Health Equity and Accountability Act of 2024

The purpose of the amendments made by this subsection is to promote culturally and linguistically appropriate data collection, analysis, and reporting by race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, age, and socioeconomic status in federally supported health programs.

Section 902(a) of the Public Health Service Act (42 U.S.C. 299a(a)) is amended—

(A) in paragraph (8), by striking and at the end;

(B) in paragraph (9), by striking the period at the end and inserting; and; and

(C) by adding at the end the following:

(10) cultural and linguistic competence of health care services and of data collection activities described under section 3101.

Section 1707(g)(1) of the Public Health Service Act (42 U.S.C. 300u–6(g)(1)) is amended to read as follows:

(A) The term racial and ethnic minority group means a group of individuals who are any of the following:

(i) American Indian or Alaska Native.

(ii) Asian.

(iii) Black or African American.

(iv) Hispanic or Latino.

(v) Middle Eastern or North African.

(vi) Native Hawaiian or Pacific Islander.

(B) The terms listed in clauses (i) through (vi) of subparagraph (A) shall have the meanings given such terms for purposes of the Revisions to OMB's Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (89 Fed. Reg. 22182; March 29, 2024).

Except as otherwise specified, any reference to the term racial and ethnic minority group in any Federal regulation, guidance, order, or document for establishment or implementation of any federally conducted or supported health care or public health program, activity, or survey shall be treated as having the definition given to such term in section 1707(g) of the Public Health Service Act (42 U.S.C. 300u–6(g)).

Not later than 2 years after the date of enactment of this Act, the Secretary of Health and Human Services shall—

(i) identify all regulations, guidance, orders, and documents of the Department of Health and Human Services for establishment or implementation of a health care or public health program, activity, or survey that use, without a definition, terminology that is similar to the term racial and ethnic minority group; and

(ii) take such actions as may be necessary to clarify whether the definition of the term racial and ethnic minority group in section 1707(g)(1) of the Public Health Service Act (42 U.S.C. 300u–6(g)(1)), as amended by subparagraph (A), applies to such terminology.

Section 1707(b)(6) of the Public Health Service Act (42 U.S.C. 300u–6(b)(6)) is amended by inserting and, to the extent practicable, subgroups of racial and ethnic minority groups after the health status of each minority group.

Section 3001 of the Public Health Service Act (42 U.S.C. 300jj–11) is amended—

(A) in subsection (b)—

(i) in paragraph (10), by striking and at the end;

(ii) in paragraph (11), by striking the period at the end and inserting; and; and

(iii) by adding at the end the following:

(12) ensures the interoperability of health information systems among federally conducted or supported health care or public health programs, State health agencies, and social service agencies.

(iii) ; and

(B) by amending clause (vii) in subsection (c)(3)(A) to read as follows:

(vii) Strategies to enhance the use of health information technology in improving the quality of health care; reducing medical errors; reducing health disparities and ensuring the provision of equitable health services; improving public health; increasing prevention and coordination with community resources; ensuring interoperability among federally conducted or supported health care or public health programs, State health agencies, and social service agencies; and improving the continuity of care among health care settings.

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

(A) in subsections (a)(1)(A), (a)(1)(C), (a)(2)(B), and (a)(2)(E), by striking and disability status and inserting sexual orientation, gender identity, age, disability status, and socioeconomic status;

(B) in subsection (a)(1), by amending subparagraph (D) to read as follows:

(D) data for additional population groups if such groups can be aggregated into the data collection standards described under paragraph (2).

(C) in subsection (a)(2)—

(i) in subparagraph (C)—

(I) in clause (i), by striking and at the end;

(II) in clause (ii)—

(aa) by striking is a minor or legally incapacitated and inserting is a minor, requires assistance with communication in speech or writing, or is legally incapacitated; and

(bb) by striking the semicolon at the end and inserting; and; and

(III) by adding at the end the following:

(iii) collects data in a manner that is culturally and linguistically appropriate and does not include questions unrelated to, or that could potentially deter, care, such as questions related to immigration status;

(ii) in subparagraph (D)(iii), by striking and at the end;

(iii) in subparagraph (E), by striking the period at the end and inserting; and; and

(iv) by adding at the end the following:

(F) use, where practicable, the standards developed by the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (formerly known as the Institute of Medicine) in the 2009 publication titled Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement.

(iv) ; and

(D) in subsection (a)(3), by amending subparagraph (B) to read as follows:

(B) develop interoperability and security systems for data management among federally conducted or supported health care or public health programs, State health agencies, and social service agencies.

The Data Council of the Department of Health and Human Services, in consultation with the Director of the National Center for Health Statistics, the Deputy Assistant Secretary for Minority Health, the Deputy Assistant Secretary for Women’s Health, the Administrator of the Centers for Medicare & Medicaid, the National Coordinator for Health Information Technology, and other appropriate public and private entities and officials, shall make recommendations to the Secretary of Health and Human Services concerning how to—

(A) implement the amendments made by this section, while minimizing the cost and administrative burdens of data collection and reporting on all parties, including patients and providers;

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

(C) ensure that future patient record systems follow Federal standards promulgated under the HITECH Act (42 U.S.C. 201 note) for the collection and meaningful use of electronic health data on race, ethnicity, sex, primary language, sexual orientation, gender identity, age, socioeconomic status, and disability status;

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

(E) provide researchers with greater access to racial, ethnic, primary language, sex, sexual orientation, gender identity, age, socioeconomic status, and disability status data, subject to all applicable privacy and confidentiality requirements, including HIPAA privacy and security law as defined in section 3009(a) of the Public Health Service Act (42 U.S.C. 300jj–19(a));

(F) ensure the cultural and linguistic competence of entities that receive Federal support to collect and report data pursuant to the amendments made by subsection (a); and

(G) safeguard and prevent the misuse of data collected under section 3101 of the Public Health Service Act (42 U.S.C. 300kk), as amended by subsection (a)(6).

Nothing in this section shall be construed to—

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

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

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

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

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

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

(D) identifying the level at which data analysis should be conducted;

(E) sharing data with external organizations for research and quality improvement purposes; and

(F) identifying and addressing issues relating to the interoperability of Federal- and State-level health information systems which undermine the ability of health-related programs collecting data under this section to achieve the purpose described in subsection (a)(1).

To carry out this subsection, subsection (a), and the amendments made by subsection (a), there are authorized to be appropriated such sums as may be necessary for each of fiscal years 2025 through 2029.

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

The Secretary, acting through the Director of the Agency for Healthcare Research and Quality and in consultation with the Deputy Assistant Secretary for Minority Health, the Director of the National Institutes of Health, the Assistant Secretary for Planning and Evaluation, the National Coordinator for Health Information Technology, and the Director of the National Center for Health Statistics, shall establish a technical assistance program under which the Secretary provides grants to eligible entities to assist such entities in complying with section 3101.

A grant provided under this section may be used to—

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

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

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

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

(5) develop educational programs to train health providers, health care organizations, health plans, health-related agencies, and frontline health care workers on how to collect and report disaggregated data in a culturally and linguistically appropriate manner.

To be eligible for grants under this section, an entity shall be a State, territory, Indian Tribe, municipality, county, health provider, health care organization, or health plan making a demonstrated effort to bring data collections into compliance with section 3101.

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Secretary, acting through the Director of the National Center for Health Statistics, and other officials within the Department of Health and Human Services as the Secretary determines appropriate, shall develop and implement a sustainable national strategy for oversampling underrepresented populations within the categories of race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, and socioeconomic status as determined appropriate by the Secretary in Federal health surveys and program data collections. Such national strategy shall include a strategy for oversampling of Middle Easterners and North Africans, Asian Americans, Native Hawaiians, and Pacific Islanders.

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

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

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

(C) consult on, and use as models, the 2014 National Health Interview Survey oversample of Native Hawaiian and Pacific Islander populations, the 2016 Behavioral Risk Factor Survey of Health Risk Behaviors Among Arab Adults Within the State of Michigan, and the 2017 Behavioral Risk Factor Surveillance System oversample of American Indian and Alaska Native communities.

Not later than 2 years after the date of enactment of this section, the Secretary shall submit to the Congress a progress report, which shall include the national strategy required by subsection (a)(1).

To carry out this section, there are authorized to be appropriated such sums as may be necessary for each of fiscal years 2025 through 2029.

Not later than 2 years after the date of enactment of this Act, the Secretary of Health and Human Services shall submit a report to Congress on the implementation of this section, including the amendments made by this section.

Section 3101 of the Public Health Service Act (42 U.S.C. 300kk), as amended by section 1001(a), is further amended—

(1) by striking subsection (h); and

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

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

The Commissioner of Social Security (in this section referred to as the Commissioner), in consultation with the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator), shall collect data on the race, ethnicity, sex, primary language, sexual orientation, gender identity, socioeconomic status, and disability status of all applicants for social security benefits under title II or Medicare benefits under title XVIII.

In collecting data under paragraph (1), the Commissioner shall at least use the standards for data collection developed under section 3101 of the Public Health Service Act (42 U.S.C. 300kk) or the standards developed by the Office of Management and Budget, whichever is more disaggregated.

In the event there are no standards for the demographic groups listed under paragraph (1), the Commissioner shall consult with stakeholder groups representing the various identities as well as with the Office of Minority Health within the Centers for Medicare & Medicaid Services to develop appropriate standards.

Where practicable, the data collected by the Commissioner under paragraph (1) shall include data for additional population groups if such groups can be aggregated into the race and ethnicity categories outlined by the data collection standards described in paragraph (2)(A).

With respect to the collection of the data described in paragraph (1) of applicants who are under 18 years of age or otherwise legally incapacitated, the Commissioner shall require that—

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

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

The Commissioner shall periodically review the quality and completeness of the data collected under paragraph (1) and make adjustments as necessary to improve both.

Upon enrollment for Medicare benefits under title XVIII, the Commissioner shall transmit the demographic data of an individual as collected under paragraph (1) to the Centers for Medicare & Medicaid Services.

With respect to the data transmitted under paragraph (6), the Administrator, in consultation with the Commissioner, shall—

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

(B) incorporate such data in other analysis and reporting on health disparities and the provision of inequitable health care services by a health care provider, as appropriate;

(C) make such data available to researchers, under the protections outlined in paragraph (8);

(D) provide opportunities to individuals enrolled for Medicare benefits under title XVIII to submit updated data; and

(E) ensure that the provision of assistance or benefits to an applicant is not denied or otherwise adversely affected because of the failure of the applicant to provide any of the data collected under paragraph (1).

The Commissioner shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to paragraph (1) is protected—

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

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

Nothing in this section shall be construed to permit the use of information collected under this section in a manner that would adversely affect any individual providing any such information.

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

There are authorized to be appropriated to carry out this section $500,000,000 for fiscal year 2025 and $100,000,000 for each fiscal year thereafter.

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

(1) the use, at a minimum, of standards for data collection on race, ethnicity, sex, primary language, sexual orientation, gender identity, age, disability status, and socioeconomic status developed under section 3101 of the Public Health Service Act (42 U.S.C. 300kk), as amended by section 1001(a)(6); and

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

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

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

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

(1) in paragraph (1), by striking 2003 and inserting 2025;

(2) in paragraph (2), in the first sentence, by striking 2003 and inserting 2025; and

(3) in paragraph (3), by striking 2002 and inserting 2025.

The Secretary of Health and Human Services, in coordination with the officials referenced in subsection (b), shall establish a centralized electronic repository of Federal Government data on factors related to the health and well-being of the population of the United States.

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

Not later than April 30, 2024, and April 30 of each year thereafter, the Secretary of Health and Human Services, acting through the Assistant Secretary for Planning and Evaluation, the Assistant Secretary for Health, the Director of the Agency for Healthcare Research and Quality, the Director of the National Center for Health Statistics, the Administrator of the Centers for Medicare & Medicaid Services, the Director of the National Institute on Minority Health and Health Disparities, and the Deputy Assistant Secretary for Minority Health, shall—

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

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

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

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

In this section, the term eligible entity means an entity that has an accredited public health, health policy, or health services research program and is any of the following:

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

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

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

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

To carry out this section, there are authorized to be appropriated such sums as may be necessary for each of fiscal years 2025 through 2029.

Chapter V of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 351 et seq.) is amended by inserting after section 505G (21 U.S.C. 355h) the following:

If there is evidence of a racial or ethnic disparity in safety or effectiveness with respect to a drug or biological product, then—

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

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

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

If there is evidence of a racial or ethnic disparity in safety or effectiveness with respect to a drug for which there is an approved application under section 505 of this Act or of a biological product for which there is an approved license under section 351 of the Public Health Service Act, the Secretary may by order require the holder of the approved application or license to conduct, by a date specified by the Secretary, postmarket studies to investigate the disparity.

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

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

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

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

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

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

In this section, the term evidence of a racial or ethnic disparity in safety or effectiveness, with respect to a drug or biological product, includes—

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

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

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

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

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

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

Part B of title III of the Public Health Service Act (42 U.S.C. 243 et seq.) is amended by inserting after section 317V (42 U.S.C. 247b–24) the following:

In this section:

The term insular area means Guam, the Commonwealth of the Northern Mariana Islands, American Samoa, the United States Virgin Islands, the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands.

The term Native Hawaiians and Pacific Islanders or NHPI means people having origins in any of the original peoples of American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaii, the Republic of the Marshall Islands, the Republic of Palau, or any other Pacific Island.

The term NHPI stakeholder group includes each of the following:

A group of NHPI who are organized at the community level, and may include a church group, social service group, national advocacy organization, or cultural group.

A group of NHPI with a demonstrated history of addressing NHPI issues, including a NHPI coalition.

An entity established to represent NHPI populations and which has statutory responsibilities to provide, or has community support for providing, health care.

Representatives from Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands.

The Secretary, acting through the Director of the National Center for Health Statistics of the Centers for Disease Control and Prevention (referred to in this section as NCHS), shall conduct a preliminary health survey in order to identify the major areas and regions in the continental United States, Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands in which NHPI people reside.

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

(A) useful in determining health status and health care needs of NHPI populations; or

(B) required for developing or implementing the national strategy under subsection (c).

Methodology for the health survey described in paragraph (1), including plans for designing questions, implementation, sampling, and analysis, shall be developed in consultation with NHPI stakeholder groups.

The survey required under this subsection shall be completed not later than 18 months after the date of enactment of the Health Equity and Accountability Act of 2024.

The Secretary, acting through the Director of the NCHS and other agencies within the Department of Health and Human Services as the Secretary determines appropriate, shall develop and implement a sustainable national strategy for identifying and evaluating the health status and health care needs of NHPI populations living in the continental United States, Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands.

In developing and implementing a national strategy, as described in paragraph (1), not later than 180 days after the date of enactment of the Health Equity and Accountability Act of 2024, the Secretary—

(A) shall consult with representatives of NHPI stakeholder groups; and

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

Not later than 2 years after the date of enactment of the Health Equity and Accountability Act of 2024, the Secretary shall submit to Congress a progress report, which shall include the national strategy described in subsection (c)(1).

The Secretary shall seek to enter into an agreement with the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to conduct a study, with input from stakeholders in insular areas, on each of the following:

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

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

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

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

An agreement described in paragraph (1) shall require the Health and Medicine Division to submit to the Secretary and to Congress, not later than 2 years after the date of the enactment of the Health Equity and Accountability Act of 2024, a report containing a description of the results of the study conducted under paragraph (1), including the conclusions and recommendations of the Health and Medicine Division for each of the items described in subparagraphs (A) through (D) of such paragraph.

To carry out this section, there are authorized to be appropriated such sums as may be necessary for fiscal years 2025 through 2029.

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

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

Section 1819 of the Social Security Act (42 U.S.C. 1395i–3) is amended by adding at the end the following new subsection:

During a public health emergency declared by the Secretary pursuant to section 319 of the Public Health Service Act, a skilled nursing facility shall, not later than 1 year after the first day of such declaration, and monthly thereafter during the application of such declaration, submit to the Secretary the following information, with respect to such facility and the residents of such facility:

(1) Information described in section 483.80(g)(1) of title 42, Code of Federal Regulations.

(2) The age, race, ethnicity, sex, sexual orientation, gender identity, socioeconomic status, disability status, and preferred language of the residents of such skilled nursing facility.

The Secretary of Health and Human Services shall post the following information with respect to skilled nursing facilities (as defined in section 1819(a) of the Social Security Act (42 U.S.C. 1395i–3(a))), congregate care settings (including skilled nursing facilities, assisted living facilities, prisons and jails, residential behavioral health care and psychiatric facilities, and facilities providing services for aging adults and people with disabilities), and nursing facilities (as defined in section 1919(a) of such Act (42 U.S.C. 1396r(a))) on the Nursing Home Compare website (as described in section 1819(i) of such Act (42 U.S.C. 1395i–3(i))), or a successor website, aggregated by State:

(A) The age, race, ethnicity, sex, sexual orientation, gender identity, socioeconomic status, disability status, and preferred language of the residents of such skilled nursing facilities, congregate care settings (including skilled nursing facilities, assisted living facilities, prisons and jails, residential behavioral health care and psychiatric facilities, and facilities providing services for aging adults and people with disabilities), and nursing facilities with suspected or confirmed infections, including residents previously treated for COVID–19.

(B) The age, race, ethnicity, sex, sexual orientation, gender identity, socioeconomic status, disability status, and preferred language relating to total deaths and public health emergency-related deaths among residents of such skilled nursing facilities, congregate settings (including skilled nursing facilities, assisted living facilities, prisons and jails, residential behavioral health care and psychiatric facilities, and facilities providing services for aging adults and people with disabilities), and nursing facilities.

Any information reported under this subsection that is made available to the public shall be made so available in a manner that protects the identity of residents of skilled nursing facilities, congregate care settings (including skilled nursing facilities, assisted living facilities, prisons and jails, residential behavioral health care and psychiatric facilities, and facilities providing services for aging adults and people with disabilities), and nursing facilities.

Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of this subsection by program instruction or otherwise.

Part A of title XI of the Social Security Act (42 U.S.C. 1301 et seq.) as amended by section 1003, is further amended by adding at the end the following new section:

Not later than 60 days after the Secretary submits to Congress written notification of the determination that a disease or disorder presents a public health emergency or that a public health emergency otherwise exists, subject to subsections (b) and (c), the Secretary, acting through the Director of the Centers for Disease Control and Prevention and the Administrator of the Centers for Medicare & Medicaid Services and in consultation with the Director of the Indian Health Service, shall collect and make publicly available on the website of the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services, and update every day during a pandemic, data collected across all surveillance systems relating to a public health emergency declared under section 319 of the Public Health Service Act that is caused by a disease (as determined by the Secretary), disaggregated by race, ethnicity, sex, sexual orientation, gender identity, age, preferred language, socioeconomic status, disability status, and county. Such data shall include the following:

(1) Data relating to all testing for the pathogen or pathogens causing the pandemic, including the number of individuals tested and the number of tests that were positive.

(2) Data relating to treatment for the pathogen causing the pandemic, including hospitalizations and intensive care unit admissions.

(3) Data relating to pandemic outcomes, including total fatalities and case fatality rates (expressed as the proportion of individuals who were infected with the pathogen causing the pandemic and died from the pathogen).

(4) In the case a vaccine is developed in response to a pandemic, data relating to such vaccination, including—

(A) the number of vaccines administered;

(B) the number of vaccinations offered, accepted, and refused;

(C) the most common reasons for refusal; and

(D) the percentage of vaccine doses allocated and administered to each priority group.

To the extent practicable, data collected under subsection (a) shall follow standards developed by the Department of Health and Human Services Office of Minority Health and be collected, analyzed, and reported in accordance with the standards promulgated by the Assistant Secretary for Planning and Evaluation under title XXXI of the Public Health Service Act.

In publishing data pursuant to subsection (a), the Secretary shall take all necessary steps to protect the privacy of individuals whose information is included in such data, including—

(1) complying with privacy protections provided under the regulations promulgated under section 264(c) of the Health Insurance and Accountability Act of 1996; and

(2) protections from all inappropriate internal use by an entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from inappropriate uses.

Not later than 60 days after the date on which the Secretary of Health and Human Services certifies that a public health emergency declared under section 319 of the Public Health Service Act has ended, the Secretary shall make publicly available on the website of the Department of Health and Human Services a summary of the final statistics related to such emergency.

Not later than 60 days after the date on which the Secretary of Health and Human Services certifies that a public health emergency declared under section 319 of the Public Health Service Act has ended, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions and the Committee on Finance of the Senate and the Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives a report—

(A) describing the testing, hospitalization, mortality rates, vaccination rates, and preferred language of patients associated with the pandemic by race and ethnicity, rural and urban areas (as defined in section 1886(d)(2)(D) of the Social Security Act (42 U.S.C. 1395ww(d)(2)(D))), and congregate care settings (including skilled nursing facilities, assisted living facilities, prisons and jails, residential behavioral health care and psychiatric facilities, and facilities providing services for aging adults and people with disabilities) and noncongregate care settings (as such terms are defined by the Secretary); and

(B) proposing evidenced-based response strategies to safeguard the health of these communities in future pandemics.

Not later than 30 days after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this section as the Secretary) shall establish a commission, to be known as the Commission on Ensuring Data for Health Equity (referred to in this section as the Commission) to provide clear and robust guidance to improve the collection, analysis, and use of demographic data in responding to future public health emergencies.

The Commission shall be composed of—

(A) the Assistant Secretary for Preparedness and Response;

(B) the Director of the Centers for Disease Control and Prevention;

(C) the Director of the National Institutes of Health;

(D) the Commissioner of Food and Drugs;

(E) the Administrator of the Federal Emergency Management Agency;

(F) the Director of the National Institute on Minority Health and Health Disparities;

(G) the Director of the Indian Health Service;

(H) the Administrator of the Centers for Medicare & Medicaid Services;

(I) the Director of the Agency for Healthcare Research and Quality;

(J) the Surgeon General;

(K) the Administrator of the Health Resources and Services Administration;

(L) the Director of the Office of Minority Health;

(M) the Director of the Office on Women’s Health;

(N) the Chairperson of the National Council on Disability;

(O) at least 4 State, local, territorial, and Tribal public health officials representing departments of public health, or an Urban Indian health representative, who shall represent jurisdictions from different regions of the United States with relatively high concentrations of historically marginalized populations and rural populations, to be appointed by the Secretary;

(P) the National Coordinator for Health Information Technology;

(Q) at least 3 independent individuals with expertise on racially and ethnically diverse representation with knowledge or field experience with community-based participatory research on racial and ethnic disparities in public health, to be appointed by the Secretary; and

(R) at least 4 individuals with expertise on health equity and demographic data disparities with knowledge of, or field experience in, language, disability status, sex, sexual orientation, gender identity, or socioeconomic status.

The Assistant Secretary for Preparedness and Response shall serve as the Chairperson of the Commission.

The Commission shall—

(1) examine barriers to collecting, analyzing, and using demographic data in public health;

(2) determine how to best use such data to promote health equity across the United States and reduce racial, Tribal, and other demographic disparities in health outcomes;

(A) gather available data related to treatment of individuals with disabilities during the COVID–19 pandemic and other public health emergencies, including access to vaccinations, denial of treatment for preexisting conditions, removal or denial of disability related equipment (including ventilators and continuous positive airway pressure (commonly referred to as CPAP) machines), and data on completion of do-not-resuscitate orders; and

(B) identify barriers to obtaining accurate and timely data related to treatment of such individuals;

(4) solicit input from public health officials, community-connected organizations, health care providers, State and local agency officials, Tribal officials, and other experts on barriers to, and best practices for, collecting demographic data; and

(5) recommend policy changes that the data indicates are necessary to reduce demographic disparities in health outcomes.

Not later than 1 year after the date of the enactment of this Act, the Commission shall submit to Congress, and publish on the website of the Department of Health and Human Services, a report containing—

(1) the findings of the Commission pursuant to subsection (c);

(2) to the extent possible, an analysis of—

(A) racial and other demographic disparities in COVID–19 mortality, including an analysis of comorbidities and case fatality rates;

(B) sex, sexual orientation, and gender identity disparities in COVID–19 treatment and mortality; and

(C) Federal Government policies that disparately exacerbate the COVID–19 impact, and recommendations to improve racial and other demographic disparities in health outcomes;

(3) an analysis of COVID–19 treatment of individuals with disabilities, including equity of access to treatment and equipment and intersections of disability status with other demographic factors, including race;

(4) an analysis of what demographic data is currently being collected, the accuracy of that data and any gaps, how this data is currently being used to inform efforts to combat COVID–19, and what resources are needed to supplement existing public health data collection; and

(5) the Commission’s recommendations with respect to—

(A) how to enhance State, local, territorial, and Tribal capacity to conduct public health research on COVID–19 and in future public health emergencies, with a focus on expanded capacity to analyze data on disparities correlated with race, ethnicity, income, sex, sexual orientation, gender identity, age, disability status, specific geographic areas, and other relevant demographic characteristics;

(B) how to collect, process, and disclose to the public the data described in subparagraph (A) in a way that maintains individual privacy while helping direct the State, local, and Tribal response to public health emergencies;

(C) how to improve demographic data collection related to COVID–19 and other public health emergencies in the short-term and long-term, including how to continue to grow and value the Tribal sovereignty of data and information concerning urban and rural Tribal communities;

(D) how to improve transparency and equity of treatment for individuals with disabilities during the COVID–19 public health emergency and future public health emergencies; and

(E) how to support State, local, and Tribal capacity to eliminate barriers to vaccinations, testing, and treatment during the COVID–19 public health emergency and future public health emergencies.

The Chairperson of the Commission may appoint and fix the pay of additional staff to the Commission as the Chairperson considers appropriate.

The staff of the Commission may be appointed without regard to the provisions of title 5, United States Code, governing appointments in the competitive service, and may be paid without regard to the provisions of chapter 51 and subchapter III of chapter 53 of that title relating to classification and General Schedule pay rates.

Any Federal Government employee may be detailed to the Commission without reimbursement from the Commission, and the detailee shall retain the rights, status, and privileges of his or her regular employment without interruption.

The Secretary shall, in establishing the Commission under this section, take such steps as may be necessary to ensure that the work of the Commission does not overlap with, or otherwise duplicate, other Federal Government efforts with respect to ensuring health equity in data collection in public health emergencies.

There are authorized to be appropriated such sums as may be necessary to carry out this section.

Not later than 30 days after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this section as the Secretary) shall establish a Task Force to be known as the Task Force on Preventing AI and Algorithmic Bias in Health Care (referred to in this section as the Task Force) to provide clear and robust guidance on how to ensure that the development and integration of artificial intelligence and algorithmic technologies within the health care service delivery process does not exacerbate health disparities and inequities, expands access to health care services, and improves health care delivery.

