I

103D CONGRESS

2D SESSION H. R. 4555

To provide assistance for the establishment of community rural health networks in chronically underserved areas, to provide incentives for providers

of health care services to furnish services in such areas, to assist providers of emergency medical services in such areas, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

JUNE 9, 1994

Mr. STENHOLM (for himself, Mr. ROBERTS, Mr. SLATTERY, Mr. GUNDERSON,

Mr. CLINGER, Mr. COOPER, Mr. EMERSON, Mr. LAUGHLIN, Ms. LONG,

Mr. NUSSLE, Mr. OBERSTAR, Mr. PAYNE of Virginia, Mr. POSHARD, Mr.

ROWLAND, Mr. THOMAS of Wyoming) introduced the following bill; which

was referred jointly to the Committees on Energy and Commerce, Ways

and Means, Foreign Affairs and the Judiciary

A BILL

To provide assistance for the establishment of community

rural health networks in chronically underserved areas,

to provide incentives for providers of health care services

to furnish services in such areas, to assist providers

of emergency medical services in such areas, and for

other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

2 (a) SHORT TITLE.—This Act may be cited as the

3 ‘‘Rural Health Delivery System Development Act of

4 1994’’.

5 (b) TABLE OF CONTENTS.—The table of contents of

6 this Act is as follows:

Sec. 1. Short title; table of contents.

TITLE I—GRANTS TO ENCOURAGE ESTABLISHMENT OF

COMMUNITY RURAL HEALTH NETWORKS

Sec. 101. Assistance for implementation of access plans for chronically underserved areas.

Sec. 102. Technical assistance grants for networks.

Sec. 103. Development grants for networks.

Sec. 104. Definitions.

TITLE II—INCENTIVES FOR HEALTH PROFESSIONALS TO

PRACTICE IN RURAL AREAS

Subtitle A—National Health Service Corps Program

Sec. 201. National health service corps loan repayments excluded from gross income.

Sec. 202. Modification in criteria for designation as health professional shortage area.

Sec. 203. Other provisions regarding national health service corps.

Subtitle B—Incentives Under Other Programs

Sec. 211. Extension of additional payment under medicare for physicians’ services furnished in former shortage areas.

Sec. 212. Refinement of geographic adjustment factor for medicare physicians’

services.

Sec. 213. Extension of student loan deferments.

Sec. 214. Development of model State scope of practice law.

TITLE III—ASSISTANCE FOR INSTITUTIONAL PROVIDERS

Subtitle A—Community and Migrant Health Centers

Sec. 301. Community and migrant health centers.

Subtitle B—Emergency Medical Systems

Sec. 311. Emergency medical services.

Sec. 312. Grants to states regarding aircraft for transporting rural victims of

medical emergencies.

Subtitle C—Assistance to Rural Providers Under Medicare
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PART 1—MEDICARE ESSENTIAL ACCESS COMMUNITY HOSPITALS

Sec. 321. Amendments to essential access community hospital (EACH) program under medicare.

PART 2—ESTABLISHMENT OF RURAL EMERGENCY ACCESS CARE HOSPITALS

Sec. 331. Rural emergency access care hospitals described.

Sec. 332. Coverage of and payment for services.

Sec. 333. Effective date.

Subtitle D—Demonstration Projects to Encourage Primary

Care and Rural-Based Graduate Medical Education

Sec. 341. State and consortium demonstration projects.

Sec. 342. Goals for projects.

Sec. 343. Definitions.

TITLE IV—UNITED STATES-MEXICO BORDER HEALTH

COMMISSION

Sec. 401. Agreement to establish binational commission.

Sec. 402. Duties.

Sec. 403. Other authorized functions.

Sec. 404. Membership.

Sec. 405. Regional offices.

Sec. 406. Reports.

Sec. 407. Definitions.

TITLE V—HOSPITAL ANTITRUST FAIRNESS

Sec. 501. Antitrust exemption.

Sec. 502. Requirements.

Sec. 503. Definition.

TITLE VI—FINANCING

Sec. 601. Increase in medicare part B premium for individuals with high income.
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1 TITLE I—GRANTS TO ENCOUR2 AGE ESTABLISHMENT OF

3 COMMUNITY RURAL HEALTH

4 NETWORKS

5 SEC. 101. ASSISTANCE FOR DEVELOPMENT OF ACCESS

6 PLANS FOR CHRONICALLY UNDERSERVED

7 AREAS.

8 (a) AVAILABILITY OF FINANCIAL ASSISTANCE TO IM9 PLEMENT ACTION PLANS TO INCREASE ACCESS.—

10 (1) IN GENERAL.—The Secretary shall provide

11 grants (in amounts determined in accordance with

12 paragraph (3)) over a 3-year period to an eligible

13 State for the development of plans to increase access

14 to health care services during such period for resi15 dents of areas in the State that are designated as

16 chronically underserved areas in accordance with

17 subsection (b).

18 (2) ELIGIBILITY REQUIREMENTS.—A State is

19 eligible to receive grants under this section if the

20 State submits to the Secretary (at such time and in

21 such form as the Secretary may require) assurances

22 that the State has developed (or is in the process of

23 developing) a plan to increase the access of residents

24 of a chronically underserved area to health care serv25 ices that meets the requirements of subsection (c),
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1 together with such other information and assurances

2 as the Secretary may require.

3 (3) AMOUNT OF ASSISTANCE.—

4 (A) IN GENERAL.—Subject to subpara5 graph (B), the amount of assistance provided to

6 a State under this subsection with respect to

7 any plan during a 3-year period shall be equal

8 to—

9 (i) for the first year of the period, an

10 amount equal to 100% of the amounts ex11 pended by the State during the year to im12 plement the plan described in paragraph

13 (1) (as reported to the Secretary in accord14 ance with such requirements as the Sec15 retary may impose);

16 (ii) for the second year of the period,

17 an amount equal to 50% of the amounts

18 expended by the State during the year to

19 implement the plan; and

20 (iii) for the third year of the period,

21 an amount equal to 33% of the amounts

22 expended by the State during the year to

23 implement the plan.

24 (B) AGGREGATE PER PLAN LIMIT.—The

25 amount of assistance provided to a State under
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1 this subsection with respect to any plan may

2 not exceed $100,000 during any year of the 3-

3 year period for which the State receives assist4 ance.

5 (b) DESIGNATION OF AREAS.—

6 (1) DESIGNATION BY GOVERNOR.—In accord7 ance with the guidelines developed under paragraph

8 (2), the Governor of a State may designate an area

9 in the State as a chronically underserved area for

10 purposes of this section upon the request of a local

11 official of the area or upon the Governor’s initiative.

12 (2) GUIDELINES FOR DESIGNATION.—

13 (A) DEVELOPMENT BY SECRETARY.—Not

14 later than 1 year after the date of the enact15 ment of this Act, the Secretary shall develop

16 guidelines for the designation of areas as chron17 ically underserved areas under this section.

18 (B) FACTORS CONSIDERED IN DEVELOP19 MENT OF GUIDELINES.—In developing guide20 lines under paragraph (1), the Secretary shall

21 consider the following factors:

22 (i) Whether the area (or a significant

23 portion of the area)—

24 (I) is designated as a health pro25 fessional shortage area (under section
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1 332(a) of the Public Health Service

2 Act), or meets the criteria for des3 ignation as such an area; or

4 (II) was previously designated as

5 such an area or previously met such

6 criteria for an extended period prior

7 to the designation of the area under

8 this section (in accordance with cri9 teria established by the Secretary).

10 (ii) The availability and adequacy of

11 health care providers and facilities for resi12 dents of the area.

13 (iii) The extent to which the availabil14 ity of assistance under other Federal and

15 State programs has failed to alleviate the

16 lack of access to health care services for

17 residents of the area.

18 (iv) The percentage of residents of the

19 area whose income is at or below the pov20 erty level.

21 (v) The percentage of residents of the

22 area who are age 65 or older.

23 (vi) The existence of cultural or geo24 graphic barriers to access to health care
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1 services in the area, including weather con2 ditions.

3 (3) REVIEW BY SECRETARY.—No designation

4 under paragraph (1) shall take effect under this sec5 tion unless the Secretary—

6 (A) has been notified of the proposed des7 ignation; and

8 (B) has not, within 60 days after the date

9 of receipt of the notice, disapproved the des10 ignation.

11 (4) PERIOD OF DESIGNATION.—A designation

12 under this section shall be effective during a period

13 specified by the Governor of not longer than 3 years.

14 The Governor may extend the designation for addi15 tional 3-year periods, except that a State may not

16 receive assistance under subsection (a)(3) for

17 amounts expended during any such additional peri18 ods.

19 (c) REQUIREMENTS FOR STATE ACCESS PLANS.—A

20 State plan to increase the access of residents of chronically

21 underserved areas to health care services meets the re22 quirements of this section if the Secretary finds that the

23 plan was developed with the participation of health care

24 providers and facilities and residents of the area that is
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1 the subject of the plan, together with such other require2 ments as the Secretary may impose.

3 (d) AUTHORIZATION OF APPROPRIATIONS.—There

4 are authorized to be appropriated for assistance under this

5 section $10,000,000 for each of the first 3 fiscal years

6 beginning after the date on which the Secretary develops

7 guidelines for the designation of areas as chronically un8 derserved areas under subsection (b)(2).

9 SEC. 102. TECHNICAL ASSISTANCE GRANTS FOR NET10 WORKS.

11 (a) IN GENERAL.—The Secretary shall make funds

12 available under this section to provide technical assistance

13 (including information regarding eligibility for other Fed14 eral programs) and advice for entities described in sub15 section (b) seeking to establish or enhance a community

16 rural health network in an underserved rural area.

17 (b) ENTITIES ELIGIBLE TO RECEIVE FUNDS.—The

18 following entities are eligible to receive funds for technical

19 assistance under this section:

20 (1) An entity receiving a grant under section

21 103.

22 (2) A State or unit of local government.

23 (3) An entity providing health care services (in24 cluding health professional education services) in the

25 area involved.
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1 (c) USE OF FUNDS.—

2 (1) IN GENERAL.—Funds made available under

3 this section may be used—

4 (A) for planning a community health net5 work and the submission of the plan for the

6 network to the Secretary under section 103(c)

7 (subject to the limitation described in para8 graph (2));

9 (B) to provide assistance in conducting

10 community-based needs and prioritization, iden11 tifying existing regional health resources, and

12 developing networks, utilizing existing local pro13 viders and facilities where appropriate;

14 (C) to provide advice on obtaining the

15 proper balance of primary and secondary facili16 ties for the population served by the network;

17 (D) to provide assistance in coordinating

18 arrangements for tertiary care;

19 (E) to provide assistance in recruitment

20 and retention of health care professionals;

21 (F) to provide assistance in coordinating

22 the delivery of emergency services with the pro23 vision of other health care services in the area

24 served by the network;
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1 (G) to provide assistance in coordinating

2 arrangements for mental health and substance

3 abuse treatment services; and

4 (H) to provide information regarding the

5 area or proposed network’s eligibility for Fed6 eral and State assistance for health care-related

7 activities, together with information on funds

8 available through private sources.

9 (2) LIMITATION ON AMOUNT AVAILABLE FOR

10 DEVELOPMENT OF NETWORK.—The amount of fi11 nancial assistance available for activities described in

12 paragraph (1) may not exceed $50,000 and may not

13 be available for a period of time exceeding 1 year.

14 (d) USE OF RURAL HEALTH OFFICES.—In carrying

15 out this section with respect to entities in rural areas, the

16 Secretary shall make funds available through—

17 (1) not more than 10 regional centers acting as

18 clearinghouses for the distribution of such funds;

19 (2) State Offices of Rural Health,

20 or any combination of such centers and Offices.

