42 U.S.C. § 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 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)); and (B) as may be appropriate for particular centers, additional health services (as defined in subsection (b)(2)) 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). **(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 vaccine-preventable diseases; (ee) screenings for elevated blood lead levels, communicable diseases, and cholesterol; (ff) pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care; (gg) voluntary family planning services; and (hh) preventive dental services; (IV) emergency medical services; and (V) pharmaceutical services as may be appropriate for particular centers; (ii) referrals to providers of medical services (including specialty referral when medically indicated) and other health-related services (including substance use disorder and mental health services); (iii) patient case management services (including counseling, referral, and follow-up services) and other services designed to assist health center patients in establishing eligibility for and gaining access to 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), 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 use disorder 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), 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 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) **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— (A) 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; (B) the design of a health center program for such population based on such assessment; (C) efforts to secure, within the proposed catchment area of such center, financial and professional assistance and support for the project; (D) initiation and encouragement of continuing community involvement in the development and operation of the project; and (E) 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. (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. (3) **Recognition of high poverty** (A) *In general* — In making grants under this subsection, the Secretary may recognize the unique needs of high poverty areas. (B) *High poverty area defined* — For purposes of subparagraph (A), the term “high poverty area” means a catchment area which is established in a manner that is consistent with the factors in subsection (k)(3)(J), and the poverty rate of which is greater than the national average poverty rate as determined by the Bureau of the Census. **(d) Improving quality of care** (1) **Supplemental awards** — The Secretary may award supplemental grant funds to health centers funded under this section to implement evidence-based models for increasing access to high-quality primary care services, which may include models related to— (A) improving the delivery of care for individuals with multiple chronic conditions; (B) workforce configuration; (C) reducing the cost of care; (D) enhancing care coordination; (E) expanding the use of telehealth and technology-enabled collaborative learning and capacity building models; (F) care integration, including integration of behavioral health, mental health, or substance use disorder services; (G) addressing emerging public health or substance use disorder issues to meet the health needs of the population served by the health center; and (H) improving access to recommended immunizations. (2) **Sustainability** — In making supplemental awards under this subsection, the Secretary may consider whether the health center involved has submitted a plan for continuing the activities funded under this subsection after supplemental funding is expended. (3) **Special consideration** — The Secretary may give special consideration to applications for supplemental funding under this subsection that seek to address significant barriers to access to care in areas with a greater shortage of health care providers and health services relative to the national average. **(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 1 year, 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). The Secretary shall not make a grant under this paragraph unless the applicant provides assurances to the Secretary that within 120 days of receiving grant funding for the operation of the health center, the applicant will submit, for approval by the Secretary, an implementation plan to meet the requirements of subsection (k)(3). The Secretary may extend such 120-day period for achieving compliance upon a demonstration of good cause by the health center. (C) *Operation of networks* — 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 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 including— (i) the purchase or lease of equipment, which may include data and information systems (including the costs of amortizing the principal of, and paying the interest on, loans for equipment); (ii) the provision of training and technical assistance; and (iii) other activities that— (I) reduce costs associated with the provision of health services; (II) improve access to, and availability of, health services provided to individuals served by the centers; (III) enhance the quality and coordination of health services; or (IV) improve the health status of communities. (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 expanding 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* — The total amount of grant funds made available for any fiscal year under paragraph (1)(C) to a health center or to a network 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. (6) **New access points and expanded services** (A) *Approval of new access points* (i) *In general* — The Secretary may approve applications for grants under subparagraph (A) or (B) of paragraph (1) to establish new delivery sites. (ii) *Special consideration* — In carrying out clause (i), the Secretary may give special consideration to applicants that have demonstrated the new delivery site will be located within a sparsely populated area, or an area which has a level of unmet need that is higher relative to other applicants. (iii) *Consideration of applications* — In carrying out clause (i), the Secretary shall approve applications for grants 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 the applicants involved to the medically underserved populations in urban areas which may be expected to use the services provided by the applicants is not less than two to three or greater than three to two. (iv) *Service area overlap* — If in carrying out clause (i) the applicant proposes to serve an area that is currently served by another health center funded under this section, the Secretary may consider whether the award of funding to an additional health center in the area can be justified based on the unmet need for additional services within the catchment area. (v) *Mobile units* — An existing health center may be awarded funds under clause (i) to establish a new delivery site that is a mobile unit, regardless of whether the applicant additionally proposes to establish a permanent, full-time site. In the case of a health center that is not currently receiving funds under this section, such health center may be awarded funds under clause (i) to establish a new delivery site that