The Task Force shall be composed of—

(A) the Chief Information Officer of the Department of Health and Human Services;

(B) the Director of the Centers for Disease Control and Prevention;

(C) the Director of the National Institutes of Health;

(D) the Commissioner of Food and Drugs;

(E) the Administrator of the Federal Emergency Management Agency;

(F) the Director of the National Institute on Minority Health and Health Disparities;

(G) the Director of the Indian Health Service;

(H) the Administrator of the Centers for Medicare & Medicaid Services;

(I) the Director of the Agency for Healthcare Research and Quality;

(J) the Surgeon General;

(K) the Administrator of the Health Resources and Services Administration;

(L) the Director of the Office of Minority Health;

(M) the Director of the Office on Women’s Health;

(N) the Chairperson of the National Council on Disability;

(O) the National Coordinator for Health Information Technology;

(P) at least 4 State, local, territorial, and Tribal public health officials representing departments of public health, or an Urban Indian health representative, who shall represent jurisdictions from different regions of the United States with relatively high concentrations of historically marginalized populations, to be appointed by the Secretary;

(Q) at least 3 independent individuals with expertise on racially and ethnically diverse representation with knowledge or field experience with community-based participatory research on racial and ethnic disparities in public health, to be appointed by the Secretary; and

(R) at least 4 individuals with expertise on health equity and demographic data disparities with knowledge of, or field experience in, language, disability status, sex, sexual orientation, gender identity, or socioeconomic status.

The Chief Information Officer of the Department of Health and Human Services (or the Chief Information Officer’s designee) shall serve as the Chairperson of the Task Force.

The Task Force shall—

(1) examine artificial intelligence and algorithms in the health care service sector, including the health care delivery process relative to the use of autonomous human decision makers;

(2) identify the risks of health care system utilization of artificial intelligence and algorithms in terms of civil rights, civil liberties, and discriminatory bias in health care access, quality, and outcomes; and

(3) prepare and submit the report under subsection (d).

Not later than 1 year after the date of enactment of this Act, the Task Force shall—

(1) submit a written report of the findings of the examination under subsection (c)(1) and recommendations to Congress with respect to implementation of artificial intelligence and algorithms in health care delivery and mitigation of the risks associated with that implementation; and

(2) publish such report on the website of the Department of Health and Human Services.

Not later than 60 days after the date of the enactment of this Act, the Task Force shall publish in the Federal Register a notice providing for a public comment period on the duties and activities of the Task Force of not less than 90 days, beginning on the date of that publication.

The Chairperson of the Task Force may appoint and fix the pay of additional staff to the Task Force as the Chairperson considers appropriate.

The staff of the Task Force may be appointed without regard to the provisions of title 5, United States Code, governing appointments in the competitive service, and may be paid without regard to the provisions of chapter 51 and subchapter III of chapter 53 of that title relating to classification and General Schedule pay rates.

Any Federal Government employee may be detailed to the Task Force without reimbursement from the Task Force, and the detailee shall retain the rights, status, and privileges of his or her regular employment without interruption.

The Secretary of Health and Human Services (referred to in this section as the Secretary) shall conduct or support a comprehensive study regarding the unique health patterns and outcomes of Middle Eastern and North African (referred to in this section as MENA) populations.

The comprehensive study under subsection (a) shall include an enumeration of MENA populations across the United States, disaggregated by subpopulation, and with respect to each such population and subpopulation—

(1) the rates of—

(A) obesity, diabetes, sickle cell anemia, stroke, asthma, pneumonia, lung cancer, HIV/AIDS, HPV, high cholesterol, high blood pressure, and chronic heart, lung, and kidney disease;

(B) morbidity and mortality, including the rates of morbidity and mortality associated with the health conditions listed in subparagraph (A);

(C) mental health and substance use disorders; and

(D) domestic violence, dating violence, sexual assault, sexual harassment, and stalking;

(2) analysis of—

(A) the rates described in paragraph (1);

(B) the leading causes of pregnancy-associated morbidity and mortality; and

(C) access to health care facilities and the associated outcomes of care;

(3) analysis, enumeration, or quantification of any other health or health-related parameters the Secretary may determine necessary; and

(4) analysis of the relationship between the health factors, outcomes, and conditions described in paragraphs (1) through (3) and the implementation of Federal health programs.

The Secretary shall—

(1) carry out this section in consultation, as appropriate, with the Director of the Census Bureau, the Director of the Centers for Disease Control and Prevention, the Director of the National Institutes of Health, the Assistant Secretary for Mental Health and Substance Use, and other stakeholders (including community-based organizations); and

(2) determine through such consultation the subpopulations to be used for purposes of disaggregation of data pursuant to subsection (b).

Upon conclusion of the comprehensive study under this section, the Secretary shall establish a public online portal to catalogue the results of the study, its underlying data, and information in the report submitted pursuant to subsection (e).

Not later than 2 years after the date of enactment of this Act, the Secretary shall submit to Congress a report outlining the challenges associated with, and progress towards implementing health data collection for MENA populations as a distinct category and the plan for completing a comprehensive study regarding the unique health patterns and outcomes of MENA populations.

Not later than 30 days after the conclusion of the comprehensive study under this section, the Secretary shall submit to Congress a report describing—

(A) the results of the study conducted under this section; and

(B) the rulemakings and other actions the agencies described in subsection (c)(1) can undertake to more equitably include MENA individuals in their programs.

The Secretary shall not include any personally identifiable information on the online portal under subsection (d) or in a report under subsection (e).

In this section, the terms Middle Eastern and North African or MENA, with respect to individuals or populations, includes individuals and populations who identify with or belong to one or more nationalities or ethnic groups originating in a country (or portion thereof) in the Middle Eastern and North African region (such as Lebanese, Iranians, Egyptians, Moroccans, Yemenis, Chaldeans, Imazighen, Kurds, Palestinians, and Yazidis).

In this title, the definitions in section 3400 of the Public Health Service Act, as added by section 2004, shall apply.

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

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

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

(3) to require each Federal agency to translate any English language written material prepared for the general public into the top 15 non-English languages in the United States (according to the most recent data from the American Community Survey or its replacement) within established timelines described in subsection (b)(2)(C)(v);

(4) to require each Federal agency to ensure that recipients of Federal financial assistance provide culturally competent services and meaningful access to applicants and beneficiaries who are individuals with limited English proficiency;

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

(6) to ensure compliance with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) (prohibiting health care providers and organizations from discriminating in the provision of services).

Not later than 120 days after the date of enactment of this Act, each Federal agency providing financial assistance to, or administering, a health program or activity described in section 2003(a) shall prepare a plan or update a plan to improve culturally and linguistically appropriate access to such program or activity with respect to individuals with limited English proficiency. Not later than 1 year after the date of enactment of this Act, each such Federal agency shall ensure that such plan is fully implemented.

Each plan under paragraph (1) shall include—

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

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

(C) the steps the agency will take for such program or activity to be culturally and linguistically appropriate by—

(i) providing a range of language assistance options;

(ii) giving notice to individuals with limited English proficiency of the right to competent language services;

(iii) training staff (at least annually);

(iv) monitoring and assessing the quality of the language services (at least annually); and

(v) translating any English language written material prepared for the general public into the top 15 non-English languages in the United States (according to the most recent data from the American Community Survey or its replacement) within established timelines that ensure that high-quality, culturally competent translated material is provided promptly within not more than 15 calendar days in general and within not more than 7 calendar days in the case of any national emergency or State disaster declaration;

(D) the steps the agency will take for such program or activity to provide reasonable accommodations necessary for individuals with limited English proficiency, including those individuals with a communication disability, to understand communications from the agency;

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

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

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

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

(I) the steps the agency will take and resources the agency will provide to ensure that individuals know their rights, including the ability to file a complaint.

Each agency that is required to prepare a plan under paragraph (1) shall—

(A) consult with populations who are directly impacted by policies in the plan and their representatives in the development of the plan; and

(B) when the plan is finalized, send a copy of such plan to the Attorney General, to serve as the central repository of all such plans.

This section shall apply to any health program or activity—

(1) of which any part is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance; or

(2) that is carried out (including indirectly through contracts, subcontracts, or other support) by an executive agency or any entity established under title I of the Patient Protection and Affordable Care Act (42 U.S.C. 18001 et seq.) (or amendments made thereby).

Each program or activity described in subsection (a)—

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

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

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

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

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

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

(C) signage; and

(D) any other documents or types of documents designated by the Secretary;

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

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

(7) shall ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note; Public Law 104–191), data on an individual required to be collected pursuant to section 3101 of the Public Health Service Act (42 U.S.C. 300kk), including the individual’s alternative format preferences and policy modification needs, are—

(A) collected in health records;

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

(C) reported in such a way as to be interoperable with health information systems at the Federal and State levels; and

(D) periodically updated;

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

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

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

(11) shall annually—

(A) make available to the public—

(i) information about the progress and successful innovations of the program or activity in implementing the standards under this section; and

(ii) translated materials of such information that is culturally and linguistically appropriate to the communities served under this section; and

(B) provide public notice in such communities about the availability of such information; and

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

An executive agency carrying out a program or activity described in subsection (a)—

(1) shall ensure that comments with respect to such program or activity that are accepted through notice and comment rulemaking are accepted in all languages;

(2) may not require such comments to be submitted only in English; and

(3) shall ensure that any such comments that are not submitted in English are considered, during the agency’s review of such comments, equally as such comments that are submitted in English.

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

In this title:

The term bilingual, with respect to an individual, means an individual who has a sufficient degree of proficiency in 2 languages.

The term community health worker means a frontline health worker who is a trusted member of the community in which the worker serves or who has an unusually close understanding of the community served that enables the worker to build trusted relationships, serve as a liaison between health and social services and the community, facilitate access to services, and improve the quality and cultural competence of service delivery.

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

The term culturally and linguistically appropriate means being respectful of and responsive to the cultural and linguistic needs of all individuals.

The term effective communication means an exchange of information between the provider of health care or health care-related services and the recipient of such services who is limited in English proficiency, or has a communication impairment such as a hearing, vision, speaking, or cognitive disability, that enables access to, understanding of, and benefit from health care or health care-related services, and full participation in the development of the treatment plan of the recipient.

The term grievance resolution process means all aspects of dispute resolution including filing complaints, grievance and appeal procedures, and court action.

The term health care group means a group of physicians organized, at least in part, for the purposes of providing physician services under the Medicaid program under title XIX of the Social Security Act, the State Children's Health Insurance Program under title XXI of such Act, or the Medicare program under title XVIII of such Act, including a provider of services under part B of such title XVIII, and may include a hospital, a hospice provider, a palliative care provider, and any other individual or entity furnishing services covered under any such program that is affiliated with the health care group.

The term health care includes all health care needed throughout the life cycle and the end of life.

The term health care services means services that address physical and mental health conditions, as well as conditions impacted by social determinants of health, in all care settings throughout the life cycle and the end of life.

The term health care-related services means human or social services programs or activities that provide access, referrals, or links to health care services.

The term health educator includes a professional with a baccalaureate degree who is responsible for designing, implementing, and evaluating individual and population health promotion, health education (including education on end-of-life care options), end-of-life care, or chronic disease prevention programs.

The terms Indian and Indian Tribe have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act.

The term individual with a disability means any individual who has a disability as defined for the purpose of section 504 of the Rehabilitation Act of 1973.

The term individual with limited English proficiency means an individual who self-identifies on the Census as speaking English less than very well.

The term integrated health care delivery system means an interdisciplinary system that brings together providers from the primary health, mental health, substance use disorder, hospice and palliative care, and related disciplines to improve the health outcomes of an individual and the community. Such providers may include hospitals, health, mental health, or substance use prevention and treatment clinics and providers, home health agencies, home- and community-based services providers, congregate settings (including any skilled nursing facilities, assisted living facilities, prisons and jails, residential behavioral health care and psychiatric facilities, and facilities providing services for aging adults and individuals with disabilities), ambulatory surgery centers, rehabilitation centers, employed, independent, or contracted physicians, and oral health care providers.

The terms interpreting and interpretation mean the transmission of a spoken, written, or signed message from one language or format into another, faithfully, accurately, and objectively.

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

The term language assistance services includes—

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

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

(C) taglines.

The term minority populations means individuals of racial and ethnic minority groups, individuals of sexual and gender minority groups, and individuals with a disability.

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

The term qualified individual with a disability means, with respect to a health program or activity, an individual with a disability who, with or without reasonable modifications to policies, practices, or procedures, the removal of architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility requirements for the receipt of aids, benefits, or services offered or provided by the health program or activity.

The term qualified interpreter for an individual with a disability, with respect to an individual with a disability—

(A) means an interpreter for such individual who by means of a remote interpreting service or an onsite appearance—

(i) adheres to generally accepted interpreter ethics principles, including client confidentiality; and

(ii) is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary, terminology, and phraseology; and

(B) may include—

(i) sign language interpreters;

(ii) oral transliterators, which are individuals who represent or spell in the characters of another alphabet; and

(iii) cued language transliterators, which are individuals who represent or spell by using a small number of handshapes.

The term qualified interpreter for an individual with limited English proficiency means an interpreter who by means of a remote interpreting service or an onsite appearance—

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

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

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

The term qualified translator means a translator who—

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

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

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

The term racial and ethnic minority group has the meaning given such term in section 1707(g).

The term Secretary means the Secretary of Health and Human Services, acting through the Director of the Agency for Healthcare Research and Quality.

The term sexual and gender minority group includes lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expression, or reproductive development varies from traditional, societal, cultural, or physiological norms.

The term sight translation means the transmission of a written message in one language into a spoken or signed message in another language, or an alternative format in English or another language.

Notwithstanding section 2, the term State means each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.

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

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

The term underserved communities means populations sharing particular characteristics, or geographic communities, who have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, such as—

(A) Black, Latino, Indigenous, and Native American persons, Asian Americans, Native Hawaiians and Pacific Islanders, Middle Easterners and North Africans, and other persons of color;

(B) members of religious minorities;

(C) lesbian, gay, bisexual, transgender, and queer persons;

(D) individuals with a disability;

(E) persons who live in rural areas; and

(F) persons otherwise adversely affected by persistent poverty or inequality.

The term video remote interpreting services means the provision, in health care services or health care-related services, through a qualified interpreter for an individual with limited English proficiency, of video remote interpreting services that are—

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

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

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

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

The Secretary shall establish and support a center to be known as the Robert T. Matsui Center for Culturally and Linguistically Appropriate Health Care (referred to in this section as the Center) to carry out each of the following activities:

The Center shall provide resources via the internet to identify and link health care providers to competent and qualified interpreter and translation services.

For purposes of providing the services described in subparagraph (A), the Center shall adopt a language access plan that includes training requirements for Center staff to provide such services.

The Center shall provide, directly or through contract, to providers of health care services and health care-related services, at no cost to such providers and in a timely and reasonable manner, vital documents—

(i) which may be submitted by an entity described in subparagraph (C) for translation into non-English languages, or alternative formats, at a fifth-grade reading level; and

(ii) from competent translation services, the quality of which shall be monitored and reported publicly.

For each form developed or revised by the Secretary that will be used by individuals with limited English proficiency in health care or health care-related settings, the Center shall, not later than 45 calendar days of the Secretary receiving final approval of the form from the Office of Management and Budget—

(i) translate the form, at a minimum, into the top 15 non-English languages in the United States according to the most recent data from the American Community Survey or its replacement; and

(ii) post all translated forms on the Center’s website.

An entity described in this subparagraph is—

(I) an entity that operates a health program or activity, any part of which receives Federal financial assistance;

(II) an entity established under title I of the Patient Protection and Affordable Care Act that administers a health program or activity; or

(III) the Department of Health and Human Services.

For purposes of clause (i), the term health program or activity has the meaning given such term in section 92.4 of title 45, Code of Federal Regulations, as in effect on July 5, 2024.

The Center shall provide, through a toll-free number, a customer service line for individuals with limited English proficiency that is linked to the toll-free telephone number 1–800–MEDICARE and a toll-free telephone hotline provided for pursuant to section 1311(d)(4)(B) of the Patient Protection and Affordable Care Act by an Exchange established under title I of such Act—

(A) to obtain information about federally conducted or funded health programs, including the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the State Children's Health Insurance Program under title XXI of such Act, and coverage available through an Exchange established under title I of the Patient Protection and Affordable Care Act, and other sources of free or reduced care including federally qualified health centers, entities receiving assistance under title X, and public health departments;

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

(C) to learn how to access language services.

The Center shall develop and maintain, and make available on the internet and in print, an information clearinghouse that includes the information described in subparagraphs (B) through (G)—

(i) to facilitate the provision of language services by providers of health care services and health care-related services to reduce medical errors;

(ii) to improve medical outcomes, improve cultural competence, reduce health care costs caused by miscommunication with individuals with limited English proficiency; and

(iii) to reduce or eliminate the duplication of efforts to translate materials.

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

(i) Administrative and legal documents, including—

(I) intake forms;

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

(III) forms informing patients of the compliance and consent requirements pursuant to the regulations under section 264(c) of the Health Insurance Portability and Accountability Act of 1996; and

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

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

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

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

In operating the clearinghouse, the Center shall—

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

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

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

(iv) facilitate access to such documents;

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

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

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

The Center shall provide, at no cost, to all health care providers and all providers of health care-related services, information relating to culturally and linguistically appropriate health care for minority populations residing in the United States, including—

(i) tenets of culturally and linguistically appropriate care;

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

(iii) culturally and linguistically appropriate training tools;

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

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

The Center shall—

(i) develop and publish on its website translation glossaries that provide standardized translations of commonly used terms and phrases utilized in documents translated by the Center; and

(ii) make such glossaries available—

(I) free of charge;

(II) in each language in which the Center translates forms under paragraph (2)(B);

(III) in alternative formats in accordance with the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.); and

(IV) in paper format upon request.

The Center shall—

(i) regularly collect and make publicly available information about the progress of entities receiving grants under section 3402 regarding successful innovations in implementing the requirements of this subsection; and

(ii) provide public notice in the entities’ communities about the availability of such information.

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

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

The Secretary, directly or through contract, shall undertake a national education campaign to inform providers, individuals with limited English proficiency, individuals with hearing or vision impairments, health professionals, graduate schools, community health centers, social service providers, and community-based organizations about—

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

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

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

(4) promising practices to effectively provide language services.

There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2025 through 2029.

The Secretary shall award grants to eligible entities to enable such entities to design, implement, and evaluate innovative, cost-effective programs to improve culturally and linguistically appropriate access to health care services for individuals with limited English proficiency and communication disabilities.

In making grants under this section, and in the design and implementation of the program established under this section, the Secretary shall coordinate with, and ensure the participation of, other agencies including the Health Resources and Services Administration, the National Institute on Minority Health and Health Disparities at the National Institutes of Health, and the Office of Minority Health.

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

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

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

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

(4) a solo or group physician practice;

(5) an integrated health care delivery system;

(6) a public hospital;

(7) a health care group, university, or college; or

(8) any other entity designated by the Secretary.

An eligible entity seeking a grant under this section shall prepare and submit to the Secretary an application, at such time, in such manner, and containing such additional information as the Secretary may reasonably require.

An entity shall use funds received through a grant under this section to—

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

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

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

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

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

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

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

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

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

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

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

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

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

(14) ensure that culturally competent care and language assistance are available to individuals with limited English proficiency.

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

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

The Director of the Agency for Healthcare Research and Quality shall evaluate or arrange with other individuals or organizations to evaluate projects funded under this section.

There is authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2025 through 2029.

The Secretary shall expand research concerning language access in the provision of health care services.

The Secretary may conduct the research described in subsection (a) or enter into contracts with other individuals or organizations to conduct such research.

Research conducted under this section shall be designed to do one or more of the following:

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

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

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

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

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

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

(C) effective privacy safeguards for collected data.

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

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

(A) provider type;

(B) languages needed and their frequency of use;

(C) type of encounter;

(D) time of encounter, including whether the encounter occurs during regular business hours and after hours; and

(E) location of encounter.

There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2025 through 2029.

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

A grant awarded under this section is authorized for the period of 3 fiscal years beginning on October 1, 2024, and ending on September 30, 2027.

In awarding a grant under this section, the Secretary shall give preference to a State—

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

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

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

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

A State receiving a grant under this section shall use the grant funds to—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In this section:

The term qualified LEP enrollee means an individual—

(A) who is limited English proficient; and

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

The term State has the meaning given the term in section 1101(a)(1) of the Social Security Act (42 U.S.C. 1301(a)(1)), for purposes of title XIX of such Act (42 U.S.C. 1396 et seq.).

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

The term United States has the meaning given the term in section 1101(a)(2) of the Social Security Act (42 U.S.C. 1301(a)(2)), for purposes of title XIX of such Act (42 U.S.C. 1396 et seq.).

Any State receiving a grant under this section must agree to directly pay for language services in Medicaid for all Medicaid providers by the end of the grant period.

There is authorized to be appropriated $5,000,000 to carry out this section.

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

Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)) is amended by inserting (or, in the case of a State that was awarded a grant under section 2005 of the Health Equity and Accountability Act of 2024, 100 percent for each quarter occurring during the grant period specified in subsection (b) of such section) after 75 percent.

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

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

In determining a hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program for education and training in culturally and linguistically appropriate service delivery, which shall include all medically underserved populations (as defined in section 330(b)(3) of the Public Health Service Act), shall be counted toward the determination of full-time equivalency.

Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following new clause:

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

The amendments made by subsections (a) and (b) shall apply with respect to payments made to hospitals on or after the date that is 1 year after the date of the enactment of this Act.

Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services (in this subsection referred to as the Secretary), acting through the Centers for Medicare & Medicaid Services and in consultation with the Center for Medicare and Medicaid Innovation (as referred to in section 1115A of the Social Security Act (42 U.S.C. 1315a)), shall establish a demonstration program under which the Secretary shall award grants to eligible Medicare service providers to provide culturally and linguistically appropriate services to Medicare beneficiaries who are limited English proficient, including beneficiaries who live in diverse and underserved communities.

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

To the extent practicable, the Secretary shall award not less than 24 grants under this subsection.

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

To be eligible for a grant under this subsection, an entity must meet the following requirements:

The entity must be—

(i) a provider of services under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.);

(ii) a provider of services under part B of such title (42 U.S.C. 1395j et seq.);

(iii) a Medicare Advantage organization offering a Medicare Advantage plan under part C of such title (42 U.S.C. 1395w–21 et seq.); or

(iv) a PDP sponsor offering a prescription drug plan under part D of such title (42 U.S.C. 1395w–101 et seq.).

The entity must serve a community that, with respect to necessary language services for improving access and utilization of health care among individuals who are limited English proficient, is disproportionally underserved.

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

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

To the extent feasible, the Secretary shall award—

(A) at least 10 grants to providers of services described in paragraph (2)(A)(i);

(B) at least 10 grants to service providers described in paragraph (2)(A)(ii);

(C) at least 10 grants to organizations described in paragraph (2)(A)(iii); and

(D) at least 10 grants to sponsors described in paragraph (2)(A)(iv).

In awarding grants under this subsection, the Secretary shall select grantees to ensure the following:

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

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

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

(iv) The grantees represent each Centers for Medicare & Medicaid Services region, as defined by the Secretary.

(v) The grantees serve Medicare beneficiaries in at least 2 large metropolitan statistical areas with diverse populations, including diversity in race, ethnicity, sexual orientation, gender identity, disability status, and socioeconomic status.

In awarding grants under this subsection, the Secretary shall give priority to eligible entities that have a partnership with 1 or more of the following entities that have experience in providing language services:

(i) A community organization.

(ii) A consortium of community organizations, State agencies, and local agencies.

Subject to subparagraph (E), a grantee may only use grant funds received under this subsection to pay for the provision of competent language services to Medicare beneficiaries who are individuals who are limited English proficient to supplement existing Medicare requirements.

For purposes of this subsection, the term competent language services means—

(i) interpreter and translation services that—

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

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

(bb) if the grantee operates in a State that does not have statewide health care interpreter standards, utilize competent interpreters who follow the National Council on Interpreting in Health Care’s Code of Ethics and Standards of Practice and comply with the requirements of section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) as published in the Federal Register on May 18, 2016, 81 Fed. Reg. 31375; and

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

(aa) onsite interpretation;

(bb) telephonic interpretation; or

(cc) video interpretation; and

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

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

(I) in the case of a Medicare beneficiary who is limited English proficient, if—

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

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

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

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

A grantee that is a Medicare Advantage organization or a prescription drug plan sponsor must provide at least 50 percent of the grant funds that the grantee receives under this subsection directly to the entity’s network providers (including all health providers and pharmacists) for the purpose of providing support for such providers to provide competent language services to Medicare beneficiaries who are individuals who are limited English proficient.

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

Payments to grantees under this subsection shall be calculated based on the estimated numbers of Medicare beneficiaries who are limited English proficient in a grantee’s service area utilizing—

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

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

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

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

Grantees under this subsection shall, as a condition of receiving a grant under this subsection—

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

(B) ensure the linguistic competence of bilingual providers;

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

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

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

(F) ensure that—

(i) primary language data are collected for recipients of language services and such data are consistent with standards developed under title XXXIV of the Public Health Service Act, as added by section 2002 of this Act, to the extent such standards are available upon the initiation of the demonstration program; and

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

Medicare beneficiaries who are limited English proficient shall not have to pay cost sharing or co-payments for competent language services provided under this demonstration program.

Not later than the end of each calendar year, a grantee that receives funds under this subsection in such year shall submit to the Secretary a report that includes the following information:

(A) The number of Medicare beneficiaries to whom competent language services are provided, disaggregated by age and entitlement basis (on the basis of age, disability, or determination of end stage renal disease).

(B) The primary languages of those Medicare beneficiaries.

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

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

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

(F) The costs of providing competent language services.

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

Not later than 1 year after the completion of a 3-year grant under this subsection, the Secretary shall conduct an evaluation of the demonstration program under this subsection and shall submit to the Congress a report that includes the following:

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

(B) The effect of delivering language services on—

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

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

(iii) patient satisfaction with respect to both health service delivery and language assistance;

(iv) health outcomes; and

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

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

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

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

In this subsection, the term limited English proficient means individuals who self-identify on the Census as speaking English less than very well.

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—

(A) in subsection (aa)(1)—

(i) in subparagraph (C), by striking and at the end;

(ii) in subparagraph (D), by inserting and after the comma at the end; and

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

(E) language assistance services as defined in subsection (nnn),

(iii) ; and

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

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

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

(A) in subparagraph (I), by striking and at the end;

(B) in subparagraph (J), by striking the period at the end and inserting; and; and

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

(K) language assistance services (as defined in section 1861(nnn)).