21 (e) AUTHORIZATION OF APPROPRIATIONS.—There

22 are authorized to be appropriated $10,000,000 for each

23 of fiscal years 1995 through 1999 to carry out this sec24 tion. Amounts appropriated under this section shall be

25 available until expended.
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1 SEC. 103. DEVELOPMENT GRANTS FOR NETWORKS.

2 (a) IN GENERAL.—The Secretary shall provide finan3 cial assistance to eligible entities in order to provide for

4 the development and implementation of community rural

5 health networks.

6 (b) ELIGIBLE ENTITIES.—

7 (1) IN GENERAL.—An entity is eligible to re8 ceive financial assistance under this section only if

9 the entity—

10 (A) is (i) based in a rural area or (ii) is

11 described in paragraph (2), (3), or (4) of sec12 tion 102(b),

13 (B) is undertaking to develop and imple14 ment a community rural health network in an

15 underserved rural area (or underserved rural

16 areas) with the active participation of at least

17 3 health care providers or facilities in the area,

18 and

19 (C) has consulted with the local govern20 ments of the area to be served by the network

21 and with individuals who reside in the area.

22 (2) COORDINATION WITH PROVIDERS OUTSIDE

23 OF AREA PERMITTED.—Nothing in this section shall

24 be construed as preventing an entity that coordi25 nates the delivery of services in an underserved rural

26 area with an entity outside the area from qualifying
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1 for financial assistance under this section, or as pre2 venting an entity consisting of a consortia of mem3 bers located in adjoining States from qualifying for

4 such assistance.

5 (3) PERMITTING ENTITIES NOT RECEIVING

6 FUNDING FOR DEVELOPMENT OF PLAN TO RECEIVE

7 FUNDING FOR IMPLEMENTATION.—An entity that is

8 eligible to receive financial assistance under this sec9 tion may receive assistance to carry out activities de10 scribed in subsection (c)(1)(B) notwithstanding that

11 the entity does not receive assistance to carry out

12 activities described in subsection (c)(1)(A).

13 (c) USE OF FUNDS.—

14 (1) IN GENERAL.—Financial assistance made

15 available to eligible entities under this section may

16 be used only—

17 (A) for the development of a community

18 health network and the submission of the plan

19 for the network to the Secretary; and

20 (B) after the Secretary approves the plan

21 for the network, for activities to implement the

22 network, including (but not limited to)—

23 (i) establishing information systems,

24 including telecommunications,

25 (ii) recruiting health care providers,
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1 (iii) providing services to enable indi2 viduals to have access to health care serv3 ices, including transportation and language

4 interpretation services (including interpre5 tation services for the hearing-impaired),

6 and

7 (iv) establishing and operating a com8 munity health advisor program described

9 in paragraph (2).

10 (2) COMMUNITY HEALTH ADVISOR PROGRAM.—

11 (A) PROGRAM DESCRIBED.—In paragraph

12 (1), a ‘‘community health advisor program’’ is

13 a program under which community health advi14 sors carry out the following activities:

15 (i) Collaborating efforts with health

16 care providers and related entities to facili17 tate the provision of health services and

18 health-related social services.

19 (ii) Providing public education on

20 health promotion and disease prevention

21 and efforts to facilitate the use of available

22 health services and health-related social

23 services.

24 (iii) Providing health-related counsel25 ing.
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1 (iv) Making referrals for available

2 health services and health-related social

3 services.

4 (v) Improving the ability of individ5 uals to use health services and health-relat6 ed social services under Federal, State,

7 and local programs through assisting indi8 viduals in establishing eligibility under the

9 programs.

10 (vi) Providing outreach services to in11 form the community of the availability of

12 the services provided under the program.

13 (B) COMMUNITY HEALTH ADVISOR DE14 FINED.—In subparagraph (A), the term ‘‘com15 munity health advisor’’ means, with respect to

16 a community health advisor program, an indi17 vidual—

18 (i) who has demonstrated the capacity

19 to carry out one or more of the activities

20 carried out under the program; and

21 (ii) who, for not less than one year,

22 has been a resident of the community in

23 which the program is to be operated.
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1 (3) LIMITATIONS ON ACTIVITIES FUNDED.—Fi2 nancial assistance made available under this section

3 may not be used for any of the following:

4 (A) For a telecommunications system un5 less such system is coordinated with, and does

6 not duplicate, a system existing in the area.

7 (B) For construction or remodeling of

8 health care facilities.

9 (4) LIMITATION ON AMOUNT AVAILABLE FOR

10 DEVELOPMENT OF NETWORK.—The amount of fi11 nancial assistance available for activities described in

12 paragraph (1)(A) may not exceed $50,000 and may

13 not be made available for a period of time exceeding

14 1 year.

15 (d) APPLICATION.—

16 (1) IN GENERAL.—No financial assistance shall

17 be provided under this section to an entity unless

18 the entity has submitted to the Secretary, in a time

19 and manner specified by the Secretary, and had ap20 proved by the Secretary an application.

21 (2) INFORMATION TO BE INCLUDED.—Each

22 such application shall include—

23 (A) a description of the community rural

24 health network, including service area and ca25 pacity, and
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1 (B) a description of how the proposed net2 work will utilize existing health care facilities in

3 a manner that avoids unnecessary duplication.

4 (e) AUTHORIZATION OF APPROPRIATIONS.—

5 (1) IN GENERAL.—There are authorized to be

6 appropriated $100,000,000 for each of fiscal years

7 1995 through 1999 to carry out this section.

8 Amounts appropriated under this section shall be

9 available until expended.

10 (2) INTEGRATION OF OTHER AUTHORIZA11 TIONS.—In order to provide for the authorization of

12 appropriations under paragraph (1), notwithstanding

13 any other provision of law, no funds are authorized

14 to be appropriated to carry out the following pro15 grams in fiscal years after fiscal year 1994:

16 (A) The rural health transition grant pro17 gram (under section 4005(e) of the Omnibus

18 Budget Reconciliation Act of 1987).

19 (B) The rural health outreach program

20 (for which appropriations were annually pro21 vided under the Departments of Labor, Health

22 and Human Services, and Education, and Re23 lated Agencies Appropriation Acts).

24 (3) ANNUAL LIMIT ON ASSISTANCE TO GRANT25 EE.—The amount of financial assistance provided to
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1 an entity under this section during a year may not

2 exceed $250,000.

3 SEC. 104. DEFINITIONS.

4 For purposes of this title:

5 (1) COMMUNITY RURAL HEALTH NETWORK.—

6 The term ‘‘community rural health network’’ means

7 a formal cooperative arrangement between partici8 pating hospitals, physicians, and other health care

9 providers which—

10 (A) is located in an underserved rural

11 area;

12 (B) furnishes health care services to indi13 viduals residing in the area; and

14 (C) is governed by a board of directors se15 lected by participating health care providers

16 and residents of the area.

17 (2) RURAL AREA.—The term ‘‘rural area’’ has

18 the meaning given such term in section

19 1886(d)(2)(D) of the Social Security Act.

20 (3) SECRETARY.—The term ‘‘Secretary’’ means

21 the Secretary of Health and Human Services.

22 (4) STATE.—The term ‘‘State’’ means each of

23 the several States, the District of Columbia, Puerto

24 Rico, the Virgin Islands, Guam, the Northern Mari25 ana Islands, and American Samoa.
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1 (5) UNDERSERVED RURAL AREA.—The term

2 ‘‘underserved rural area’’ means a rural area des3 ignated—

4 (A) as a health professional shortage area

5 under section 332(a) of the Public Health Serv6 ice Act; or

7 (B) as a chronically underserved area

8 under section 101.

9 TITLE II—INCENTIVES FOR

10 HEALTH PROFESSIONALS TO

11 PRACTICE IN RURAL AREAS

12 Subtitle A—National Health

13 Service Corps Program

14 SEC. 201. NATIONAL HEALTH SERVICE CORPS LOAN REPAY15 MENTS EXCLUDED FROM GROSS INCOME.

16 (a) IN GENERAL.—Part III of subchapter B of chap17 ter 1 of the Internal Revenue Code of 1986 (relating to

18 items specifically excluded from gross income) is amended

19 by redesignating section 137 as section 138 and by insert20 ing after section 136 the following new section:

21 ‘‘SEC. 137. NATIONAL HEALTH SERVICE CORPS LOAN RE22 PAYMENTS.

23 ‘‘(a) GENERAL RULE.—Gross income shall not in24 clude any qualified loan repayment.
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1 ‘‘(b) QUALIFIED LOAN REPAYMENT.—For purposes

2 of this section, the term ‘qualified loan repayment’ means

3 any payment made on behalf of the taxpayer by the Na4 tional Health Service Corps Loan Repayment Program

5 under section 338B(g) of the Public Health Service Act.’’.

6 (b) CONFORMING AMENDMENT.—Paragraph (3) of

7 section 338B(g) of the Public Health Service Act is

8 amended by striking ‘‘Federal, State, or local’’ and insert9 ing ‘‘State or local’’.

10 (c) CLERICAL AMENDMENT.—The table of sections

11 for part III of subchapter B of chapter 1 of the Internal

12 Revenue Code of 1986 is amended by striking the item

13 relating to section 137 and inserting the following:

‘‘Sec. 137. National Health Service Corps loan repayments.

‘‘Sec. 138. Cross references to other Acts.’’.

14 (d) EFFECTIVE DATE.—The amendments made by

15 this section shall apply to payments made under section

16 338B(g) of the Public Health Service Act after the date

17 of the enactment of this Act.

18 SEC. 202. MODIFICATION IN CRITERIA FOR DESIGNATION

19 AS HEALTH PROFESSIONAL SHORTAGE AREA.

20 (a) CONSIDERATIONS REGARDING MEDICARE AND

21 MEDICAID PROGRAMS AS MEANS OF PAYMENT.—Section

22 332(b) of the Public Health Service Act (42 U.S.C.

23 254e(b)) is amended by adding at the end the following

24 paragraph:
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1 ‘‘(4) With respect to determining the need for

2 health services through the indicators of need under

3 paragraphs (1) and (2), consideration of the follow4 ing:

5 ‘‘(A) The number of individuals in the pop6 ulation involved whose means of payment for

7 health services is the program under title XVIII

8 of the Social Security Act.

9 ‘‘(B) The number of individuals in the

10 population whose means of payment for health

11 services is the program under title XIX of such

12 Act.

13 ‘‘(C) The number of individuals in the pop14 ulation who are uninsured with respect to

15 health policies or plans.

16 ‘‘(D) The percentage of the population

17 constituted by the aggregate number of individ18 uals under subparagraphs (A) through (C).

19 ‘‘(E) In the case of community-based phy20 sicians who provide primary health services and

21 who are accepting additional patients whose

22 means of payment is through the program es23 tablished in title XVIII or XIX of the Social

24 Security Act, the percentage constituted by the
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1 ratio of the number of such physicians to the

2 number of individuals in the population.’’.

3 (b) RELEVANCE OF TRAVEL TIMES WITHIN FRON4 TIER AREAS.—Section 332(a) of the Public Health Service

5 Act (42 U.S.C. 245e(a)) is amended by adding at the end

6 the following new paragraph:

7 ‘‘(4) With respect to meeting the criteria under

8 paragraph (1)(A) for an area to be designated as a

9 health professional shortage area, the Secretary

10 shall, in the case of a frontier area, make the deter11 mination of whether the frontier area is a rational

12 area for the delivery of health services without re13 gard to—

14 ‘‘(A) the travel time between population

15 centers in the frontier area; or

16 ‘‘(B) the travel time to contiguous area re17 sources in the frontier area.’’.

18 (c) AGENCY RECOMMENDATIONS FOR IMPROVE19 MENTS.—Not later than February 1, 1995, the Secretary

20 of Health and Human Services shall submit to the Con21 gress a report specifying the recommendations of the Sec22 retary for improving the manner of determining the extent

23 to which a geographic area has a need for assignments

24 of members of the National Health Service Corps, and for
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1 equitably allocating such assignments among the geo2 graphic areas with a need for such assignments.

