Regulations

Attachment 1
2006 USC Title 42 Section 254b

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

specialized health resources, and providing for
reciprocal reimbursement.
Any reimbursement pursuant to any such agreement or arrangement shall be based on charges
covering the reasonable cost of such utilization,
including normal depreciation and amortization
costs of equipment. Any proceeds to the Government under this subsection shall be credited to
the applicable appropriation of the Public
Health Service for the year in which such proceeds are received.
(July 1, 1944, ch. 373, title III, § 327A, formerly
§ 328, as added Pub. L. 90–174, § 7, Dec. 5, 1967, 81
Stat. 539; renumbered § 327A, Pub. L. 95–626, title
I, § 113(a)(2), Nov. 10, 1978, 92 Stat. 3562; amended
Pub. L. 100–607, title VI, § 629(a)(1), Nov. 4, 1988,
102 Stat. 3146.)
AMENDMENTS
1988—Subsec. (b)(1). Pub. L. 100–607 inserted ‘‘schools
of osteopathic medicine,’’ after ‘‘schools of medicine,’’
and ‘‘professions’’ after ‘‘health’’.
AVAILABILITY OF APPROPRIATIONS FOR EXPENSES OF
SHARING MEDICAL CARE FACILITIES AND RESOURCES
Pub. L. 102–394, title II, § 204, Oct. 6, 1992, 106 Stat.
1811, provided that: ‘‘Funds advanced to the National
Institutes of Health Management Fund from appropriations in this Act or subsequent Departments of Labor,
Health and Human Services, and Education, and Related Agencies Appropriations Acts shall be available for
the expenses of sharing medical care facilities and resources pursuant to section 327A of the Public Health
Service Act [42 U.S.C. 254a].’’
Similar provisions were contained in the following
prior appropriation acts:
Pub. L. 102–170, title II, § 204, Nov. 26, 1991, 105 Stat.
1126.
Pub. L. 101–517, title II, § 204, Nov. 5, 1990, 104 Stat.
2208.
Pub. L. 101–166, title II, § 205, Nov. 21, 1989, 103 Stat.
1177.
Pub. L. 100–202, § 101(h) [title II, § 205], Dec. 22, 1987, 101
Stat. 1329–256, 1329–274.
Pub. L. 99–500, § 101(i) [H.R. 5233, title II, § 205], Oct. 18,
1986, 100 Stat. 1783–287, and Pub. L. 99–591, § 101(i) [H.R.
5233, title II, § 205], Oct. 30, 1986, 100 Stat. 3341–287.
Pub. L. 99–178, title II, § 205, Dec. 12, 1985, 99 Stat. 1119.
Pub. L. 98–619, title II, § 205, Nov. 8, 1984, 98 Stat. 3321.
Pub. L. 98–139, title II, § 205, Oct. 31, 1983, 97 Stat. 887.
Pub. L. 97–377, title I, § 101(e)(1) [title II, § 205], Dec. 21,
1982, 96 Stat. 1878, 1894.

PART D—PRIMARY HEALTH CARE
SUBPART I—HEALTH CENTERS

AMENDMENTS
1996—Pub. L. 104–299, § 2, Oct. 11, 1996, 110 Stat. 3626,
substituted ‘‘Health Centers’’ for ‘‘Primary Health Centers’’ in subpart heading.
1978—Pub. L. 95–626, title I, § 113(a)(3), Nov. 10, 1978, 92
Stat. 3562, added heading ‘‘Part D—Primary Health
Care’’ and, immediately under it, heading ‘‘Subpart I—
Primary Health Centers’’.

§ 254b. Health centers
(a) ‘‘Health center’’ defined
(1) In general
For purposes of this section, the term
‘‘health center’’ means an entity that serves a
population that is medically underserved, or a
special medically underserved population comprised of migratory and seasonal agricultural

§ 254b

workers, the homeless, and residents of public
housing, by providing, either through the staff
and supporting resources of the center or
through contracts or cooperative arrangements—
(A) required primary health services (as
defined in subsection (b)(1) of this section);
and
(B) as may be appropriate for particular
centers, additional health services (as defined in subsection (b)(2) of this section) necessary for the adequate support of the primary health services required under subparagraph (A);
for all residents of the area served by the center (hereafter referred to in this section as the
‘‘catchment area’’).
(2) Limitation
The requirement in paragraph (1) to provide
services for all residents within a catchment
area shall not apply in the case of a health
center receiving a grant only under subsection
(g), (h), or (i) of this section.
(b) Definitions
For purposes of this section:
(1) Required primary health services
(A) In general
The term ‘‘required primary health services’’ means—
(i) basic health services which, for purposes of this section, shall consist of—
(I) health services related to family
medicine, internal medicine, pediatrics,
obstetrics, or gynecology that are furnished by physicians and where appropriate, physician assistants, nurse practitioners, and nurse midwives;
(II) diagnostic laboratory and radiologic services;
(III) preventive health services, including—
(aa) prenatal and perinatal services;
(bb) appropriate cancer screening;
(cc) well-child services;
(dd) immunizations against vaccinepreventable diseases;
(ee) screenings for elevated blood
lead levels, communicable diseases,
and cholesterol;
(ff) pediatric eye, ear, and dental
screenings to determine the need for
vision and hearing correction and dental care;
(gg) voluntary family planning services; and
(hh) preventive dental services;
(IV) emergency medical services; and
(V) pharmaceutical services as may be
appropriate for particular centers;
(ii) referrals to providers of medical services (including specialty referral when
medically indicated) and other health-related services (including substance abuse
and mental health services);
(iii) patient case management services
(including counseling, referral, and followup services) and other services designed to

§ 254b

TITLE 42—THE PUBLIC HEALTH AND WELFARE

assist health center patients in establishing eligibility for and gaining access to
Federal, State, and local programs that
provide or financially support the provision of medical, social, housing, educational, or other related services;
(iv) services that enable individuals to
use the services of the health center (including outreach and transportation services and, if a substantial number of the individuals in the population served by a
center are of limited English-speaking
ability, the services of appropriate personnel fluent in the language spoken by a predominant number of such individuals); and
(v) education of patients and the general
population served by the health center regarding the availability and proper use of
health services.
(B) Exception
With respect to a health center that receives a grant only under subsection (g) of
this section, the Secretary, upon a showing
of good cause, shall—
(i) waive the requirement that the center
provide all required primary health services under this paragraph; and
(ii) approve, as appropriate, the provision of certain required primary health
services only during certain periods of the
year.
(2) Additional health services
The term ‘‘additional health services’’
means services that are not included as required primary health services and that are
appropriate to meet the health needs of the
population served by the health center involved. Such term may include—
(A) behavioral and mental health and substance abuse services;
(B) recuperative care services;
(C) environmental health services, including—
(i) the detection and alleviation of unhealthful conditions associated with—
(I) water supply;
(II) chemical and pesticide exposures;
(III) air quality; or
(IV) exposure to lead;
(ii) sewage treatment;
(iii) solid waste disposal;
(iv) rodent and parasitic infestation;
(v) field sanitation;
(vi) housing; and
(vii) other environmental factors related
to health; and
(D) in the case of health centers receiving
grants under subsection (g) of this section,
special occupation-related health services
for migratory and seasonal agricultural
workers, including—
(i) screening for and control of infectious
diseases, including parasitic diseases; and
(ii) injury prevention programs, including prevention of exposure to unsafe levels
of agricultural chemicals including pesticides.
(3) Medically underserved populations
(A) In general
The term ‘‘medically underserved population’’ means the population of an urban or