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

(A) in paragraph (9), by striking and at the end;

(B) in paragraph (10), by striking the period at the end and inserting; and; and

(C) by inserting after paragraph (10) the following new paragraph:

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

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

Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:

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

(A) The collection of data in a manner that meets the requirements of title I of the Health Equity and Accountability Act of 2024, regarding the enrollee population.

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

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

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

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

Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)), as amended by section 2005(h)(3), is further amended by—

(A) striking 75 and inserting 95;

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

(C) striking children of families and inserting individuals.

Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking and (30) and inserting (30), and (32).

Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended—

(A) in paragraph (31), by striking and at the end;

(B) by redesignating paragraph (32) as paragraph (33); and

(C) by inserting after paragraph (31) the following new paragraph:

(32) language assistance services, as such term is defined in section 1861(nnn), provided in a timely manner to individuals with limited English proficiency as defined in section 3400 of the Public Health Service Act; and

Subsections (a)(2) and (b)(2) of section 1916 of the Social Security Act (42 U.S.C. 1396o) are each amended—

(A) in subparagraph (I), by striking or at the end;

(B) in subparagraph (J), by striking; and and inserting, or; and

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

(K) language assistance services described in section 1905(a)(32); and

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

(A) in subsection (a), in the matter before paragraph (1), by striking (5), (6), (7) and (8) and inserting (5) through (13);

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

The child health assistance provided to a targeted low-income child shall include coverage of language assistance services, as such term is defined in section 1861(nnn), provided in a timely manner to individuals with limited English proficiency (as defined in section 3400 of the Public Health Service Act).

(B) ; and

(C) in subsection (e)(2)—

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

(ii) by inserting language assistance services described in subsection (c)(12), before or for pregnancy-related assistance.

Section 2110(a)(27) of the Social Security Act (42 U.S.C. 1397jj(a)(27)) is amended by striking transportation, translation, and outreach services and inserting transportation services, language assistance services as described in section 2103(c)(13), and outreach services.

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

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

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

Section 2105 of the Social Security Act (42 U.S.C. 1397ee) is amended—

(A) in subsection (a)(1)—

(i) in the matter preceding subparagraph (A), by striking 75 and inserting 95; and

(ii) in subparagraph (D)(iv), by striking translation or interpretation services and inserting language assistance services; and

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

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

Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary such sums as may be necessary for each of fiscal years 2025 through 2029.

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

The Secretary shall establish a methodology to determine the average per person cost of language assistance services.

In establishing such methodology, the Secretary may establish different methodologies for different types of eligible entities.

The Secretary may not require eligible entities to submit individual claims for language assistance services for individual patients as a requirement for payment under this subsection.

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

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

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

Not later than 2 years after the date of enactment of this Act, and every 2 years thereafter, the Secretary shall submit a report to Congress concerning the implementation of this subsection.

In this subsection:

The term eligible costs means, with respect to an eligible entity that provides language assistance services to limited English proficient individuals, the product of—

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

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

The term eligible entity means an entity that—

(i) is a Medicaid provider that is—

(I) a physician;

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

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

(IV) a hospice provider; or

(V) a palliative care provider;

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

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

The term language assistance services has the meaning given such term in section 1861(nnn) of the Social Security Act, as added by subsection (b).

Nothing in this section shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), section 1557 of the Affordable Care Act (42 U.S.C. 18116), or other laws that protect the civil rights of individuals.

Except as otherwise provided and subject to paragraph (2), the amendments made by this section shall take effect on January 1, 2025.

In the case of a State plan for medical assistance under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) or a State plan for child health assistance under title XXI of such Act (42 U.S.C. 1397aa et seq.) which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made by this section, such State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.

The Secretary, in consultation with the Director of the National Institute on Minority Health and Health Disparities and the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities to improve health care for patient populations that have low health literacy.

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

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

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

A grant under subsection (a) that is awarded through the Director of the Agency for Healthcare Research and Quality shall be used—

(A) to define and increase the understanding of health literacy across all areas of health care, including end of life care;

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

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

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

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

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

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

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

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

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

(F) the conduct of educational campaigns concerning health directed specifically at patients with mental disabilities, including those with cognitive and intellectual disabilities, designed to reduce the incidence of low health literacy among these populations, which shall have instructional materials in the plain language standards promulgated under the Plain Writing Act of 2010 (5 U.S.C. 301 note) for Federal agencies; and

(G) other activities determined appropriate by the Administrator.

In this section:

The term low health literacy means the inability of an individual to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

The term Secretary means the Secretary of Health and Human Services—

(A) acting through the Director of the Agency for Healthcare Research and Quality, with respect to grants under subsection (c)(1); and

(B) acting through the Administrator of the Health Resources and Services Administration with respect to grants under subsection (c)(2).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

In this section:

The term covered entity means an entity described in clause (i) of section 3401(a)(2)(C) of the Public Health Service Act, as added by section 2004.

The term health program or activity has the meaning given such term in clause (ii) of such section 3401(a)(2)(C).

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

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

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

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

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

The requirements of subsection (b)(4) shall not apply as follows:

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

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

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

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

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

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

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

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

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

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

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

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

(3) recommendations on the development and implementation of policies and practices by providers of health care services and health care-related services for individuals with limited English proficiency, including people with cognitive, hearing, vision, or print impairments;

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

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

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Secretary of Education is authorized to provide grants to eligible entities for the provision of English as a second language (in this section referred to as ESL) instruction to individuals with limited English proficiency, including health care-related English instruction, and shall determine, after consultation with appropriate stakeholders, the mechanism for administering and distributing such grants.

In this section, the term eligible entity means—

(1) a State; or

(2) a community-based organization that predominantly employs and serves racial and ethnic minority groups (as defined in section 1707(g) of the Public Health Service Act (42 U.S.C. 300u–6(g)).

An eligible entity that desires to receive a grant under this section shall apply by submitting to the Secretary of Education an application at such time, in such manner, and containing such information as the Secretary may require.

An eligible entity shall use grant funds provided under this section to—

(1) develop and implement a plan for assuring the availability of ESL instruction, free of charge, to the community served by the eligible entity, that effectively integrates information about the nature of the United States health care system, how to access care, and any special language skills that may be required for individuals with limited English proficiency to access and regularly negotiate the health care system effectively;

(2) develop a plan for making ESL instruction available free to charge to individuals with limited English proficiency in the community served by the eligible entity who are seeking instruction, including, where appropriate, through the use of public-private partnerships; and

(3) provide ESL instruction to individuals with limited English proficiency in the community served by the eligible entity.

An eligible entity awarded a grant under this section shall use funds made available under this section to supplement, and not supplant, other Federal, State, and local funds that would otherwise be expended to carry out activities under this section.

The Secretary of Education shall—

(1) collect and make publicly available annual data on how much Federal, State, and local governments spend annually on ESL instruction;

(2) collect data from eligible entities awarded a grant under this section to identify the unmet needs of individuals with limited English proficiency for appropriate ESL instruction, including—

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

(B) the availability of enrollment in ESL instruction programs in the communities served by each eligible entity awarded a grant under this section, including the extent of waiting lists for ESL instruction, how many programs maintain waiting lists, and, for programs that do not have waiting lists, the reasons why such a list is unnecessary or otherwise not maintained;

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

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

(E) the number of individuals with limited English proficiency and the number of individuals enrolled in ESL instruction programs in the communities served by each eligible entity awarded a grant under this section;

(F) the effectiveness of the ESL instruction provided through grants awarded under this section in meeting the needs of individuals receiving such instruction; and

(G) an assessment of the need for programs that integrate job training and ESL instruction, to assist individuals with limited English proficiency in obtaining better jobs;

(3) determine the cost and most appropriate methods of making ESL instruction available to all individuals with limited English proficiency in the United States who are seeking instruction; and

(4) not later than 1 year after the date of enactment of this Act, issue a report to Congress that—

(A) assesses the information collected in paragraphs (1), (2), and (3) and makes recommendations on steps that should be taken to realize the goal of making ESL instruction available to all individuals with limited English proficiency in the United States who are seeking instruction; and

(B) evaluates the impact of the grant program authorized under this section on the accessibility of, and ability to effectively negotiate, the health care system for individuals with limited English proficiency who have received ESL instruction funded by a grant under this section.

There are authorized to be appropriated to the Secretary of Education $250,000,000 for each of fiscal years 2025 through 2029 to carry out this section.

A person injured by a violation of this title (including an amendment made by this title) by a State may bring a civil action in the appropriate Federal court for such injury in accordance with this section.

In a civil action under this section for a violation of this title, such remedies shall be available as would be available in a civil action for such violation against any party other than a State.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Secretary of Health and Human Services shall—

(1) amend the single streamlined application form developed pursuant to section 1413 of the Patient Protection and Affordable Care Act (42 U.S.C. 18083) to collect the preferred spoken and written language for each household member applying for coverage under a qualified health plan through an Exchange under title I of such Act (42 U.S.C. 18001 et seq.);

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

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

The amendments made by this section shall not apply to plans beginning prior to the date of the enactment of this Act.

Section 330(b)(3) of the Public Health Service Act (42 U.S.C. 254b(b)(3)) is amended to read as follows:

The term medically underserved population means—

(A) the population of an urban or rural area designated by the Secretary as—

(i) an area with a shortage of personal health services; or

(ii) a population group having a shortage of such services; or

(B) a population of individuals, not confined to a particular urban or rural area, who are designated by the Secretary as having a shortage of personal health services due to a specific demographic trait.

Title XXXIV of the Public Health Service Act, as added by section 2004, is amended by adding at the end the following:

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

In establishing the national working group under subsection (a):

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

(A) The Health Resources and Services Administration.

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

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

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

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

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

(G) The Agency for Healthcare Research and Quality.

(H) The National Academy of Medicine.

(I) The Indian Health Service.

(J) The Centers for Medicare & Medicaid Services.

(K) The Department of Education.

(L) Institutions described in section 371(a) of the Higher Education Act of 1965.

(M) Consumer organizations.

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

(O) Researchers in the area of health workforce.

(P) Health workforce accreditation entities.

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

(R) Local and State health departments.

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

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

(U) The Veterans Health Administration.

(V) Other entities determined appropriate by the Secretary.

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

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

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

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

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

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

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

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

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

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

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

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

(11) Other activities determined appropriate by the Secretary.

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

In providing for the establishment of the working group under subsection (a), the Secretary shall take such steps as may be necessary to ensure that the work of the working group does not overlap with, or otherwise duplicate, other Federal Government efforts with respect to ensuring health equity in data collection in public health emergencies.

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

The clearinghouse established under subsection (a) shall offer the following information and services:

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

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

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

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

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

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

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

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

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

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

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

(B) historically Black professional or graduate institutions eligible for grants under section 326 of such Act;

(C) Hispanic-serving health professions schools;

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

(E) Tribal Colleges or Universities, as defined in section 316 of such Act;

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

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

(H) health professional associations, which may include health professional associations representing underrepresented minority populations; and

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

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

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

(iii) in which at least 20 percent of the enrolled participants are from underrepresented minority populations; and

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

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

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

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

(3) postbaccalaureate programs;

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

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

(6) mentoring programs;

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

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

(9) leadership training.

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

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

The head of each agency listed in subsection (a) shall collect data on the number (expressed as an absolute number and a percentage) of underrepresented applicants from minority populations, and applicants from populations that are not minority populations, who receive and are denied agency funding at every stage of review. Such data shall be reported annually to the Secretary and the appropriate committees of Congress.

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

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Secretary, acting through the Director of the Centers for Disease Control and Prevention, the Assistant Secretary for Mental Health and Substance Use, the Administrator of the Health Resources and Services Administration, and the Administrator of the Centers for Medicare & Medicaid Services, shall establish a program to award grants to universities and other institutions to enter into agreements with eligible individuals under which—

(1) the university or institution supports the eligible individual’s career in a nonresearch-related health and wellness profession; and

(2) the eligible individual commits to performing a period of obligated service in such a career to serve, or to work on health issues affecting, underserved communities, such as communities of racial and ethnic minority groups.

To be an eligible individual for purposes of subsection (a), an individual shall be a student in a health professions school, a graduate of such a school who is working in a health profession, an individual working in a health or wellness profession (including mental and behavioral health), or a faculty member of such a school.

To seek a grant under this section, a university or other institution shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

A university or other institution receiving a grant under this section shall use the grant for agreements described in subsection (a). Such agreements may—

(1) support an eligible individual’s health activities or projects that involve underserved communities, including communities of racial and ethnic minority groups;

(2) support an eligible individual’s health-related career advancement activities;

(3) pay, or reimburse for payment of, student loans or training or credentialing costs for eligible individuals who are health professionals and are focused on health issues affecting underserved communities, including communities of racial and ethnic minority groups; and

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

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

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

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

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

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

(1) language access;

(2) cultural competence;

(3) patient satisfaction;

(4) timeliness of care;

(5) safety of care;

(6) effectiveness of care;

(7) efficiency of care;

(8) patient outcomes;

(9) community engagement;

(10) resource allocation;

(11) organizational structure;

(12) compliance of care; or

(13) other topics determined appropriate by the Director.

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

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

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

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

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

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

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

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

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

The Secretary, acting through the Administrator of the Health Resources and Services Administration and in consultation with the Secretary of Education, shall award grants to Hispanic-serving institutions, historically Black colleges and universities, historically Black professional or graduate institutions eligible for grants under section 326 of the Higher Education Act of 1965, Asian American and Native American Pacific Islander-serving institutions, Tribal Colleges or Universities, regional community-based organizations, and national minority medical associations, for counseling, mentoring, and providing information on financial assistance to prepare underrepresented minority individuals to enroll in and graduate from health professional schools and to increase services for underrepresented minority students including—

(1) mentoring with underrepresented health professionals;

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

(3) retaining existing enrolled underrepresented minority students in a health professions school.

In this section:

The term Asian American and Native American Pacific Islander-serving institution has the meaning given such term in section 320(b) of the Higher Education Act of 1965.

The term Hispanic-serving institution means an entity that—

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

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

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

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

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

(F) is a Hispanic Center of Excellence in Health Professions Education designated under section 736(d)(2).

The term historically Black college and university has the meaning given the term part B institution as defined in section 322 of the Higher Education Act of 1965.

The term Tribal College or University has the meaning given such term in section 316(b) of the Higher Education Act of 1965.

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

Section 317F(c)(1) of the Public Health Service Act (42 U.S.C. 247b–7(c)(1)) is amended by striking $500,000 for fiscal year 1994, and such sums as may be necessary for each of the fiscal years 1995 through 2002 and inserting such sums as may be necessary for each of fiscal years 2025 through 2029.

Part D of title VII of the Public Health Service Act (42 U.S.C. 294 et seq.) is amended by inserting after section 755 of such Act (42 U.S.C. 294e) the following:

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

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

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

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

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

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

The period during which payments are made through a cooperative agreement entered into under this section may not exceed 3 years.

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

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

Section 5101(h)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 294q(h)(2)) is amended by striking such sums as may be necessary and inserting $3,000,000 for each of fiscal years 2025 through 2027.

Subtitle B of title XXXIV of the Public Health Service Act, as added by section 3001, is further amended by inserting after section 3417 the following:

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

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

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

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

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

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

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

(1) Medicine.

(2) Nursing.

(3) Public health.

(4) Pharmacy.

(5) Health administration and management.

(6) Health policy.

(7) Psychology.

(8) Dentistry.

(9) International health.

(10) Social work.

(11) Allied health.

(12) Psychiatry.

(13) Hospice care.

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

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

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

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

(2) have experience in health disparity elimination programs;

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

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

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

A stipend awarded under paragraph (1) to an individual—

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

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

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Director of the Centers for Disease Control and Prevention, in collaboration with the Deputy Assistant Secretary for Minority Health, shall award scholarships to eligible individuals under subsection (b) who seek a career in public health.

To be eligible to receive a scholarship under subsection (a), an individual shall—

(1) have interest, knowledge, or skill in public health research or public health practice, or other health professions as determined appropriate by the Director of the Centers for Disease Control and Prevention;

(2) reside in a health professional shortage area as determined by the Secretary;

(3) demonstrate promise for becoming a leader in public health;

(4) secure admission to a 4-year institution of higher education; and

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

Amounts received under an award under subsection (a) shall be used to support opportunities for students to become public health professionals.

In awarding grants under subsection (a), the Director shall give priority to those students that—

(1) are from disadvantaged backgrounds;

(2) have secured admissions to an institution described in section 371(a) of the Higher Education Act of 1965; and

(3) have identified a health professional as a mentor at their institution described in subsection (b)(4) and an academic advisor to assist in the completion of their baccalaureate degree.

The Secretary may approve payment of scholarships under this section for such individuals for any period of education in student undergraduate tenure, except that such a scholarship may not be provided to an individual for more than 4 years, and such a scholarship may not exceed $10,000 per academic year for an individual (notwithstanding any other provision of law regarding the amount of a scholarship).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Director of the Centers for Disease Control and Prevention, in collaboration with the Deputy Assistant Secretary for Minority Health, the Assistant Secretary for Mental Health and Substance Use, and the Director of the Indian Health Service, shall award research fellowships to eligible individuals under subsection (b) to conduct research that will examine gender and health disparities and to pursue a career in the health professions.

To be eligible to receive a fellowship under subsection (a), an individual shall—

(1) have experience in health research or public health practice;

(2) reside in a health professional shortage area designated by the Secretary under section 332;

(3) have expressed an interest in the health professions;

(4) demonstrate promise for becoming a leader in the field of women’s sexual and reproductive health, including family planning;

(5) secure admission to a health professions school or graduate program with an emphasis in gender studies; and

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

A fellowship awarded under subsection (a) to an eligible individual under subsection (b) shall be used to support an opportunity for the individual to become a researcher and advance the research base on the intersection between gender and health.

In awarding fellowships under subsection (a), the Director of the Centers for Disease Control and Prevention shall give priority to those applicants that—

(1) are from disadvantaged backgrounds; and

(2) have identified a mentor and academic advisor who will assist in the completion of their graduate or professional degree and have secured a research assistant position with a researcher working in the area of gender and health.

The Director of the Centers for Disease Control and Prevention may approve fellowships for individuals under this section for any period of education in the student’s graduate or health profession tenure, except that such a fellowship may not be provided to an individual for more than 3 years, and such a fellowship may not exceed $18,000 per academic year for an individual (notwithstanding any other provision of law regarding the amount of a fellowship).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Director of the Agency for Healthcare Research and Quality, in collaboration with the Deputy Assistant Secretary for Minority Health, shall award research fellowships to eligible individuals under subsection (b) to advance their understanding of international health.

To be eligible to receive a fellowship under subsection (a), an individual shall—

(1) have educational experience in the field of international health;

(2) reside in a health professional shortage area as determined by the Secretary;

(3) demonstrate promise for becoming a leader in the field of international health;

(4) be in the fourth year of a 4-year institution of higher education or a recent graduate of a 4-year institution of higher education; and

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

A fellowship awarded under subsection (a) to an eligible individual under subsection (b) shall be used to support an opportunity for the individual to become a health professional and to advance the knowledge of the individual about international issues relating to health care access and quality.

In awarding fellowships under subsection (a), the Director of the Agency for Healthcare Research and Quality shall give priority to eligible individuals under subsection (b) that—

(1) are from a disadvantaged background; and

(2) have identified a mentor at a health professions school or institution, an academic advisor to assist in the completion of their graduate or professional degree, and an advisor from an international health non-governmental organization, private volunteer organization, or other international institution or program that focuses on increasing health care access and quality for residents in developing countries.

A fellowship awarded under this section may not—

(1) be provided to an eligible individual for more than a period of 6 months;

(2) be awarded to a graduate of a 4-year institution of higher education that has not been enrolled in such institution for more than 1 year; or

(3) exceed $4,000 per academic year (notwithstanding any other provision of law regarding the amount of a fellowship).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Director of the Agency for Healthcare Research and Quality, the Administrator of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration, in collaboration with the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities under subsection (b) to expose entering graduate students to the health professions.

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

(1) be a clinical, public health, or health services organization, community-based, academic, or nonprofit entity, or other entity determined appropriate by the Director of the Agency for Healthcare Research and Quality;

(2) serve in a health professional shortage area designated by the Secretary under section 332;

(3) work with students obtaining a degree in the health professions; and

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

Amounts received under a grant awarded under subsection (a) shall be used to support opportunities that expose students to non-research-based health professions, including—

(1) public health policy;

(2) health care and pharmaceutical policy;

(3) health care administration and management;

(4) health economics; and

(5) other professions determined appropriate by the Director of the Agency for Healthcare Research and Quality, the Administrator of the Centers for Medicare & Medicaid Services, or the Administrator of the Health Resources and Services Administration.

In awarding grants under subsection (a), the Director of the Agency for Healthcare Research and Quality, the Administrator of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration, in collaboration with the Deputy Assistant Secretary for Minority Health, shall give priority to entities that—

(1) have experience with health disparity elimination programs;

(2) facilitate training in the fields described in subsection (c); and

(3) provide counseling or other services designed to assist students in successfully completing their education at the postsecondary level.

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

A stipend awarded under paragraph (1) to an individual—

(A) may not be provided for a period that exceeds 2 months; and

(B) may not exceed $100 per day (notwithstanding any other provision of law regarding the amount of a stipend).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

The Secretary shall award grants to national minority medical or health professional associations to develop leadership fellowship programs for underrepresented health professionals in order to—

(1) assist such professionals in becoming future leaders in public health and health care delivery institutions; and

(2) increase diversity in decision-making positions that can improve the health of underserved communities.

A leadership fellowship program supported under this section shall—

(1) focus on training mid-career physicians and health care executives who have documented leadership experience and a commitment to public health services in underserved communities; and

(2) support Federal public health policy and budget programs, and priorities that impact health equity, through activities such as didactic lectures and leader site visits.

The period during which payments are made under a grant awarded under subsection (a) may not exceed 3 years.

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

Section 402E of the Higher Education Act of 1965 (20 U.S.C. 1070a–15) is amended by striking subsection (g) and inserting the following:

The Secretary shall coordinate with the Secretary of Health and Human Services to ensure that there is collaboration between the goals of the program under this section and programs of the Health Resources and Services Administration that promote health workforce diversity. The Secretary of Education shall take such measures as may be necessary to encourage students participating in projects assisted under this section to consider health profession careers.

From amounts appropriated pursuant to the authority of section 402A(g), the Secretary shall, to the extent practicable, allocate funds for projects authorized by this section in an amount that is not less than $31,000,000 for each of the fiscal years 2025 through 2029.

Section 1886(h)(4) of the Social Security Act (42 U.S.C. 1395ww(h)(4)), as amended by section 2006(a), is amended—

(1) in subparagraph (E), by striking Subject to subparagraphs (J) and (K), such rules and inserting Subject to subparagraphs (J), (K), and (M), such rules;

(2) in subparagraph (J), by striking Such rules and inserting Subject to subparagraph (M), such rules;

(3) in subparagraph (K), by striking In determining and inserting Subject to subparagraph (M), in determining; and

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

For purposes of cost-reporting periods beginning on or after October 1, 2025, in determining the hospital’s number of full-time equivalent residents for purposes of this paragraph, all time spent by an intern or resident in an approved medical residency training program shall be counted toward the determination of full-time equivalency if the hospital—

(i) is recognized as a subsection (d) hospital;

(ii) is recognized as a subsection (d) Puerto Rico hospital;

(iii) is reimbursed under a reimbursement system authorized under section 1814(b)(3); or

(iv) is a provider-based hospital outpatient department.

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

(1) in subclause (II), by striking In determining and inserting Subject to subclause (IV), in determining;

(2) in subclause (III), by striking In determining and inserting Subject to subclause (IV), in determining; and

(3) by inserting after subclause (III) the following new subclause:

(IV) For purposes of cost-reporting periods beginning on or after October 1, 2025, the provisions of subparagraph (M) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.

The Secretary of Health and Human Services, acting jointly with the Secretary of Education and the Secretary of Labor, shall make grants to eligible institutions of higher educations for the purposes of—

(1) in accordance with subsection (b), developing capacity—

(A) to build an evidence base for successful strategies for increasing local health equity; and

(B) to serve as national models of driving local health equity; and

(2) in accordance with subsection (c), developing a strategic partnership with the community in which the institution is located.

As a condition of receipt of a grant under subsection (a), an institution of higher education shall agree to use such grant to build an evidence base for successful strategies for increasing local health equity, and to serve as a national model of driving local health equity, by supporting—

(1) resources to strengthen institutional metrics and capacity to execute institution-wide health workforce goals that can serve as models for increasing health equity in communities across the United States;

(2) collaborations among a cohort of institutions in implementing systemic change, partnership development, and programmatic efforts supportive of health equity goals across disciplines and populations; and

(3) enhanced or newly developed data systems and research infrastructure capable of informing current and future workforce efforts and building a foundation for a broader research agenda targeting urban health disparities.

As a condition of receipt of a grant under subsection (a), an institution of higher education shall agree to use the grant to develop a strategic partnership with the community in which such institution is located for the purposes of—

(1) strengthening connections between such institution and the community—

(A) to improve evaluation of, and address, the health and health workforce needs of such community; and

(B) to engage such community in health workforce development;

(2) developing, enhancing, or accelerating innovative undergraduate and graduate programs in the biomedical sciences and health professions; and

(3) strengthening pipeline programs in the biomedical sciences and health professions, including by developing partnerships between institutions of higher education and elementary schools and secondary schools to recruit the next generation of health professionals earlier in the pipeline to a health care career.

For purposes of this section, the term eligible institution of higher education includes—

(1) a program authorized under section 317(a) of the Higher Education Act of 1965 (20 U.S.C. 1059d(a)); and

(2) a professional or graduate institution described in section 326 of such Act (20 U.S.C. 1063b).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2029.

There is established in the Health Resources and Services Administration of the Department of Health and Human Services a Health Professions Workforce Fund to provide for expanded and sustained national investment in the health professions and nursing workforce development programs under titles VII and title VIII of the Public Health Service Act (42 U.S.C. 292 et seq.; 42 U.S.C. 296 et seq.).

There is authorized to be appropriated, and there is appropriated, out of any monies in the Treasury not otherwise appropriated, to the Health Professions Workforce Fund—

(A) $392,000,000 for fiscal year 2025;

(B) $412,000,000 for fiscal year 2026;

(C) $432,000,000 for fiscal year 2027;

(D) $454,000,000 for fiscal year 2028;

(E) $476,000,000 for fiscal year 2029;

(F) $500,000,000 for fiscal year 2030;

(G) $525,000,000 for fiscal year 2031; and

(H) $552,000,000 for fiscal year 2032.

