This Act may be cited as the “Health Equity and Accountability Act of 2018”.

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) By 2020, the Nation will face a shortage of health care providers and allied health workers and this shortage disproportionately affects health professional shortage areas where many racial and ethnic minority populations reside.

(4) All efforts to reduce health disparities and barriers to quality health services require better and more consistent 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, two strategic plans that represent the country’s first coordinated roadmap to reducing health disparities. Along with the National Prevention Strategy, Healthy People 2020, and the National Health Care Quality Strategy, as well as critical resources such as the 2012 National Healthcare Quality and Disparities Reports, these comprehensive plans will work to increase the number of Americans who are healthy at every stage of life.

(9) The Department of Health and Human Services has also reviewed and advanced updated clinical guidelines and developed other strategic planning documents—

(A) to combat health disparities with a high impact on minority populations including the National HIV/AIDS Strategy, the Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis; and

(B) to provide high-quality family planning services including recommendations of the Centers for Disease Control and Prevention and the Office of Population Affairs.

(10) The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act, represents the biggest advancement for minority health in the last 40 years.

(a) Purpose.—It is the purpose of this section to promote data collection, analysis, and reporting by race, ethnicity, sex, primary language, sexual orientation, disability status, gender identity, 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 A 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, and gender identity 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 health 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 health 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) 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, or socioeconomic status during the preceding calendar year shall submit such data to a centralized electronic repository of Government data on factors related to the health and well-being of the American population.

(b) Analysis; public availability; reporting.—Not later than April 30, 2018, and each April 30 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 data sets are publicly identified on a centralized electronic repository of Government data 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 National Institute on Minority Health and Health Disparities and the Deputy Assistant Secretary for Minority Health, shall award grants to access and analyze racial and ethnic, and where possible other health disparity data, 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 a historically Black college or university, a Hispanic-serving institution, a Tribal college or university, or an Asian American, Native American, or Pacific Islander-serving institution with an accredited public health, health policy, or health services research program.

(c) Authorization of appropriations.—To carry out this section, there are authorized to be appropriated such sums as may be necessary for fiscal years 2019 through 2024.

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,” before “and disability status”;

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

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

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

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

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

(3) in paragraph (2)(B), by inserting “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 505F 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:

“(ee) 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 505G.”.

(c) Drug fees.—Section 736(a)(1)(A)(ii) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 379h) is amended by adding after “are required” the following: “, including supplements required under section 505G”.

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, as added, 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.—The administrative notification requirement under section 421(e)(2) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1631(e)(2)) shall be satisfied by the submission by an agency of a report on the aggregate number of exceptions granted under such section by such agency in each year.”.

In this title, the definitions contained in section 3400 of the Public Health Service Act, as added by section 202, shall apply.

(a) 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 limited-English-proficient individuals and individuals with communication disabilities such as 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 limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments is a societal one that cannot fairly be visited solely upon the health care, public health, or social services community.

(5) Title VI of the Civil Rights Act of 1964 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 Department must take adequate steps to ensure that their policies and procedures do not deny or have the effect of denying limited-English-proficient individuals with equal access to benefits and services for which such persons qualify.

(6) Both the Americans with Disabilities Act and the Rehabilitation Act of 1973 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, but the ultimate decision as to what measures to take rests with the public accommodation, provided that the method chosen results in effective communication. In order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability.

(7) 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.

(8) 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 limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments.

(9) Access to English as a second language, and sign language instructions, readers, and other auxiliary aids and services, are essential to ensure effective communication and eliminate the language barriers that impede access to health care.

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

(b) Amendment.—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 shall award one grant in accordance with this section to each of three States to assist each such State in designing, implementing, and evaluating a statewide program to provide onsite interpreter services under Medicaid.

(b) Grant period.—A grant awarded under this section is authorized for a period of three fiscal years beginning on October 1, 2019.

(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 LEP individuals, 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 plan under Medicaid 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 plan under Medicaid; 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 LEP individuals seeking to enroll in the State plan under Medicaid;

(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 plan under Medicaid.

(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 plan under Medicaid.

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

(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 plan under Medicaid.

(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.

(3) 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.

(g) Funding.—

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

(2) AVAILABILITY OF FUNDS.—The funds authorized by paragraph (1) shall be 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)), as amended by section 205(d)(1) of this Act, is further amended by inserting “(or, in the case of a State receiving a grant under section 203 of the Health Equity and Accountability Act of 2018, 100 percent for each quarter occurring during the grant period)” after “90 percent”.

