42 U.S.C. § 256 — Grants to strengthen the effectiveness, efficiency, and coordination of services for the uninsured and underinsured

**(a) In general** The Secretary may award grants to eligible entities to assist in the development of integrated health care delivery systems to serve communities of individuals who are uninsured and individuals who are underinsured— (1) to improve the efficiency of, and coordination among, the providers providing services through such systems; (2) to assist communities in developing programs targeted toward preventing and managing chronic diseases; and (3) to expand and enhance the services provided through such systems. **(b) Eligible entities** To be eligible to receive a grant under this section, an entity shall be an entity that— (1) represents a consortium— (A) whose principal purpose is to provide a broad range of coordinated health care services for a community defined in the entity’s grant application as described in paragraph (2); and (B) that includes at least one of each of the following providers that serve the community (unless such provider does not exist within the community, declines or refuses to participate, or places unreasonable conditions on their participation)— (i) a Federally qualified health center (as defined in [section 1395x(aa) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/aa&num=0&edition=prelim)); (ii) a hospital with a low-income utilization rate (as defined in [section 1396r–4(b)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396r–4/b/3&num=0&edition=prelim)), that is greater than 25 percent; (iii) a public health department; and (iv) an interested public or private sector health care provider or an organization that has traditionally served the medically uninsured and underserved; and (2) submits to the Secretary an application, in such form and manner as the Secretary shall prescribe, that— (A) defines a community or geographic area of uninsured and underinsured individuals; (B) identifies the providers who will participate in the consortium’s program under the grant, and specifies each provider’s contribution to the care of uninsured and underinsured individuals in the community, including the volume of care the provider provides to beneficiaries under the medicare, medicaid, and State child health insurance programs and to patients who pay privately for services; (C) describes the activities that the applicant and the consortium propose to perform under the grant to further the objectives of this section; (D) demonstrates the consortium’s ability to build on the current system (as of the date of submission of the application) for serving a community or geographic area of uninsured and underinsured individuals by involving providers who have traditionally provided a significant volume of care for that community; (E) demonstrates the consortium’s ability to develop coordinated systems of care that either directly provide or ensure the prompt provision of a broad range of high-quality, accessible services, including, as appropriate, primary, secondary, and tertiary services, as well as substance abuse treatment and mental health services in a manner that assures continuity of care in the community or geographic area; (F) provides evidence of community involvement in the development, implementation, and direction of the program that the entity proposes to operate; (G) demonstrates the consortium’s ability to ensure that individuals participating in the program are enrolled in public insurance programs for which the individuals are eligible or know of private insurance programs where available; (H) presents a plan for leveraging other sources of revenue, which may include State and local sources and private grant funds, and integrating current and proposed new funding sources in a way to assure long-term sustainability of the program; (I) describes a plan for evaluation of the activities carried out under the grant, including measurement of progress toward the goals and objectives of the program and the use of evaluation findings to improve program performance; (J) demonstrates fiscal responsibility through the use of appropriate accounting procedures and appropriate management systems; (K) demonstrates the consortium’s commitment to serve the community without regard to the ability of an individual or family to pay by arranging for or providing free or reduced charge care for the poor; and (L) includes such other information as the Secretary may prescribe. **(c) Limitations** (1) **Number of awards** (A) *In general* — For each of fiscal years 2003, 2004, 2005, and 2006, the Secretary may not make more than 35 new awards under subsection (a) (excluding renewals of such awards). (B) *Rule of construction* — This paragraph shall not be construed to affect awards made before fiscal year 2003. (2) **In general** — An eligible entity may not receive a grant under this section (including with respect to any such grant made before fiscal year 2003) for more than 3 consecutive fiscal years, except that such entity may receive such a grant award for not more than 1 additional fiscal year if— (A) the eligible entity submits to the Secretary a request for a grant for such an additional fiscal year; (B) the Secretary determines that extraordinary circumstances (as defined in paragraph (3)) justify the granting of such request; and (C) the Secretary determines that granting such request is necessary to further the objectives described in subsection (a). (3) **Extraordinary circumstances** (A) *In general* — In paragraph (2), the term “extraordinary circumstances” means an event (or events) that is outside of the control of the eligible entity that has prevented the eligible entity from fulfilling the objectives described by such entity in the application submitted under subsection (b)(2). (B) *Examples* — Extraordinary circumstances include— (i) natural disasters or other major disruptions to the security or health of the community or geographic area served by the eligible entity; or (ii) a significant economic deterioration in the community or geographic area served by such eligible entity, that directly and adversely affects the entity receiving an award under subsection (a). **(d) Priorities** In awarding grants under this section, the Secretary— (1) shall accord priority to applicants that demonstrate the extent of unmet need in the community involved for a more coordinated system of care; and (2) may accord priority to applicants that best promote the objectives of this section, taking into consideration the extent to which the application involved— (A) identifies a community whose geographical area has a high or increasing percentage of individuals who are uninsured; (B) demonstrates that the applicant has included in its consortium providers, support systems, and programs that have a tradition of serving uninsured individuals and underinsured individuals in the community; (C) shows evidence that the program would expand utilization of preventive and primary care services for