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rural area designated by the Secretary as an
area with a shortage of personal health services or a population group designated by the
Secretary as having a shortage of such services.
(B) Criteria
In carrying out subparagraph (A), the Secretary shall prescribe criteria for determining the specific shortages of personal health
services of an area or population group.
Such criteria shall—
(i) take into account comments received
by the Secretary from the chief executive
officer of a State and local officials in a
State; and
(ii) include factors indicative of the
health status of a population group or residents of an area, the ability of the residents of an area or of a population group
to pay for health services and their accessibility to them, and the availability of
health professionals to residents of an area
or to a population group.
(C) Limitation
The Secretary may not designate a medically underserved population in a State or
terminate the designation of such a population unless, prior to such designation or
termination, the Secretary provides reasonable notice and opportunity for comment
and consults with—
(i) the chief executive officer of such
State;
(ii) local officials in such State; and
(iii) the organization, if any, which represents a majority of health centers in
such State.
(D) Permissible designation
The Secretary may designate a medically
underserved population that does not meet
the criteria established under subparagraph
(B) if the chief executive officer of the State
in which such population is located and local
officials of such State recommend the designation of such population based on unusual local conditions which are a barrier to
access to or the availability of personal
health services.
(c) Planning grants
(1) In general
(A) Centers
The Secretary may make grants to public
and nonprofit private entities for projects to
plan and develop health centers which will
serve medically underserved populations. A
project for which a grant may be made under
this subsection may include the cost of the
acquisition and lease of buildings and equipment (including the costs of amortizing the
principal of, and paying the interest on,
loans) and shall include—
(i) an assessment of the need that the
population proposed to be served by the
health center for which the project is
undertaken has for required primary
health services and additional health services;
(ii) the design of a health center program
for such population based on such assessment;

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

(iii) efforts to secure, within the proposed catchment area of such center, financial and professional assistance and
support for the project;
(iv) initiation and encouragement of continuing community involvement in the development and operation of the project;
and
(v) proposed linkages between the center
and other appropriate provider entities,
such as health departments, local hospitals, and rural health clinics, to provide
better coordinated, higher quality, and
more cost-effective health care services.
(B) Managed care networks and plans
The Secretary may make grants to health
centers that receive assistance under this
section to enable the centers to plan and develop a managed care network or plan. Such
a grant may only be made for such a center
if—
(i) the center has received grants under
subsection (e)(1)(A) of this section for at
least 2 consecutive years preceding the
year of the grant under this subparagraph
or has otherwise demonstrated, as required
by the Secretary, that such center has
been providing primary care services for at
least the 2 consecutive years immediately
preceding such year; and
(ii) the center provides assurances satisfactory to the Secretary that the provision
of such services on a prepaid basis, or
under another managed care arrangement,
will not result in the diminution of the
level or quality of health services provided
to the medically underserved population
served prior to the grant under this subparagraph.
(C) Practice management networks
The Secretary may make grants to health
centers that receive assistance under this
section to enable the centers to plan and develop practice management networks that
will enable the centers to—
(i) reduce costs associated with the provision of health care services;
(ii) improve access to, and availability
of, health care services provided to individuals served by the centers;
(iii) enhance the quality and coordination of health care services; or
(iv) improve the health status of communities.
(D) Use of funds
The activities for which a grant may be
made under subparagraph (B) or (C) may include the purchase or lease of equipment,
which may include data and information
systems (including paying for the costs of
amortizing the principal of, and paying the
interest on, loans for equipment), the provision of training and technical assistance related to the provision of health care services
on a prepaid basis or under another managed
care arrangement, and other activities that
promote the development of practice management or managed care networks and
plans.

§ 254b

(2) Limitation
Not more than two grants may be made
under this subsection for the same project, except that upon a showing of good cause, the
Secretary may make additional grant awards.
(d) Loan guarantee program
(1) Establishment
(A) In general
The Secretary shall establish a program
under which the Secretary may, in accordance with this subsection and to the extent
that appropriations are provided in advance
for such program, guarantee up to 90 percent
of the principal and interest on loans made
by non-Federal lenders to health centers,
funded under this section, for the costs of developing and operating managed care networks or plans described in subsection
(c)(1)(B) of this section, or practice management networks described in subsection
(c)(1)(C) of this section.
(B) Use of funds
Loan funds guaranteed under this subsection may be used—
(i) to establish reserves for the furnishing of services on a pre-paid basis;
(ii) for costs incurred by the center or
centers, otherwise permitted under this
section, as the Secretary determines are
necessary to enable a center or centers to
develop, operate, and own the network or
plan; or
(iii) to refinance an existing loan (as of
the date of refinancing) to the center or
centers, if the Secretary determines—
(I) that such refinancing will be beneficial to the health center and the Federal Government; or
(II) that the center (or centers) can
demonstrate an ability to repay the refinanced loan equal to or greater than the
ability of the center (or centers) to repay
the original loan on the date the original
loan was made.
(C) Publication of guidance
Prior to considering an application submitted under this subsection, the Secretary
shall publish guidelines to provide guidance
on the implementation of this section. The
Secretary shall make such guidelines available to the universe of parties affected under
this subsection, distribute such guidelines to
such parties upon the request of such parties, and provide a copy of such guidelines to
the appropriate committees of Congress.
(D) Provision directly to networks or plans
At the request of health centers receiving
assistance under this section, loan guarantees provided under this paragraph may be
made directly to networks or plans that are
at least majority controlled and, as applicable, at least majority owned by those health
centers.
(E) Federal credit reform
The requirements of the Federal Credit
Reform Act of 1990 (2 U.S.C. 661 et seq.) shall
apply with respect to loans refinanced under
subparagraph (B)(iii).

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

(2) Protection of financial interests
(A) In general
The Secretary may not approve a loan
guarantee for a project under this subsection
unless the Secretary determines that—
(i) the terms, conditions, security (if
any), and schedule and amount of repayments with respect to the loan are sufficient to protect the financial interests of
the United States and are otherwise reasonable, including a determination that
the rate of interest does not exceed such
percent per annum on the principal obligation outstanding as the Secretary determines to be reasonable, taking into account the range of interest rates prevailing in the private market for similar loans
and the risks assumed by the United
States, except that the Secretary may not
require as security any center asset that
is, or may be, needed by the center or centers involved to provide health services;
(ii) the loan would not be available on
reasonable terms and conditions without
the guarantee under this subsection; and
(iii) amounts appropriated for the program under this subsection are sufficient
to provide loan guarantees under this subsection.
(B) Recovery of payments
(i) In general
The United States shall be entitled to recover from the applicant for a loan guarantee under this subsection the amount of
any payment made pursuant to such guarantee, unless the Secretary for good cause
waives such right of recovery (subject to
appropriations remaining available to permit such a waiver) and, upon making any
such payment, the United States shall be
subrogated to all of the rights of the recipient of the payments with respect to which
the guarantee was made. Amounts recovered under this clause shall be credited as
reimbursements to the financing account
of the program.
(ii) Modification of terms and conditions
To the extent permitted by clause (iii)
and subject to the requirements of section
504(e) of the Credit Reform Act of 1990 (2
U.S.C. 661c(e)), any terms and conditions
applicable to a loan guarantee under this
subsection (including terms and conditions
imposed under clause (iv)) may be modified
or waived by the Secretary to the extent
the Secretary determines it to be consistent with the financial interest of the
United States.
(iii) Incontestability
Any loan guarantee made by the Secretary under this subsection shall be incontestable—
(I) in the hands of an applicant on
whose behalf such guarantee is made unless the applicant engaged in fraud or
misrepresentation in securing such guarantee; and
(II) as to any person (or successor in
interest) who makes or contracts to

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make a loan to such applicant in reliance thereon unless such person (or successor in interest) engaged in fraud or
misrepresentation in making or contracting to make such loan.
(iv) Further terms and conditions
Guarantees of loans under this subsection shall be subject to such further
terms and conditions as the Secretary determines to be necessary to assure that
the purposes of this section will be
achieved.
(3) Loan origination fees
(A) In general
The Secretary shall collect a loan origination fee with respect to loans to be guaranteed under this subsection, except as provided in subparagraph (C).
(B) Amount
The amount of a loan origination fee collected by the Secretary under subparagraph
(A) shall be equal to the estimated long term
cost of the loan guarantees involved to the
Federal Government (excluding administrative costs), calculated on a net present value
basis, after taking into account any appropriations that may be made for the purpose
of offsetting such costs, and in accordance
with the criteria used to award loan guarantees under this subsection.
(C) Waiver
The Secretary may waive the loan origination fee for a health center applicant who
demonstrates to the Secretary that the applicant will be unable to meet the conditions
of the loan if the applicant incurs the additional cost of the fee.
(4) Defaults
(A) In general
Subject to the requirements of the Credit
Reform Act of 1990 1 (2 U.S.C. 661 et seq.), the
Secretary may take such action as may be
necessary to prevent a default on a loan
guaranteed under this subsection, including
the waiver of regulatory conditions, deferral
of loan payments, renegotiation of loans,
and the expenditure of funds for technical
and consultative assistance, for the temporary payment of the interest and principal
on such a loan, and for other purposes. Any
such expenditure made under the preceding
sentence on behalf of a health center or centers shall be made under such terms and conditions as the Secretary shall prescribe, including the implementation of such organizational, operational, and financial reforms
as the Secretary determines are appropriate
and the disclosure of such financial or other
information as the Secretary may require to
determine the extent of the implementation
of such reforms.
(B) Foreclosure
The Secretary may take such action, consistent with State law respecting foreclosure
1 See

References in Text note below.