3 (d) EFFECTIVE DATE.—This section shall take effect

4 on October 1, 1994, or upon the date of the enactment

5 of this Act, whichever occurs later.

6 SEC. 203. OTHER PROVISIONS REGARDING NATIONAL

7 HEALTH SERVICE CORPS.

8 (a) SCHOLARSHIP AND LOAN REPAYMENT PRO9 GRAMS.—

10 (1) AUTHORIZATION OF APPROPRIATIONS.—

11 Section 338H(b)(1) of the Public Health Service Act

12 (42 U.S.C. 254q(b)(1)) is amended—

13 (A) by striking ‘‘and’’ after ‘‘1991,’’; and

14 (B) by striking ‘‘through 2000.’’ and in15 serting ‘‘through 1994, $150,000,000 for fiscal

16 year 1995, $175,000,000 for fiscal year 1996,

17 $200,000,000 for fiscal year 1997,

18 $225,000,000 for fiscal year 1998, and

19 $250,000,000 for fiscal year 1999.’’.

20 (2) ALLOCATION FOR PARTICIPATION OF

21 NURSES IN SCHOLARSHIP PROGRAM.—Section

22 338H(b)(2) of the Public Health Service Act (42

23 U.S.C. 254q(b)(2)) is amended by adding at the end

24 the following subparagraph:
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1 ‘‘(C) Of the amounts appropriated under

2 paragraph (1) for fiscal year 1995 and subse3 quent fiscal years, the Secretary shall reserve

4 such amounts as may be necessary to ensure

5 that, of the aggregate number of individuals

6 who are participants in the Scholarship Pro7 gram, the total number who are being educated

8 as nurses or are serving as nurses, respectively,

9 is increased to 20 percent.’’.

10 (b) INCREASE IN NUMBER OF MENTAL HEALTH

11 PROFESSIONALS IN SHORTAGE AREAS.—

12 (1) IN GENERAL.—Section 338H(b) of the Pub13 lic Health Service Act (42 U.S.C. 254q(b)) is

14 amended by adding at the end the following para15 graph:

16 ‘‘(3) MENTAL HEALTH PROFESSIONALS.—In

17 providing contracts under this subpart for scholar18 ships and loan repayments, the Secretary shall en19 sure that an appropriate number of mental health

20 professionals is assigned under section 333 for

21 health professional shortage areas.’’.

22 (2) APPLICABILITY.—With respect to contracts

23 for scholarships and loan repayments under subpart

24 III of part D of title III of the Public Health Service

25 Act, the amendment made by subsection (a) applies
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1 with respect to contracts entered into on or after Oc2 tober 1, 1994.

3 Subtitle B—Incentives Under Other

4 Programs

5 SEC. 211. EXTENSION OF ADDITIONAL PAYMENT UNDER

6 MEDICARE FOR PHYSICIANS’ SERVICES FUR7 NISHED IN FORMER SHORTAGE AREAS.

8 (a) IN GENERAL.—Section 1833(m) of the Social Se9 curity Act (42 U.S.C. 1395l(m)) is amended by striking

10 ‘‘area,’’ and inserting ‘‘area (or, in the case of an area

11 for which the designation as a health professional shortage

12 area under such section is withdrawn, in the case of physi13 cians’ services furnished to such an individual during the

14 3-year period beginning on the effective date of the with15 drawal of such designation),’’.

16 (b) EFFECTIVE DATE.—The amendment made by

17 subsection (a) shall apply to physicians’ services furnished

18 in an area for which the designation as a health profes19 sional shortage area under section 332(a)(1)(A) of the

20 Public Health Service Act is withdrawn on or after Janu21 ary 1, 1995.
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1 SEC. 212. REFINEMENT OF GEOGRAPHIC ADJUSTMENT

2 FACTOR FOR MEDICARE PHYSICIANS’ SERV3 ICES.

4 (a) DEADLINE FOR INITIAL REVIEW AND REVI5 SION.—Section 1848(e)(1)(C) of the Social Security Act

6 (42 U.S.C. 1395w–4(e)(1)(C)) is amended by adding at

7 the end the following: ‘‘The first such review and revision

8 shall apply to services furnished on or after January 1,

9 1997.’’.

10 (b) AUTHORITY TO ADJUST INDEX VALUE FOR

11 INPUT COMPONENT UNDER CERTAIN CIRCUMSTANCES.—

12 (1) Section 1848(e)(1) of the Social Security Act (42

13 U.S.C. 1395w–4(e)(1)) is amended—

14 (A) in subparagraph (A), by striking ‘‘(B) and

15 (C)’’ and inserting ‘‘(B), (C), and (D)’’;

16 (B) by redesignating subparagraph (C) as sub17 paragraph (D); and

18 (C) by inserting after subparagraph (B) the fol19 lowing:

20 ‘‘(C) SPECIAL ADJUSTMENT TO CORRECT

21 FOR UNIQUE LOCAL CIRCUMSTANCES.—The

22 Secretary may adjust the value assigned to an

23 input component of an index in a fee schedule

24 area if the Secretary determines that the value

25 that would otherwise apply in such area does

26 not accurately reflect the relative costs of such
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1 input for such area because of unique local cir2 cumstances.’’.

3 (2) Section 1848(i)(1)(D) of the Social Security Act

4 (42 U.S.C. 1395w–4(i)(1)(D)) is amended by inserting

5 ‘‘(including any adjustment under subparagraph (C)

6 thereof)’’ after ‘‘subsection (e)’’.

7 (c) REPORT ON REVIEW PROCESS.—Not later than

8 April 1, 1996, the Secretary of Health and Human Serv9 ices (in this section referred to as the ‘‘Secretary’’) shall

10 study and report to the Committee on Finance of the Sen11 ate and the Committees on Ways and Means and Energy

12 and Commerce of the House of Representatives on—

13 (1) the data necessary to review and revise the

14 indices established under section 1848(e)(1)(A) of

15 the Social Security Act, including—

16 (A) the shares allocated to physicians’

17 work effort, practice expenses (other than mal18 practice expenses), and malpractice expenses;

19 (B) the weights assigned to the input com20 ponents of such shares; and

21 (C) the index values assigned to such com22 ponents;

23 (2) any limitations on the availability of data

24 necessary to review and revise such indices at least

25 every three years;
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1 (3) ways of addressing such limitations, with

2 particular attention to the development of alternative

3 data sources for input components for which current

4 index values are based on data collected less fre5 quently than every three years; and

6 (4) the costs of developing more accurate and

7 timely data sources.

8 (d) STUDY ON LOW-VOLUME ADJUSTMENT IN ISO9 LATED AREAS.—(1) Not later than July 1, 1996, the Phy10 sician Payment Review Commission shall study and report

11 to the Committee on Finance of the Senate and the Com12 mittees on Ways and Means and Energy and Commerce

13 of the House of Representatives on the feasibility and de14 sirability of providing for a special adjustment to the index

15 value of the medical equipment and supplies input compo16 nent of the index used under section 1848(e) of the Social

17 Security Act with respect to services described in para18 graph (2).

19 (2) Services described in this paragraph are serv20 ices—

21 (A) furnished by a physician who practices in

22 an isolated area;

23 (B) requiring the presence of expensive medical

24 equipment and supplies in the physician’s office; and
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1 (C) with respect to which the cost per service

2 of operating the equipment is increased because of

3 the low volume of patients of such physician.

4 SEC. 213. EXTENSION OF STUDENT LOAN DEFERMENTS.

5 (a) STAFFORD LOANS.—

6 (1) GSL LOANS.—Section 428(b)(1)(M) of the

7 Higher Education Act of 1965 (20 U.S.C.

8 1078(b)(1)(M)) is amended—

9 (A) by striking ‘‘or’’ at the end of clause

10 (ii);

11 (B) by inserting ‘‘or’’ after the semicolon

12 at the end of clause (iii); and

13 (C) by adding at the end thereof the fol14 lowing new clause:

15 ‘‘(iv) during which the borrower is

16 serving in an internship or residency pro17 gram in preparation for practice in an area

18 of primary care (including internal medi19 cine, pediatrics, obstetrics/gynecology, fam20 ily medicine, and osteopathy);’’.

21 (2) FISL LOANS.—Section 427(a)(2)(C) of

22 such Act (20 U.S.C. 1077(a)(2)(C)) is amended—

23 (A) by striking ‘‘or’’ at the end of clause

24 (ii);
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1 (B) by inserting ‘‘or’’ after the semicolon

2 at the end of clause (iii); and

3 (C) by adding at the end thereof the fol4 lowing new clause:

5 ‘‘(iv) during which the borrower is

6 serving in an internship or residency pro7 gram in preparation for practice in an area

8 of primary care (including internal medi9 cine, pediatrics, obstetrics/gynecology, fam10 ily medicine, and osteopathy);’’.

11 (b) PERKINS LOANS.—Section 464(c)(2)(A) of such

12 Act (20 U.S.C. 1087dd(c)(2)(A)) is amended—

13 (1) by striking ‘‘or’’ at the end of clause (iii);

14 (2) by inserting ‘‘or’’ after the semicolon at the

15 end of clause (iv); and

16 (3) by adding at the end thereof the following

17 new clause:

18 ‘‘(v) during which the borrower is

19 serving in an internship or residency pro20 gram in preparation for practice in an area

21 of primary care (including internal medi22 cine, pediatrics, obstetrics/gynecology, fam23 ily medicine, and osteopathy);’’.

24 (c) EFFECTIVE DATE.—The amendments made by

25 this section shall apply on and after the date of the enact-
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1 ment of this Act with respect to loans made under the

2 Higher Education Act of 1965 before, on, or after that

3 date.

4 SEC. 214. DEVELOPMENT OF MODEL STATE SCOPE OF

5 PRACTICE LAW.

6 (a) IN GENERAL.—The Secretary of Health and

7 Human Services shall develop and publish a model law

8 that may be adopted by States to increase the access of

9 individuals residing in underserved rural areas to health

10 care services by expanding the services which non-physi11 cian health care professionals may provide in such areas.

12 (b) DEADLINE.—The Secretary shall publish the

13 model law developed under subsection (a) not later than

14 1 year after the date of the enactment of this Act.

15 TITLE III—ASSISTANCE FOR

16 INSTITUTIONAL PROVIDERS

17 Subtitle A—Community and

18 Migrant Health Centers

19 SEC. 301. COMMUNITY AND MIGRANT HEALTH CENTERS.

20 (a) MIGRANT HEALTH CENTERS.—Section

21 329(h)(1)(A) of the Public Health Service Act (42 U.S.C.

22 254b(h)(1)(A)) is amended—

23 (1) by striking ‘‘and’’ after ‘‘1991,’’; and

24 (2) by inserting before the period the following:

25 ‘‘, $75,000,0000 for fiscal year 1995, and such sums
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1 as may be necessary for each of the fiscal years

2 1996 through 1999’’.

3 (b) COMMUNITY HEALTH CENTERS.—Section

4 330(g)(1)(A) of the Public Health Service Act (42 U.S.C.

5 254c(g)(1)(A)) is amended—

6 (1) by striking ‘‘and’’ after ‘‘1991,’’; and

7 (2) by inserting before the period the following:

8 ‘‘, $650,000,0000 for fiscal year 1995, and such

9 sums as may be necessary for each of the fiscal

10 years 1996 through 1999’’.

