This Act may be cited as the “Health Equity and Accountability Act of 2020”.

The table of contents of this Act is as follows:

Sec. 1. Short title.
Sec. 2. Table of contents.
Sec. 3. Findings.

The Congress finds as follows:

(1) The population of racial and ethnic minorities is expected to increase over the next few decades, yet racial and ethnic minorities have the poorest health status and face substantial cultural, social, and economic barriers to obtaining quality health care.

(2) Health disparities are a function of not only access to health care, but also the social determinants of health—including the environment, the physical structure of communities, nutrition and food options, educational attainment, employment, race, ethnicity, sex, geography, language preference, immigrant or citizenship status, sexual orientation, gender identity, socioeconomic status, or disability status—that directly and indirectly affect the health, health care, and wellness of individuals and communities.

(3) Over the next few decades, the United States will face a shortage of health care providers and allied health workers.

(4) All efforts to reduce health disparities and barriers to quality health services require better and more consistent data and better and more consistent collection of and access to data.

(5) A full range of culturally and linguistically appropriate health care and public health services must be available and accessible in every community.

(6) Racial and ethnic minorities and underserved populations must be included early and equitably in health reform innovations.

(7) Efforts to improve minority health have been limited by inadequate resources in funding, staffing, stewardship, and accountability. Targeted investments that are focused on disparities elimination must be made in providing care and services that are community-based, including prevention and policies addressing social determinants of health.

(8) In 2011, the Department of Health and Human Services developed the HHS Action Plan to Reduce Racial and Ethnic Health Disparities and the National Stakeholder Strategy for Achieving Health Equity, which are 2 strategic plans that represent the first coordinated roadmap in the United States to reducing health disparities. These comprehensive plans, along with the National Prevention Strategy issued by the National Prevention Council of the Department of Health and Human Services, Healthy People 2030, and the National Quality Strategy of the Agency for Healthcare Research and Quality, as well as critical resources such as the 2012 National Healthcare Quality and Disparities Reports, will work to increase the number of people in the United States who are healthy at every stage of life.

(9) The Secretary of Health and Human Services has also reviewed and advanced updated clinical guidelines and developed other strategic planning documents to combat health disparities with a high impact on minority populations and to provide high-quality family planning services. Such guidelines and documents include the National HIV/AIDS Strategy, the Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis, and recommendations of the Centers for Disease Control and Prevention and the Office of Population Affairs.

(10) The Patient Protection and Affordable Care Act (Public Law 111–148), as amended by the Health Care and Education Reconciliation Act (Public Law 111–152), represents the biggest advancement for minority health in the 40 years immediately preceding the enactment of this Act.

(11) The Health Information Technology for Economic and Clinical Health Act of 2009, part of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5), provides that the nationwide health information exchange infrastructure be developed and used to reduce health disparities, among other purposes.

(a) Purpose.—It is the purpose of the amendment made by this section to promote data collection, analysis, and reporting by race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, age, and socioeconomic status among federally supported health programs.

(b) Amendment.—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:

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

(a) In general.—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 race, ethnicity, and primary language in a health-related transaction, to require—

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

(b) Dissemination.—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.

(c) Compliance.—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 “2022”;

(2) in paragraph (2), in the first sentence, by striking “2003” and inserting “2022”; and

(3) in paragraph (3), by striking “2002” and inserting “2022”.

(a) Repository of Government data.—The Secretary of Health and Human Services, in coordination with the departments, agencies, or offices described in subsection (b), shall establish a centralized electronic repository of Government data on factors related to the health and well-being of the population of the United States.

(b) Collection; submission.—Not later than 180 days after the date of the 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, disability status, gender identity, age, or socioeconomic status during the preceding calendar year shall submit such data to the repository of Government data established under subsection (a).

(c) Analysis; public availability; reporting.—Not later than April 30, 2021, 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, and other areas of health and well-being by factors that include race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, 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.

(a) Authority.—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.

(b) Eligible entity.—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)).

(c) Authorization of appropriations.—To carry out this section, there are authorized to be appropriated such sums as may be necessary for fiscal years 2021 through 2025.

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

(1) in paragraph (1)(A), by inserting “sexual orientation, gender identity, socioeconomic status,” before “and disability status”;

(2) in paragraph (1)(C), by inserting “sexual orientation, gender identity, socioeconomic status,” before “and disability status”; and

(3) in paragraph (2)(B), by inserting “sexual orientation, gender identity, socioeconomic status,” before “and disability status”.

(a) In general.—Chapter V of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 351 et seq.) is amended by adding after section 505G the following:

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

“(gg) 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, or comply with any other requirement, of section 505H.”.

(c) Drug fees.—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 317U the following:

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:

“(5) SIMPLIFIED ADMINISTRATIVE REPORTING REQUIREMENT.—With respect to any obligation of a State agency carrying out the supplemental nutrition assistance program 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.”.

(a) Definitions.—In this title, the definitions in section 3400 of the Public Health Service Act, as added by section 204, shall apply.

(b) Findings.—Congress finds the following:

(1) Effective communication is essential to meaningful access to quality physical and mental health care.

(2) Research indicates that the lack of appropriate language services creates language barriers that result in increased risk of misdiagnosis, ineffective treatment plans, and poor health outcomes for individuals with limited English proficiency and individuals with communication disabilities such as cognitive, hearing, vision, or print impairments.

(3) The number of limited English-speaking residents in the United States who speak English less than very well and, therefore, cannot effectively communicate with health and social service providers continues to increase significantly.

(4) The responsibility to fund language services in the provision of health care and health-care-related services to individuals with limited English proficiency and individuals with communication disabilities such as cognitive hearing, vision, or print impairments is a societal one that cannot fairly be placed solely upon the health care, public health, or social services community.