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

procedures and, with respect to reserves required for furnishing services on a prepaid
basis, subject to the consent of the affected
States, as the Secretary determines appropriate to protect the interest of the United
States in the event of a default on a loan
guaranteed under this subsection, except
that the Secretary may only foreclose on assets offered as security (if any) in accordance with paragraph (2)(A)(i).
(5) Limitation
Not more than one loan guarantee may be
made under this subsection for the same network or plan, except that upon a showing of
good cause the Secretary may make additional loan guarantees.
(6) Authorization of appropriations
There are authorized to be appropriated to
carry out this subsection such sums as may be
necessary.
(e) Operating grants
(1) Authority
(A) In general
The Secretary may make grants for the
costs of the operation of public and nonprofit private health centers that provide
health services to medically underserved
populations.
(B) Entities that fail to meet certain requirements
The Secretary may make grants, for a period of not to exceed 2 years, for the costs of
the operation of public and nonprofit private
entities which provide health services to
medically underserved populations but with
respect to which the Secretary is unable to
make each of the determinations required by
subsection (k)(3) of this section.
(C) Operation of networks and plans
The Secretary may make grants to health
centers that receive assistance under this
section, or at the request of the health centers, directly to a network or plan (as described in subparagraphs (B) and (C) of subsection (c)(1) of this section) that is at least
majority controlled and, as applicable, at
least majority owned by such health centers
receiving assistance under this section, for
the costs associated with the operation of
such network or plan, including the purchase or lease of equipment (including the
costs of amortizing the principal of, and paying the interest on, loans for equipment).
(2) Use of funds
The costs for which a grant may be made
under subparagraph (A) or (B) of paragraph (1)
may include the costs of acquiring and leasing
buildings and equipment (including the costs
of amortizing the principal of, and paying interest on, loans), and the costs of providing
training related to the provision of required
primary health services and additional health
services and to the management of health center programs.
(3) Construction
The Secretary may award grants which may
be used to pay the costs associated with ex-

§ 254b

panding and modernizing existing buildings or
constructing new buildings (including the
costs of amortizing the principal of, and paying the interest on, loans) for projects approved prior to October 1, 1996.
(4) Limitation
Not more than two grants may be made
under subparagraph (B) of paragraph (1) for
the same entity.
(5) Amount
(A) In general
The amount of any grant made in any fiscal year under subparagraphs (A) and (B) of
paragraph (1) to a health center shall be determined by the Secretary, but may not exceed the amount by which the costs of operation of the center in such fiscal year exceed
the total of—
(i) State, local, and other operational
funding provided to the center; and
(ii) the fees, premiums, and third-party
reimbursements, which the center may
reasonably be expected to receive for its
operations in such fiscal year.
(B) Networks and plans
The total amount of grant funds made
available for any fiscal year under paragraph
(1)(C) and subparagraphs (B) and (C) of subsection (c)(1) of this section to a health center or to a network or plan shall be determined by the Secretary, but may not exceed
2 percent of the total amount appropriated
under this section for such fiscal year.
(C) Payments
Payments under grants under subparagraph (A) or (B) of paragraph (1) shall be
made in advance or by way of reimbursement and in such installments as the Secretary finds necessary and adjustments may
be made for overpayments or underpayments.
(D) Use of nongrant funds
Nongrant funds described in clauses (i) and
(ii) of subparagraph (A), including any such
funds in excess of those originally expected,
shall be used as permitted under this section, and may be used for such other purposes as are not specifically prohibited
under this section if such use furthers the
objectives of the project.
(f) Infant mortality grants
(1) In general
The Secretary may make grants to health
centers for the purpose of assisting such centers in—
(A) providing comprehensive health care
and support services for the reduction of—
(i) the incidence of infant mortality; and
(ii) morbidity among children who are
less than 3 years of age; and
(B) developing and coordinating service
and referral arrangements between health
centers and other entities for the health
management of pregnant women and children described in subparagraph (A).
(2) Priority
In making grants under this subsection the
Secretary shall give priority to health centers

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

providing services to any medically underserved population among which there is a substantial incidence of infant mortality or
among which there is a significant increase in
the incidence of infant mortality.
(3) Requirements
The Secretary may make a grant under this
subsection only if the health center involved
agrees that—
(A) the center will coordinate the provision of services under the grant to each of
the recipients of the services;
(B) such services will be continuous for
each such recipient;
(C) the center will provide follow-up services for individuals who are referred by the
center for services described in paragraph
(1);
(D) the grant will be expended to supplement, and not supplant, the expenditures of
the center for primary health services (including prenatal care) with respect to the
purpose described in this subsection; and
(E) the center will coordinate the provision of services with other maternal and
child health providers operating in the
catchment area.
(g) Migratory and seasonal agricultural workers
(1) In general
The Secretary may award grants for the purposes described in subsections (c), (e), and (f)
of this section for the planning and delivery of
services to a special medically underserved
population comprised of—
(A) migratory agricultural workers, seasonal agricultural workers, and members of
the families of such migratory and seasonal
agricultural workers who are within a designated catchment area; and
(B) individuals who have previously been
migratory agricultural workers but who no
longer meet the requirements of subparagraph (A) of paragraph (3) because of age or
disability and members of the families of
such individuals who are within such catchment area.
(2) Environmental concerns
The Secretary may enter into grants or contracts under this subsection with public and
private entities to—
(A) assist the States in the implementation and enforcement of acceptable environmental health standards, including enforcement of standards for sanitation in migratory agricultural worker and seasonal agricultural worker labor camps, and applicable
Federal and State pesticide control standards; and
(B) conduct projects and studies to assist
the several States and entities which have
received grants or contracts under this section in the assessment of problems related
to camp and field sanitation, exposure to unsafe levels of agricultural chemicals including pesticides, and other environmental
health hazards to which migratory agricultural workers and seasonal agricultural
workers, and members of their families, are
exposed.

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(3) Definitions
For purposes of this subsection:
(A) Migratory agricultural worker
The term ‘‘migratory agricultural worker’’
means an individual whose principal employment is in agriculture, who has been so employed within the last 24 months, and who
establishes for the purposes of such employment a temporary abode.
(B) Seasonal agricultural worker
The term ‘‘seasonal agricultural worker’’
means an individual whose principal employment is in agriculture on a seasonal basis
and who is not a migratory agricultural
worker.
(C) Agriculture
The term ‘‘agriculture’’ means farming in
all its branches, including—
(i) cultivation and tillage of the soil;
(ii) the production, cultivation, growing,
and harvesting of any commodity grown
on, in, or as an adjunct to or part of a commodity grown in or on, the land; and
(iii) any practice (including preparation
and processing for market and delivery to
storage or to market or to carriers for
transportation to market) performed by a
farmer or on a farm incident to or in conjunction with an activity described in
clause (ii).
(h) Homeless population
(1) In general
The Secretary may award grants for the purposes described in subsections (c), (e), and (f)
of this section for the planning and delivery of
services to a special medically underserved
population comprised of homeless individuals,
including grants for innovative programs that
provide outreach and comprehensive primary
health services to homeless children and
youth and children and youth at risk of homelessness.
(2) Required services
In addition to required primary health services (as defined in subsection (b)(1) of this section), an entity that receives a grant under
this subsection shall be required to provide
substance abuse services as a condition of such
grant.
(3) Supplement not supplant requirement
A grant awarded under this subsection shall
be expended to supplement, and not supplant,
the expenditures of the health center and the
value of in kind contributions for the delivery
of services to the population described in paragraph (1).
(4) Temporary continued provision of services
to certain former homeless individuals
If any grantee under this subsection has provided services described in this section under
the grant to a homeless individual, such grantee may, notwithstanding that the individual is
no longer homeless as a result of becoming a
resident in permanent housing, expend the
grant to continue to provide such services to
the individual for not more than 12 months.

