health care outcomes between veterans who are members of a racial or ethnic minority group and other veterans, including cultural competency as a method of eliminating such health disparities.

“(8) To perform such other functions and duties as the Secretary or the Under Secretary for Health considers appropriate.

“(d) Definitions.—In this section:

“(1) The term ‘racial or ethnic minority group’ means any of the following:

“(A) American Indians (including Alaska Natives, Eskimos, and Aleuts).

“(B) Asian Americans.

“(C) Native Hawaiians and other Pacific Islanders.

“(D) Blacks.

“(E) Hispanics.

“(2) The term ‘Hispanic’ means individuals whose origin is Mexican, Puerto Rican, Cuban, Central or South American, or any other Spanish-speaking country.”.

(b) Clerical amendment.—The table of sections at the beginning of such chapter is amended by inserting after the item relating to section 7309A the following new item:

“7310. Office of Minority Health.”.

SEC. 424. Indian defined in title I of PPACA.

(a) Definition of Indian.—Section 1304 of the Patient Protection and Affordable Care Act (42 U.S.C. 18024) is amended by adding at the end the following:

“(f) Indian.—

“(1) IN GENERAL.—In this title, the term ‘Indian’ means any individual—

“(A) described in paragraph (13) or (28) of section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603);

“(B) who is eligible for health services provided by the Indian Health Service under section 809 of the Indian Health Care Improvement Act (25 U.S.C. 1679);

“(C) who is of Indian descent and belongs to the Indian community served by the local facilities and program of the Indian Health Service; or

“(D) who is described in paragraph (2).

“(2) INCLUSIONS.—An individual is described in this paragraph if the individual is any of the following:

“(A) A member of a federally recognized Indian Tribe.

“(B) A resident of an urban center who meets any of the following criteria:

“(i) Membership in a Tribe, band, or other organized group of Indians, including those Tribes, bands, or groups terminated since 1940 and those recognized as of the date of enactment of the Health Equity and Accountability Act of 2018 or later by the State in which they reside, or being a descendant, in the first or second degree, of any such member.

“(ii) Is an Eskimo or Aleut or other Alaska Native.

“(iii) Is considered by the Secretary of the Interior to be an Indian for any purpose.

“(iv) Is determined to be an Indian under regulations promulgated by the Secretary.

“(C) An individual who is considered by the Secretary of the Interior to be an Indian for any purpose.

“(D) An individual who is considered by the Secretary to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native.”.

(b) Conforming amendments.—

(1) AFFORDABLE CHOICES HEALTH BENEFIT PLANS.—Section 1311(c)(6)(D) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(6)(D)) is amended by striking “(as defined in section 4 of the Indian Health Care Improvement Act)”.

(2) REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN QUALIFIED HEALTH PLANS.—Section 1402(d) of the Patient Protection and Affordable Care Act (42 U.S.C. 18071(d)) is amended—

(A) in paragraph (1), in the matter preceding subparagraph (A), by striking “(as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(d))”; and

(B) in paragraph (2), in the matter preceding subparagraph (A), by striking “(as so defined)”.

(3) EXEMPTION FROM PENALTY FOR NOT MAINTAINING MINIMUM ESSENTIAL COVERAGE.—Section 5000A(e) of the Internal Revenue Code of 1986 is amended by striking paragraph (3) and inserting the following:

“(3) INDIANS.—Any applicable individual who is an Indian (as defined in section 1304(f) of the Patient Protection and Affordable Care Act).”.

SEC. 425. Study of DSH payments to ensure hospital access for low-income patients.

(a) In general.—Not later than January 1, 2019, the Comptroller General of the United States shall conduct a study on how amendments made by the Patient Protection and Affordable Care Act (Public Law 111–148) and the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152) to titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq., 1396 et seq.) relating to disproportionate share hospital adjustment payments under Medicare and Medicaid (and subsequent amendments made with respect to such payments) affect the timely access to health care services for low-income patients. Such study shall—

(1) evaluate and examine whether States electing to make medical assistance available under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(VIII)) (including States making such an election through a waiver of the State plan) to individuals described in such section mitigate the need for payments to disproportionate share hospitals under section 1886(d)(5)(F) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) and section 1923 of such Act (42 U.S.C. 1396r–4), including the impact of such States electing to make medical assistance available to such individuals on—

(A) the number of individuals in the United States who are without health insurance and the distribution of such individuals in relation to areas primarily served by disproportionate share hospitals; and

(B) the low-income utilization rate of such hospitals and the resulting fiscal sustainability of such hospitals;

(2) evaluate the appropriate level and distribution of such payments among such disproportionate share hospitals for purposes of—

(A) sufficiently accounting for the level of uncompensated care provided by such hospitals to low-income patients; and

(B) providing timely access to health services for individuals in medically underserved areas; and

(3) assess, with respect to such disproportionate share hospitals—

(A) the role played by such hospitals in providing critical access to emergency, inpatient, and outpatient health services, as well as the location of such hospitals in relation to medically underserved areas; and

(B) the extent to which such hospitals satisfy the requirements established for charitable hospital organizations under section 501(r) of the Internal Revenue Code of 1986 with respect to community health needs assessments, financial assistance policy requirements, limitations on charges, and billing and collection requirements.

(b) Reports.—

(1) REPORT TO CONGRESS.—Not later than 180 days after the date on which the study under subsection (a) is completed, the Comptroller General of the United States shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report that contains—

(A) the results of the study;

(B) recommendations to Congress for any legislative changes to the payments to disproportionate share hospitals under section 1886(d)(5)(F) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) and section 1923 of such Act (42 U.S.C. 1396r–4) that are needed to ensure access to health services for low-income patients that—

(i) are based on the number of individuals without health insurance, the amount of uncompensated care provided by such hospitals, and the impact of reduced payment levels on low-income communities; and

(ii) takes into account any reports submitted by the Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, to Congressional committees regarding the costs incurred by charitable hospital organizations for charity care, bad debt, nonreimbursed expenses for services provided to individuals under the Medicare program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act, and any community benefit activities provided by such organizations.

(2) REPORT TO THE SECRETARY OF HEALTH AND HUMAN SERVICES.—Not later than 180 days after the date on which the study under subsection (a) is completed, the Comptroller General of the United States shall submit to the Secretary of Health and Human Services a report that contains—

(A) the results of the study; and

(B) any recommendations for purposes of assisting in the development of the methodology for the adjustment of payments to disproportionate share hospitals, as required under section 1886(r) of the Social Security Act (42 U.S.C. 1395ww(r)) and the reduction of such payments under section 1923(f)(7) of such Act (42 U.S.C. 1396r–4(f)(7)), taking into account the reports referred to in paragraph (1)(B)(ii).

SEC. 426. Assistant Secretary of the Indian Health Service.

(a) References.—Any reference in a law, regulation, document, paper, or other record of the United States to the Director of the Indian Health Service shall be deemed to be a reference to the Assistant Secretary of the Indian Health Service.

(b) Executive Schedule.—Section 5315 of title 5, United States Code, is amended in the matter relating to the Assistant Secretaries of Health and Human Services by striking “(6)” and inserting “(7), 1 of whom shall be the Assistant Secretary of the Indian Health Service”.

(c) Conforming amendment.—Section 5316 of title 5, United States Code, is amended by striking “Director, Indian Health Service, Department of Health and Human Services.”.

SEC. 427. Reauthorization of the Native Hawaiian Health Care Improvement Act.

(a) Native Hawaiian health care systems.—Section 6(h)(1) of the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11705(h)(1)) is amended by striking “may be necessary for fiscal years 1993 through 2019” and inserting “are necessary”.

(b) Administrative grant for papa ola lokahi.—Section 7(b) of the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11706(b)) is amended by striking “may be necessary for fiscal years 1993 through 2019” and inserting “are necessary”.

(c) Native Hawaiian health scholarships.—Section 10(c) of the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11709(c)) is amended by striking “may be necessary for fiscal years 1993 through 2019” and inserting “are necessary”.

SEC. 428. Availability of non-English language speaking providers.

(a) In general.—Section 1311(c)(1)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(B)) is amended by inserting before the semicolon the following: “and the ability of such provider to provide care in a language other than English either through the provider speaking such language or by the provider having a qualified interpreter for an individual with limited-English proficiency (as defined in section 3400 of such Act) who speaks such language available during office hours”.

(b) Effective date.—The amendment made by subsection (a) shall not apply to any plan beginning on or prior to the date that is 1 year after the date of the enactment of this Act.

SEC. 429. Access to essential community providers.

(a) Essential community providers.—Section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(C)) is amended—

(1) by inserting “(i)” after “(C)”; and

(2) by adding at the end the following new clauses:

“(ii) not later than January 1, 2020, increase the percentage of essential community providers as described in clause (i) included in its network by 10 percent annually (based on the level in the plan for 2016) until 90 percent of all federally-qualified health centers and 75 percent of all other such essential community providers in the contract service area are in-network; and

“(iii) include at least one essential community provider in each of the essential community provider categories described in section 156.235(a)(2)(ii)(B) of title 45, Code of Federal Regulations (as in effect on the date of enactment of the Health Equity and Accountability Act of 2018) in each county in the service area, where available;”.

(b) Reporting requirements.—Section 1311(e)(3) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)) is amended by adding at the end the following new subparagraph:

“(E) DATA ON ESSENTIAL COMMUNITY PROVIDERS.—The Secretary shall require qualified health plans to submit annually to the Secretary data on the percentage of essential community providers as described in clause (ii) of subsection (c)(1)(C), by county, that contract with each qualified health plan offered in that county and the percentage of such essential community providers, by category as described in clause (iii) of such subsection, that contract with each qualified health plan offered in that county. Such data shall be made available to the general public.”.

(c) Essential Community Provider provisions applied under Medicare and Medicaid.—

(1) MEDICARE.—Section 1852(d)(1) of the Social Security Act (42 U.S.C. 1395w–22(d)(1)) is amended—

(A) by striking “and” at the end of subparagraph (D);

(B) by striking the period at the end of subparagraph (E) and inserting “; and”; and

(C) by adding at the end the following new subparagraph:

“(F) the plan meets the requirements of clauses (ii) and (iii) of section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (relating to inclusion in networks of essential community providers).”.

(2) MEDICAID.—Section 1932(b)(5) of the Social Security Act (42 U.S.C. 1396u–2(b)(5)) is amended—

(A) by striking “and” at the end of subparagraph (A);

(B) by striking the period at the end of subparagraph (B) and inserting “; and”; and

(C) by adding at the end the following new subparagraph:

“(C) meets the requirements of clauses (ii) and (iii) of section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (relating to inclusion in networks of essential community providers) with respect to services offered in the service area involved.”.

SEC. 430. Provider network adequacy in communities of color.

(a) In general.—Section 1311(c)(1)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(B)), as amended by section 428(a), is further amended—

(1) by inserting “(i)” after “(B)”; and

(2) by adding at the end the following the following new clauses:

“(ii) meet such network adequacy standards as the Secretary may establish with regard to—

“(I) appointment wait time;

“(II) travel time and distance to health care provider facilities and providers by public and private transit;

“(III) hours of operation to accommodate individuals who cannot come to provider appointments during standard business hours; and

“(IV) other network adequacy standards to ensure that care through these plans is accessible to diverse communities, including individuals with limited-English proficiency as defined in section 3400 of such Act; and

“(iii) provide coverage for services for enrollees through out-of-network providers at no additional cost to the enrollees in cases where in-network providers are unable to comply with the standards established under subclause (III) or (IV) of clause (ii) for such services and the out-of-network providers can deliver such services in compliance with such standards.

“(b) Effective date.—The amendments made by subsection (a) shall not apply to plans beginning on or prior to the date that is 1 year after the date of the enactment of this Act.”.

SEC. 431. Improving access to dental care.

(a) Reports to Congress.—

(1) GAO REPORTS.—Not later than 1 year after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress—

(A) a report on the Alaska Dental Health Aide Therapists program and the Dental Therapist and Advanced Dental Therapist programs in Minnesota, to assess the effectiveness of dental therapists in—

(i) improving access to timely dental care among communities of color;

(ii) providing high quality care; and

(iii) providing culturally competent care; and

(B) a report on State variations in the use of dental hygienists and the effectiveness of expanding the scope of practice for dental hygienists in—

(i) improving access to timely dental care among communities of color;

(ii) providing high quality care; and

(iii) providing culturally competent care.

(2) HRSA REPORT ON DENTAL SHORTAGE AREAS.—Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, shall submit to Congress a report which details geographic dental access shortages and the preparedness of dental providers to offer culturally and linguistically appropriate, affordable, accessible, and timely services.

(b) Expansion of dental health aid therapists in Tribal communities.—Section 119(d) of the Indian Health Care Improvement Act (25 U.S.C. 1616l(d)) is amended—

(1) in paragraph (2), by striking “Subject to” and all that follows and inserting “Subject to paragraph (3), in establishing a national program under paragraph (1), the Secretary shall not reduce the amounts provided for the Community Health Aide Program described in subsections (a) and (b).”;

(2) by striking paragraph (3); and

(3) by redesignating paragraph (4) as paragraph (3).

(c) Coverage of dental services under the Medicare program.—

(1) COVERAGE.—Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—

(A) in subparagraph (FF), by striking “and” at the end;

(B) in subparagraph (GG), by adding “and” after the semicolon at the end; and

(C) by adding at the end the following new subparagraph:

“(HH) oral health services (as defined in subsection (kkk));”.

(2) ORAL HEALTH SERVICES DEFINED.—Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 205(b) and 413(a), is amended by adding at the end the following new subsection:

“Oral Health Services

“(kkk) (1) The term ‘oral health services’ means services (as defined by the Secretary) that are necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.

“(2) For purposes of paragraph (1), such term shall include mobile and portable oral health services (as defined by the Secretary) that—

“(A) are provided for the purpose of overcoming mobility, transportation, and access barriers for individuals; and

“(B) satisfy the standards and certification requirements established under section 1902(a)(82)(B) for the State in which the services are provided.”.

(3) PAYMENT AND COINSURANCE.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—

(A) by striking “and” before “(BB)”; and

(B) by inserting before the semicolon at the end the following: “, and (CC) with respect to oral health services (as defined in section 1861(kkk)), the amount paid shall be (i) in the case of such services that are preventive, 100 percent of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848, and (ii) in the case of all other such services, 80 percent of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848”.

(4) PAYMENT UNDER PHYSICIAN FEE SCHEDULE.—Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting “(2)(HH),” after “risk assessment),”.

(5) DENTURES.—Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended—

(A) by striking “(other than dental)” and inserting “(including dentures)”; and

(B) by striking “internal body”.

(6) REPEAL OF GROUND FOR EXCLUSION.—Section 1862(a) of the Social Security Act (42 U.S.C. 1395y) is amended by striking paragraph (12).

(7) EFFECTIVE DATE.—The amendments made by this section shall apply to services furnished on or after January 1, 2019.

(d) Coverage of dental services under the Medicaid program.—

(1) IN GENERAL.—Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—

(A) in subsection (a)(10), by striking “dental services” and inserting “oral health services (as defined in subsection (ee)(1))”; and

(B) by adding at the end the following new subsection:

“(ee)(1) Subject to paragraphs (2) and (3), for purposes of this title, the term ‘oral health services’ means services (as defined by the Secretary) that are necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions. These services shall include, in the case of pregnant or postpartum women, such services as are necessary to address oral health conditions that exist or are exacerbated by pregnancy or childbirth or which, if left untreated, could adversely affect fetal or child development.

“(2) For purposes of paragraph (1), such term shall include—

“(A) dentures; and

“(B) mobile and portable oral health services (as defined by the Secretary) that—

“(i) are provided for the purpose of overcoming mobility, transportation, and access barriers for individuals; and

“(ii) satisfy the standards and certification requirements established under section 1902(a)(84)(C) for the State in which the services are provided.

“(3) For purposes of paragraph (1), such term shall not include dental care or services provided to individuals under the age of 21 under subsection (r)(3).”.

(2) CONFORMING AMENDMENTS.—

(A) STATE PLAN REQUIREMENTS.—Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended—

(i) in paragraph (10)(A), in the matter preceding clause (i), by inserting “(10),” after “(5),”;

(ii) in paragraph (82), by striking “and” at the end;

(iii) in paragraph (83), by striking the period at the end and inserting “; and”; and

(iv) by inserting after paragraph (83) the following:

“(84) provide for—

“(A) informing, in writing, all individuals who have been determined to be eligible for medical assistance of the availability of oral health services (as defined in section 1905(ee));

“(B) conducting targeted outreach to pregnant women who have been determined to be eligible for medical assistance about the availability of medical assistance for such dental services and the importance of receiving dental care while pregnant; and

“(C) establishing and maintaining standards for and certification of mobile and portable oral health services (as described in subsections (r)(3)(C) and (ee)(2)(B) of section 1905).”.

(B) DEFINITION OF MEDICAL ASSISTANCE.—Section 1905(a)(12) of the Social Security Act (42 U.S.C. 1396d(a)(12)) is amended by striking “, dentures,”.

(3) MOBILE AND PORTABLE ORAL HEALTH SERVICES UNDER EPSDT.—Section 1905(r)(3) of the Social Security Act (42 U.S.C. 1396d(r)(3)) is amended—

(A) in subparagraph (A)(ii), by striking “; and” and inserting a semicolon;

(B) in subparagraph (B), by striking the period at the end and inserting “; and”; and

(C) by adding at the end the following new subparagraph:

“(C) which shall include mobile and portable oral health services (as defined by the Secretary) that—

“(i) are provided for the purpose of overcoming mobility, transportation, or access barriers for children; and

“(ii) satisfy the standards and certification requirements established under section 1902(a)(82)(C) for the State in which the services are provided.”.

(e) Oral health services as an essential health benefit.—Section 1302(b) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(b)) is amended—

(1) in paragraph (1)—

(A) in subparagraph (J), by striking “oral and”; and

(B) by adding at the end the following:

“(K) Oral health services for children and adults.”; and

(2) by adding at the end the following:

“(6) ORAL HEALTH SERVICES.—For purposes of paragraph (1)(K), the term ‘oral health services’ means services (as defined by the Secretary), that are necessary to prevent any oral disease and promote oral health, restore oral structures to health and function, and treat emergency oral conditions.”.

(f) Demonstration program on training and employment of alternative dental health care providers for dental health care services for veterans in rural and other underserved communities.—

(1) DEMONSTRATION PROGRAM AUTHORIZED.—The Secretary of Veterans Affairs may carry out a demonstration program to establish programs to train and employ alternative dental health care providers in order to increase access to dental health care services for veterans who are entitled to such services from the Department of Veterans Affairs and reside in rural and other underserved communities.

(2) TELEHEALTH.—For purposes of alternative dental health care providers and other dental care providers who are licensed to provide clinical care, dental services provided under the demonstration program under this subsection may be administered by such providers through telehealth-enabled collaboration and supervision when appropriate and feasible.

(3) ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEFINED.—In this subsection, the term “alternative dental health care providers” has the meaning given that term in section 340G–1(a)(2) of the Public Health Service Act (42 U.S.C. 256g–1(a)(2)).

(4) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary to carry out the demonstration program under this subsection.

(g) Demonstration program on training and employment of alternative dental health care providers for dental health care services for members of the Armed Forces and dependents lacking ready access to such services.—

(1) DEMONSTRATION PROGRAM AUTHORIZED.—The Secretary of Defense may carry out a demonstration program to establish programs to train and employ alternative dental health care providers in order to increase access to dental health care services for members of the Armed Forces and their dependents who lack ready access to such services, including the following:

(A) Members and dependents who reside in rural areas or areas otherwise underserved by dental health care providers.

(B) Members of the National Guard and Reserves in active status who are potentially deployable.

(2) TELEHEALTH.—For purposes of alternative dental health care providers and other dental care providers who are licensed to provide clinical care, dental services provided under the demonstration program under this subsection may be administered by such providers through telehealth-enabled collaboration and supervision when appropriate and feasible.

(3) ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEFINED.—In this subsection, the term “alternative dental health care providers” has the meaning given that term in section 340G–1(a)(2) of the Public Health Service Act (42 U.S.C. 256g–1(a)(2)).

(4) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary to carry out the demonstration program under this subsection.

(h) Demonstration program on training and employment of alternative dental health care providers for dental health care services for prisoners within the custody of the bureau of prisons.—

(1) DEMONSTRATION PROGRAM AUTHORIZED.—The Attorney General, acting through the Director of the Bureau of Prisons, may carry out a demonstration program to establish programs to train and employ alternative dental health care providers in order to increase access to dental health services for prisoners within the custody of the Bureau of Prisons.

(2) TELEHEALTH.—For purposes of alternative dental health care providers and other dental care providers who are licensed to provide clinical care, dental services provided under the demonstration program under this subsection may be administered by such providers through telehealth-enabled collaboration and supervision when appropriate and feasible.

(3) ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEFINED.—In this subsection and subsection (i), the term “alternative dental health care providers” has the meaning given that term in section 340G–1(a)(2) of the Public Health Service Act (42 U.S.C. 256g–1(a)(2)).

(4) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary to carry out the demonstration program under this subsection.

(i) Demonstration program on training and employment of alternative dental health care providers for dental health care services under the indian health service.—

(1) DEMONSTRATION PROGRAM AUTHORIZED.—The Secretary of Health and Human Services, acting through the Indian Health Service, may carry out a demonstration program to establish programs to train and employ alternative dental health care providers in order to help eliminate oral health disparities and increase access to dental services through health programs operated by the Indian Health Service, Indian tribes, tribal organizations, and urban Indian organizations (as the preceding 3 terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)).

(2) TELEHEALTH.—For purposes of alternative dental health care providers and other dental care providers who are licensed to provide clinical care, dental services provided under the demonstration program under this subsection may be administered by such providers through telehealth-enabled collaboration and supervision when appropriate and feasible.

(3) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary to carry out the demonstration program under this subsection.

subtitle CAdvancing Health Equity Through Payment and Delivery Reform

SEC. 441. Sense of Congress.

It is the Sense of Congress that—

(1) the sustainability of the health care system in the United States hinges on restructuring how health care is paid for, shifting away from paying for the volume of services provided to the value the services provide;

(2) high value care is care that provides higher quality care more efficiently, achieving greater health improvement and better health outcomes at lower cost (per patient and overall);

(3) a high value health care system must deliver timely, accessible, well-coordinated, high-quality, culturally centered, and language-appropriate care to everyone;

(4) eliminating health disparities and achieving health equity must be central to efforts to achieve a high value health care system;

(5) eliminating such disparities and achieving such equity will require tailored interventions and targeted investments to address inequities in health and health care to make sure that health care delivery and payment efforts are responsive to and inclusive of the needs of communities of color and other communities experiencing disparities; and

(6) new models of value-based payment and care delivery should consider the holistic needs of the patient population, including social determinants of health and behavioral health needs.

SEC. 442. Centers for Medicare & Medicaid Services quality payment program.

(a) Integrating achieving health equity across measures and activities.—

(1) IN GENERAL.—The Centers for Medicare & Medicaid Services Quality Payment Program (in this section referred to as the “Quality Payment Program”), developed through implementation of the provisions of and amendments made by the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) relating to improving quality and payment under title XVIII of the Social Security Act, shall explicitly integrate “achieving health equity” across all measures and activities under the Quality Payment Program, including under the Merit-based Incentive Payment System under section 1848(q) of such Act (42 U.S.C. 1395w–4(q)) or alternative payment models in accordance with this section.

(2) IDENTIFICATION OF LIMITED-ENGLISH PROFICIENT INDIVIDUALS AS UNDERSERVED GROUP.—The Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the “Administrator”) shall identify individuals with limited-English proficiency as a specific underserved group within the Quality Payment Program and give high weight under the Quality Payment Program to measures and activities relating to providing language services for non-English speakers. A clinician or other professional may demonstrate performance on measures and activities with respect to this category by developing language assistance plans, providing oral interpretation services, and providing translated documents for the population served or eligible to be served.