11 Subtitle B—Emergency Medical

12 Systems

13 SEC. 311. EMERGENCY MEDICAL SERVICES.

14 (a) ESTABLISHMENT OF FEDERAL OFFICE.—Title

15 XII of the Public Health Service Act (42 U.S.C. 300d et

16 seq.) is amended—

17 (1) in the heading for the title, by striking

18 ‘‘TRAUMA CARE’’ and inserting ‘‘EMERGENCY

19 MEDICAL SERVICES’’;

20 (2) in the heading for part A, by striking

21 ‘‘GENERAL’’ and all that follows and inserting

22 ‘‘GENERAL AUTHORITIES AND DUTIES’’; and

23 (3) by amending section 1201 to read as fol24 lows:
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1 ‘‘SEC. 1201. ESTABLISHMENT OF OFFICE OF EMERGENCY

2 MEDICAL SERVICES.

3 ‘‘(a) IN GENERAL.—The Secretary shall establish an

4 office to be known as the Office of Emergency Medical

5 Services, which shall be headed by a director appointed

6 by the Secretary. The Secretary shall carry out this title

7 acting through the Director of such Office.

8 ‘‘(b) GENERAL AUTHORITIES AND DUTIES.—With

9 respect to emergency medical services (including trauma

10 care), the Secretary shall—

11 ‘‘(1) conduct and support research, training,

12 evaluations, and demonstration projects;

13 ‘‘(2) foster the development of appropriate,

14 modern systems of such services through the sharing

15 of information among agencies and individuals in16 volved in the study and provision of such services;

17 ‘‘(3) foster the development of regional systems

18 for the provision of such services;

19 ‘‘(4) sponsor workshops and conferences;

20 ‘‘(5) as appropriate, disseminate to public and

21 private entities information obtained in carrying out

22 paragraphs (1) through (4);

23 ‘‘(6) provide technical assistance to State and

24 local agencies;

25 ‘‘(7) coordinate activities of the Department of

26 Health and Human Services; and
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1 ‘‘(8) as appropriate, coordinate activities of

2 such Department with activities of other Federal

3 agencies.

4 ‘‘(c) CERTAIN REQUIREMENTS.—With respect to

5 emergency medical services (including trauma care), the

6 Secretary shall ensure that activities under subsection (b)

7 are carried out regarding—

8 ‘‘(1) maintaining an adequate number of health

9 professionals with expertise in the provision of the

10 services, including hospital-based professionals and

11 prehospital-based professionals;

12 ‘‘(2) developing, periodically reviewing, and re13 vising as appropriate, in collaboration with appro14 priate public and private entities, guidelines for the

15 provision of such services (including, for various typ16 ical circumstances, guidelines on the number and va17 riety of professionals, on equipment, and on train18 ing);

19 ‘‘(3) the appropriate use of available tech20 nologies, including communications technologies; and

21 ‘‘(4) the unique needs of underserved inner-city

22 areas and underserved rural areas.

23 ‘‘(d) GRANTS, COOPERATIVE AGREEMENTS, AND

24 CONTRACTS.—In carrying out subsections (b) and (c), the
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1 Secretary may make grants and enter into cooperative

2 agreements and contracts.

3 ‘‘(e) DEFINITIONS.—For purposes of this part:

4 ‘‘(1) The term ‘hospital-based professional’

5 means a health professional (including an allied

6 health professional) who has expertise in providing

7 one or more emergency medical services and who

8 normally provides the services at a medical facility.

9 ‘‘(2) The term ‘prehospital-based professional’

10 means a health professional (including an allied

11 health professional) who has expertise in providing

12 one or more emergency medical services and who

13 normally provides the services at the site of the med14 ical emergency or during transport to a medical fa15 cility.’’.

16 (b) STATE OFFICES OF EMERGENCY MEDICAL SERV17 ICES; DEMONSTRATION PROGRAM REGARDING TELE18 COMMUNICATIONS.—Part A of title XII of the Public

19 Health Service Act (42 U.S.C. 300d et seq.), as amended

20 by section 601(b) of Public Law 103–183 (107 Stat.

21 2238), is amended—

22 (1) by redesignating sections 1202 and 1203 as

23 sections 1203 and 1204, respectively;

24 (2) by inserting after section 1201 the following

25 section:
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1 ‘‘SEC. 1202. STATE OFFICES OF EMERGENCY MEDICAL

2 SERVICES.

3 ‘‘(a) PROGRAM OF GRANTS.—The Secretary may

4 make grants to States for the purpose of improving the

5 availability and quality of emergency medical services

6 through the operation of State offices of emergency medi7 cal services.

8 ‘‘(b) REQUIREMENT OF MATCHING FUNDS.—

9 ‘‘(1) IN GENERAL.—The Secretary may not

10 make a grant under subsection (a) unless the State

11 involved agrees, with respect to the costs to be in12 curred by the State in carrying out the purpose de13 scribed in such subsection, to provide non-Federal

14 contributions toward such costs in an amount that—

15 ‘‘(A) for the first fiscal year of payments

16 under the grant, is not less than $1 for each $3

17 of Federal funds provided in the grant;

18 ‘‘(B) for any second fiscal year of such

19 payments, is not less than $1 for each $1 of

20 Federal funds provided in the grant; and

21 ‘‘(C) for any third fiscal year of such pay22 ments, is not less than $3 for each $1 of Fed23 eral funds provided in the grant.

24 ‘‘(2) DETERMINATION OF AMOUNT OF NON25 FEDERAL CONTRIBUTION.—
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1 ‘‘(A) Subject to subparagraph (B), non2 Federal contributions required in paragraph (1)

3 may be in cash or in kind, fairly evaluated, in4 cluding plant, equipment, or services. Amounts

5 provided by the Federal Government, or serv6 ices assisted or subsidized to any significant ex7 tent by the Federal Government, may not be in8 cluded in determining the amount of such non9 Federal contributions.

10 ‘‘(B) The Secretary may not make a grant

11 under subsection (a) unless the State involved

12 agrees that—

13 ‘‘(i) for the first fiscal year of pay14 ments under the grant, 100 percent or less

15 of the non-Federal contributions required

16 in paragraph (1) will be provided in the

17 form of in-kind contributions;

18 ‘‘(ii) for any second fiscal year of such

19 payments, not more than 50 percent of

20 such non-Federal contributions will be pro21 vided in the form of in-kind contributions;

22 and

23 ‘‘(iii) for any third fiscal year of such

24 payments, such non-Federal contributions

25 will be provided solely in the form of cash.
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1 ‘‘(c) CERTAIN REQUIRED ACTIVITIES.—The Sec2 retary may not make a grant under subsection (a) unless

3 the State involved agrees that activities carried out by an

4 office operated pursuant to such subsection will include—

5 ‘‘(1) coordinating the activities carried out in

6 the State that relate to emergency medical services;

7 ‘‘(2) activities regarding the matters described

8 in paragraphs (1) through (4) section 1201(b); and

9 ‘‘(3) identifying Federal and State programs re10 garding emergency medical services and providing

11 technical assistance to public and nonprofit private

12 entities regarding participation in such programs.

13 ‘‘(d) REQUIREMENT REGARDING ANNUAL BUDGET

14 FOR OFFICE.—The Secretary may not make a grant

15 under subsection (a) unless the State involved agrees that,

16 for any fiscal year for which the State receives such a

17 grant, the office operated pursuant to subsection (a) will

18 be provided with an annual budget of not less than

19 $50,000.

20 ‘‘(e) CERTAIN USES OF FUNDS.—

21 ‘‘(1) RESTRICTIONS.—The Secretary may not

22 make a grant under subsection (a) unless the State

23 involved agrees that—

24 ‘‘(A) if research with respect to emergency

25 medical services is conducted pursuant to the
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1 grant, not more than 10 percent of the grant

2 will be expended for such research; and

3 ‘‘(B) the grant will not be expended to pro4 vide emergency medical services (including pro5 viding cash payments regarding such services).

6 ‘‘(2) ESTABLISHMENT OF OFFICE.—Activities

7 for which a State may expend a grant under sub8 section (a) include paying the costs of establishing

9 an office of emergency medical services for purposes

10 of such subsection.

11 ‘‘(f) REPORTS.—The Secretary may not make a

12 grant under subsection (a) unless the State involved

13 agrees to submit to the Secretary reports containing such

14 information as the Secretary may require regarding activi15 ties carried out under this section by the State.

16 ‘‘(g) REQUIREMENT OF APPLICATION.—The Sec17 retary may not make a grant under subsection (a) unless

18 an application for the grant is submitted to the Secretary

19 and the application is in such form, is made in such man20 ner, and contains such agreements, assurances, and infor21 mation as the Secretary determines to be necessary to

22 carry out this section.’’; and

23 (3) in section 1204 (as redesignated by para24 graph (1) of this subsection)—
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1 (A) by redesignating subsection (c) as sub2 section (d); and

3 (B) by inserting after subsection (b) the

4 following new subsection:

5 ‘‘(c) DEMONSTRATION PROGRAM REGARDING TELE6 COMMUNICATIONS.—

7 ‘‘(1) LINKAGES FOR RURAL FACILITIES.—

8 Projects under subsection (a)(1) shall include dem9 onstration projects to establish telecommunications

10 between rural medical facilities and medical facilities

11 that have expertise or equipment that can be utilized

12 by the rural facilities through the telecommuni13 cations.

14 ‘‘(2) MODES OF COMMUNICATION.—The Sec15 retary shall ensure that the telecommunications

16 technologies demonstrated under paragraph (1) in17 clude interactive video telecommunications, static

18 video imaging transmitted through the telephone

19 system, and facsimiles transmitted through such sys20 tem.’’.

21 (c) FUNDING.—Section 1232 of the Public Health

22 Service Act (42 U.S.C. 300d–32) is amended by striking

23 subsections (a) and (b) and inserting the following:

24 ‘‘(a) EMERGENCY MEDICAL SERVICES GEN25 ERALLY.—
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1 ‘‘(1) IN GENERAL.—For the purpose of carry2 ing out section 1201 other than with respect to trau3 ma care, and for the purpose of carrying out section

4 1204(c), there are authorized to be appropriated

5 $2,000,000 for fiscal year 1995, and such sums as

6 may be necessary for each of the fiscal years 1996

7 and 1997.

8 ‘‘(2) STATE OFFICES.—For the purpose of car9 rying out section 1202, there are authorized to be

10 appropriated $3,000,000 for fiscal year 1995, and

11 such sums as may be necessary for each of the fiscal

12 years 1996 and 1997.

13 ‘‘(b) TRAUMA CARE AND CERTAIN OTHER ACTIVI14 TIES.—

15 ‘‘(1) IN GENERAL.—For the purpose of carry16 ing out part A with respect to trauma care, and for

17 the purpose of carrying out part B, there are au18 thorized to be appropriated $60,000,000 for fiscal

19 year 1995, and such sums as may be necessary for

20 each of the fiscal years 1996 and 1997.

21 ‘‘(2) ALLOCATION OF FUNDS BY SECRETARY.—

22 ‘‘(A) For the purpose of carrying out part

23 A with respect to trauma care, the Secretary

24 shall make available 10 percent of the amounts
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1 appropriated for a fiscal year under paragraph

2 (1).

3 ‘‘(B) For the purpose of carrying out sec4 tion 1204 (other than subsection (c) of such

5 section), the Secretary shall make available 10

6 percent of the amounts appropriated for a fiscal

7 year under paragraph (1).

8 ‘‘(C)(i) For the purpose of making allot9 ments under section 1211(a), the Secretary

10 shall, subject to subsection (c), make available

11 80 percent of the amounts appropriated for a

12 fiscal year under paragraph (1).

13 ‘‘(ii) Amounts paid to a State under sec14 tion 1211(a) for a fiscal year shall, for the pur15 poses for which the amounts were paid, remain

16 available for obligation until the end of the fis17 cal year immediately following the fiscal year

18 for which the amounts were paid.’’.

