42 U.S.C. § 256 — Grants to strengthen the effectiveness, effi-

Page 428 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256 (4) Applications for grants and contracts under this subsection shall be in such form and con- tain such information as the Secretary shall prescribe. (5) There are authorized to be appropriated for grants and contracts under this subsection $2,000,000 for each of the fiscal years ending Sep- tember 30, 1983, September 30, 1984, September 30, 1985, September 30, 1986, and September 30, 1987. (c) Report to Congress with respect to grants and loans and training of personnel The Secretary shall report to the Committee on Labor and Human Resources of the Senate and the Committee on Energy and Commerce of the House of Representatives on or before Janu- ary 1, 1984, with respect to— (1) the impact of grants made and contracts entered into under subsections (a) and (b) (as such subsections were in effect prior to Octo- ber 1, 1981); (2) the need to continue grants and loans under subsections (a) and (b) (as such sub- sections are in effect on the day after January 4, 1983); and (3) the extent to which standards have been applied to the training of personnel who pro- vide home health services. (d) ‘‘Home health services’’ defined For purposes of this section, the term ‘‘home health services’’ has the meaning prescribed for the term by section 1395x(m) of this title. (July 1, 1944, ch. 373, title III, § 339, as added Pub. L. 97–414, § 6(a), Jan. 4, 1983, 96 Stat. 2057; amend- ed Pub. L. 98–555, § 6, Oct. 30, 1984, 98 Stat. 2856.) Editorial Notes REFERENCES IN TEXT Subsections (a) and (b) (as such subsections were in effect prior to October 1, 1981), referred to in subsec. (c)(1), mean subsections (a) and (b) of section 255 of this title prior to repeal of section 255 by Pub. L. 97–35, title IX, § 902(b), Aug. 13, 1981, 95 Stat. 559, effective Oct. 1, 1981. PRIOR PROVISIONS A prior section 255, act July 1, 1944, ch. 373, title III, § 339, as added Nov. 10, 1978, Pub. L. 95–626, title II, § 207(a), 92 Stat. 3585, related to grant authority, etc., for home health services, prior to repeal by Pub. L. 97–35, title IX, § 902(b), (h), Aug. 13, 1981, 95 Stat. 559, 561, eff. Oct. 1, 1981. Another prior section 339 of act July 1, 1944, ch. 373, title III, formerly § 331, 58 Stat. 698; June 25, 1948, ch. 654, § 4, 62 Stat. 1018; June 25, 1952, ch. 460, 66 Stat. 157; July 12, 1960, Pub. L. 86–624, § 29(b), 74 Stat. 419; renum- bered § 339, Oct. 12, 1976, Pub. L. 94–484, title IV, § 407(b)(2), 90 Stat. 2268, which related to reception of persons suffering from leprosy in any hospital, was re- numbered section 320 of act July 1, 1944, and transferred to section 247e of this title. AMENDMENTS 1984—Subsecs. (a)(5), (b)(5). Pub. L. 98–555 inserted provisions authorizing appropriations for fiscal years ending Sept. 30, 1985, 1986, and 1987. Statutory Notes and Related Subsidiaries CHANGE OF NAME Committee on Labor and Human Resources of Senate changed to Committee on Health, Education, Labor, and Pensions of Senate by Senate Resolution No. 20, One Hundred Sixth Congress, Jan. 19, 1999. Committee on Energy and Commerce of House of Representatives treated as referring to Committee on Commerce of House of Representatives by section 1(a) of Pub. L. 104–14, set out as a note preceding section 21 of Title 2, The Congress. Committee on Commerce of House of Representatives changed to Committee on En- ergy and Commerce of House of Representatives, and jurisdiction over matters relating to securities and ex- changes and insurance generally transferred to Com- mittee on Financial Services of House of Representa- tives by House Resolution No. 5, One Hundred Seventh Congress, Jan. 3, 2001. REPORT TO CONGRESS CONCERNING RESULTS OF STUD- IES EVALUATING HOME AND COMMUNITY BASED HEALTH SERVICES; STUDIES OF REIMBURSEMENT METHODOLOGIES; INVESTIGATION OF FRAUD; DEM- ONSTRATION PROJECTS; HOME HEALTH SERVICES, DE- FINED Pub. L. 97–414, § 6(b)–(f), Jan. 4, 1983, 96 Stat. 2058, 2059, directed Secretary of Health and Human Services to re- port results of studies evaluating home and community based health services, and any recommendations for legislative action which might improve the provision of such services, to Congress prior to Jan. 1, 1985, to com- pile and analyze results of significant public or private studies relating to reimbursement methodologies for home health services and to report recommendations to Congress within 180 days after Jan. 4, 1983, to inves- tigate methods available to stem medicare and med- icaid fraud and abuse and extent to which such meth- ods are applied and to report results to Congress within 18 months of Jan. 4, 1983, and to develop and carry out demonstration projects commencing no later than Jan. 1, 1984, to test methods for identifying patients at risk of institutionalization who could be treated more cost- effectively with home health services, and to test alter- native reimbursement methodologies for home health agencies in order to determine most cost-effective way of providing home health services, and to report to Congress with regard to the demonstrations no later than Jan. 1, 1985; and defined ‘‘home health services’’ for purposes of this section. SUBPART V—HEALTHY COMMUNITIES ACCESS PROGRAM Editorial Notes PRIOR PROVISIONS A prior subpart VI, consisting of section 256a, related to health services for residents of public housing, prior to repeal by Pub. L. 104–299, § 4(a)(3), Oct. 