(5) Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) prohibits discrimination based on the grounds of race, color, or national origin by any entity receiving Federal financial assistance. In order to avoid discrimination on the grounds of national origin, all programs or activities administered by the Federal Government must take adequate steps to ensure that their policies and procedures do not deny or have the effect of denying individuals with limited English proficiency with equal access to benefits and services for which such persons qualify.

(6) Both the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.) and the Rehabilitation Act of 1973 (29 U.S.C. 701 et seq.) prohibit discrimination on the basis of disability and require the provision of appropriate auxiliary aids and services necessary to ensure effective communication with individuals with disabilities. The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the method of communication used by the individual; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place. A public accommodation should consult with individuals with disabilities whenever possible to determine what type of auxiliary aid is needed to ensure effective communication. The public accommodation should use the individual's preferred method of communication whenever possible, unless it would be an undue burden to the public accommodation and an alternative would provide an equally effective means of communication. The ultimate decision as to what measures to take rests with the public accommodation, provided that the method chosen results in effective communication.

(7) Section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) builds on title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), prohibits discrimination on the basis of race, color, national origin, disability, sex, and age, requires the provision of language services to ensure effective communication with individuals with limited English proficiency, and requires the provision of appropriate auxiliary aids and services necessary to ensure effective communication with individuals with disabilities.

(8) Linguistic diversity in the health care and health-care-related services workforce is important for providing all patients the environment most conducive to positive health outcomes.

(9) All members of the health care and health-care-related services community should continue to educate their staff and constituents about limited English-proficient and disability communication issues and help them identify resources to improve access to quality care for individuals with limited English proficiency and individuals with communication disabilities such as cognitive, hearing, vision, or print impairments.

(10) Access to English as a second language, foreign language, and sign language interpreters, translated and alternative format documents, readers, and other auxiliary aids and services, are essential to ensure effective communication and eliminate the language barriers that impede access to health care.

(11) Competent language services in health care settings should be available as a matter of course.

(a) Purpose.—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 competence 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 ensure that recipients of Federal financial assistance provide culturally competence services and meaningful access to applicants and beneficiaries that are individuals with limited English proficiency;

(4) 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

(5) 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) as published in the Federal Register on May 18, 2016, that health care providers and organizations do not discriminate in the provision of services.

(b) Federally Conducted programs and activities.—

(1) IN GENERAL.—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 203(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.

(2) PLAN REQUIREMENT.—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 providing a range of language assistance options, notice to individuals with limited English proficiency of the right to competent language services, periodic training of staff, monitoring and quality assessment of the language services and, in appropriate circumstances, the translation of written materials;

(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 relevant 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; and

(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 regulations implementing 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.

(3) SUBMISSION OF PLAN TO DOJ.—Each agency that is required to prepare a plan under paragraph (1) shall send a copy of such plan to the Attorney General, which shall serve as the central repository of all such plans.

(a) Applicability.—This section shall apply to any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or any program or activity that is administered 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).

(b) Standards.—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 annually;

(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 the 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. 1320–2 note), data on an individual required to be collected pursuant to section 3101, 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; and

(C) 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 communities 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 regularly make available to the public information about their progress and successful innovations in implementing the standards under this section and provide public notice in their communities about the availability of this 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.

(c) Comments accepted through notice and comment rulemaking.—An agency carrying out a program described in subsection (a)—

(1) shall ensure that comments with respect to such program 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:

(a) Grants authorized.—The Secretary of Health and Human Services 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.

(b) Grant period.—A grant awarded under this section is authorized for the period of 3 fiscal years beginning on October 1, 2021, and ending on September 30, 2024.

(c) Preference.—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.

(d) Use of funds.—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 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.

(e) Application.—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.

(f) Definitions.—In this section:

(1) QUALIFIED LEP ENROLLEE.—The term “qualified LEP enrollee” means an individual—

(A) who is limited English proficient; and

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

(2) STATE.—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.).

(3) STATE MEDICAID PLAN.—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.

(4) UNITED STATES.—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.).

(g) Continuation past demonstration.—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.

(h) Funding.—

(1) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated $5,000,000 to carry out this section.

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

(3) INCREASED FEDERAL FINANCIAL PARTICIPATION.—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 205 of the Health Equity and Accountability Act of 2020, 100 percent for each quarter occurring during the grant period specified in subsection (b) of such section)” after “75 percent”.

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

(a) Direct graduate medical education.—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:

“(L) TREATMENT OF CULTURALLY AND LINGUISTICALLY APPROPRIATE TRAINING.—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 diverse populations including people with disabilities and the Lesbian, gay, bisexual, transgender, queer, questioning, questioning and intersex (LGBTQIA) community, shall be counted toward the determination of full-time equivalency.”.

(b) Indirect medical education.—Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended—

(1) by redesignating the clause (x) added by section 5505(b) of the Patient Protection and Affordable Care Act as clause (xi) and moving the left margin of such clause and each subclause and item therein 2 ems to the left; and

(2) by adding at the end the following new clause:

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

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

(a) Language Access grants for Medicare Providers.—

(1) ESTABLISHMENT.—

(A) IN GENERAL.—Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services, 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 improve communication between such providers and Medicare beneficiaries who are limited English proficient, including beneficiaries who live in diverse and underserved communities.

(B) APPLICATION OF INNOVATION RULES.—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).

(C) NUMBER OF GRANTS.—To the extent practicable, the Secretary shall award not less than 24 grants under this subsection.