19 SEC. 312. GRANTS TO STATES REGARDING AIRCRAFT FOR

20 TRANSPORTING RURAL VICTIMS OF MEDICAL

21 EMERGENCIES.

22 Part E of title XII of the Public Health Service Act

23 (42 U.S.C. 300d–51 et seq.) is amended by adding at the

24 end the following new section:
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1 ‘‘SEC. 1252. GRANTS FOR SYSTEMS TO TRANSPORT RURAL

2 VICTIMS OF MEDICAL EMERGENCIES.

3 ‘‘(a) IN GENERAL.—The Secretary shall make grants

4 to States to assist such States in the creation or enhance5 ment of air medical transport systems that provide victims

6 of medical emergencies in rural areas with access to treat7 ments for the injuries or other conditions resulting from

8 such emergencies.

9 ‘‘(b) APPLICATION AND PLAN.—

10 ‘‘(1) APPLICATION.—To be eligible to receive a

11 grant under subsection (a), a State shall prepare

12 and submit to the Secretary an application in such

13 form, made in such manner, and containing such

14 agreements, assurances, and information, including

15 a State plan as required in paragraph (2), as the

16 Secretary determines to be necessary to carry out

17 this section.

18 ‘‘(2) STATE PLAN.—An application submitted

19 under paragraph (1) shall contain a State plan that

20 shall—

21 ‘‘(A) describe the intended uses of the

22 grant proceeds and the geographic areas to be

23 served;

24 ‘‘(B) demonstrate that the geographic

25 areas to be served, as described under subpara26 graph (A), are rural in nature;
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1 ‘‘(C) demonstrate that there is a lack of

2 facilities available and equipped to deliver ad3 vanced levels of medical care in the geographic

4 areas to be served;

5 ‘‘(D) demonstrate that in utilizing the

6 grant proceeds for the establishment or en7 hancement of air medical services the State

8 would be making a cost-effective improvement

9 to existing ground-based or air emergency medi10 cal service systems;

11 ‘‘(E) demonstrate that the State will not

12 utilize the grant proceeds to duplicate the capa13 bilities of existing air medical systems that are

14 effectively meeting the emergency medical needs

15 of the populations they serve;

16 ‘‘(F) demonstrate that in utilizing the

17 grant proceeds the State is likely to achieve a

18 reduction in the morbidity and mortality rates

19 of the areas to be served, as determined by the

20 Secretary;

21 ‘‘(G) demonstrate that the State, in utiliz22 ing the grant proceeds, will—

23 ‘‘(i) maintain the expenditures of the

24 State for air and ground medical transport

25 systems at a level equal to not less than
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1 the level of such expenditures maintained

2 by the State for the fiscal year preceding

3 the fiscal year for which the grant is re4 ceived; and

5 ‘‘(ii) ensure that recipients of direct

6 financial assistance from the State under

7 such grant will maintain expenditures of

8 such recipients for such systems at a level

9 at least equal to the level of such expendi10 tures maintained by such recipients for the

11 fiscal year preceding the fiscal year for

12 which the financial assistance is received;

13 ‘‘(H) demonstrate that persons experienced

14 in the field of air medical service delivery were

15 consulted in the preparation of the State plan;

16 and

17 ‘‘(I) contain such other information as the

18 Secretary may determine appropriate.

19 ‘‘(c) CONSIDERATIONS IN AWARDING GRANTS.—In

20 determining whether to award a grant to a State under

21 this section, the Secretary shall—

22 ‘‘(1) consider the rural nature of the areas to

23 be served with the grant proceeds and the services

24 to be provided with such proceeds, as identified in

25 the State plan submitted under subsection (b); and
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1 ‘‘(2) give preference to States with State plans

2 that demonstrate an effective integration of the pro3 posed air medical transport systems into a com4 prehensive network or plan for regional or statewide

5 emergency medical service delivery.

6 ‘‘(d) STATE ADMINISTRATION AND USE OF

7 GRANT.—

8 ‘‘(1) IN GENERAL.—The Secretary may not

9 make a grant to a State under subsection (a) unless

10 the State agrees that such grant will be adminis11 tered by the State agency with principal responsibil12 ity for carrying out programs regarding the provi13 sion of medical services to victims of medical emer14 gencies or trauma.

15 ‘‘(2) PERMITTED USES.—A State may use

16 amounts received under a grant awarded under this

17 section to award subgrants to public and private en18 tities operating within the State.

19 ‘‘(3) OPPORTUNITY FOR PUBLIC COMMENT.—

20 The Secretary may not make a grant to a State

21 under subsection (a) unless that State agrees that,

22 in developing and carrying out the State plan under

23 subsection (b)(2), the State will provide public notice

24 with respect to the plan (including any revisions
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1 thereto) and facilitate comments from interested

2 persons.

3 ‘‘(e) NUMBER OF GRANTS.—The Secretary shall

4 award grants under this section to not less than 7 States.

5 ‘‘(f) REPORTS.—

6 ‘‘(1) REQUIREMENT.—A State that receives a

7 grant under this section shall annually (during each

8 year in which the grant proceeds are used) prepare

9 and submit to the Secretary a report that shall con10 tain—

11 ‘‘(A) a description of the manner in which

12 the grant proceeds were utilized;

13 ‘‘(B) a description of the effectiveness of

14 the air medical transport programs assisted

15 with grant proceeds; and

16 ‘‘(C) such other information as the Sec17 retary may require.

18 ‘‘(2) TERMINATION OF FUNDING.—In reviewing

19 reports submitted under paragraph (1), if the Sec20 retary determines that a State is not using amounts

21 provided under a grant awarded under this section

22 in accordance with the State plan submitted by the

23 State under subsection (b), the Secretary may termi24 nate the payment of amounts under such grant to

25 the State until such time as the Secretary deter-
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1 mines that the State comes into compliance with

2 such plan.

3 ‘‘(g) DEFINITION.—As used in this section, the term

4 ‘rural areas’ means geographic areas that are located out5 side of standard metropolitan statistical areas, as identi6 fied by the Secretary.

7 ‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—There

8 are authorized to be appropriated to make grants under

9 this section, $15,000,000 for fiscal year 1995, and such

10 sums as may be necessary for each of the fiscal years 1996

11 and 1997.’’.

12 Subtitle C—Assistance to Rural

13 Providers Under Medicare

14 PART 1—MEDICARE ESSENTIAL ACCESS

15 COMMUNITY HOSPITALS

16 SEC. 321. AMENDMENTS TO ESSENTIAL ACCESS COMMU17 NITY HOSPITAL (EACH) PROGRAM UNDER

18 MEDICARE.

19 (a) INCREASING NUMBER OF PARTICIPATING

20 STATES.—Section 1820(a)(1) of the Social Security Act

21 (42 U.S.C. 1395i–4(a)(1)) is amended by striking ‘‘7’’ and

22 inserting ‘‘9’’.

23 (b) TREATMENT OF INPATIENT HOSPITAL SERVICES

24 PROVIDED IN RURAL PRIMARY CARE HOSPITALS.—
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1 (1) IN GENERAL.—Section 1820(f)(1)(F) of

2 such Act (42 U.S.C. 1395i–4(f)(1)(F)) is amended

3 to read as follows:

4 ‘‘(F) subject to paragraph (4), provides not

5 more than 6 inpatient beds (meeting such con6 ditions as the Secretary may establish) for pro7 viding inpatient care to patients requiring sta8 bilization before discharge or transfer to a hos9 pital, except that the facility may not provide

10 any inpatient hospital services—

11 ‘‘(i) to any patient whose attending

12 physician does not certify that the patient

13 may reasonably be expected to be dis14 charged or transferred to a hospital within

15 72 hours of admission to the facility; or

16 ‘‘(ii) consisting of surgery or any

17 other service requiring the use of general

18 anesthesia (other than surgical procedures

19 specified by the Secretary under section

20 1833(i)(1)(A)), unless the attending physi21 cian certifies that the risk associated with

22 transferring the patient to a hospital for

23 such services outweighs the benefits of

24 transferring the patient to a hospital for

25 such services.’’.
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1 (2) LIMITATION ON AVERAGE LENGTH OF

2 STAY.—Section 1820(f) of such Act (42 U.S.C.

3 1395i–4(f)) is amended by adding at the end the fol4 lowing new paragraph:

5 ‘‘(4) LIMITATION ON AVERAGE LENGTH OF IN6 PATIENT STAYS.—The Secretary may terminate a

7 designation of a rural primary care hospital under

8 paragraph (1) if the Secretary finds that the average

9 length of stay for inpatients at the facility during

10 the previous year in which the designation was in ef11 fect exceeded 72 hours. In determining the compli12 ance of a facility with the requirement of the pre13 vious sentence, there shall not be taken into account

14 periods of stay of inpatients in excess of 72 hours

15 to the extent such periods exceed 72 hours because

16 transfer to a hospital is precluded because of inclem17 ent weather or other emergency conditions.’’.

18 (3) CONFORMING AMENDMENT.—Section

19 1814(a)(8) of such Act (42 U.S.C. 1395f(a)(8)) is

20 amended by striking ‘‘such services’’ and all that fol21 lows and inserting ‘‘the individual may reasonably be

22 expected to be discharged or transferred to a hos23 pital within 72 hours after admission to the rural

24 primary care hospital.’’.
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1 (4) GAO REPORTS.—Not later than 2 years

2 after the date of the enactment of this Act, the

3 Comptroller General shall submit reports to Con4 gress on—

5 (A) the application of the requirements

6 under section 1820(f) of the Social Security Act

7 (as amended by this subsection) that rural pri8 mary care hospitals provide inpatient care only

9 to those individuals whose attending physicians

10 certify may reasonably be expected to be dis11 charged within 72 hours after admission and

12 maintain an average length of inpatient stay

13 during a year that does not exceed 72 hours;

14 and

15 (B) the extent to which such requirements

16 have resulted in such hospitals providing inpa17 tient care beyond their capabilities or have lim18 ited the ability of such hospitals to provide

19 needed services.

20 (c) DESIGNATION OF HOSPITALS.—

21 (1) PERMITTING DESIGNATION OF HOSPITALS

22 LOCATED IN URBAN AREAS.—

23 (A) IN GENERAL.—Section 1820 of such

24 Act (42 U.S.C. 1395i–4) is amended—
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1 (i) by striking paragraph (1) of sub2 section (e) and redesignating paragraphs

3 (2) through (6) as paragraphs (1) through

4 (5);

5 (ii) in subsection (e)(1)(A) (as redes6 ignated by subparagraph (A))—

7 (I) by striking ‘‘is located’’ and

8 inserting ‘‘except in the case of a hos9 pital located in an urban area, is lo10 cated’’,

11 (II) by striking ‘‘, (ii)’’ and in12 serting ‘‘or (ii)’’, and

13 (III) by striking ‘‘or (iii)’’ and all

14 that follows through ‘‘section,’’; and

15 (iii) in subsection (i)(1)(B), by strik16 ing ‘‘paragraph (3)’’ and inserting ‘‘para17 graph (2)’’.

18 (B) NO CHANGE IN MEDICARE PROSPEC19 TIVE PAYMENT.—Section 1886(d)(5)(D) of

20 such Act (42 U.S.C. 1395ww(d)(5)(D)) is

21 amended—

22 (i) in clause (iii)(III), by inserting ‘‘lo23 cated in a rural area and’’ after ‘‘that is’’,

24 and
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1 (ii) in clause (v), by inserting ‘‘located

2 in a rural area and’’ after ‘‘in the case of

3 a hospital’’.