11, 1996, 110 Stat. 3645. § 256. Grants to strengthen the effectiveness, effi- ciency, 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 inte- grated health care delivery systems to serve communities of individuals who are uninsured and individuals who are underinsured— (1) to improve the efficiency of, and coordi- nation among, the providers providing services through such systems; (2) to assist communities in developing pro- grams targeted toward preventing and man- aging chronic diseases; and (3) to expand and enhance the services pro- vided through such systems. (b) Eligible entities To be eligible to receive a grant under this section, an entity shall be an entity that— Page 429 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256 (1) represents a consortium— (A) whose principal purpose is to provide a broad range of coordinated health care serv- ices 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 com- munity (unless such provider does not exist within the community, declines or refuses to participate, or places unreasonable condi- tions on their participation)— (i) a Federally qualified health center (as defined in section 1395x(aa) of this title); (ii) a hospital with a low-income utiliza- tion rate (as defined in section 1396r–4(b)(3) of this title), that is greater than 25 per- cent; (iii) a public health department; and (iv) an interested public or private sector health care provider or an organization that has traditionally served the medi- cally 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 individ- uals; (B) identifies the providers who will par- ticipate in the consortium’s program under the grant, and specifies each provider’s con- tribution to the care of uninsured and under- insured individuals in the community, in- cluding the volume of care the provider pro- vides 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 appli- cant 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 appro- priate, primary, secondary, and tertiary services, as well as substance abuse treat- ment and mental health services in a man- ner that assures continuity of care in the community or geographic area; (F) provides evidence of community in- volvement in the development, implementa- tion, 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 eligi- ble 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, in- cluding measurement of progress toward the goals and objectives of the program and the use of evaluation findings to improve pro- gram performance; (J) demonstrates fiscal responsibility through the use of appropriate accounting procedures and appropriate management systems; (K) demonstrates the consortium’s com- mitment to serve the community without regard to the ability of an individual or fam- ily 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) (exclud- ing 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, ex- cept 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 Sec- retary a request for a grant for such an addi- tional fiscal year; (B) the Secretary determines that extraor- dinary circumstances (as defined in para- graph (3)) justify the granting of such re- quest; and (C) the Secretary determines that granting such request is necessary to further the ob- jectives 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 dis- ruptions 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 Page 430 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256 served by such eligible entity, that di- rectly and adversely affects the entity re- ceiving an award under subsection (a). (d) Priorities In awarding grants under this section, the Sec- retary— (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 geo- graphical area has a high or increasing per- centage of individuals who are uninsured; (B) demonstrates that the applicant has included in its consortium providers, sup- port systems, and programs that have a tra- dition 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 serv- ices, oral health services, or substance abuse services; (D) proposes a program that would im- prove coordination between health care pro- viders and appropriate social service pro- viders; (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 sup- port 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 cul- turally competent services, as appropriate, including primary, secondary, and tertiary services, as well as substance abuse treat- ment and mental health services; and (ii) direct patient care and service expan- sions 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 condi- tions 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 com- munity. (v) Recruitment, training, and com- pensation of necessary personnel. (vi) Acquisition of technology for the purpose of coordinating care. (vii) Improvements to provider commu- nication, including implementation of shared information systems or shared clin- ical systems. (viii) Development of common processes for determining eligibility for the pro- grams provided through the system, in- cluding creating common identification cards and single sliding scale discounts. (ix) Development of specific prevention and disease management tools and proc- esses. (x) Translation services. (xi) Carrying out other activities that may be appropriate to a community and that would increase access by the unin- sured to health care, such as access initia- tives 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 pro- vided 