is a mobile unit only if such health center uses a portion of such funds to also establish a permanent, full-time site. (B) *Approval of expanded service applications* (i) *In general* — The Secretary may approve applications for grants under subparagraph (A) or (B) of paragraph (1) to expand the capacity of the applicant to provide required primary health services described in subsection (b)(1) or additional health services described in subsection (b)(2). (ii) *Priority expansion projects* — In carrying out clause (i), the Secretary may give special consideration to expanded service applications that seek to address emerging public health or behavioral health, mental health, or substance abuse issues through increasing the availability of additional health services described in subsection (b)(2) in an area in which there are significant barriers to accessing care. (iii) *Consideration of applications* — In carrying out clause (i), the Secretary shall approve applications for grants 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 the applicants involved to the medically underserved populations in urban areas which may be expected to use the services provided by such applicants is not less than two to three or greater than three to two. **(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 providing services to any medically underserved population among which there is a substantial incidence of infant mortality or among which there is a significant increase in the incidence of infant mortality. (3) **Requirements** — The Secretary may make a grant under this subsection only if the health center involved agrees that— (A) the center will coordinate the provision of services under the grant to each of the recipients of the services; (B) such services will be continuous for each such recipient; (C) the center will provide follow-up services for individuals who are referred by the center for services described in paragraph (1); (D) the grant will be expended to supplement, and not supplant, the expenditures of the center for primary health services (including prenatal care) with respect to the purpose described in this subsection; and (E) the center will coordinate the provision of services with other maternal and child health providers operating in the catchment area. **(g) Migratory and seasonal agricultural workers** (1) **In general** — The Secretary may award grants for the purposes described in subsections (c), (e), and (f) for the planning and delivery of services to a special medically 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. (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) 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, children and youth at risk of homelessness, homeless veterans, and veterans at risk of homelessness. (2) **Required services** — In addition to required primary health services (as defined in subsection (b)(1)), an entity that receives a grant under this subsection shall be required to provide substance abuse services as a condition of such grant. (3) **Supplement not supplant requirement** — A grant awarded under this subsection shall be expended to 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. (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 use disorder services* — The term “substance use disorder 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) 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1437a/b/1&num=0&edition=prelim)) 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); (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 unmet need** — An application for a grant under subparagraph (A) or (B) of subsection (e)(1) or subsection (e)(6) for a health center shall include— (A) a description of the unmet 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; (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; and (D) in the case of an application for a grant pursuant to subsection (e)(6), a demonstration that the applicant has consulted with appropriate State and local government agencies, and health care providers regarding the need for the health services to be provided at the proposed delivery site. Such a demonstration shall be made on the basis of the criteria prescribed by the Secretary under subsection (b)(3) or on any other criteria which the Secretary may prescribe to determine if the area or population group to be served by the applicant has a shortage of personal health services. In considering an application for a grant under subparagraph (A) or (B) of subsection (e)(1), 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) 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) or subsection (e)(6), the Secretary may not approve an application for a grant under subparagraph (A) or (B) of subsection (e)(1) unless the Secretary determines that the entity for which the application is submitted is a health center (within the meaning of subsection (a)) and that— (A) the required primary health services of the center will be available and accessible in the catchment area of the center promptly, as appropriate, and in a manner which assures continuity; (B) the center has made and will continue to make every reasonable effort to establish and maintain collaborative relationships with other health care providers, including other health care providers that provide care within the catchment area, local hospitals, and specialty providers in the catchment area of the center, to provide access to services not available through the health center and to reduce the non-urgent use of hospital emergency departments; (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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396&num=0&edition=prelim) 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 administering the program under title XXI of such Act ([42 U.S.C. 1397aa](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397aa&num=0&edition=prelim) 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395&num=0&edition=prelim) et seq.], to medical assistance under a State plan approved under title XIX of such Act [[42 U.S.C. 1396](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396&num=0&edition=prelim) 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. 5321](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title25-section5321&num=0&edition=prelim) et seq.] or an urban Indian organization under the Indian Health Care Improvement Act ([25 U.S.C. 1651](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title25-section1651&num=0&edition=prelim) 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 services will be provided, approves the center’s annual budget, approves the selection of a director for the center who shall be directly employed by 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); (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 individuals 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; (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); and (N) the center has written policies and procedures in place to ensure the appropriate use of Federal funds in compliance with applicable Federal statutes, regulations, and the terms and conditions of the Federal award. 