(h) Limitation.—No Federal funds 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 COMPETENCY 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 cultural competency and linguistically appropriate service delivery 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

(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, 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 English learners, 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;

(ii) a provider of services under part B of such title;

(iii) a Medicare Advantage organization offering a Medicare Advantage plan under part C of such title; or

(iv) a PDP sponsor offering a prescription drug plan under part D of such title.

(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

(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 or a PDP sponsor offering a prescription drug plan under part D of such title, 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 subsection (c) of section 1907 of this Act.

(D) Recommendations, if any, regarding the extension of such project to the entire Medicare Program, subject to the provisions of section 1115A(c) of the Social Security Act (42 U.S.C. 1315a(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 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 (iii)(1),”; and

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

“(iii) (1) The term ‘language assistance services’ has the same meaning given the term ‘language or language assistance services’ in section 3400 of the Public Health Service Act.

“(2) The term ‘interpreter services’ has the meaning given the term ‘qualified interpreter for an individual with limited-English proficiency’ in section 3400(3) of the Public Health Service Act.

“(3) The term ‘qualified interpreter for an individual with limited-English proficiency’ means an interpreter who via a remote interpreting service or an onsite appearance—

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

“(B) has demonstrated proficiency in speaking and understanding both spoken English and at least one other spoken language; and

“(C) is able to interpret effectively, accurately, and impartially and in a culturally competent manner, both receptively and expressly, to and from such language(s) and English, using any necessary specialized vocabulary, terminology, and phraseology.

“(4) The term ‘qualified translator’ means a translator who—

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

“(B) has demonstrated proficiency in writing and understanding both written English and at least one other written non-English language; and

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

“(5) 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.”.

(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 services (as defined in paragraph (1) of section 1861(iii)) furnished by an interpreter (as defined in paragraph (3) of such section) or translator.”.

(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 services described in section 1861(iii)(1), 100 percent of the reasonable charges for such services, as determined in consultation with the Medicare Payment Advisory Commission; and”.

(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 services (as such term is defined in section 1861(iii)(1) of such Act).

(c) Medicare parts C and D.—

(1) IN GENERAL.—Medicare Advantage plans under part C of the Social Security Act and prescription drug plans under part D of such Act shall comply with title VI of the Civil Rights Act of 1964 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:

“(5) 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 plan’s internal policies and procedures 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 2018, 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 health plan’s language services programs and services with respect to the plan’s 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 plan’s enrollee population.

“(E) The periodic provision of educational information to plan enrollees on the plan’s language services and programs.”.

(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)) is amended by—

(A) striking “75” and inserting “90”;

(B) striking “translation or interpretation services” and inserting “language 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 (28)” and inserting “(28), and (29)”.

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

(A) in paragraph (28), by striking “and” at the end;

(B) by redesignating paragraph (29) as paragraph (30); and

(C) by inserting after paragraph (28) the following new paragraph:

“(29) language services, as such term is defined in section 1861(iii)(1), provided in a timely manner to English learners (as defined in section 1861(iii)(5)) who need such services; and”.

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

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

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

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

“(F) language services described in section 1905(a)(29); 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 “and (7)” and inserting “(7), and (9)”; and

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

“(9) LANGUAGE SERVICES.—The child health assistance provided to a targeted low-income child shall include coverage of language services, as such term is defined in section 1861(iii)(1), provided in a timely manner to English learners (as defined in section 1861(iii)(5)) who need such services.”; and

(C) in subsection (e)(2)—

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

(ii) by inserting “or subsection (c)(9)” after “subsection (c)(1)(D)”.

(6) DEFINITION OF CHILD HEALTH ASSISTANCE.—Section 2110(a)(27) of the Social Security Act (42 U.S.C. 1397jj) is amended by striking “translation” and inserting “language services as described in section 2103(c)(9)”.

(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; 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(c)) is amended—

(A) in subsection (a)(1), by striking “75” and inserting “90”; 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 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 shall make payments (on a quarterly basis) directly to eligible entities to support the provision of language services to English learners in an amount equal to an eligible entity’s eligible costs for 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 2017 through 2021.

(C) RELATION TO MEDICAID DSH.—Payments under this subsection shall not offset or reduce payments under section 1923 of the Social Security Act, nor shall payments under such section be considered when determining uncompensated costs associated with the provision of language services.