For the purpose of carrying out health professions education programs authorized under title VII of the Public Health Service Act (42 U.S.C. 292 et seq.), in addition to any other amounts authorized to be appropriated for such purpose, there is authorized to be appropriated out of any monies in the Health Professions Workforce Fund, the following:

(A) $265,000,000 for fiscal year 2025.

(B) $278,000,000 for fiscal year 2026.

(C) $292,000,000 for fiscal year 2027.

(D) $307,000,000 for fiscal year 2028.

(E) $322,000,000 for fiscal year 2029.

(F) $338,000,000 for fiscal year 2030.

(G) $355,000,000 for fiscal year 2031.

(H) $373,000,000 for fiscal year 2032.

For the purpose of carrying out nursing workforce development programs authorized under title VIII of the Public Health Service Act (42 U.S.C. 296 et seq.), in addition to any other amounts authorized to be appropriated for such purpose, there is authorized to be appropriated out of any monies in the Health Professions Workforce Fund, the following:

(A) $127,000,000 for fiscal year 2025.

(B) $134,000,000 for fiscal year 2026.

(C) $140,000,000 for fiscal year 2027.

(D) $147,000,000 for fiscal year 2028.

(E) $154,000,000 for fiscal year 2029.

(F) $162,000,000 for fiscal year 2030.

(G) $170,000,000 for fiscal year 2031.

(H) $179,000,000 for fiscal year 2032.

Part D of title VIII of the Public Health Service Act (42 U.S.C. 296p et seq.) is amended by adding at the end the following:

The Secretary, acting through the Administrator of the Health Resources and Services Administration, may award grants to schools of nursing for—

(1) increasing the number of faculty and students at such schools in order to enhance the preparedness of the United States for, and the ability of the United States to address and quickly respond to, public health emergencies declared under section 319 and pandemics; or

(2) the enhancement and modernization of nursing education programs.

In selecting grant recipients under this section, the Secretary shall give priority to schools of nursing that—

(1) are located in a medically underserved community;

(2) are located in a health professional shortage area as defined under section 332(a); or

(3) are institutions of higher education listed under section 371(a) of the Higher Education Act of 1965.

In awarding grants under this section, the Secretary, to the extent practicable, may ensure equitable distribution of awards among the geographic regions of the United States.

A school of nursing that receives a grant under this section may use the funds awarded through such grant for activities that include—

(1) enhancing enrollment and retention of students at such school, with a priority for students from disadvantaged backgrounds (including racial or ethnic groups underrepresented in the nursing workforce), individuals from rural and underserved areas, low-income individuals, and first generation college students (as defined in section 402A(h)(3) of the Higher Education Act of 1965);

(2) creating, supporting, or modernizing educational programs and curriculum at such school;

(3) retaining current faculty, and hiring new faculty, with an emphasis on faculty from racial or ethnic groups who are underrepresented in the nursing workforce;

(4) modernizing infrastructure at such school, including audiovisual or other equipment, personal protective equipment, simulation and augmented reality resources, telehealth technologies, and virtual and physical laboratories;

(5) partnering with a health care facility, nurse-managed health clinic, community health center, or other facility that provides health care in order to provide educational opportunities for the purpose of establishing or expanding clinical education;

(6) enhancing and expanding nursing programs that prepare nurse researchers and scientists;

(7) establishing nurse-led intradisciplinary and interprofessional educational partnerships; and

(8) other activities that the Secretary determines further the development, improvement, and expansion of schools of nursing.

Each school of nursing awarded a grant under this section shall submit an annual report to the Secretary on the activities conducted under such grant, and other information as the Secretary may require.

Not later than 5 years after the date of the enactment of this section, the Secretary shall 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 that provides a summary of the activities and outcomes associated with grants made under this section. Such report shall include—

(1) a list of schools of nursing receiving grants under this section, including the primary geographic location of any school of nursing that was improved or expanded through such a grant;

(2) the total number of students who are enrolled at or who have graduated from any school of nursing that was improved or expanded through a grant under this section, which such statistic shall—

(A) to the extent such information is available, be deidentified and disaggregated by race, ethnicity, age, sex, geographic region, disability status, and other relevant factors; and

(B) include an indication of the number of such students who are from racial or ethnic groups underrepresented in the nursing workforce, such students who are from rural or underserved areas, such students who are low-income students, and such students who are first generation college students (as defined in section 402A(h)(3) of the Higher Education Act of 1965);

(3) to the extent such information is available, the effects of the grants awarded under this section on retaining and hiring of faculty, including any increase in diverse faculty, the number of clinical education partnerships, the modernization of nursing education infrastructure, and other ways this section helps address and quickly respond to public health emergencies and pandemics;

(4) recommendations for improving the grants awarded under this section; and

(5) any other considerations as the Secretary determines appropriate.

To carry out this section, there is authorized to be appropriated $1,000,000,000, to remain available until expended.

The heading of part D of title VIII of the Public Health Service Act (42 U.S.C. 296p et seq.) is amended by striking Basic.

It is the sense of Congress that eliminating the limit of the number of residency positions that receive some level of Medicare support under section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), also referred to as the Medical graduate medical education cap, is critical to—

(1) ensuring an appropriate supply of physicians to meet the health care needs in the United States;

(2) facilitating equitable access for all who seek health care;

(3) increasing the racial and ethnic diversity of physicians in the United States; and

(4) mitigating disparities in health and health care.

The Secretary of Health and Human Services (in this section referred to as the Secretary), acting through the Bureau of Health Workforce within the Health Resources and Services Administration, the National Institute on Minority Health and Health Disparities, or the Office of Minority Health, may award grants to eligible entities under paragraph (2) to carry out activities described in subsection (b).

To be eligible to receive a grant under this section, an entity shall—

(A) be a clinical, public health, or health services organization, a community-based or nonprofit entity, an academic institution, a faith-based organization, a State, county, or local government, an area health education center, or another entity determined appropriate by the Secretary; and

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

A grant awarded under this section shall be used—

(1) to provide services to assist unemployed and underemployed skilled immigrants, residing in the United States, who have legal, permanent work authorization and who are internationally educated health professionals, enter into the health workforce of the United States with employment matching their health professional skills and education, and advance in employment to positions that better match their health professional education and expertise;

(2) to provide training opportunities to reduce barriers to entry and advancement in the health workforce for skilled, internationally educated immigrants;

(3) to educate employers regarding the abilities and capacities of internationally educated health professionals;

(4) to assist in the evaluation of foreign credentials;

(5) to support preceptorships for international medical graduates in hospital primary care training; and

(6) to facilitate access to contextualized and accelerated courses on English as a second language.

The Comptroller General of the United States shall conduct a study on strategies for increasing the diversity of the health professional workforce. Such study shall include an analysis of strategies for increasing the number of health professionals from rural, lower income, and underrepresented minority communities, including which strategies are most effective for achieving such goal.

Not later than 2 years after the date of enactment of this Act, the Comptroller General shall submit to Congress a report on the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.

Section 220(c) of the Immigration and Nationality Technical Corrections Act of 1994 (Public Law 103–416; 8 U.S.C. 1182 note) is amended by striking September 30, 2015 and inserting the date that is 3 years after the date of the enactment of the Health Equity and Accountability Act of 2024.

The amendment made by paragraph (1) shall take effect as if enacted on September 30, 2018.

Section 201(b)(1) of the Immigration and Nationality Act (8 U.S.C. 1151(b)(1)) is amended by adding at the end the following:

(i) Alien physicians who have completed service requirements of a waiver requested under section 203(b)(2)(B)(ii), including—

(I) alien physicians who completed such service before the date of the enactment of the Health Equity and Accountability Act of 2024; and

(II) the spouse or children of an alien physician described in subclause (I).

(ii) Nothing in this subparagraph may be construed—

(I) to prevent the filing of a petition with the Secretary of Homeland Security for classification under section 204(a) or the filing of an application for adjustment of status under section 245 by an alien physician described in clause (i)(I) before the date on which such alien physician completed the service described in section 214(l) or worked full-time as a physician for an aggregate of 5 years at the location identified in the section 214(l) waiver or in an area or areas designated by the Secretary of Health and Human Services as having a shortage of health care professionals; or

(II) to permit the Secretary of Homeland Security to grant a petition or application described in subclause (I) until the alien has satisfied all of the requirements of the waiver received under section 214(l).

Section 214(l)(1) of the Immigration and Nationality Act (8 U.S.C. 1184(l)(1)) is amended—

(A) in the matter preceding subparagraph (A), by striking Attorney General and inserting Secretary of Homeland Security;

(B) in subparagraph (A), by striking Director of the United States Information Agency and inserting Secretary of State;

(C) in subparagraph (B), by inserting, except as provided in paragraphs (7) and (8) before the semicolon at the end;

(D) in subparagraph (C), by amending clauses (i) and (ii) to read as follows:

(i) the alien demonstrates a bona fide offer of full-time employment at a health facility or health care organization, which employment has been determined by the Secretary of Homeland Security to be in the public interest; and

(ii) the alien—

(I) has accepted employment with the health facility or health care organization in a geographic area or areas which are designated by the Secretary of Health and Human Services as having a shortage of health care professionals;

(II) begins employment by the later of the date that is—

(aa) 120 days after receiving such waiver;

(bb) 120 days after completing graduate medical education or training under a program approved pursuant to section 212(j)(1); or

(cc) 120 days after receiving nonimmigrant status or employment authorization, if the alien or the alien’s employer petitions for such nonimmigrant status or employment authorization not later than 120 days after the date on which the alien completes his or her graduate medical education or training under a program approved pursuant to section 212(j)(1); and

(III) agrees to continue to work for a total of not less than 3 years in the status authorized for such employment under this subsection, except as provided in paragraph (8); and

(D) ; and

(E) in subparagraph (D), in the matter preceding clause (i), by inserting except as provided in paragraph (8), before in the case.

Section 214(l)(2)(A) of such Act (8 U.S.C. 1184(l)(2)(A)) is amended to read as follows:

(A) Upon the request of an interested Federal agency or an interested State agency for recommendation of a waiver under this section by a physician who is maintaining valid nonimmigrant status under section 101(a)(15)(J) and received a favorable recommendation by the Secretary of State, the Secretary of Homeland Security may adjust the status of such physician to any status authorized for employment under this Act. The numerical limitations set forth in subsection (g)(1)(A) shall not apply to any alien whose status is adjusted pursuant to this subparagraph.

Section 214(l)(3)(A) of such Act (8 U.S.C. 1184(l)(3)(A)) is amended by inserting substantial requirement of an before agreement entered into.

Section 214(l) of such Act, as amended by this subsection, is further amended by adding at the end the following:

(A) If an interested State agency denies an application for a waiver under paragraph (1)(B) from a physician pursuing graduate medical education or training pursuant to section 101(a)(15)(J) because the State has requested the maximum number of waivers permitted for that fiscal year, the physician’s nonimmigrant status shall be extended for up to 6 months if the physician agrees to seek a waiver under this subsection (except for paragraph (1)(D)(ii)) to work for an employer described in paragraph (1)(C) in a State that has not yet requested the maximum number of waivers.

(B) Such physician shall be authorized to work only for the employer referred to in subparagraph (A) during the period beginning on the date on which a new waiver application is filed with such State and ending on the earlier of—

(i) the date on which the Secretary of Homeland Security denies such waiver; or

(ii) the date on which the Secretary approves an application for adjustment of status under paragraph (2)(A) pursuant to the approval of such waiver.

Section 214(l) of such Act, as amended by this subsection, is further amended by adding at the end the following:

(5) An alien granted a waiver under paragraph (1)(C) shall enter into an employment agreement with the contracting health facility or health care organization that—

(A) specifies—

(i) the maximum number of on-call hours per week (which may be a monthly average) that the alien will be expected to be available; and

(ii) the compensation the alien will receive for on-call time;

(B) specifies—

(i) whether the contracting facility or organization—

(I) has secured medical malpractice liability protection for the alien under section 224(g) of the Public Health Service Act (42 U.S.C. 233(g); or

(II) will pay the alien's malpractice insurance premiums; and

(ii) the amount of such liability protection that will be provided;

(C) describes all of the work locations that the alien will work and includes a statement that the contracting facility or organization will not add additional work locations without the approval of the Federal agency or State agency that requested the waiver; and

(D) does not include a non-compete provision.

(6) An alien granted a waiver under this subsection whose employment relationship with a health facility or health care organization terminates under paragraph (1)(C)(ii) during the 3-year service period required under paragraph (1) shall be considered to be maintaining lawful status in an authorized period of stay during the 120-day period referred to in items (aa) and (bb) of subclause (III) of paragraph (1)(C)(ii) or the 45-day period referred to in subclause (III)(cc) of such paragraph.

Section 214(l) of such Act, as amended by this subsection, is further amended by adding at the end the following:

(7) If a recipient of a waiver under this subsection terminates the recipient’s employment with a health facility or health care organization pursuant to paragraph (1)(C)(ii), including termination of employment because of circumstances described in paragraph (1)(C)(ii)(III), and accepts new employment with such a facility or organization in a different State, the State from which the alien is departing may be granted an additional waiver by the Secretary of State for use in the fiscal year in which the alien’s employment was terminated.

Section 214(l) of such Act, as amended by this subsection, is further amended by adding at the end the following:

(8) The 3-year work requirement set forth in subparagraphs (C) and (D) of paragraph (1) shall not apply if—

(i) the Secretary of Homeland Security determines the existence of extenuating circumstances, including violations by the employer of the employment agreement with the alien or of labor and employment laws, which justify a lesser period of employment at such facility or organization; and

(ii) the alien demonstrates, not later than 120 days after the employment termination date (unless the Secretary determines that extenuating circumstances would justify an extension), another bona fide offer of employment at a health facility or health care organization in a geographic area or areas designated by the Secretary of Health and Human Services as having a shortage of health care professionals, for the remainder of such 3-year period;

(i) the interested State agency that requested the waiver attests to the existence of extenuating circumstances, including violations by the employer of the employment agreement with the alien or of labor and employment laws, which justify a lesser period of employment at such facility or organization; and

(ii) the alien demonstrates, not later than 120 days after the employment termination date (unless the Secretary determines that extenuating circumstances would justify an extension), another bona fide offer of employment at a health facility or health care organization in a geographic area or areas designated by the Secretary of Health and Human Services as having a shortage of health care professionals, for the remainder of such 3-year period; or

(C) the alien—

(i) elects not to pursue a determination of extenuating circumstances pursuant to subparagraph (A) or (B);

(ii) terminates the alien’s employment relationship with the health facility or health care organization at which the alien was employed;

(iii) demonstrates, not later than 45 days after the employment termination date, another bona fide offer of employment at a health facility or health care organization in a geographic area or areas, in the State that requested the alien’s waiver, which are designated by the Secretary of Health and Human Services as having a shortage of health care professionals; and

(iv) agrees to be employed for the remainder of such 3-year period, and 1 additional year for each termination under clause (ii).

Section 214(l) of the Immigration and Nationality Act (8 U.S.C. 1184(l)), as amended by subsection (c), is further amended by adding at the end the following:

(i) All States shall be allotted a total of 35 waivers under paragraph (1)(B) for a fiscal year if 90 percent of the waivers available to the States receiving at least 5 waivers were used in the previous fiscal year.

(ii) When an allotment occurs under clause (i), all States shall be allotted an additional 5 waivers under paragraph (1)(B) for each subsequent fiscal year if 90 percent of the waivers available to the States receiving at least 5 waivers were used in the previous fiscal year. If the States are allotted 45 or more waivers for a fiscal year, the States will only receive an additional increase of 5 waivers the following fiscal year if 95 percent of the waivers available to the States receiving at least 1 waiver were used in the previous fiscal year.

(B) Any increase in allotments under subparagraph (A) shall be maintained indefinitely, unless in a fiscal year the total number of such waivers granted is 5 percent lower than in the last year in which there was an increase in the number of waivers allotted pursuant to this paragraph, in which case—

(i) the number of waivers allotted shall be decreased by 5 for all States beginning in the next fiscal year; and

(ii) each additional 5 percent decrease in such waivers granted from the last year in which there was an increase in the allotment, shall result in an additional decrease of 5 waivers allotted for all States, provided that the number of waivers allotted for all States shall not drop below 30.

Section 214(l)(1)(D) of such Act, as amended by subsection (c)(1)(E), is further amended—

(A) in clause (ii), by striking and at the end;

(B) in clause (iii), by striking the period at the end and inserting; and; and

(C) by adding at the end the following:

(iv) in the case of a request by an interested State agency—

(I) the head of such agency determines that the alien is to practice medicine in, or be on the faculty of a residency program at, an academic medical center (as defined in section 411.355(e)(2) of title 42, Code of Federal Regulations, or a similar successor regulation), without regard to whether such facility is located within an area designated by the Secretary of Health and Human Services as having a shortage of health care professionals; and

(II) the head of such agency determines that—

(aa) the alien physician’s work is in the public interest; and

(bb) the grant of such waiver would not cause the number of the waivers granted on behalf of aliens for such State for a fiscal year to exceed 3 (within the limitation in subparagraph (B) and subject to paragraph (6)), in accordance with the conditions of this clause.

Section 214(b) of the Immigration and Nationality Act (8 U.S.C. 1184(b)) is amended by striking and other than a nonimmigrant described in any provision of section 101(a)(15)(H)(i) except subclause (b1) of such section) and inserting a nonimmigrant described in any provision of section 101(a)(15)(H)(i) (except subclause (b1) of such section), and an alien coming to the United States to receive graduate medical education or training as described in section 212(j) or to take examinations required to receive graduate medical education or training as described in section 212(j)).

Section 203(b)(2)(B)(ii)(I) of the Immigration and Nationality Act (8 U.S.C. 1153(b)(2)(B)(ii)(I)) is amended by striking items (aa) and (bb) and inserting the following:

(aa) the alien physician agrees to work on a full-time basis practicing primary care, specialty medicine, or a combination thereof, in an area or areas designated by the Secretary of Health and Human Services as having a shortage of health care professionals, or at a health care facility under the jurisdiction of the Secretary of Veterans Affairs; or

(bb) the alien physician is pursuing such waiver based upon service at a facility or facilities that serve patients who reside in a geographic area or areas designated by the Secretary of Health and Human Services as having a shortage of health care professionals (without regard to whether such facility or facilities are located within such an area) and a Federal agency, or a local, county, regional, or State department of public health determines the alien physician’s work was or will be in the public interest.

Section 203(b)(2)(B)(ii) of such Act, as amended by subparagraph (A), is further amended—

(i) by moving subclauses (II), (III), and (IV) 4 ems to the left; and

(ii) in subclause (II)—

(I) by inserting (aa) after (II); and

(II) by adding at the end the following:

(bb) The 5-year service requirement described in item (aa) shall begin on the date on which the alien physician begins work in the shortage area in any legal status and not on the date on which an immigrant visa petition is filed or approved. Such service shall be aggregated without regard to when such service began and without regard to whether such service began during or in conjunction with a course of graduate medical education.

(cc) An alien physician shall not be required to submit an employment contract with a term exceeding the balance of the 5-year commitment yet to be served or an employment contract dated within a minimum time period before filing a visa petition under this subsection.

(dd) An alien physician shall not be required to file additional immigrant visa petitions upon a change of work location from the location approved in the original national interest immigrant petition.

Section 203(b)(2)(A) of such Act is amended by adding at the end the following: An alien physician holding a foreign medical degree that has been deemed sufficient for acceptance by an accredited United States medical residency or fellowship program is a member of the professions holding an advanced degree or its equivalent..

A physician completing graduate medical education or training described in section 212(j) of the Immigration and Nationality Act (8 U.S.C. 1182(j)) as a nonimmigrant described in section 101(a)(15)(H)(i) of such Act (8 U.S.C. 1101(a)(15)(H)(i))—

(i) shall have such nonimmigrant status automatically extended until October 1 of the fiscal year for which a petition for a continuation of such nonimmigrant status has been submitted in a timely manner and the employment start date for the beneficiary of such petition is October 1 of that fiscal year; and

(ii) shall be authorized to be employed incident to status during the period between the filing of such petition and October 1 of such fiscal year.

The physician's status and employment authorization shall terminate on the date that is 30 days after the date on which a petition described in clause (i)(I) is rejected, denied, or revoked.

A physician's status and employment authorization will automatically extend to October 1 of the next fiscal year if all of the visas described in section 101(a)(15)(H)(i) of the Immigration and Nationality Act (8 U.S.C. 1101(a)(15)(H)(i)) that were authorized to be issued for the fiscal year have been issued.

A spouse or child of an exchange visitor described in section 101(a)(15)(J) of the Immigration and Nationality Act (8 U.S.C. 1101(a)(15)(J)) shall not be subject to the requirements under section 212(e) of such Act (8 U.S.C. 1182(e)).

The Director of U.S. Citizenship and Immigration Service shall submit an annual report to Congress and to the Secretary of Health and Human Services that identifies the number of aliens admitted during the most recently concluded fiscal year as a result of the Conrad State 30 J–1 Visa Waiver Program established under sections 212(e) and 214(l) of the Immigration and Nationality Act (8 U.S.C. 1182(e) and 1184(l)), broken down by State.

Subpart II of part C of title VII of the Public Health Service Act (42 U.S.C. 293m et seq.) is amended by adding at the end the following:

The Secretary may award grants to institutions of higher education (including consortiums of such institutions) for the establishment, improvement, or expansion of a school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine.

In selecting grant recipients under this section, the Secretary shall give priority to any institution of higher education (or consortium of such institutions) that—

(1) proposes to use the grant for the establishment of a school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine, in an area—

(A) in which—

(i) no other such school is based; or

(ii) in the case in which the school of medicine or osteopathic medicine proposed to be established would be a minority-serving institution, no other minority-serving institution that includes a school of medicine or osteopathic medicine is based; and

(B) that is a medically underserved community or a health professional shortage area; or

(2) is a minority-serving institution described in section 371(a) of the Higher Education Act of 1965 or an institution or program described in section 326(e) of such Act.

In awarding grants under this section, the Secretary, to the extent practicable, may ensure equitable distribution of awards among the geographical regions of the United States.

An institution of higher education (or a consortium of such institutions)—

(1) shall use grant amounts received under this section to—

(A) recruit, enroll, and retain medical students who are pursuing a degree of doctor of medicine or doctor of osteopathy, including individuals who are from disadvantaged backgrounds (including racial and ethnic groups underrepresented among medical students and health professions), individuals from rural and underserved areas, low-income individuals, and first generation college students, at a school of medicine or osteopathic medicine or a branch campus of a school of medicine or osteopathic medicine; and

(B) develop, implement, and expand curriculum that emphasizes care for rural and underserved populations, including accessible and culturally and linguistically appropriate care and services, at such school or branch campus; and

(2) may use grant amounts received under this section to—

(A) plan and construct—

(i) a school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine, in an area in which no other such school is based; or

(ii) a school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine, that will be a minority-serving institution, in an area in which no other such school that is a minority-serving institution is based;

(B) plan, develop, and meet criteria for accreditation for a school of medicine or osteopathic medicine or a branch campus of a school of medicine or osteopathic medicine;

(C) hire faculty, including faculty from racial and ethnic groups who are underrepresented among the medical and other health professions, and other staff to serve at such a school or branch campus;

(D) support educational programs at such a school or branch campus;

(E) modernize and expand infrastructure at such a school or branch campus; and

(F) support other activities that the Secretary determines further the establishment, improvement, or expansion of a school of medicine or osteopathic medicine or a branch campus of a school of medicine or osteopathic medicine.

To be eligible to receive a grant under subsection (a), an institution of higher education (or a consortium of such institutions), shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including a description of the institution’s or consortium's planned activities described in subsection (d).

Each institution of higher education, or consortium of such institutions, awarded a grant under this section shall submit an annual report to the Secretary on the activities conducted under such grant, and other information as the Secretary may require.

Not later than 5 years after the date of enactment of this section and every 5 years thereafter, the Secretary shall 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 that provides a summary of the activities and outcomes associated with grants made under this section. Such reports shall include—

(A) a list of awardees, including their primary geographic location, and location of any school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine that was established, improved, or expanded under this program;

(B) the total number of students (including the number of students from racial and ethnic groups underrepresented among medical students and health professions, low-income students, and first generation college students) who—

(i) are enrolled at or who have graduated from any school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine, that was established, improved, or expanded under this program, deidentified and disaggregated by race, ethnicity, age, sex, geographic region, disability status, and other relevant factors, to the extent such information is available; and

(ii) who subsequently participate in an accredited internship or medical residency program upon graduation from any school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine, that was established, improved, or expanded under this program, deidentified and disaggregated by race, ethnicity, age, sex, geographic region, disability status, medical specialty pursued, and other relevant factors, to the extent such information is available;

(C) the effects of such program on the health care provider workforce, including any impact on demographic representation disaggregated by race, ethnicity, and sex, and the fields or specialties pursued by students who have graduated from any school of medicine or osteopathic medicine, or a branch campus of a school of medicine or osteopathic medicine, that was established, improved, or expanded under this program;

(D) the effects of such program on health care access in underserved areas, including medically underserved communities and health professional shortage areas; and

(E) recommendations for improving the program described in this section, and any other considerations as the Secretary determines appropriate.

The Secretary shall make reports submitted under paragraph (2) publicly available on the website of the Department of Health and Human Services.

In this section:

The term branch campus, with respect to a school of medicine or osteopathic medicine, means an additional location of such school that is geographically apart and independent of the main campus, at which the school offers at least 50 percent of the program leading to a degree of doctor of medicine or doctor of osteopathy that is offered at the main campus.

For purposes of subparagraph (A), the location of a school described in such subparagraph shall be considered to be independent of the main campus described in such subparagraph if the location—

(i) is permanent in nature;

(ii) offers courses in educational programs leading to a degree, certificate, or other recognized educational credential;

(iii) has its own faculty and administrative or supervisory organization; and

(iv) has its own budgetary and hiring authority.

The term first generation college student has the meaning given such term in section 402A(h)(3) of the Higher Education Act of 1965.

The term health professional shortage area has the meaning given such term in section 332(a).

The term institution of higher education has the meaning given such term in section 101 of the Higher Education Act of 1965.

The term medically underserved community has the meaning given such term in section 799B(6).

There is authorized to be appropriated such sums as may be necessary to carry out this section.

In this title and the amendments made by this title, the term health care includes all health care needed throughout the life cycle and the end of life.