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

(2) ELIGIBILITY REQUIREMENTS.—To be eligible for a grant under this subsection, an entity must meet the following requirements:

(A) MEDICARE PROVIDER.—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.).

(B) UNDERSERVED COMMUNITIES.—The entity must serve a community that, with respect to necessary language services for improving access and utilization of health care among English learners, is disproportionally underserved.

(C) APPLICATION.—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.

(D) REPORTING.—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 requirement 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.

(3) DISTRIBUTION.—To the extent feasible, the Secretary shall award—

(A) at least 6 grants to providers of services described in paragraph (2)(A)(i);

(B) at least 6 grants to service providers described in paragraph (2)(A)(ii);

(C) at least 6 grants to organizations described in paragraph (2)(A)(iii); and

(D) at least 6 grants to sponsors described in paragraph (2)(A)(iv).

(4) CONSIDERATIONS IN AWARDING GRANTS.—

(A) VARIATION IN GRANTEES.—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 serve Medicare beneficiaries in at least two geographic regions, as defined by the Secretary.

(v) The grantees serve Medicare beneficiaries in at least two large metropolitan statistical areas with racial, ethnic, sexual, gender, disability, and economically diverse populations.

(B) PRIORITY FOR PARTNERSHIPS WITH COMMUNITY ORGANIZATIONS AND AGENCIES.—In awarding grants under this subsection, the Secretary shall give priority to eligible entities that have a partnership with—

(i) a community organization; or

(ii) a consortia of community organizations, State agencies, and local agencies,

that has experience in providing language services.

(5) USE OF FUNDS FOR COMPETENT LANGUAGE SERVICES.—

(A) IN GENERAL.—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 English learners.

(B) COMPETENT LANGUAGE SERVICES DEFINED.—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, utilizes 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; and

(II) that, 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.

(C) EXCEPTIONS.—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 an English learner if—

(I) 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

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

(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 (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 English learners from any applicable legal or regulatory requirements related to providing competent interpreter and translation services without undue delay.

(D) MEDICARE ADVANTAGE ORGANIZATIONS AND PDP SPONSORS.—If a grantee is a Medicare Advantage organization offering a Medicare Advantage plan under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w–21 et seq.) or a PDP sponsor offering a prescription drug plan under part D of such title (42 U.S.C. 1395w–101 et seq.), such entity must provide at least 50 percent of the grant funds that the entity 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 English learners.

(E) ADMINISTRATIVE AND REPORTING COSTS.—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).

(6) DETERMINATION OF AMOUNT OF GRANT PAYMENTS.—

(A) IN GENERAL.—Payments to grantees under this subsection shall be calculated based on the estimated numbers of Medicare beneficiaries who are English learners 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 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 English learners than would be estimated using the data under clause (i).

(B) DISCRETION OF SECRETARY.—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.

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

(7) ASSURANCES.—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 an English learner 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;

(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 202 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 are collected on the parent or legal guardian of such recipient.

(8) NO COST SHARING.—Medicare beneficiaries who are English learners shall not have to pay cost sharing or co-payments for competent language services provided under this demonstration program.

(9) REPORTING REQUIREMENTS FOR GRANTEES.—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.

(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.

(10) EVALUATION AND REPORT TO CONGRESS.—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 English learners 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;

(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).

(11) APPROPRIATIONS.—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.

(12) ENGLISH LEARNER DEFINED.—In this subsection, the term “English learner” has the meaning given such term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.

(b) Language assistance services under the Medicare program.—

(1) INCLUSION AS RURAL HEALTH CLINIC SERVICES.—Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—

(A) in subsection (aa)(1)—

(i) in subparagraph (B), by striking “and” at the end;

(ii) by adding “and” at the end of subparagraph (C); and

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

“(D) language assistance services as defined in subsection (kkk)(1),”; and

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

“(kkk) (1) 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) or an ‘English learner’ (as defined in paragraph (2)).

“(2) The term ‘English learner’ has the meaning given that term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.”.

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

(A) by striking “and” at the end of subparagraph (I);

(B) by striking the period at the end of subparagraph (J) and inserting “; and”; and

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

“(K) language assistance services (as defined in section 1861(kkk)(1)).”.

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

(A) by striking “and” at the end of paragraph (8);

(B) by striking the period at the end of paragraph (9) and inserting “; and”; and

(C) by inserting after paragraph (9) the following new paragraph:

“(10) in the case of language assistance services (as defined in section 1861(kkk)(1)), 100 percent of the reasonable charges for such services, as determined in consultation with the Medicare Payment Advisory Commission.”.

(4) WAIVER OF BUDGET NEUTRALITY.—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(kkk)(1) of such Act).

(c) Medicare parts C and D.—

(1) IN GENERAL.—Medicare Advantage plans under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w–21 et seq.) and prescription drug plans under part D of such title (42 U.S.C. 1395q–101) shall comply 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) to provide effective language services to enrollees of such plans.

(2) MEDICARE ADVANTAGE PLANS AND PRESCRIPTION DRUG PLANS REPORTING REQUIREMENT.—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:

“(6) REPORTING REQUIREMENTS RELATING TO EFFECTIVE LANGUAGE SERVICES.—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 2020, 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).”.

(d) Improving language services in Medicaid and CHIP.—

(1) PAYMENTS TO STATES.—Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)), as amended by section 205(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”.

(2) STATE PLAN REQUIREMENTS.—Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking “and (29)” and inserting “(29), and (30)”.

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

(A) in paragraph (29), by striking “and” at the end;

(B) by redesignating paragraph (30) as paragraph (31); and

(C) by inserting after paragraph (29) the following new paragraph:

“(30) language assistance services, as such term is defined in section 1861(kkk)(1), provided in a timely manner to individuals with limited English proficiency as defined in section 3400 of the Public Health Service Act; and”.