(2) METHODOLOGY FOR PAYMENT OF CLAIMS.—

(A) IN GENERAL.—The Secretary shall establish a methodology to determine the average per person cost of language 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 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 of Health and Human Services 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 services to English learners, the product of—

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

(ii) the number of English learners who are provided language services by the entity and for whom no reimbursement is available for such services under the amendments made by subsections (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) provide language services to at least 8 percent of the entity’s total number of patients, not later than 6 months after the date of the enactment of the Act; and

(iii) prepare and submit 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, except that subparagraphs (A), (B), and (D) of such section shall not apply.

(D) LANGUAGE SERVICES.—The term “language services” has the meaning given such term in section 1861(iii)(1) of the Social Security Act.

(f) Application of Civil Rights Act of 1964 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. 2000(d) et seq.) 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, 2017.

(2) EXCEPTION IF STATE LEGISLATION REQUIRED.—In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet 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, acting through the Director of the Agency for Healthcare Research and Quality and the Administrator of the Health Resources and Services Administration, 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 require.

(c) Use of funds.—

(1) AGENCY FOR HEALTHCARE RESEARCH AND QUALITY.—Grants awarded under subsection (a) through 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 of the Agency.

(2) HEALTH RESOURCES AND SERVICES ADMINISTRATION.—Grants awarded under subsection (a) through 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 existing 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; and

(F) other activities determined appropriate by the Administrator of the Health Resources and Services Administration.

(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 2019 through 2023.

(a) In general.—Any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, and 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 (or amendments made thereby), as such programs, activities, agencies, and entities are described in section 1557(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18116), in order to ensure the right of LEP individuals to receive access to quality health care, shall—

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

(2) offer and provide appropriate language assistance services at no additional charge to each patient 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, as defined in section 3400 of the Public Health Service Act.

(b) Exemptions.—The requirements of subsection (a)(4) shall not apply as follows:

(1) When a patient (who has been informed in his or her primary language of the availability of free interpreter and translation services) requests the use of family, friends, or other persons untrained in interpretation or translation if the following conditions are met:

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

(B) The recipient informs the patient that he or she has the option of having the recipient provide an interpreter for him or her without charge, or of using his or her own interpreter.

(C) The recipient informs the patient that the recipient may not require an LEP person to use a family member or friend as an interpreter.

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

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

(F) The recipient 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 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.

(c) Rule of construction.—Subsection (b)(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 culturally competent to health care and health-care-related services. 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 and health-care-related services for limited-English-proficient individuals;

(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 2019 through 2023.

(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.—For purposes of 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 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 them 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 the additional funds to supplement rather than supplant any funds expended for ESL instruction in the State as of January 1, 2019.

(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 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 individuals in the State and each participating locality;

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

(G) as 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 2019 through 2022 to carry out this section.

(a) General provisions.—

(1) A State shall not be immune under the Eleventh Amendment of the Constitution of the United States from suit in Federal court for failing to provide the language access funded pursuant to this title.

(2) In a suit against a State for a violation of this title, remedies (including remedies at 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 the 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. 2000(d) et seq.) or any other 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 54.9815–2719T(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, 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 written translations of notices, to apply a threshold that 5 percent of the population or at least 500 individuals per service area are literate only in the same non-English language in lieu of 10 percent or more residing in a county.

(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 the Patient Protection and Affordable Care Act;

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

(3) require the Federal and State call centers 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 call center and language line have taken to actively address some of the consumer complaints.

(f) Effective date.—The amendments made by this section shall apply to plan years beginning after the date of the enactment of this Act.

Title XXXIV of the Public Health Service Act, as added by section 202, is amended by adding at the end the following:

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) of the Public Health Service Act (42 U.S.C. 247b–7(c)) 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 2019, and such sums as may be necessary for each of the fiscal years 2020 through 2024”.

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 A 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 which is not less than $31,000,000 for each of the fiscal years 2019 through 2025.”.

(a) DGME determinations.—Section 1886(h)(4) of the Social Security Act (42 U.S.C. 1395ww(h)(4)), as amended by section 204(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, 2016, 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)(x) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(x)) 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) The provisions of subparagraph (L) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.”.

(a) Grants.—The Secretaries of Health and Human Services, Education, and Labor, acting jointly, shall make grants to academic institutions 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 academic 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 academic institution 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 institutionwide health workforce goals that can serve as models for increasing health equity in communities across the country;

(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 academic institution 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 and secondary schools to recruit the next generation of health professionals earlier in the pipeline to a health care career.