Section 287 of the Immigration and Nationality Act (8 U.S.C. 1357) is amended—

(1) by striking the Service each place such term appears and inserting the Department of Homeland Security;

(2) by striking Attorney General each place such term appears and inserting Secretary of Homeland Security;

(3) in subsection (f)(1), by striking Commissioner and inserting Director of U.S. Citizenship and Immigration Services;

(4) in subsection (h)—

(A) by striking of the Immigration and Nationality Act; and

(B) by striking of such Act; and

(5) by adding at the end the following:

(1) In this subsection:

(A) The term appropriate congressional committees means—

(i) the Committee on Homeland Security and Governmental Affairs of the Senate;

(ii) the Committee on the Judiciary of the Senate;

(iii) the Committee on Homeland Security of the House of Representatives; and

(iv) the Committee on the Judiciary of the House of Representatives.

(B) The term enforcement action —

(i) means an apprehension, arrest, inspection interview, request for identification, search, seizure, service of charging documents or subpoenas, or surveillance for the purposes of immigration enforcement; and

(ii) includes an enforcement action at, or focused on, a protected area that is part of a joint case led by another law enforcement agency.

(C) The term exigent circumstances means a situation involving—

(i) the imminent risk of death, violence, or physical harm to any person or property, including a situation implicating terrorism or the national security of the United States;

(ii) the immediate arrest or pursuit of a dangerous felon, terrorist suspect, or other individual presenting an imminent danger; or

(iii) the imminent risk of destruction of evidence that is material to an ongoing criminal case.

(D) The term prior approval means—

(i) in the case of officers and agents of U.S. Immigration and Customs Enforcement, prior written approval to carry out an enforcement action involving a specific individual or individuals authorized by—

(I) the Assistant Director of Operations, Homeland Security Investigations;

(II) the Executive Associate Director, Homeland Security Investigations;

(III) the Assistant Director for Field Operations, Enforcement and Removal Operations; or

(IV) the Executive Associate Director for Field Operations, Enforcement and Removal Operations;

(ii) in the case of officers and agents of U.S. Customs and Border Protection, prior written approval to carry out an enforcement action involving a specific individual or individuals authorized by—

(I) a Chief Patrol Agent;

(II) the Director of Field Operations;

(III) the Director of Air and Marine Operations; or

(IV) the Internal Affairs Special Agent in Charge; and

(iii) in the case of other Federal, State, or local law enforcement officers, to carry out an enforcement action involving a specific individual or individuals authorized by—

(I) the head of the Federal agency carrying out the enforcement action; or

(II) the head of the State or local law enforcement agency carrying out the enforcement action.

(E) The term protected area includes all of the physical space located within 1,000 feet of—

(i) any medical treatment or mental health care facility, including any hospital, doctor’s office, health clinic, alcohol or drug prevention, counseling, or treatment facilities, syringe exchange services, vaccination, treatment, or testing sites, emergent or urgent care facility, sites that serve pregnant individuals, or community health centers;

(ii) any public or private school, including any known and licensed day care facility, preschool, sites of early childhood programs, primary school, secondary school, postsecondary school (including colleges and universities), or other institution of learning (including vocational or trade schools);

(iii) any scholastic or education-related activity or event or before or after school program, including field trips and interscholastic events;

(iv) any school bus or school bus stop;

(v) any place where children gather, such as a playground, a recreation center, a library, a foster care facility, or a group home for children;

(vi) any physical structure of an organization or subdivision of government that—

(I) assists children, pregnant women, victims of crime or abuse, or individuals with significant mental or physical disabilities;

(II) provides social services and assistance, including homeless shelters, community-based organizations, facilities that serve disabled persons, drug or alcohol counseling and treatment facilities, food banks or food pantries, and other places providing emergency and disaster services or assistance with food and nutrition, housing affordability and income or other services funded by State or local government, charitable giving, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Social Security, or the United States Housing Act; or

(III) provides hospice, palliative, or other available end-of-life care services to terminally ill persons;

(vii) any church, synagogue, mosque, or other place of worship or religious study, including buildings rented for the purpose of religious services, retreats, counseling, workshops, instruction, and education;

(viii) any Federal, State, or local courthouse, including the office of an individual’s legal counsel or representative, and a probation, parole, or supervised release office;

(ix) the site of a funeral, grave-side ceremony, rosary, wedding, or other religious ceremony or observance;

(x) any public demonstration, such as a march, a rally, or a parade;

(xi) any domestic violence shelter, rape crisis center, child advocacy center, supervised visitation center, family justice center, or victim services provider;

(xii) any congressional district office;

(xiii) indoor and outdoor premises of a State department of motor vehicles;

(xiv) a place where disaster or emergency response and relief is provided, including evacuation routes, places where shelter or emergency supplies, food, or water are distributed, or places where registration for disaster-relief assistance or family reunification is underway; or

(xv) any other location specified by the Secretary of Homeland Security for purposes of this subsection.

(A) An enforcement action may not take place at, or be focused on, a protected area unless—

(i) the action involves exigent circumstances; and

(ii) prior approval for the enforcement action was obtained.

(B) If an enforcement action is initiated pursuant to subparagraph (A) and the exigent circumstances permitting the enforcement action cease, the enforcement action shall be discontinued until such exigent circumstances reemerge.

(C) If an enforcement action is carried out in violation of this subsection—

(i) no information resulting from the enforcement action may be entered into the record or received into evidence in a removal proceeding resulting from the enforcement action; and

(ii) the noncitizen who is the subject of such removal proceeding may file a motion for the immediate termination of the removal proceeding.

(A) This subsection shall apply to any enforcement action by officers or agents of the Department of Homeland Security, including—

(i) officers or agents of U.S. Immigration and Customs Enforcement;

(ii) officers or agents of U.S. Customs and Border Protection; and

(iii) any individual designated to perform immigration enforcement functions pursuant to subsection (g).

(B) While carrying out an enforcement action within a protected area, officers and agents referred to in subparagraph (A) shall make every effort—

(i) to limit the time spent in the protected area;

(ii) to limit the enforcement action in the protected area to the person or persons for whom prior approval was obtained; and

(iii) to conduct themselves discreetly.

(C) If, while carrying out an enforcement action that is not initiated in or focused on a protected area, officers or agents are led into a protected area, and no exigent circumstance and prior approval with respect to the protected area, such officers or agents shall—

(i) cease before taking any further enforcement action;

(ii) conduct themselves in a discreet manner;

(iii) maintain surveillance on an individual; and

(iv) immediately consult their supervisor in order to determine whether such enforcement action should be discontinued.

(D) The limitations under this paragraph shall not apply to the transportation of an individual apprehended at or near a land or sea border to a hospital or health care provider for the purpose of providing medical care to such individual.

(A) Each official specified in subparagraph (B) shall ensure that the employees under his or her supervision receive annual training regarding compliance with—

(i) the requirements under this subsection with respect to enforcement actions at or focused on protected areas and enforcement actions that lead officers or agents to a protected area; and

(ii) the requirements under section 239 of this Act and section 384 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (8 U.S.C. 1367).

(B) The officials specified in this subparagraph are—

(i) the Chief Counsel of each Field Office of U.S. Immigration and Customs Enforcement;

(ii) each Field Office Director of U.S. Immigration and Customs Enforcement;

(iii) each Special Agent in Charge of U.S. Immigration and Customs Enforcement;

(iv) each Chief Patrol Agent of U.S. Customs and Border Protection;

(v) the Director of Field Operations of U.S. Customs and Border Protection;

(vi) the Director of Air and Marine Operations of U.S. Customs and Border Protection;

(vii) the Internal Affairs Special Agent in Charge of U.S. Customs and Border Protection; and

(viii) the chief law enforcement officer of each State or local law enforcement agency that enters into a written agreement with the Department of Homeland Security pursuant to subsection (g).

(5) Not later than 180 days after the date of the enactment of the Health Equity and Accountability Act of 2024, the Secretary of Homeland Security shall modify the Notice to Appear form (Form I–862)—

(A) to provide the subject of an enforcement action with information, written in plain language, summarizing the restrictions against enforcement actions at protected areas (as described in this subsection) and the remedies available to the individual if such action violates such restrictions;

(B) to ensure that the information provided pursuant to subparagraph (A) is accessible to an individual with limited English proficiency; and

(C) to ensure that the subject of an enforcement action is not permitted to verify that the officers or agents that carried out such action complied with the restrictions set forth in this subsection.

(A) The Director of U.S. Immigration and Customs Enforcement and the Commissioner of U.S. Customs and Border Protection shall each submit an annual report to the appropriate congressional committees that includes the information set forth in subparagraph (B) with respect to the respective agency.

(B) Each report submitted pursuant to subparagraph (A) shall include, with respect to the submitting agency during the reporting period—

(i) the number of enforcement actions that were carried out at, or focused on, a protected area;

(ii) the number of enforcement actions in which officers or agents were subsequently led to a protected area; and

(iii) for each enforcement action described in clause (i) or (ii)—

(I) the date on which such action occurred;

(II) the specific site, city, county, and State in which such action occurred;

(III) if the site of the enforcement action was in a protected area—

(aa) the identification of the protected area;

(bb) the reasons such action was taken in such area;

(cc) if such action was taken without prior approval, certification that notification to headquarters of a submitting agency was provided after such action took place; and

(dd) a report describing what occurred during and immediately after such action;

(IV) the components of the agency involved in the enforcement action;

(V) a description of the enforcement action, including the nature of the criminal activity of its intended target;

(VI) the number of individuals, if any, arrested or taken into custody;

(VII) the number of collateral arrests, if any, and the reasons for each such arrest;

(VIII) a certification whether the location administrator of a protected area was contacted before, during, or after the enforcement action; and

(IX) the percentage of all of the staff members and supervisors reporting to the officials listed in paragraph (4)(B) who completed the training required under paragraph (4)(A).

(7) Nothing in the subsection may be construed—

(A) to affect the authority of Federal, State, or local law enforcement agencies—

(i) to enforce generally applicable Federal or State criminal laws unrelated to immigration; or

(ii) to protect residents from imminent threats to public safety; or

(B) to limit or override the protections provided in—

(i) section 239; or

(ii) section 384 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (8 U.S.C. 1367).

Subsections (i)(22) and (x) of section 1903 of the Social Security Act (42 U.S.C. 1396b) are each repealed.

Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended—

(A) by amending paragraph (46) of subsection (a) to read as follows:

(46) provide that information is requested and exchanged for purposes of income and eligibility verification in accordance with a State system which meets the requirements of section 1137 of this Act;

(B) in subsection (e)(13)(A)(i)—

(i) in the matter preceding subclause (I), by striking sections 1902(a)(46)(B) and 1137(d) and inserting section 1137(d); and

(ii) in subclause (IV), by striking 1902(a)(46)(B) or; and

(C) by striking subsection (ee).

Subsection (c) of section 6036 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396b note) is repealed.

The amendments made by this section shall take effect on the date of enactment of this Act.

Sections 402, 403, 411, 412, 421, and 422 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612, 1613, 1621, 1622, 1631, and 1632) are repealed.

Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1601 et seq.) is amended—

(A) in section 401(b)(5) (8 U.S.C. 1611(b)(5)), by striking the program defined in section 402(a)(3)(A) (relating to the supplemental security income program) and inserting the Supplemental Security Income Program under title XVI of the Social Security Act (42 U.S.C. 1381 et seq.);

(B) in section 404(a) (8 U.S.C. 1614(a)), by striking, 402, or 403;

(C) in section 413 (8 U.S.C. 1625)—

(i) by striking A State and inserting the following:

In this section, the term State or local public benefit —

(1) except as provided in paragraphs (2) and (3), means—

(A) any grant, contract, loan, professional license, or commercial license provided by an agency of a State or local government or by appropriated funds of a State or local government; and

(B) any retirement, welfare, health, disability, public or assisted housing, postsecondary education, food assistance, unemployment benefit, or any other similar benefit for which payments or assistance are provided to an individual, household, or family eligibility unit by an agency of a State or local government or by appropriated funds of a State or local government;

(2) does not apply—

(A) to any contract, professional license, or commercial license for a nonimmigrant whose visa for entry is related to such employment in the United States, or to a citizen of a freely associated state, if section 141 of the applicable compact of free association approved in Public Law 99–239 or 99–658 (or a successor provision) is in effect;

(B) with respect to benefits for an alien who as a work authorized nonimmigrant or as an alien lawfully admitted for permanent residence under the Immigration and Nationality Act qualified for such benefits and for whom the United States under reciprocal treaty agreements is required to pay benefits, as determined by the Secretary of State, after consultation with the Attorney General; or

(C) to the issuance of a professional license to, or the renewal of a professional license by, a foreign national not physically present in the United States; and

(3) does not include any Federal public benefit.

A State

(i) ; and

(ii) in subsection (b), as redesignated, by striking (as defined in section 411(c));

(D) in section 432(d) (8 U.S.C. 1642(d)), by striking (as defined in section 411(c)) and inserting (as defined in section 413(a));

(E) in section 435 (8 U.S.C. 1645), by striking (as provided under section 403); and

(F) in section 436 (8 U.S.C. 1646)—

(i) by striking the food stamp program (as defined in section 402(a)(3)(B)) and inserting the supplemental nutrition assistance program established under the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.); and

(ii) by striking the supplemental security income program (as defined in section 402(a)(3)(A)) and inserting the Supplemental Security Income Program under title XVI of the Social Security Act (42 U.S.C. 1381 et seq.).

Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1601 et seq.) is amended—

(1) in the title header, by striking Aliens and inserting Noncitizens;

(2) in the header of section 401 (8 U.S.C. 1611), by striking Aliens who are not qualified aliens and inserting Noncitizens who are not qualified noncitizens;

(3) by striking qualified alien each place such term appears and inserting qualified noncitizen;

(4) by striking qualified aliens each place such term appears and inserting qualified noncitizens;

(5) by striking qualified alien’s each place such term appears and inserting qualified noncitizen’s;

(6) by striking an alien each place such term appears and inserting a noncitizen;

(7) by striking alien each place such term appears and inserting noncitizen;

(8) by striking aliens each place such term appears and inserting noncitizens; and

(9) by striking alien’s each place such term appears and inserting noncitizen’s.

Section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1641) is amended—

(1) by striking subsection (b) and inserting the following:

For purposes of this title, the term qualified noncitizen means a noncitizen who, at the time the noncitizen applies for, receives, or attempts to receive a Federal public benefit, is lawfully present in the United States.

(2) in subsection (c)—

(A) in the header, by striking qualified aliens and inserting qualified noncitizens;

(B) in paragraph (3), by striking or at the end;

(C) in paragraph (4), by striking the period at the end and inserting; or; and

(D) by inserting after paragraph (4) the following:

(5) a noncitizen—

(A) in a category that was treated as lawfully present for purposes of section 1101 of the Patient Protection and Affordable Care Act of 2010 (42 U.S.C. 18001);

(B) who met the requirements of section 402(a)(2)(D) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612(a)(2)(D)) on or before January 1, 2021;

(C) who is granted special immigrant juvenile status as described by section 101(a)(27)(J) of the Immigration and Nationality Act (8 U.S.C. 1101(a)(27)(J));

(D) who has a pending, bona fide application for nonimmigrant status under section 101(a)(15)(U) of the Immigration and Nationality Act (8 U.S.C. 1101(1)(15)(U));

(E) who was granted relief under the Deferred Action for Childhood Arrivals program; or

(F) who is not described in subparagraphs (A) through (E), is not a citizen of the United States, resides in a State or territory of the United States, and is authorized by Federal law to be present in the United States.

(D) ; and

(3) by adding at the end the following:

In this title, the term noncitizen means any individual who is not a citizen of the United States.

Section 742 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1615) is amended—

(1) in subsection (a)—

(A) in the header by striking School lunch and breakfast programs and inserting Child nutrition programs;

(B) by striking the school lunch program and inserting any program; and

(C) by striking the school breakfast program under section 4 of the and inserting any program under; and

(2) in subsection (b), by amending paragraph (1) to read as follows:

A State may not deny benefits under programs established under the provisions of law described in paragraph (2) on the basis of an individual’s citizenship or immigration status.

Section 1108(h) of the Social Security Act (42 U.S.C. 1308(h)) is amended—

(1) by striking Expenditures and inserting:

Expenditures

(1) ; and

(2) by adding at the end the following:

With respect to eligibility for benefits under a State plan approved under title XIX (other than medical assistance described in section 401(b)(1)(A) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1611(b)(1)(A))), paragraph (1) shall not apply to any individual who lawfully resides in 1 of the 50 States or in the District of Columbia in accordance with the Compacts of Free Association between the Government of the United States and the Governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau and shall not apply, at the option of the Governor of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa as communicated to the Secretary of Health and Human Services in writing, to any individual who lawfully resides in the respective territory in accordance with such Compacts.

Effective January 1, 2025, section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended—

(1) by striking subparagraph (P); and

(2) by redesignating subparagraphs (Q), (R), (S), (T), and (U) as subparagraphs (P), (Q), (R), (S), and (T), respectively.

The Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.) is amended—

(A) in section 5 (7 U.S.C. 2014)—

(i) in subsection (d)(10), by striking (k) and inserting (j);

(ii) by striking subsection (i); and

(iii) by redesignating subsections (j), (k), (l), (m), and (n) as subsections (i), (j), (k), (l), and (m), respectively;

(B) in section 6 (7 U.S.C. 2015)—

(i) in subsection (f), by striking an alien lawfully admitted for permanent and all that follows through the end of the subsection and inserting a noncitizen who is lawfully present in the United States.; and

(ii) in subsection (s)(2), by striking (i), (k), (l), (m), and (n) and inserting (j), (k), (l), and (m); and

(C) in section 11(e)(2)(B)(v)(II) (7 U.S.C. 2020(e)(2)(B)(v)(II)) by striking aliens and inserting noncitizens.

Section 1903(v) of the Social Security Act (42 U.S.C. 1396b(v)) is amended—

(A) in paragraph (1), by striking admitted for and all that follows and inserting present in the United States.; and

(B) by striking paragraph (4).

Section 214(a) of the Housing and Community Development Act of 1980 (42 U.S.C. 1436a(a)) is amended—

(A) by redesignating paragraphs (6) and (7) as paragraphs (7) and (8), respectively; and

(B) by inserting after paragraph (5) the following:

(6) a qualified noncitizen (as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1641));

Section 213A of the Immigration and Nationality Act (8 U.S.C. 1183a) is amended—

(A) in subsection (a)(3)—

(i) in subparagraph (A), by striking (as provided under section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996); and

(ii) in subparagraph (B), in the undesignated matter following clause (ii), by striking (as provided under section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996); and

(B) in subsection (b)(1)(A) is amended by striking benefit, and inserting benefit by fraud,.

Not later than 180 days after the date of the enactment of this Act, each Federal agency affected by any of the amendments made by this section shall issue guidance with respect to the implementation of such amendments.

Except as otherwise provided in this section, the amendments made by this section—

(1) shall take effect on the date of the enactment of this Act; and

(2) shall apply to services furnished on or after the date that is 180 days after the date on which any guidance is issued pursuant to subsection (h).

Section 36B(b)(3)(A) of the Internal Revenue Code of 1986 is amended to read as follows:

The applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier:

In the case of household income (expressed as a percent of poverty line) within the following income tier: The initial premium percentage is— The final premium percentage is— Up to 150 percent 0.0 0.0 150 percent up to 200 percent 0.0 3.0 200 percent up to 250 percent 3.0 4.0 250 percent up to 300 percent 4.0 6.0 300 percent up to 400 percent 6.0 8.5 400 percent and higher 8.5 8.5.

Section 36B(c)(1) of the Internal Revenue Code of 1986 is amended—

(1) by striking but does not exceed 400 percent in subparagraph (A), and

(2) by striking subparagraph (E).

The amendments made by this section shall apply to taxable years beginning after December 31, 2023.

Section 36B of the Internal Revenue Code of 1986 is amended—

(A) in subsection (c)(1), by amending subparagraph (B) to read as follows:

If—

(i) a taxpayer has a household income which is not greater than 100 percent of an amount equal to the poverty line for a family of the size involved,

(ii) the taxpayer is a noncitizen who is not eligible for the Medicaid program under title XIX of the Social Security Act by reason of the individual’s immigration status,

(iii) the taxpayer is ineligible for minimum essential coverage under section 5000A(f)(1)(A)(ii), and

(iv) under the Medicaid eligibility criteria for noncitizens in effect on December 26, 2020, the taxpayer would be ineligible for such minimum essential coverage by reason of the taxpayer’s immigration status,

the taxpayer shall, for purposes of the credit under this section, be treated as an applicable taxpayer with a household income which is equal to 100 percent of the poverty line for a family of the size involved.

(B) by striking subsection (e).

Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended—

(A) by striking subsection (e); and

(B) by redesignating subsections (f) and (g) as subsections (e) and (f), respectively.

Section 1331(e)(1)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18051(e)(1)(B)) is amended by striking lawfully present in the United States,.

Section 1412 of the Patient Protection and Affordable Care Act (42 U.S.C. 18082) is amended—

(A) by striking subsection (d); and

(B) by redesignating subsection (e) as subsection (d).

Section 5000A(d) of the Internal Revenue Code of 1986 is amended—

(A) by striking paragraph (3); and

(B) by redesignating paragraph (4) as paragraph (3).

Section 1411(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18081(a)) is amended—

(A) by striking paragraph (1); and

(B) by redesignating paragraphs (2), (3), and (4) as paragraphs (1), (2), and (3), respectively.

Section 1312(f) of the Patient Protection and Affordable Care Act (42 U.S.C. 18032(f)) is amended—

(A) in the heading, by striking; access limited to citizens and lawful residents; and

(B) by striking paragraph (3).

The amendments made by this section shall apply to years, plan years, and taxable years, as applicable, beginning after December 31, 2024.

For purposes of eligibility under any of the provisions described in paragraph (2), all individuals granted federally authorized presence in the United States shall be considered to be lawfully present in the United States.

The provisions described in this paragraph are the following:

Section 1411 of the Patient Protection and Affordable Care Act (42 U.S.C. 18031).

Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071).

Section 36B of the Internal Revenue Code of 1986 (26 U.S.C. 36B).

Titles XIX and XXI of the Social Security Act, including under section 1903(v) of such Act (42 U.S.C. 1396b(v)).

Paragraph (1) shall take effect on the date of enactment of this Act.

In the case of an individual described in paragraph (1) who, before the first day of the first annual open enrollment period under subparagraph (B) of section 1311(c)(6) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(6)) beginning after the date of enactment of this Act, is granted federally authorized presence in the United States and who, as a result of such subsection, qualifies for a subsidy under a provision described in subparagraph (B) or (C) of paragraph (2), the Secretary of Health and Human Services shall establish a special enrollment period under subparagraph (C) of such section 1311(c)(6) during which such individual may enroll in qualified health plans through Exchanges under title I of the Patient Protection and Affordable Care Act and qualify for such a subsidy. For such an individual who has been granted federally authorized presence in the United States as of the date of enactment of this Act, such special enrollment period shall begin not later than 90 days after such date of enactment. Nothing in this paragraph shall be construed as affecting the authority of the Secretary to establish additional special enrollment periods under such subparagraph (C).

Section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended—

(i) in subclause (XXII), by striking or at the end;

(ii) in subclause (XXIII), by striking the semicolon and inserting; or; and

(iii) by adding at the end the following new subclause:

(XXIV) who would be eligible under the State plan (or waiver of such plan) under this title if they were citizens of the United States;

Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended, in the matter preceding paragraph (1)—

(i) in the matter designated as clause (xvi), by striking or at the end;

(ii) in the matter designated as clause (xvii), by adding or at the end; and

(iii) by inserting after the matter designated as clause (xvii) the following:

(xviii) individuals described in section 1902(a)(10)(A)(ii)(XXIV),

Title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) is amended by inserting after section 2112 the following new section:

A State may elect through an amendment to its State child health plan under section 2102 to treat an individual as a targeted low-income child or a targeted low-income pregnant woman for purposes of this title if such individual would otherwise be included as such a child or such a pregnant woman (as applicable) under such plan if the individual were a citizen of the United States.

Section 401(a) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (42 U.S.C. 1611(a)) is amended by adding at the end the following new sentence: The preceding sentence shall not apply with respect to a noncitizen’s eligibility under a State plan (or waiver of such plan) under title XIX of the Social Security Act or under a State child health plan (or waiver of such plan) under title XXI of such Act to the extent that such State has elected to make such individual so eligible pursuant to section 1902(a)(10)(A)(ii)(XXIV) or 2112A of such Act, respectively..

Nothing in this section, including the amendments made by this section, shall prevent lawfully present noncitizens who are ineligible for full benefits under the Medicaid program under title XIX of the Social Security Act from securing a credit for which such lawfully present noncitizens would be eligible under section 36B(c)(1)(B) of the Internal Revenue Code of 1986 and under the Medicaid provisions for lawfully present noncitizens, as in effect on the date prior to the date of enactment of this Act.

For purposes of paragraph (1), the term full benefits means, with respect to an individual and State, medical assistance for all services covered under the State plan under title XIX of the Social Security Act that is not less in amount, duration, or scope, or is determined by the Secretary of Health and Human Services to be substantially equivalent to the medical assistance available for an individual described in section 1902(a)(10)(A)(i) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)).

The Secretary of Health and Human Services (in this section referred to as the Secretary) shall—

(1) conduct a study, in accordance with the standards under section 3101 of the Public Health Service Act (42 U.S.C. 300kk), on the demographic characteristics of the population of individuals who do not have health insurance or oral health coverage; and

(2) predict, based on such study, the demographic characteristics of the population of individuals who would remain without health insurance after the end of any annual open enrollment or any special enrollment period or upon enactment and implementation of any legislative changes to the Patient Protection and Affordable Care Act (Public Law 111–148) that affect the number of persons eligible for health insurance.

Not later than 12 months after the date of the enactment of this Act, the Secretary shall submit to the Congress the results of the study under subsection (a)(1) and the prediction made under subsection (a)(2).

The Secretary shall—

(A) report the demographic characteristics under paragraphs (1) and (2) of subsection (a) on the basis of racial and ethnic minority group (as defined in section 1707(g)(1) of the Public Health Service Act), and stratify the reporting on each racial and ethnic minority group by other demographic characteristics that can impact access to health insurance, such as sexual orientation, gender identity, primary language, disability status, sex, socioeconomic status, age group, citizenship, and immigration status, in a manner consistent with title I of this Act, including the amendments made by such title; and

(B) not use such report, or any information gathered in preparing such report—

(i) to engage in or anticipate any deportation or immigration related enforcement action by any entity, including the Department of Homeland Security; or

(ii) for the exploitation of, or discrimination against, communities of color or the LGBTQ+ population.

