42 U.S.C. § 300m — Requirements with respect to type and quality of services

(a) Providing every service on time: The Secretary can't give a state a grant under section 300k unless the state agrees to spend at least 60 percent of the grant on the core screening and referral services in section 300k(a)(1) and (2) — making sure both breast and cervical cancer screening are available — and, subject to subsection (b), to make sure breast cancer screening always includes both a physical breast exam and a mammogram, and cervical cancer screening always includes both a pelvic exam and a pap smear. By the end of the grant's second year, the state must be providing every service listed in section 300k(a). And the state can spend no more than 40 percent of the grant on the other services in section 300k(a)(3) through (6). (b) Keeping up with better screening: If a better screening method than the physical exam/mammogram or pelvic exam/pap smear combination becomes widely available and recommended, the state must agree that anyone providing screenings with grant money will switch to using it. (c) Quality assurance: The state must agree to assure the quality of its screening procedures, following whatever law applies. (d) Waiving the spending rules: The Secretary must run a demonstration project letting up to 5 states skip the 60%/40% spending split in subsection (a)(1) and (a)(4), if the state will use the waiver to bring in extra non-federal money for the core screening services, if the 60%/40% rule is actually keeping qualifying women from enrolling, if the state shows how it'll use the waiver to expand screening and follow-up beyond what it was already doing (and promises to document that every year), if the state promises to keep spending on the core services at least at its pre-waiver level (based on the year before the waiver, or, if the state prefers and the Secretary agrees, its 3-year average) and has a plan to keep that level up after the waiver ends, and if the Secretary decides the waiver will both increase the number of women getting core services and not hurt the quality of those services. A waiver lasts 1 to 2 years, and the Secretary can extend it for another 1 to 2 years at the state's request — reviewing the state's performance first, and extending it only if without the extension there'd be an enrollment barrier, the state will keep bringing in outside money, the waiver has been (and will keep) increasing the number of women served, the waiver hasn't hurt (and won't hurt) service quality, and the state has kept up its required spending level. The Secretary's regular reports on this program must also cover, for waiver states: how much outside money was leveraged and how it was spent, what percentage of the grant went to core versus other services, how many states got waivers each year, and how many women were served and what the state was spending before and after the waiver. Waived funds can't be used to hire more salaried staff. For this subsection, "Indian tribe" and "tribal organization" have the same meanings as in a separate Indian affairs law, and "State" is defined more broadly than usual — covering the states, D.C., Puerto Rico, American Samoa, the Northern Mariana Islands, the Marshall Islands, the Federated States of Micronesia, Palau, an Indian tribe, or a tribal organization. The Secretary could not grant a new waiver or extension after September 30, 2012.