(b) Stratified data.—

(1) IN GENERAL.—The Administrator shall include an explicit reference under the Quality Payment Program indicating that data stratification and reporting is one way of working to achieve health equity.

(2) STRATIFICATION OF DATA.—The Administrator shall require that a clinician or other professional, in reporting measures relating to achieving health quality under this the Quality Payment Program, stratify clinical quality measures by disparity variables, including race, ethnicity, preferred language, disability status, sexual orientation, gender identity, and psychological and behavioral status. A clinician or other professional may use existing demographic data collection fields in certified electronic health record technology (as defined in section 1848(o)(4) of the Social Security Act (42 U.S.C. 1395w–4(o)(4))) to carry out such data stratification under the preceding sentence. Such stratified data may assist clinicians and other professionals in the identification of disparities and distinguish efforts to improve quality from efforts to reduce disparities, which may not correlate without dedicated work.

(3) REQUIREMENT OF ADOPTION OF CERT.—All entities, clinicians, or other professionals participating in the Quality Payment Program shall be required to adopt 2015 certified electronic health record technology (as so defined) as a condition of participating in the Quality Payment Program.

(c) Quality improvement activities.—The Administrator, upon yearly review of the Quality Payment Program, shall add quality improvement activities that implement the Culturally and Linguistically Accessible Standards (CLAS) standards as Improvement Activities under the Quality Payment Program.

SEC. 443. Development and testing of disparity reducing delivery and payment models.

(a) In general.—The Center for Medicare and Medicaid Innovation established under section 1115A of the Social Security Act (42 U.S.C. 1315a) (in this section referred to as the “CMI”) shall establish a dedicated fund to identify, test, evaluate, and scale delivery and payment models under the applicable titles (as defined in subsection (a)(4)(B) of such section) that target health disparities among racial and ethnic minorities, including models that support high-value non-medical services that address socially determined barriers to health, including English proficiency status, low health literacy, and case management, transportation, and enrollment assistance needs, which will help to reduce disparities and impact the overall cost of care.

(b) Pilot programs.—The CMI shall prioritize the testing of models under such section 1115A that include partnerships with entities, including community based organizations or other non-profit entities, to help address socially determined barriers to health and health care.

(c) Alternatives.—Any model tested by the CMI under such 1115A shall include measures to assess and track the impact of the model on health disparities, using existing measures such as the Healthcare Disparities and Cultural Competency Measures endorsed by the entity with a contract under section 1890(a) of the Social Security Act (42 U.S.C. 1395aaa(a)), and stratified by race, ethnicity, English proficiency, gender identity, sexual orientation, and disability status.

SEC. 444. Supporting safety net and community-based providers to compete in value-based payment systems.

(a) In general.—Any pay-for-performance or alternative payment model that is developed and tested by the Center for Medicare and Medicaid Innovation established under section 1115A of the Social Security Act (42 U.S.C. 1315a), or any other agency of the Department of Health and Human Services with respect to the programs under titles XVIII, XIX, or XXI of such Act, shall be assessed for potential impact on safety net, community based, and critical access providers, including Federally qualified health centers.

(b) New models.—The rollout of any such models shall include training and additional up front resources for community based and safety net providers to enable those providers to participate in the model.

subtitle DHealth Empowerment Zones

SEC. 451. Short title.

This subtitle may be cited as the “Health Empowerment Zone Act of 2018”.

SEC. 452. Findings.

Congress finds the following:

(1) Numerous studies and reports, including the 2015 National Healthcare Quality and Disparities Report of the Agency for Healthcare Research and Quality and the 2002 report of the Institute of Medicine entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care”, document the extensiveness to which health disparities exist across the country.

(2) These studies have found that, on average, racial and ethnic minorities are disproportionately afflicted with chronic and acute conditions—such as cancer, diabetes, musculoskeletal disease, obesity, and hypertension—and suffer worse health outcomes, worse health status, and higher mortality rates than their White counterparts.

(3) Several recent studies also show that health disparities are a function of not only access to health care, but also the social determinants of health—including the environment, the physical structure of communities, nutrition and food options, educational attainment and health literacy, employment, race, ethnicity, immigration status, geography, and language preference—that directly and indirectly affect the health, health care, and wellness of individuals and communities.

(4) Integrally involving and fully supporting the communities most affected by health inequities in the assessment, planning, launch, and evaluation of health disparity elimination efforts are among the leading recommendations made to adequately address and ultimately reduce health disparities.

(5) Recommendations also include supporting the efforts of community stakeholders from a broad cross section—including local businesses, local departments of commerce, education, labor, urban planning, and transportation, and community-based and other nonprofit organizations, including national and regional intermediaries with demonstrated capacity to serve low-income urban communities—to find areas of common ground around health disparity elimination and collaborate to improve the overall health and wellness of a community and its residents.

SEC. 453. Designation of health empowerment zones.

(a) In general.—The Secretary may, at the request of an eligible community partnership described in subsection (b)(1), designate an eligible area described in subsection (b)(2) as a health empowerment zone for the purpose of eligibility for a grant under section 455.

(b) Eligibility criteria.—

(1) ELIGIBLE COMMUNITY PARTNERSHIP.—A community partnership is eligible to submit a request under this section if the partnership—

(A) demonstrates widespread public support from key individuals and entities in the eligible area, including members of the target community, State and local governments, nonprofit organizations including national and regional intermediaries with demonstrated capacity to serve low-income urban communities, and community and industry leaders, for designation of the eligible area as a health empowerment zone; and

(B) includes representatives of—

(i) a broad cross section of stakeholders and residents from communities in the eligible area experiencing disproportionate disparities in health status and health care; and

(ii) organizations, facilities, and institutions that have a history of working within and serving such communities.

(2) ELIGIBLE AREA.—An area is eligible to be designated as a health empowerment zone under this section if one or more communities in the area experience disproportionate disparities in health status and health care. In determining whether a community experiences such disparities, the Secretary shall consider data collected by the Department of Health and Human Services focusing on the following areas:

(A) Access to affordable, high-quality health services.

(B) The prevalence of disproportionate rates of certain illnesses or diseases including the following:

(i) Arthritis, osteoporosis, chronic back conditions, and other musculoskeletal diseases.

(ii) Cancer.

(iii) Chronic kidney disease.

(iv) Diabetes.

(v) Injury (intentional and unintentional).

(vi) Violence (intimate and nonintimate).

(vii) Maternal and paternal illnesses and diseases.

(viii) Infant mortality.

(ix) Mental illness and other disabilities.

(x) Substance use disorder treatment and prevention, including underage drinking.

(xi) Nutrition, obesity, and overweight conditions.

(xii) Heart disease.

(xiii) Hypertension.

(xiv) Cerebrovascular disease or stroke.

(xv) Tuberculosis.

(xvi) HIV/AIDS and other sexually transmitted infections.

(xvii) Viral hepatitis.

(xviii) Asthma.

(xix) Tooth decay and other oral health issues.

(C) Within the community, the historical and persistent presence of conditions that have been found to contribute to health disparities including any such conditions respecting any of the following:

(i) Poverty.

(ii) Educational status and the quality of community schools.

(iii) Income.

(iv) Access to high-quality affordable health care.

(v) Work and work environment.

(vi) Environmental conditions in the community, including with respect to clean water, clean air, and the presence or absence of pollutants.

(vii) Language and English proficiency.

(viii) Access to affordable healthy food.

(ix) Access to ethnically and culturally diverse health and human service providers and practitioners.

(x) Access to culturally and linguistically competent health and human services and health and human service providers.

(xi) Health-supporting infrastructure.

(xii) Health insurance that is adequate and affordable.

(xiii) Race, racism, and bigotry (conscious and unconscious).

(xiv) Sexual orientation.

(xv) Health literacy.

(xvi) Place of residence (such as urban areas, rural areas, and reservations of Indian tribes).

(xvii) Stress.

(c) Procedure.—

(1) REQUEST.—A request under subsection (a) shall—

(A) describe the bounds of the area to be designated as a health empowerment zone and the process used to select those bounds;

(B) demonstrate that the partnership submitting the request is an eligible community partnership described in subsection (b)(1);

(C) demonstrate that the area is an eligible area described in subsection (b)(2);

(D) include a comprehensive assessment of disparities in health status and health care experience by one or more communities in the area;

(E) set forth—

(i) a vision and a set of values for the area; and

(ii) a comprehensive and holistic set of goals to be achieved in the area through designation as a health empowerment zone; and

(F) include a strategic plan and an action plan for achieving the goals described in subparagraph (E)(ii).

(2) APPROVAL.—Not later than 60 days after the receipt of a request for designation of an area as a health empowerment zone under this section, the Secretary shall approve or disapprove the request.

(d) Minimum number.—The Secretary—

(1) shall designate not more than 110 health empowerment zones under this section; and

(2) shall designate at least one health empowerment zone in each of the several States, the District of Columbia, and each territory or possession of the United States.

SEC. 454. Assistance to those seeking designation.

At the request of any organization or entity seeking to submit a request under section 453(a), the Secretary shall provide technical assistance, and may award a grant, to assist such organization or entity—

(1) to form an eligible community partnership described in section 453(b)(1);

(2) to complete a health assessment, including an assessment of health disparities under section 453(c)(1)(D); or

(3) to prepare and submit a request, including a strategic plan, in accordance with section 453.

SEC. 455. Benefits of designation.

(a) Priority.—In awarding a grant under subsection (b), a Federal official shall give priority to any applicant that—

(1) meets the eligibility criteria for the grant;

(2) proposes to use the grant for activities in a health empowerment zone; and

(3) demonstrates that such activities will directly and significantly further the goals of the strategic plan approved for such zone under section 453.

(b) Grants for initial implementation of strategic plan.—

(1) IN GENERAL.—Upon designating an eligible area as a health empowerment zone at the request of an eligible community partnership, the Secretary shall, subject to the availability of appropriations, make a grant to the community partnership for implementation of the strategic plan for such zone.

(2) GRANT PERIOD.—A grant under paragraph (1) for a health empowerment zone shall be for a period of 2 years and may be renewed, except that the total period of grants under paragraph (1) for such zone may not exceed 10 years.

(3) LIMITATION.—In awarding grants under this subsection, the Secretary shall not give less priority to an applicant or reduce the amount of a grant because the Secretary rendered technical assistance or made a grant to the same applicant under section 454.

(4) REPORTING.—The Secretary shall establish metrics for measuring the progress of grantees under this subsection and, based on such metrics, require each such grantee to report to the Secretary not less than every 6 months on the progress in implementing the strategic plan for the health empowerment zone.

SEC. 456. Definition of Secretary.

In this subtitle, the term “Secretary” means the Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration and the Deputy Assistant Secretary for Minority Health, and in cooperation with the Director of the Office of Community Services and the Director of the National Institute on Minority Health and Health Disparities.

SEC. 457. Authorization of appropriations.

To carry out this subtitle, there is authorized to be appropriated $100,000,000 for fiscal year 2019.

subtitle EAt-Risk community coverage

SEC. 461. Medicaid coverage for citizens of Freely Associated States.

(a) In general.—Section 402(b)(2) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612(b)(2)) is amended by adding at the end the following new subparagraph:

“(G) MEDICAID EXCEPTION FOR CITIZENS OF FREELY ASSOCIATED STATES.—With respect to eligibility for benefits for the designated Federal program described in paragraph (3)(C), section 401(a) and paragraph (1) shall not apply to any individual who lawfully resides in 1 of the 50 States or the District of Columbia in accordance with the Compacts of Free Association between the Government of the United States and the Governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau and shall not apply, at the option of the Governors of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa, respectively, as communicated to the Secretary of Health and Human Services in writing, to any individual who lawfully resides in the respective territory in accordance with such Compacts.”.

(b) Exception to 5-Year limited eligibility.—Section 403(d) of such Act (8 U.S.C. 1613(d)) is amended—

(1) in paragraph (1), by striking “or” at the end;

(2) in paragraph (2), by striking the period at the end and inserting “; or”; and

(3) by adding at the end the following new paragraph:

“(3) an individual described in section 402(b)(2)(G), but only with respect to the designated Federal program described in section 402(b)(3)(C).”.

(c) Definition of qualified alien.—Section 431(b) of such Act (8 U.S.C. 1641(b)) is amended—

(1) in paragraph (6), by striking “; or” at the end and inserting a comma;

(2) in paragraph (7), by striking the period at the end and inserting “, or”; and

(3) by adding at the end the following new paragraph:

“(8) an individual who lawfully resides in the United States in accordance with a Compact of Free Association referred to in section 402(b)(2)(G), but only with respect to the designated Federal program described in section 402(b)(3)(C) (relating to the Medicaid program).”.

(d) Effective date.—The amendments made by this section take effect on October 1, 2018.

SEC. 462. At-risk youth Medicaid protection.

(a) In general.—Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended by section 431(d)(2), is further amended—

(1) in subsection (a)—

(A) by striking “and” at the end of paragraph (83);

(B) by striking the period at the end of paragraph (84) and inserting “; and”; and

(C) by inserting after paragraph (84) the following new paragraph:

“(85) provide that—

“(A) the State shall not terminate eligibility for medical assistance under a State plan for an individual who is an eligible juvenile (as defined in subsection (nn)(2)) because the juvenile is an inmate of a public institution (as defined in subsection (nn)(3)), but may suspend coverage during the period the juvenile is such an inmate;

“(B) the State shall restore coverage for such medical assistance to such an individual upon the individual’s release from any such public institution, without requiring a new application from the individual, unless (and until such date as) there is a determination that the individual no longer meets the eligibility requirements for such medical assistance; and

“(C) the State shall process any application for medical assistance submitted by, or on behalf of, a juvenile who is an inmate of a public institution notwithstanding that the juvenile is such an inmate.”; and

(2) by adding at the end the following new subsection:

“(nn) Juvenile; eligible juvenile; public institution.—For purposes of subsection (a)(84) and this subsection:

“(1) JUVENILE.—The term ‘juvenile’ means an individual who is—

“(A) under 21 years of age; or

“(B) is described in subsection (a)(10)(A)(i)(IX).

“(2) ELIGIBLE JUVENILE.—The term ‘eligible juvenile’ means a juvenile who is an inmate of a public institution and was eligible for medical assistance under the State plan immediately before becoming an inmate of such a public institution or who becomes eligible for such medical assistance while an inmate of a public institution.

“(3) INMATE OF A PUBLIC INSTITUTION.—The term ‘inmate of a public institution’ has the meaning given such term for purposes of applying the subdivision (A) following paragraph (30) of section 1905(a), taking into account the exception in such subdivision for a patient of a medical institution.”.

(b) No change in exclusion from medical assistance for inmates of public institutions.—Nothing in this section shall be construed as changing the exclusion from medical assistance under the subdivision (A) following paragraph (30) of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)), including any applicable restrictions on a State submitting claims for Federal financial participation under title XIX of such Act for such assistance.

(c) No change in continuity of eligibility before adjudication or sentencing.—Nothing in this section shall be construed to mandate, encourage, or suggest that a State suspend or terminate coverage for individuals before they have been adjudicated or sentenced.

(d) Effective date.—

(1) IN GENERAL.—Except as provided in paragraph (2), the amendments made by subsection (a) shall apply to eligibility for medical assistance under a State plan under title XIX of the Social Security Act of juveniles who become inmates of public institutions on or after the date that is 1 year after the date of the enactment of this Act.

(2) RULE FOR CHANGES REQUIRING STATE LEGISLATION.—In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by subsection (a), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.

TITLE VIMPROVING HEALTH OUTCOMES FOR WOMEN, CHILDREN, AND FAMILIES

subtitle AIn General

SEC. 501. Grants to promote health for underserved communities.

Part Q of title III of the Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding at the end the following:

“SEC. 399Z–3. Grants to promote health for underserved communities.

“(a) Grants Authorized.—The Secretary, in collaboration with the Administrator of the Health Resources and Services Administration and other Federal officials determined appropriate by the Secretary, is authorized to award grants to eligible entities—

“(1) to promote health for underserved communities, with preference given to projects that benefit racial and ethnic minority women, racial and ethnic minority children, adolescents, and lesbian, gay, bisexual, transgender, queer, or questioning communities; and

“(2) to strengthen health outreach initiatives in medically underserved communities, including linguistically isolated populations.

“(b) Use of Funds.—Grants awarded pursuant to subsection (a) may be used to support the activities of community health workers, including such activities—

“(1) to educate and provide outreach regarding enrollment in health insurance including the State Children’s Health Insurance Program under title XXI of the Social Security Act, Medicare under title XVIII of such Act, and Medicaid under title XIX of such Act;

“(2) to educate and provide outreach in a community setting regarding health problems prevalent among underserved communities, and especially among racial and ethnic minority women, racial and ethnic minority children, adolescents, and lesbian, gay, bisexual, transgender, queer, or questioning communities;

“(3) to educate and provide experiential learning opportunities and target risk factors and healthy behaviors that impede or contribute to achieving positive health outcomes, including—

“(A) healthy nutrition;

“(B) physical activity;

“(C) overweight or obesity;

“(D) tobacco use;

“(E) alcohol and substance use;

“(F) injury and violence;

“(G) sexual health;

“(H) mental health;

“(I) musculoskeletal health and arthritis;

“(J) dental and oral health;

“(K) understanding informed consent; and

“(L) stigma;

“(4) to promote community wellness and awareness; and

“(5) to educate and refer target populations to appropriate health care agencies and community-based programs and organizations in order to increase access to quality health care services, including preventive health services.

“(c) Application.—

“(1) IN GENERAL.—Each eligible entity that desires to receive a grant under subsection (a) shall submit an application to the Secretary, at such time, in such manner, and accompanied by such additional information as the Secretary may require.

“(2) CONTENTS.—Each application submitted pursuant to paragraph (1) shall—

“(A) describe the activities for which assistance under this section is sought;

“(B) contain an assurance that, with respect to each community health worker program receiving funds under the grant awarded, such program provides in-language training and supervision to community health workers to enable such workers to provide authorized program activities in (at least) the most commonly used languages within a particular geographic region;

“(C) contain an assurance that the applicant will evaluate the effectiveness of community health worker programs receiving funds under the grant;

“(D) contain an assurance that each community health worker program receiving funds under the grant will provide culturally competent services in the linguistic context most appropriate for the individuals served by the program;

“(E) contain a plan to document and disseminate project descriptions and results to other States and organizations as identified by the Secretary; and

“(F) describe plans to enhance the capacity of individuals to utilize health services and health-related social services under Federal, State, and local programs by—

“(i) assisting individuals in establishing eligibility under the programs and in receiving the services or other benefits of the programs; and

“(ii) providing other services, as the Secretary determines to be appropriate, which may include transportation and translation services.

“(d) Priority.—In awarding grants under subsection (a), the Secretary shall give priority to those applicants—

“(1) who propose to target geographic areas that—

“(A)(i) have a high percentage of residents who are uninsured or underinsured (if the targeted geographic area is located in a State that has elected to make medical assistance available under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act to individuals described in such section);

“(ii) have a high percentage of underinsured residents in a particular geographic area (if the targeted geographic area is located in a State that has not so elected); or

“(iii) have a high number of households experiencing extreme poverty; and

“(B) have a high percentage of families for whom English is not their primary language or including smaller limited-English-proficient communities within the region that are not otherwise reached by linguistically appropriate health services;

“(2) with experience in providing health or health-related social services to individuals who are underserved with respect to such services; and

“(3) with documented community activity and experience with community health workers.

“(e) Collaboration With Academic Institutions.—The Secretary shall encourage community health worker programs receiving funds under this section to collaborate with academic institutions, including minority-serving institutions. Nothing in this section shall be construed to require such collaboration.

“(f) Quality Assurance and Cost Effectiveness.—The Secretary shall establish guidelines for ensuring the quality of the training and supervision of community health workers under the programs funded under this section and for ensuring the cost effectiveness of such programs.

“(g) Monitoring.—The Secretary shall monitor community health worker programs identified in approved applications and shall determine whether such programs are in compliance with the guidelines established under subsection (f).

“(h) Technical Assistance.—The Secretary may provide technical assistance to community health worker programs identified in approved applications with respect to planning, developing, and operating programs under the grant.

“(i) Report to Congress.—

“(1) IN GENERAL.—Not later than 4 years after the date on which the Secretary first awards grants under subsection (a), the Secretary shall submit to Congress a report regarding the grant project.

“(2) CONTENTS.—The report required under paragraph (1) shall include the following:

“(A) A description of the programs for which grant funds were used.

“(B) The number of individuals served.

“(C) An evaluation of—

“(i) the effectiveness of these programs;

“(ii) the cost of these programs; and

“(iii) the impact of these programs on the health outcomes of the community residents.

“(D) Recommendations for sustaining the community health worker programs developed or assisted under this section.

“(E) Recommendations regarding training to enhance career opportunities for community health workers.

“(j) Definitions.—In this section:

“(1) COMMUNITY HEALTH WORKER.—The term ‘community health worker’ means an individual who promotes health or nutrition within the community in which the individual resides—

“(A) by serving as a liaison between communities and health care agencies;

“(B) by providing guidance and social assistance to community residents;

“(C) by enhancing community residents’ ability to effectively communicate with health care providers;

“(D) by providing culturally and linguistically appropriate health or nutrition education;

“(E) by advocating for individual and community health, including dental, oral, mental, and environmental health, or nutrition needs;

“(F) by taking into consideration the needs of the communities served, including the prevalence rates of risk factors that impede achieving positive healthy outcomes among women and children, especially among racial and ethnic minority women and children; and

“(G) by providing referral and followup services.

“(2) COMMUNITY SETTING.—The term ‘community setting’ means a home or a community organization that serves a population.

“(3) ELIGIBLE ENTITY.—The term ‘eligible entity’ means—

“(A) a unit of State, territorial, local, or Tribal government (including a federally recognized Tribe or Alaska Native village); or

“(B) a community-based organization.

“(4) MEDICALLY UNDERSERVED COMMUNITY.—The term ‘medically underserved community’ means a community—

“(A) that has a substantial number of individuals who are members of a medically underserved population, as defined by section 330(b)(3);

“(B) a significant portion of which is a health professional shortage area as designated under section 332; and

“(C) that includes populations that are linguistically isolated, such as geographic areas with a shortage of health professionals able to provide linguistically appropriate services.

“(5) SUPPORT.—The term ‘support’ means the provision of training, supervision, and materials needed to effectively deliver the services described in subsection (b), reimbursement for services, and other benefits.

“(k) Authorization of Appropriations.—There are authorized to be appropriated to carry out this section $15,000,000 for each of fiscal years 2019 through 2023.”.

SEC. 502. Removing barriers to health care and nutrition assistance for children, pregnant persons, and lawfully present individuals.

(a) Medicaid.—Section 1903(v) of the Social Security Act (42 U.S.C. 1396b(v)) is amended by striking paragraph (4) and inserting the following new paragraph:

“(4)(A) Notwithstanding sections 401(a), 402(b), 403, and 421 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and paragraph (1), payment shall be made to a State under this section for medical assistance furnished to an alien under this title (including an alien described in such paragraph) who meets any of the following conditions:

“(i) The alien is otherwise eligible for such assistance under the State plan approved under this title (other than the requirement of the receipt of aid or assistance under title IV, supplemental security income benefits under title XVI, or a State supplementary payment) within either or both of the following eligibility categories:

“(I) Children under 21 years of age, including any optional targeted low-income child (as such term is defined in section 1905(u)(2)(B)).

“(II) Pregnant persons during pregnancy and during the 60-day period beginning on the last day of the pregnancy.

“(ii) The alien is lawfully present in the United States.

“(B) No debt shall accrue under an affidavit of support against any sponsor of an alien who meets the conditions specified in subparagraph (A) on the basis of the provision of medical assistance to such alien under this paragraph and the cost of such assistance shall not be considered as an unreimbursed cost.”.