As soon as possible after the date of enactment of this Act the Secretary of Health and Human Services (in this section referred to as the Secretary) shall—

(1) directly or by contract, establish a program that offers eligible individuals the opportunity to enroll in health benefits coverage that meets the requirements described in subsection (c) and any requirements applicable to such coverage pursuant to subsection (d); and

(2) ensure that such program is administered consistent with the requirements of section 431.10(c)(2) of title 42, Code of Federal Regulations.

In this section, the term eligible individual means an individual who—

(1) is described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(VIII));

(2) resides in a State that—

(A) does not expend amounts for medical assistance under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) for all individuals described in such section; and

(B) did not expend amounts for medical assistance under such title for all such individuals as of the date of enactment of this Act; and

(3) would not be eligible for medical assistance under such State's plan for medical assistance under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or a waiver of such plan, as such plan or waiver was in effect on such date.

The requirements described in this subsection with respect to health benefits coverage are the following:

At a minimum, the coverage meets the minimum standards required under paragraph (5) of section 1937(b) of the Social Security Act (42 U.S.C. 1396u–7(b)) for benchmark coverage described in paragraph (1) of such section or benchmark equivalent coverage described in paragraph (2) of such section.

No premiums are imposed for the coverage, and de­duct­ibles, cost-sharing, or similar charges may only be imposed in accordance with the requirements imposed on State Medicaid plans under section 1916 of the Social Security Act (42 U.S.C. 1396o).

The Secretary shall specify that—

(1) any requirement applicable to the furnishing of medical assistance under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) by States that have elected to make medical assistance available to individuals described in section 1902(a)(10)(A)(i)(VIII) of such title (42 U.S.C. 1396a(a)(10)(A)(i)(VIII)) that does not conflict with the requirements specified in subsection (c) applies to the program established under this section; and

(2) other provisions of such title apply to such program.

Nothing in this section shall be construed as requiring a State to make expenditures related to the program established under this section and the Secretary shall not impose any such requirement.

There are appropriated to the Secretary for each fiscal year beginning with fiscal year 2025 from any funds in the Treasury not otherwise appropriated, such sums as are necessary to carry out this section.

Section 1905(ii)(1) of the Social Security Act (42 U.S.C. 1396d(ii)(1)) is amended—

(1) by striking 8-quarter period and inserting 40-quarter period; and

(2) by striking 5 percentage points and inserting 10 percentage points.

The amendments made by this section shall take effect as if included in the enactment of section 9814 of the American Rescue Plan Act of 2021 (Public Law 117–2).

Section 1108 of the Social Security Act (42 U.S.C. 1308) is amended—

(A) in subsection (f), in the matter preceding paragraph (1), by striking subsections (g) and (h) and inserting subsections (g), (h), and (j);

(B) in subsection (g)(2), in the matter preceding subparagraph (A), by inserting subsection (j) and after subject to;

(C) in subsection (i), by striking paragraph (4); and

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

Subsections (f) and (g) shall not apply to Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa beginning with fiscal year 2025.

(A) Section 1902(j) of the Social Security Act (42 U.S.C. 1396a(j)) is amended by striking, the limitation in section 1108(f),,.

(B) Section 1903(u) of the Social Security Act (42 U.S.C. 1396b(u)) is amended by striking paragraph (4).

The amendments made by this subsection shall apply beginning with fiscal year 2025.

Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—

(1) in subsection (b), in the first sentence, by inserting for fiscal years before fiscal year 2026 after American Samoa; and

(2) in subsection (ff)(2), by striking 2027 and inserting 2025.

Section 1923(f) of the Social Security Act (42 U.S.C. 1396r–4(f)) is amended—

(1) in paragraph (6), by adding at the end the following new subparagraph:

For fiscal year 2025, the DSH allotment for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa shall bear the same ratio to $300,000,000 as the ratio of the number of individuals who are low-income or uninsured and residing in such respective territory (as estimated from time to time by the Secretary) bears to the sums of the number of such individuals residing in all of the territories.

For each subsequent fiscal year, the DSH allotment for each such territory is subject to an increase in accordance with paragraph (3).

(1) ; and

(2) in paragraph (9), by inserting before the period at the end the following:, and includes, beginning with fiscal year 2025, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Section 303 of the Social Security Amendments of 1972 (86 Stat. 1484) is amended by striking subsection (b).

Section 1101(a)(1) of the Social Security Act (42 U.S.C. 1301(a)(1)) is amended by striking the 5th sentence and inserting the following: Such term when used in title XVI includes Puerto Rico, the United States Virgin Islands, Guam, and American Samoa..

Section 1108 of such Act (42 U.S.C. 1308) is amended—

(A) in the section heading, by striking; limitation on total payments;

(B) by striking subsection (a); and

(C) in subsection (c), by striking paragraphs (2) and (4) and redesignating paragraphs (3) and (5) as paragraphs (2) and (4), respectively.

Section 1614(a)(1)(B) of such Act (42 U.S.C. 1382c(a)(1)(B)) is amended—

(A) in clause (i)(I), by inserting or national, after citizen;

(B) in clause (i)(II), by adding; or at the end; and

(C) in clause (ii), by inserting or national after citizen.

Section 1614(e) of such Act (42 U.S.C. 1382c(e)) is amended by striking and the District of Columbia and inserting, the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, and American Samoa.

The Commissioner of Social Security may waive or modify any statutory requirement relating to the provision of benefits under the Supplemental Security Income Program under title XVI of the Social Security Act in Puerto Rico, the United States Virgin Islands, Guam, or American Samoa, to the extent that the Commissioner deems it necessary in order to adapt the program to the needs of the territory involved.

This section and the amendments made by this section shall take effect on the 1st day of the 1st Federal fiscal year that begins 1 year or more after the date of the enactment of this Act.

Section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)) is amended—

(1) in the last sentence, by inserting, and before January 1, 2025 after prior to such date); and

(2) by adding at the end the following new sentence: Effective for items and services furnished on or after January 1, 2025 (with respect to periods beginning on or after the date that is 42 months prior to such date), clauses (i) and (ii) shall be applied by substituting 42-month for 12-month each place it appears..

The amendments made by this section shall take effect on the date of enactment of this Act. For purposes of determining an individual’s status under section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)), as amended by subsection (a), an individual who is within the coordinating period as of the date of enactment of this Act shall have that period extended to the full 42 months described in the last sentence of such section, as added by the amendment made by subsection (a)(2).

Section 1304 of the Patient Protection and Affordable Care Act (42 U.S.C. 18024) is amended by adding at the end the following:

In this title:

The term Indian means—

(A) an Indian, a California Indian, or an Urban Indian (as those terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)); or

(B) an individual who is of Indian descent and a member of an Indian community served by a local facility or program of the Indian Health Service.

The term Indian includes the following individuals:

(A) A member of a federally recognized Indian Tribe.

(B) A resident of an urban center who meets 1 or more of the following criteria:

(i) A member of a Tribe, band, or other organized group of Indians, including those Tribes, bands, or groups terminated since 1940 and those recognized as of the date of enactment of the Health Equity and Accountability Act of 2024 or later by the State in which they reside, or being a descendant, in the first or second degree, of any such member.

(ii) An Eskimo or Aleut or other Alaska Native.

(iii) An individual who is determined to be an Indian under regulations promulgated by the Secretary.

(C) An individual who is considered by the Secretary of the Interior to be an Indian for any purpose.

(D) An individual who is considered by the Secretary to be an Indian for purposes of eligibility for services provided by the Indian Health Service, including as a California Indian, Eskimo, Aleut, or other Alaska Native.

Section 1311(c)(6)(D) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(6)(D)) is amended by striking (as defined in section 4 of the Indian Health Care Improvement Act).

Section 1402(d) of the Patient Protection and Affordable Care Act (42 U.S.C. 18071(d)) is amended—

(A) in paragraph (1), in the matter preceding subparagraph (A), by striking (as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(d))); and

(B) in paragraph (2), in the matter preceding subparagraph (A), by striking (as so defined).

Section 5000A(e) of the Internal Revenue Code of 1986 is amended by striking paragraph (3) and inserting the following:

Any applicable individual who is an Indian (as defined in section 1304(f) of the Patient Protection and Affordable Care Act).

The amendment made by subsection (b)(3) shall apply to taxable years beginning after the date of the enactment of this Act.

Section 1818(a)(3)(B) of the Social Security Act (42 U.S.C. 1395i–2(a)(3)(B)) is amended by striking an alien and all that follows through under this section and inserting an individual who is lawfully present in the United States.

Section 1836(a)(2)(B) of the Social Security Act (42 U.S.C. 1395o(a)(2)(B)) is amended by striking an alien and all that follows through under this part and inserting an individual who is lawfully present in the United States.

Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by adding at the end the following new section:

Effective beginning January 1, 2025, in the case of a Medicare Cost Assistance Program eligible individual (as defined in subsection (b)(1)), the Secretary shall provide Medicare cost assistance for the following costs incurred with respect to the individual:

(1) Premiums under section 1818.

(2) Premiums under section 1839.

(3) Coinsurance under this title (including coinsurance described in section 1813).

(4) Deductibles established under this title (including those described in section 1813 and section 1833(b)).

(5) The difference between the amount that is paid under section 1833(a) and the amount that would be paid under such section if any reference to a percent less than 100 percent therein were deemed a reference to 100 percent.

The term Medicare Cost Assistance Program eligible individual means an individual who—

(A) is eligible for, and is receiving, medical assistance for the payment of medicare cost-sharing under a State Medicaid program pursuant to clause (i), (iii), or (iv) of section 1902(a)(10)(E) as of December 31, 2024; or

(i) is entitled to hospital insurance benefits under part A (including an individual entitled to such benefits pursuant to an enrollment under section 1818); and

(ii) has income at or below 200 percent of the poverty line applicable to a family of the size involved.

The determination of whether an individual is a Medicare Cost Assistance Program eligible individual shall be determined by the Commissioner of Social Security (referred to in this section as the Commissioner) jointly with the determination of whether an individual is a subsidy eligible individual described in section 1860D–14(a)(3). Such determination shall be made with respect to eligibility for Medicare cost assistance under this section and premium and cost-sharing subsidies under section 1860D–14 upon application of an individual for a determination with respect to eligibility for either such assistance or such subsidies. There are authorized to be appropriated to the Social Security Administration such sums as may be necessary for the determination of eligibility under this paragraph.

Determinations under this paragraph with respect to eligibility for each of such assistance or such subsidies shall be effective beginning with the month in which the individual applies for a determination described in subparagraph (A) and shall remain in effect until such time as the Secretary determines the individual is no longer eligible as determined under subparagraph (C)(ii).

With respect to eligibility determinations under this paragraph—

(i) redeterminations shall be made at the same time with respect to eligibility for Medicare cost assistance under this section and cost-sharing subsidies under section 1860D–14, but not more frequently than once every 12 months;

(ii) a redetermination shall automatically determine that an individual remains eligible for such assistance or subsidies unless—

(I) the Commissioner has information indicating that the individual's circumstances have changed such that the individual is no longer eligible for such assistance or subsidies;

(II) the Commissioner sends notice to the individual regarding such information that requests a response either confirming or correcting such information; and

(III) the individual either confirms such information or fails to provide documentation indicating that such circumstances have not changed within 60 days of receiving the notice described in subclause (II);

(iii) the Commissioner shall establish procedures for appeals of such determinations that are similar to the procedures described in the third sentence of section 1631(c)(1)(A); and

(iv) judicial review of the final decision of the Commissioner made after a hearing shall be available to the same extent, and with the same limitations, as provided in subsections (g) and (h) of section 205.

The Secretary shall provide that individuals who are full-benefit dual eligible individuals (as defined in section 1935(c)(6)) or who are recipients of supplemental security income benefits under title XVI shall be treated as a Medicare Cost Assistance Program eligible individual and, in the case of such individual who is a part D eligible individual, a subsidy eligible individual described in section 1860D–14(a)(3).

The Secretary shall develop and distribute a simplified application form for use by individuals in applying for Medicare cost assistance under this section and premium and cost-sharing subsidies under section 1860D–14. Such form shall be easily readable based on culturally fluid language for all demographics beyond just the various languages offered. An audio version, digital version, and photo-voice option should also be provided for all learners. The Secretary shall provide for the translation of such application form into at least the 10 languages (other than English) that are most often used by individuals applying for hospital insurance benefits under section 226 or 226A and shall make the translated forms available to the Commissioner of Social Security.

In developing the form under clause (i), the Secretary shall consult with beneficiary groups.

For purposes of applying this section—

(A) in the case of an individual who is not treated as a Medicare Cost Assistance Program eligible individual or a subsidy eligible individual under paragraph (2)(D), income shall be determined in the manner described under section 1612 for purposes of the supplemental security income program, except that support and maintenance furnished in kind shall not be counted as income; and

(B) the term poverty line has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.

In the case in which the payment for Medicare cost assistance for a Medicare Cost Assistance Program eligible individual with respect to an item or service is reduced or eliminated, the individual shall not have any legal liability to make payment to a provider of services (as defined in section 1861(u)), a supplier (as defined in section 1861(d)), or to an organization described in section 1903(m)(1)(A) for the service, and any lawful sanction that may be imposed upon a provider of services, a supplier, or such an organization for excess charges under this title or title XIX shall apply to the imposition of any charge imposed upon the individual in such case.

This paragraph shall not be construed as preventing payment of any medicare cost assistance by a medicare supplemental policy or an employer retiree health plan on behalf of an individual.

The Secretary shall establish procedures for the administration of the program under this section.

For purposes of carrying out this section, the Secretary shall make payments from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate, of such amounts as the Secretary determines necessary to provide Medicare cost assistance under this section.

Effective beginning January 1, 2025, any reference to medicare cost-sharing described in section 1905(p) shall be deemed a reference to Medicare cost assistance under this section.

For provisions relating to outreach efforts to increase awareness of the availability of Medicare cost assistance, see section 1144.

Section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended, in the last sentence, by inserting the following before the period: or, effective beginning January 1, 2025, for individuals who are Medicare Cost Assistance Program eligible individuals (as defined in section 1899C(b)(1))..

Section 1837 of the Social Security Act (42 U.S.C. 1395p) is amended by adding at the end the following new subsection:

Effective beginning January 1, 2025, the Secretary shall establish special enrollment periods for Medicare Cost Assistance Program eligible individuals (as defined in section 1899C(b)(1)).

In the case of an individual who enrolls during the special enrollment period provided under paragraph (1), the coverage period under this part shall—

(A) begin on the first day of the first month in which the individual applies for a determination under section 1899C(b)(2)(A); and

(B) remain in effect until such time as the Secretary determines the individual is no longer eligible as determined under section 1899C(b)(2)(C)(ii).

Section 1818(g) of the Social Security Act (42 U.S.C. 1395i–2(g)) is amended by adding at the end the following new paragraph:

This subsection shall not apply on or after January 1, 2025.

Section 1843(h) of the Social Security Act (42 U.S.C. 1395v(h)) is amended by adding at the end the following new paragraph:

This subsection shall not apply with respect to qualified medicare beneficiaries on or after January 1, 2025.

Section 1144 of the Social Security Act (42 U.S.C. 1320b–14) is amended by adding at the end the following new subsection:

The Commissioner shall conduct a public awareness campaign to educate Medicare beneficiaries on the availability of Medicare cost assistance for low-income individuals under section 1899C.

In carrying out the public awareness campaign under paragraph (1), the Commissioner shall coordinate with State health insurance assistance programs described in subsection (a)(1)(A) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395b–3 note), the Administrator of the Administration for Community Living, and the Administrator of the Centers for Medicare & Medicaid Services.

There is appropriated to the Commissioner, out of any funds in the Treasury not otherwise appropriated, $10,000,000 for each of fiscal years 2025 through 2029, to provide grants to State health insurance assistance programs to carry out outreach and education activities under the public awareness campaign pursuant to this subsection.

Section 1902(a)(10) of the Social Security Act (42 U.S.C. 1396a(a)(10)) is amended—

(A) by inserting for calendar quarters beginning before January 1, 2025, before for making each place it appears in clauses (i), (iii), and (iv) of subparagraph (E); and

(B) in the matter following subparagraph (G)—

(i) by inserting furnished during calendar quarters beginning before January 1, 2025 after (described in section 1905(p)(3));

(ii) by striking (XV) and inserting, (XV);

(iii) by striking and (XVIII) and inserting, (XVIII);

(iv) by striking and (XIX) and inserting (XIX); and

(v) by inserting, and (XX) no medical assistance for medicare cost-sharing, other than medical assistance for medicare cost-sharing for qualified disabled and working individuals described in section 1905(s), shall be made available after January 1, 2025 before the semicolon at the end.

(i) Section 1903(i) of such Act (42 U.S.C. 1396b(i)), as amended by section 4002, is amended—

(I) in paragraph (26), by striking or at the end;

(II) in paragraph (27), by striking the period at the end and inserting; or; and

(III) by inserting after paragraph (27) the following new paragraph:

(28) with respect to any amount expended for medical assistance for medicare cost-sharing (other than medical assistance for medicare cost-sharing for qualified disabled and working individuals described in section 1905(s)) furnished during calendar quarters beginning on or after January 1, 2025.

(ii) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is amended, in the first sentence, by inserting furnished during calendar quarters beginning before January 1, 2025 after medicare cost-sharing.

(iii) Section 1933(g) of such Act (42 U.S.C. 1396u–3(g)) is amended—

(I) in paragraph (2)(Q), by striking paragraph (4), for each subsequent year and inserting paragraphs (4) and (5), for each subsequent year before 2025; and

(II) by adding at the end the following:

No individual shall be selected to be a qualifying individual for any calendar year or period under this section beginning on or after January 1, 2025, and no State allocation shall be made for any fiscal year or period under this section beginning on or after January 1, 2025.

(iv) Section 1935(a) of such Act (42 U.S.C. 1396u–5(a)) is amended—

(I) in paragraph (2)(A), by striking make determinations and inserting prior to January 1, 2025, make determinations; and

(II) in paragraph (3), by inserting prior to January 1, 2025, before the State shall.

Section 1860D–14 of the Social Security Act (42 U.S.C. 1395w–114) is amended—

(A) in subsection (a)—

(i) in paragraph (1), in the matter preceding subparagraph (A)—

(I) by striking 150 percent and inserting 200 percent; and

(II) by striking and who meets the resources requirement described in paragraph (3)(D) (or, with respect to a plan year beginning on or after January 1, 2025, paragraph (3)(E)) or who is covered under this paragraph under paragraph (3)(B)(i);

(ii) by striking paragraph (2);

(iii) in paragraph (3)—

(I) in subparagraph (A)—

(aa) in clause (i), by adding and at the end;

(bb) in clause (ii)—

(AA) by striking 150 percent and inserting 200 percent; and

(BB) by striking; and at the end and inserting a period; and

(cc) by striking clause (iii);

(II) by striking subparagraphs (B) and (C) and inserting the following:

For provisions relating to joint determinations with respect to eligibility for Medicare cost assistance under section 1899C and premium and cost-sharing subsidies under this section, see section 1899C(b)(2).

For purposes of applying this section—

(i) in the case of an individual who is not treated as a Medicare cost-sharing assistance eligible individual and a subsidy eligible individual under section 1899C(b)(2)(D), income shall be determined in the manner described under section 1612 for purposes of the supplemental security income program, except that support and maintenance furnished in kind shall not be counted as income; and

(ii) the term poverty line has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.

(II) ; and

(III) by striking subparagraphs (D), (E), and (G); and

(iv) in paragraph (4)—

(I) in subparagraph (A)—

(aa) by striking (A) Copayment for lowest income dual eligible individuals.—;

(bb) by redesignating clauses (i) and (ii) as subparagraphs (A) and (B), respectively and indenting appropriately; and

(cc) by moving the flush text at the end 2 ems to the left; and

(II) by striking subparagraph (B); and

(B) in subsection (c)(1), in the second sentence, by striking subsections (a)(1)(D) and (a)(2)(E) and inserting subsection (a)(1)(D).

Section 1860D–14(a)(1)(D)(i) of the Social Security Act (42 U.S.C. 1395w–114(a)(1)(D)(i)) is amended—

(A) by striking who would be such an institutionalized individual or couple, if the full-benefit dual eligible individual were not; and

(B) by striking or subsection (c) or (d) of section 1915 or under a State plan amendment under subsection (i) of such section and inserting, section 1115A, section 1915, or under a State plan amendment.

The amendments made by this subsection shall apply to plan year 2025 and subsequent plan years.

Section 1905(p)(2)(A) of the Social Security Act (42 U.S.C. 1396d(p)(2)(A)) is amended by striking shall be at least the percent provided under subparagraph (B) (but not more than 100 percent) of the official poverty line and all that follows through the period at the end and inserting the following:

shall be—

(i) before January 1, 2025, at least the percent provided under subparagraph (B) (but not more than 100 percent) of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)) applicable to a family of the size involved; and

(ii) on or after January 1, 2025, equal to 135 percent of the official poverty line (as so defined and revised) applicable to a family of the size involved.

Section 1905(p)(2)(D) of the Social Security Act (42 U.S.C. 1396d(p)(2)(D)) is amended by adding at the end the following new clause:

(iii) In determining income under this subsection, support and maintenance furnished in kind shall not be counted as income.

Section 1902(a)(10)(E) of the Social Security Act (42 U.S.C. 1396a(a)(10)(E)) is amended—

(A) by adding and at the end of clause (ii);

(B) in clause (iii)—

(i) by striking and 120 percent in 1995 and years thereafter and inserting 120 percent in 1995 and years thereafter before 2025, and 200 percent in 2025 and years thereafter; and

(ii) by striking and at the end; and

(C) by striking clause (iv).

Section 1905(p)(1) of the Social Security Act (42 U.S.C. 1396d(p)(1)) is amended by adding at and below subparagraph (C) the following flush sentence:

The term specified low-income medicare beneficiary means an individual described in section 1902(a)(10)(E)(iii).

(A) The first sentence of section 1905(b) of such Act (42 U.S.C. 1396d(b)) is amended by striking “and section 1933(d)”.

(B) Section 1933 of such Act (42 U.S.C. 1396u–3) is repealed.

Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—

(1) in subsection (b), by striking and (ii) and inserting (ii), and (kk); and

(2) amended by adding at the end the following new subsection:

Notwithstanding subsection (b), with respect to expenditures described in paragraph (2) the Federal medical assistance percentage shall be equal to 100 percent.

The expenditures described in this paragraph are expenditures made on or after January 1, 2025, for medical assistance for medicare cost-sharing provided to any individual under clause (i), (ii), or (iii) of section 1902(a)(10)(E) who would not have been eligible for medicare cost-sharing under any such clause under the income or resource eligibility standards in effect on October 1, 2018.

Section 1860D–14(a)(3) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)) is amended—

(A) by striking subparagraph (D);

(B) by redesignating subparagraphs (E) through (G) as subparagraphs (D) through (F), respectively; and

(C) in the heading of subparagraph (D), as so redesignated, by striking Alternative resource and inserting Resource.

Section 1860D–14(a)(3) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)), as amended by paragraph (1), is amended by striking subparagraph (F) and inserting the following new subparagraphs:

In determining the resources of an individual (and the eligible spouse of the individual, if any) under section 1613 for purposes of subparagraph (D)—

(i) no part of the value of any life insurance policy shall be taken into account;

(ii) no part of the value of any vehicle shall be taken into account;

(iii) there shall be excluded an amount equal to $1,500 each with respect to any individual or eligible spouse of an individual who attests that some of the resources of such individual or spouse will be used to meet the burial and related expenses of such individual or spouse; and

(iv) no balance in, or benefits received under, an employee pension benefit plan (as defined in section 3 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1002)) shall be taken into account.

In determining the size of the family of an individual for purposes of determining the income eligibility of such individual under this section, an individual's family shall consist of—

(i) the individual;

(ii) the individual's spouse who lives in the same household as the individual (if any); and

(iii) any other individuals who—

(I) are related to the individual whose income eligibility is in question or such individual's spouse who lives in the same household;

(II) are living in the same household as such individual; and

(III) are dependent on such individual or such individual's spouse who is living in the same household for at least one-half of their financial support.

Section 1860D–14(a) of the Social Security Act (42 U.S.C. 1395w–114(a)) is amended—

(A) in paragraph (1), in the matter preceding subparagraph (A), by inserting (as determined under paragraph (3)(G)) after family of the size involved; and

(B) in paragraph (3), as amended by paragraphs (1) and (2)—

(i) in subparagraph (A), in the matter preceding clause (i), by striking subparagraph (F) and inserting subparagraph (E);

(ii) in subparagraph (A)(ii), by inserting (as determined under subparagraph (G)) after family of the size involved;

(iii) in subparagraph (A)(iii), by striking or (E);

(iv) in subparagraph (B)(v), in the matter preceding subclause (I), by striking subparagraph (F) and inserting subparagraph (E); and

(v) in subparagraph (D)(i), in the matter preceding subclause (I), by striking subject to the life insurance policy exclusion provided under subparagraph (G) and inserting subject to the resource exclusions provided under subparagraph (F).

Section 1905(p)(1)(C) of the Social Security Act (42 U.S.C. 1396d(p)(1)(C)) is amended to read as follows:

(C) whose resources (as determined under section 1613 for purposes of the supplemental security income program subject to the resource exclusions under subparagraph (F) of section 1860D–14(a)(3)) do not exceed—

(i) in the case of an individual with a spouse, an amount equal to the sum of the first amount specified in subsection (f)(2)(A)(i) of section 1924 (as adjusted under subsection (g) of such section) and the amount specified in subsection (f)(2)(A)(ii)(II) of such section (as so adjusted); or

(ii) in the case of an individual who does not have a spouse, an amount equal to ½ of the amount described in clause (i).

Section 1905(s)(3) of the Social Security Act (42 U.S.C. 1396d(s)(3)) is amended to read as follows:

(3) whose resources (as determined under section 1613 for purposes of the supplemental security income program subject to the resource exclusions under subparagraph (F) of section 1860D–14(a)(3)) do not exceed—

(A) in the case of an individual with a spouse, the amount in effect for the year under clause (i) of subsection (p)(1)(C); and

(B) in the case of an individual who does not have a spouse, the amount in effect for the year under clause (ii) of subsection (p)(1)(C); and

Clause (i) of section 1860D–14(a)(3)(D) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)(D)), as redesignated and amended by subsection (d)(1), is amended to read as follows:

The resources requirement of this subparagraph is that an individual's resources (as determined under section 1613 for purposes of the supplemental security income program subject to the resource exclusions provided under subparagraph (F)) do not exceed the amount in effect for the year under section 1905(p)(1)(C)(ii).

Section 1902(e)(8) of the Social Security Act (42 U.S.C. 1396a(e)(8)) is amended by striking after the end of the month in which the determination first occurs and inserting in or after the third month before the month in which the individual makes application for assistance.