4 (2) PERMITTING HOSPITALS LOCATED IN AD5 JOINING STATES TO PARTICIPATE IN STATE PRO6 GRAM.—

7 (A) IN GENERAL.—Section 1820 of such

8 Act (42 U.S.C. 1395i–4) is amended—

9 (i) by redesignating subsection (k) as

10 subsection (l); and

11 (ii) by inserting after subsection (j)

12 the following new subsection:

13 ‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN

14 PARTICIPATING STATES.—Notwithstanding any other

15 provision of this section—

16 ‘‘(1) for purposes of including a hospital or fa17 cility as a member institution of a rural health net18 work, a State may designate a hospital or facility

19 that is not located in the State as an essential access

20 community hospital or a rural primary care hospital

21 if the hospital or facility is located in an adjoining

22 State and is otherwise eligible for designation as

23 such a hospital;

24 ‘‘(2) the Secretary may designate a hospital or

25 facility that is not located in a State receiving a
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1 grant under subsection (a)(1) as an essential access

2 community hospital or a rural primary care hospital

3 if the hospital or facility is a member institution of

4 a rural health network of a State receiving a grant

5 under such subsection; and

6 ‘‘(3) a hospital or facility designated pursuant

7 to this subsection shall be eligible to receive a grant

8 under subsection (a)(2).’’.

9 (B) CONFORMING AMENDMENTS.—(i) Sec10 tion 1820(c)(1) of such Act (42 U.S.C. 1395i–

11 4(c)(1)) is amended by striking ‘‘paragraph

12 (3)’’ and inserting ‘‘paragraph (3) or subsection

13 (k)’’.

14 (ii) Paragraphs (1)(A) and (2)(A) of sec15 tion 1820(i) of such Act (42 U.S.C. 1395i–4(i))

16 are each amended—

17 (I) in clause (i), by striking ‘‘(a)(1)’’

18 and inserting ‘‘(a)(1) (except as provided

19 in subsection (k))’’, and

20 (II) in clause (ii), by striking ‘‘sub21 paragraph (B)’’ and inserting ‘‘subpara22 graph (B) or subsection (k)’’.

23 (d) SKILLED NURSING SERVICES IN RURAL PRIMARY

24 CARE HOSPITALS.—Section 1820(f)(3) of such Act (42

25 U.S.C. 1395i–4(f)(3)) is amended by striking ‘‘because
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1 the facility’’ and all that follows and inserting the follow2 ing: ‘‘because, at the time the facility applies to the State

3 for designation as a rural primary care hospital, there is

4 in effect an agreement between the facility and the Sec5 retary under section 1883 under which the facility’s inpa6 tient hospital facilities are used for the furnishing of ex7 tended care services, except that the number of beds used

8 for the furnishing of such services may not exceed the total

9 number of licensed inpatient beds at the time the facility

10 applies to the State for such designation (minus the num11 ber of inpatient beds used for providing inpatient care pur12 suant to paragraph (1)(F)). For purposes of the previous

13 sentence, the number of beds of the facility used for the

14 furnishing of extended care services shall not include any

15 beds of a unit of the facility that is licensed as a distinct16 part skilled nursing facility at the time the facility applies

17 to the State for designation as a rural primary care hos18 pital.’’.

19 (e) DEADLINE FOR DEVELOPMENT OF PROSPECTIVE

20 PAYMENT SYSTEM FOR INPATIENT RURAL PRIMARY

21 CARE HOSPITAL SERVICES.—Section 1814(l)(2) of such

22 Act (42 U.S.C. 1395f(l)(2)) is amended by striking ‘‘Jan23 uary 1, 1993’’ and inserting ‘‘January 1, 1996’’.

24 (f) PAYMENT FOR OUTPATIENT RURAL PRIMARY

25 CARE HOSPITAL SERVICES.—
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1 (1) IMPLEMENTATION OF PROSPECTIVE PAY2 MENT SYSTEM.—Section 1834(g) of such Act (42

3 U.S.C. 1395m(g)) is amended—

4 (A) in paragraph (1), by striking ‘‘during

5 a year before 1993’’ and inserting ‘‘during a

6 year before the prospective payment system de7 scribed in paragraph (2) is in effect’’; and

8 (B) in paragraph (2), by striking ‘‘January

9 1, 1993,’’ and inserting ‘‘January 1, 1996,’’.

10 (2) NO USE OF CUSTOMARY CHARGE IN DETER11 MINING PAYMENT.—Section 1834(g)(1) of such Act

12 (42 U.S.C. 1395m(g)(1)) is amended by adding at

13 the end the following new flush sentence:

14 ‘‘The amount of payment shall be determined under

15 either method without regard to the amount of the

16 customary or other charge.’’.

17 (g) CLARIFICATION OF PHYSICIAN STAFFING RE18 QUIREMENT FOR RURAL PRIMARY CARE HOSPITALS.—

19 Section 1820(f)(1)(H) of such Act (42 U.S.C. 1395i–

20 4(f)(1)(H)) is amended by striking the period and insert21 ing the following: ‘‘, except that in determining whether

22 a facility meets the requirements of this subparagraph,

23 subparagraphs (E) and (F) of that paragraph shall be ap24 plied as if any reference to a ‘physician’ is a reference

25 to a physician as defined in section 1861(r)(1).’’.
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1 (h) TECHNICAL AMENDMENTS RELATING TO PART

2 A DEDUCTIBLE, COINSURANCE, AND SPELL OF ILL3 NESS.—(1) Section 1812(a)(1) of such Act (42 U.S.C.

4 1395d(a)(1)) is amended—

5 (A) by striking ‘‘inpatient hospital services’’ the

6 first place it appears and inserting ‘‘inpatient hos7 pital services or inpatient rural primary care hos8 pital services’’;

9 (B) by striking ‘‘inpatient hospital services’’ the

10 second place it appears and inserting ‘‘such serv11 ices’’; and

12 (C) by striking ‘‘and inpatient rural primary

13 care hospital services’’.

14 (2) Sections 1813(a) and 1813(b)(3)(A) of such Act

15 (42 U.S.C. 1395e(a), 1395e(b)(3)(A)) are each amended

16 by striking ‘‘inpatient hospital services’’ each place it ap17 pears and inserting ‘‘inpatient hospital services or inpa18 tient rural primary care hospital services’’.

19 (3) Section 1813(b)(3)(B) of such Act (42 U.S.C.

20 1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos21 pital services’’ and inserting ‘‘inpatient hospital services,

22 inpatient rural primary care hospital services’’.

23 (4) Section 1861(a) of such Act (42 U.S.C. 1395x(a))

24 is amended—
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1 (A) in paragraph (1), by striking ‘‘inpatient

2 hospital services’’ and inserting ‘‘inpatient hospital

3 services, inpatient rural primary care hospital serv4 ices’’; and

5 (B) in paragraph (2), by striking ‘‘hospital’’

6 and inserting ‘‘hospital or rural primary care hos7 pital’’.

8 (i) AUTHORIZATION OF APPROPRIATIONS.—Section

9 1820(l) of such Act (42 U.S.C. 1395i–4(l)), as redesig10 nated by subsection (c)(2)(A), is amended by striking

11 ‘‘1990, 1991, and 1992’’ and inserting ‘‘1990 through

12 1995’’.

13 (j) EFFECTIVE DATE.—The amendments made by

14 this section shall take effect on the date of the enactment

15 of this Act.

16 PART 2—ESTABLISHMENT OF RURAL

17 EMERGENCY ACCESS CARE HOSPITALS

18 SEC. 331. RURAL EMERGENCY ACCESS CARE HOSPITALS

19 DESCRIBED.

20 (a) IN GENERAL.—Section 1861 of the Social Secu21 rity Act (42 U.S.C. 1395x) is amended by adding at the

22 end the following new subsection:
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1 ‘‘Rural Emergency Access Care Hospital; Rural

2 Emergency Access Care Hospital Services

3 ‘‘(oo)(1) The term ‘rural emergency access care hos4 pital’ means, for a fiscal year, a facility with respect to

5 which the Secretary finds the following:

6 ‘‘(A) The facility is located in a rural area (as

7 defined in section 1886(d)(2)(D)).

8 ‘‘(B) The facility was a hospital under this title

9 at any time during the 5-year period that ends on

10 the date of the enactment of this subsection.

11 ‘‘(C) The facility is in danger of closing due to

12 low inpatient utilization rates and negative operating

13 losses, and the closure of the facility would limit the

14 access of individuals residing in the facility’s service

15 area to emergency services.

16 ‘‘(D) The facility has entered into (or plans to

17 enter into) an agreement with a hospital with a par18 ticipation agreement in effect under section 1866(a),

19 and under such agreement the hospital shall accept

20 patients transferred to the hospital from the facility

21 and receive data from and transmit data to the facil22 ity.

23 ‘‘(E) There is a practitioner who is qualified to

24 provide advanced cardiac life support services (as de-
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1 termined by the State in which the facility is lo2 cated) on-site at the facility on a 24-hour basis.

3 ‘‘(F) A physician is available on-call to provide

4 emergency medical services on a 24-hour basis.

5 ‘‘(G) The facility meets such staffing require6 ments as would apply under section 1861(e) to a

7 hospital located in a rural area, except that—

8 ‘‘(i) the facility need not meet hospital

9 standards relating to the number of hours dur10 ing a day, or days during a week, in which the

11 facility must be open, except insofar as the fa12 cility is required to provide emergency care on

13 a 24-hour basis under subparagraphs (E) and

14 (F); and

15 ‘‘(ii) the facility may provide any services

16 otherwise required to be provided by a full-time,

17 on-site dietician, pharmacist, laboratory techni18 cian, medical technologist, or radiological tech19 nologist on a part-time, off-site basis.

20 ‘‘(H) The facility meets the requirements appli21 cable to clinics and facilities under subparagraphs

22 (C) through (J) of paragraph (2) of section

23 1861(aa) and of clauses (ii) and (iv) of the second

24 sentence of such paragraph (or, in the case of the

25 requirements of subparagraph (E), (F), or (J) of
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1 such paragraph, would meet the requirements if any

2 reference in such subparagraph to a ‘nurse practi3 tioner’ or to ‘nurse practitioners’ was deemed to be

4 a reference to a ‘nurse practitioner or nurse’ or to

5 ‘nurse practitioners or nurses’); except that in deter6 mining whether a facility meets the requirements of

7 this subparagraph, subparagraphs (E) and (F) of

8 that paragraph shall be applied as if any reference

9 to a ‘physician’ is a reference to a physician as de10 fined in section 1861(r)(1).

11 ‘‘(2) The term ‘rural emergency access care hospital

12 services’ means the following services provided by a rural

13 emergency access care hospital:

14 ‘‘(A) An appropriate medical screening exam15 ination (as described in section 1867(a)).

16 ‘‘(B) Necessary stabilizing examination and

17 treatment services for an emergency medical condi18 tion and labor (as described in section 1867(b)).’’.

19 (b) REQUIRING RURAL EMERGENCY ACCESS CARE

20 HOSPITALS TO MEET HOSPITAL ANTI-DUMPING RE21 QUIREMENTS.—Section 1867(e)(5) of such Act (42 U.S.C.

22 1395dd(e)(5)) is amended by striking ‘‘1861(mm)(1))’’

23 and inserting ‘‘1861(mm)(1)) and a rural emergency ac24 cess care hospital (as defined in section 1861(oo)(1))’’.
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1 SEC. 332. COVERAGE OF AND PAYMENT FOR SERVICES.

2 (a) COVERAGE UNDER PART B.—Section 1832(a)(2)

3 of the Social Security Act (42 U.S.C. 1395k(a)(2)) is

4 amended—

5 (1) by striking ‘‘and’’ at the end of subpara6 graph (I);

7 (2) by striking the period at the end of sub8 paragraph (J) and inserting ‘‘; and’’; and

9 (3) by adding at the end the following new sub10 paragraph:

11 ‘‘(K) rural emergency access care hospital

12 services (as defined in section 1861(oo)(2)).’’.

13 (b) PAYMENT BASED ON PAYMENT FOR OUTPATIENT

14 RURAL PRIMARY CARE HOSPITAL SERVICES.—

15 (1) IN GENERAL.—Section 1833(a)(6) of the

16 Social Security Act (42 U.S.C. 1395l(a)(6)) is

17 amended by striking ‘‘services,’’ and inserting ‘‘serv18 ices and rural emergency access care hospital serv19 ices,’’.