(4) USE OF DEDUCTIONS AND COST SHARING.—Section 1916(a)(2) of the Social Security Act (42 U.S.C. 1396o(a)(2)) is amended—

(A) by striking “or” at the end of subparagraph (F);

(B) by striking “; and” at the end of subparagraph (G) and inserting “, or”; and

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

“(H) language assistance services described in section 1905(a)(30); and”.

(5) CHIP COVERAGE REQUIREMENTS.—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 “(7) and (8)” and inserting “(7), (10), and (11)”;

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

“(11) LANGUAGE ASSISTANCE SERVICES.—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(kkk)(1), provided in a timely manner to individuals with limited English proficiency (as defined in section 3400 of the Public Health Service Act).”; 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)(11),” before “visits described in”.

(6) DEFINITION OF CHILD HEALTH ASSISTANCE.—Section 2110(a)(27) of the Social Security Act (42 U.S.C. 1397jj(a)(27)) is amended by striking “translation” and inserting “language assistance services as described in section 2103(c)(11)”.

(7) STATE DATA COLLECTION.—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.

(8) CHIP PAYMENTS TO STATES.—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”.

(e) Funding language assistance services furnished by providers of health care and health-Care-Related services that serve high rates of uninsured LEP individuals.—

(1) PAYMENT OF COSTS.—

(A) IN GENERAL.—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 English learners in an amount equal to an eligible entity’s eligible costs for providing such services for the quarter.

(B) FUNDING.—Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services such sums as may be necessary for each of fiscal years 2021 through 2025.

(C) RELATION TO MEDICAID DSH.—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 section.

(2) METHODOLOGY FOR PAYMENT OF CLAIMS.—

(A) IN GENERAL.—The Secretary shall establish a methodology to determine the average per person cost of language assistance services.

(B) DIFFERENT ENTITIES.—In establishing such methodology, the Secretary may establish different methodologies for different types of eligible entities.

(C) NO INDIVIDUAL CLAIMS.—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.

(3) DATA COLLECTION INSTRUMENT.—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 are provided.

(4) GUIDELINES.—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.

(5) REPORTING REQUIREMENTS.—

(A) REPORT TO SECRETARY.—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.

(B) REPORT TO CONGRESS.—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.

(6) DEFINITIONS.—In this subsection:

(A) ELIGIBLE COSTS.—The term “eligible costs” means, with respect to an eligible entity that provides language assistance services to English learners, 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 English learners 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.

(B) ELIGIBLE ENTITY.—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; or

(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)));

(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.

(C) ENGLISH LEARNER.—The term “English learner” has the meaning given such term in section 8101(20) of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801(20)), except that subparagraphs (A), (B), and (D) of such section shall not apply.

(D) LANGUAGE ASSISTANCE SERVICES.—The term “language assistance services” has the meaning given such term in section 1861(kkk)(1) of the Social Security Act, as added by subsection (b).

(f) Application of Civil Rights Act of 1964, section 1557 of the Affordable Care Act, and other laws.—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, or other laws that protect the civil rights of individuals.

(g) Effective date.—

(1) IN GENERAL.—Except as otherwise provided and subject to paragraph (2), the amendments made by this section shall take effect on January 1, 2021.

(2) EXCEPTION IF STATE LEGISLATION REQUIRED.—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.

(a) In general.—The Secretary of Health and Human Services, acting through the Director of the Agency for Healthcare Research and Quality with respect to grants under subsection (c)(1) and through the Administrator of the Health Resources and Services Administration with respect to grants under subsection (c)(2), 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 functional health literacy.

(b) Eligibility.—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.

(c) Use of funds.—

(1) AGENCY FOR HEALTHCARE RESEARCH AND QUALITY.—A grant awarded under subsection (a) through the Director of the Agency for Healthcare Research and Quality shall be used—

(A) to define and increase the understanding of health literacy;

(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.

(2) HEALTH RESOURCES AND SERVICES ADMINISTRATION.—A grant awarded under subsection (a) 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 programs for patients with low health literacy;

(B) the tailoring of disease management programs 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.

(d) Definitions.—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.

(e) 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 2021 through 2025.

(a) Covered entity; covered program or activity.—In this section—

(1) the term “covered entity” has the meaning given such term in section 92.4 of title 45, Code of Federal Regulations, as in effect on May 18, 2016 (81 Fed. Reg. 31466 (May 18, 2016)); and

(2) 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 May 18, 2016 (81 Fed. Reg. 31466 (May 18, 2016)).

(b) Requirements.—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 covered program or activity, shall—

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

(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).

(c) Exemptions.—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.

(d) Rule of construction.—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.

(a) Report.—Not later than 1 year after the date of enactment of this Act and annually thereafter, the Secretary of Health and Human Services shall 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.

(b) 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 2021 through 2025.

(a) Grants authorized.—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 “ESL”) instruction and shall determine, after consultation with appropriate stakeholders, the mechanism for administering and distributing such grants.

(b) Eligible entity defined.—In this section, the term “eligible entity” means a State or community-based organization that employs and serves minority populations.

(c) Application.—An eligible entity may apply for a grant under this section by submitting such information as the Secretary of Education may require and in such form and manner as the Secretary may require.

(d) Use of grant.—As a condition of receiving a grant under this section, an eligible entity shall—

(1) develop and implement a plan for assuring the availability of ESL instruction 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 to access and regularly negotiate the system effectively;

(2) develop a plan, including, where appropriate, public-private partnerships, for making ESL instruction progressively available to all individuals seeking instruction; and

(3) maintain current ESL instruction efforts by using funds available under this section to supplement rather than supplant any funds expended for ESL instruction in the State as of January 1, 2020.