Section 1902(e)(8) of the Social Security Act (42 U.S.C. 1396a(e)(8)) is further amended by adding at the end the following: The Secretary shall provide for a process under which claims for medical assistance under the State plan may be submitted for services furnished to such an individual during such 3-month period before the month in which the individual made application for assistance..

Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended, in the matter preceding paragraph (1), by striking or, in the case of medicare cost-sharing with respect to a qualified medicare beneficiary described in subsection (p)(1), if provided after the month in which the individual becomes such a beneficiary.

Section 1902(e)(12) of the Social Security Act (42 U.S.C. 1396a(e)(12)) is amended—

(A) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively;

(B) by inserting (A) after (12); and

(C) by adding at the end the following:

(B) At the option of the State, the plan may provide that an individual who is determined to be eligible for benefits under a State plan approved under this title under any of the following eligibility categories, or who is redetermined to be eligible for such benefits under any of such categories, shall be considered to meet the eligibility requirements met on the date of application and shall remain eligible for those benefits until the end of the 12-month period following the date of the determination or redetermination of eligibility, except that a State may provide for such determinations more frequently, but not more frequently than once every 6 months for an individual:

(i) A specified low-income medicare beneficiary described in subsection (a)(10)(E)(iii) of this section who is determined eligible for medicare cost-sharing described in section 1905(p)(3)(A)(ii).

(ii) A qualified disabled and working individual described in section 1905(s) who is determined eligible for medicare cost-sharing described in section 1905(p)(3)(A)(i).

Section 1902(e)(13)(A) of the Social Security Act (42 U.S.C. 1396a(e)(13)(A)) is amended by adding at the end the following new clause:

At the option of the State, the State may apply the provisions of this paragraph with respect to determining eligibility under this title for an eligible individual (as defined in subclause (II)). In applying this paragraph in the case of a State making such an option, any reference in this paragraph to a child with respect to this title (other than a reference to child health assistance) shall be deemed to be a reference to an eligible individual.

In this clause, the term eligible individual means any of the following:

(aa) A qualified medicare beneficiary described in section 1905(p)(1) for purposes of determining eligibility for medicare cost-sharing (as defined in section 1905(p)(3)).

(bb) A specified low-income medicare beneficiary described in subsection (a)(10)(E)(iii) of this section for purposes of determining eligibility for medicare cost-sharing described in section 1905(p)(3)(A)(ii).

(cc) A qualified disabled and working individual described in section 1905(s) for purposes of determining eligibility for medicare cost-sharing described in section 1905(p)(3)(A)(i).

Section 1902(n) of the Social Security Act (42 U.S.C. 1396a(n)) is amended by adding at the end the following new paragraph:

(4) A State plan shall not deny a claim from a provider or supplier with respect to medicare cost-sharing described in subparagraph (B), (C), or (D) of section 1905(p)(3) for an item or service which is eligible for payment under title XVIII on the basis that the provider or supplier does not have a provider agreement in effect under this title or does not otherwise serve all individuals entitled to medical assistance under this title. The State shall create a mechanism through which providers or suppliers that do not otherwise have provider agreements with the State can bill the State for medicare cost-sharing for qualified medicare beneficiaries.

Section 1905(p) of the Social Security Act (42 U.S.C. 1396d(p)) is amended by adding at the end the following new paragraph:

(7) Notwithstanding any other provision of law, any medical assistance for some or all medicare cost-sharing under this title shall not be considered income or resources in determining eligibility for, or the amount of assistance or benefits provided under, any other public benefit provided under Federal law or the law of any State or political subdivision thereof.

Section 1862 of the Social Security Act (42 U.S.C. 1395y) is amended by adding at the end the following new subsection:

Nothing in this title shall be construed as authorizing a provider of services or supplier to discriminate (through a private contractual arrangement or otherwise) against an individual who is otherwise entitled to services under this title on the basis that the individual is a qualified medicare beneficiary (as defined in section 1905(p)(1)), a specified low-income medicare beneficiary, or is otherwise eligible for medical assistance for medicare cost-sharing or other benefits under title XIX.

The Secretary of Health and Human Services (in this subsection referred to as the Secretary) shall use amounts made available under subparagraph (B) to make grants to States for State health insurance assistance programs receiving assistance under section 4360 of the Omnibus Budget Reconciliation Act of 1990 (42 U.S.C. 1395b–4).

For purposes of making grants under this subsection, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w–23(f)), of $50,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of the fiscal years 2025 through 2029, to remain available until expended.

The amount of a grant to a State under this subsection from the total amount made available under paragraph (1) shall be equal to the sum of the amount allocated to the State under paragraph (3)(A) and the amount allocated to the State under subparagraph (3)(B).

The amount allocated to a State under this subparagraph from 2/3 of the total amount made available under paragraph (1) shall be based on the number of individuals who meet the requirement under subsection (a)(3)(A)(ii) of section 1860D–14 of the Social Security Act (42 U.S.C. 1395w–114) but who have not enrolled to receive a subsidy under such section 1860D–14 relative to the total number of individuals who meet the requirement under such subsection (a)(3)(A)(ii) in each State, as estimated by the Secretary.

The amount allocated to a State under this subparagraph from 1/3 of the total amount made available under paragraph (1) shall be based on the number of part D eligible individuals (as defined in section 1860D–1(a)(3)(A) of such Act (42 U.S.C. 1395w–101(a)(3)(A))) residing in a rural area relative to the total number of such individuals in each State, as estimated by the Secretary.

Each grant awarded under this subsection with respect to amounts allocated under paragraph (3)(A) shall be used to provide outreach to individuals who may be subsidy eligible individuals (as defined in section 1860D–14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)(A))) or eligible for the program of medical assistance for payment of the cost of medicare cost-sharing under the Medicaid program pursuant to sections 1902(a)(10)(E) and 1933 of such Act (42 U.S.C. 1396a(a)(10)(E), 1396u–3).

Except as provided in paragraph (2), the amendments and repeal made by this section take effect on January 1, 2025, and, with respect to title XIX of the Social Security Act, apply to calendar quarters beginning on or after January 1, 2025.

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

The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended by striking for the 8 fiscal year quarters beginning with the first fiscal year quarter beginning after the date of the enactment of the American Rescue Plan Act of 2021, and inserting and.

The amendment made by this section shall apply to medical assistance provided on or after the date of enactment of this Act.

The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended by striking, for such 8 fiscal year quarters.

The amendment made by this section shall apply to medical assistance provided on or after the date of enactment of this Act.

Section 1917 of the Social Security Act (42 U.S.C. 1396p) is amended—

(1) in subsection (a)—

(A) by amending paragraph (1) to read as follows:

(1) No lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual.

(B) by striking paragraph (2);

(C) in paragraph (3), by striking (1)(B) and inserting (1); and

(D) by redesignating paragraph (3) as paragraph (2); and

(2) by amending subsection (b) to read as follows:

No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made.

Section 1837(i) of the Social Security Act (42 U.S.C. 1395p(i)) is amended by adding at the end the following new paragraph:

(A) In the case of an individual who—

(i) at the time the individual first satisfies paragraph (1) or (2) of section 1836(a), is incarcerated; or

(ii) has elected not to enroll (or to be deemed enrolled) under this section during the individual’s initial enrollment period;

(A) there shall be a special enrollment period described in subparagraph (B).

(B) The special enrollment period referred to in subparagraph (A) is the 6-month period beginning on the first day after which the individual is no longer incarcerated.

Section 1839(a) of the Social Security Act (42 U.S.C. 1395r(a)) is amended—

(1) in paragraph (1), in the second sentence, by striking and (7), and inserting (7), and (8),; and

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

(8) In the case of an individual whose coverage period includes months in which by reason of custody under penal authority coverage is excluded pursuant to section 1862(a)(3), the premium amount for such months such individual is in custody under penal authority shall be zero.

Section 1818(d)(5) of the Social Security Act (42 U.S.C. 1395i–2(d)(5)) is amended by adding at the end the following:

(D) In the case of an individual who is a person who is excluded from coverage pursuant to section 1862(a)(3) by reason of custody under penal authority, the amount of the monthly premium for such individual shall be zero for any month in which such individual is in custody under penal authority.

The Director of the Office of Personnel Management shall issue such regulations as are necessary to ensure that pregnancy is considered a change in family status and a qualifying life event for an individual who is eligible to enroll, but is not enrolled, in a health benefits plan under chapter 89 of title 5, United States Code.

The requirement in paragraph (1) shall apply with respect to any contract entered into under section 8902 of title 5, United States Code, on or after the date that is 1 year after the date of enactment of this Act.

Section 1902(l)(2)(A) of the Social Security Act (42 U.S.C. 1396a(l)(2)(A)) is amended—

(1) in clause (i), by striking and not more than 185 percent;

(2) in clause (ii)—

(A) in subclause (I), by striking and after the comma;

(B) in subclause (II), by striking the period at the end and inserting, and; and

(C) by adding at the end the following:

(III) January 1, 2025, is the percentage provided under clause (v).

(C) ; and

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

(v) The percentage provided under clause (ii) for medical assistance provided on or after January 1, 2025, with respect to individuals described in subparagraph (A) or (B) of paragraph (1) shall not be less than—

(I) the percentage specified for such individuals by the State in an amendment to its State plan (whether approved or not) as of January 1, 2014; or

(II) if no such percentage is specified as of January 1, 2014, the percentage established for such individuals under the State’s authorizing legislation or provided for under the State’s appropriations as of that date.

Title XXXIV of the Public Health Service Act, as amended by titles I, II, and III of this Act, is further amended by inserting after subtitle C the following:

The Secretary, in collaboration with the Administrator of the Health Resources and Services Administration, the Director of the Agency for Healthcare Research and Quality, and the Administrator of the Centers for Medicare & Medicaid Services, shall award grants to eligible entities for the conduct of demonstration projects to improve the quality of and access to health care.

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

(1) be a health center, hospital, health plan, health system, community clinic, hospice or palliative care provider, or other health entity determined appropriate by the Secretary—

(A) that, by legal mandate or explicitly adopted mission, provides patients with access to services regardless of their ability to pay;

(B) that provides care or treatment for a substantial number of patients who are uninsured, are receiving assistance under a State plan under title XIX of the Social Security Act (or under a waiver of such plan), or are members of vulnerable populations, as determined by the Secretary; and

(i) with respect to which, not less than 50 percent of the entity’s patient population is made up of racial and ethnic minority groups; or

(ii) that—

(I) serves a disproportionate percentage of local patients who are from a racial and ethnic minority group, or has a patient population at least 50 percent of which is composed of individuals with limited English proficiency; and

(II) provides an assurance that amounts received under the grant will be used only to support quality improvement activities in the racial and ethnic minority group served; and

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

In awarding grants under subsection (a), the Secretary shall give priority to eligible entities that—

(1) demonstrate an intent to operate as part of a health care partnership, network, collaborative, coalition, or alliance where each member entity contributes to the design, implementation, and evaluation of the proposed intervention; or

(2) intend to use funds to carry out systemwide changes with respect to health care quality improvement, including—

(A) improved systems for data collection and reporting;

(B) innovative collaborative or similar processes;

(C) group programs with behavioral or self-management interventions;

(D) case management services;

(E) physician or patient reminder systems;

(F) educational interventions;

(G) comprehensive and patient-centric health care;

(H) creation and distribution of education materials on available health care options; or

(I) other activities determined appropriate by the Secretary.

An entity shall use amounts received under a grant under subsection (a) to support the implementation and evaluation of health care quality improvement activities or minority health and health care disparity reduction activities that include—

(1) with respect to health care systems, activities relating to improving—

(A) patient safety;

(B) timeliness of care;

(C) effectiveness of care;

(D) efficiency of care;

(E) patient centeredness;

(F) health information technology;

(G) accessibility and availability of information on health care;

(H) comprehensiveness of health care; and

(I) patient involvement and choice in health care; and

(2) with respect to patients, activities relating to—

(A) staying healthy;

(B) getting well, mentally and physically;

(C) living effectively with illness or disability;

(D) preparing for end of life and ensuring that end-of-life care is accessible and available, as well as coping with end-of-life issues; and

(E) shared decision making.

The Secretary shall provide financial and other technical assistance to grantees under this section for the development of common data systems.

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2032.

The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall designate centers of excellence at public hospitals, and other health systems serving large numbers of patients from minority populations, that—

(1) meet the requirements of section 3441(b)(1);

(2) demonstrate excellence in providing care to minority populations; and

(3) demonstrate excellence in reducing disparities in health and health care.

A hospital or health system that serves as a center of excellence under subsection (a) shall—

(1) design, implement, and evaluate programs and policies relating to the delivery of care in racially, ethnically, and linguistically diverse populations;

(2) provide training and technical assistance to other hospitals and health systems relating to the provision of high-quality health care to minority populations; and

(3) develop activities for graduate or continuing medical education that institutionalize a focus on cultural competence training for health care providers.

There are authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2025 through 2032.

The Secretary shall provide direct financial assistance to designated health care providers and community health centers in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, and Hawaii for the purposes of reconstructing and improving health care facilities and services in a culturally competent and sustainable manner.

To be eligible to receive direct financial assistance under subsection (a), an entity shall be a public health facility or community health center located in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, or Hawaii that—

(1) is owned or operated by—

(A) the Government of American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, or Hawaii or a unit of local government; or

(B) a nonprofit organization; and

(A) provides care or treatment for a substantial number of patients who are uninsured, are receiving assistance under title XVIII of the Social Security Act or under a State plan under title XIX of such Act (or under a waiver of such plan), or are members of a vulnerable population, as determined by the Secretary; or

(B) serves a disproportionate percentage of local patients that are from a racial and ethnic minority group.

Not later than 180 days after the date of enactment of this title and annually thereafter, the Secretary shall submit to the Congress and the President a report that includes an assessment of health resources and facilities serving populations in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, and Hawaii. In preparing such report, the Secretary shall—

(1) consult with and obtain information on all health care facilities needs from the entities receiving direct financial assistance under subsection (a);

(2) include all amounts of Federal assistance received by each such entity in the preceding fiscal year;

(3) review the total unmet needs of health care facilities serving American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the United States Virgin Islands, Puerto Rico, and Hawaii, including needs for renovation and expansion of existing facilities;

(4) include a strategic plan for addressing the needs of each such population identified in the report; and

(5) evaluate the effectiveness of the care provided by measuring patient outcomes and cost measures.

There are authorized to be appropriated such sums as necessary to carry out this section.

In this section:

The term border area means the United States-Mexico Border Area, as defined in section 8 of the United States-Mexico Border Health Commission Act (22 U.S.C. 290n–6).

The term eligible entity means an entity that is located in the border area and is any of the following:

(A) A State, local government, or Tribal government.

(B) A public institution of higher education.

(C) A nonprofit health organization.

(D) A community health center.

(E) A community clinic that is a health center receiving assistance under section 330 of the Public Health Service Act (42 U.S.C. 254b).

(F) A nonprofit organization serving immigrants.

From funds appropriated pursuant to subsection (f), the Secretary of Health and Human Services (in this section referred to as the Secretary), acting through the United States members of the United States-Mexico Border Health Commission, shall award grants to eligible entities to address priorities and recommendations to improve the health of border area residents that are established by—

(1) the United States members of the United States-Mexico Border Health Commission;

(2) the State border health offices; and

(3) the Secretary.

An eligible entity that desires a grant under subsection (b) shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require and demonstrating the entity’s capacity to provide culturally and linguistically appropriate services to border area residents.

An eligible entity that receives a grant under subsection (b) shall use the grant funds for—

(1) programs relating to—

(A) maternal and child health;

(B) primary care and preventative health;

(C) public health and public health infrastructure;

(D) musculoskeletal health and obesity;

(E) health education and promotion;

(F) oral health;

(G) mental and behavioral health;

(H) substance use disorders;

(I) health conditions that have a high prevalence in the border area;

(J) medical and health services research;

(K) workforce training and development;

(L) community health workers, patient navigators, and promotores;

(M) health care infrastructure problems in the border area (including planning and construction grants);

(N) health disparities in the border area;

(O) environmental health;

(P) outreach and enrollment services with respect to Federal programs (including programs authorized under titles XIX and XXI of the Social Security Act (42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.));

(Q) end-of-life care; and

(R) addressing social determinants of health; and

(2) other programs determined appropriate by the Secretary.

Amounts provided to an eligible entity awarded a grant under subsection (b) shall be used to supplement and not supplant other funds available to the eligible entity to carry out the activities described in subsection (d).

There are authorized to be appropriated to carry out this section, $200,000,000 for fiscal year 2025, and such sums as may be necessary for each succeeding fiscal year.

Section 1834(l)(8) of the Social Security Act (42 U.S.C. 1395m(l)(8)) is amended—

(A) in subparagraph (B)—

(i) by striking owned and; and

(ii) by inserting (including when such services are provided by the entity under an arrangement with the hospital) after hospital; and

(B) by striking the comma at the end of subparagraph (B) and all that follows and inserting a period.

The amendments made by this subsection shall apply to services furnished on or after January 1, 2025.

Section 1820(c)(2) of the Social Security Act (42 U.S.C. 1395i–4(c)(2)) is amended—

(A) in subparagraph (B)(iii), by striking provides not more than and inserting subject to subparagraph (F), provides not more than; and

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

A State may elect to treat a facility, with respect to the designation of the facility for a cost reporting period, as satisfying the requirement of subparagraph (B)(iii) relating to a maximum number of acute care inpatient beds if the facility elects, in accordance with a method specified by the Secretary and before the beginning of the cost reporting period, to meet the requirement under clause (ii).

The requirement under this clause, with respect to a facility and a cost reporting period, is that the total number of inpatient bed days described in subparagraph (B)(iii) during such period will not exceed 7,300. For purposes of this subparagraph, an individual who is an inpatient in a bed in the facility for a single day shall be counted as one inpatient bed day.

The option described in clause (i) shall not apply to a facility for a cost reporting period if the facility (for any two consecutive cost reporting periods during the previous 5 cost-reporting periods) was treated under such option and had a total number of inpatient bed days for each of such two cost reporting periods that exceeded the number specified in such clause.

The amendments made by paragraph (1) shall apply to cost reporting periods beginning on or after the date of the enactment of this Act.

Not later than 9 months after the date of enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the Secretary) shall conduct pilot projects under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for the purpose of providing incentives to home health agencies to utilize home monitoring and communications technologies that—

(A) enhance health and health care outcomes for Medicare beneficiaries; and

(B) reduce expenditures under such title.

The Secretary shall conduct the pilot projects under this section in both urban and rural areas.

The Secretary shall conduct at least 3 of the pilot projects in a State with a population of less than 1,000,000.

In this section, the term home health agency has the meaning given that term in section 1861(o) of the Social Security Act (42 U.S.C. 1395x(o)).

The Secretary shall specify the criteria for identifying those Medicare beneficiaries who shall be considered within the scope of the pilot projects under this section for purposes of the application of subsection (c) and for the assessment of the effectiveness of the home health agency in achieving the objectives of this section. Such criteria may provide for the inclusion in the projects of Medicare beneficiaries who begin receiving home health services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) after the date of the implementation of the projects.

The Secretary shall establish for each home health agency participating in a pilot project under this section a performance target using one of the following methodologies, as determined appropriate by the Secretary:

The Secretary shall establish for the agency—

(i) a base expenditure amount equal to the average total payments made to the agency under parts A and B of title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for Medicare beneficiaries determined to be within the scope of the pilot project in a base period determined by the Secretary; and

(ii) an annual per capita expenditure target for such beneficiaries, reflecting the base expenditure amount adjusted for risk and adjusted growth rates.

The Secretary shall establish for the agency a comparative performance target equal to the average total payments under such parts A and B during the pilot project for comparable individuals in the same geographic area that are not determined to be within the scope of the pilot project.

Subject to paragraph (3), the Secretary shall pay to each participating home care agency an incentive payment for each year under the pilot project equal to a portion of the Medicare savings realized for such year relative to the performance target under paragraph (1).

The Secretary shall limit incentive payments under this section in order to ensure that the aggregate expenditures under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) (including incentive payments under this subsection) do not exceed the amount that the Secretary estimates would have been expended if the pilot projects under this section had not been implemented.

The Secretary may waive such provisions of titles XI and XVIII of the Social Security Act (42 U.S.C. 1301 et seq.; 42 U.S.C. 1395 et seq.) as the Secretary determines to be appropriate for the conduct of the pilot projects under this section.

Not later than 5 years after the date that the first pilot project under this section is implemented, the Secretary shall submit to Congress a report on the pilot projects. Such report shall contain a detailed description of issues related to the expansion of the projects under subsection (f) and recommendations for such legislation and administrative actions as the Secretary considers appropriate.

If the Secretary determines that any of the pilot projects under this section enhance health outcomes for Medicare beneficiaries and reduce expenditures under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), the Secretary may initiate comparable projects in additional areas.

An incentive payment under this section—

(1) shall be in addition to the payments that a home health agency would otherwise receive under title XVIII of the Social Security Act for the provision of home health services; and

(2) shall have no effect on the amount of such payments.

Section 330(r)(4) of the Public Health Service Act (42 U.S.C. 254b(r)(4)) is amended—

(1) in subparagraph (A), by striking primary health care services each place it appears and inserting primary health care and other mental, dental, and physical health services; and

(2) in subparagraph (B)—

(A) in clause (i), by striking and at the end;

(B) in clause (ii), by striking the period at the end and inserting; and; and

(C) by adding at the end the following:

(iii) in the case of a rural health clinic described in such subparagraph—

(I) that such clinic provides, to the extent possible, enabling services, such as transportation and language assistance (including translation and interpretation); and

(II) that the primary health care and other services described in such subparagraph are subject to full reimbursement according to the prospective payment system for Federally qualified health center services under section 1834(o) of the Social Security Act.

For purposes of expediting the provision of telehealth services, for which payment is made under the Medicare Program established under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). across State lines, the Secretary of Health and Human Services shall, in consultation with representatives of States, physicians, health care practitioners, and patient advocates, encourage and facilitate the adoption of provisions allowing for multistate practitioner practice across State lines.

In subsection (a):

The term telehealth service has the meaning given that term in subparagraph (F) of section 1834(m)(4) of the Social Security Act (42 U.S.C. 1395m(m)(4)).

The terms physician and practitioner have the meaning given those terms in subparagraphs (D) and (E), respectively, of section 1834(m)(4) of the Social Security Act (42 U.S.C. 1395m(m)(4)).

The term Medicare Program means the program of health insurance administered by the Secretary of Health and Human Services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

Section 202 of the Congressional Budget and Impoundment Control Act of 1974 (2 U.S.C. 602) is amended by adding at the end the following:

Upon a request by the chairman or ranking minority member of the Committee on the Budget of the Senate, or by the chairman or ranking minority member of the Committee on the Budget of the House of Representatives, the Director shall determine if a proposed measure would result in reductions in budget outlays in budgetary outyears through the use of preventive health and preventive health services.

If the Director determines that a measure would result in substantial reductions in budget outlays as described in paragraph (1), the Director—

(A) shall include, in any projection prepared by the Director, a description and estimate of the reductions in budget outlays in the budgetary outyears and a description of the basis for such conclusions; and

(B) may prepare a budget projection that includes some or all of the budgetary outyears, notwithstanding the time periods for projections described in subsection (e) and sections 308, 402, and 424.

As used in this subsection—

(A) the term budgetary outyears means the 2 consecutive 10-fiscal-year periods beginning with the first fiscal year that is 10 years after the budget year provided for in the most recently agreed to concurrent resolution on the budget; and

(B) the term preventive health means an action that focuses on the health of the public, individuals, and defined populations in order to protect, promote, and maintain health, wellness, and functional ability, and prevent disease, disability, and premature death that is demonstrated by credible and publicly available epidemiological projection models, incorporating clinical trials or observational studies in humans, to avoid future health care costs.

It is the sense of the Congress that—

(1) the maintenance of effort provisions added to sections 1902 and 2105(d) of the Social Security Act (42 U.S.C. 1396a; 42 U.S.C. 1397ee(d)) by sections 2001(b) and 2101(b) of the Patient Protection and Affordable Care Act were intended to maintain the eligibility standards for the Medicaid program under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) and Children’s Health Insurance Program under title XXI of such Act (42 U.S.C. 1397aa et seq.) to protect vulnerable and disabled adults, children, and senior citizens, many of whom are also members of communities of color;

(2) the maintenance of effort provisions for children’s coverage have been extended by the Congress through September 30, 2029;

(3) the maintenance of effort provisions ensure the continued success of the Medicaid program and Children’s Health Insurance Program and were intended to specifically protect vulnerable and disabled children, many of whom are also members of communities of color; and

(4) the maintenance of effort provisions must be strictly enforced and proposals to weaken or waive the maintenance of effort provisions must not be considered.

Pursuant to section 1707A of the Public Health Service Act (42 U.S.C. 300u–6a), the Offices of Minority Health established within the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, the Agency for Healthcare Research and Quality, the Food and Drug Administration, and the Centers for Medicare & Medicaid Services, are offices that, regardless of change in the structure of the Department of Health and Human Services, shall report to the Secretary of Health and Human Services.

It is the sense of the Congress that the Offices of Minority Health referred to in subsection (a) play a critical role in addressing health disparities and should be adequately funded and given a prominent role in evaluating and establishing health policies and programs.

Subchapter I of chapter 73 of title 38, United States Code, is amended by inserting after section 7308 the following new section:

There is established in the Department within the Office of the Under Secretary for Health an office to be known as the Office of Minority Health (in this section referred to as the Office).

The Director of the Office of Minority Health shall be the head of the Office. The Director of the Office of Minority Health shall be appointed by the Under Secretary for Health from among individuals qualified to perform the duties of the position.

The functions of the Office are as follows:

(1) To establish short-range and long-range goals and objectives and coordinate all other activities within the Veterans Health Administration that relate to disease prevention, health promotion, health care services delivery, health and health care education, health care quality, and health care research concerning veterans who are members of a racial or ethnic minority group.

(2) To support research, demonstrations, and evaluations to test new and innovative models for the discharge of activities described in paragraph (1).

(3) To increase knowledge and understanding of health risk factors for veterans who are members of a racial or ethnic minority group.

(4) To develop mechanisms that support better health care information dissemination, education, prevention, and services delivery to veterans from disadvantaged backgrounds, including veterans who are members of a racial or ethnic minority group.

(5) To enter into contracts or agreements with appropriate public and nonprofit private entities to develop and carry out programs to provide bilingual or interpretive services to assist veterans who are members of a racial or ethnic minority group and who lack proficiency in speaking the English language in accessing and receiving health care services through the Veterans Health Administration.