(b) SCHIP.—Subparagraph (N) of section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended to read as follows:

“(N) Paragraph (4) of section 1903(v) (relating to coverage of categories of children, pregnant persons, and other lawfully present individuals).”.

(c) Supplemental nutrition assistance.—Notwithstanding sections 401(a), 402(a), and 403(a) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1611(a); 1612(a); 1613(a)) and section 6(f) of the Food and Nutrition Act of 2008 (7 U.S.C. 2015(f)), persons who are lawfully present in the United States shall be not be ineligible for benefits under the supplemental nutrition assistance program on the basis of their immigration status or date of entry into the United States.

(d) Eligibility for families with children.—Section 421(d)(3) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1631(d)(3)) is amended by striking “to the extent that a qualified alien is eligible under section 402(a)(2)(J)” and inserting, “to the extent that a child is a member of a household under the supplemental nutrition assistance program”.

(e) Ensuring proper screening.—Section 11(e)(2)(B) of the Food and Nutrition Act of 2008 (7 U.S.C. 2020(e)(2)(B)) is amended—

(1) by redesignating clauses (vi) and (vii) as clauses (vii) and (viii); and

(2) by inserting after clause (v) the following:

“(vi) shall provide a method for implementing section 421 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1631) that does not require any unnecessary information from persons who may be exempt from that provision;”.

SEC. 503. Repeal of denial of benefits.

Section 115 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (21 U.S.C. 862a) is amended—

(1) in subsection (a), by striking “for—” and all that follows and inserting “for assistance under any State program funded under part A of title IV of the Social Security Act (42 U.S.C. 601 et seq.).”;

(2) in subsection (b)—

(A) by striking “(1) Program of temporary assistance for needy families.—”; and

(B) by striking paragraph (2); and

(3) in subsection (e), by striking “it—” and all that follows and inserting “the term in section 419(5) of the Social Security Act (42 U.S.C. 619(5)) when referring to assistance provided under a State program funded under paragraph A of title IV of the Social Security Act (42 U.S.C. 601 et seq.).”.

SEC. 504. Birth defects prevention, risk reduction, and awareness.

(a) In general.—The Secretary shall establish and implement a birth defects prevention and public awareness program, consisting of the activities described in subsections (c) and (d).

(b) Definitions.—In this section:

(1) MATERNAL.—The term “maternal” refers to persons who are pregnant or breastfeeding of all gender identities.

(2) PREGNANCY AND BREASTFEEDING INFORMATION SERVICES.—The term “pregnancy and breastfeeding information services” includes only—

(A) information services to provide accurate, evidence-based, clinical information regarding maternal exposures during pregnancy that may be associated with birth defects or other health risks, such as exposures to medications, chemicals, infections, foodborne pathogens, illnesses, nutrition, or lifestyle factors;

(B) information services to provide accurate, evidence-based, clinical information regarding maternal exposures during breast­feeding that may be associated with health risks to a breast-fed infant, such as exposures to medications, chemicals, infections, foodborne pathogens, illnesses, nutrition, or lifestyle factors;

(C) the provision of accurate, evidence-based information weighing risks of exposures during breast­feeding against the benefits of breast­feeding; and

(D) the provision of information described in subparagraph (A), (B), or (C) through counselors, Websites, fact sheets, telephonic or electronic communication, community outreach efforts, or other appropriate means.

(3) SECRETARY.—The term “Secretary” means the Secretary of Health and Human Services, acting through the Director of the Centers for Disease Control and Prevention.

(c) Nationwide media campaign.—In carrying out subsection (a), the Secretary shall conduct or support a nationwide media campaign to increase awareness among health care providers and at-risk populations about pregnancy and breastfeeding information services.

(d) Grants for pregnancy and breastfeeding information services.—

(1) IN GENERAL.—In carrying out subsection (a), the Secretary shall award grants to State or regional agencies or organizations for any of the following:

(A) INFORMATION SERVICES.—The provision of, or campaigns to increase awareness about, pregnancy and breastfeeding information services.

(B) SURVEILLANCE AND RESEARCH.—The conduct or support of—

(i) surveillance of or research on—

(I) maternal exposures and maternal health conditions that may influence the risk of birth defects, prematurity, or other adverse pregnancy outcomes; and

(II) maternal exposures that may influence health risks to a breastfed infant; or

(ii) networking to facilitate surveillance or research described in this subparagraph.

(2) PREFERENCE FOR CERTAIN STATES.—The Secretary, in making any grant under this subsection, shall give preference to States, otherwise equally qualified, that have a pregnancy and breastfeeding information service in place.

(3) MATCHING FUNDS.—The Secretary may only award a grant under this subsection to a State or regional agency or organization that agrees, with respect to the costs to be incurred in carrying out the grant activities, to make available (directly or through donations from public or private entities) non-Federal funds toward such costs in an amount equal to not less than 25 percent of the amount of the grant.

(4) COORDINATION.—The Secretary shall ensure that activities funded through a grant under this subsection are coordinated, to the maximum extent practicable, with other birth defects prevention and environmental health activities of the Federal Government, including with respect to pediatric environmental health specialty units and children’s environmental health centers.

(e) Evaluation.—In furtherance of the program under subsection (a), the Secretary shall provide for an evaluation of pregnancy and breastfeeding information services to identify efficient and effective models of—

(1) providing information;

(2) raising awareness and increasing knowledge about birth defects prevention measures and targeting education to at-risk groups;

(3) modifying risk behaviors; or

(4) other outcome measures as determined appropriate by the Secretary.

(f) Authorization of appropriations.—To carry out this section, there are authorized to be appropriated $5,000,000 for fiscal year 2019, $6,000,000 for fiscal year 2020, $7,000,000 for fiscal year 2021, $8,000,000 for fiscal year 2022, and $9,000,000 for fiscal year 2023.

SEC. 505. Preventing maternal deaths.

(a) Program authorized.—

(1) IN GENERAL.—The Secretary of Health and Human Services, acting through the Director of the Centers for Disease Control and Prevention, shall establish a grant program under which the Secretary may make grants to States for the purpose of—

(A) carrying out the activities described in subsection (b)(1);

(B) establishing and sustaining a State maternal mortality review committee, in accordance with subsection (b)(2);

(C) ensuring that the State department of health carries out the activities described in subsection (b)(3);

(D) disseminating the case abstraction form developed under subsection (c); and

(E) providing for the public disclosure of information, in accordance with subsection (d).

(2) CRITERIA.—The Secretary shall establish criteria for determining eligibility for, and the amount of a grant awarded to, a State under paragraph (1). Such criteria shall provide that in the case of a State that receives a grant under paragraph (1) for a fiscal year and is determined by the Secretary to have not used such grant in accordance with this section, such State may not be eligible for such a grant for any subsequent fiscal year.

(b) Use of funds.—

(1) REVIEW OF PREGNANCY-RELATED AND PREGNANCY-ASSOCIATED DEATHS.—With respect to a State that receives a grant under subsection (a)(1), the following shall apply:

(A) PROCESS FOR MANDATORY REPORTING OF PREGNANCY-RELATED AND PREGNANCY-ASSOCIATED DEATHS.—

(i) IN GENERAL.—The State, through the State maternal mortality review committee established under subsection (a)(1), shall develop a process that provides for mandatory and confidential case reporting to the State department of health by individuals and entities described in clause (ii) with respect to pregnancy-related and pregnancy-associated deaths.

(ii) INDIVIDUALS AND ENTITIES DESCRIBED.—Individuals and entities described in this clause include each of the following:

(I) Health care professionals.

(II) Medical examiners.

(III) Medical coroners.

(IV) Hospitals.

(V) Birth centers.

(VI) Other health care facilities.

(VII) Other individuals responsible for completing death records.

(VIII) Other appropriate individuals or entities specified by the Secretary.

(B) PROCESS FOR VOLUNTARY REPORTING OF PREGNANCY-RELATED AND PREGNANCY-ASSOCIATED DEATHS.—The State, through the State maternal mortality review committee established under subsection (a)(1), shall develop a process that provides for voluntary and confidential case reporting to the State department of health by family members of the deceased and other individuals on possible pregnancy-related and pregnancy-associated deaths. Such process shall include—

(i) making publicly available on the website of the State department of health a telephone number, Internet web link, and email address for such reporting; and

(ii) publicizing to local professional organizations, community organizations, and social services agencies the availability of the telephone number, Internet web link, and email address made available under clause (i).

(C) IDENTIFICATION OF PREGNANCY-RELATED AND PREGNANCY-ASSOCIATED DEATHS BY STATE VITAL STATISTICS UNIT.—The State, through the vital statistics unit of the State, shall annually identify pregnancy-related and pregnancy-associated deaths occurring in such State in the year involved by—

(i) matching each death record of a person in such year to a live birth certificate or an infant death record for the purpose of identifying deaths of persons that occurred during pregnancy and within one year after the end of a pregnancy;

(ii) identifying each death of a person reported during such year as having an underlying or contributing cause of death related to pregnancy, regardless of the time that has passed between the end of the pregnancy and the death;

(iii) collecting data from medical examiner and coroner reports; and

(iv) using any other method the State may devise to identify maternal deaths such as reviewing a random sample of reported deaths of persons who could have been pregnant to ascertain cases of pregnancy-related and pregnancy-associated deaths that are not discernable from a review of death records alone.

For purposes of effectively collecting and obtaining data on pregnancy-related and pregnancy-associated deaths, the State shall adopt the most recent standardized birth and death records, as issued by the National Center for Vital Health Statistics, including the recommended checkbox section for pregnancy on each death record.

(D) CASE INVESTIGATION AND DEVELOPMENT OF CASE SUMMARIES.—

(i) IN GENERAL.—Following the receipt of reports by the State department of health pursuant to subparagraph (A) or (B) and the collection of cases of pregnancy-related and pregnancy-associated deaths by the vital statistics unit of the State under subparagraph (C), the State, through the State maternal mortality review committee established under subsection (a)(1), shall investigate each case, using the case abstraction form described in subsection (c), and prepare a de-identified case summary for each case, which shall be reviewed by the committee and included in applicable reports. The State department of health or vital statistics unit of the State, as the case may be, shall provide the State maternal mortality review committee with access to the information collected pursuant to subparagraph (A) or (B), or under subparagraph (C), as necessary to carry out this subparagraph.

(ii) MANDATORY DATA AND INFORMATION.—Each case investigation under this subparagraph shall, subject to availability, include data and information obtained through—

(I) medical examiner and autopsy reports of the person involved;

(II) medical records of the person, including such records related to health care prior to pregnancy, prenatal and postnatal care, labor and delivery care, emergency room care, hospital discharge records, and any care delivered up until the time of death of the person;

(III) oral and written interviews of individuals directly involved in the maternal care of the person during and immediately following the pregnancy of the person, including health care, mental health, and social service providers, as applicable;

(IV) socioeconomic and other relevant background information about the person;

(V) any information collected under subparagraph (C)(i); and

(VI) any other information on the cause of death of the person, such as social services and child welfare reports.

(iii) DISCRETIONARY DATA AND INFORMATION.—Each case investigation under this subparagraph may include data and information obtained through oral or written interviews of the family of the person.

(2) STATE MATERNAL MORTALITY REVIEW COMMITTEES.—

(A) MANDATORY ACTIVITIES.—A State maternal mortality review committee established under subsection (a)(1) shall carry out the following activities:

(i) Develop the processes described in subparagraphs (A) and (B) of paragraph (1).

(ii) Review the data and information collected by the vital statistics unit of the State under paragraph (1)(C) regarding pregnancy-related and pregnancy-associated deaths to identify trends, patterns, and disparities in adverse outcomes and address medical, non-medical, and system-related factors that may have contributed to such pregnancy-related and pregnancy-associated deaths and disparities.

(iii) Carry out the activities described in paragraph (1)(D).

(iv) Develop recommendations, based on the case summaries prepared under paragraph (1)(D) and the data and information collected under paragraph (1)(C), to improve maternal care, social and health services, and public health policy and institutions, including improving access to maternal care and social and health services and identifying disparities in maternal care and outcomes.

(B) DISCRETIONARY ACTIVITIES.—

(i) IN GENERAL.—A State maternal mortality review committee established under subsection (a)(1) may, while subject to confidentiality requirements, present findings and recommendations based on the case summaries prepared under paragraph (1)(D) directly to a health care facility or its local or State professional organization for the purpose of—

(I) instituting policy changes, educational activities, and improvements in the quality of care provided by the facility; and

(II) exploring and forming regional collaborations.

(ii) INVESTIGATION OF CASES OF SEVERE MATERNAL MORBIDITY.—A State maternal mortality review committee may investigate cases of severe maternal morbidity and any such investigation may include data and information obtained through—

(I) identified patient registries; or

(II) oral or written interviews of the person concerned and the family of such person.

(C) COMPOSITION OF STATE MATERNAL MORTALITY REVIEW COMMITTEES.—

(i) IN GENERAL.—A State maternal mortality review committee established under subsection (a)(1) shall be multidisciplinary and diverse. Membership on the State maternal mortality review committee shall be reviewed annually by the State department of health to ensure that membership representation requirements are being fulfilled in accordance with this subparagraph.

(ii) REQUIRED MEMBERSHIP.—Each State maternal mortality review committee shall include—

(I) representatives from medical specialties providing care to pregnant and postpartum patients, including obstetricians (including generalists and maternal fetal medicine specialists) and family practice physicians;

(II) certified nurse midwives, certified midwives, and advanced practice nurses;

(III) hospital-based registered nurses;

(IV) representatives of the maternal and child health department of the State department of health;

(V) social service providers or social workers, including those with experience working with communities diverse with respect to race, ethnicity, and limited-English proficiency;

(VI) chief medical examiners or designees;

(VII) facility representatives, such as from hospitals or birth centers;

(VIII) patient advocates, community maternal health organizations, and minority advocacy groups that represent those diverse racial and ethnic communities within the State that are the most affected by pregnancy-related or pregnancy-associated deaths and by a lack of access to maternal health care services; and

(IX) representatives of the departments of health or public health of major cities in the State.

(iii) DISCRETIONARY MEMBERSHIP.—Each State maternal mortality review committee may also include representatives from other relevant academic, health, social service, or policy professions or community organizations on an ongoing basis, or as needed, as determined beneficial by the committee, including—

(I) anesthesiologists;

(II) emergency physicians;

(III) pathologists;

(IV) epidemiologists;

(V) intensivists;

(VI) nutritionists;

(VII) mental health professionals;

(VIII) substance use disorder treatment specialists;

(IX) representatives of relevant patient and provider advocacy groups;

(X) academics;

(XI) paramedics; and

(XII) risk management specialists.

(iv) STAFF.—Staff of each State maternal mortality review committee shall include—

(I) vital health statisticians, maternal child health statisticians, or epidemiologists;

(II) a coordinator of the State maternal mortality review committee, to be designated by the State; and

(III) administrative staff.

(D) OPTION FOR STATES TO ESTABLISH REGIONAL MATERNAL MORTALITY REVIEW COMMITTEES.—States may choose to partner with one or more neighboring States to carry out the activities required of a State maternal mortality review committee under this section. In such a case, with respect to the States in such a partnership, any requirement under this section relating to the reporting of information related to such activities shall be deemed to be fulfilled by each such State if a single such report is submitted for the partnership.

(E) TREATMENT AS PUBLIC HEALTH AUTHORITY FOR PURPOSES OF HIPAA.—For purposes of applying HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act (42 U.S.C. 300jj–19)), each State maternal mortality review committee and regional maternal mortality review committee established under subsection (a)(1) or subsection (b)(2)(D), as the case may be, shall be deemed to be a public health authority described in section 164.501 (and referenced in section 164.512(b)(1)(i)) of title 45, Code of Federal Regulations (or any successor regulation), carrying out public health activities and purposes described in such section 164.512(b)(1)(i) (or any such successor regulation).

(3) STATE DEPARTMENT OF HEALTH ACTIVITIES.—With respect to a State that receives a grant under subsection (a)(1), the State department of health shall—

(A) in consultation with the State maternal mortality review committee and in conjunction with relevant professional organizations and patient advocacy organizations, develop a plan for ongoing health care provider education, based on the findings and recommendations of the committee, in order to improve the quality of maternal care; and

(B) take steps to widely disseminate the findings and recommendations of the State maternal mortality review committee and implement the recommendations of the committee.

(c) Case abstraction form.—

(1) DISSEMINATION.—The Director of the Centers for Disease Control and Prevention shall disseminate a uniform case abstraction form to States and State maternal mortality review committees for the purpose of—

(A) ensuring that the data and information collected and reviewed by such committees can be pooled for review by the Department of Health and Human Services and its agencies; and

(B) preserving the uniformity of the information collected for Federal public health purposes.

(2) PERMISSIBLE STATE MODIFICATION.—Each State may modify the form developed under paragraph (1) for implementation and use by such State or by the State maternal mortality review committee of such State by including on such form additional information to be collected, but may not alter the standard questions on such form, in order to ensure that the information can be collected and reviewed centrally at the Federal level.

(d) Public disclosure of information.—

(1) IN GENERAL.—For fiscal year 2019, or a subsequent fiscal year, each State receiving a grant under this section for such year shall, subject to paragraph (3), provide for the public disclosure, and submission to the information clearinghouse established under paragraph (2), of the information included in the report of the State under subsection (f)(1) for such year.

(2) INFORMATION CLEARINGHOUSE.—The Secretary shall establish an information clearinghouse, to be administered by the Director of the Centers for Disease Control and Prevention, that will maintain findings and recommendations submitted pursuant to paragraph (1) and provide such findings and recommendations for public review and research purposes by State departments of health, State maternal mortality review committees, health providers and institutions, and national patient and provider advocacy groups.

(3) CONFIDENTIALITY OF INFORMATION.—In no case may any individually identifiable health information be provided to the public, or submitted to the information clearinghouse, under this subsection.

(e) Confidentiality of proceedings of state maternal mortality review committees.—

(1) IN GENERAL.—All proceedings and activities of a State maternal mortality review committee established under subsection (a)(1), opinions of members of such a committee formed as a result of such proceedings and activities, and records obtained, created, or maintained pursuant to this section, including records of interviews, written reports, and statements procured by the Department of Health and Human Services or by any other person, agency, or organization acting jointly with the Department, in connection with morbidity and mortality reviews under this section, shall be confidential and may not be subject to discovery, subpoena, or introduction into evidence in any civil, criminal, legislative, or other proceeding. Such records shall not be open to public inspection.

(2) TESTIMONY OF MEMBERS OF COMMITTEE.—

(A) IN GENERAL.—Members of a State maternal mortality review committee established under subsection (a)(1) may not be questioned in any civil, criminal, legislative, or other proceeding regarding information presented in, or opinions formed as a result of, a meeting or communication of the committee.

(B) CLARIFICATION.—Nothing in this subsection may be construed to prevent a member of a State maternal mortality review committee established under subsection (a)(1) from testifying regarding information that was obtained independent of such member’s participation on the committee, or public information.

(3) AVAILABILITY OF INFORMATION FOR RESEARCH PURPOSES.—Nothing in this subsection may prohibit a State maternal mortality review committee established under subsection (a)(1) or the Department of Health and Human Services from publishing statistical compilations and research reports that—

(A) are based on confidential information, relating to morbidity and mortality reviews under this section; and

(B) do not contain identifying information or any other information that could be used to ultimately identify the individuals concerned.

(f) Reports.—

(1) STATE REPORTS.—Not later than one year after the end of fiscal year 2019, and each subsequent fiscal year, each State maternal mortality review committee established under subsection (a)(1) and receiving a grant under this section for such year, shall submit to the Director of the Centers for Disease Control and Prevention a report on the findings and recommendations of such committee and information on the implementation of such recommendations during such year.

(2) ANNUAL REPORTS TO CONGRESS.—Not later than 60 days after the deadline for State reports under paragraph (1) for fiscal year 2019, and each subsequent fiscal year, the Secretary of Health and Human Services shall submit to Congress a report on—

(A) the findings, recommendations, and implementation information submitted by any State pursuant to paragraph (1); and

(B) the status of pregnancy-related and pregnancy-associated deaths in the United States, including recommendations on methods to prevent such deaths in the United States.

(g) Definitions.—In this section:

(1) PREGNANCY-ASSOCIATED DEATH.—The term “pregnancy-associated death” means the death of a person while pregnant or during the one-year period following the date of the end of pregnancy, irrespective of the cause of such death.

(2) PREGNANCY-RELATED DEATH.—The term “pregnancy-related death” means the death of a person while pregnant or during the one-year period following the date of the end of pregnancy, irrespective of the duration of the pregnancy, from any cause related to, or aggravated by, the pregnancy or its management, excluding any accidental or incidental cause.

(3) SEVERE MATERNAL MORBIDITY.—The term “severe maternal morbidity” means the physical and psychological conditions that result from, or are aggravated by, pregnancy and have an adverse effect on the health of a person.

(4) STATE.—The term “State” means each of the 50 States, the District of Columbia, and each of the territories.

(5) VITAL STATISTICS UNIT.—The term “vital statistics unit” means the entity that is responsible for maintaining vital records for a State, including official records of live births, deaths, fetal deaths, marriages, divorces, and annulments.

(h) Authorization of appropriations.—There is authorized to be appropriated to carry out this section $7,000,000 for each of fiscal years 2019 through 2023.

SEC. 506. Eliminating disparities in maternity health outcomes.

Part B of title III of the Public Health Service Act is amended by inserting after section 317V (as added by section 110), the following:

“SEC. 317W. Eliminating disparities in maternal health outcomes.

“(a) In general.—The Secretary shall, in consultation with relevant national stakeholder organizations, such as national medical specialty organizations, national maternal child health organizations, national patient advocacy organizations, and national health disparity organizations, carry out the following activities to eliminate disparities in maternal health outcomes:

“(1) Conduct research into the determinants and the distribution of disparities in maternal care, health risks, and health outcomes, and improve the capacity of the performance measurement infrastructure to measure such disparities.

“(2) Expand access to health care services, resources, and information that have been demonstrated to improve the quality and outcomes of maternity care for vulnerable populations.

“(3) Establish a demonstration project to compare the effectiveness of interventions to reduce disparities in maternity services and outcomes and to implement and assess effective interventions.

“(b) Scope and selection of states for demonstration project.—The demonstration project under subsection (a)(3) shall be conducted in no more than 8 States, which shall be selected by the Secretary based on—

“(1) applications submitted by States, which specify which regions and populations the State involved will serve under the demonstration project;

“(2) criteria designed by the Secretary to ensure that, as a whole, the demonstration project is, to the greatest extent possible, representative of the demographic and geographic composition of communities most affected by disparities;

“(3) criteria designed by the Secretary to ensure that a variety of models are tested through the demonstration project and that such models include interventions that have an existing evidence base for effectiveness; and

“(4) criteria designed by the Secretary to ensure that the demonstration projects and models will be carried out in consultation with local and regional provider organizations, such as community health centers, hospital systems, and medical societies representing providers of maternity services.

“(c) Duration of demonstration project.—The demonstration project under subsection (a)(3) shall begin on January 1, 2019, and end on December 31, 2022.

“(d) Grants for evaluation and monitoring.—The Secretary may make grants to States and health care providers participating in the demonstration project under subsection (a)(3) for the purpose of collecting data necessary for the evaluation and monitoring of such project.

“(e) Reports.—

“(1) STATE REPORTS.—Each State that participates in the demonstration project under subsection (a)(3) shall report to the Secretary, in a time, form, and manner specified by the Secretary, the data necessary to—

“(A) monitor the—

“(i) outcomes of the project;

“(ii) costs of the project; and

“(iii) quality of maternity care provided under the project; and

“(B) evaluate the rationale for the selection of the items and services included in any bundled payment made by the State under the project.

“(2) FINAL REPORT.—Not later than December 31, 2022, the Secretary shall submit to Congress a report on the results of the demonstration project under subsection (a)(3).”.