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

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

“(1) IN GENERAL.—The Secretary shall cancel the balance of interest and principal due 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, 2016, 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) Purpose.—It is the purpose of this section to establish a Health Professions Workforce Fund to be administered through the Health Resources and Services Administration within the Department of Health and Human Services 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.

(b) Establishing the Health Professions Workforce Fund.—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—

(1) $355,000,000 for fiscal year 2019;

(2) $375,000,000 for fiscal year 2020;

(3) $392,000,000 for fiscal year 2021;

(4) $412,000,000 for fiscal year 2022;

(5) $432,000,000 for fiscal year 2023;

(6) $454,000,000 for fiscal year 2024;

(7) $476,000,000 for fiscal year 2025;

(8) $500,000,000 for fiscal year 2026;

(9) $525,000,000 for fiscal year 2027; and

(10) $552,000,000 for fiscal year 2028.

(c) Funding.—

(1) 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 2019.

(B) $253,000,000 for fiscal year 2020.

(C) $265,000,000 for fiscal year 2021.

(D) $278,000,000 for fiscal year 2022.

(E) $292,000,000 for fiscal year 2023.

(F) $307,000,000 for fiscal year 2024.

(G) $322,000,000 for fiscal year 2025.

(H) $338,000,000 for fiscal year 2026.

(I) $355,000,000 for fiscal year 2027.

(J) $373,000,000 for fiscal year 2028.

(2) 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 2019.

(B) $122,000,000 for fiscal year 2020.

(C) $127,000,000 for fiscal year 2021.

(D) $134,000,000 for fiscal year 2022.

(E) $140,000,000 for fiscal year 2023.

(F) $147,000,000 for fiscal year 2024.

(G) $154,000,000 for fiscal year 2025.

(H) $162,000,000 for fiscal year 2026.

(I) $170,000,000 for fiscal year 2027.

(J) $179,000,000 for fiscal year 2028.

(a) Findings.—Congress finds the following:

(1) Projections by the Association of American Medical Colleges (AAMC) and other expert entities, such as the Health Resources and Services Administration (HRSA), have indicated a nationwide shortage of up to 104,900 physicians, split evenly between primary care and specialists, by 2030.

(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 million in 2015 to 347 million in 2025. Further, the number of Medicare beneficiaries is estimated to increase from 47.8 million in 2015 to approximately 66 million 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 Americans 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/ethnic minorities and the approximately 20 percent of Americans who live in rural or inner-city locations designated as health professional shortage areas.

(8) The AAMC’s Health Care Utilization Equity model 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, medical education and training need to be accessible for students and physicians from all backgrounds. International graduates play an important role in U.S. health care, representing roughly 25 percent of the health care workforce. 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 country.

(10) United States medical schools have committed to and have initiated a 30 percent increase in enrollment by 2017 to help reduce the Nation’s shortage of quality physicians.

(11) An increase in United States medical school graduates must be accompanied by an increase of 4,000 graduate medical education (GME) 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 (having more beneficiaries than any other health care program), supports its “fair share” of the costs associated with graduate medical education (GME).

(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 Nation’s health care needs;

(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 the Association of Schools of Public Health, projections indicate a nationwide shortage of up to 250,000 public health workers needed by 2020.

(2) Similar trends are projected for other health professions indicating shortages across disciplines, 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, over 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 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 American health workforce 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.

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

(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 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; 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) IN GENERAL.—Section 1108 of the Social Security Act (42 U.S.C. 1308) is amended—

(A) in subsection (f), in the matter before paragraph (1), by striking “subsection (g)” and inserting “subsections (g) and (h)”;

(B) in subsection (g)(2), in the matter before subparagraph (A), by inserting “and subsection (h)” after “paragraphs (3) and (5)”; and

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

“(h) Sunset of Medicaid funding limitations for Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa.—Subsections (f) and (g) shall not apply to Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa beginning with fiscal year 2019.”.

(2) CONFORMING AMENDMENTS.—

(A) Section 1902(j) of the Social Security Act (42 U.S.C. 1396a(j)) is amended by striking “, the limitation in section 1108(f),”.

(B) Section 1903(u) of the Social Security Act (42 U.S.C. 1396b(u)) is amended by striking paragraph (4).

(C) Section 1323(c)(1) of the Patient Protection and Affordable Care Act (42 U.S.C. 18043(c)(1)) is amended by striking “2019” and inserting “2018”.

(3) EFFECTIVE DATE.—The amendments made by this section shall apply beginning with fiscal year 2019.

