Authorizing Legislation

PUBLIC LAW 101-354—AUG. 10, 1990

104 STAT. 409

Public Law 101-354
101st Congress
An Act
To amend the Public Health Service Act to establish a program of grants for the
detection and control of breast and cervical cancer.

Aug. 10, 1990
[H.R. 4790]

Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled.
Breast and
SECTION 1. SHORT TITLE.

Cervical Cancer
Mortality
Prevention Act

This Act may be cited as the Breast and Cervical Cancer Mortal- of 1990.
ity Prevention Act of 1990".
42 use 201 note.
SEC. 2. ESTABLISHMENT OF PROGRAM OF GRANTS TO STATES FOR
PREVENTION AND CONTROL OF BREAST AND CERVICAL
CANCER
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended
by inserting after title XIV the following new title:

"TITLE XV-«PREVENTIVE HEALTH MEASURES WITH RESPECT TO BREAST AND
CERVICAL CANCERS
"SEC. 1501. ESTABLISHMENT OF PROGRAM OF GRANTS TO STATES.

"(a) I N GENERAL.—The Secretary, acting through the Director of
the Centers for Disease Control, may make grants to States on the
basis of an established competitive review process for the purpose of
carrying out programs—
"(1) to screen women for breast and cervical cancer as a
preventive health measure;
"(2) to provide appropriate referrals for medical treatment of
women screened pursuant to paragraph (1) and to ensure, to the
extent practicable, the provision of appropriate follow-up
services;
"(3) to develop and disseminate public information and education programs for the detection and control of breast and
cervical cancer;
"(4) to improve the education, training, and skills of health
professionals (including allied health professionals) in the detection and control of breast and cervical cancer;
"(5) to establish mechanisms through which the States can
monitor the quality of screening procedures for breast and
cervical cancer, including the interpretation of such procedures;
and
"(6) to evaluate activities conducted under paragraphs (1)
through (5) through appropriate surveillance or programmonitoring activities.
"Ot)) GRANT AND CONTRACT AUTHORITY OF STATES.—A State receiving a grant under subsection (a) may expend the grant to carry out

42 USC 300k.

104 STAT. 410

PUBLIC LAW 101-354—AUG. 10, 1990

the purpose described in such subsection through grants to, and
contracts with, pubUc or nonprofit private entities.
42 u s e 300/.

"SEC. 1502. REQUIREMENT OF MATCHING FUNDS.

"(a) I N GENERAL.—The Secretary may not make a grant under
section 1501 unless the State involved agrees, with respect to the
costs to be incurred by the State in carrying out the purpose
described in such section, to make available non-Federal contributions (in cash or in kind under subsection Ot>)) toward such costs in
an amount equal to not less than $1 for each $3 of Federal funds
provided in the grant. Such contributions may be made directly or
through donations from public or private entities.
"(b) DETERMINATION OF AMOUNT OF NON-FEDERAL CONTRIBUTION.—

"(1) I N GENERAL.—Non-Federal contributions required in
subsection (a) may be in cash or in kind, fairly evaluated,
including equipment or services (and excluding indirect or overhead costs). Amounts provided by the Federal Government, or
services assisted or subsidized to any significant extent by the
Federal Government, may not be included in determining the
amount of such non-Federal contributions.
"(2) MAINTENANCE OF EFFORT.—In making a determination of

the amount of non-Federal contributions for purposes of
subsection (a), the Secretary may include only non-Federal
contributions in excess of the average amount of non-Federal
contributions made by the State involved toward the purpose
described in section 1501 for the 2-year period preceding the
first fiscal year for which the State is applying to receive a
grant under such section.
"(3) INCLUSION OF RELEVANT NON-FEDERAL CONTRIBUTIONS FOR

MEDICAID.—In making a determination of the amount of nonFederal contributions for purposes of subsection (a), the Secretary shall, subject to paragraphs (1) and (2) of this subsection,
include any non-Federal amounts expended pursuant to title
XIX of the Social Security Act by the State involved toward the
purpose described in paragraphs (1) and (2) of section 1501(a).
42 u s e 300m

"SEC. 1503. REQUIREMENTS WITH RESPECT TO TYPE AND QUALITY OF
SERVICES.
"(a) REQUIREMENT OF PROVISION OF ALL SERVICES BY DATE CER-