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. **(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). 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. Funds expended to carry out activities under this subsection and operational support activities under subsection (m) shall not exceed 3 percent of the amount appropriated for this section for the fiscal year involved. **(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; (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) 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), and the granting of waivers as appropriate and permitted under subsections (b)(1)(B)(i) and (k)(3)(G). **(q) Audits** (1) **In general** — Each entity which receives a grant under this section shall provide for an independent annual financial audit of any books, accounts, financial records, files, and other papers and property which relate to the disposition or use of the funds received under such grant and such other funds received by or allocated to the project for which such grant was made. For purposes of assuring accurate, current, and complete disclosure of the disposition or use of the funds received, each such audit shall be conducted in accordance with generally accepted accounting principles. Each audit shall evaluate— (A) the entity’s implementation of the guidelines established by the Secretary respecting cost accounting, (B) the processes used by the entity to meet the financial and program reporting requirements of the Secretary, and (C) the billing and collection procedures of the entity and the relation of the procedures to its fee schedule and schedule of discounts and to the availability of health 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 11 So in original. Probably should be “an”. 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. A waiver provided by the Secretary under this paragraph may not remain in effect for more than 1 year and may not be extended after such period. An entity may not receive more than one waiver under this paragraph in consecutive years. **(r) Authorization of appropriations** (1) **General amounts for grants** — For the purpose of carrying out this section, in addition to the amounts authorized to be appropriated under subsection (d), there is authorized to be appropriated the following: (A) For fiscal year 2010, $2,988,821,592. (B) For fiscal year 2011, $3,862,107,440. (C) For fiscal year 2012, $4,990,553,440. (D) For fiscal year 2013, $6,448,713,307. (E) For fiscal year 2014, $7,332,924,155. (F) For fiscal year 2015, $8,332,924,155. (G) For fiscal year 2016, and each subsequent fiscal year, the amount appropriated for the preceding fiscal year adjusted by the product of— (i) one plus the average percentage increase in costs incurred per patient served; and (ii) one plus the average percentage increase in the total number of patients served. (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)) the governing boards of which (as described in subsection (k)(3)(H)) 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). (B) *Distribution of grants* — For fiscal year 2002 and each of the following fiscal years, the Secretary, in awarding grants under this section, shall ensure that the proportion of the amount made available under each of subsections (g), (h), and (i), 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 Committee on Health, Education, Labor, and Pensions of the Senate, and the Committee on Energy and Commerce of the House of Representatives, a report including, at a minimum— (A) the distribution of funds for carrying out 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; (B) an assessment of the relative health care access needs of the targeted populations; (C) the distribution of awards and funding for new or expanded services in each of rural areas and urban areas; (D) the distribution of awards and funding for establishing new access points, and the number of new access points created; (E) the amount of unexpended funding for loan guarantees and loan guarantee authority under subchapter XIV; (F) the rationale for any substantial changes in the distribution of funds; (G) the rate of closures for health centers and access points; (H) the number and reason for any grants awarded pursuant to subsection (e)(1)(B); and (I) the number and reason for any waivers provided pursuant to subsection (q)(4). (4) **Rule of construction with respect to rural health clinics** (A) *In general* — Nothing in this section shall be construed to prevent a community health center from contracting with a Federally certified rural health clinic (as defined in section 1861(aa)(2) of the Social Security Act [[42 U.S.C. 1395x(aa)(2)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/aa/2&num=0&edition=prelim)]), a low-volume hospital (as defined for purposes of section 1886 of such Act [[42 U.S.C. 1395ww](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww&num=0&edition=prelim)]), a critical access hospital, a sole community hospital (as defined for purposes of section 1886(d)(5)(D)(iii) of such Act), or a medicare-dependent share hospital (as defined for purposes of section 1886(d)(5)(G)(iv) of such Act) for the delivery of primary health care services that are available at the clinic or hospital to individuals who would otherwise be eligible for free or reduced cost care if that individual were able to obtain that care at the community health center. Such services may be limited in scope to those primary health care services available in that clinic or hospitals.22 So in original. Probably should be “hospital”. (B) *Assurances* — In order for a clinic or hospital to receive funds under this section through a contract with a community health center under subparagraph (A), such clinic or hospital shall establish policies to ensure— (i) nondiscrimination based on the ability of a patient to pay; and (ii) the establishment of a sliding fee scale for low-income patients. (5) **Funding for participation of health centers in All of Us Research Program** — In addition to any amounts made available pursuant to paragraph (1) of this subsection, [section 282a of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section282a&num=0&edition=prelim), or [section 254b–2 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b-2&num=0&edition=prelim), there is authorized to be appropriated, and there is appropriated, out of any monies in the Treasury not otherwise appropriated, to the Secretary $25,000,000 for fiscal year 2018 to support the participation of health centers in the All of Us Research Program under the Precision Medicine Initiative under [section 289g–5 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section289g-5&num=0&edition=prelim). (6) **Additional amounts for supplemental awards** — In addition to any amounts made available pursuant to this subsection, [section 282a of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section282a&num=0&edition=prelim), or section 254b—2 of this title, there is authorized to be appropriated, and there is appropriated, out of any monies in the Treasury not otherwise appropriated, $1,320,000,000 for fiscal year 2020 for supplemental awards under subsection (d) for the detection of SARS–CoV–2 or the prevention, diagnosis, and treatment of COVID–19.