(b) Elimination of specific Federal medical assistance percentage (FMAP) limitation for territories.—Section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended, in clause (2), by inserting “for fiscal years before fiscal year 2019” after “American Samoa”.

(c) Application of Medicaid waiver authority to all of the territories.—

(1) IN GENERAL.—Section 1902(j) of the Social Security Act (42 U.S.C. 1396a(j)) is amended—

(A) by striking “American Samoa and the Northern Mariana Islands” and inserting “Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa”;

(B) by striking “American Samoa or the Northern Mariana Islands” and inserting “Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, or American Samoa”;

(C) by inserting “(1)” after “(j)”;

(D) by inserting “except as otherwise provided in this subsection,” after “Notwithstanding any other requirement of this title”; and

(E) by adding at the end the following:

“(2) The Secretary may not waive under this subsection the requirement of subsection (a)(10)(A)(i)(IX) (relating to coverage of adults formerly under foster care) with respect to any territory.”.

(2) EFFECTIVE DATE.—The amendments made by this section shall apply beginning October 1, 2018.

(d) Permitting Medicaid DSH allotments for territories.—Section 1923(f) of the Social Security Act (42 U.S.C. 1396) is amended—

(1) in paragraph (6), by adding at the end the following new subparagraph:

“(C) TERRITORIES.—

“(i) FISCAL YEAR 2019.—For fiscal year 2019, the DSH allotment for Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa shall bear the same ratio to $150,000,000 as the ratio of the number of individuals who are low-income or uninsured and residing in such respective territory (as estimated from time to time by the Secretary) bears to the sums of the number of such individuals residing in all of the territories.

“(ii) SUBSEQUENT FISCAL YEAR.—For each subsequent fiscal year, the DSH allotment for each such territory is subject to an increase in accordance with paragraph (2).”; and

(2) in paragraph (9), by inserting before the period at the end the following: “, and includes, beginning with fiscal year 2019, Puerto Rico, the Virgin Islands of the United States, Guam, the Northern Mariana Islands, and American Samoa”.

(a) In general.—Section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)) is amended—

(1) in the last sentence, by inserting “, and before January 1, 2019” after “prior to such date)”; and

(2) by adding at the end the following new sentence: “Effective for items and services furnished on or after January 1, 2019 (with respect to periods beginning on or after the date that is 42 months prior to such date), clauses (i) and (ii) shall be applied by substituting ‘42-month’ for ‘12-month’ each place it appears in the first sentence.”.

(b) Effective date.—The amendments made by this section shall take effect on the date of enactment of this Act. For purposes of determining an individual’s status under section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)), as amended by subsection (a), an individual who is within the coordinating period as of the date of enactment of this Act shall have that period extended to the full 42 months described in the last sentence of such section, as added by the amendment made by subsection (a)(2).

(a) Eligible entity defined.—In this section, the term “eligible entity” means a State, public institution of higher education, local government, Tribal government, nonprofit health organization, community health center, or community clinic receiving assistance under section 330 of the Public Health Service Act (42 U.S.C. 254b), that is located in the border area.

(b) Authorization.—From funds appropriated under subsection (f), the Secretary of Health and Human Services (in this section referred to as the “Secretary”), acting through the United States members of the United States-Mexico Border Health Commission, shall award grants to eligible entities to address priorities and recommendations to improve the health of border area residents that are established by—

(1) the United States members of the United States-Mexico Border Health Commission;

(2) the State border health offices; and

(3) the Secretary.

(c) Application.—An eligible entity that desires a grant under subsection (b) shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.

(d) Use of funds.—An eligible entity that receives a grant under subsection (b) shall use the grant funds for—

(1) programs relating to—

(A) maternal and child health;

(B) primary care and preventative health;

(C) public health and public health infrastructure;

(D) musculoskeletal health and obesity;

(E) health education and promotion;

(F) oral health;

(G) mental and behavioral health;

(H) substance abuse;

(I) health conditions that have a high prevalence in the border area;

(J) medical and health services research;

(K) workforce training and development;

(L) community health workers, patient navigators, and promotoras;

(M) health care infrastructure problems in the border area (including planning and construction grants);

(N) health disparities in the border area;

(O) environmental health; and

(P) outreach and enrollment services with respect to Federal programs (including programs authorized under titles XIX and XXI of the Social Security Act (42 U.S.C. 1396 and 1397aa)); and

(2) other programs determined appropriate by the Secretary.