TAIN.—The Secretary may not make a grant under section 1501
unless the State involved agrees—
"(1) to ensure that, initially and throughout the period during
which amounts are received pursuant to the grant, not less than
60 percent of the grant is expended to provide each of the
services or activities described in paragraphs (1) and (2) of
section 1501(a), including making available screening procedures for both breast and cervical cancers;
"(2) subject to subsection (b), to ensure that—
"(A) in the case of breast cancer, both a physical examination of the breasts and the screening procedure known
as a mammography are conducted; and
"(B) in the case of cervical cancer, both a pelvic examination and the screening procedure known as a pap smear are
conducted;

PUBLIC LAW 101-354—AUG. 10, 1990

104 STAT. 411

"(3) to ensure that, by the end of any second fiscal year of
payments pursuant to the grant, each of the services or activities described in section 1501(a) is provided; and
"(4) to ensure that not more than 40 percent of the grant is
expended to provide the services or activities described in paragraphs (3) through (6) of such section.
"(b)

USE OF IMPROVED SCREENING PROCEDURES.—The Secretary

may not make a grant under section 1501 unless the State involved
agrees that, if any screening procedure superior to a procedure
described in subsection (aX2) becomes commonly available and is
recommended for use, any entity providing screening procedures
pursuant to the grant will utilize the superior procedure rather than
the procedure described in such subsection.
"(c)

QUALITY ASSURANCE REGARDING SCREENING FOR BREAST

CANCER.—The Secretary may not make a grant under section 1501
unless the State involved agrees that the State will assure the
quality of any screening procedure for breast cancer conducted
pursuant to such section and, in the case of mammography, will
provide that—
"(1) the equipment used to perform the mammography will be
specifically designed for mammography and will meet appropriate radiologic standards for mammography;
"(2) the mammography will be performed by an individual
who—
"(A) is licensed by a State to perform radiological procedures; or
"(B) is certified as qualified to perform radiological procedures by an appropriate orgemization;
"(3) the results of the mammography will be interpreted by a
physician who—
"(A) is certified as qualified to interpret radiological
procedures by an appropriate board; or
"(B) is certified as qualified to interpret screening
mammography procedures by an appropriate program for
assuring the qualifications of the individual with respect to
such interpretations; and
"(4) with resj)ect to the first screening mammography performed on a woman for which payment is made pursuant to
section 1501(a), there are satisfactory assurances that the results of the m a m m c ^ a p h y will be placed in permanent medical
records maintained with respect to the woman.
"(d)

QUALITY ASSURANCE REGARDING SCREENING FOR CERVICAL

CANCER.—The Secretary may not make a grant under section 1501
unless the State involved agrees that the State will assure the
quality of any screening procedure for cervical cancer conducted
pursuant to such section and, in the case of the pap smear (or other
cytological screening procedure replacing the pap smear pursuant to
subsection Ob)), will provide—
"(1) the maximum number of cytology slides that anyindividual may screen in a 24-hour period;
"(2) requirements that a clinical laboratory maintain a record
'=;"• of^"(A) the number of cytology slides screened during each
24-hour period by each individual who examines C3rtology
slides for the laboratory; and
"(B) the number of hours devoted during each 24-hour
period to screening cytolc^y slides by such individual;

. ,
Records.

: :.

. .

,

104 STAT. 412

PUBLIC LAW 101-354—AUG. 10, 1990
"(3) criteria for requiring rescreening of cytological preparations, such as—
"(A) random rescreening of cj^ology specimens determined to be in the benign category;
"(B) focused rescreening of such preparations in high risk
groups; and
"(C) for each abnormal cj^ological result, rescreening of
all prior cytological specimens for the patient, if available;
"(4) periodic confirmation and evaluation of the proficiency of
individuals involved in screening or interpreting cytological
preparations, including announced and unannounced on-site
proficiency testing of such individuals, with such testing to take
place, to the extent practicable, under normal working
conditions;
"(5) procedures for detecting inadequately prepared slides, for
assuring that no cj^ological diagnosis is rendered on such slides,
and for notifying referring physicians of such slides;
"(6) requirements that all cytological screening be done on the
premises of an appropriately qualified laboratory;
"(7) requirements for the retention of cytology slides by laboratories for appropriate periods of time; and
"(8) requirements of periodic inspection of cytology services by
persons capable of evaluating the quality of cj^ology services.
"(e) ISSUANCE BY SECRETARY OF GUIDELINES WITH RESPECT TO
QUALITY OF MAMMOGRAPHY AND CYTOLOGICAL SERVICES.—