SEC. 507. Decreasing the risk factors for sudden unexpected infant death and sudden unexplained death in childhood.

(a) Establishment.—The Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration and in consultation with the Director of the Centers for Disease Control and Prevention and the Director of the National Institutes of Health (in this section referred to as the “Secretary”), shall establish and implement a culturally and linguistically competent public health awareness and education campaign to provide information that is focused on decreasing the risk factors for sudden unexpected infant death and sudden unexplained death in childhood, including educating individuals about safe sleep environments, sleep positions, and reducing exposure to smoking during pregnancy and after birth.

(b) Targeted Populations.—The campaign under subsection (a) shall be designed to reduce health disparities through the targeting of populations with high rates of sudden unexpected infant death and sudden unexplained death in childhood.

(c) Consultation.—In establishing and implementing the campaign under subsection (a), the Secretary shall consult with national organizations representing health care providers, including nurses and physicians, parents, child care providers, children's advocacy and safety organizations, maternal and child health programs, nutrition professionals focusing on women, infants, and children, and other individuals and groups determined necessary by the Secretary for such establishment and implementation.

(d) Grants.—

(1) IN GENERAL.—In carrying out the campaign under subsection (a), the Secretary shall award grants to national organizations, State and local health departments, and community-based organizations for the conduct of education and outreach programs for nurses, parents, child care providers, public health agencies, and community organizations.

(2) APPLICATION.—To be eligible to receive a grant under paragraph (1), an entity shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2023.

SEC. 508. Reducing unintended teenage pregnancies.

Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) is amended by adding at the end the following:

“PART WYouth Access to Sexual Health Services

“SEC. 399OO. Authorization of grants to support the access of marginalized youth to sexual health services.

“(a) Grants.—The Secretary may award grants on a competitive basis to eligible entities to support the access of marginalized youth to sexual health services.

“(b) Use of funds.—An eligible entity that is awarded a grant under subsection (a) may use the funds to—

“(1) provide medically accurate and complete and age-, developmentally, and culturally appropriate sexual health information to marginalized youth, including information on how to access sexual health services;

“(2) promote effective communication regarding sexual health among marginalized youth;

“(3) promote and support better health, education, and economic opportunities for school-age parents; and

“(4) train individuals who work with marginalized youth to promote—

“(A) the prevention of unintended pregnancy;

“(B) the prevention of sexually transmitted infections, including the human immunodeficiency virus (HIV);

“(C) healthy relationships; and

“(D) the development of safe and supportive environments.

“(c) Application.—To be awarded a grant under subsection (a), an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.

“(d) Priority.—In awarding grants under subsection (a), the Secretary shall give priority to eligible entities—

“(1) with a history of supporting the access of marginalized youth to sexuality education or sexual health services; and

“(2) that plan to serve marginalized youth that are not served by Federal adolescent programs for the prevention of pregnancy, HIV, and other sexually transmitted infections.

“(e) Requirements.—The Secretary may not award a grant under subsection (a) to an eligible entity unless—

“(1) such eligible entity has formed a partnership with a community organization; and

“(2) such eligible entity agrees—

“(A) to employ a scientifically effective strategy;

“(B) that all information provided to marginalized youth will be—

“(i) age- and developmentally appropriate;

“(ii) medically accurate and complete;

“(iii) scientifically based; and

“(iv) provided in the language and cultural context that is most appropriate for the individuals served by the eligible entity; and

“(C) that for each year the eligible entity receives grant funds under subsection (a), the eligible entity will submit to the Secretary an annual report that includes—

“(i) the use of grant funds by the eligible entity;

“(ii) how the use of grant funds has increased the access of marginalized youth to sexual health services; and

“(iii) such other information as the Secretary may require.

“(f) Publication and evaluations.—

“(1) EVALUATIONS.—Not less than once every two years after the date of the enactment of this part, the Secretary shall evaluate the effectiveness of whichever of the following is greater:

“(A) Eight grants awarded under subsection (a).

“(B) Ten percent of the grants awarded under subsection (a).

“(2) PUBLICATION.—The Secretary shall make available to the public—

“(A) the evaluations required under paragraph (1); and

“(B) the reports required under subsection (e)(2)(C).

“(g) Limitations.—No funds made available to an eligible entity under this section may be used by such entity to provide access to sexual health services that—

“(1) withhold sexual health-promoting or life-saving information;

“(2) are medically inaccurate or have been scientifically shown to be ineffective;

“(3) promote gender stereotypes;

“(4) are insensitive or unresponsive to the needs of young people, including—

“(A) youth with varying gender identities, gender expressions, and sexual orientations;

“(B) sexually active youth;

“(C) pregnant or parenting youth;

“(D) survivors of sexual abuse or assault; and

“(E) youth of all physical, developmental, and mental abilities; or

“(5) are inconsistent with the ethical imperatives of medicine and public health.

“(h) Transfer of funds.—Any unobligated balance of funds made available under section 510(d) of the Social Security Act (42 U.S.C. 710(d)) (as in effect on the day before the date of the enactment of this part) are hereby transferred and made available to the Secretary to carry out this section. The amounts transferred and made available to carry out this section shall remain available until expended.

“(i) Definitions.—In this section:

“(1) COMMUNITY ORGANIZATION.—The term ‘community organization’ includes a State or local health or education agency, public school, youth-focused organization that is faith-based and community-based, juvenile justice entity, or other organization that provides confidential and appropriate sexuality education or sexual health services to marginalized youth.

“(2) ELIGIBLE ENTITY.—The term ‘eligible entity’ includes a State or local health or education agency, public school, nonprofit organization, hospital, or an Indian Tribe or Tribal organization (as such terms are defined in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304)).

“(3) MARGINALIZED YOUTH.—The term ‘marginalized youth’ means a person under the age of 26 that is disadvantaged by underlying structural barriers and social inequity.

“(4) MEDICALLY ACCURATE AND COMPLETE.—The term ‘medically accurate and complete’, when used with respect to information, means information that—

“(A) is supported by research and recognized as accurate, objective, and complete by leading medical, psychological, psychiatric, or public health organizations and agencies; and

“(B) does not withhold any information relating to the effectiveness and benefits of correct and consistent use of condoms or other contraceptives and pregnancy prevention methods.

“(5) SCIENTIFICALLY EFFECTIVE STRATEGY.—The term ‘scientifically effective strategy’ means a strategy that—

“(A) is widely recognized by leading medical and public health agencies as effective in promoting sexual health awareness and healthy behavior; and

“(B) either—

“(i) has been demonstrated to be effective on the basis of rigorous scientific research; or

“(ii) incorporates characteristics of effective programs.

“(6) SEXUAL HEALTH SERVICES.—The term ‘sexual health services’ includes—

“(A) sexual health information, education, and counseling;

“(B) contraception;

“(C) emergency contraception;

“(D) condoms and other barrier methods to prevent pregnancy or sexually transmitted infections;

“(E) routine gynecological care, including human papillomavirus (HPV) vaccines and cancer screenings;

“(F) pre-exposure prophylaxis or post-exposure prophylaxis;

“(G) mental health services;

“(H) sexual assault survivor services; and

“(I) other prevention, care, or treatment.”.

SEC. 509. Gestational diabetes.

Part B of title III of the Public Health Service Act (42 U.S.C. 243 et seq.) is amended by adding after section 317H the following:

“SEC. 317H–1. Gestational diabetes.

“(a) Understanding and monitoring gestational diabetes.—

“(1) IN GENERAL.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, in consultation with the Diabetes Mellitus Interagency Coordinating Committee established under section 429 and representatives of appropriate national health organizations, shall develop a multisite gestational diabetes research project within the diabetes program of the Centers for Disease Control and Prevention to expand and enhance surveillance data and public health research on gestational diabetes.

“(2) AREAS TO BE ADDRESSED.—The research project developed under paragraph (1) shall address—

“(A) procedures to establish accurate and efficient systems for the collection of gestational diabetes data within each State and commonwealth, territory, or possession of the United States;

“(B) the progress of collaborative activities with the National Vital Statistics System, the National Center for Health Statistics, and State health departments with respect to the standard birth certificate, in order to improve surveillance of gestational diabetes;

“(C) postpartum methods of tracking individuals with gestational diabetes after delivery as well as targeted interventions proven to lower the incidence of type 2 diabetes in that population;

“(D) variations in the distribution of diagnosed and undiagnosed gestational diabetes, and of impaired fasting glucose tolerance and impaired fasting glucose, within and among groups of pregnant individuals; and

“(E) factors and culturally sensitive interventions that influence risks and reduce the incidence of gestational diabetes and related complications during childbirth, including cultural, behavioral, racial, ethnic, geographic, demographic, socioeconomic, and genetic factors.

“(3) REPORT.—Not later than 2 years after the date of the enactment of this section, and annually thereafter, the Secretary shall generate a report on the findings and recommendations of the research project including prevalence of gestational diabetes in the multisite area and disseminate the report to the appropriate Federal and non-Federal agencies.

“(b) Expansion of gestational diabetes research.—

“(1) IN GENERAL.—The Secretary shall expand and intensify public health research regarding gestational diabetes. Such research may include—

“(A) developing and testing novel approaches for improving postpartum diabetes testing or screening and for preventing type 2 diabetes in individuals who can become pregnant with a history of gestational diabetes; and

“(B) conducting public health research to further understanding of the epidemiologic, socioenvironmental, behavioral, translation, and biomedical factors and health systems that influence the risk of gestational diabetes and the development of type 2 diabetes in individuals who can become pregnant with a history of gestational diabetes.

“(2) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this subsection $5,000,000 for each of fiscal years 2019 through 2023.

“(c) Demonstration grants To lower the rate of gestational diabetes.—

“(1) IN GENERAL.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall award grants, on a competitive basis, to eligible entities for demonstration projects that implement evidence-based interventions to reduce the incidence of gestational diabetes, the recurrence of gestational diabetes in subsequent pregnancies, and the development of type 2 diabetes in individuals who can become pregnant with a history of gestational diabetes.

“(2) PRIORITY.—In making grants under this subsection, the Secretary shall give priority to projects focusing on—

“(A) helping individuals who can become pregnant who have 1 or more risk factors for developing gestational diabetes;

“(B) working with individuals who can become pregnant with a history of gestational diabetes during a previous pregnancy;

“(C) providing postpartum care for individuals who can become pregnant with gestational diabetes;

“(D) tracking cases where individuals who can become pregnant with a history of gestational diabetes developed type 2 diabetes;

“(E) educating mothers with a history of gestational diabetes about the increased risk of their child developing diabetes;

“(F) working to prevent gestational diabetes and prevent or delay the development of type 2 diabetes in individuals who can become pregnant with a history of gestational diabetes; and

“(G) achieving outcomes designed to assess the efficacy and cost-effectiveness of interventions that can inform decisions on long-term sustainability, including third-party reimbursement.

“(3) APPLICATION.—An eligible entity desiring to receive a grant under this subsection shall submit to the Secretary—

“(A) an application at such time, in such manner, and containing such information as the Secretary may require; and

“(B) a plan to—

“(i) lower the rate of gestational diabetes during pregnancy; or

“(ii) develop methods of tracking individuals who can become pregnant with a history of gestational diabetes and develop effective interventions to lower the incidence of the recurrence of gestational diabetes in subsequent pregnancies and the development of type 2 diabetes.

“(4) USES OF FUNDS.—An eligible entity receiving a grant under this subsection shall use the grant funds to carry out demonstration projects described in paragraph (1), including—

“(A) expanding community-based health promotion education, activities, and incentives focused on the prevention of gestational diabetes and development of type 2 diabetes in individuals who can become pregnant with a history of gestational diabetes;

“(B) aiding State- and Tribal-based diabetes prevention and control programs to collect, analyze, disseminate, and report surveillance data on individuals who can become pregnant with, and at risk for, gestational diabetes, the recurrence of gestational diabetes in subsequent pregnancies, and, for individuals who can become pregnant with a history of gestational diabetes, the development of type 2 diabetes; and

“(C) training and encouraging health care providers—

“(i) to promote risk assessment, high-quality care, and self-management for gestational diabetes and the recurrence of gestational diabetes in subsequent pregnancies; and

“(ii) to prevent the development of type 2 diabetes in individuals who can become pregnant with a history of gestational diabetes, and its complications in the practice settings of the health care providers.

“(5) REPORT.—Not later than 4 years after the date of the enactment of this section, the Secretary shall prepare and submit to the Congress a report concerning the results of the demonstration projects conducted through the grants awarded under this subsection.

“(6) DEFINITION OF ELIGIBLE ENTITY.—In this subsection, the term ‘eligible entity’ means a nonprofit organization (such as a nonprofit academic center or community health center) or a State, Tribal, or local health agency.

“(7) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this subsection $5,000,000 for each of fiscal years 2019 through 2023.

“(d) Postpartum followup regarding gestational diabetes.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall work with the State- and Tribal-based diabetes prevention and control programs assisted by the Centers to encourage postpartum followup after gestational diabetes, as medically appropriate, for the purpose of reducing the incidence of gestational diabetes, the recurrence of gestational diabetes in subsequent pregnancies, the development of type 2 diabetes in individuals with a history of gestational diabetes, and related complications.”.

SEC. 510. Emergency contraception education and information programs.

(a) Emergency Contraception Public Education Program.—

(1) IN GENERAL.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall develop and disseminate to the public medically accurate and complete information on emergency contraception.

(2) DISSEMINATION.—The Secretary may disseminate medically accurate and complete information under paragraph (1) directly or through arrangements with nonprofit organizations, community health workers including promotoras, consumer groups, institutions of higher education, clinics, the media, and Federal, State, and local agencies.

(3) INFORMATION.—The information disseminated under paragraph (1) shall—

(A) include, at a minimum, a description of emergency contraception and an explanation of the use, safety, efficacy, and availability of such contraception and options for no-copay access through insurance; and

(B) be pilot tested for consumer comprehension, cultural and linguistic appropriateness, and acceptance of the messages across geographically, racially, ethnically, and linguistically diverse populations.

(b) Emergency Contraception Information Program for Health Care Providers.—

(1) IN GENERAL.—The Secretary, acting through the Administrator of the Health Resources and Services Administration and in consultation with major medical and public health organizations, shall develop and disseminate to health care providers information on emergency contraception.

(2) INFORMATION.—The information disseminated under paragraph (1) shall include, at a minimum—

(A) information describing the use, safety, efficacy, availability of emergency contraception, and options for no-copay access through insurance;

(B) a recommendation regarding the use of such contraception; and

(C) information explaining how to obtain copies of the information developed under subsection (a) for distribution to the patients of the providers.

(c) Definitions.—In this section:

(1) EMERGENCY CONTRACEPTION.—The term “emergency contraception” means a drug or device (as the terms are defined in section 201 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321)) or a drug regimen that—

(A) is used postcoitally;

(B) prevents pregnancy primarily by preventing or delaying ovulation, and does not terminate an established pregnancy; and

(C) is approved by the Food and Drug Administration.

(2) HEALTH CARE PROVIDER.—The term “health care provider” means an individual who is licensed or certified under State law to provide health care services and who is operating within the scope of such license. Such term shall include a pharmacist.

(3) INSTITUTION OF HIGHER EDUCATION.—The term “institution of higher education” has the same meaning given such term in section 101(a) of the Higher Education Act of 1965 (20 U.S.C. 1001(a)).

(4) MEDICALLY ACCURATE AND COMPLETE.—The term “medically accurate and complete” means, with respect to information, activities, or services verified or supported by the weight of research conducted in compliance with accepted scientific methods and—

(A) published in peer-reviewed journals, where applicable; or

(B) comprising information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete.

(5) SECRETARY.—The term “Secretary” means the Secretary of Health and Human Services.

(d) Authorization of Appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of the fiscal years 2019 through 2023.

SEC. 511. Comprehensive sex education programs.

(a) Purposes; finding; sense of congress.—

(1) PURPOSES.—The purposes of this section are to provide young people with comprehensive sex education programs that—

(A) promote and uphold the rights of young people to information in order to make healthy decisions about their sexual health;

(B) provide the information and skills all young people need to make informed, responsible, and healthy decisions in order to become sexually healthy adults and have healthy relationships;

(C) provide information about the prevention of unintended pregnancy, sexually transmitted infections, including HIV, dating violence, sexual assault, bullying, and harassment; and

(D) provide resources and information on topics ranging from gender stereotyping and gender roles and stigma and socio-cultural influences surrounding sex and sexuality.

(2) FINDING ON REQUIRED RESOURCES.—In order to provide the comprehensive sex education described in paragraph (1), Congress finds that increased resources are required for sex education programs that—

(A) substantially incorporate elements of evidence-based programs or characteristics of effective programs;

(B) cover a broad range of topics, including medically accurate and complete information that is age and developmentally appropriate about all the aspects of sex, sexual health, and sexuality;

(C) are gender and gender identity-sensitive, emphasizing the importance of equality and the social environment for achieving sexual and reproductive health and overall well-being;

(D) promote educational achievement, critical thinking, decisionmaking, self-esteem, and self-efficacy;

(E) help develop healthy attitudes and insights necessary for understanding relationships between oneself and others and society;

(F) foster leadership skills and community engagement by—

(i) promoting principles of fairness, human dignity, and respect; and

(ii) engaging young people as partners in their communities; and

(G) are culturally and linguistically appropriate, reflecting the diverse circumstances and realities of young people.

(3) SENSE OF CONGRESS.—It is the sense of Congress that—

(A) federally funded sex education programs should aim to—

(i) provide information about a range of human sexuality topics, including—

(I) human development, healthy relationships, personal skills;

(II) sexual behavior including abstinence;

(III) sexual health including preventing unintended pregnancy;

(IV) sexually transmitted infections including HIV; and

(V) society and culture;

(ii) promote safe and healthy relationships;

(iii) promote gender equity;

(iv) use, and be informed by, the best scientific information available;

(v) be culturally appropriate and inclusive of youth with varying gender identities, gender expressions, and sexual orientations;

(vi) be built on characteristics of effective programs;

(vii) expand the existing body of research on comprehensive sex education programs through program evaluation;

(viii) expand training programs for teachers of comprehensive sex education;

(ix) build on programs funded under section 513 of the Social Security Act (42 U.S.C. 713) and the Office of Adolescent Health’s Teen Pregnancy Prevention Program, funded under title II of the Consolidated Appropriations Act, 2010 (Public Law 111–117; 123 Stat. 3253), and on programs supported through the Centers for Disease Control and Prevention (CDC); and

(x) promote and uphold the rights of young people to information in order to make healthy and autonomous decisions about their sexual health; and

(B) no Federal funds should be used for health education programs that—

(i) withhold health-promoting or life-saving information about sexuality-related topics, including HIV;

(ii) are medically inaccurate or have been scientifically shown to be ineffective;

(iii) promote gender or racial stereotypes;

(iv) are insensitive and unresponsive to the needs of sexually active young people;

(v) are insensitive and unresponsive to the needs of survivors of sexual violence;

(vi) are insensitive and unresponsive to the needs of youth of all physical, developmental, and mental abilities;

(vii) are insensitive and unresponsive to the needs of youth with varying gender identities, gender expressions, and sexual orientations; or

(viii) are inconsistent with the ethical imperatives of medicine and public health.

(b) Grants for comprehensive sex education for adolescents.—

(1) PROGRAM AUTHORIZED.—The Secretary of Health and Human Services, in coordination with the Associate Commissioner of the Family and Youth Services Bureau of the Administration on Children, Youth, and Families of the Department of Health and Human Services, the Director of the Office of Adolescent Health, the Director of the Division of Adolescent and School Health within the Centers for Disease Control and Prevention and the Secretary of Education, shall award grants, on a competitive basis, to eligible entities to enable such eligible entities to carry out programs that provide adolescents with comprehensive sex education, as described in paragraph (6).

(2) DURATION.—Grants awarded under this section shall be for a period of 5 years.

(3) ELIGIBLE ENTITY.—In this section, the term “eligible entity” means a public or private entity that focuses on adolescent health and education or has experience working with adolescents.

(4) APPLICATIONS.—An eligible entity desiring a grant under this subsection shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including an assurance to participate in the evaluation described in subsection (e).

(5) PRIORITY.—In awarding grants under this section, the Secretary shall give priority to eligible entities that—

(A) are State or local public entities;

(B) are entities not currently receiving funds under—

(i) section 513 of the Social Security Act (42 U.S.C. 713);

(ii) the Office of Adolescent Health’s Teen Pregnancy Prevention Program, funded under title II of the Consolidated Appropriations Act, 2010 (Public Law 111–117; 123 Stat. 3253), or any substantially similar successive program; or

(iii) the Centers for Disease Control and Prevention’s Division of Adolescent and School Health; and

(C) address health inequities among young people that face systemic barriers resulting in disproportionate rates of not less than one of the following:

(i) Unintended pregnancies.

(ii) Sexually transmitted infections, including HIV.

(iii) Dating violence and sexual violence.

(6) USE OF FUNDS.—

(A) IN GENERAL.—Each eligible entity that receives a grant under this section shall use the grant funds to carry out an education program that provides adolescents with comprehensive sex education that—

(i) is age and developmentally appropriate;

(ii) is medically accurate and complete;

(iii) substantially incorporates elements of evidence-based sex education instruction; or

(iv) creates a demonstration project based on characteristics of effective programs.

(B) CONTENTS OF COMPREHENSIVE SEX EDUCATION PROGRAMS.—The comprehensive sex education programs funded under this section shall include instruction and materials that address—

(i) the physical, social, and emotional changes of human development including, human anatomy, reproduction, and sexual development;

(ii) healthy relationships, including friendships, within families, and society, that are based on mutual respect, and the ability to distinguish between healthy and unhealthy relationships, including—

(I) effective communication, negotiation and refusal skills, including the skills to recognize and report inappropriate or abusive sexual advances;

(II) bodily autonomy, setting and respecting personal boundaries, practicing personal safety, and consent; and

(III) the limitations and harm of gender- role stereotypes, violence, coercion, bullying, harassment, and intimidation in relationships;

(iii) healthy decisionmaking skills about sexuality and relationships that include—

(I) critical thinking, problem solving, self-efficacy, stress-management, self-care, and decisionmaking;

(II) individual values and attitudes;

(III) the promotion of positive body images;

(IV) developing an understanding that there are a range of body types and encouraging positive feeling about students’ own body types;

(V) information on how to respect others and ensure safety on the internet and when using other forms of digital communication;

(VI) information on local services and resources where students can obtain additional information related to bullying, harassment, dating violence and sexual assault, suicide prevention, and other related care;

(VII) encouragement for youth to communicate with their parents or guardians, health and social service professionals, and other trusted adults about sexuality and intimate relationships;

(VIII) information on how to create a safe environment for all students and others in society;

(IX) examples of varying types of relationships, couples, and family structures; and

(X) affirmative representation of varying gender identities, gender expressions, and sexual orientations, including individuals and relationships between same sex couples and their families;

(iv) abstinence, delaying age of first sexual activity, the use of condoms, preventive medication, vaccination, birth control, and other sexually transmitted infection prevention measures, and the options for pregnancy, including parenting, adoption, and abortion, including—

(I) the importance of effectively using condoms, preventive medication, and applicable vaccinations to protect against sexually transmitted infections, including HIV;

(II) the benefits of effective contraceptive and condom use in avoiding unintended pregnancy;

(III) the relationship between substance use and sexual health and behaviors; and

(IV) information about local health services where students can obtain additional information and services related to sexual and reproductive health and other related care;

(v) through affirmative recognition, the roles that traditions, values, religion, norms, gender roles, acculturation, family structure, health beliefs, and political power play in how students make decisions that affect their sexual health, using examples of various types of races, ethnicities, cultures, and families, including single-parent households and young families;

(vi) information about gender identity, gender expression, and sexual orientation for all students, including—

(I) affirmative recognition that people have different gender identities, gender expressions, and sexual orientations; and

(II) community resources that can provide additional support for individuals with varying gender identities, gender expressions, and sexual orientations; and

(vii) opportunities to explore the roles that race, ethnicity, immigration status, disability status, economic status, homelessness, foster care status, and language within different communities affect sexual attitudes in society and culture and how this may impact student sexual health.