(e) Supplement, not supplant.—Amounts provided to an eligible entity awarded a grant under subsection (b) shall be used to supplement and not supplant other funds available to the eligible entity to carry out the activities described in subsection (d).

(f) Authorization of appropriations.—There are authorized to be appropriated to carry out this section, $200,000,000 for fiscal year 2019, and such sums as may be necessary for each succeeding fiscal year.

(a) Part A.—Section 1818(a)(3) of the Social Security Act (42 U.S.C. 1395i–2(a)(3)) is amended by striking “an alien” and all that follows through “under this section” and inserting “an individual who is lawfully present in the United States”.

(b) Part B.—Section 1836(2) of the Social Security Act (42 U.S.C. 1395o(2)) is amended by striking “an alien” and all that follows through “under this part” and inserting “an individual who is lawfully present in the United States”.

(a) In general.—The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396(b)) is amended by inserting “or are received through a program operated by an urban Indian organization through a grant or contract under title V of such Act” after “(as defined in section 4 of the Indian Health Care Improvement Act)”.

(b) Effective date.—The amendment made by this section shall apply to medical assistance provided on or after the date of enactment of this Act.

(a) In general.—The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)), as amended by section 418(a), is amended by inserting before the period the following: “; and, with respect to medical assistance provided to a Native Hawaiian (as defined in section 12(2) of the Native Hawaiian Health Care Improvement Act) through a federally qualified health center or a Native Hawaiian health care system (as defined in section 12(6) of such Act), whether directly, by referral, or under contract or other arrangement between such federally qualified health center or Native Hawaiian health care system and another health care provider”.

(b) Effective date.—The amendment made by this section shall apply to medical assistance provided on or after the date of enactment of this Act.

Section 287 of the Immigration and Nationality Act (8 U.S.C. 1357) is amended by adding at the end the following:

“(i) (1) In this subsection:

“(A) The term ‘appropriate committees of Congress’ means—

“(i) the Committee on Homeland Security and Governmental Affairs of the Senate;

“(ii) the Committee on the Judiciary of the Senate;

“(iii) the Committee on Homeland Security of the House of Representatives; and

“(iv) the Committee on the Judiciary of the House of Representatives.

“(B) The term ‘enforcement action’—

“(i) means an apprehension, arrest, interview, request for identification, search, or surveillance for the purposes of immigration enforcement; and

“(ii) includes an enforcement action at, or focused on, a sensitive location that is part of a joint case led by another law enforcement agency.

“(C) The term ‘exigent circumstances’ means a situation involving—

“(i) the imminent risk of death, violence, or physical harm to any person or property, including a situation implicating terrorism or the national security of the United States;

“(ii) the immediate arrest or pursuit of a dangerous felon, terrorist suspect, or other individual presenting an imminent danger; or

“(iii) the imminent risk of destruction of evidence that is material to an ongoing criminal case.

“(D) The term ‘prior approval’ means—

“(i) in the case of officers and agents of U.S. Immigration and Customs Enforcement, prior written approval to carry out an enforcement action involving a specific individual or individuals authorized by—

“(I) the Assistant Director of Operations, Homeland Security Investigations;

“(II) the Executive Associate Director of Homeland Security Investigations;

“(III) the Assistant Director for Field Operations, Enforcement and Removal Operations; or

“(IV) the Executive Associate Director for Field Operations, Enforcement and Removal Operations;

“(ii) in the case of officers and agents of U.S. Customs and Border Protection, prior written approval to carry out an enforcement action involving a specific individual or individuals authorized by—

“(I) a Chief Patrol Agent;

“(II) the Director of Field Operations;

“(III) the Director of Air and Marine Operations; or

“(IV) the Internal Affairs Special Agent in Charge; and

“(iii) in the case of other Federal, State, or local law enforcement officers, to carry out an enforcement action involving a specific individual or individuals authorized by—

“(I) the head of the Federal agency carrying out the enforcement action; or

“(II) the head of the State or local law enforcement agency carrying out the enforcement action.

“(E) The term ‘sensitive location’ includes all of the physical space located within 1,000 feet of—

“(i) any medical treatment or health care facility, including any hospital, doctor’s office, accredited health clinic, alcohol or drug treatment center, or emergent or urgent care facility;

“(ii) any public or private school, including any known and licensed day care facility, preschool, other early learning program facility, primary school, secondary school, postsecondary school (including colleges and universities), or other institution of learning (including vocational or trade schools);