"(1) IN GENERAL.—The Secretary shall establish guidelines for
assuring the quality of any mammography and cytological
screening procedure conducted pursuant to section 1501(a). Such
guidelines with respect to mammography shall include the
provisions of paragraphs (1) through (4) of subsection (c), and
such guidelines with respect to cytological screening procedures
shall include the provisions of paragraphs (1) through (8) of
subsection (d).
"(2) APPLICABIUTY WITH RESPECT TO GRANTS.—The Secretary

may not make a grant under section 1501 unless the State
involved agrees that the State will, with respect to any
mammography or cjrtological screening procedure conducted
pursuant to such section, ensure that the procedure is conducted in accordance with the guidelines issued by the Secretary under paragraph (1).
"(3) RESPONSIBIUTY OF STATES IN ABSENCE OF GUIDEUNES.—

With respect to circumstances in which a State receives a grant
under section 1501 before the issuance of guidelines under
paragraph (1), this subsection may not be construed to affect in
such circumstances the obligation of the State pursuant to
subsection (a)(1) to provide for screening procedures and referrals or the obligations under subsections (c) and (d) with respect
to providing for quality in the screening procedures.
42 u s e 300n.

"SEC. 1504. ADDITIONAL REQUIRED AGREEMENTS.
"(a) PRIORITY FOR LOW-INCOME WOMEN.—The Secretary may not

make a grant under section 1501 unless the State involved agrees
that low-income women will be given priority in the provision of
services and activities pursuant to paragraphs (1) and (2) of section
1501(a).
"(b) LIMITATION ON IMPOSITION OF FEES FOR SERVICES.—The Secretary may not make a grant under section 1501 unless the State

PUBLIC LAW 101-354—AUG. 10, 1990
involved agrees that, if a charge is imposed for the provision of
services or activities under the grant, such charge—
"(1) will be made according to a schedule of charges that is
made available to the public;
"(2) will be adjusted to reflect the income of the woman
involved; and
"(3) will not be imposed on any woman with an income of less
than 100 percent of the official poverty line, as established by
the Director of the Office of Management and Budget and
revised by the Secretary in accordance with section 673(2) of the
Omnibus Budget Reconciliation Act of 1981.
"(c) STATEWIDE PROVISION OF SERVICES.—

"(1) IN GENERAL.—The Secretary may not make a grant under
section 1501 unless the State involved agrees that services and
activities under the grant will be made available throughout the
State, including availability to members of any Indian tribe or
tribal organization (as such terms are defined in section 4 of the
Indian Self-Determination and Ekiucation Assistance Act).
"(2) WAIVER.—The Secretary may waive the requirement
established in paragraph (1) for a State if the Secretary determines that compliance by the State with the requirement would
result in an inefficient allocation of resources with respect to
carrjdng out the purpose described in section 1501(a).
"(d) RELATIONSHIP TO ITEMS AND SERVICES UNDER OTHER PRO-

GRAMS.—The Secretary may not make a grant under section 1501
unless the State involved agrees that the grant will not be expended
to make payment for any item or service to the extent that payment
has been made, or can reasonably be expected to be made, with
respect to such item or service—
"(1) under any State compensation program, under an insurance policy, or under any Federal or State health benefits
program; or
"(2) by an entity that provides health services on a prepaid
basis.
"(e) COORDINATION WITH OTHER BREAST AND CERVICAL CANCER

PROGRAMS.—The Secretary may not make a grant under section
1501 unless the State involved agrees that the services and activities
funded through the grant shall be coordinated with other Federal,
State, and local breast and cervical cancer programs.
"(f) LIMITATION ON ADMINISTRATIVE EXPENSES.—The Secretary

may not make a grant under section 1501 unless the State involved
agrees that not more than 10 percent of the grant will be expended
for administrative expenses with respect to the grant.
"(g) RESTRICTIONS ON U S E OF GRANT.—The Secretary may not

make a grant under section 1501 unless the State involved agrees
that the grant will not be expended to provide inpatient hospital
services for any individual.
"(h) RECORDS AND AUDITS.—The Secretary may not make a grant
under section 1501 unless the State involved agrees that—
"(1) the State will establish such fiscal control and fund
accounting procedures as may be necessary to ensure the proper
disbursal of, and accounting for, amounts received by the State
under such section; and
"(2) upon request, the State will provide records maintained
pursuant to paragraph (1) to the Secretary or the Comptroller of
the United States for purposes of auditing the expenditures by
the State of the grant.

104 STAT. 413

104 STAT. 414

PUBLIC LAW 101-354—AUG. 10, 1990
"(i) REPORTS TO SECRETARY.—The Secretary may not make a grant
under section 1501 unless the State involved agrees to submit to the
Secretary such reports as the Secretary may require with respect to
the grant.