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

(5) Definitions
For purposes of this section:
(A) Homeless individual
The term ‘‘homeless individual’’ means an
individual who lacks housing (without regard to whether the individual is a member
of a family), including an individual whose
primary residence during the night is a supervised public or private facility that provides temporary living accommodations and
an individual who is a resident in transitional housing.
(B) Substance abuse
The term ‘‘substance abuse’’ has the same
meaning given such term in section
290cc–34(4) of this title.
(C) Substance abuse services
The term ‘‘substance abuse services’’ includes detoxification, risk reduction, outpatient treatment, residential treatment,
and rehabilitation for substance abuse provided in settings other than hospitals.
(i) Residents of public housing
(1) In general
The Secretary may award grants for the purposes described in subsections (c), (e), and (f)
of this section for the planning and delivery of
services to a special medically underserved
population comprised of residents of public
housing (such term, for purposes of this subsection, shall have the same meaning given
such term in section 1437a(b)(1) of this title)
and individuals living in areas immediately
accessible to such public housing.
(2) Supplement not supplant
A grant awarded under this subsection shall
be expended to supplement, and not supplant,
the expenditures of the health center and the
value of in kind contributions for the delivery
of services to the population described in paragraph (1).
(3) Consultation with residents
The Secretary may not make a grant under
paragraph (1) unless, with respect to the residents of the public housing involved, the applicant for the grant—
(A) has consulted with the residents in the
preparation of the application for the grant;
and
(B) agrees to provide for ongoing consultation with the residents regarding the planning and administration of the program carried out with the grant.
(j) Access grants
(1) In general
The Secretary may award grants to eligible
health centers with a substantial number of
clients with limited English speaking proficiency to provide translation, interpretation,
and other such services for such clients with
limited English speaking proficiency.
(2) Eligible health center
In this subsection, the term ‘‘eligible health
center’’ means an entity that—
(A) is a health center as defined under subsection (a) of this section;

§ 254b

(B) provides health care services for clients for whom English is a second language;
and
(C) has exceptional needs with respect to
linguistic access or faces exceptional challenges with respect to linguistic access.
(3) Grant amount
The amount of a grant awarded to a center
under this subsection shall be determined by
the Administrator. Such determination of
such amount shall be based on the number of
clients for whom English is a second language
that is served by such center, and larger grant
amounts shall be awarded to centers serving
larger numbers of such clients.
(4) Use of funds
An eligible health center that receives a
grant under this subsection may use funds received through such grant to—
(A) provide translation, interpretation,
and other such services for clients for whom
English is a second language, including hiring professional translation and interpretation services; and
(B) compensate bilingual or multilingual
staff for language assistance services provided by the staff for such clients.
(5) Application
An eligible health center 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 reasonably require, including—
(A) an estimate of the number of clients
that the center serves for whom English is a
second language;
(B) the ratio of the number of clients for
whom English is a second language to the
total number of clients served by the center;
(C) a description of any language assistance services that the center proposes to
provide to aid clients for whom English is a
second language; and
(D) a description of the exceptional needs
of such center with respect to linguistic access or a description of the exceptional challenges faced by such center with respect to
linguistic access.
(6) Authorization of appropriations
There are authorized to be appropriated to
carry out this subsection, in addition to any
funds authorized to be appropriated or appropriated for health centers under any other subsection of this section, such sums as may be
necessary for each of fiscal years 2002 through
2006.
(k) Applications
(1) Submission
No grant may be made under this section unless an application therefore is submitted to,
and approved by, the Secretary. Such an application shall be submitted in such form and
manner and shall contain such information as
the Secretary shall prescribe.
(2) Description of need
An application for a grant under subparagraph (A) or (B) of subsection (e)(1) of this section for a health center shall include—

§ 254b

TITLE 42—THE PUBLIC HEALTH AND WELFARE

(A) a description of the need for health
services in the catchment area of the center;
(B) a demonstration by the applicant that
the area or the population group to be served
by the applicant has a shortage of personal
health services; and
(C) a demonstration that the center will be
located so that it will provide services to the
greatest number of individuals residing in
the catchment area or included in such population group.
Such a demonstration shall be made on the
basis of the criteria prescribed by the Secretary under subsection (b)(3) of this section
or on any other criteria which the Secretary
may prescribe to determine if the area or population group to be served by the applicant
has a shortage of personal health services. In
considering an application for a grant under
subparagraph (A) or (B) of subsection (e)(1) of
this section, the Secretary may require as a
condition to the approval of such application
an assurance that the applicant will provide
any health service defined under paragraphs
(1) and (2) of subsection (b) of this section that
the Secretary finds is needed to meet specific
health needs of the area to be served by the
applicant. Such a finding shall be made in
writing and a copy shall be provided to the applicant.
(3) Requirements
Except as provided in subsection (e)(1)(B) of
this section, the Secretary may not approve
an application for a grant under subparagraph
(A) or (B) of subsection (e)(1) of this section
unless the Secretary determines that the entity for which the application is submitted is
a health center (within the meaning of subsection (a) of this section) and that—
(A) the required primary health services of
the center will be available and accessible in
the catchment area of the center promptly,
as appropriate, and in a manner which assures continuity;
(B) the center has made and will continue
to make every reasonable effort to establish
and maintain collaborative relationships
with other health care providers in the
catchment area of the center;
(C) the center will have an ongoing quality
improvement system that includes clinical
services and management, and that maintains the confidentiality of patient records;
(D) the center will demonstrate its financial responsibility by the use of such accounting procedures and other requirements
as may be prescribed by the Secretary;
(E) the center—
(i)(I) has or will have a contractual or
other arrangement with the agency of the
State, in which it provides services, which
administers or supervises the administration of a State plan approved under title
XIX of the Social Security Act [42 U.S.C.
1396 et seq.] for the payment of all or a
part of the center’s costs in providing
health services to persons who are eligible
for medical assistance under such a State
plan; and
(II) has or will have a contractual or
other arrangement with the State agency

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administering the program under title XXI
of such Act (42 U.S.C. 1397aa et seq.) with
respect to individuals who are State children’s health insurance program beneficiaries; or
(ii) has made or will make every reasonable effort to enter into arrangements described in subclauses (I) and (II) of clause
(i);
(F) the center has made or will make and
will continue to make every reasonable effort to collect appropriate reimbursement
for its costs in providing health services to
persons who are entitled to insurance benefits under title XVIII of the Social Security
Act [42 U.S.C. 1395 et seq.], to medical assistance under a State plan approved under title
XIX of such Act [42 U.S.C. 1396 et seq.], or to
assistance for medical expenses under any
other public assistance program or private
health insurance program;
(G) the center—
(i) has prepared a schedule of fees or payments for the provision of its services consistent with locally prevailing rates or
charges and designed to cover its reasonable costs of operation and has prepared a
corresponding schedule of discounts to be
applied to the payment of such fees or payments, which discounts are adjusted on the
basis of the patient’s ability to pay;
(ii) has made and will continue to make
every reasonable effort—
(I) to secure from patients payment for
services in accordance with such schedules; and
(II) to collect reimbursement for
health services to persons described in
subparagraph (F) on the basis of the full
amount of fees and payments for such
services without application of any discount;
(iii)(I) will assure that no patient will be
denied health care services due to an individual’s inability to pay for such services;
and
(II) will assure that any fees or payments
required by the center for such services
will be reduced or waived to enable the
center to fulfill the assurance described in
subclause (I); and
(iv) has submitted to the Secretary such
reports as the Secretary may require to
determine compliance with this subparagraph;
(H) the center has established a governing
board which except in the case of an entity
operated by an Indian tribe or tribal or Indian organization under the Indian Self-Determination Act [25 U.S.C. 450f et seq.] or an
urban Indian organization under the Indian
Health Care Improvement Act (25 U.S.C. 1651
et seq.)—
(i) is composed of individuals, a majority
of whom are being served by the center
and who, as a group, represent the individuals being served by the center;
(ii) meets at least once a month, selects
the services to be provided by the center,
schedules the hours during which such