uninsured and underinsured individuals and families in the community, including behavioral and mental health services, oral health services, or substance abuse services; (D) proposes a program that would improve coordination between health care providers and appropriate social service providers; (E) demonstrates collaboration with State and local governments; (F) demonstrates that the applicant makes use of non-Federal contributions to the greatest extent possible; or (G) demonstrates a likelihood that the proposed program will continue after support under this section ceases. **(e) Use of funds** (1) **Use by grantees** (A) *In general* — Except as provided in paragraphs (2) and (3), a grantee may use amounts provided under this section only for— (i) direct expenses associated with achieving the greater integration of a health care delivery system so that the system either directly provides or ensures the provision of a broad range of culturally competent services, as appropriate, including primary, secondary, and tertiary services, as well as substance abuse treatment and mental health services; and (ii) direct patient care and service expansions to fill identified or documented gaps within an integrated delivery system. (B) *Specific uses* — The following are examples of purposes for which a grantee may use grant funds under this section, when such use meets the conditions stated in subparagraph (A): (i) Increases in outreach activities and closing gaps in health care service. (ii) Improvements to case management. (iii) Improvements to coordination of transportation to health care facilities. (iv) Development of provider networks and other innovative models to engage physicians in voluntary efforts to serve the medically underserved within a community. (v) Recruitment, training, and compensation of necessary personnel. (vi) Acquisition of technology for the purpose of coordinating care. (vii) Improvements to provider communication, including implementation of shared information systems or shared clinical systems. (viii) Development of common processes for determining eligibility for the programs provided through the system, including creating common identification cards and single sliding scale discounts. (ix) Development of specific prevention and disease management tools and processes. (x) Translation services. (xi) Carrying out other activities that may be appropriate to a community and that would increase access by the uninsured to health care, such as access initiatives for which private entities provide non-Federal contributions to supplement the Federal funds provided through the grants for the initiatives. (2) **Direct patient care limitation** — Not more than 15 percent of the funds provided under a grant awarded under this section may be used for providing direct patient care and services. (3) **Reservation of funds for national program purposes** — The Secretary may use not more than 3 percent of funds appropriated to carry out this section for providing technical assistance to grantees, obtaining assistance of experts and consultants, holding meetings, developing of tools, disseminating of information, evaluation, and carrying out activities that will extend the benefits of programs funded under this section to communities other than the community served by the program funded. **(f) Grantee requirements** (1) **Evaluation of effectiveness** — A grantee under this section shall— (A) report to the Secretary annually regarding— (i) progress in meeting the goals and measurable objectives set forth in the grant application submitted by the grantee under subsection (b); and (ii) the extent to which activities conducted by such grantee have— (I) improved the effectiveness, efficiency, and coordination of services for uninsured and underinsured individuals in the communities or geographic areas served by such grantee; (II) resulted in the provision of better quality health care for such individuals; and (III) resulted in the provision of health care to such individuals at lower cost than would have been possible in the absence of the activities conducted by such grantee; and (B) provide for an independent annual financial audit of all records that relate to the disposition of funds received through the grant. (2) **Progress** — The Secretary may not renew an annual grant under this section for an entity for a fiscal year unless the Secretary is satisfied that the consortium represented by the entity has made reasonable and demonstrable progress in meeting the goals and measurable objectives set forth in the entity’s grant application for the preceding fiscal year. **(g) Maintenance of effort** With respect to activities for which a grant under this section is authorized, the Secretary may award such a grant only if the applicant for the grant, and each of the participating providers, agree that the grantee and each such provider will maintain its expenditures of non-Federal funds for such activities at a level that is not less than the level of such expenditures during the fiscal year immediately preceding the fiscal year for which the applicant is applying to receive such grant. **(h) Technical assistance** The Secretary may, either directly or by grant or contract, provide any entity that receives a grant under this section with technical and other nonfinancial assistance necessary to meet the requirements of this section. **(i) Evaluation of program** Not later than September 30, 2005, the Secretary shall prepare and submit to the appropriate committees of Congress a report that describes the extent to which projects funded under this section have been successful in improving the effectiveness, efficiency, and coordination of services for uninsured and underinsured individuals in the communities or geographic areas served by such projects, including whether the projects resulted in the provision of better quality health care for such individuals, and whether such care was provided at lower costs, than would have been provided in the absence of such projects. **(j) Demonstration authority** The Secretary may make demonstration awards under this section to historically black health professions schools for the purposes of— (1) developing patient-based research infrastructure at historically black health professions schools, which have an affiliation, or affiliations, with any of the providers identified in subsection (b)(1)(B); (2) establishment of joint and collaborative programs of medical research and data collection between historically black health professions schools and such providers, whose goal is to improve the health status of medically underserved populations; or (3) supporting the research-related costs of patient care, data collection, and academic training resulting from such affiliations. **(k) Authorization of appropriations** There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2002 through 2006. **(l) Date certain for termination of program** Funds may not be appropriated to carry out this section after September 30, 2006.