(6) To carry out programs to improve access to health care services through the Veterans Health Administration for veterans with limited proficiency in speaking the English language, including the development and evaluation of demonstration and pilot projects for that purpose.

(7) To advise the Under Secretary for Health on matters relating to the development, implementation, and evaluation of health professions education in decreasing disparities in health care outcomes between veterans who are members of a racial or ethnic minority group and other veterans, including cultural competency as a method of eliminating such health disparities.

(8) To perform such other functions and duties as the Secretary or the Under Secretary for Health considers appropriate.

In this section:

(1) The term racial or ethnic minority group means any of the following:

(A) American Indians (including Alaska Natives, Eskimos, and Aleuts).

(B) Asian Americans.

(C) Native Hawaiians and Pacific Islanders.

(D) Blacks.

(E) Hispanics.

(2) The term Hispanic means individuals whose origin is from Mexico, Puerto Rico, Cuba, Central or South America, or any other Spanish-speaking country.

The table of sections at the beginning of such subchapter is amended by inserting after the item relating to section 7308 the following new item:

Not later than January 1, 2025, the Comptroller General of the United States shall conduct a study on how amendments made by the Patient Protection and Affordable Care Act (Public Law 111–148) and the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152) to titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 42 U.S.C. 1396 et seq.) relating to disproportionate share hospital adjustment payments under Medicare and Medicaid (and subsequent amendments made with respect to such payments) affect the timely access to health care services for low-income patients. Such study shall—

(1) evaluate and examine whether States electing to make medical assistance available under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(VIII)) (including States making such an election through a waiver of the State plan) to individuals described in such section mitigate the need for payments to disproportionate share hospitals under section 1886(d)(5)(F) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) and section 1923 of such Act (42 U.S.C. 1396r–4), including the impact of such States electing to make medical assistance available to such individuals on—

(A) the number of individuals in the United States who are without health insurance and the distribution of such individuals in relation to areas primarily served by disproportionate share hospitals; and

(B) the low-income utilization rate of such hospitals and the resulting fiscal sustainability of such hospitals;

(2) evaluate the appropriate level and distribution of such payments among such disproportionate share hospitals for purposes of—

(A) sufficiently accounting for the level of uncompensated care provided by such hospitals to low-income patients; and

(B) providing timely access to health care services for individuals in medically underserved areas; and

(3) assess, with respect to such disproportionate share hospitals—

(A) the role played by such hospitals in providing critical access to emergency, inpatient, and outpatient health services, including end-of-life services, as well as the location of such hospitals in relation to medically underserved areas; and

(B) the extent to which such hospitals satisfy the requirements established for charitable hospital organizations under section 501(r) of the Internal Revenue Code of 1986 with respect to community health needs assessments, financial assistance policy requirements, limitations on charges, and billing and collection requirements.

Not later than 180 days after the date on which the study under subsection (a) is completed, the Comptroller General of the United States shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report that contains—

(A) the results of the study;

(B) recommendations to Congress for any legislative changes to the payments to disproportionate share hospitals under section 1886(d)(5)(F) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) and section 1923 of such Act (42 U.S.C. 1396r–4) that are needed to ensure access to health services for low-income patients that—

(i) are based on the number of individuals without health insurance, the amount of uncompensated care provided by such hospitals, and the impact of reduced payment levels on low-income communities; and

(ii) takes into account any reports submitted by the Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, to congressional committees regarding the costs incurred by charitable hospital organizations for charity care, bad debt, nonreimbursed expenses for services provided to individuals under the Medicare program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act, and any community benefit activities provided by such organizations.

Not later than 180 days after the date on which the study under subsection (a) is completed, the Comptroller General of the United States shall submit to the Secretary of Health and Human Services a report that contains—

(A) the results of the study; and

(B) any recommendations for purposes of assisting in the development of the methodology for the adjustment of payments to disproportionate share hospitals, as required under section 1886(r) of the Social Security Act (42 U.S.C. 1395ww(r)) and the reduction of such payments under section 1923(f)(7) of such Act (42 U.S.C. 1396r–4(f)(7)), taking into account the reports referred to in paragraph (1)(B)(ii).

Section 6(h)(1) of the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11705(h)(1)) is amended by striking may be necessary for fiscal years 1993 through 2019 and inserting are necessary.

Section 7(b) of the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11706(b)) is amended by striking may be necessary for fiscal years 1993 through 2019 and inserting are necessary.

Section 10(c) of the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11709(c)) is amended by striking may be necessary for fiscal years 1993 through 2019 and inserting are necessary.

Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 2007(b)(1), is amended by adding at the end of the following new subsection:

(1) The term rural community hospital means a hospital (as defined in subsection (e)) that—

(A) is located in a rural area (as defined in section 1886(d)(2)(D)) or treated as being so located pursuant to section 1886(d)(8)(E);

(B) subject to paragraph (2), has less than 51 acute care inpatient beds, as reported in its most recent cost report;

(C) makes available 24-hour emergency care services;

(D) subject to paragraph (3), has a provider agreement in effect with the Secretary and is open to the public as of January 1, 2010; and

(E) applies to the Secretary for such designation.

(2) For purposes of paragraph (1)(B), beds in a psychiatric or rehabilitation unit of the hospital which is a distinct part of the hospital shall not be counted.

(3) Paragraph (1)(D) shall not be construed to prohibit any of the following from qualifying as a rural community hospital:

(A) A replacement facility (as defined by the Secretary in regulations in effect on January 1, 2012) with the same service area (as defined by the Secretary in regulations in effect on such date).

(B) A facility obtaining a new provider number pursuant to a change of ownership.

(C) A facility which has a binding written agreement with an outside, unrelated party for the construction, reconstruction, lease, rental, or financing of a building as of January 1, 2012.

(4) Nothing in this subsection shall be construed as prohibiting a critical access hospital from qualifying as a rural community hospital if the critical access hospital meets the conditions otherwise applicable to hospitals under subsection (e) and section 1866.

(5) Nothing in this subsection shall be construed as prohibiting a rural community hospital participating in the demonstration program under section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395ww note; Public Law 108–173) from qualifying as a rural community hospital if the rural community hospital meets the conditions otherwise applicable to hospitals under subsection (e) and section 1866.

Section 1814 of the Social Security Act (42 U.S.C. 1395f) is amended by adding at the end the following new subsection:

The amount of payment under this part for inpatient hospital services furnished in a rural community hospital, other than such services furnished in a psychiatric or rehabilitation unit of the hospital which is a distinct part, is, at the election of the hospital in the application referred to in section 1861(ooo)(1)(E)—

(1) 101 percent of the reasonable costs of providing such services, without regard to the amount of the customary or other charge, or

(2) the amount of payment provided for under the prospective payment system for inpatient hospital services under section 1886(d).

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

The amount of payment under this part for outpatient services furnished in a rural community hospital is, at the election of the hospital in the application referred to in section 1861(ooo)(1)(E)—

(1) 101 percent of the reasonable costs of providing such services, without regard to the amount of the customary or other charge and any limitation under section 1861(v)(1)(U), or

(2) the amount of payment provided for under the prospective payment system for covered OPD services under section 1833(t).

Section 1861(v)(1)(T) of the Social Security Act (42 U.S.C. 1395x(v)(1)(T)) is amended in the matter preceding clause (i) by inserting (other than for a rural community hospital) after In determining such reasonable costs for hospitals.

Section 1834(aa) of the Social Security Act (as added by subsection (b)(2)) is amended—

(1) by redesignating paragraphs (1) and (2) as subparagraphs (A) and (B), respectively;

(2) by inserting (1) after (aa); and

(3) by adding at the end the following:

(2) The amounts of beneficiary cost-sharing for outpatient services furnished in a rural community hospital under this part shall be as follows:

(A) For items and services that would have been paid under section 1833(t) if furnished by a hospital, the amount of cost-sharing determined under paragraph (8) of such section.

(B) For items and services that would have been paid under section 1833(h) if furnished by a provider of services or supplier, no cost-sharing shall apply.

(C) For all other items and services, the amount of cost-sharing that would apply to the item or service under the methodology that would be used to determine payment for such item or service if provided by a physician, provider of services, or supplier, as the case may be.

Section 1814(b) of the Social Security Act (42 U.S.C. 1395f(b)) is amended in the matter preceding paragraph (1) by inserting other than inpatient hospital services furnished by a rural community hospital, after critical access hospital services,.

Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)), as amended by section 2207(b)(3), is amended—

(A) by striking and at the end of paragraph (10);

(B) by striking the period at the end of paragraph (11) and inserting; and; and

(C) by adding at the end the following:

(12) in the case of outpatient services furnished by a rural community hospital, the amounts described in section 1834(aa).

Section 1863 of the Social Security Act (42 U.S.C. 1395z) is amended by striking and (dd)(2) and inserting (dd)(2), and (ooo)(1).

Section 1866(a)(2)(A) of the Social Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by inserting section 1834(aa)(2), after section 1833(b),.

The amendments made by this section shall apply to items and services furnished on or after the date that is 30 days after the date of the enactment of this Act.

Not later than 6 months after the date of the enactment of this section, the Secretary of Health and Human Services (in this section referred to as the Secretary) shall establish a commission to be known as the Rural Health Quality Advisory Commission (in this section referred to as the Commission).

The Commission shall develop, coordinate, and facilitate implementation of a national plan for rural health quality improvement. The national plan shall—

(i) identify objectives for rural health quality improvement;

(ii) identify strategies to eliminate known gaps in rural health system capacity and improve rural health quality; and

(iii) provide recommendations for Federal programs to identify opportunities for strengthening and aligning policies and programs to improve rural health quality.

The Commission shall design demonstration projects to recommend to the Secretary to test alternative models for rural health quality improvement, including with respect to both personal and population health.

The Commission shall monitor progress toward the objectives identified pursuant to subparagraph (A)(i).

The Commission shall be composed of 11 members appointed by the Secretary.

The Secretary shall select the members of the Commission from among individuals with significant rural health care and health care quality expertise, including expertise in clinical health care, health care quality research, end-of-life care, population or public health, or purchaser organizations.

Subject to the availability of funds, the Commission may enter into contracts and make other arrangements, as may be necessary to carry out the duties described in paragraph (2).

Upon the request of the Commission, the Secretary may detail, on a reimbursable basis, any of the personnel of the Office of Rural Health Policy of the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, or the Centers for Medicare & Medicaid Services to the Commission to assist in carrying out this subsection.

Not later than 1 year after the establishment of the Commission, and annually thereafter, the Commission shall submit a report to the Congress on rural health quality. Each such report shall include the following:

(A) An inventory of relevant programs and recommendations for improved coordination and integration of policy and programs.

(B) An assessment of achievement of the objectives identified in the national plan developed under paragraph (2) and recommendations for realizing such objectives.

(C) Recommendations on Federal legislation, regulations, or administrative policies to enhance rural health quality and outcomes.

Not later than 270 days after the date of the enactment of this section, the Secretary, in consultation with the Rural Health Quality Advisory Commission, the Office of Rural Health Policy of the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services, shall make grants to eligible entities for a total of 5 demonstration projects to implement and evaluate methods for improving the quality of health care in rural communities. Each such demonstration project shall include—

(A) alternative community models that—

(i) will achieve greater integration of personal and population health services; and

(ii) address safety, effectiveness, patient- or community-centeredness, timeliness, efficiency, and equity (the 6 aims identified by the National Academy of Medicine (formerly known as the Institute of Medicine) in its report entitled Crossing the Quality Chasm: A New Health System for the 21st Century released on March 1, 2001);

(B) innovative approaches to the financing and delivery of health care services to achieve rural health quality and accessibility goals for patients; and

(C) development of quality improvement support structures to assist rural health systems and professionals in the provision of health care (such as workforce support structures, quality monitoring and reporting, clinical care protocols, and information technology applications).

In this subsection, the term eligible entity means a consortium that—

(A) shall include—

(i) at least one health care provider or health care delivery system located in a rural area; and

(ii) at least one organization representing multiple community stakeholders; and

(B) may include other partners such as rural research centers.

In developing the program for awarding grants under this subsection, the Secretary shall consult with the Administrator of the Agency for Healthcare Research and Quality, rural health care providers, rural health care researchers, and private and nonprofit groups (including national associations) which are undertaking similar efforts.

The Secretary shall expedite the processing of any waiver that—

(A) is authorized under title XVIII or XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 42 U.S.C. 1396 et seq.); and

(B) is necessary to carry out a demonstration project under this subsection.

The Secretary shall ensure that the 5 demonstration projects funded under this subsection are conducted at a variety of sites representing the diversity of rural communities in the United States.

Each demonstration project under this subsection shall be for a period of 4 years.

The Secretary shall enter into an arrangement with an entity that has experience working directly with rural health systems for the conduct of an independent evaluation of the program carried out under this subsection.

Not later than 1 year after the conclusion of all of the demonstration projects funded under this subsection, the Secretary shall submit a report to the Congress on the results of such projects. The report shall include—

(A) an evaluation of patient access to care, patient outcomes, and an analysis of the cost-effectiveness of each such project; and

(B) recommendations on Federal legislation, regulations, or administrative policies to enhance rural health quality and outcomes.

Out of funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary to carry out this section $30,000,000 for the period of fiscal years 2025 through 2029.

Except as provided in subparagraph (B), funds appropriated under paragraph (1) shall remain available for expenditure through fiscal year 2028.

For purposes of carrying out subsection (b)(8), funds appropriated under paragraph (1) shall remain available for expenditure through fiscal year 2029.

Of the amount appropriated under paragraph (1), the Secretary shall reserve—

(A) $5,000,000 to carry out subsection (a); and

(B) $25,000,000 to carry out subsection (b), of which—

(i) 2 percent shall be for the provision of technical assistance to grant recipients; and

(ii) 5 percent shall be for the independent evaluation under subsection (b)(7).

Section 330A of the Public Health Service Act (42 U.S.C. 254c) is amended to read as follows:

The purpose of this section is to provide for grants—

(1) under subsection (b), to promote rural health care services outreach;

(2) under subsection (c), to provide for the planning and implementation of integrated health care networks in rural areas;

(3) under subsection (d), to assist rural communities in the Delta Region to reduce health disparities and to promote and enhance health system development; and

(4) under subsection (e), to provide for the planning and implementation of small rural health care provider quality improvement activities.

The Director of the Office of Rural Health Policy of the Health Resources and Services Administration (referred to in this section as the Director) may award grants to eligible entities to promote rural health care services outreach by expanding the delivery of health care services to include new and enhanced services in rural areas. The Director may award the grants for periods of not more than 3 years.

To be eligible to receive a grant under this subsection for a project, an entity—

(A) shall be a rural public or rural nonprofit private entity, a facility that qualifies as a rural health clinic under title XVIII of the Social Security Act, a public or nonprofit entity existing exclusively to provide services to migrant and seasonal farm workers in rural areas, or a Tribal government whose grant-funded activities will be conducted within federally recognized Tribal areas;

(B) shall represent a consortium composed of members—

(i) that include 3 or more independently owned health care entities; and

(ii) that may be nonprofit or for-profit entities; and

(C) shall not previously have received a grant under this subsection for the same or a similar project, unless the entity is proposing to expand the scope of the project or the area that will be served through the project.

To be eligible to receive a grant under this subsection, an eligible entity shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

(B) a description of the manner in which the project funded under the grant will meet the health care needs of rural populations in the local community or region to be served;

(C) a plan for quantifying how health care needs will be met through identification of the target population and benchmarks of service delivery or health status, such as—

(i) quantifiable measurements of health and health care status improvement for projects focusing on health promotion; or

(ii) benchmarks of increased access to primary and end-of-life care, including tracking factors such as the number and type of primary and end-of-life care visits, identification of a medical home, or other general measures of such access;

(D) a description of how the local community or region to be served will be involved in the development and ongoing operations of the project;

(E) a plan for sustaining the project after Federal support for the project has ended;

(F) a description of how the project will be evaluated;

(G) the administrative capacity to submit annual performance data electronically as specified by the Director; and

(H) other such information as the Director determines to be appropriate.

The Director may award rural health network development grants to eligible entities to promote, through planning and implementation, the development of integrated health care networks that have combined the functions of the entities participating in the networks in order to—

(i) achieve efficiencies and economies of scale;

(ii) expand access to, coordinate, and improve the quality of the health care delivery system through development of organizational efficiencies;

(iii) implement health information technology to achieve efficiencies, reduce medical errors, and improve quality;

(iv) coordinate care and manage chronic and terminal illness; and

(v) strengthen the rural health care system as a whole and across all facets of the health care delivery system, including end-of-life care, in such a manner as to show a quantifiable return on investment to the participants in the network.

The Director may award such a rural health network development grant—

(i) for a period of 3 years for implementation activities; or

(ii) for a period of 1 year for planning activities to assist in the initial development of an integrated health care network, if the proposed participants in the network do not have a history of collaborative efforts and a 3-year grant would be inappropriate.

To be eligible to receive a grant under this subsection, an entity—

(A) shall be a rural public or rural nonprofit private entity, a facility that qualifies as a rural health clinic under title XVIII of the Social Security Act, a public or nonprofit entity existing exclusively to provide services to migrant and seasonal farm workers in rural areas, or a Tribal government whose grant-funded activities will be conducted within federally recognized Tribal areas;

(B) shall represent a network composed of participants—

(i) that include 3 or more independently owned health care entities; and

(ii) that may be nonprofit or for-profit entities; and

(C) shall not previously have received a grant under this subsection (other than a 1-year grant for planning activities) for the same or a similar project.

To be eligible to receive a grant under this subsection, an eligible entity, in consultation with the appropriate State office of rural health or another appropriate State entity, shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

(B) an explanation of the reasons why Federal assistance is required to carry out the project;

(C) a description of—

(i) the history of collaborative activities carried out by the participants in the network;

(ii) the degree to which the participants are ready to integrate their functions; and

(iii) how the local community or region to be served will benefit from and be involved in the activities carried out by the network;

(D) a description of how the local community or region to be served will experience increased access to quality health care services across the continuum of care as a result of the integration activities carried out by the network, including a description of—

(i) return on investment for the community and the network members; and

(ii) other quantifiable performance measures that show the benefit of the network activities;

(E) a plan for sustaining the project after Federal support for the project has ended;

(F) a description of how the project will be evaluated;

(G) the administrative capacity to submit annual performance data electronically as specified by the Director; and

(H) other such information as the Director determines to be appropriate.

The Director may award grants to eligible entities to support reduction of health disparities, improve access to health care, and enhance rural health system development in the Delta Region.

To be eligible to receive a grant under this subsection, an entity shall be a rural public or rural nonprofit private entity, a facility that qualifies as a rural health clinic under title XVIII of the Social Security Act, a public or nonprofit entity existing exclusively to provide services to migrant and seasonal farm workers in rural areas, or a Tribal government whose grant-funded activities will be conducted within federally recognized Tribal areas.

To be eligible to receive a grant under this subsection, an eligible entity shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

(B) an explanation of the reasons why Federal assistance is required to carry out the project;

(C) a description of the manner in which the project funded under the grant will meet the health care needs of the Delta Region;

(D) a description of how the local community or region to be served will experience increased access to quality health care services as a result of the activities carried out by the entity;

(E) a description of how health disparities will be reduced or the health system will be improved;

(F) a plan for sustaining the project after Federal support for the project has ended;

(G) a description of how the project will be evaluated including process and outcome measures related to the quality of care provided or how the health care system improves its performance;

(H) a description of how the grantee will develop an advisory group made up of representatives of the communities to be served to provide guidance to the grantee to best meet community need; and

(I) other such information as the Director determines to be appropriate.

The Director may award grants to provide for the planning and implementation of small rural health care provider quality improvement activities. The Director may award the grants for periods of 1 to 3 years.

To be eligible for a grant under this subsection, an entity—

(A) shall be—

(i) a rural public or rural nonprofit private health care provider or provider of health care services, such as a rural health clinic; or

(ii) another rural provider or network of small rural providers identified by the Director as a key source of local care; and

(B) shall not previously have received a grant under this subsection for the same or a similar project.

In awarding grants under this subsection, the Director shall give preference to facilities that qualify as rural health clinics under title XVIII of the Social Security Act.

To be eligible to receive a grant under this subsection, an eligible entity shall prepare and submit to the Director an application at such time, in such manner, and containing such information as the Director may require, including—

(A) a description of the project that the eligible entity will carry out using the funds provided under the grant;

(B) an explanation of the reasons why Federal assistance is required to carry out the project;

(C) a description of the manner in which the project funded under the grant will assure continuous quality improvement in the provision of services by the entity;

(D) a description of how the local community or region to be served will experience increased access to quality health care services as a result of the activities carried out by the entity;

(E) a plan for sustaining the project after Federal support for the project has ended;

(F) a description of how the project will be evaluated including process and outcome measures related to the quality of care provided; and

(G) other such information as the Director determines to be appropriate.

An entity that receives a grant under this section may not use funds provided through the grant—

(A) to build or acquire real property; or

(B) for construction.

The Director shall coordinate activities carried out under grant programs described in this section, to the extent practicable, with Federal and State agencies and nonprofit organizations that are operating similar grant programs, to maximize the effect of public dollars in funding meritorious proposals.

Not later than September 30, 2025, the Secretary shall prepare and submit to the appropriate committees of Congress a report on the progress and accomplishments of the grant programs described in subsections (b), (c), (d), and (e).

In this section, the term Delta Region has the meaning given to the term region in section 382A of the Consolidated Farm and Rural Development Act (7 U.S.C. 2009aa).

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2025 through 2028.

Any reference in a law, regulation, document, paper, or other record of the United States to the Director of the Indian Health Service shall be deemed to be a reference to the Assistant Secretary of the Indian Health Service.

Section 5315 of title 5, United States Code, is amended, in the matter relating to the Assistant Secretaries of Health and Human Services, by striking (6) and inserting (7), 1 of whom shall be the Assistant Secretary of the Indian Health Service.

Section 5316 of title 5, United States Code, is amended by striking Director, Indian Health Service, Department of Health and Human Services..

Section 1905(a)(9) of the Social Security Act (42 U.S.C. 1396d(a)(9)) is amended to read as follows:

(9) clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician, including—

(A) such services furnished outside the clinic by clinic personnel to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address; and

(B) such services furnished outside the clinic by any Indian Health Service facility, a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (Public Law 93–638), or an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act;

Section 514 of the Indian Health Care Improvement Act (25 U.S.C. 1660d) is amended by striking subsection (b) and inserting the following:

The Secretary shall ensure that the Service and other agencies and offices of the Department and the Department of Veterans Affairs confer, to the maximum extent practicable, with urban Indian organizations in carrying out—

(1) this Act; and

(2) other provisions of law relating to Indian health care.

Section 1311(c)(1)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(B)) is amended by inserting before the semicolon the following: and the ability of such provider to provide care in a language other than English either through the provider speaking such language or by the provider having a qualified interpreter for an individual with limited English proficiency (as defined in section 3400 of such Act) who speaks such language available during office hours.

The amendment made by subsection (a) shall not apply to any plan beginning on or prior to the date that is 1 year after the date of the enactment of this Act.

Section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(C)) is amended—

(1) by inserting (i) after (C); and

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

(ii) not later than January 1, 2025, increase the percentage of essential community providers as described in clause (i) included in its network by 10 percent annually (based on the level in the plan for 2023) until 90 percent of all federally qualified health centers and 75 percent of all other such essential community providers in the contract service area are in-network; and

(iii) include at least one essential community provider in each of the essential community provider categories described in section 156.235(a)(2)(ii)(B) of title 45, Code of Federal Regulations (as in effect on the date of enactment of the Health Equity and Accountability Act of 2024), in each county in the service area, where available;

Section 1311(e)(3) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)) is amended by adding at the end the following new subparagraph:

The Secretary shall require qualified health plans to submit annually to the Secretary data on the percentage of essential community providers as described in clause (ii) of subsection (c)(1)(C), by county, that contract with each qualified health plan offered in that county and the percentage of such essential community providers, by category as described in clause (iii) of such subsection, that contract with each qualified health plan offered in that county. Such data shall be made available to the general public.

Section 1852(d)(1) of the Social Security Act (42 U.S.C. 1395w–22(d)(1)) is amended—

(A) by striking and at the end of subparagraph (D);

(B) by striking the period at the end of subparagraph (E) and inserting; and; and

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

(F) the plan meets the requirements of clauses (ii) and (iii) of section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (relating to inclusion in networks of essential community providers).

Section 1932(b)(5) of the Social Security Act (42 U.S.C. 1396u–2(b)(5)) is amended—

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

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

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

(C) meets the requirements of clauses (ii) and (iii) of section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (relating to inclusion in networks of essential community providers) with respect to services offered in the service area involved.

Section 1311(c)(1)(B) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(B)), as amended by section 4241(a), is further amended—

(1) by inserting (i) after (B); and

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

(ii) meet such network adequacy standards as the Secretary may establish with regard to—

(I) appointment wait time;

(II) travel time and distance to health care provider facilities and providers by public and private transit;

(III) hours of operation to accommodate individuals who cannot come to provider appointments during standard business hours;

(IV) availability of health care options for patients; and

(V) other network adequacy standards to ensure that care through these plans is accessible to diverse communities, including individuals with limited English proficiency as defined in section 3400 of such Act; and

(iii) provide coverage for services for enrollees through out-of-network providers at no additional cost to the enrollees in cases where in-network providers are unable to comply with the standards established under subclause (III) or (IV) of clause (ii) for such services and the out-of-network providers can deliver such services in compliance with such standards;

The amendments made by subsection (a) shall not apply to plans beginning on or prior to the date that is 1 year after the date of the enactment of the Health Equity and Accountability Act of 2024.

Not later than 1 year after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress—

(A) a report on the Alaska Dental Health Aide Therapists program and the Dental Therapist and Advanced Dental Therapist programs in Minnesota, to assess the effectiveness of dental therapists in—

(i) improving access to timely dental care among communities of color;

(ii) providing high-quality care;

(iii) providing culturally competent care; and

(iv) providing accessible care to people with disabilities;

(B) a report on State variations in the use of dental hygienists and the effectiveness of expanding the scope of practice for dental hygienists in—

(i) improving access to timely dental care among communities of color;

(ii) providing high-quality care;

(iii) providing culturally competent care; and

(iv) providing accessible care to people with disabilities; and

(C) a report on the use of telehealth services to enhance services provided by dental hygienists and therapists, including recommendations for any modifications to the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) and the Medicaid program under title XIX of such Act (42 U.S.C. 1396 et seq.) to better provide for telehealth consultations in conjunction with therapists’ and hygienists’ care.

Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, shall submit to Congress a report which details geographic dental access shortages and the preparedness of dental providers to offer culturally and linguistically appropriate, affordable, accessible, and timely services.