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

services will be provided, approves the center’s annual budget, approves the selection
of a director for the center, and, except in
the case of a governing board of a public
center (as defined in the second sentence
of this paragraph), establishes general
policies for the center; and
(iii) in the case of an application for a
second or subsequent grant for a public
center, has approved the application or if
the governing body has not approved the
application, the failure of the governing
body to approve the application was unreasonable;
except that, upon a showing of good cause
the Secretary shall waive, for the length of
the project period, all or part of the requirements of this subparagraph in the case of a
health center that receives a grant pursuant
to subsection (g), (h), (i), or (p) of this section;
(I) the center has developed—
(i) an overall plan and budget that meets
the requirements of the Secretary; and
(ii) an effective procedure for compiling
and reporting to the Secretary such statistics and other information as the Secretary may require relating to—
(I) the costs of its operations;
(II) the patterns of use of its services;
(III) the availability, accessibility, and
acceptability of its services; and
(IV) such other matters relating to operations of the applicant as the Secretary may require;
(J) the center will review periodically its
catchment area to—
(i) ensure that the size of such area is
such that the services to be provided
through the center (including any satellite) are available and accessible to the
residents of the area promptly and as appropriate;
(ii) ensure that the boundaries of such
area conform, to the extent practicable, to
relevant boundaries of political subdivisions, school districts, and Federal and
State health and social service programs;
and
(iii) ensure that the boundaries of such
area eliminate, to the extent possible, barriers to access to the services of the center, including barriers resulting from the
area’s physical characteristics, its residential patterns, its economic and social
grouping, and available transportation;
(K) in the case of a center which serves a
population including a substantial proportion of individuals of limited English-speaking ability, the center has—
(i) developed a plan and made arrangements responsive to the needs of such population for providing services to the extent
practicable in the language and cultural
context most appropriate to such individuals; and
(ii) identified an individual on its staff
who is fluent in both that language and in
English and whose responsibilities shall
include providing guidance to such individ-

§ 254b

uals and to appropriate staff members with
respect to cultural sensitivities and bridging linguistic and cultural differences;
(L) the center, has developed an ongoing
referral relationship with one or more hospitals; and
(M) the center encourages persons receiving or seeking health services from the center to participate in any public or private
(including employer-offered) health programs or plans for which the persons are eligible, so long as the center, in complying
with this subparagraph, does not violate the
requirements of subparagraph (G)(iii)(I).
For purposes of subparagraph (H), the term
‘‘public center’’ means a health center funded
(or to be funded) through a grant under this
section to a public agency.
(4) Approval of new or expanded service applications
The Secretary shall approve applications for
grants under subparagraph (A) or (B) of subsection (e)(1) of this section for health centers
which—
(A) have not received a previous grant
under such subsection; or
(B) have applied for such a grant to expand
their services;
in such a manner that the ratio of the medically underserved populations in rural areas
which may be expected to use the services provided by such centers to the medically underserved populations in urban areas which may
be expected to use the services provided by
such centers is not less than two to three or
greater than three to two.
(l) Technical assistance
The Secretary shall establish a program
through which the Secretary shall provide (either through the Department of Health and
Human Services or by grant or contract) technical and other assistance to eligible entities to
assist such entities to meet the requirements of
subsection (k)(3) of this section. Services provided through the program may include necessary technical and nonfinancial assistance, including fiscal and program management assistance, training in fiscal and program management, operational and administrative support,
and the provision of information to the entities
of the variety of resources available under this
subchapter and how those resources can be best
used to meet the health needs of the communities served by the entities.
(m) Memorandum of agreement
In carrying out this section, the Secretary
may enter into a memorandum of agreement
with a State. Such memorandum may include,
where appropriate, provisions permitting such
State to—
(1) analyze the need for primary health services for medically underserved populations
within such State;
(2) assist in the planning and development of
new health centers;
(3) review and comment upon annual program plans and budgets of health centers, including comments upon allocations of health
care resources in the State;

§ 254b

TITLE 42—THE PUBLIC HEALTH AND WELFARE

(4) assist health centers in the development
of clinical practices and fiscal and administrative systems through a technical assistance
plan which is responsive to the requests of
health centers; and
(5) share information and data relevant to
the operation of new and existing health centers.
(n) Records
(1) In general
Each entity which receives a grant under
subsection (e) of this section shall establish
and maintain such records as the Secretary
shall require.
(2) Availability
Each entity which is required to establish
and maintain records under this subsection
shall make such books, documents, papers,
and records available to the Secretary or the
Comptroller General of the United States, or
any of their duly authorized representatives,
for examination, copying or mechanical reproduction on or off the premises of such entity
upon a reasonable request therefore. The Secretary and the Comptroller General of the
United States, or any of their duly authorized
representatives, shall have the authority to
conduct such examination, copying, and reproduction.
(o) Delegation of authority
The Secretary may delegate the authority to
administer the programs authorized by this section to any office, except that the authority to
enter into, modify, or issue approvals with respect to grants or contracts may be delegated
only within the central office of the Health Resources and Services Administration.
(p) Special consideration
In making grants under this section, the Secretary shall give special consideration to the
unique needs of sparsely populated rural areas,
including giving priority in the awarding of
grants for new health centers under subsections
(c) and (e) of this section, and the granting of
waivers as appropriate and permitted under subsections (b)(1)(B)(i) and (k)(3)(G) of this section.
(q) Audits
(1) In general
Each entity which receives a grant under
this section shall provide for an independent
annual financial audit of any books, accounts,
financial records, files, and other papers and
property which relate to the disposition or use
of the funds received under such grant and
such other funds received by or allocated to
the project for which such grant was made.
For purposes of assuring accurate, current,
and complete disclosure of the disposition or
use of the funds received, each such audit shall
be conducted in accordance with generally accepted accounting principles. Each audit shall
evaluate—
(A) the entity’s implementation of the
guidelines established by the Secretary respecting cost accounting,
(B) the processes used by the entity to
meet the financial and program reporting requirements of the Secretary, and

Page 246

(C) the billing and collection procedures of
the entity and the relation of the procedures
to its fee schedule and schedule of discounts
and to the availability of health insurance
and public programs to pay for the health
services it provides.
A report of each such audit shall be filed with
the Secretary at such time and in such manner as the Secretary may require.
(2) Records
Each entity which receives a grant under
this section shall establish and maintain such
records as the Secretary shall by regulation
require to facilitate the audit required by
paragraph (1). The Secretary may specify by
regulation the form and manner in which such
records shall be established and maintained.
(3) Availability of records
Each entity which is required to establish
and maintain records or to provide for and 2
audit under this subsection shall make such
books, documents, papers, and records available to the Secretary or the Comptroller General of the United States, or any of their duly
authorized representatives, for examination,
copying or mechanical reproduction on or off
the premises of such entity upon a reasonable
request therefore. The Secretary and the
Comptroller General of the United States, or
any of their duly authorized representatives,
shall have the authority to conduct such examination, copying, and reproduction.
(4) Waiver
The Secretary may, under appropriate circumstances, waive the application of all or
part of the requirements of this subsection
with respect to an entity.
(r) Authorization of appropriations
(1) In general
For the purpose of carrying out this section,
in addition to the amounts authorized to be
appropriated under subsection (d) of this section, there are authorized to be appropriated
$1,340,000,000 for fiscal year 2002 and such sums
as may be necessary for each of the fiscal
years 2003 through 2006.
(2) Special provisions
(A) Public centers
The Secretary may not expend in any fiscal year, for grants under this section to
public centers (as defined in the second sentence of subsection (k)(3) of this section) the
governing boards of which (as described in
subsection (k)(3)(H) of this section) do not
establish general policies for such centers,
an amount which exceeds 5 percent of the
amounts appropriated under this section for
that fiscal year. For purposes of applying
the preceding sentence, the term ‘‘public
centers’’ shall not include health centers
that receive grants pursuant to subsection
(h) or (i) of this section.
(B) Distribution of grants
For fiscal year 2002 and each of the following fiscal years, the Secretary, in awarding
2 So

in original. Probably should be ‘‘an’’.