(e) Additional duties of the secretary.—The Secretary of Education shall—

(1) collect and publicize annual data on how much Federal, State, and local governments spend on ESL instruction;

(2) collect data from State and local governments to identify the unmet needs of English language learners for appropriate ESL instruction, including—

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

(B) the extent of waiting lists for ESL instruction, including how many programs maintain waiting lists and, for programs that do not have waiting lists, the reasons why not;

(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 in the State and each participating locality;

(F) the effectiveness of the instruction in meeting the needs of individuals receiving instruction and individuals needing instruction;

(G) an assessment of the need for programs that integrate job training and ESL instruction, to assist individuals to obtain better jobs; and

(H) the availability of ESL slots by State and locality;

(3) determine the cost and most appropriate methods of making ESL instruction available to all English language learners seeking instruction; and

(4) not later than 1 year after the date of enactment of this Act, issue a report to Congress that assesses the information collected in paragraphs (1), (2), and (3) and makes recommendations on steps that should be taken to progressively realize the goal of making ESL instruction available to all English language learners seeking instruction.

(f) Authorization of Appropriations.—There are authorized to be appropriated to the Secretary of Education $250,000,000 for each of fiscal years 2021 through 2024 to carry out this section.

(a) General provisions.—

(1) IMMUNITY.—A State shall not be immune under the 11th Amendment to the Constitution of the United States from suit in Federal court for a violation of this title (including an amendment made by this title).

(2) REMEDIES.—In a suit against a State for a violation of this title (including an amendment made by this title), remedies (including remedies both at law and in equity) are available for such a violation to the same extent as such remedies are available for such a violation in a suit against any public or private entity other than a State.

(b) Rule of construction.—Nothing in this title 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.) or any other Federal statute.

(a) Essential benefits.—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.”.

(b) Employer-Sponsored minimum essential coverage.—

(1) IN GENERAL.—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:

“(iii) COVERAGE MUST INCLUDE LANGUAGE ACCESS AND SERVICES.—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.”.

(2) CONFORMING AMENDMENTS.—

(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)”.

(c) Quality Reporting.—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.”.

(d) Regulations regarding internal claims and appeals and external review processes for health plans and health insurance issuers.—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, section 2590.715– 2719(e) of title 29, Code of Federal Regulations, and section 147.136(e) of title 45, Code of Federal Regulations (or a successor regulation), 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.

(e) Data collection and reporting.—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, 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.

(f) Effective date.—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)(A) of the Public Health Service Act (42 U.S.C. 254b(b)(3)(A)) is amended to read as follows:

“(A) IN GENERAL.—The term ‘medically underserved’, with respect to a population, means—

“(i) 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

“(ii) 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 204, is amended by adding at the end the following:

(a) In general.—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:

Section 317F(c)(1) of the Public Health Service Act (42 U.S.C. 247b–7(c)(1)) is amended—

(1) by striking “and” after “1994,”; and

(2) by inserting before the period at the end the following: “, $750,000 for fiscal year 2021, and such sums as may be necessary for each of the fiscal years 2022 through 2026”.

Part B of title VII of the Public Health Service Act (42 U.S.C. 293 et seq.), as amended by section 302, is further amended by adding at the end the following:

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 minorities, 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.

Subtitle B of title XXXIV of the Public Health Service Act, as added by section 301, is further amended by inserting after section 3417 the following:

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:

“(g) Collaboration in health profession diversity training programs.—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.

“(h) Funding.—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 2021 through 2026.”.

(a) DGME determinations.—Section 1886(h)(4) of the Social Security Act (42 U.S.C. 1395ww(h)(4)), as amended by section 206(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:

“(M) TREATMENT OF CERTAIN RESIDENTS AND INTERNS.—For purposes of cost-reporting periods beginning on or after October 1, 2021, in determining the hospital’s number of full-time equivalent residents for purposes of this paragraph, all the 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.”.

(b) IME determinations.—Section 1886(d)(5)(B)(xi) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(xi)), as redesignated by section 206(b), 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, 2021, the provisions of subparagraph (M) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.”.

(a) Grants.—The Secretary of Health and Human Services, acting jointly with the Secretary of Education and the Secretary of Labor, shall make grants to institutions of higher education 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;

(2) in accordance with subsection (c), developing a strategic partnership with the community in which the institution is located; and

(3) collecting data on, and periodically evaluating, the effectiveness of the institution’s programs funded through this section to enable the institution to adapt accordingly for maximum efficiency and success.

(b) Developing capacity for increasing local health equity.—As a condition on receipt of a grant under subsection (a), an institution of higher education shall agree to use the 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.

(c) Strategic partnerships.—As a condition on 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 the institution is located for the purposes of—

(1) strengthening connections between the institution and the community—

(A) to improve evaluation of and address the community’s health and health workforce needs; and

(B) to engage the 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.

(d) Authorization of appropriations.—There is authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2021 through 2026.