(c) Grants for comprehensive sex education at institutions of higher education.—

(1) PROGRAM AUTHORIZED.—The Secretary, in coordination with the Secretary of Education, shall award grants, on a competitive basis, to institutions of higher education or consortia of such institutions to enable such institutions to provide young people with comprehensive sex education, as described in paragraph (5)(B).

(2) DURATION.—Grants awarded under this subsection shall be for a period of 5 years.

(3) APPLICATIONS.—An institution of higher education or consortium of such institutions desiring a grant under this subsection shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including an assurance to participate in the evaluation described in subsection (e).

(4) PRIORITY.—In awarding grants under this subsection, the Secretary shall give priority to an institution of higher education that—

(A) has an enrollment of needy students, as defined in section 318(b) of the Higher Education Act of 1965 (20 U.S.C. 1059e(b));

(B) is a Hispanic-serving institution, as defined in section 502(a) of such Act (20 U.S.C. 1101a(a));

(C) is a Tribal College or University, as defined in section 316(b) of such Act (20 U.S.C. 1059c(b));

(D) is an Alaska Native-serving institution, as defined in section 317(b) of such Act (20 U.S.C. 1059d(b));

(E) is a Native Hawaiian-serving institution, as defined in section 317(b) of such Act (20 U.S.C. 1059d(b));

(F) is a Predominately Black Institution, as defined in section 318(b) of such Act (20 U.S.C. 1059e(b));

(G) is a Native American-serving, nontribal institution, as defined in section 319(b) of such Act (20 U.S.C. 1059f(b));

(H) is an Asian American and Native American Pacific Islander-serving institution, as defined in section 320(b) of such Act (20 U.S.C. 1059g(b)); or

(I) is a minority institution, as defined in section 365 of such Act (20 U.S.C. 1067k), with an enrollment of needy students, as defined in section 312 of such Act (20 U.S.C. 1058).

(5) USES OF FUNDS.—

(A) IN GENERAL.—An institution of higher education, or a consortium, receiving a grant under this subsection shall use grant funds to integrate issues relating to comprehensive sex education into the institution of higher education, or consortium, in order to reach a large number of students, by carrying out 1 or more of the following activities:

(i) Developing or adopting educational content for issues relating to comprehensive sex education that will be incorporated into student orientation, general education, or core courses.

(ii) Developing or adopting, and implementing schoolwide educational programming outside of class that delivers elements of comprehensive sex education programs to students, faculty, and staff.

(iii) Developing or adopting innovative technology-based approaches to deliver sex education to students, faculty, and staff.

(iv) Developing or adopting, and implementing peer-outreach and education programs to generate discussion, educate, and raise awareness among students about issues relating to comprehensive sex education.

(B) CONTENTS OF SEX EDUCATION PROGRAMS.—Each institution of higher education’s program of comprehensive sex education funded under this section shall include instruction and materials that address the contents required under subsection (b)(6).

(d) Grants for pre-Service and in-Service teacher training.—

(1) PROGRAM AUTHORIZED.—The Secretary, in coordination with the Director of the Centers for Disease Control and Prevention and the Secretary of Education, shall award grants, on a competitive basis, to eligible entities to enable such eligible entities to carry out the activities described in paragraph (5).

(2) DURATION.—Grants awarded under this section shall be for a period of 5 years.

(3) ELIGIBLE ENTITY.—In this section, the term “eligible entity” means—

(A) a State educational agency, as defined in section 8101 of the Elementary and Secondary Education of 1965 (20 U.S.C. 7801);

(B) a local educational agency, as defined in section 8101 of the Elementary and Secondary Education of 1965 (20 U.S.C. 7801);

(C) a Tribe or Tribal organization, as defined in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304);

(D) a State or local department of health;

(E) a State or local department of education;

(F) an educational service agency, as defined in section 8101 of the Elementary and Secondary Education of 1965 (20 U.S.C. 7801);;

(G) a nonprofit institution of higher education, as defined in section 101 of the Higher Education Act of 1965 (20 U.S.C. 1001);

(H) a national or statewide nonprofit organization that has as its primary purpose the improvement of provision of comprehensive sex education through training and effective teaching of comprehensive sex education; or

(I) a consortium of nonprofit organizations that has as its primary purpose the improvement of provision of comprehensive sex education through training and effective teaching of comprehensive sex education.

(4) APPLICATION.—An eligible entity desiring a grant under this subsection shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including an assurance to participate in the evaluation described in subsection (e).

(5) AUTHORIZED ACTIVITIES.—

(A) REQUIRED ACTIVITY.—Each eligible entity receiving a grant under this section shall use grant funds for professional development and training of relevant faculty, school administrators, teachers, and staff, in order to increase effective teaching of comprehensive sex education students.

(B) PERMISSIBLE ACTIVITIES.—Each eligible entity receiving a grant under this section may use grant funds to—

(i) provide research-based training of teachers for comprehensive sex education for adolescents as a means of broadening student knowledge about issues related to human development, healthy relationships, personal skills, and sexual behavior, including abstinence, sexual health, and society and culture;

(ii) support the dissemination of information on effective practices and research findings concerning the teaching of comprehensive sex education;

(iii) support research on—

(I) effective comprehensive sex education teaching practices; and

(II) the development of assessment instruments and strategies to document—

(aa) student understanding of comprehensive sex education; and

(bb) the effects of comprehensive sex education;

(iv) convene national conferences on comprehensive sex education, in order to effectively train teachers in the provision of comprehensive sex education; and

(v) develop and disseminate appropriate research-based materials to foster comprehensive sex education.

(C) SUBGRANTS.—Each eligible entity receiving a grant under this subsection may award subgrants to nonprofit organizations that possess a demonstrated record of providing training to faculty, school administrators, teachers, and staff on comprehensive sex education to—

(i) train teachers in comprehensive sex education;

(ii) support Internet or distance learning related to comprehensive sex education;

(iii) promote rigorous academic standards and assessment techniques to guide and measure student performance in comprehensive sex education;

(iv) encourage replication of best practices and model programs to promote comprehensive sex education;

(v) develop and disseminate effective, research-based comprehensive sex education learning materials;

(vi) develop academic courses on the pedagogy of sex education at institutions of higher education; or

(vii) convene State-based conferences to train teachers in comprehensive sex education and to identify strategies for improvement.

(e) Impact evaluation and reporting.—

(1) MULTI-YEAR EVALUATION.—

(A) IN GENERAL.—Not later than 6 months after the date of the enactment of this Act, the Secretary shall enter into a contract with a nonprofit organization with experience in conducting impact evaluations, to conduct a multi-year evaluation on the impact of the grants under subsections (b), (c), and (d), and to report to Congress and the Secretary on the findings of such evaluation.

(B) EVALUATION.—The evaluation conducted under this subsection shall—

(i) be conducted in a manner consistent with relevant, nationally recognized professional and technical evaluation standards;

(ii) use sound statistical methods and techniques relating to the behavioral sciences, including quasi-experimental designs, inferential statistics, and other methodologies and techniques that allow for conclusions to be reached;

(iii) be carried out by an independent organization that has not received a grant under subsection (b), (c), or (d); and

(iv) be designed to provide information on—

(I) output measures, such as the number of individuals served under the grant and the number of hours of instruction;

(II) outcome measures, including measures relating to—

(aa) the knowledge that individuals participating in the grant program have gained in each of the following age and developmentally appropriate areas—

(AA) growth and development;

(BB) relationship dynamics;

(CC) ways to prevent unintended pregnancy and sexually transmitted infections, including HIV; and

(DD) sexual health;

(bb) the age and developmentally appropriate skills that individuals participating in the grant program have gained regarding—

(AA) negotiation and communication;

(BB) decisionmaking and goal-setting;

(CC) interpersonal skills and healthy relationships; and

(DD) condom use; and

(cc) the behaviors of adolescents participating in the grant program, including data about—

(AA) age of first intercourse;

(BB) condom and contraceptive use at first intercourse;

(CC) recent condom and contraceptive use;

(DD) substance use;

(EE) dating abuse and lifetime history of sexual assault, dating violence, bullying, harassment, stalking; and

(FF) academic performance; and

(III) other measures necessary to evaluate the impact of the grant program.

(C) REPORT.—Not later than 6 years after the date of enactment of this Act, the organization conducting the evaluation under this subsection shall prepare and submit to the appropriate committees of Congress and the Secretary an evaluation report. Such report shall be made publicly available, including on the website of the Department of Health and Human Services.

(2) SECRETARY’S REPORT TO CONGRESS.—Not later than 1 year after the date of the enactment of this Act, and annually thereafter for a period of 5 years, the Secretary shall prepare and submit to the appropriate committees of Congress a report on the activities to provide adolescents and young people with comprehensive sex education and pre-service and in-service teacher training funded under this section. The Secretary’s report to Congress shall include—

(A) a statement of how grants awarded by the Secretary meet the purposes described in subsection (a)(1); and

(B) information about—

(i) the number of eligible entities and institutions of higher education that are receiving grant funds under subsections (b), (c), and (d);

(ii) the specific activities supported by grant funds awarded under subsections (b), (c), and (d);

(iii) the number of adolescents served by grant programs funded under subsection (b);

(iv) the number of young people served by grant programs funded under subsection (c);

(v) the number of faculty, school administrators, teachers, and staff trained under subsection (d); and

(vi) the status of the evaluation required under paragraph (1).

(f) Nondiscrimination.—Programs funded under this section shall not discriminate on the basis of actual or perceived sex, race, color, ethnicity, national origin, disability, sexual orientation, gender identity, or religion. Nothing in this section shall be construed to invalidate or limit rights, remedies, procedures, or legal standards available under any other Federal law or any law of a State or a political subdivision of a State, including the Civil Rights Act of 1964 (42 U.S.C. 2000a et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.), and section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116).

(g) Limitation.—No Federal funds provided under this section may be used for health education programs that—

(1) withhold health-promoting or life-saving information about sexuality-related topics, including HIV;

(2) are medically inaccurate or have been scientifically shown to be ineffective;

(3) promote gender or racial stereotypes;

(4) are insensitive and unresponsive to the needs of sexually active young people;

(5) are insensitive and unresponsive to the needs of pregnant or parenting young people;

(6) are insensitive and unresponsive to the needs of survivors of sexual abuse or assault;

(7) are insensitive and unresponsive to the needs of youth of all physical, developmental, or mental abilities;

(8) are insensitive and unresponsive to individuals with varying gender identities, gender expressions, and sexual orientations; or

(9) are inconsistent with the ethical imperatives of medicine and public health.

(h) Amendments to other laws.—

(1) AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.—Section 2500 of the Public Health Service Act (42 U.S.C. 300ee) is amended by striking subsections (b) through (d) and inserting the following:

“(b) Contents of programs.—All programs of education and information receiving funds under this subchapter shall include information about the potential effects of intravenous substance abuse.”.

(2) AMENDMENTS TO THE ELEMENTARY AND SECONDARY EDUCATION ACT OF 1965.—Section 8526 of the Elementary and Secondary Education Act of (20 U.S.C. 7906) is amended—

(A) by striking paragraph (3);

(B) by redesignating paragraphs (4) and (5) as paragraphs (3) and (4), respectively;

(C) in paragraph (4), by inserting “or” after the semicolon;

(D) in paragraph (5), by striking “; or” and inserting a period; and

(E) by striking paragraph (6).

(i) Definitions.—In this section:

(1) ADOLESCENTS.—The term “adolescents” means individuals who are ages 10 through 19 at the time of commencement of participation in a program supported under this section.

(2) AGE AND DEVELOPMENTALLY APPROPRIATE.—The term “age and developmentally appropriate” means topics, messages, and teaching methods suitable to particular age, age group of children and adolescents, or developmental levels, based on cognitive, emotional, social, and behavioral capacity of most students at that age level.

(3) APPROPRIATE COMMITTEES OF CONGRESS.—The term “appropriate committees of Congress” means the Committee on Health, Education, Labor, and Pensions of the Senate, the Committee on Appropriations of the Senate, the Committee on Energy and Commerce of the House of Representatives, the Committee on Education and the Workforce of the House of Representatives, and the Committee on Appropriations of the House of Representatives.

(4) CHARACTERISTICS OF EFFECTIVE PROGRAMS.—The term “characteristics of effective programs” means the aspects of evidence-based programs, including development, content, and implementation of such programs, that—

(A) have been shown to be effective in terms of increasing knowledge, clarifying values and attitudes, increasing skills, and impacting upon behavior; and

(B) are widely recognized by leading medical and public health agencies to be effective in changing sexual behaviors that lead to sexually transmitted infections, including HIV, unintended pregnancy, and dating violence and sexual assault among young people.

(5) COMPREHENSIVE SEX EDUCATION.—The term “comprehensive sex education” means instructional part of a comprehensive school health education approach which addresses the physical, mental, emotional, and social dimensions of human sexuality; designed to motivate and assist students to maintain and improve their sexual health, prevent disease and reduce sexual health-related risk behaviors; and enable and empower students to develop and demonstrate age and developmentally appropriate sexuality and sexual health-related knowledge, attitudes, skills, and practices.

(6) CONSENT.—The term “consent” means affirmative, conscious, and voluntary agreement to engage in interpersonal, physical, or sexual activity.

(7) CULTURALLY APPROPRIATE.—The term “culturally appropriate” means materials and instruction that respond to culturally diverse individuals, families and communities in an inclusive, respectful and effective manner; including materials and instruction that are inclusive of race, ethnicity, languages, cultural background, religion, sex, gender identity, sexual orientation, and different abilities.

(8) EVIDENCE-BASED.—The term “evidence-based”, when used with respect to sex education instruction, means a sex education program that has been proven through rigorous evaluation to be effective in changing sexual behavior or incorporates elements of other programs that have been proven to be effective in changing sexual behavior.

(9) GENDER EXPRESSION.—The term “gender expression”, when used with respect to a sex education program, means the expression of one’s gender, such as through behavior, clothing, haircut, or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.

(10) GENDER IDENTITY.—Except with respect to subsection (f), the term “gender identity”, when used with respect to a sex education program, means the gender-related identity, appearance, mannerisms, or other gender-related characteristics of an individual, regardless of the individual’s designated sex at birth including a person’s deeply held sense or knowledge of their own gender; such as male, female, both or neither.

(11) INCLUSIVE.—The term “inclusive”, when used with respect to a sex education program, means curriculum that ensures that students from historically marginalized communities are reflected in classroom materials and lessons.

(12) INSTITUTION OF HIGHER EDUCATION.—The term “institution of higher education” has the meaning given the term in section 101 of the Higher Education Act of 1965 (20 U.S.C. 1001).

(13) MEDICALLY ACCURATE AND COMPLETE.—The term “medically accurate and complete”, when used with respect to a sex education program, means that—

(A) the information provided through the program is verified or supported by the weight of research conducted in compliance with accepted scientific methods and is published in peer-reviewed journals, where applicable; or

(B)(i) the program contains information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete; and

(ii) the program does not withhold information about the effectiveness and benefits of correct and consistent use of condoms and other contraceptives.

(14) SECRETARY.—The term “Secretary” means the Secretary of Health and Human Services.

(15) SEXUAL DEVELOPMENT.—The term “sexual development” means the lifelong process of physical, behavioral, cognitive, and emotional growth and change as it relates to an individual’s sexuality and sexual maturation, including puberty, identity development, socio-cultural influences, and sexual behaviors.

(16) SEXUAL ORIENTATION.—Except with respect to subsection (f), the term “sexual orientation”, when used with respect to a sex education program, means an individual’s attraction, including physical or emotional, to the same or different gender.

(17) YOUNG PEOPLE.—The term “young people” means individuals who are ages 10 through 24 at the time of commencement of participation in a program supported under this section.

(j) Funding.—

(1) APPROPRIATION.—For the purpose of carrying out this section, there is appropriated $75,000,000 for each of fiscal years 2019 through 2024. Amounts appropriated under this subsection shall remain available until expended.

(2) RESERVATIONS OF FUNDS.—

(A) The Secretary shall reserve 50 percent of the amount appropriated under paragraph (1) for the purposes of awarding grants for comprehensive sex education for adolescents under subsection (c).

(B) The Secretary shall reserve 25 percent of the amount appropriated under paragraph (1) for the purposes of awarding grants for comprehensive sex education at institutes of higher education under subsection (d).

(C) The Secretary shall reserve 20 percent of the amount appropriated under paragraph (1) for the purposes of awarding grants for pre-service and in-service teacher training under subsection (e).

(D) The Secretary shall reserve 2 percent of the amount appropriated under paragraph (1) for the purpose of carrying out the impact evaluation and reporting required under subsection (a).

(3) SECRETARIAL RESPONSIBILITIES.—The Secretary shall reserve 3 percent of the amount appropriated under paragraph (1) for each fiscal year for expenditures by the Secretary to provide, directly or through a competitive grant process, research, training, and technical assistance, including dissemination of research and information regarding effective and promising practices, providing consultation and resources, and developing resources and materials to support the activities of recipients of grants. In carrying out such functions, the Secretary shall collaborate with a variety of entities that have expertise in adolescent sexual health development, education, and promotion.

(4) REPROGRAMMING OF ABSTINENCE ONLY UNTIL MARRIAGE PROGRAM FUNDING.—The unobligated balance of funds made available to carry out section 510 of the Social Security Act (42 U.S.C. 710) (as in effect on the day before the date of enactment of this Act) are hereby transferred and shall be used by the Secretary to carry out this section. The amounts transferred and made available to carry out this section shall remain available until expended.

(5) REPEAL OF ABSTINENCE ONLY UNTIL MARRIAGE PROGRAM.—Section 510 of the Social Security Act (42 U.S.C. 710 et seq.) is repealed.

SEC. 512. Compassionate assistance for rape emergencies.

(a) Medicare.—

(1) LIMITATION ON PAYMENT.—Section 1866(a)(1) of the Social Security Act (42 U.S.C. 1395cc(a)(1)) is amended—

(A) by moving the indentation of subparagraph (W) 2 ems to the left;

(B) in subparagraph (X)—

(i) by moving the indentation 2 ems to the left; and

(ii) by striking “and” at the end;

(C) in subparagraph (Y), by striking the period at the end and inserting “; and”; and

(D) by inserting after subparagraph (Y) the following new subparagraph:

“(Z) in the case of a hospital or critical access hospital, to adopt and enforce a policy to ensure compliance with the requirements of subsection (l) and to meet the requirements of such subsection.”.

(2) ASSISTANCE TO VICTIMS.—Section 1866 of the Social Security Act (42 U.S.C. 1395cc) is amended by adding at the end the following new subsection:

“(l) Compassionate assistance for rape emergencies.—

“(1) IN GENERAL.—For purposes of section 1866(a)(1)(Z), a hospital meets the requirements of this subsection if the hospital provides each of the services described in paragraph (2) to each individual, whether or not eligible for benefits under this title or under any other form of health insurance, who comes to the hospital on or after January 1, 2019, and—

“(A) who states to hospital personnel that they are victims of sexual assault;

“(B) who is accompanied by an individual who states to hospital personnel that the individual is a victim of sexual assault; or

“(C) whom hospital personnel, during the course of treatment and care for the individual, have reason to believe is a victim of sexual assault.

“(2) REQUIRED SERVICES DESCRIBED.—For purposes of paragraph (1), the services described in this subparagraph are the following:

“(A) Provision of medically and factually accurate and unbiased written and oral information about emergency contraception that—

“(i) is written in clear and concise language;

“(ii) is readily comprehensible;

“(iii) includes an explanation that emergency contraception—

“(I) has been approved by the Food and Drug Administration as an over-the-counter or prescription medication for individuals and is a safe and effective way to prevent pregnancy after unprotected intercourse or contraceptive failure if taken in a timely manner;

“(II) is more effective the sooner it is taken; and

“(III) does not cause an abortion and cannot interrupt an established pregnancy;

“(iv) meets such conditions regarding the provision of such information in languages other than English as the Secretary may establish; and

“(v) is provided without regard to the ability of the individual or their family to pay costs associated with the provision of such information to the individual.

“(B) Immediate offer to provide emergency contraception to the individual at the hospital and, in the case that the individual accepts such offer, immediate provision to the individual of such contraception on the same day it is requested without regard to the inability of the individual or their family to pay costs associated with the offer and provision of such contraception.

“(C) Development and implementation of a written policy to ensure that an individual is present at the hospital, or on-call, who—

“(i) has authority to dispense or prescribe emergency contraception, independently, or under a protocol prepared by a physician for the administration of emergency contraception at the hospital to a victim of sexual assault; and

“(ii) is trained to comply with the requirements of this section.

“(D) Provision of medically and factually accurate and unbiased written and oral information and counseling about post-exposure prophylaxis (PEP) protocol for the prevention of HIV.

“(E) Immediately offer to begin PEP to the individual at the hospital except in cases where the medical professional’s best judgement is that further evaluation is required or that such a regimen will be substantially detrimental to the individual’s health. Such provision shall be offered regardless of the individual’s ability to pay. Hospitals shall be responsible for ensuring adequate supply of PEP medications to provide to patients.

“(3) DEFINITIONS.—For purposes of this paragraph:

“(A) The term ‘emergency contraception’ means a drug or device (as such terms are defined in section 201 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321)) or a drug regimen that—

“(i) is used postcoitally;

“(ii) prevents pregnancy primarily by preventing or delaying ovulation, and does not terminate an established pregnancy; and

“(iii) is approved by the Food and Drug Administration.

“(B) The term ‘hospital’ includes a critical access hospital, as defined in section 1861(mm)(1).

“(C) The term ‘sexual assault’ means coitus in which the individual involved does not consent or lacks the legal capacity to consent.”.

(b) Limitation on payment under Medicaid.—Section 1903(i) of the Social Security Act (42 U.S.C. 1396b(i)) is amended by inserting after paragraph (11) the following new paragraph:

“(12) with respect to any amount expended for care or services furnished under the plan by a hospital on or after January 1, 2019, unless such hospital meets the requirements specified in section 1866(l) for purposes of title XVIII.”.

SEC. 513. Access to birth control duties of pharmacies to ensure provision of FDA-approved contraception.

Part B of title II of the Public Health Service Act (42 U.S.C. 238 et seq.) is amended by adding at the end the following:

“SEC. 249. Duties of pharmacies to ensure provision of FDA-approved contraception.

“(a) In general.—Subject to subsection (c), a pharmacy that receives Food and Drug Administration-approved drugs or devices in interstate commerce shall maintain compliance with the following:

“(1) If a customer requests a contraceptive, including emergency contraception, that is in stock, the pharmacy shall ensure that the contraceptive is provided to the customer—

“(A) without delay;

“(B) without regard to the customer’s age, gender, gender identity, or sexual orientation;

“(C) without a requirement that identification be presented; and

“(D) despite any conflicts of employees to filling a prescription and dispensing a particular prescription drug or device due to sincerely held moral, philosophical, or religious beliefs.

“(2) If a customer requests a contraceptive that is not in stock and the pharmacy in the normal course of business stocks contraception, the pharmacy shall immediately inform the customer that the contraceptive is not in stock and without delay offer the customer the following options:

“(A) If the customer prefers to obtain the contraceptive through a referral or transfer, the pharmacy shall—

“(i) locate a pharmacy of the customer’s choice or the closest pharmacy confirmed to have the contraceptive in stock; and

“(ii) refer the customer or transfer the prescription to that pharmacy.

“(B) If the customer prefers for the pharmacy to order the contraceptive, the pharmacy shall obtain the contraceptive under the pharmacy’s standard procedure for expedited ordering of medication and notify the customer when the contraceptive arrives.