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

grants under this section, shall ensure that
the proportion of the amount made available
under each of subsections (g), (h), and (i) of
this section, relative to the total amount appropriated to carry out this section for that
fiscal year, is equal to the proportion of the
amount made available under that subsection for fiscal year 2001, relative to the
total amount appropriated to carry out this
section for fiscal year 2001.
(3) Funding report
The Secretary shall annually prepare and
submit to the appropriate committees of Congress a report concerning the distribution of
funds under this section that are provided to
meet the health care needs of medically underserved populations, including the homeless,
residents of public housing, and migratory and
seasonal agricultural workers, and the appropriateness of the delivery systems involved in
responding to the needs of the particular populations. Such report shall include an assessment of the relative health care access needs
of the targeted populations and the rationale
for any substantial changes in the distribution
of funds.
(July 1, 1944, ch. 373, title III, § 330, as added Pub.
L. 104–299, § 2, Oct. 11, 1996, 110 Stat. 3626; amended Pub. L. 107–251, title I, § 101, Oct. 26, 2002, 116
Stat. 1622; Pub. L. 108–163, § 2(a), Dec. 6, 2003, 117
Stat. 2020.)
REFERENCES IN TEXT
The Federal Credit Reform Act of 1990, referred to in
subsec. (d)(1)(E), is title V of Pub. L. 93–344, as added by
Pub. L. 101–508, title XIII, § 13201(a), Nov. 5, 1990, 104
Stat. 1388–609, which is classified generally to subchapter III (§ 661 et seq.) of chapter 17A of Title 2, The
Congress. The Credit Reform Act of 1990, referred to in
subsec. (d)(4)(A), probably means the Federal Credit Reform Act of 1990. For complete classification of this Act
to the Code, see Short Title note set out under section
621 of Title 2 and Tables.
The Social Security Act, referred to in subsec.
(k)(3)(E)(i), (F), is act Aug. 14, 1935, ch. 531, 49 Stat. 620,
as amended. Titles XVIII, XIX, and XXI of the Act are
classified generally to subchapters XVIII (§ 1395 et seq.),
XIX (§ 1396 et seq.), and XXI (§ 1397aa et seq.) of chapter
7 of this title, respectively. For complete classification
of this Act to the Code, see section 1305 of this title and
Tables.
The Indian Self-Determination Act, referred to in
subsec. (k)(3)(H), is title I of Pub. L. 93–638, Jan. 4, 1975,
88 Stat. 2206, as amended, which is classified principally
to part A (§ 450f et seq.) of subchapter II of chapter 14
of Title 25, Indians. For complete classification of this
Act to the Code, see Short Title note set out under section 450 of Title 25 and Tables.
The Indian Health Care Improvement Act, referred to
in subsec. (k)(3)(H), is Pub. L. 94–437, Sept. 30, 1976, 90
Stat. 1400, as amended, which is classified principally
to chapter 18 (§ 1601 et seq.) of Title 25. For complete
classification of this Act to the Code, see Short Title
note set out under section 1601 of Title 25 and Tables.
PRIOR PROVISIONS
A prior section 254a–1, act July 1, 1944, ch. 373, title
III, § 328, as added Nov. 10, 1978, Pub. L. 95–626, title I,
§ 114, 92 Stat. 3563; amended Pub. L. 96–88, title V,
§ 509(b), Oct. 17, 1979, 93 Stat. 695, related to hospital-affiliated primary care centers, prior to repeal by Pub. L.
99–117, § 12(c), Oct. 7, 1985, 99 Stat. 495.
A prior section 254b, act July 1, 1944, ch. 373, title III,
§ 329, formerly § 310, as added Sept. 25, 1962, Pub. L.

§ 254b

87–692, 76 Stat. 592; amended Aug. 5, 1965, Pub. L. 89–109,
§ 3, 79 Stat. 436; Oct. 15, 1968, Pub. L. 90–574, title II,
§ 201, 82 Stat. 1006; Mar. 12, 1970, Pub. L. 91–209, 84 Stat.
52; June 18, 1973, Pub. L. 93–45, title I, § 105, 87 Stat. 91;
renumbered § 319, July 23, 1974, Pub. L. 93–353, title I,
§ 102(d), 88 Stat. 362; amended July 29, 1975, Pub. L.
94–63, title IV, § 401(a), title VII, § 701(c), 89 Stat. 334, 352;
Apr. 22, 1976, Pub. L. 94–278, title VIII, § 801(a), 90 Stat.
414; Aug. 1, 1977, Pub. L. 95–83, title III, § 303, 91 Stat.
388; renumbered § 329 and amended Nov. 10, 1978, Pub. L.
95–626, title I, §§ 102(a), 103(a)–(g)(1)(B), (2), (h), (i), 92
Stat. 3551–3555; July 10, 1979, Pub. L. 96–32, § 6(a), 93
Stat. 83; Oct. 17, 1979, Pub. L. 96–88, title V, § 509(b), 93
Stat. 695; Aug. 13, 1981, Pub. L. 97–35, title IX, § 930, 95
Stat. 569; Dec. 21, 1982, Pub. L. 97–375, title I, § 107(b), 96
Stat. 1820; Apr. 24, 1986, Pub. L. 99–280, §§ 6, 7, 100 Stat.
400, 401; Aug. 10, 1988, Pub. L. 100–386, § 2, 102 Stat. 919;
Nov. 6, 1990, Pub. L. 101–527, § 9(b), 104 Stat. 2333; Oct. 27,
1992, Pub. L. 102–531, title III, § 309(a), 106 Stat. 3499, related to migrant health centers, prior to the general
amendment of this subpart by Pub. L. 104–299, § 2.
Another prior section 254b, act July 1, 1944, ch. 373,
title III, § 329, as added Dec. 31, 1970, Pub. L. 91–623, § 2,
84 Stat. 1868; amended Nov. 18, 1971, Pub. L. 92–157, title
II, § 203, 85 Stat. 462; Oct. 27, 1972, Pub. L. 92–585, § 2, 86
Stat. 1290; July 29, 1975, Pub. L. 94–63, title VIII,
§§ 801–803, 89 Stat. 353, 354; Oct. 12, 1976, Pub. L. 94–484,
title I, § 101(b), 90 Stat. 2244, related to establishment of
National Health Service Corps, assignment of personnel
and statement of purpose, prior to repeal by Pub. L.
94–484, title IV, § 407(b)(1), Oct. 12, 1976, 90 Stat. 2268. See
section 254d et seq. of this title.
A prior section 330 of act July 1, 1944, was classified
to section 254c of this title prior to the general amendment of this subpart by Pub. L. 104–299.
AMENDMENTS
2003—Subsec. (c)(1)(B). Pub. L. 108–163, § 2(a)(2)(A),
substituted ‘‘plan.’’ for ‘‘plan..’’ in introductory provisions.
Subsec. (d)(1)(B)(iii)(I). Pub. L. 108–163, § 2(a)(2)(B), inserted ‘‘or’’ at end.
Subsec. (e)(3) to (5). Pub. L. 108–163, § 2(a)(1)(A),
amended pars. (3) to (5) to read as if subpar. (C) of the
second par. (4) of section 101 of Pub. L. 107–251 had not
been enacted. See 2002 Amendment notes below.
Subsec. (j). Pub. L. 108–163, § 2(a)(2)(E), added subsec.
(j) identical to the subsec. (j) appearing in the amendment by section 101(8)(C) of Pub. L. 107–251. See 2002
Amendment notes below. Former subsec. (j) redesignated (k).
Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (j) to
read as if pars. (8) through (11) of section 101 of Pub. L.
107–251 had not been enacted. See 2002 Amendment
notes below.
Subsec. (j)(3)(H). Pub. L. 108–163, § 2(a)(1)(B), amended
subpar. (H) to read as if subpar. (C) of par. (7) of section
101 of Pub. L. 107–251 had not been enacted. See 2002
Amendment note below.
Subsec. (k). Pub. L. 108–163, § 2(a)(2)(C), (D), redesignated subsec. (j) as (k) and struck out heading and text
of former subsec. (k). Text read as follows: ‘‘The Secretary may provide (either through the Department of
Health and Human Services or by grant or contract) all
necessary technical and other nonfinancial assistance
(including fiscal and program management assistance
and training in such management) to any public or private nonprofit entity to assist entities in developing
plans for, or operating as, health centers, and in meeting the requirements of subsection (j)(2) of this section.’’
Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (k) to
read as if pars. (8) through (11) of section 101 of Pub. L.
107–251 had not been enacted. See 2002 Amendment
notes below.
Subsec. (l). Pub. L. 108–163, § 2(a)(2)(H), inserted ‘‘(either through the Department of Health and Human
Services or by grant or contract)’’ after ‘‘shall provide’’
and substituted ‘‘(k)(3)’’ for ‘‘(l)(3)’’.
Pub. L. 108–163, § 2(a)(2)(G), added subsec. (l) identical
to the subsec. (m) appearing in the amendment by sec-