Section 455 of the Higher Education Act of 1965 (20 U.S.C. 1087e) is amended by adding at the end the following:

“(r) Repayment plan for mental and behavioral health social workers.—

“(1) IN GENERAL.—The Secretary shall cancel the balance of interest and principal due, in accordance with paragraph (2), on any eligible Federal Direct Loan not in default for a borrower who—

“(A) has made 120 monthly payments on the eligible Federal Direct Loan after October 1, 2020, pursuant to any one or a combination of the following—

“(i) payments under an income-based repayment plan under section 493C;

“(ii) payments under a standard repayment plan under subsection (d)(1)(A), based on a 10-year repayment period;

“(iii) monthly payments under a repayment plan under subsection (d)(1) or (g) of not less than the monthly amount calculated under subsection (d)(1)(A), based on a 10-year repayment period; or

“(iv) payments under an income contingent repayment plan under subsection (d)(1)(D); and

“(B) (i) is employed as a mental health or behavioral health social worker, as defined by the Secretary by regulation, at the time of such forgiveness; and

“(ii) has been employed as such a mental health or behavioral health social worker during the period in which the borrower makes each of the 120 payments as described in subparagraph (A).

“(2) LOAN CANCELLATION AMOUNT.—After the conclusion of the employment period described in paragraph (1), the Secretary shall cancel the obligation to repay the balance of principal and interest due as of the time of such cancellation, on the eligible Federal Direct Loans made to the borrower under this part.

“(3) INELIGIBILITY FOR DOUBLE BENEFITS.—No borrower may, for the same employment as a mental health or behavioral health social worker, receive a reduction of loan obligations under both this subsection and subsection (m), 428J, 428K, 428L, or 460.

“(4) DEFINITION OF ELIGIBLE FEDERAL DIRECT LOAN.—In this subsection, the term ‘eligible Federal Direct Loan’ means a Federal Direct Stafford Loan, Federal Direct PLUS Loan, Federal Direct Unsubsidized Stafford Loan, or a Federal Direct Consolidation Loan.”.

(a) Establishment.—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 title VII and title VIII of the Public Health Service Act (42 U.S.C. 292 et seq.; 42 U.S.C. 296 et seq.).

(b) Funding.—

(1) IN GENERAL.—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) $355,000,000 for fiscal year 2021;

(B) $375,000,000 for fiscal year 2022;

(C) $392,000,000 for fiscal year 2023;

(D) $412,000,000 for fiscal year 2024;

(E) $432,000,000 for fiscal year 2025;

(F) $454,000,000 for fiscal year 2026;

(G) $476,000,000 for fiscal year 2027;

(H) $500,000,000 for fiscal year 2028;

(I) $525,000,000 for fiscal year 2029; and

(J) $552,000,000 for fiscal year 2030.

(2) HEALTH PROFESSIONS EDUCATION PROGRAMS.—For the purpose of carrying out health professions education programs authorized under title VII of the Public Health Service Act, 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) $240,000,000 for fiscal year 2021.

(B) $253,000,000 for fiscal year 2022.

(C) $265,000,000 for fiscal year 2023.

(D) $278,000,000 for fiscal year 2024.

(E) $292,000,000 for fiscal year 2025.

(F) $307,000,000 for fiscal year 2026.

(G) $322,000,000 for fiscal year 2027.

(H) $338,000,000 for fiscal year 2028.

(I) $355,000,000 for fiscal year 2029.

(J) $373,000,000 for fiscal year 2030.

(3) NURSING WORKFORCE DEVELOPMENT PROGRAMS.—For the purpose of carrying out nursing workforce development programs authorized under title VIII of the Public Health Service Act, 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) $115,000,000 for fiscal year 2021.

(B) $122,000,000 for fiscal year 2022.

(C) $127,000,000 for fiscal year 2023.

(D) $134,000,000 for fiscal year 2024.

(E) $140,000,000 for fiscal year 2025.

(F) $147,000,000 for fiscal year 2026.

(G) $154,000,000 for fiscal year 2027.

(H) $162,000,000 for fiscal year 2028.

(I) $170,000,000 for fiscal year 2029.

(J) $179,000,000 for fiscal year 2030.

(a) Findings.—Congress finds the following:

(1) Projections by the Association of American Medical Colleges and other expert entities, such as the Health Resources and Services Administration, have indicated a nationwide shortage of up to 121,900 physicians, split evenly between primary care and specialists, by 2032.

(2) Primarily due to the growing and aging population, over the next decade, physician demand is expected to grow up to 17 percent.

(3) The United States Census Bureau estimates that the United States population will grow from 321,000,000 in 2015 to 347,000,000 in 2025. Further, the number of Medicare beneficiaries is estimated to increase from 47,800,000 in 2015 to approximately 66,000,000 in 2025.

(4) Approximately 36 percent of practicing physicians are over the age of 55 and are likely to retire within the next decade.

(5) A nationwide physician shortage will result in many people in the United States waiting longer and traveling farther for health care; seeking nonemergent care in emergency departments; and delaying treatment until their health care needs become more serious, complex, and costly.

(6) Changing demographics (such as an aging population), new health care delivery models (such as medical homes), and other factors (such as disaster preparedness) are contributing to a shortage of both generalist and specialist physicians.

(7) These shortages will have the most severe impact on vulnerable and underserved populations, including racial and ethnic minorities and the approximately 20 percent of people in the United States who live in rural or inner-city locations designated as health professional shortage areas.

(8) The health care utilization equity model of the Association of American Medical Colleges estimates that if racial and ethnic minorities and individuals from rural areas utilized health care in a similar way to their Caucasian counterparts living in metropolitan areas, the physician shortage would require an additional 96,000 physicians.

(9) To address the physician shortage in rural and medically underserved areas, medical education and training need to be accessible to underrepresented minorities (including individuals who are African American, Hispanic, Native American, or Native Hawaiian), and need to increase pathway programs for such underrepresented minorities who make up less than 12 percent of individuals enrolled in graduate medical education and for international students who make up 25 percent of individuals enrolled in graduate medical education. Immigration pathways like student, exchange-visitor, and employment visas, and programs like the National Interest Waiver and Conrad 30 J–1 Visa Waiver, help improve health access across the United States.