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 per- cent 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, evalua- tion, and carrying out activities that will ex- tend 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 re- garding— (i) progress in meeting the goals and measurable objectives set forth in the grant application submitted by the grant- ee under subsection (b); and (ii) the extent to which activities con- ducted by such grantee have— (I) improved the effectiveness, effi- ciency, 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 ab- Page 431 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256 sence of the activities conducted by such grantee; and (B) provide for an independent annual fi- nancial 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 fis- cal 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 pro- viders, agree that the grantee and each such pro- vider will maintain its expenditures of non-Fed- eral funds for such activities at a level that is not less than the level of such expenditures dur- ing 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 Sec- retary shall prepare and submit to the appro- priate committees of Congress a report that de- scribes the extent to which projects funded under this section have been successful in im- proving the effectiveness, efficiency, and coordi- nation of services for uninsured and under- insured individuals in the communities or geo- graphic 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 ab- sence 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 infra- structure at historically black health profes- sions schools, which have an affiliation, or af- filiations, with any of the providers identified in subsection (b)(1)(B); (2) establishment of joint and collaborative programs of medical research and data collec- tion between historically black health profes- sions schools and such providers, whose goal is to improve the health status of medically un- derserved 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 nec- essary 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. (July 1, 1944, ch. 373, title III, § 340, as added Pub. L. 107–251, title IV, § 402, Oct. 26, 2002, 116 Stat. 1655.) Editorial Notes PRIOR PROVISIONS A prior section 256, act July 1, 1944, ch. 373, title III, § 340, as added July 22, 1987, Pub. L. 100–77, title VI, § 601, 101 Stat. 511; amended Nov. 4, 1988, Pub. L. 100–607, title VIII, §§ 801(a), (c), 802(a), (b)(1), 803, 804, 102 Stat. 3168, 3169; Nov. 7, 1988, Pub. L. 100–628, title VI, §§ 601(a), (c), 602(a), (b)(1), 603, 604, 102 Stat. 3241, 3242; Aug. 16, 1989, Pub. L. 101–93, § 5(t)(1), (3), 103 Stat. 615; Nov. 29, 1990, Pub. L. 101–645, title V, §§ 501–503, 104 Stat. 4724; Oct. 27, 1992, Pub. L. 102–531, title III, § 309(c), 106 Stat. 3501, re- lated to grant program for certain health services for the homeless, prior to repeal by Pub. L. 104–299, § 4(a)(3), Oct. 11, 1996, 110 Stat. 3645, eff. Oct. 1, 1996. Another prior section 256, act July 1, 1944, ch. 373, title III, § 340, as added Nov. 10, 1978, Pub. L. 95–626, title I, § 115(2), 92 Stat. 3567; amended Dec. 12, 1979, Pub. L. 96–142, title III, § 301(a), 93 Stat. 1073; Aug. 13, 1981, Pub. L. 97–35, title IX, § 903(b)(1), 95 Stat. 561; Jan. 4, 1983, Pub. L. 97–414, § 8(h), 96 Stat. 2061, related to primary care research and demonstration projects to serve medically underserved population, prior to repeal by Pub. L. 97–35, title IX, § 903(c), Aug. 13, 1981, 95 Stat. 561, eff. Oct. 1, 1982. Another prior section 256, act July 1, 1944, ch. 373, title III, § 340, formerly § 332, 58 Stat. 698; renumbered § 340, Oct. 12, 1976, Pub. L. 94–484, title IV, § 407(b)(2), 90 Stat. 2268, related to apprehension, detention, treat- ment, and release of persons being treated for leprosy, prior to repeal by Pub. L. 95–626, title I, § 105(b), Nov. 10, 1978, 92 Stat. 3560. Statutory Notes and Related Subsidiaries DEMONSTRATION PROJECT TO PROVIDE ACCESS TO AFFORDABLE CARE Pub. L. 111–148, title X, § 10504, Mar. 23, 2010, 124 Stat. 1004, provided that: ‘‘(a) IN GENERAL.—Not later than 6 months after the date of enactment of this Act [Mar. 23, 2010], the Sec- retary of Health and Human Services (referred to in this section as the ‘Secretary’), acting through the Health Resources and Services Administration, shall establish a 3 year demonstration project in up to 10 States to provide access to comprehensive health care services to the uninsured at reduced fees. The Sec- retary shall evaluate the feasibility of expanding the project to additional States. ‘‘(b) ELIGIBILITY.—To be eligible to participate in the demonstration project, an entity shall be a State- based, nonprofit, public-private partnership that pro- vides access to comprehensive health care services to the uninsured at reduced fees. Each State in which a participant selected by the Secretary is located shall receive not more than $2,000,000 to establish and carry out the project for the 3-year demonstration period. ‘‘(c) AUTHORIZATION.—There is authorized to be appro- priated such sums as may be necessary to carry out this section.’’ PURPOSE Pub. L. 107–251, title IV, § 401, Oct. 26, 2002, 116 Stat. 1655, provided that: ‘‘The purpose of this title [enacting this subpart and subpart X (§ 256f et seq.) of this part Page 432 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256a and provisions set out as a note under section 1396a of this title] is to provide assistance to communities and consortia of health care providers and others, to de- velop or strengthen integrated community health care delivery systems that coordinate health care services for individuals who are uninsured or underinsured and to develop or strengthen activities related to providing coordinated care for individuals with chronic condi- tions who are uninsured or underinsured, through the— ‘‘(1) coordination of services to allow individuals to receive efficient and higher quality care and to gain entry into and receive services from a comprehensive system of care; ‘‘(2) development of the infrastructure for a health care delivery system characterized by effective col- laboration, information sharing, and clinical and fi- nancial coordination among all providers of care in the community; and ‘‘(3) provision of new Federal resources that do not supplant funding for existing Federal categorical pro- grams that support entities providing services to low- income populations.’’ § 256a. Patient navigator grants (a) Grants The Secretary, acting through the Adminis- trator of the Health Resources and Services Ad- ministration, may make grants to eligible enti- ties for the development and operation of dem- onstration programs to provide patient navi- gator services to improve health care outcomes. The Secretary shall coordinate with, and ensure the participation of, the Indian Health Service, the National Cancer Institute, the Office of Rural Health Policy, and such other offices and agencies as deemed appropriate by the Sec- retary, regarding the design and evaluation of the demonstration programs. (b) Use of funds The Secretary shall require each recipient of a grant under this section to use the grant to re- cruit, assign, train, and employ patient naviga- tors who have direct knowledge of the commu- nities they serve to facilitate the care of indi- viduals, including by performing each of the fol- lowing duties: (1) Acting as contacts, including by assisting in the coordination of health care services and provider referrals, for individuals who are seeking prevention or early detection services for, or who following a screening or early de- tection service are found to have a symptom, abnormal finding, or diagnosis of, cancer or other chronic disease. (2) Facilitating the involvement of commu- nity organizations in assisting individuals who are at risk for or who have cancer or other chronic diseases to receive better access to high-quality health care services (such as by creating partnerships with patient advocacy groups, charities, health care centers, commu- nity hospice centers, other health care pro- viders, or other organizations in the targeted community). (3) Notifying individuals of clinical trials and, on request, facilitating enrollment of eli- gible individuals in these trials. (4) Anticipating, identifying, and helping pa- tients to overcome barriers within the health care system to ensure prompt diagnostic and treatment resolution of an abnormal finding of cancer or other chronic disease. (5) Coordinating with the relevant health in- surance ombudsman programs to provide in- formation to individuals who are at risk for or who have cancer or other chronic diseases about health coverage, including private in- surance, health care savings accounts, and other publicly funded programs (such as Medi- care, Medicaid, health programs operated by the Department of Veterans Affairs or the De- partment of Defense, the State children’s health insurance program, and any private or governmental prescription assistance pro- grams). (6) Conducting ongoing outreach to health disparity populations, including the unin- sured, rural populations, and other medically underserved populations, in addition to assist- ing other individuals who are at risk for or who have cancer or other chronic diseases to seek preventative care. (c) Prohibitions (1) Referral fees The Secretary shall require each recipient of a grant under this section to prohibit any pa- tient navigator providing services under the grant from accepting any referral fee, kick- back, or other thing of value in return for re- ferring an individual to a particular health care provider. (2) Legal fees and costs The Secretary shall prohibit the use of any grant funds received under this section to pay any fees or costs resulting from any litigation, arbitration, mediation, or other proceeding to resolve a legal dispute. (d) Grant period (1) In general Subject to paragraphs (2) and (3), the Sec- retary may award grants under this section for periods of not more than 3 years. (2) Extensions Subject to paragraph (3), the Secretary may extend the period of a grant under this sec- tion. Each such extension shall be for a period of not more than 1 year. (3) Limitations on grant period In carrying out this section, the Secretary shall ensure that the total period of a grant does not exceed 4 years. (e) Application (1) In general To seek a grant under this section, an eligi- ble entity shall submit an application to the Secretary in such form, in such manner, and containing such information as the Secretary may require. (2) Contents At a minimum, the Secretary shall require each such application to outline how the eligi- ble entity will establish baseline measures and benchmarks that meet the Secretary’s re- quirements to evaluate program outcomes. (3) Minimum core proficiencies The Secretary shall not award a grant to an entity under this section unless such entity