§ 254b

TITLE 42—THE PUBLIC HEALTH AND WELFARE

tion 101(9) of Pub. L. 107–251. See 2002 Amendment notes
below. Former subsec. (l) redesignated (r).
Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (l) to read
as if pars. (8) through (11) of section 101 of Pub. L.
107–251 had not been enacted. See 2002 Amendment note
below.
Subsecs. (m) to (o). Pub. L. 108–163, § 2(a)(1)(C), amended subsecs. (m) to (o) to read as if pars. (8) through (11)
of section 101 of Pub. L. 107–251 had not been enacted.
See 2002 Amendment notes below.
Subsec. (p). Pub. L. 108–163, § 2(a)(2)(I), substituted
‘‘(k)(3)(G)’’ for ‘‘(j)(3)(G)’’.
Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (p) to
read as if pars. (8) through (11) of section 101 of Pub. L.
107–251 had not been enacted. See 2002 Amendment note
below.
Subsec. (q). Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (q) to read as if pars. (8) through (11) of section 101
of Pub. L. 107–251 had not been enacted. See 2002
Amendment note below.
Subsec. (r). Pub. L. 108–163, § 2(a)(2)(F), redesignated
subsec. (l) as (r).
Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (r) to
read as if pars. (8) through (11) of section 101 of Pub. L.
107–251 had not been enacted. See 2002 Amendment note
below.
Subsec. (r)(1). Pub. L. 108–163, § 2(a)(2)(J)(i), substituted ‘‘$1,340,000,000 for fiscal year 2002 and such
sums as may be necessary for each of the fiscal years
2003 through 2006’’ for ‘‘$802,124,000 for fiscal year 1997,
and such sums as may be necessary for each of the fiscal years 1998 through 2001’’.
Subsec. (r)(2)(A). Pub. L. 108–163, § 2(a)(2)(J)(ii), substituted ‘‘(k)(3)’’ for ‘‘(j)(3)’’ and ‘‘(k)(3)(H)’’ for
‘‘(j)(3)(G)(ii)’’.
Subsec. (r)(2)(B). Pub. L. 108–163, § 2(a)(2)(J)(iii), added
subpar. (B) identical to the subpar. (B) appearing in the
amendment by section 101(11)(B)(ii) of Pub. L. 107–251
and struck out heading and text of former subpar. (B)
relating to distribution of grants for fiscal years 1997
through 1999. See 2002 Amendment note below.
Subsec. (s). Pub. L. 108–163, § 2(a)(1)(C), amended subsec. (s) to read as if pars. (8) through (11) of section 101
of Pub. L. 107–251 had not been enacted. See 2002
Amendment notes below.
2002—Subsec. (b)(1)(A)(i)(III)(bb). Pub. L. 107–251,
§ 101(1)(A), substituted ‘‘appropriate cancer screening’’
for ‘‘screening for breast and cervical cancer’’.
Subsec. (b)(1)(A)(ii). Pub. L. 107–251, § 101(1)(B), inserted ‘‘(including specialty referral when medically indicated)’’ after ‘‘medical services’’.
Subsec. (b)(1)(A)(iii). Pub. L. 107–251, § 101(1)(C), inserted ‘‘housing,’’ after ‘‘social,’’.
Subsec. (b)(2)(A). Pub. L. 107–251, § 101(2)(C), added
subpar. (A). Former subpar. (A) redesignated (C).
Subsec. (b)(2)(A)(i). Pub. L. 107–251, § 101(2)(A), substituted ‘‘associated with—’’ and subcls. (I) to (IV) for
‘‘associated with water supply;’’.
Subsec. (b)(2)(B) to (D). Pub. L. 107–251, § 101(2)(B), (C),
added subpar. (B) and redesignated former subpars. (A)
and (B) as (C) and (D), respectively.
Subsec. (c)(1)(B). Pub. L. 107–251, § 101(3)(A)(iii),
struck out concluding provisions which read as follows:
‘‘Any such grant may include the acquisition and lease
of buildings and equipment which may include data and
information systems (including the costs of amortizing
the principal of, and paying the interest on, loans), and
providing training and technical assistance related to
the provision of health services on a prepaid basis or
under another managed care arrangement, and for
other purposes that promote the development of managed care networks and plans.’’
Pub. L. 107–251, § 101(3)(A)(ii), in introductory provisions, substituted ‘‘managed care network or plan.’’ for
‘‘network or plan for the provision of health services,
which may include the provision of health services on
a prepaid basis or through another managed care arrangement, to some or to all of the individuals which
the centers serve’’.
Pub. L. 107–251, § 101(3)(A)(i), substituted ‘‘Managed
care’’ for ‘‘Comprehensive service delivery’’ in heading.

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Subsec. (c)(1)(C), (D). Pub. L. 107–251, § 101(3)(B), added
subpars. (C) and (D).
Subsec. (d). Pub. L. 107–251, § 101(4)(A), substituted
‘‘Loan guarantee program’’ for ‘‘Managed care loan
guarantee program’’ in heading.
Subsec. (d)(1)(A). Pub. L. 107–251, § 101(4)(B)(i), substituted ‘‘up to 90 percent of the principal and interest
on loans made by non-Federal lenders to health centers, funded under this section, for the costs of developing and operating managed care networks or plans described in subsection (c)(1)(B) of this section, or practice management networks described in subsection
(c)(1)(C) of this section’’ for ‘‘the principal and interest
on loans made by non-Federal lenders to health centers
funded under this section for the costs of developing
and operating managed care networks or plans’’.
Subsec. (d)(1)(B)(iii). Pub. L. 107–251, § 101(4)(B)(ii),
added cl. (iii).
Subsec. (d)(1)(D), (E). Pub. L. 107–251, § 101(4)(B)(iii),
added subpars. (D) and (E).
Subsec. (d)(6) to (8). Pub. L. 107–251, § 101(4)(C), redesignated par. (8) as (6) and struck out headings and text
of former pars. (6) and (7) which related to annual reports and program evaluation, respectively.
Subsec. (e)(1)(B). Pub. L. 107–251, § 101(4)(A)(i), substituted ‘‘subsection (k)(3)’’ for ‘‘subsection (j)(3)’’.
Subsec. (e)(1)(C). Pub. L. 107–251, § 101(4)(A)(ii), added
subpar. (C).
Subsec. (e)(3). Pub. L. 107–251, § 101(4)(C), redesignated
par. (4), relating to limitation, as (3).
Subsec. (e)(4). Pub. L. 107–251, § 101(4)(C), redesignated
par. (5) as (4). Former par. (4) redesignated (3).
Subsec. (e)(5). Pub. L. 107–251, § 101(4)(B), (C), redesignated par. (5) as (4), inserted ‘‘subparagraphs (A) and
(B) of’’ after ‘‘any fiscal year under’’ in subpar. (A),
added subpar. (B), and redesignated former subpars. (B)
and (C) as (C) and (D), respectively.
Subsec. (g)(2)(A). Pub. L. 107–251, § 101(5)(A)(i), inserted ‘‘and seasonal agricultural worker’’ after ‘‘migratory agricultural worker’’.
Subsec. (g)(2)(B). Pub. L. 107–251, § 101(5)(A)(ii), substituted ‘‘and seasonal agricultural workers, and members of their families,’’ for ‘‘and members of their families’’.
Subsec. (g)(3)(A). Pub. L. 107–251, § 101(5)(B), struck
out ‘‘on a seasonal basis’’ after ‘‘in agriculture’’.
Subsec. (h)(1). Pub. L. 107–251, § 101(6)(A), substituted
‘‘homeless children and youth and children and youth
at risk of homelessness’’ for ‘‘homeless children and
children at risk of homelessness’’.
Subsec. (h)(4). Pub. L. 107–251, § 101(6)(B)(ii), added
par. (4). Former par. (4) redesignated (5).
Subsec. (h)(5). Pub. L. 107–251, § 101(6)(B)(i), (C), redesignated par. (4) as (5) and substituted ‘‘, risk reduction,
outpatient treatment, residential treatment, and rehabilitation’’ for ‘‘and residential treatment’’ in subpar.
(C).
Subsec. (j). Pub. L. 107–251, § 101(8)(C), added subsec.
(j) relating to access grants.
Pub. L. 107–251, § 101(8)(B), which directed the redesignation of subsecs. (j), (k), and (m) through (q) as subsecs. (n), (o), and (p) through (s), respectively, could not
be executed.
Subsec. (j)(3)(E)(i). Pub. L. 107–251, § 101(7)(A)(i), designated existing provisions as subcl. (I) and added
subcl. (II).
Subsec. (j)(3)(E)(ii). Pub. L. 107–251, § 101(7)(A)(ii), substituted ‘‘arrangements described in subclauses (I) and
(II) of clause (i)’’ for ‘‘such an arrangement’’.
Subsec. (j)(3)(G)(iii), (iv). Pub. L. 107–251, § 101(7)(B),
added cl. (iii) and redesignated former cl. (iii) as (iv).
Subsec. (j)(3)(H). Pub. L. 107–251, § 101(7)(C), substituted ‘‘or (q)’’ for ‘‘or (p)’’ in concluding provisions.
Subsec. (j)(3)(M). Pub. L. 107–251, § 101(7)(D)–(F), added
subpar. (M).
Subsec. (k). Pub. L. 107–251, § 101(8)(B), which directed
the redesignation of subsecs. (j), (k), and (m) through
(q) as subsecs. (n), (o), and (p) through (s), respectively,
could not be executed.
Subsec. (l). Pub. L. 107–251, § 101(8)(A), redesignated
subsec. (l) as (s).