(10) United States medical school enrollment was expected to grow by 30 percent from 2018 to 2019 to help reduce the shortage of quality physicians in the United States.

(11) An increase in United States medical school graduates must be accompanied by an increase of 4,000 graduate medical education training positions each year.

(12) Graduate medical education programs and teaching hospitals provide venues in which the next generation of physicians learns to work collaboratively with other physicians and health professionals, adopt more efficient care delivery models (such as care coordination and medical homes), incorporate health information technology and electronic health records in every aspect of their work, apply new methods of assuring quality and safety, and participate in groundbreaking clinical and public health research.

(13) The Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) (having more beneficiaries than any other health care program) supports its “fair share” of the costs associated with graduate medical education.

(14) In general, the level of support of graduate medical education by the Medicare program has been capped since 1997 and has not been increased to support the expansion of graduate medical education programs needed to avert the projected physician shortage or to accommodate the increase in United States medical school graduates.

(b) Sense of Congress.—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; and

(3) mitigating disparities in health and health care.

(a) Findings.—Congress finds the following:

(1) According to a 2018 study, the State and local public health workforce has shrunk by more than 50,000 individuals since the beginning of the 2008 Great Recession and almost one quarter of individuals comprising the governmental public health workforce plan to leave or retire in the coming years.

(2) Shortages are projected for other health professions, including within the fields of nursing (500,000 by 2025), dentistry (15,000 by 2025), pharmacy (38,000 by 2030), mental and behavioral health, primary care (46,000 by 2025), and community and allied health.

(3) A nationwide health workforce shortage will result in serious health threats and more severe and costly health care needs, due to, in part, a delayed response to food-borne outbreaks, emerging infectious diseases, natural disasters, fewer cancer screenings, and delayed treatment.

(4) Vulnerable and underserved populations and health professional shortage areas will be most severely impacted by the health workforce shortage.

(5) According to the Migration Policy Institute, more than 2,000,000 college-educated immigrants in the United States today are unemployed or underemployed in low- or semi-skilled jobs that fail to draw on their education and expertise.

(6) Approximately 2 out of every 5 internationally educated immigrants are unemployed or underemployed.

(7) According to the Drexel University Center for Labor Markets and Policy, underemployment for internationally educated immigrant women is 28 percent higher than for their male counterparts.

(8) According to the Drexel University Center for Labor Markets and Policy, the mean annual earnings of underemployed immigrants were $32,000, or 43 percent less than United States born college graduates employed in the college labor market.

(9) According to Upwardly Global and the Welcome Back Initiative, with proper guidance and support, underemployed skilled immigrants typically increase their income by 215 percent to 900 percent.

(10) According to the Brookings Institution and the Partnership for a New American Economy, immigrants working in the health workforce are, on average, better educated than United States-born workers in the health workforce.

(b) Grants to eligible entities.—

(1) AUTHORITY TO PROVIDE GRANTS.—The Secretary of Health and Human Services, 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 (in this section referred to as the “Secretary”), may award grants to eligible entities to carry out activities described in subsection (c).

(2) ELIGIBILITY.—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.

(c) Authorized activities.—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.

(a) Study.—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.

(b) Report.—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.

(a) Conrad State 30 program extension.—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 “September 30, 2021”.

(b) Retaining physicians who have practiced in medically underserved communities.—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:

“(F) (i) Alien physicians who have completed service requirements for a national interest 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 2020; 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) before the date on which such alien physician completes 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 waiver of the 2-year foreign residence requirement under section 214(l) 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).”.

(c) Employment protections for physicians.—

(1) EXCEPTIONS TO 2-YEAR FOREIGN RESIDENCY REQUIREMENT.—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 shall not” and inserting “Secretary of Homeland Security may not”;

(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

(E) in subparagraph (D), in the matter preceding clause (i), by inserting “subject to paragraph (8),” before “in the case”.

(2) ALLOWABLE VISA STATUS FOR PHYSICIANS FULFILLING WAIVER REQUIREMENTS IN MEDICALLY UNDERSERVED AREAS.—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 change 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 changed under this subparagraph.”.

(3) VIOLATION OF AGREEMENTS.—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”.

(4) PHYSICIAN EMPLOYMENT IN UNDERSERVED AREAS.—Section 214(l) of such Act (8 U.S.C. 1184(l)), as amended by this section, is further amended by adding at the end the following:

“(4) (A) If an interested State agency denies the 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) A physician described in subparagraph (A) may only work 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 change of status under paragraph (2)(A) pursuant to the approval of such waiver.”.

(5) CONTRACT REQUIREMENTS.—Section 214(l) of such Act, as amended by this section, 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 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 the compensation the alien will receive for on-call time;

“(B) specifies—

“(i) whether the contracting facility or organization will pay the alien’s malpractice insurance premiums;

“(ii) whether the employer will provide malpractice insurance; and

“(iii) the amount of such insurance that will be provided;

“(C) describes all of the work locations that the alien will work, including 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.”.

(6) RECAPTURING WAIVER SLOTS LOST TO OTHER STATES.—Section 214(l) of such Act, as amended by this section, 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 accorded an additional waiver by the Secretary of State for use in the fiscal year in which the alien’s employment was terminated.”.