20 (2) PAYMENT METHODOLOGY DESCRIBED.—

21 Section 1834(g) of such Act (42 U.S.C. 1395m(g))

22 is amended—

23 (A) in the heading, by striking ‘‘SERV24 ICES’’ and inserting ‘‘SERVICES AND RURAL

25 EMERGENCY ACCESS CARE HOSPITAL SERV26 ICES’’; and
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1 (B) in paragraph (1), by striking ‘‘during

2 a year before 1993’’ and inserting ‘‘during a

3 year before the prospective payment system de4 scribed in paragraph (2) is in effect’’;

5 (C) in paragraph (1), by adding at the end

6 the following:

7 ‘‘The amount of payment shall be determined under

8 either method without regard to the amount of the

9 customary or other charge.’’;

10 (D) in paragraph (2), by striking ‘‘Janu11 ary 1, 1993,’’ and inserting ‘‘January 1,

12 1996,’’; and

13 (E) by adding at the end the following new

14 paragraph:

15 ‘‘(3) APPLICATION OF METHODS TO PAYMENT

16 FOR RURAL EMERGENCY ACCESS CARE HOSPITAL

17 SERVICES.—The amount of payment for rural emer18 gency access care hospital services provided during

19 a year shall be determined using the applicable

20 method provided under this subsection for determin21 ing payment for outpatient rural primary care hos22 pital services during the year.’’.

23 SEC. 333. EFFECTIVE DATE.

24 The amendments made by this part shall apply to fis25 cal years beginning on or after October 1, 1994.
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1 Subtitle D—Demonstration

2 Projects to Encourage Primary

3 Care and Rural-Based Graduate

4 Medical Education

5 SEC. 341. STATE AND CONSORTIUM DEMONSTRATION

6 PROJECTS.

7 (a) IN GENERAL.—

8 (1) PARTICIPATION OF STATES AND CONSOR9 TIA.—The Secretary shall establish and conduct a

10 demonstration project to increase the number and

11 percentage of medical students entering primary

12 care practice relative to those entering nonprimary

13 care practice under which the Secretary shall make

14 payments in accordance with subsection (d)—

15 (A) to not more than 10 States for the

16 purpose of testing and evaluating mechanisms

17 to meet the goals described in section 342; and

18 (B) to not more than 10 health care train19 ing consortia for the purpose of testing and

20 evaluating mechanisms to meet such goals.

21 (2) EXCLUSION OF CONSORTIA IN PARTICIPAT22 ING STATES.—A consortia may not receive payments

23 under the demonstration project under paragraph

24 (1)(B) if any of its members is located in a State
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1 receiving payments under the project under para2 graph (1)(A).

3 (b) APPLICATIONS.—

4 (1) IN GENERAL.—Each State and consortium

5 desiring to conduct a demonstration project under

6 this section shall prepare and submit to the Sec7 retary an application, at such time, in such manner,

8 and containing such information as the Secretary

9 may require to assure that the State or consortium

10 will meet the goals described in section 342. In the

11 case of an application of a State, the application

12 shall include—

13 (A) information demonstrating that the

14 State has consulted with interested parties with

15 respect to the project, including State medical

16 associations, State hospital associations, and

17 medical schools located in the State;

18 (B) an assurance that no hospital conduct19 ing an approved medical residency training pro20 gram in the State will lose more than 10 per21 cent of such hospital’s approved medical resi22 dency positions in any year as a result of the

23 project; and

24 (C) an explanation of a plan for evaluating

25 the impact of the project in the State.
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1 (2) APPROVAL OF APPLICATIONS.—A State or

2 consortium that submits an application under para3 graph (1) may begin a demonstration project under

4 this subsection—

5 (A) upon approval of such application by

6 the Secretary; or

7 (B) at the end of the 60-day period begin8 ning on the date such application is submitted,

9 unless the Secretary denies the application dur10 ing such period.

11 (3) NOTICE AND COMMENT.—A State or con12 sortium shall issue a public notice on the date it

13 submits an application under paragraph (1) which

14 contains a general description of the proposed dem15 onstration project. Any interested party may com16 ment on the proposed demonstration project to the

17 State or consortium or the Secretary during the 30-

18 day period beginning on the date the public notice

19 is issued.

20 (c) SPECIFIC REQUIREMENTS FOR PARTICIPANTS.—

21 (1) REQUIREMENTS FOR STATES.—Each State

22 participating in the demonstration project under this

23 subtitle shall use the payments provided under sub24 section (d) to test and evaluate either of the follow25 ing mechanisms to increase the number and percent-
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1 age of medical students entering primary care prac2 tice relative to those entering nonprimary care prac3 tice:

4 (A) USE OF ALTERNATIVE WEIGHTING

5 FACTORS.—

6 (i) IN GENERAL.—The State may

7 make payments to hospitals in the State

8 for direct graduate medical education costs

9 in amounts determined under the meth10 odology provided under section 1886(h) of

11 the Social Security Act, except that the

12 State shall apply weighting factors that are

13 different than the weighting factors other14 wise set forth in section 1886(h)(4)(C) of

15 the Social Security Act.

16 (ii) USE OF PAYMENTS FOR PRIMARY

17 CARE RESIDENTS.—In applying different

18 weighting factors under clause (i), the

19 State shall ensure that the amount of pay20 ment made to hospitals for costs attrib21 utable to primary care residents shall be

22 greater than the amount that would have

23 been paid to hospitals for costs attributable

24 to such residents if the State had applied

25 the weighting factors otherwise set forth in
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1 section 1886(h)(4)(C) of the Social Secu2 rity Act.

3 (B) PAYMENTS FOR MEDICAL EDUCATION

4 THROUGH CONSORTIUM.—The State may make

5 payments for graduate medical education costs

6 through payments to a health care training con7 sortium (or through any entity identified by

8 such a consortium as appropriate for receiving

9 payments on behalf of the consortium) that is

10 established in the State but that is not other11 wise participating in the demonstration project.

12 (2) REQUIREMENTS FOR CONSORTIUM.—

13 (A) IN GENERAL.—In the case of a consor14 tium participating in the demonstration project

15 under this subtitle, the Secretary shall make

16 payments for graduate medical education costs

17 through a health care training consortium

18 whose members provide medical residency train19 ing (or through any entity identified by such a

20 consortium as appropriate for receiving pay21 ments on behalf of the consortium).

22 (B) USE OF PAYMENTS.—

23 (i) IN GENERAL.—Each consortium

24 receiving payments under subparagraph

25 (A) shall use such funds to conduct activi-
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1 ties which test and evaluate mechanisms to

2 increase the number and percentage of

3 medical students entering primary care

4 practice relative to those entering

5 nonprimary care practice, and may use

6 such funds for the operation of the consor7 tium.

8 (ii) PAYMENTS TO PARTICIPATING

9 PROGRAMS.—The consortium shall ensure

10 that the majority of the payments received

11 under subparagraph (A) are directed to

12 consortium members for primary care resi13 dency programs, and shall designate for

14 each resident assigned to the consortium a

15 hospital operating an approved medical

16 residency training program for purposes of

17 enabling the Secretary to calculate the con18 sortium’s payment amount under the

19 project. Such hospital shall be the hospital

20 where the resident receives the majority of

21 the resident’s hospital-based, non22 ambulatory training experience.

23 (d) ALLOCATION OF PORTION OF MEDICARE GME

24 PAYMENTS FOR ACTIVITIES UNDER PROJECT.—Notwith25 standing any provision of title XVIII of the Social Security
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1 Act, the following rules apply with respect to each State

2 and each health care training consortium participating in

3 the demonstration project established under this section

4 during a year:

5 (1) In the case of a State—

6 (A) the Secretary shall reduce the amount

7 of each payment made to hospitals in the State

8 during the year for direct graduate medical

9 education costs under section 1886(h) of the

10 Social Security Act by 3 percent; and

11 (B) the Secretary shall pay the State an

12 amount equal to the Secretary’s estimate of the

13 sum of the reductions made during the year

14 under subparagraph (A) (as adjusted by the

15 Secretary in subsequent years for over- or

16 under-estimations in the amount estimated

17 under this subparagraph in previous years).

18 (2) In the case of a consortium—

19 (A) the Secretary shall reduce the amount

20 of each payment made to hospitals who are

21 members of the consortium during the year for

22 direct graduate medical education costs under

23 section 1886(h) of the Social Security Act by 3

24 percent; and
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1 (B) the Secretary shall pay the consortium

2 an amount equal to the Secretary’s estimate of

3 the sum of the reductions made during the year

4 under subparagraph (A) (as adjusted by the

5 Secretary in subsequent years for over- or

6 under-estimations in the amount estimated

7 under this subparagraph in previous years).

8 (e) ADDITIONAL GRANT FOR PLANNING AND EVAL9 UATION.—

10 (1) IN GENERAL.—The Secretary may award

11 grants to States and consortia participating in the

12 demonstration project under this section for the pur13 pose of developing and evaluating such projects. A

14 State or consortia may conduct such an evaluation

15 or contract with a private entity to conduct the eval16 uation. Each State and consortia desiring to receive

17 a grant under this paragraph shall prepare and sub18 mit to the Secretary an application, at such time, in

19 such manner, and containing such information as

20 the Secretary may require.

21 (2) AUTHORIZATION OF APPROPRIATIONS.—

22 There are authorized to be appropriated such sums

23 as may be necessary for grants under this paragraph

24 for fiscal years 1995 through 2000.
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1 (f) DURATION.—A demonstration project under this

2 section shall be conducted for a period not to exceed 5

3 years. The Secretary may terminate a project if the Sec4 retary determines that the State or consortium conducting

5 the project is not in substantial compliance with the terms

6 of the application approved by the Secretary.

7 (g) EVALUATIONS AND REPORTS.—

8 (1) EVALUATIONS.—Each State or consortium

9 participating in the demonstration project shall sub10 mit to the Secretary a final evaluation within 360

11 days of the termination of the State or consortium’s

12 participation and such interim evaluations as the

13 Secretary may require.

14 (2) REPORTS TO CONGRESS.—Not later than

15 360 days after the first demonstration project under

16 this subtitle begins, and annually thereafter for each

17 year in which such a project is conducted, the Sec18 retary shall submit a report to Congress which eval19 uates the effectiveness of the State and consortium

20 activities conducted under such projects and includes

21 any legislative recommendations determined appro22 priate by the Secretary.

23 (h) MAINTENANCE OF EFFORT.—Any funds available

24 for the activities covered by a demonstration project under

25 this subtitle shall supplement, and shall not supplant,
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1 funds that are expended for similar purposes under any

2 State, regional, or local program.

3 SEC. 342. GOALS FOR PROJECTS.

4 The goals referred to in this section for a State or

5 consortium participating in the demonstration project

6 under this subtitle are as follows:

7 (1) The training of an equal number of physi8 cian and non-physician primary care providers.

9 (2) The recruiting of residents for graduate

10 medical education training programs who received a

11 portion of undergraduate training in a rural area.

12 (3) The allocation of not less than 50 percent

13 of the training spent in a graduate medical residency

14 training program at sites at which acute care inpa15 tient hospital services are not furnished.

16 (4) The rotation of residents in approved medi17 cal residency training programs among practices

18 that serve residents of rural areas.

19 (5) The development of a plan under which,

20 after a 5-year transition period, not less than 50

21 percent of the residents who begin an initial resi22 dency period in an approved medical residency train23 ing program shall be primary care residents.

24 SEC. 343. DEFINITIONS.

25 In this subtitle:
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1 (1) APPROVED MEDICAL RESIDENCY TRAINING

2 PROGRAM.—The term ‘‘approved medical residency

3 training program’’ has the meaning given such term

4 in section 1886(h)(5)(A) of the Social Security Act.