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

Subsec. (m). Pub. L. 107–251, § 101(9), which directed
striking subsec. (m) (as redesignated by paragraph
(9)(B)) and adding a new subsec. (m), could not be executed. The new subsec. (m) to be added read as follows:
‘‘(m) TECHNICAL ASSISTANCE.—The Secretary shall establish a program through which the Secretary shall
provide technical and other assistance to eligible entities to assist such entities to meet the requirements of
subsection (l)(3) of this section. Services provided
through the program may include necessary technical
and nonfinancial assistance, including fiscal and program management assistance, training in fiscal and
program management, operational and administrative
support, and the provision of information to the entities of the variety of resources available under this subchapter and how those resources can be best used to
meet the health needs of the communities served by
the entities.’’
Pub. L. 107–251, § 101(8)(B), which directed the redesignation of subsecs. (j), (k), and (m) through (q) as subsecs. (n), (o), and (p) through (s), respectively, could not
be executed.
Subsecs. (n) to (p). Pub. L. 107–251, § 101(8)(B), which
directed the redesignation of subsecs. (j), (k), and (m)
through (q) as subsecs. (n), (o), and (p) through (s), respectively, could not be executed.
Subsec. (q). Pub. L. 107–251, § 101(10), which directed
the substitution of ‘‘(l)(3)(G)’’ for ‘‘(j)(3)(G)’’ in subsec.
(q) ‘‘(as redesignated by paragraph (9)(B))’’, could not
be executed.
Pub. L. 107–251, § 101(8)(B), which directed the redesignation of subsecs. (j), (k), and (m) through (q) as subsecs. (n), (o), and (p) through (s), respectively, could not
be executed.
Subsec. (r). Pub. L. 107–251, § 101(8)(B), which directed
the redesignation of subsecs. (j), (k), and (m) through
(q) as subsecs. (n), (o), and (p) through (s), respectively,
could not be executed.
Subsec. (s). Pub. L. 107–251, § 101(8)(B), which directed
the redesignation of subsecs. (j), (k), and (m) through
(q) as subsecs. (n), (o), and (p) through (s), respectively,
could not be executed.
Subsec. (s)(1). Pub. L. 107–251, § 101(11)(A), substituted
‘‘$1,340,000,000 for fiscal year 2002 and such sums as may
be necessary for each of the fiscal years 2003 through
2006’’ for ‘‘$802,124,000 for fiscal year 1997, and such sums
as may be necessary for each of the fiscal years 1998
through 2001’’.
Subsec. (s)(2)(A). Pub. L. 107–251, § 101(11)(B)(i), substituted ‘‘(l)(3)’’ for ‘‘(j)(3)’’ and ‘‘(l)(3)(H)’’ for
‘‘(j)(3)(G)(ii)’’.
Subsec. (s)(2)(B). Pub. L. 107–251, § 101(11)(B)(ii), added
subpar. (B) and struck out heading and text of former
subpar. (B) relating to distribution of grants for fiscal
years 1997 through 1999.
EFFECTIVE DATE OF 2003 AMENDMENT
Amendments by Pub. L. 108–163 deemed to have taken
effect immediately after the enactment of Pub. L.
107–251, see section 3 of Pub. L. 108–163, set out as a note
under section 233 of this title.
EFFECTIVE DATE
Section effective Oct. 1, 1996, see section 5 of Pub. L.
104–299, as amended, set out as an Effective Date of 1996
Amendment note under section 233 of this title.
SAVINGS PROVISION FOR CURRENT GRANTS, CONTRACTS,
AND COOPERATIVE AGREEMENTS
Section 3(b) of Pub. L. 104–299 provided that: ‘‘The
Secretary of Health and Human Services shall ensure
the continued funding of grants made, or contracts or
cooperative agreements entered into, under subpart I of
part D of title III of the Public Health Service Act (42
U.S.C. 254b et seq.) (as such subpart existed on the day
prior to the date of enactment of this Act [Oct. 11,
1996]), until the expiration of the grant period or the
term of the contract or cooperative agreement. Such
funding shall be continued under the same terms and

§ 254c

conditions as were in effect on the date on which the
grant, contract or cooperative agreement was awarded,
subject to the availability of appropriations.’’
GUARANTEE STUDY
Pub. L. 107–251, title V, § 501, Oct. 26, 2002, 116 Stat.
1664, as amended by Pub. L. 108–163, § 2(n)(2), Dec. 6,
2003, 117 Stat. 2023, provided that: ‘‘The Secretary of
Health and Human Services shall conduct a study regarding the ability of the Department of Health and
Human Services to provide for guarantees of solvency
for managed care networks or plans involving health
centers receiving funding under section 330 of the Public Health Service Act [this section]. The Secretary
shall prepare and submit a report to the appropriate
Committees of Congress regarding such ability not
later than 2 years after the date of enactment of the
Health Care Safety Net Amendments of 2002 [Oct. 26,
2002].’’
REFERENCE TO COMMUNITY, MIGRANT, PUBLIC HOUSING,
OR HOMELESS HEALTH CENTER CONSIDERED REFERENCE TO HEALTH CENTER
Section 4(c) of Pub. L. 104–299 provided that: ‘‘Whenever any reference is made in any provision of law, regulation, rule, record, or document to a community
health center, migrant health center, public housing
health center, or homeless health center, such reference shall be considered a reference to a health center.’’
LEGISLATIVE PROPOSAL FOR CHANGES CONFORMING TO
PUB. L. 104–299
Section 4(e) of Pub. L. 104–299 provided that: ‘‘After
consultation with the appropriate committees of the
Congress, the Secretary of Health and Human Services
shall prepare and submit to the Congress a legislative
proposal in the form of an implementing bill containing technical and conforming amendments to reflect
the changes made by this Act [see Short Title of 1996
Amendments note set out under section 201 of this
title].’’

§ 254c. Rural health care services outreach, rural
health network development, and small
health care provider quality improvement
grant programs
(a) Purpose
The purpose of this section is to provide
grants for expanded delivery of health care services in rural areas, for the planning and implementation of integrated health care networks in
rural areas, and for the planning and implementation of small health care provider quality improvement activities.
(b) Definitions
(1) Director
The term ‘‘Director’’ means the Director
specified in subsection (d) of this section.
(2) Federally qualified health center; rural
health clinic
The terms ‘‘Federally qualified health center’’ and ‘‘rural health clinic’’ have the meanings given the terms in section 1395x(aa) of
this title.
(3) Health professional shortage area
The term ‘‘health professional shortage
area’’ means a health professional shortage
area designated under section 254e of this
title.
(4) Medically underserved community
The term ‘‘medically underserved community’’ has the meaning given the term in section 295p(6) of this title.