(7) EXCEPTION TO 3-YEAR WORK REQUIREMENT.—Section 214(l) of such Act, as amended by this section, 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—

“(A) (i) the Secretary of Homeland Security determines that extenuating circumstances, including violations by the employer of the employment agreement with the alien or of labor and employment laws, exist that justify a lesser period of employment at such facility or organization; and

“(ii) not later than 120 days after the employment termination date (unless the Secretary determines that extenuating circumstances would justify an extension), the alien demonstrates another bona fide offer of employment at a 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, for the remainder of such 3-year period;

“(B) (i) the interested State agency that requested the waiver attests that extenuating circumstances, including violations by the employer of the employment agreement with the alien or of labor and employment laws, exist that justify a lesser period of employment at such facility or organization; and

“(ii) not later than 120 days after the employment termination date (unless the Secretary determines that extenuating circumstances would justify an extension), the alien demonstrates another bona fide offer of employment at a 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, for the remainder of such 3-year period; or

“(C) the alien—

“(i) elects not to pursue a determination of extenuating circumstances pursuant to subclause (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) not later than 45 days after the employment termination date, demonstrates 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).”.

(d) Allotment of Conrad 30 waivers.—

(1) IN GENERAL.—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:

“(9) (A) (i) All States shall be allotted 35 waivers under paragraph (1)(B) for each 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 such case—

“(i) the number of waivers allotted beginning in the next fiscal year shall be decreased by 5 for all States; 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.”.

(2) ACADEMIC MEDICAL CENTERS.—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), 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) subject to paragraph (6), 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 under subparagraph (B).”.

(e) Amendments to the procedures, definitions, and other provisions related to physician immigration.—

(1) DUAL INTENT FOR PHYSICIANS SEEKING GRADUATE MEDICAL TRAINING.—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))”.

(2) PHYSICIAN NATIONAL INTEREST WAIVER CLARIFICATIONS.—

(A) PRACTICE AND GEOGRAPHIC AREA.—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.”.

(B) FIVE-YEAR SERVICE REQUIREMENT.—Section 203(b)(2)(B)(ii) of such Act is 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.”.

(3) TECHNICAL CLARIFICATION REGARDING ADVANCED DEGREE FOR PHYSICIANS.—Section 203(b)(2)(A) of such Act (8 U.S.C. 1153(b)(2)(A)) 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 shall be considered a member of the professions holding an advanced degree or its equivalent for purposes of this paragraph.”.

(4) SHORT-TERM WORK AUTHORIZATION FOR PHYSICIANS COMPLETING THEIR RESIDENCIES.—

(A) IN GENERAL.—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.

(B) TERMINATION.—The status and employment authorization of a physician described in subparagraph (A) 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.

(C) AUTOMATIC EXTENSION.—The status and employment authorization of a physician described in subparagraph (A) 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.

(5) APPLICABILITY OF SECTION 212(e) TO SPOUSES AND CHILDREN OF J–1 EXCHANGE VISITORS.—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)).

(a) Repeal.—Subsections (i)(22) and (x) of section 1903 of the Social Security Act (42 U.S.C. 1396b) are each repealed.

(b) Conforming amendments.—

(1) STATE PAYMENTS FOR MEDICAL ASSISTANCE.—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).

(2) PAYMENT TO STATES.—Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended—

(A) in subsection (i), by redesignating paragraphs (23) through (27) as paragraphs (22) through (26), respectively; and

(B) by redesignating subsections (y), (z), and (aa) as subsections (x), (y), and (z), respectively.

(3) REPEAL.—Subsection (c) of section 6036 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396b note) is repealed.

(c) Effective date.—The amendments made by this section shall take effect on the date of enactment of this Act.

(a) In general.—

(1) PREMIUM TAX CREDITS.—Section 36B of the Internal Revenue Code of 1986 is amended—

(A) in subsection (c)(1)(B)—

(i) by amending the heading to read as follows: “Special rule for certain individuals ineligible for Medicaid due to status”; and

(ii) in clause (ii), by striking “lawfully present in the United States, but” and inserting “who”; and

(B) by striking subsection (e).

(2) COST-SHARING REDUCTIONS.—Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended by striking subsection (e).

(3) BASIC HEALTH PROGRAM ELIGIBILITY.—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”.

(4) RESTRICTIONS ON FEDERAL PAYMENTS.—Section 1412 of the Patient Protection and Affordable Care Act (42 U.S.C. 18082) is amended by striking subsection (d).

(5) REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.—Section 5000A(d) of the Internal Revenue Code of 1986 is amended by striking paragraph (3) and by redesignating paragraph (4) as paragraph (3).

(b) Conforming amendments.—

(1) Section 1411(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18081(a)) is amended by striking paragraph (1) and redesignating paragraphs (2), (3), and (4) as paragraphs (1), (2), and (3), respectively.

(2) 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).

(a) In general.—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 coverage 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 coverage 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 coverage.

(b) Reporting requirements.—

(1) IN GENERAL.—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).

(2) REPORTING OF DEMOGRAPHIC CHARACTERISTICS.—The Secretary shall—

(A) report the demographic characteristics under paragraphs (1) and (2) of subsection (a) on the basis of racial and ethnic group, and shall stratify the reporting on each racial and ethnic group by other demographic characteristics that can impact access to health insurance coverage, such as sexual orientation, gender identity, primary language, disability status, sex, socioeconomic status, age group, and 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 to engage in or anticipate any deportation or immigration related enforcement action by any entity, including the Department of Homeland Security.

(a) Elimination of general Medicaid funding limitations (“Cap”) for territories.—

(1) REPEAL OF PROVISIONS RELATED TO CAP AFTER 2019.—Subsections (a), (b), and (d) of section 202 of subtitle B of title I of division N of the Further Consolidated Appropriations Act, 2020 (Public Law 116–94) and section 6009 of the Families First Coronavirus Response Act (Public Law 116–127) are repealed and the provisions of law amended by such subsections and section are restored as if such subsections and section had not been enacted.