“(3) The pharmacy shall ensure that its employees do not—

“(A) intimidate, threaten, or harass customers in the delivery of services relating to a request for contraception;

“(B) interfere with or obstruct the delivery of services relating to a request for contraception;

“(C) intentionally misrepresent or deceive customers about the availability of contraception or its mechanism of action;

“(D) breach medical confidentiality with respect to a request for contraception or threaten to breach such confidentiality; or

“(E) refuse to return a valid, lawful prescription for contraception upon customer request.

“(b) Contraceptives not ordinarily stocked.—Nothing in subsection (a)(2) shall be construed to require any pharmacy to comply with such subsection if the pharmacy does not ordinarily stock contraceptives in the normal course of business.

“(c) Refusals pursuant to standard pharmacy practice.—This section does not prohibit a pharmacy from refusing to provide a contraceptive to a customer in accordance with any of the following:

“(1) If it is unlawful to dispense the contraceptive to the customer without a valid, lawful prescription and no such prescription is presented.

“(2) If the customer is unable to pay for the contraceptive.

“(3) If the employee of the pharmacy refuses to provide the contraceptive on the basis of a professional clinical judgment.

“(d) Rule of construction.—Nothing in this section shall be construed to invalidate or limit rights, remedies, procedures, or legal standards under title VII of the Civil Rights Act of 1964.

“(e) Preemption.—This section does not preempt any provision of State law or any professional obligation made applicable by a State board or other entity responsible for licensing or discipline of pharmacies or pharmacists, to the extent that such State law or professional obligation provides protections for customers that are greater than the protections provided by this section.

“(f) Enforcement.—

“(1) CIVIL PENALTY.—A pharmacy that violates a requirement of subsection (a) is liable to the United States for a civil penalty in an amount not exceeding $1,000 per day of violation, not to exceed $100,000 for all violations adjudicated in a single proceeding.

“(2) PRIVATE CAUSE OF ACTION.—Any person aggrieved as a result of a violation of a requirement of subsection (a) may, in any court of competent jurisdiction, commence a civil action against the pharmacy involved to obtain appropriate relief, including actual and punitive damages, injunctive relief, and a reasonable attorney’s fee and cost.

“(3) LIMITATIONS.—A civil action under paragraph (1) or (2) may not be commenced against a pharmacy after the expiration of the 5-year period beginning on the date on which the pharmacy allegedly engaged in the violation involved.

“(g) Definitions.—In this section:

“(1) CONTRACEPTION.—The term ‘contraception’ or ‘contraceptive’ means any drug or device approved by the Food and Drug Administration to prevent pregnancy.

“(2) EMPLOYEE.—The term ‘employee’ means a person hired, by contract or any other form of an agreement, by a pharmacy.

“(3) PHARMACY.—The term ‘pharmacy’ means an entity that—

“(A) is authorized by a State to engage in the business of selling prescription drugs at retail; and

“(B) employs one or more employees.

“(4) PRODUCT.—The term ‘product’ means a Food and Drug Administration-approved drug or device.

“(5) PROFESSIONAL CLINICAL JUDGMENT.—The term ‘professional clinical judgment’ means the use of professional knowledge and skills to form a clinical judgment, in accordance with prevailing medical standards.

“(6) WITHOUT DELAY.—The term ‘without delay’, with respect to a pharmacy providing, providing a referral for, or ordering contraception, or transferring the prescription for contraception, means within the usual and customary timeframe at the pharmacy for providing, providing a referral for, or ordering other products, or transferring the prescription for other products, respectively.

“(h) Effective date.—This section shall take effect on the 31st day after the date of the enactment of this section, without regard to whether the Secretary has issued any guidance or final rule regarding this section.”.

SEC. 514. Additional focus area for the Office on Women’s Health.

Section 229(b) of the Public Health Service Act (42 U.S.C. 237a(b)) is amended—

(1) in paragraph (6), at the end, by striking “and”;

(2) in paragraph (7), at the end, by striking the period and inserting a semicolon; and

(3) by adding at the end the following new paragraph:

“(8) facilitate policymakers, health system leaders and providers, consumers, and other stakeholders in understanding optimal maternity care and support for the provision of such care, including the priorities of—

“(A) protecting, promoting, and supporting the innate capacities of childbearing individuals and their newborns for childbirth, breast­feed­ing, and attachment;

“(B) using obstetric interventions only when such interventions are supported by strong, high-quality evidence, and minimizing overuse of maternity practices that have been shown to have benefit in limited situations and that can expose women, infants, or both to risk of harm if used routinely and indiscriminately, including continuous electronic fetal monitoring, labor induction, epidural analgesia, primary cesarean section, and routine repeat cesarean birth;

“(C) reliably incorporating noninvasive, evidence-based practices that have documented correlation with considerable improvement in outcomes with no detrimental side effects, such as smoking cessation programs in pregnancy and proven models of group prenatal care that integrate health assessment, education, and support into a unified program and supporting evidence-based breastfeeding promotion efforts with respect for a breastfeeding individual’s personal decisionmaking;

“(D) a shared understanding of the qualifications of licensed providers of maternity care and the best evidence about the safety, satisfaction, outcomes, and costs of their care, and appropriate deployment of such caregivers within the maternity care workforce to address the needs of childbearing individuals and newborns and the growing shortage of maternity caregivers;

“(E) a shared understanding of the results of the best available research comparing hospital, birth center, and planned home births, including information about each setting’s safety, satisfaction, outcomes, and costs; and

“(F) high-quality, evidence-based childbirth education that promotes a natural, healthy, and safe approach to pregnancy, childbirth, and early parenting; is taught by certified educators, peer counselors, and health professionals; and promotes informed decisionmaking by childbearing individual;”.

SEC. 515. Interagency coordinating committee on the promotion of optimal maternity outcomes.

(a) In general.—Part A of title II of the Public Health Service Act (42 U.S.C. 202 et seq.) is amended by adding at the end the following:

“SEC. 229A. Interagency coordinating committee on the promotion of optimal maternity outcomes.

“(a) In general.—The Secretary, acting through the Deputy Assistant Secretary for Women’s Health under section 229 and in collaboration with the Federal officials specified in subsection (b), shall establish the Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes (referred to in this section as the ‘ICCPOM’).

“(b) Other agencies.—The officials specified in this subsection are the Secretary of Labor, the Secretary of Defense, the Secretary of Veterans Affairs, the Surgeon General, the Director of the Centers for Disease Control and Prevention, the Administrator of the Health Resources and Services Administration, the Administrator of the Centers for Medicare & Medicaid Services, the Director of the Indian Health Service, the Administrator of the Substance Abuse and Mental Health Services Administration, the Director of the National Institute on Child Health and Development, the Director of the Agency for Healthcare Research and Quality, the Assistant Secretary for Children and Families, the Deputy Assistant Secretary for Minority Health, the Director of the Office of Personnel Management, and such other Federal officials as the Secretary of Health and Human Services determines to be appropriate.

“(c) Chair.—The Deputy Assistant Secretary for Women’s Health shall serve as the chair of the ICCPOM.

“(d) Duties.—The ICCPOM shall guide policy and program development across the Federal Government with respect to promotion of optimal maternity care, provided, however, that nothing in this section shall be construed as transferring regulatory or program authority from an agency to the ICCPOM.

“(e) Consultations.—The ICCPOM shall actively seek the input of, and shall consult with, all appropriate and interested stakeholders, including State health departments, public health research and interest groups, foundations, childbearing individuals and their advocates, and maternity care professional associations and organizations, reflecting racially, ethnically, demographically, and geographically diverse communities.

“(f) Annual report.—

“(1) IN GENERAL.—The Secretary, on behalf of the ICCPOM, shall annually submit to Congress a report that summarizes—

“(A) all programs and policies of Federal agencies (including the Medicare Program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act) designed to promote optimal maternity care, focusing particularly on programs and policies that support the adoption of evidence based maternity care, as defined by timely, scientifically sound systematic reviews;

“(B) all programs and policies of Federal agencies (including the Medicare Program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act) designed to address the problems of maternal mortality and morbidity, infant mortality, prematurity, and low birth weight, including such programs and policies designed to address racial and ethnic disparities with respect to each of such problems;

“(C) the extent of progress in reducing maternal mortality and infant mortality, low birth weight, and prematurity at State and national levels; and

“(D) such other information regarding optimal maternity care as the Secretary determines to be appropriate.

The information specified in subparagraph (C) shall be included in each such report in a manner that disaggregates such information by race, ethnicity, and indigenous status in order to determine the extent of progress in reducing racial and ethnic disparities and disparities related to indigenous status.

“(2) CERTAIN INFORMATION.—Each report under paragraph (1) shall include information (disaggregated by race, ethnicity, and indigenous status, as applicable) on the following rates and costs by State:

“(A) The rate of primary cesarean deliveries and repeat cesarean deliveries.

“(B) The rate of vaginal births after cesarean.

“(C) The rate of vaginal breech births.

“(D) The rate of induction of labor.

“(E) The rate of freestanding birth center births.

“(F) The rate of planned and unplanned home birth.

“(G) The rate of attended births by provider, including by an obstetrician-gynecologist, family practice physician, obstetrician-gynecologist physician assistant, certified nurse-midwife, certified midwife, and certified professional midwife.

“(H) The cost of maternity care disaggregated by place of birth and provider of care, including—

“(i) uncomplicated vaginal birth;

“(ii) complicated vaginal birth;

“(iii) uncomplicated cesarean birth; and

“(iv) complicated cesarean birth.

“(g) Authorization of appropriations.—There is authorized to be appropriated, in addition to amounts authorized to be appropriated under section 229(e), to carry out this section $1,000,000 for each of the fiscal years 2019 through 2023.”.

(b) Conforming amendments.—

(1) INCLUSION AS DUTY OF HHS OFFICE ON WOMEN’S HEALTH.—Section 229(b) of such Act (42 U.S.C. 237a(b)), as amended by section 514, is further amended by adding at the end the following new paragraph:

“(9) establish the Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes in accordance with section 229A; and”.

(2) TREATMENT OF BIENNIAL REPORTS.—Section 229(d) of such Act (42 U.S.C. 237a(d)) is amended by inserting “(other than under subsection (b)(9))” after “under this section”.

SEC. 516. Consumer education campaign.

Section 229(b) of the Public Health Service Act (42 U.S.C. 237a(b)), as amended by sections 514 and 515, is further amended by adding at the end the following:

“(10) not later than one year after the date of the enactment of the Health Equity and Accountability Act of 2018, develop and implement a 4-year culturally and linguistically appropriate multimedia consumer education campaign that is designed to promote understanding and acceptance of evidence-based maternity practices and models of care for optimal maternity outcomes among individuals of childbearing ages and families of such individuals and that—

“(A) highlights the importance of protecting, promoting, and supporting the innate capacities of childbearing individuals and their newborns for childbirth, breastfeeding, and attachment;

“(B) promotes understanding of the importance of using obstetric interventions when medically necessary and when supported by strong, high-quality evidence;

“(C) highlights the widespread overuse of maternity practices that have been shown to have benefit when used appropriately in situations of medical necessity, but which can expose pregnant individuals, infants, or both to risk of harm if used routinely and indiscriminately, including continuous fetal monitoring, labor induction, epidural anesthesia, elective primary cesarean section, and repeat cesarean delivery;

“(D) emphasizes the noninvasive maternity practices that have strong proven correlation or may be associated with considerable improvement in outcomes with no detrimental side effects, and are significantly underused in the United States, including smoking cessation programs in pregnancy, group model prenatal care, continuous labor support, nonsupine positions for birth, and external version to turn breech babies at term;

“(E) educates consumers about the qualifications of licensed providers of maternity care and the best evidence about their safety, satisfaction, outcomes, and costs;

“(F) informs consumers about the best available research comparing birth center births, planned home births, and hospital births, including information about each setting’s safety, satisfaction, outcomes, and costs;

“(G) fosters participation in high-quality, evidence-based childbirth education that promotes a natural, healthy, and safe approach to pregnancy, childbirth, and early parenting; is taught by certified educators, peer counselors, and health professionals; and promotes informed decisionmaking by childbearing individuals; and

“(H) is pilot tested for consumer comprehension, cultural sensitivity, and acceptance of the messages across geographically, racially, ethnically, and linguistically diverse populations.”.

SEC. 517. Bibliographic database of systematic reviews for care of childbearing individuals and newborns.

(a) In general.—Not later than one year after the date of the enactment of this Act, the Secretary of Health and Human Services, through the Agency for Healthcare Research and Quality, shall—

(1) make publicly available an online bibliographic database identifying systematic reviews, including an explanation of the level and quality of evidence, for care of childbearing individuals and newborns; and

(2) initiate regular updates that incorporate newly issued and updated systematic reviews.

(b) Sources.—To aim for a comprehensive inventory of systematic reviews relevant to maternal and newborn care, the database shall identify reviews from diverse sources, including—

(1) scientific peer-reviewed journals;

(2) databases, including Cochrane Database of Systematic Reviews, Clinical Evidence, and Database of Abstracts of Reviews of Effects; and

(3) Internet Websites of agencies and organizations throughout the world that produce such systematic reviews.

(c) Features.—The database shall—

(1) provide bibliographic citations for each record within the database, and for each such citation include an explanation of the level and quality of evidence;

(2) include abstracts, as available;

(3) provide reference to companion documents as may exist for each review, such as evidence tables and guidelines or consumer educational materials developed from the review;

(4) provide links to the source of the full review and to any companion documents;

(5) provide links to the source of a previous version or update of the review;

(6) be searchable by intervention or other topic of the review, reported outcomes, author, title, and source; and

(7) offer to users periodic electronic notification of database updates relating to users’ topics of interest.

(d) Outreach.—Not later than the first date the database is made publicly available and periodically thereafter, the Secretary of Health and Human Services shall publicize the availability, features, and uses of the database under this section to the stakeholders described in subsection (e).

(e) Consultation.—For purposes of developing the database under this section and maintaining and updating such database, the Secretary of Health and Human Services shall convene and consult with an advisory committee composed of relevant stakeholders, including—

(1) Federal Medicaid administrators and State agencies administrating State plans under title XIX of the Social Security Act pursuant to section 1902(a)(5) of such Act (42 U.S.C. 1396a(a)(5));

(2) providers of maternity and newborn care from both academic and community-based settings, including obstetrician-gynecologists, family physicians, certified nurse midwives, certified midwives, certified professional midwives, physician assistants, perinatal nurses, pediatricians, and nurse practitioners;

(3) maternal-fetal medicine specialists;

(4) neonatologists;

(5) childbearing individuals and advocates for such individuals, including childbirth educators certified by a nationally accredited program, representing communities that are diverse in terms of race, ethnicity, indigenous status, and geographic area;

(6) employers and purchasers;

(7) health facility and system leaders, including both hospital and birth center facilities;

(8) journalists; and

(9) bibliographic informatics specialists.

(f) Authorization of appropriations.—There is authorized to be appropriated $2,500,000 for each of the fiscal years 2019 through 2021 for the purpose of developing the database and such sums as may be necessary for each subsequent fiscal year for updating the database and providing outreach and notification to users, as described in this section.

SEC. 518. Maternity care health professional shortage areas.

Section 332 of the Public Health Service Act (42 U.S.C. 254e) is amended by adding at the end the following:

“(k)(1) The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall designate maternity care health professional shortage areas in the States, publish a descriptive list of the area’s population groups, medical facilities, and other public facilities so designated, and at least annually review and, as necessary, revise such designations.

“(2) For purposes of paragraph (1), a complete descriptive list shall be published in the Federal Register not later than one year after the date of the enactment of the Health Equity and Accountability Act of 2018 and annually thereafter.

“(3) The provisions of subsections (b), (c), (e), (f), (g), (h), (i), and (j) (other than (j)(1)(B)) of this section shall apply to the designation of a maternity care health professional shortage area in a similar manner and extent as such provisions apply to the designation of health professional shortage areas, except in applying subsection (b)(3), the reference in such subsection to ‘physicians’ shall be deemed to be a reference to nationally certified and State licensed obstetricians, family practice physicians who practice full-scope maternity care, certified nurse midwives, certified midwives, certified professional midwives, and physician’s assistants who practice full scope maternity care.

“(4) For purposes of this subsection, the term ‘maternity care health professional shortage area’ means—

“(A) an area in an urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational area for the delivery of health services) which the Secretary determines has a shortage of providers of maternity care health services including those referenced in paragraph (3) or an urban or rural area that the Secretary determines has lost a significant number of such providers during the 10-year period beginning with 2004 or has no obstetrical providers licensed to provide operative obstetrical services;

“(B) an area in an urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational area for the delivery of health services) which the Secretary determines has a shortage of hospital or labor and delivery units, hospital birth center units, or freestanding birth centers or an area that lost a significant number of these units during the 10-year period beginning with 2004; or

“(C) a population group which the Secretary determines has such a shortage of providers or facilities.”.

SEC. 519. Expansion of CDC prevention research centers program to include centers on optimal maternity outcomes.

(a) In general.—Not later than one year after the date of the enactment of this Act, the Secretary of Health and Human Services, shall support the establishment of additional Prevention Research Centers under the Prevention Research Center Program administered by the Centers for Disease Control and Prevention. Such additional centers shall each be known as a Center for Excellence on Optimal Maternity Outcomes.

(b) Research.—Each Center for Excellence on Optimal Maternity Outcomes shall—

(1) conduct at least one focused program of research to improve maternity outcomes, including the reduction of cesarean birth rates, elective inductions, prematurity rates, and low birth weight rates within an underserved population that has a disproportionately large burden of suboptimal maternity outcomes, including maternal mortality and morbidity, infant mortality, prematurity, or low birth weight;

(2) work with partners on special interest projects, as specified by the Centers for Disease Control and Prevention and other relevant agencies within the Department of Health and Human Services, and on projects funded by other sources; and

(3) involve a minimum of two distinct birth setting models, such as a hospital labor and delivery model and freestanding birth center model; or a hospital labor and delivery model and planned home birth model.

(c) Interdisciplinary providers.—Each Center for Excellence on Optimal Maternity Outcomes shall include the following interdisciplinary providers of maternity care:

(1) Obstetrician-gynecologists.

(2) At least two of the following providers:

(A) Family practice physicians.

(B) Nurse practitioners.

(C) Physician assistants.

(D) Certified professional midwives.

(d) Services.—Research conducted by each Center for Excellence on Optimal Maternity Outcomes shall include at least 2 (and preferably more) of the following supportive provider services:

(1) Mental health.

(2) Doula labor support.

(3) Nutrition education.

(4) Childbirth education.

(5) Social work.

(6) Physical therapy or occupation therapy.

(7) Substance abuse services.

(8) Home visiting.

(e) Coordination.—The programs of research at each of the two Centers of Excellence on Optimal Maternity Outcomes shall compliment and not replicate the work of the other.

(f) Authorization of appropriations.—There is authorized to be appropriated to carry out this section $2,000,000 for each of the fiscal years 2019 through 2023.

SEC. 520. Expanding models allowed to be tested by Center for Medicare & Medicaid Innovation to include maternity care models.

Section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 1315a(b)(2)(B)) is amended by adding at the end the following new clause:

“(xxv) Promoting evidence-based models of care that have been associated with reductions in maternal and infant health disparities, including incorporating the use of doula and promotoras support for pregnant and childbearing individuals into evidence-based models of prenatal care, labor and delivery, and postpartum care, and supporting the appropriate use of out-of-hospital birth models, including births at home and in freestanding birth centers.”.

SEC. 521. Development of interprofessional maternity care educational models and tools.

(a) In general.—Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services, acting in conjunction with the Administrator of Health Resources and Services Administration, shall convene, for a 1-year period, an Interprofessional Maternity Provider Education Commission to discuss and make recommendations for—

(1) a consensus standard physiologic maternity care curriculum that takes into account the core competencies for basic midwifery practice such as those developed by the American College of Nurse Midwives and the North American Registry of Midwives, and the educational objectives for physicians practicing in obstetrics and gynecology as determined by the Council on Resident Education in Obstetrics and Gynecology;

(2) suggestions for multidisciplinary use of the consensus physiologic curriculum;

(3) strategies to integrate and coordinate education across maternity care disciplines, including recommendations to increase medical and midwifery student exposure to out-of-hospital birth; and

(4) pilot demonstrations of interprofessional educational models.

(b) Participants.—The Commission shall include maternity care educators, curriculum developers, service leaders, certification leaders, and accreditation leaders from the various professions that provide maternity care in the United States. Such professions shall include obstetrician gynecologists, certified nurse midwives or certified midwives, family practice physicians, nurse practitioners, physician assistants, certified professional midwives, and perinatal nurses. Additionally, the Commission shall include representation from maternity care consumer advocates.

(c) Curriculum.—The consensus standard physiologic maternity care curriculum described in subsection (a)(1) shall—

(1) have a public health focus with a foundation in health promotion and disease prevention;

(2) foster physiologic childbearing and woman and family centered care;

(3) integrate strategies to reduce maternal and infant morbidity and mortality;

(4) incorporate recommendations to ensure respectful, safe, and seamless consultation, referral, transport, and transfer of care when necessary; and

(5) include cultural sensitivity and strategies to decrease disparities in maternity outcomes.

(d) Report.—Not later than 6 months after the final meeting of the Commission, the Secretary of Health and Human Services shall—

(1) submit to Congress a report containing the recommendations made by the Commission under this section; and

(2) make such report publicly available.

(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section $1,000,000 for each of the fiscal years 2019 and 2020, and such sums as are necessary for each of the fiscal years 2021 through 2023.

SEC. 522. Including services furnished by certain students, interns, and residents supervised by certified nurse midwives within inpatient hospital services under Medicare.

(a) In general.—Section 1861(b) of the Social Security Act (42 U.S.C. 1395x(b)) is amended—

(1) in paragraph (6), by striking “; or” at the end and inserting “, or in the case of services in a hospital or osteopathic hospital by a student midwife or an intern or resident-in-training under a teaching program previously described in this paragraph who is in the field of obstetrics and gynecology, if such student midwife, intern, or resident-in-training is supervised by a certified nurse-midwife to the extent permitted under applicable State law and as may be authorized by the hospital;”;

(2) in paragraph (7), by striking the period at the end and inserting “; or”; and

(3) by adding at the end the following new paragraph:

“(8) a certified nurse-midwife where the hospital has a teaching program approved as specified in paragraph (6), if—

“(A) the hospital elects to receive any payment due under this title for reasonable costs of such services; and

“(B) all certified nurse-midwives in such hospital agree not to bill charges for professional services rendered in such hospital to individuals covered under the insurance program established by this title.”.

(b) Effective date.—The amendments made by subsection (a) shall apply to services furnished on or after the date of the enactment of this Act.

SEC. 523. Grants to professional organizations to increase diversity in maternal, reproductive, and sexual health professionals.

(a) In general.—The Secretary of Health and Human Services, through the Administrator of the Health Resources and Services Administration, shall carry out a grant program under which the Secretary may make to eligible health professional organizations—

(1) for fiscal year 2019, planning grants described in subsection (b); and

(2) for the subsequent 4-year period, implementation grants described in subsection (c).

(b) Planning grants.—

(1) IN GENERAL.—Planning grants described in this subsection are grants for the following purposes:

(A) To collect data and identify any workforce disparities, with respect to a health profession, at each of the following areas along the health professional continuum:

(i) Pipeline availability with respect to students at the high school and college or university levels considering and working toward entrance in the profession.

(ii) Entrance into the training program for the profession.

(iii) Graduation from such training program.

(iv) Entrance into practice.

(v) Retention in practice for more than a 5-year period.

(B) To develop one or more strategies to address the workforce disparities within the health profession, as identified under (and in response to the findings pursuant to) subparagraph (A).

(2) APPLICATION.—To be eligible to receive a grant under this subsection, an eligible health professional organization shall submit to the Secretary of Health and Human Services an application in such form and manner and containing such information as specified by the Secretary.

(3) AMOUNT.—Each grant awarded under this subsection shall be for an amount not to exceed $300,000.