5 (2) HEALTH CARE TRAINING CONSORTIUM.—

6 The term ‘‘health care training consortium’’ means

7 a State, regional, or local entity consisting of at

8 least one of each of the following:

9 (A) A hospital operating an approved med10 ical residency training program at which resi11 dents receive training at ambulatory training

12 sites located in rural areas.

13 (B) A school of medicine or osteopathic

14 medicine.

15 (C) A school of allied health or a program

16 for the training of physician assistants (as such

17 terms are defined in section 799 of the Public

18 Health Service Act).

19 (D) A school of nursing (as defined in sec20 tion 853 of the Public Health Service Act).

21 (3) PRIMARY CARE.—The term ‘‘primary care’’

22 means family practice, general internal medicine,

23 general pediatrics, and obstetrics and gynecology.
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1 (4) RESIDENT.—The term ‘‘resident’’ has the

2 meaning given such term in section 1886(h)(5)(H)

3 of the Social Security Act.

4 (5) RURAL AREA.—The term ‘‘rural area’’ has

5 the meaning given such term in section

6 1886(d)(2)(D) of the Social Security Act.

7 TITLE IV—UNITED STATES-MEX8 ICO BORDER HEALTH COM9 MISSION

10 SEC. 401. AGREEMENT TO ESTABLISH BINATIONAL COM11 MISSION.

12 The President is authorized and encouraged to con13 clude an agreement with Mexico to establish a binational

14 commission to be known as the United States-Mexico Bor15 der Health Commission.

16 SEC. 402. DUTIES.

17 It should be the duty of the Commission—

18 (1) to conduct a comprehensive needs assess19 ment in the United States-Mexico border area for

20 the purposes of identifying, evaluating, preventing,

21 and resolving health problems that affect the general

22 population of the area;

23 (2) to implement the actions recommended by

24 the needs assessment by—
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1 (A) assisting in the coordination of the ef2 forts of public and private persons to prevent

3 and resolve such health problems,

4 (B) assisting in the coordination of the ef5 forts of public and private persons to educate

6 such population concerning such health prob7 lems, and

8 (C) developing and implementing programs

9 to prevent and resolve such health problems

10 and to educate such population concerning such

11 health problems where a program is necessary

12 to meet a need that is not being met by the ef13 forts of other public or private persons; and

14 (3) to formulate recommendations to the Gov15 ernments of the United States and Mexico concern16 ing a fair and reasonable method by which the gov17 ernment of one country would reimburse a public or

18 private person in the other country for the cost of

19 a health care service that the person furnishes to a

20 citizen or resident alien of the first country who is

21 unable, through insurance or otherwise, to pay for

22 the service.

23 SEC. 403. OTHER AUTHORIZED FUNCTIONS.

24 In addition to the duties described in section 402, the

25 Commission should be authorized to perform the following
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1 additional functions as the Commission determines to be

2 appropriate:

3 (1) To conduct or sponsor investigations, re4 search, or studies designed to identify, study, and

5 monitor health problems that affect the general pop6 ulation in the United States-Mexico border area.

7 (2) To provide financial, technical, or adminis8 trative assistance to public or private persons who

9 act to prevent, resolve, or educate such population

10 concerning such health problems.

11 SEC. 404. MEMBERSHIP.

12 (a) NUMBER AND APPOINTMENT OF UNITED STATES

13 SECTION.—The United States section of the Commission

14 should be composed of 13 members. The section should

15 consist of the following members:

16 (1) The Secretary of Health and Human Serv17 ices or such individual’s delegate.

18 (2) The commissioners of health from the

19 States of Texas, New Mexico, California, and Ari20 zona or such individuals’ delegates.

21 (3) 2 individuals from each of the States of

22 Texas, New Mexico, California, and Arizona who are

23 nominated by the chief executive officer of one of

24 such States and are appointed by the President from

25 among individuals—
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1 (A) who have a demonstrated interest in

2 health issues of the United States-Mexico bor3 der area; and

4 (B) whose name appears on a list of 6

5 nominees submitted to the President by the

6 chief executive officer of the State where the

7 nominee resides.

8 (b) COMMISSIONER.—The Commissioner of the

9 United States section of the Commission should be the

10 Secretary of Health and Human Services or such individ11 ual’s delegate to the Commission. The Commissioner

12 should be the leader of the section.

13 SEC. 405. REGIONAL OFFICES.

14 The Commission should establish no fewer than 2 re15 gional border offices in locations selected by the Commis16 sion.

17 SEC. 406. REPORTS.

18 Not later than February 1 of each year that occurs

19 more than 1 year after the date of the establishment of

20 the Commission, the Commission should submit an annual

21 report to both the United States Government and the Gov22 ernment of Mexico regarding all activities of the Commis23 sion during the preceding calendar year.

24 SEC. 407. DEFINITIONS.

25 For purposes of this Act:
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1 (1) COMMISSION.—The term ‘‘Commission’’

2 means the United States-Mexico Border Health

3 Commission authorized in section 401.

4 (2) HEALTH PROBLEM.—The term ‘‘health

5 problem’’ means a disease or medical ailment or an

6 environmental condition that poses the risk of dis7 ease or medical ailment. The term includes diseases,

8 ailments, or risks of disease or ailment caused by or

9 related to environmental factors, control of animals

10 and rabies, control of insect and rodent vectors, dis11 posal of solid and hazardous waste, and control and

12 monitoring of air and water quality.

13 (3) RESIDENT ALIEN.—The term ‘‘resident

14 alien’’, when used in reference to a country, means

15 an alien lawfully admitted for permanent residence

16 to the country or otherwise permanently residing in

17 the country under color of law (including residence

18 as an asylee, refugee, or parolee).

19 (4) UNITED STATES-MEXICO BORDER AREA.—

20 The term ‘‘United States-Mexico border area’’

21 means the area located in the United States and

22 Mexico within 100 kilometers of the border between

23 the United States and Mexico.
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1 TITLE V—HOSPITAL ANTITRUST

2 FAIRNESS

3 SEC. 501. ANTITRUST EXEMPTION.

4 The antitrust laws shall not apply with respect to—

5 (1) the merger of, or the attempt to merge, 2

6 or more hospitals,

7 (2) a contract entered into solely by 2 or more

8 hospitals to allocate hospital services, or

9 (3) the attempt by only 2 or more hospitals to

10 enter into a contract to allocate hospital services,

11 if each of such hospitals satisfies all of the requirements

12 of section 503 at the time such hospitals engage in the

13 conduct described in paragraph (1), (2), or (3), as the case

14 may be.

15 SEC. 502. REQUIREMENTS.

16 The requirements referred to in section 501 are as

17 follows:

18 (1) The hospital is located outside of a city, or

19 in a city that has less than 150,000 inhabitants, as

20 determined in accordance with the most recent data

21 available from the Bureau of the Census.

22 (2) In the most recently concluded calendar

23 year, the hospital received more than 40 percent of

24 its gross revenue from payments made under Fed25 eral programs.
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1 (3) There is in effect with respect to the hos2 pital a certificate issued by the Health Care Financ3 ing Administration specifying that such Administra4 tion has determined that Federal expenditures would

5 be reduced, consumer costs would not increase, and

6 access to health care services would not be reduced,

7 if the hospital and the other hospitals that requested

8 such certificate merge, or allocate the hospital serv9 ices specified in such request, as the case may be.

10 SEC. 503. DEFINITION.

11 For purposes of this title, the term ‘‘antitrust laws’’

12 has the meaning given such term in subsection (a) of the

13 first section of the Clayton Act (15 U.S.C. 12), except that

14 such term includes section 5 of the Federal Trade Com15 mission Act (15 U.S.C. 45) to the extent that such section

16 5 applies with respect to unfair methods of competition.

17 TITLE VI—FINANCING

18 SEC. 601. INCREASE IN MEDICARE PART B PREMIUM FOR

19 INDIVIDUALS WITH HIGH INCOME.

20 (a) IN GENERAL.—Subchapter A of chapter 1 of the

21 Internal Revenue Code of 1986 is amended by adding at

22 the end thereof the following new part:

23 ‘‘PART VIII—MEDICARE PART B PREMIUMS FOR

24 HIGH-INCOME INDIVIDUALS

‘‘Sec. 59B. Medicare part B premium tax.
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1 ‘‘SEC. 59B. MEDICARE PART B PREMIUM TAX.

2 ‘‘(a) IMPOSITION OF TAX.—In the case of an individ3 ual to whom this section applies for the taxable year, there

4 is hereby imposed (in addition to any other tax imposed

5 by this subtitle) a tax for such taxable year equal to the

6 aggregate of the Medicare part B premium taxes for each

7 of the months during such year that such individual is

8 covered by Medicare part B.

9 ‘‘(b) INDIVIDUALS TO WHOM SECTION APPLIES.—

10 This section shall apply to any individual for any taxable

11 year if—

12 ‘‘(1) such individual is covered under Medicare

13 part B for any month during such year, and

14 ‘‘(2) the modified adjusted gross income of the

15 taxpayer for such taxable year exceeds the threshold

16 amount.

17 ‘‘(c) MEDICARE PART B PREMIUM TAX FOR

18 MONTH.—

19 ‘‘(1) IN GENERAL.—The Medicare part B premium tax for any month is 2 20 ⁄3 the amount equal to

21 the excess of—

22 ‘‘(A) 200 percent of the monthly actuarial

23 rate for enrollees age 65 and over determined

24 for that calendar year under section 1839(b) of

25 the Social Security Act, over
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1 ‘‘(B) the total monthly premium under sec2 tion 1839 of the Social Security Act (deter3 mined without regard to subsections (b) and (f)

4 of section 1839 of such Act).

5 ‘‘(2) PHASEIN OF TAX.—If the modified ad6 justed gross income of the taxpayer for any taxable

7 years exceeds the threshold amount by less than

8 $25,000, the Medicare part B premium tax for any

9 month during such taxable year shall be an amount

10 which bears the same ratio to the amount deter11 mined under paragraph (1) (without regard to this

12 paragraph) as such excess bears to $25,000. The

13 preceding sentence shall not apply to any individual

14 whose threshold amount is zero.

15 ‘‘(d) OTHER DEFINITIONS AND SPECIAL RULES.—

16 For purposes of this section—

17 ‘‘(1) THRESHOLD AMOUNT.—The term ‘thresh18 old amount’ means—

19 ‘‘(A) except as otherwise provided in this

20 paragraph, $100,000,

21 ‘‘(B) $125,000 in the case of a joint re22 turn, and

23 ‘‘(C) zero in the case of a taxpayer who—
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1 ‘‘(i) is married at the close of the tax2 able year but does not file a joint return

3 for such year, and

4 ‘‘(ii) does not live apart from his

5 spouse at all times during the taxable year.

6 ‘‘(2) MODIFIED ADJUSTED GROSS INCOME.—

7 The term ‘modified adjusted gross income’ means

8 adjusted gross income—

9 ‘‘(A) determined without regard to sections

10 135, 911, 931, and 933, and

11 ‘‘(B) increased by the amount of interest

12 received or accrued by the taxpayer during the

13 taxable year which is exempt from tax.

14 ‘‘(3) MEDICARE PART B COVERAGE.—An indi15 vidual shall be treated as covered under Medicare

16 part B for any month if a premium is paid under

17 part B of title XVIII of the Social Security Act for

18 the coverage of the individual under such part for

19 the month.

20 ‘‘(4) MARRIED INDIVIDUAL.—The determina21 tion of whether an individual is married shall be

22 made in accordance with section 7703.’’

23 (b) CLERICAL AMENDMENT.—The table of parts for

24 subchapter A of chapter 1 of such Code is amended by

25 adding at the end thereof the following new item:
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‘‘Part VIII. Medicare Part B Premiums For High-Income Individuals.’’

1 (c) EFFECTIVE DATE.—The amendments made by

2 this section shall apply to months after December 1994

3 in taxable years ending after December 31, 1994.

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