42 u s e 300n-l.

"SEC. 1505. DESCRIPTION OF INTENDED USES OF GRANT.

"The Secretary may not make a grant under section 1501 unless—
"(1) the State involved submits to the Secretary a description
of the purposes for which the State intends to expend the grant;
"(2) the description identifies the populations, areas, and
localities in the State with a need for the services or activities
described in section 1501(a);
"(3) the description provides information relating to the services and activities to be provided, including a description of the
manner in which the services and activities will be coordinated
with any similar services or activities of public or nonprivate
entities; and
"(4) the description provides assurances that the grant funds
be used in the most cost-effective manner.
42 u s e 300n-2.

"SEC. 1506. REQUIREMENT OF SUBMISSION OF APPLICATION.

"The Secretary may not make a grant under section 1501 unless
an application for the grant is submitted to the Secretary, the
application contains the description of intended uses required in
section 1505, and the application is in such form, is made in such
manner, and contains such agreements, assurances, and information
as the Secretary determines to be necessary to carry out this title.
42 u s e 300n-3.

"SEC. 1507. TECHNICAL ASSISTANCE AND PROVISION OF SUPPLIES AND
SERVICES IN LIEU OF GRANT FUNDS.
"(a) TECHNICAL ASSISTANCE.—The Secretary may provide training

and technical assistance with respect to the planning, development,
and operation of any program or service carried out pursuant to
section 1501. The Secretary may provide such technical assistance
directly or through grants to, or contracts with, public and private
entities.
"(b) PROVISION OF SUPPLIES AND SERVICES IN LIEU OF GRANT
FUNDS.—

"(1) IN GENERAL.—Upon the request of a State receiving a
grant under section 1501, the Secretary may, subject to paragraph (2), provide supplies, equipment, and services for the
purpose of aiding the State in carrying out such section and, for
such purpose, may detail to the State any officer or employee of
the Department of Health and Human Services.
"(2) CORRESPONDING REDUCTION IN PAYMENTS.—With respect
to a request described in paragraph (1), the Secretary shall
reduce the amount of payments under the grant under section
1501 to the State involved by an amount equal to the costs of
detailing personnel (including pay, allowances, and travel expenses) and the fair market value of any supplies, equipment, or
services provided by the Secretary. The Secretary shall, for the
payment of expenses incurred in complying with such request,
expend the amounts withheld.

PUBLIC LAW 101-354—AUG. 10, 1990

104 STAT. 415

"SEC. 1508. EVALUATIONS AND REPORTS.

42 USC 300n-4.

"(a) EVALUATIONS.—The Secretary shall, directly or through contracts with public or private entities, provide for annual evaluations
of programs carried out pursuant to section 1501.
"(b) REPORT TO CONGRESS.—The Secretary shall, not later than 1
year after the date on which amounts are first appropriated pursuant to section 1509(a), and annually thereafter, submit to the
Committee on Energy and Commerce of the House of Representatives, and to the Committee on Labor and Human Resources of the
Senate, a report summarizing evaluations carried out pursuant to
subsection (a) during the preceding fiscal year and making such
recommendations for administrative and legislative initiatives with
respect to this title as the Secretary determines to be appropriate.
"SEC. 1509. FUNDING.
"(a)

AUTHORIZATION OF APPROPRIATIONS.—For the

42 USC 300n-5.
purpose

of

carrying out this title, there are authorized to be appropriated
$50,000,000 for fiscal year 1991, and such sums as may be necessary
for each of the fiscal years 1992 and 1993.
"(b) SET-ASIDE FOR TECHNICAL ASSISTANCE AND PROVISION OF SUP-

PLIES AND SERVICES.—Of the amounts appropriated under subsection
(a) for a fiscal year, the Secretary shall reserve not more than 20
percent for carrying out section 1507.".
Approved August 10, 1990.

LEGISLATIVE HISTORY—H.R. 4790 (S. 2283):
HOUSE REPORTS: No. 101-543 (Comm. on Energy and Commerce).
SENATE REPORTS: No. 101-380 accompanying S. 2283 (Comm. on Labor and Human
R6SOUrC6s)

CONGRESSIONAL RECORD, Vol. 136 (1990):
June 18, considered and passed House.
Aug. 3, considered and p£issed Senate, amended. House concurred in Senate
eunendment.

39-194 O - 91 - 15 : QL 3 Part 1