(4) REPORT.—Each recipient of a grant under this subsection shall submit to the Secretary of Health and Human Services a report containing—

(A) information on the extent and distribution of workforce disparities identified through the grant; and

(B) reasonable objectives and strategies developed to address such disparities within a 5-, 10-, and 25-year period.

(c) Implementation grants.—

(1) IN GENERAL.—Implementation grants described in this subsection are grants to implement one or more of the strategies developed pursuant to a planning grant awarded under subsection (b).

(2) APPLICATION.—To be eligible to receive a grant under this subsection, an eligible health professional organization shall submit to the Secretary of Health and Human Services an application in such form and manner as specified by the Secretary. Each such application shall contain information on the capability of the organization to carry out a strategy described in paragraph (1), involvement of partners or coalitions, plans for developing sustainability of the efforts after the culmination of the grant cycle, and any other information specified by the Secretary.

(3) AMOUNT.—Each grant awarded under this subsection shall be for an amount not to exceed $500,000 each year during the 4-year period of the grant.

(4) REPORTS.—For each of the first 3 years for which an eligible health professional organization is awarded a grant under this subsection, the organization shall submit to the Secretary of Health and Human Services a report on the activities carried out by such organization through the grant during such year and objectives for the subsequent year. For the fourth year for which an eligible health professional organization is awarded a grant under this subsection, the organization shall submit to the Secretary a report that includes an analysis of all the activities carried out by the organization through the grant and a detailed plan for continuation of out-reach efforts.

(d) Eligible health professional organization defined.—For purposes of this section, the term “eligible health professional organization” means a professional organization representing obstetrician-gy­ne­col­o­gists, certified nurse midwives, certified midwives, family practice physicians, nurse practitioners whose scope of practice includes maternity or sexual and reproductive health care, physician assistants whose scope of practice includes obstetrical or sexual and reproductive health care, or certified professional midwives adolescent medicine specialists, and pediatricians who provide sexual and reproductive health care.

(e) Authorization of appropriations.—There is authorized to be appropriated to carry out this section $2,000,000 for fiscal year 2019 and $3,000,000 for each of the fiscal years 2020 through 2023.

SEC. 524. Interagency update to the quality family planning guidelines.

(a) In general.—Not later than six months after the date of enactment of this Act, the Director of the Centers for Disease Control and Prevention and the Office of Population Affairs shall review and expand the 2014 Quality Family Planning Guidelines to address—

(1) health disparities; and

(2) the importance of patient-directed contraceptive decisionmaking.

(b) Consultation.—In carrying out subsection (a), the Director of the Centers for Disease Control and Prevention and the Office of Population Affairs shall convene a meeting, and solicit the views of, stakeholders including experts on health disparities, experts on reproductive coercion, representatives of provider organizations, patient advocates, reproductive justice organizations, organizations that represent racial and ethnic minority communities, organizations that represent people with disabilities, organizations that represent LGBTQ persons, and organizations that represent people with limited-English proficiency.

SEC. 525. Dissemination of the quality family planning guidelines.

(a) In general.—Not later than six months after the date of enactment of this Act, the Secretary of Health and Human Services and the Director of the Centers for Disease Control and Prevention shall—

(1) develop a plan for outreach to publicly funded health care providers, including federally qualified health centers and branches of the Indian Health Service, about the quality family planning guidelines referred to in section 524; and

(2) award grants to eligible entities to implement these guidelines for all patients seeking family planning services.

(b) Definition.—In this section, the term “eligible entity” means a publicly funded health care provider that serves persons of reproductive age.

subtitle BPregnancy Screening

SEC. 531. Pregnancy intention screening initiative demonstration program.

Part P of title III of the Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding at the end the following:

“SEC. 399V–7. Pregnancy intention screening initiative demonstration program.

“(a) Program establishment.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish a demonstration program to facilitate the clinical adoption of pregnancy intention screening initiatives by health care providers.

“(b) Grants.—The Secretary may carry out the demonstration program through awarding grants to eligible entities to implement pregnancy intention screening initiatives, collect data, and evaluate such initiatives.

“(c) Eligible Entities.—

“(1) IN GENERAL.—An eligible entity under this section is an entity described in paragraph (2) that provides non-directive, comprehensive, medically accurate information.

“(2) ENTITIES DESCRIBED.—For purposes of paragraph (1), an entity described in this paragraph is a community-based organization, voluntary health organization, public health department, community health center, or other interested public or private health care provider or organization.

“(d) Pregnancy intention screening initiative.—For purposes of this section, the term ‘pregnancy intention screening initiative’ means any initiative by a health care provider to routinely screen women with respect to their pregnancy intentions and goals to either prevent unintended pregnancies or improve the likelihood of healthy pregnancies, in order to better provide health care that meets the contraceptive or pre-pregnancy needs of such women.

“(e) Evaluation.—

“(1) IN GENERAL.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall, by grant or contract, and after consultation as described in paragraph (2), conduct an evaluation of the demonstration program, with respect to pregnancy intention screening initiatives, conducted under this section. The evaluation shall include:

“(A) Assessment of the implementation of pregnancy intention screening protocols among a diverse group of patients and providers, including collecting data on the experiences and outcomes for diverse patient populations in a variety of clinical settings.

“(B) Analysis of outcome measures that will facilitate effective and widespread adoption of such protocols by health care providers for inquiring about and responding to pregnancy intentions of women with both contraceptive and pre-pregnancy care.

“(C) Consideration of health disparities among the population served.

“(D) Assessment of the equitable and voluntary application of such initiatives to minority and medically underserved communities.

“(E) Assessment of the training, capacity, and ongoing technical assistance needed for providers to effectively implement such pregnancy intention screening protocols.

“(F) Assessment of whether referral systems for selected protocols follow evidence-based standards that ensure access to comprehensive health services and appropriate follow-up care.

“(2) INDEPENDENT, EXPERT ADVISORY PANEL.—In conducting the evaluation under paragraph (1), the Director of the Centers for Disease Control and Prevention shall consult with physicians, physician assistants, and nurses who specialize in women’s health, and other experts in clinical practice, program evaluation, and research.

“(3) REPORT.—Not later than one year after the last day of the demonstration program under this section, the Director of the Centers for Disease Control and Prevention shall submit to Congress a report on the results of the evaluation conducted under paragraph (1) and shall make the report publicly available.

“(f) Funding.—

“(1) AUTHORIZATION OF APPROPRIATIONS.—To carry out this section, there is authorized to be appropriated $5,000,000 for each of fiscal years 2019 through 2021.

“(2) LIMITATION.—Not more than 25 percent of funds appropriated to carry out this section pursuant to paragraph (1) for a fiscal year may be used for purposes of the evaluation under subsection (e).”.

TITLE VIMental health

SEC. 601. Mental health findings.

Congress finds the following:

(1) Despite the existence of effective treatments, disparities lie in the availability, accessibility, and quality of mental health services for racial and ethnic minorities.

(2) These disparities have powerful significance for minority groups and for society as a whole.

(3) Racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity.

(4) The foremost barriers include the cost of care, societal stigma, and the fragmented organization of services.

(5) African-American attitudes toward mental illness are another barrier to seeking mental health care.

(6) Mental illness retains considerable stigma, and seeking treatment is not always encouraged.

(7) Mental illness is highly stigmatizing in many Asian cultures.

(8) Addressing mental health stigma in communities will help increase utilization of mental health services and reduce the burden of mental illness.

SEC. 602. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES, MENTAL HEALTH COUNSELOR SERVICES, AND SUBSTANCE ABUSE COUNSELOR SERVICES UNDER PART B OF THE MEDICARE PROGRAM.

(a) Coverage of Services.—

(1) IN GENERAL.—Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 431(c), is amended—

(A) in subparagraph (GG), by striking “and” at the end;

(B) in subparagraph (HH), by inserting “and” at the end; and

(C) by adding at the end the following new subparagraph:

“(II) marriage and family therapist services (as defined in subsection (lll)(1)) and mental health counselor services (as defined in subsection (lll)(3)) and substance abuse counselor services (as defined in subsection (lll)(5));”.

(2) DEFINITIONS.—Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 205(b)(a), 413(a), and 431(c), is amended by adding at the end the following new subsection:

“Marriage And Family Therapist Services; Marriage And Family Therapist; Mental Health Counselor Services; Mental Health Counselor; Substance Abuse Counselor Services; Substance Abuse Counselor

“(lll) (1) The term ‘marriage and family therapist services’ means services performed by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses, which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as an incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.

“(2) The term ‘marriage and family therapist’ means an individual who—

“(A) possesses a master’s or doctoral degree that qualifies for licensure or certification as a marriage and family therapist pursuant to State law;

“(B) after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and

“(C) in the case of an individual performing services in a State that provides for licensure or certification of marriage and family therapists, is licensed or certified as a marriage and family therapist in such State.

“(3) The term ‘mental health counselor services’ means services performed by a mental health counselor (as defined in paragraph (4)) for the diagnosis and treatment of mental illnesses that the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.

“(4) The term ‘mental health counselor’ means an individual who—

“(A) possesses a master’s or doctor’s degree in mental health counseling or a related field;

“(B) after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; and

“(C) in the case of an individual performing services in a State that provides for licensure or certification of mental health counselors or professional counselors, is licensed or certified as a mental health counselor or professional counselor in such State.

“(5) The term ‘substance abuse counselor services’ means services performed by a substance abuse counselor (as defined in paragraph (6)) for the diagnosis and treatment of substance abuse and addiction that the substance abuse counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.

“(6) The term ‘substance abuse counselor’ means an individual who—

“(A) has performed at least 2 years of supervised substance abuse counselor practice;

“(B) in the case of an individual performing services in a State that provides for licensure or certification of substance abuse counselors or professional counselors, is licensed or certified as a substance abuse counselor or professional counselor in such State; or

“(C) is a drug and alcohol counselor as defined in section 40.281 of title 49, Code of Federal Regulations.”.

(3) PROVISION FOR PAYMENT UNDER PART B.—Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended—

(A) by striking “and” at the end of clause (iv); and

(B) by adding at the end the following new clause:

“(v) marriage and family therapist services, mental health counselor services, and substance abuse counselor services; and”.

(4) AMOUNT OF PAYMENT.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 431(c)(3), is amended—

(A) by striking “and” before “(CC)”; and

(B) by inserting before the semicolon at the end the following: “, and (DD) with respect to marriage and family therapist services, mental health counselor services, and substance abuse counselor services under section 1861(s)(2)(II), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under subparagraph (L)”.

(5) EXCLUSION OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL HEALTH COUNSELOR SERVICES FROM SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM.—Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting “marriage and family therapist services (as defined in section 1861(lll)(1)), mental health counselor services (as defined in section 1861(lll)(3)),” after “qualified psychologist services,”.

(6) INCLUSION OF MARRIAGE AND FAMILY THERAPISTS, MENTAL HEALTH COUNSELORS, AND SUBSTANCE ABUSE COUNSELORS AS PRACTITIONERS FOR ASSIGNMENT OF CLAIMS.—Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clauses:

“(vii) A marriage and family therapist (as defined in section 1861(lll)(2)).

“(viii) A mental health counselor (as defined in section 1861(lll)(4)).

“(ix) A substance abuse counselor (as defined in section 1861(lll)(6)).”.

(b) Coverage of Certain Mental Health Services Provided in Certain Settings.—

(1) RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS.—Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking “or by a clinical social worker (as defined in subsection (hh)(1)),” and inserting “, by a clinical social worker (as defined in subsection (hh)(1)), by a marriage and family therapist (as defined in subsection (lll)(2)), or by a mental health counselor (as defined in subsection (lll)(4)), or by a substance abuse counselor (as defined in section 1861 (lll)(6)).”.

(2) HOSPICE PROGRAMS.—Section 1861(dd)(2)(B)(i)(III) of the Social Security Act (42 U.S.C. 1395x(dd)(2)(B)(i)(III)) is amended by inserting “or one marriage and family therapist (as defined in subsection (lll)(2))” after “social worker”.

(c) Authorization of Marriage and Family Therapists To Develop Discharge Plans for Posthospital Services.—Section 1861(ee)(2)(G) of the Social Security Act (42 U.S.C. 1395x(ee)(2)(G)) is amended by inserting “marriage and family therapist (as defined in subsection (lll)(2)),” after “social worker,”.

(d) Effective Date.—The amendments made by this section shall apply with respect to services furnished on or after January 1, 2019.

SEC. 603. Integrated Health Care Demonstration Program.

Part D of title V of the Public Health Service Act (42 U.S.C. 290dd et seq.) is amended by adding at the end the following:

“SEC. 550. Interprofessional health care teams for provision of behavioral health care in primary care settings.

“(a) Grants.—The Secretary, acting through the Assistant Secretary for Mental Health and Substance Abuse, shall award grants to eligible entities for the purpose of establishing interprofessional health care teams that provide behavioral health care.

“(b) Eligible entities.—To be eligible to receive a grant under this section, an entity shall be a Federally qualified health center (as defined in section 1861(aa) of the Social Security Act), rural health clinic, or behavioral health program, serving a high proportion of individuals from racial and ethnic minority groups (as defined in section 1707(g)).

“(c) Scientifically based.—Integrated health care funded through this section shall be scientifically based, taking into consideration the results of the most recent peer-reviewed research available.

“(d) Authorization of appropriations.—To carry out this section, there is authorized to be appropriated $20,000,000 for each of fiscal years 2019 through 2024.”.

SEC. 604. Addressing racial and ethnic minority mental health disparities research gaps.

(a) In general.—Not later than 6 months after the date of the enactment of this Act, the Director of the National Institute on Minority Health and Health Disparities shall enter into an arrangement with the National Academy of Sciences to carry out the activities under subsection (b), or, if the National Academy of Sciences declines to enter into such an arrangement, the Director of the National Institute on Minority Health and Health Disparities, in cooperation with the Agency for Healthcare Research and Quality, shall carry out the activities under subsection (b).

(b) Activities.—The applicable entity under subsection (a) shall—

(1) conduct a study with respect to mental health disparities in racial and ethnic minority groups (as defined in section 1707(g) of the Public Health Service Act (42 U.S.C. 300u–6(g))); and

(2) submit to Congress a report on the results of such study, including—

(A) a compilation of information on the dynamics of mental disorders in such racial and ethnic minority groups; and

(B) a compilation of information on the impact of exposure to community violence, adverse childhood experiences, and other psychological traumas on mental disorders in such racial and minority groups.

SEC. 605. Health professions competencies to address racial and ethnic minority mental health disparities.

(a) In general.—The Secretary of Health and Human Services, acting through the Assistant Secretary for Mental Health and Substance Use, shall award grants to qualified national organizations for the purposes of—

(1) developing, and disseminating to health professional educational programs curricula or core competencies addressing mental health disparities among racial and ethnic minority groups for use in the training of students in the professions of social work, psychology, psychiatry, marriage and family therapy, mental health counseling, and substance abuse counseling; and

(2) certifying community health workers and peer wellness specialists with respect to such curricula and core competencies and integrating and expanding the use of such workers and specialists into health care to address mental health disparities among racial and ethnic minority groups.

(b) Curricula; core competencies.—Organizations receiving funds under subsection (a) may use the funds to engage in the following activities related to the development and dissemination of curricula or core competencies described in subsection (a)(1):

(1) Formation of committees or working groups comprised of experts from accredited health professions schools to identify core competencies relating to mental health disparities among racial and ethnic minority groups.

(2) Planning of workshops in national fora to allow for public input into the educational needs associated with mental health disparities among racial and ethnic minority groups.

(3) Dissemination and promotion of the use of curricula or core competencies in undergraduate and graduate health professions training programs nationwide.

(4) Establishing external stakeholder advisory boards to provide meaningful input into policy and program development and best practices to reduce mental health disparities among racial and ethnic minority groups.

(c) Definitions.—In this section:

(1) QUALIFIED NATIONAL ORGANIZATION.—The term “qualified national organization” means a national organization that focuses on the education of students in programs of social work, psychology, psychiatry, and marriage and family therapy.

(2) RACIAL AND ETHNIC MINORITY GROUP.—The term “racial and ethnic minority group” has the meaning given to such term in section 1707(g) of the Public Health Service Act (42 U.S.C. 300u–6(g)).

(d) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2019 through 2024.

SEC. 606. Geoaccess study.

The Assistant Secretary for Mental Health and Substance Use shall—

(1) conduct a study to—

(A) determine which geographic areas of the United States have shortages of specialty mental health providers; and

(B) assess the preparedness of speciality mental health providers to deliver culturally and linguistically appropriate, affordable, and accessible services; and

(2) submit a report to Congress on the results of such study.

SEC. 607. Asian American, Native Hawaiian, and Pacific Islander behavioral and mental health outreach and education strategies.

Part D of title V of the Public Health Service Act (42 U.S.C. 290dd et seq.), as amended by section 603, is further amended by adding at the end the following new section:

“SEC. 551. Behavioral and mental health outreach and education strategies.

“(a) In general.—The Secretary, acting through the Assistant Secretary for Mental Health and Substance Use, shall, in coordination with advocacy and behavioral and mental health organizations serving populations of Asian American, Native Hawaiian, and Pacific Islander individuals or communities, develop and implement an outreach and education strategy to promote behavioral and mental health and reduce stigma associated with mental health conditions and substance abuse among the Asian American, Native Hawaiian, and Pacific Islander populations. Such strategy shall—

“(1) be designed to—

“(A) meet the diverse cultural and language needs of the various Asian American, Native Hawaiian, and Pacific Islander populations; and

“(B) ensure such strategies are developmentally and age appropriate;

“(2) increase awareness of symptoms of mental illnesses common among such populations, taking into account differences within subgroups, such as gender, gender identity, age, sexual orientation, or ethnicity, of such populations;

“(3) provide information on evidence-based, culturally and linguistically appropriate and adapted interventions and treatments;

“(4) ensure full participation of, and engage, both consumers and community members in the development and implementation of materials; and

“(5) seek to broaden the perspective among both individuals in such communities and stakeholders serving such communities to use a comprehensive public health approach to promoting behavioral health that addresses a holistic view of health by focusing on the intersection between behavioral and physical health.

“(b) Authorization of appropriations.—There is authorized to be appropriated to carry out this section $300,000 for fiscal year 2019.”.

SEC. 608. Mental health in schools.

(a) Purpose.—It is the purpose of this section to—

(1) revise, increase funding for, and expand the scope of the Project AWARE State Educational Agency Grant Program carried out by the Secretary of Health and Human Services, in order to provide access to more comprehensive school-based mental health services and supports;

(2) provide for comprehensive staff development for school and community service personnel working in the school; and

(3) provide for comprehensive training for children with mental health disorders, for parents, siblings, and other family members of such children, and for concerned members of the community.

(b) Technical amendments.—The second part G (relating to services provided through religious organizations) of title V of the Public Health Service Act (42 U.S.C. 290kk et seq.) is amended—

(1) by redesignating such part as part J; and

(2) by redesignating sections 581 through 584 as sections 596 through 596C, respectively.

(c) School-Based mental health and children and violence.—Section 581 of the Public Health Service Act (42 U.S.C. 290hh) is amended to read as follows:

“SEC. 581. School-based mental health and children and violence.

“(a) In general.—The Secretary, in collaboration with the Secretary of Education and in consultation with the Attorney General, shall, directly or through grants, contracts, or cooperative agreements awarded to eligible entities described in subsection (c), assist local communities and schools (including schools funded by the Bureau of Indian Education) in applying a public health approach to mental health services both in schools and in the community. Such approach should provide comprehensive age appropriate services and supports, be linguistically and culturally appropriate, be trauma-informed, and incorporate age appropriate strategies of positive behavioral interventions and supports. A comprehensive school mental health program funded under this section shall assist children in dealing with trauma and violence.

“(b) Activities.—Under the program under subsection (a), the Secretary may—

“(1) provide financial support to enable local communities to implement a comprehensive culturally and linguistically appropriate, trauma-informed, and age-appropriate, school-based mental health program that—

“(A) builds awareness of trauma;

“(B) trains appropriate staff to identify signs of trauma or mental health disorders; and

“(C) incorporates positive behavioral interventions, family engagement, student treatment, and multi-generational supports to foster the health and development of children;

“(2) provide technical assistance to local communities with respect to the development of programs described in paragraph (1);

“(3) provide assistance to local communities in the development of policies to address child and adolescent trauma and mental health issues and violence when and if it occurs;

“(4) facilitate community partnerships among families, students, law enforcement agencies, education systems, mental health and substance use disorder service systems, family-based mental health service systems, child welfare agencies, health care service systems (including primary care physicians), faith-based programs, trauma networks, and other community-based systems; and

“(5) establish mechanisms for children and adolescents to report incidents of violence or plans by other children, adolescents, or adults to commit violence.

“(c) Requirements.—

“(1) IN GENERAL.—To be eligible for a grant, contract, or cooperative agreement under subsection (a), an entity shall—

“(A) be a partnership that—

“(i) shall include a State educational agency and one or more local educational agencies, with a local educational agency serving as the lead partner; and

“(ii) may include, in accordance with paragraph (2)(A)(i), appropriate public or private entities that use interventions that are evidence-based, as defined in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801); and

“(B) submit an application, that is endorsed by all members of the partnership, that contains the assurances described in paragraph (2).

“(2) REQUIRED ASSURANCES.—An application under paragraph (1) shall contain assurances as follows:

“(A) That the eligible entity will ensure that, in carrying out activities under this section, the eligible entity will enter into a memorandum of understanding—

“(i) with at least 1 public or private mental health entity, health care entity, law enforcement or juvenile justice entity, child welfare agency, family-based mental health entity, trauma network, or other community-based entity; and

“(ii) that clearly states—

“(I) the responsibilities of each partner with respect to the activities to be carried out, including how family engagement will be incorporated in the activities;

“(II) how school-employed and school-based mental health professionals will be utilized for carrying out such responsibilities;

“(III) how each such partner will be accountable for carrying out such responsibilities; and

“(IV) the amount of non-Federal funding or in-kind contributions that each such partner will contribute in order to sustain the program.

“(B) That the comprehensive school-based mental health program carried out under this section supports the flexible use of funds to address—

“(i) the promotion of the social, emotional, and behavioral health of all students in an environment that is conducive to learning;

“(ii) the reduction in the likelihood of at risk students developing social, emotional, behavioral health problems, or substance use disorders;

“(iii) the early identification of social, emotional, behavioral problems, or substance use disorders and the provision of early intervention services;

“(iv) the treatment or referral for treatment of students with existing social, emotional, behavioral health problems, or substance use disorders; and

“(v) the development and implementation of programs to assist children in dealing with trauma and violence, including program curricula, school supports, and after-school programs.

“(C) That the comprehensive school-based mental health program carried out under this section will provide for in-service training of all school personnel, including ancillary staff and volunteers, in—

“(i) the techniques and supports needed to identify early children with trauma histories and children with, or at risk of, mental illness;

“(ii) the use of referral mechanisms that effectively link such children to appropriate treatment and intervention services in the school and in the community and to follow-up when services are not available;

“(iii) strategies that promote a school-wide positive environment;

“(iv) strategies for promoting the social, emotional, mental, and behavioral health of all students; and

“(v) strategies to increase the knowledge and skills of school and community leaders about the impact of trauma and violence and on the application of a public health approach to comprehensive school-based mental health programs.

“(D) That the comprehensive school-based mental health program carried out under this section will include comprehensive training for parents, siblings, and other family members of children with mental health disorders, and for concerned members of the community in—

“(i) the techniques and supports needed to identify early children with trauma histories, and children with, or at risk of, mental illness;

“(ii) the use of referral mechanisms that effectively link such children to appropriate treatment and intervention services in the school and in the community and follow-up when such services are not available; and

“(iii) strategies that promote a school-wide positive environment.

“(E) That the comprehensive school-based mental health program carried out under this section will demonstrate the measures to be taken to sustain the program after funding under this section terminates (which may include seeking funding for the program under a State Medicaid plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) or a waiver of such a plan).

“(F) That the eligible entity is supported by the State agency with primary responsibility for behavioral health to ensure that the sustainability of the programs is established after funding under this section terminates.

“(G) That the comprehensive school-based mental health program carried out under this section will be based on trauma-informed and evidence-based practices.

“(H) That the comprehensive school-based mental health program carried out under this section will be coordinated with early intervening activities carried out under the Individuals with Disabilities Education Act (20 U.S.C. 1400 et seq.).

“(I) That the comprehensive school-based mental health program carried out under this section will be trauma-informed and culturally and linguistically appropriate.

“(J) That the comprehensive school-based mental health program carried out under this section will include a broad needs assessment of youth who drop out of school due to policies of ‘zero tolerance’ with respect to drugs, alcohol, or weapons and an inability to obtain appropriate services.

“(K) That the mental health services provided through the comprehensive school-based mental health program carried out under this section will be provided by qualified mental and behavioral health professionals who are certified or licensed by the State involved and practicing within their area of expertise.

“(3) COORDINATOR.—Any entity that is a member of a partnership described in paragraph (1)(A) may serve as the coordinator of funding and activities under the grant if all members of the partnership agree.

“(4) COMPLIANCE WITH HIPAA.—A grantee under this section shall be deemed to be a covered entity for purposes of compliance with the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note) with respect to any patient records developed through activities under the grant.

“(d) Geographical distribution.—The Secretary shall ensure that grants, contracts, or cooperative agreements under subsection (a) will be distributed equitably among the regions of the country and among urban and rural areas.

“(e) Duration of awards.—With respect to a grant, contract, or cooperative agreement under subsection (a), the period during which payments under such an award will be made to the recipient shall be 5 years. An eligible entity described in subsection (c) may receive only one award under this section, except that an eligible entity that is providing services and supports on a regional basis may receive additional funding after the expiration of the preceding grant period.

“(f) Evaluation and measures of outcomes.—

“(1) DEVELOPMENT OF PROCESS.—The Assistant Secretary shall develop a fiscally appropriate process for evaluating activities carried out under this section. Such process shall include—

“(A) the development of guidelines for the submission of program data by grant, contract, or cooperative agreement recipients;

“(B) the development of measures of outcomes (in accordance with paragraph (2)) to be applied by such recipients in evaluating programs carried out under this section; and

“(C) the submission of annual reports by such recipients concerning the effectiveness of programs carried out under this section.

“(2) MEASURES OF OUTCOMES.—

“(A) IN GENERAL.—The Assistant Secretary shall develop measures of outcomes to be applied by recipients of assistance under this section, and the Assistant Secretary, in evaluating the effectiveness of programs carried out under this section. Such measures shall include student and family measures as provided for in subparagraph (B) and local educational measures as provided for under subparagraph (C).

“(B) STUDENT AND FAMILY MEASURES OF OUTCOMES.—The measures of outcomes developed under paragraph (1)(B) relating to students and families shall, with respect to activities carried out under a program under this section, at a minimum include provisions to evaluate whether the program is effective in—

“(i) increasing social and emotional competency;

“(ii) increasing academic competency (as defined by the Secretary);

“(iii) reducing disruptive and aggressive behaviors;

“(iv) improving child functioning;

“(v) reducing substance use disorders;

“(vi) reducing suspensions, truancy, expulsions, and violence;

“(vii) increasing high school graduation rates, calculated using the four-year adjusted cohort graduation rate or the extended-year adjusted cohort graduation rate (as such terms are defined in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801)); and

“(viii) improving access to care for mental health disorders.

“(C) LOCAL EDUCATIONAL OUTCOMES.—The outcome measures developed under paragraph (1)(B) relating to local educational systems shall, with respect to activities carried out under a program under this section, at a minimum include provisions to evaluate—

“(i) the effectiveness of comprehensive school mental health programs established under this section;

“(ii) the effectiveness of formal partnership linkages among child and family serving institutions, community support systems, and the educational system;

“(iii) the progress made in sustaining the program once funding under the grant has expired;

“(iv) the effectiveness of training and professional development programs for all school personnel that incorporate indicators that measure cultural and linguistic competencies under the program in a manner that incorporates appropriate cultural and linguistic training;

“(v) the improvement in perception of a safe and supportive learning environment among school staff, students, and parents;

“(vi) the improvement in case-finding of students in need of more intensive services and referral of identified students to early intervention and clinical services;

“(vii) the improvement in the immediate availability of clinical assessment and treatment services within the context of the local community to students posing a danger to themselves or others;

“(viii) the increased successful matriculation to postsecondary school; and

“(ix) reduced referrals to juvenile justice.

“(3) SUBMISSION OF ANNUAL DATA.—An eligible entity described in subsection (c) that receives a grant, contract, or cooperative agreement under this section shall annually submit to the Assistant Secretary a report that includes data to evaluate the success of the program carried out by the entity based on whether such program is achieving the purposes of the program. Such reports shall utilize the measures of outcomes under paragraph (2) in a reasonable manner to demonstrate the progress of the program in achieving such purposes.

“(4) EVALUATION BY ASSISTANT SECRETARY.—Based on the data submitted under paragraph (3), the Assistant Secretary shall annually submit to Congress a report concerning the results and effectiveness of the programs carried out with assistance received under this section.

“(5) LIMITATION.—An eligible entity shall use not more than 10 percent of amounts received under a grant under this section to carry out evaluation activities under this subsection.

“(g) Information and education.—The Secretary shall establish comprehensive information and education programs to disseminate the findings of the knowledge development and application under this section to the general public and to health care professionals.

“(h) Amount of grants and authorization of appropriations.—

“(1) AMOUNT OF GRANTS.—A grant under this section shall be in an amount that is not more than $2,000,000 for each of fiscal years 2019 through 2023. The Secretary shall determine the amount of each such grant based on the population of children up to age 21 of the area to be served under the grant.

“(2) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this section, $200,000,000 for each of fiscal years 2019 through 2023.”.

(d) Conforming amendment.—Part G of title V of the Public Health Service Act (42 U.S.C. 290hh et seq.), as amended by this section, is further amended by striking the part heading and inserting the following:

“PART GSchool-based mental health”.

TITLE VIIAddressing high impact minority diseases

subtitle ACancer

SEC. 701. Lung cancer mortality reduction.

(a) Short title.—This section may be cited as the “Lung Cancer Mortality Reduction Act of 2018”.

(b) Findings.—Congress makes the following findings:

(1) Lung cancer is the leading cause of cancer death for both men and women, accounting for 25 percent of all cancer deaths.

(2) Lung cancer kills more people annually than breast cancer, prostate cancer, colon cancer, liver cancer, melanoma, and kidney cancer combined.

(3) Since the National Cancer Act of 1971 (Public Law 92–218; 85 Stat. 778), coordinated and comprehensive research has raised the 5-year survival rates for breast cancer to 90 percent, for prostate cancer to 99 percent, and for colon cancer to 64 percent.

(4) The 5-year survival rate for lung cancer is still only 18 percent, and a similar coordinated and comprehensive research effort is required to achieve increases in lung cancer survivability rates.

(5) Sixty percent of lung cancer cases are now diagnosed in nonsmokers or former smokers.

(6) Two-thirds of nonsmokers diagnosed with lung cancer are women.

(7) Certain minority populations, such as African-American males, have disproportionately high rates of lung cancer incidence and mortality, despite their smoking rate being similar to other racial groups.

(8) Members of the Baby Boomer Generation are entering their 60s, the most common age at which people develop lung cancer.

(9) Tobacco addiction and exposure to other lung cancer carcinogens such as Agent Orange and other herbicides and battlefield emissions are serious problems among military personnel and war veterans.

(10) Significant and rapid improvements in lung cancer mortality can be expected through greater use and access to lung cancer screening tests for at-risk individuals.

(11) Recent research has shown that screening with low-dose computed tomography scan reduced lung cancer death mortality by 20 percent for those with a high risk of lung cancer through early detection. The Centers for Medicare & Medicaid Services supports annual lung cancer screening for high-risk patients with low-dose computed tomography.

(12) Additional strategies are necessary to further enhance the existing tests and therapies available to diagnose and treat lung cancer in the future.

(13) The August 2001 Report of the Lung Cancer Progress Review Group of the National Cancer Institute stated that funding for lung cancer research was “far below the levels characterized for other common malignancies and far out of proportion to its massive health impact”.

(14) The Report of the Lung Cancer Progress Review Group identified as its “highest priority” the creation of integrated, multidisciplinary, multi-institutional research consortia organized around the problem of lung cancer rather than around specific research disciplines.

(15) The United States must enhance its response to the issues raised in the Report of the Lung Cancer Progress Review Group, and this can be accomplished through the establishment of a coordinated effort designed to reduce the lung cancer mortality rate by 50 percent by 2020 and targeted funding to support this coordinated effort.

(c) Sense of Congress concerning investment in lung cancer research.—It is the sense of the Congress that—

(1) lung cancer mortality reduction should be made a national public health priority; and

(2) a comprehensive mortality reduction program coordinated by the Secretary of Health and Human Services is justified and necessary to adequately address and reduce lung cancer mortality.

(d) Lung Cancer Mortality Reduction Program.—

(1) IN GENERAL.—Subpart 1 of part C of title IV of the Public Health Service Act (42 U.S.C. 285 et seq.) is amended by adding at the end the following:

“SEC. 417H. Lung Cancer Mortality Reduction Program.

“(a) In General.—Not later than 6 months after the date of the enactment of the Health Equity and Accountability Act of 2018, the Secretary, in consultation with the Secretary of Defense, the Secretary of Veterans Affairs, the Director of the National Institutes of Health, the Director of the Centers for Disease Control and Prevention, the Commissioner of Food and Drugs, the Administrator of the Centers for Medicare & Medicaid Services, the Director of the National Institute on Minority Health and Health Disparities, and other members of the Lung Cancer Advisory Board established under section 701 of the Health Equity and Accountability Act of 2018, shall implement a comprehensive program, to be known as the Lung Cancer Mortality Reduction Program, to achieve a reduction of at least 25 percent in the mortality rate of lung cancer by 2020.

“(b) Requirements.—The Program shall include at least the following:

“(1) With respect to the National Institutes of Health—

“(A) a strategic review and prioritization by the National Cancer Institute of research grants to achieve the goal of the Lung Cancer Mortality Reduction Program in reducing lung cancer mortality;

“(B) the provision of funds to enable the Airway Biology and Disease Branch of the National Heart, Lung, and Blood Institute to expand its research programs to include predispositions to lung cancer, the interrelationship between lung cancer and other pulmonary and cardiac disease, and the diagnosis and treatment of those interrelationships;

“(C) the provision of funds to enable the National Institute of Biomedical Imaging and Bioengineering to expedite the development of computer-assisted diagnostic, surgical, treatment, and drug-testing innovations to reduce lung cancer mortality, such as through expansion of the Institute’s Quantum Grant Program and Image-Guided Interventions programs; and

“(D) the provision of funds to enable the National Institute of Environmental Health Sciences to implement research programs relative to the lung cancer incidence.

“(2) With respect to the Food and Drug Administration—

“(A) activities under section 529B of the Federal Food, Drug, and Cosmetic Act; and

“(B) activities under section 561 of the Federal Food, Drug, and Cosmetic Act to expand access to investigational drugs and devices for the diagnosis, monitoring, or treatment of lung cancer.

“(3) With respect to the Centers for Disease Control and Prevention, the establishment of an early disease research and management program under section 1511.

“(4) With respect to the Agency for Healthcare Research and Quality, the conduct of a biannual review of lung cancer screening, diagnostic, and treatment protocols, and the issuance of updated guidelines.

“(5) The promotion (including education) of lung cancer screening within minority and rural populations and the study of the effectiveness of efforts to increase such screening.

“(6) The cooperation and coordination of all minority and health disparity programs within the Department of Health and Human Services to ensure that all aspects of the Lung Cancer Mortality Reduction Program under this section adequately address the burden of lung cancer on minority and rural populations.

“(7) The cooperation and coordination of all tobacco control and cessation programs within agencies of the Department of Health and Human Services to achieve the goals of the Lung Cancer Mortality Reduction Program under this section with particular emphasis on the coordination of drug and other cessation treatments with early detection protocols.”.

(2) FEDERAL FOOD, DRUG, AND COSMETIC ACT.—Subchapter B of chapter V of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360aaa et seq.) is amended by adding at the end the following:

“SEC. 529B. Drugs relating to lung cancer.

“(a) In general.—The provisions of this subchapter shall apply to a drug described in subsection (b) to the same extent and in the same manner as such provisions apply to a drug for a rare disease or condition.

“(b) Qualified drugs.—A drug described in this subsection is—

“(1) a chemoprevention drug for precancerous conditions of the lung;

“(2) a drug for targeted therapeutic treatments, including any vaccine, for lung cancer; or

“(3) a drug to curtail or prevent nicotine addiction.

“(c) Board.—The Board established under section 701 of the Health Equity and Accountability Act of 2018 shall monitor the program implemented under this section.”.

(3) ACCESS TO UNAPPROVED THERAPIES.—Section 561(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360bbb(e)) is amended by inserting before the period the following: “and shall include expanding access to drugs under section 529B, with substantial consideration being given to whether the totality of information available to the Secretary regarding the safety and effectiveness of an investigational drug, as compared to the risk of morbidity and death from the disease, indicates that a patient may obtain more benefit than risk if treated with the drug”.

(4) CDC.—Title XV of the Public Health Service Act (42 U.S.C. 300k et seq.) is amended by adding at the end the following:

“SEC. 1511. Early disease research and management program.

“The Secretary shall establish and implement an early disease research and management program targeted at the high incidence and mortality rates of lung cancer among minority and low-income populations.”.

(e) Department of defense and the department of veterans affairs.—The Secretary of Defense and the Secretary of Veterans Affairs, each in coordination with the Secretary of Health and Human Services, shall engage—

(1) in the implementation within the Department of Defense and the Department of Veterans Affairs of an early detection and disease management research program for military personnel and veterans whose smoking history and exposure to carcinogens during active duty service has increased their risk for lung cancer; and

(2) in the implementation of coordinated care programs for military personnel and veterans diagnosed with lung cancer.

(f) Lung cancer advisory board.—

(1) IN GENERAL.—The Secretary of Health and Human Services shall convene a Lung Cancer Advisory Board (referred to in this section as the “Board”)—

(A) to monitor the programs established under this section (and the amendments made by this section); and

(B) to provide annual reports to the Congress concerning benchmarks, expenditures, lung cancer statistics, and the public health impact of such programs.

(2) COMPOSITION.—The Board shall be comprised of—

(A) the Secretary of Health and Human Services;

(B) the Secretary of Defense;

(C) the Secretary of Veterans Affairs; and

(D) 2 representatives each from the fields of clinical medicine focused on lung cancer, lung cancer research, imaging, drug development, and lung cancer advocacy, to be appointed by the Secretary of Health and Human Services.

(g) Authorization of appropriations.—

(1) IN GENERAL.—To carry out this section (and the amendments made by this section), there are authorized to be appropriated $75,000,0000 for fiscal year 2019 and such sums as may be necessary for each of fiscal years 2020 through 2023.

(2) LUNG CANCER MORTALITY REDUCTION PROGRAM.—The amounts appropriated under paragraph (1) shall be allocated as follows:

(A) $25,000,000 for fiscal year 2019, and such sums as may be necessary for each of fiscal years 2020 through 2023, for the activities described in section 417H(b)(1)(B) of the Public Health Service Act, as added by subsection (d);

(B) $25,000,000 for fiscal year 2019, and such sums as may be necessary for each of fiscal years 2020 through 2023, for the activities described in section 417H(b)(1)(C) of the Public Health Service Act;

(C) $10,000,000 for fiscal year 2019, and such sums as may be necessary for each of fiscal years 2020 through 2023, for the activities described in section 417H(b)(1)(D) of the Public Health Service Act; and

(D) $15,000,000 for fiscal year 2019, and such sums as may be necessary for each of fiscal years 2020 through 2023, for the activities described in section 417H(b)(3) of the Public Health Service Act.

SEC. 702. Expanding prostate cancer research, outreach, screening, testing, access, and treatment effectiveness.

(a) Short Title.—This section may be cited as the “Prostate Research, Outreach, Screening, Testing, Access, and Treatment Effectiveness Act of 2018” or the “PROSTATE Act”.

(b) Findings.—Congress makes the following findings:

(1) Prostate cancer is the second leading cause of cancer death among men.

(2) In 2018, an estimated 164,690 men will be diagnosed with prostate cancer and more than 29,000 will die from this disease.

(3) Roughly 2,000,000 to 3,000,000 people in the United States are living with a diagnosis of prostate cancer and its consequences.

(4) While prostate cancer generally affects older individuals, younger men are also at risk for the disease, and when prostate cancer appears in early middle age, it frequently takes on a more aggressive form.

(5) There are significant racial and ethnic disparities that demand attention; African Americans have prostate cancer mortality rates that are more than double those in the White population.

(6) Underserved rural populations have higher rates of mortality compared to their urban counterparts, and innovative and cost-efficient methods to improve rural access to high-quality care should take advantage of advances in telehealth to diagnose and treat prostate cancer when appropriate.

(7) Certain veterans populations may have nearly twice the incidence of prostate cancer as the general population of the United States.

(8) Urologists may constitute the specialists who diagnose and treat the vast majority of prostate cancer patients.

(9) Although much basic and translational research has been completed and much is currently known, there are still many unanswered questions, such as the extent to which known disparities are attributable to disease etiology, access to care, or education and awareness in the community.

(10) Causes of prostate cancer are not known. There is not good information regarding how to differentiate accurately, early on, between aggressive and indolent forms of the disease. As a result, there is significant overtreatment in prostate cancer. There are no treatments that can durably arrest growth or cure prostate cancer once it has metastasized.

(11) A significant proportion (about 23 to 54 percent) of cases may be clinically indolent and “overdiagnosed”, resulting in significant overtreatment. More accurate tests will allow men and their families to face less physical, psychological, financial, and emotional trauma, and billions of dollars could be saved in private and public health care systems in an area that has been identified by the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) as one of 8 high-volume, high-cost areas in the Resource Utilization Report Program established under the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275).

(12) Prostate cancer research and health care programs across Federal agencies should be coordinated to improve accountability and actively encourage the translation of research into practice, to identify and implement best practices, in order to foster an integrated and consistent focus on effective prevention, diagnosis, and treatment of this disease.

(c) Prostate cancer coordination and education.—

(1) INTERAGENCY PROSTATE CANCER COORDINATION AND EDUCATION TASK FORCE.—Not later than 180 days after the date of the enactment of this section, the Secretary of Veterans Affairs, in cooperation with the Secretary of Defense and the Secretary of Health and Human Services, shall establish an Interagency Prostate Cancer Coordination and Education Task Force (in this section referred to as the “Prostate Cancer Task Force”).

(2) DUTIES.—The Prostate Cancer Task Force shall—

(A) develop a summary of advances in prostate cancer research supported or conducted by Federal agencies relevant to the diagnosis, prevention, and treatment of prostate cancer, including psychosocial impairments related to prostate cancer treatment, and compile a list of best practices that warrant broader adoption in health care programs;

(B) consider establishing, and advocating for, a guidance to enable physicians to allow screening of men who are over age 74, on a case-by-case basis, taking into account quality of life and family history of prostate cancer;

(C) share and coordinate information on Federal research and health care program activities, including activities related to—

(i) determining how to improve research and health care programs, including psychosocial impairments related to prostate cancer treatment;

(ii) identifying any gaps in the overall research inventory and in health care programs;

(iii) identifying opportunities to promote translation of research into practice; and

(iv) maximizing the effects of Federal efforts by identifying opportunities for collaboration and leveraging of resources in research and health care programs that serve individuals who are susceptible to or diagnosed with prostate cancer;

(D) develop a comprehensive interagency strategy and advise relevant Federal agencies in the solicitation of proposals for collaborative, multidisciplinary research and health care programs, including proposals to evaluate factors that may be related to the etiology of prostate cancer, that would—

(i) result in innovative approaches to study emerging scientific opportunities or eliminate knowledge gaps in research to improve the prostate cancer research portfolio of the Federal Government;

(ii) outline key research questions, methodologies, and knowledge gaps; and

(iii) ensure consistent action, as outlined by section 402(b) of the Public Health Service Act;

(E) develop a coordinated message related to screening and treatment for prostate cancer to be reflected in educational and beneficiary materials for Federal health programs as such documents are updated; and

(F) not later than 2 years after the date of the establishment of the Prostate Cancer Task Force, submit to the Expert Advisory Panel to be reviewed and returned within 30 days, and then within 90 days submitted to Congress recommendations—

(i) regarding any appropriate changes to research and health care programs, including recommendations to improve the research portfolio of the Department of Veterans Affairs, the Department of Defense, National Institutes of Health, and other Federal agencies to ensure that scientifically based strategic planning is implemented in support of research and health care program priorities;

(ii) designed to ensure that the research and health care programs and activities of the Department of Veterans Affairs, the Department of Defense, the Department of Health and Human Services, and other Federal agencies are free of unnecessary duplication;

(iii) regarding public participation in decisions relating to prostate cancer research and health care programs to increase the involvement of patient advocates, community organizations, and medical associations representing a broad geographical area;

(iv) on how to best disseminate information on prostate cancer research and progress achieved by health care programs;

(v) about how to expand partnerships between public entities, including Federal agencies, and private entities to encourage collaborative, cross-cutting research and health care delivery;

(vi) assessing any cost savings and efficiencies realized through the efforts identified and supported in this section and recommending expansion of those efforts that have proved most promising while also ensuring against any conflicts in directives from other congressional or statutory mandates or enabling statutes;

(vii) identifying key priority action items from among the recommendations; and

(viii) with respect to the level of funding needed by each agency to implement the recommendations contained in the report.

(3) MEMBERS OF THE PROSTATE CANCER TASK FORCE.—The Prostate Cancer Task Force described in this subsection shall be comprised of representatives from such Federal agencies, as each head of such applicable agencies determines necessary, to coordinate a uniform message relating to prostate cancer screening and treatment where appropriate, including representatives of the following:

(A) The Department of Veterans Affairs, including representatives of each relevant program area of the Department of Veterans Affairs.

(B) The Prostate Cancer Research Program of the Congressionally Directed Medical Research program of the Department of Defense.

(C) The Department of Health and Human Services, including at a minimum representatives of each of the following:

(i) The National Institutes of Health.

(ii) National research institutes and centers, including the National Cancer Institute, the National Institute of Allergy and Infectious Diseases, and the Office of Minority Health.

(iii) The Centers for Medicare & Medicaid Services.

(iv) The Food and Drug Administration.

(v) The Centers for Disease Control and Prevention.

(vi) The Agency for Healthcare Research and Quality.

(vii) The Health Resources and Services Administration.

(4) APPOINTING EXPERT ADVISORY PANELS.—The Prostate Cancer Task Force shall appoint expert advisory panels, as such task force determines appropriate, to provide input and concurrence from individuals and organizations from the medical, prostate cancer patient and advocate, research, and delivery communities with expertise in prostate cancer diagnosis, treatment, and research, including practicing urologists, primary care providers, and others and individuals with expertise in education and outreach to underserved populations affected by prostate cancer.

(5) MEETINGS.—The Prostate Cancer Task Force shall convene not less than twice a year, or more frequently as the Secretary of Veterans Affairs determines to be appropriate.

(6) FEDERAL ADVISORY COMMITTEE ACT.—

(A) IN GENERAL.—Except as provided in subparagraph (B), the Federal Advisory Committee Act (5 U.S.C. App.) shall apply to the Prostate Cancer Task Force.

(B) EXCEPTION.—Section 14(a)(2)(B) of such Act (relating to the termination of advisory committees) shall not apply to the Prostate Cancer Task Force.