II

103D CONGRESS

1ST SESSION S. 1143

To improve the delivery of health care services in rural areas by creating

an Assistant Secretary for Rural Health, to amend title XVIII of the

Social Security Act to provide that medical assistance facilities be reimbursed based on reasonable cost, to establish a grant program for the

use of interactive telecommunications systems, and to adjust the payments made for certain direct graduate medical education expenses.

IN THE SENATE OF THE UNITED STATES

JUNE 22, 1993

Mr. BAUCUS (for himself, Mr. CONRAD, Mrs. MURRAY, Mr. INOUYE, and Mr.

DORGAN) introduced the following bill; which was read twice and referred

to the Committee on Finance

A BILL

To improve the delivery of health care services in rural

areas by creating an Assistant Secretary for Rural

Health, to amend title XVIII of the Social Security Act

to provide that medical assistance facilities be reimbursed

based on reasonable cost, to establish a grant program

for the use of interactive telecommunications systems,

and to adjust the payments made for certain direct graduate medical education expenses.

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.

2 This Act may be cited as the ‘‘Rural Health Improve3 ment Act of 1993’’.

4 SEC. 2. OFFICE OF RURAL HEALTH POLICY.

5 (a) APPOINTMENT OF ASSISTANT SECRETARY.—

6 (1) IN GENERAL.—Section 711(a) of the Social

7 Security Act (42 U.S.C. 912(a)) is amended—

8 (A) by striking ‘‘by a Director, who shall

9 advise the Secretary’’ and inserting ‘‘by an As10 sistant Secretary for Rural Health (in this sec11 tion referred to as the ‘Assistant Secretary’),

12 who shall report directly to the Secretary’’; and

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

14 sentence: ‘‘The Office shall not be a component

15 of any other office, service, or component of the

16 Department.’’.

17 (2) CONFORMING AMENDMENTS.—(A) Section

18 711(b) of the Social Security Act (42 U.S.C. 912(b))

19 is amended by striking ‘‘the Director’’ and inserting

20 ‘‘the Assistant Secretary’’.

21 (B) Section 338J(a) of the Public Health Serv22 ice Act (42 U.S.C. 254r(a)) is amended by striking

23 ‘‘Director of the Office of Rural Health Policy’’ and

24 inserting ‘‘Assistant Secretary for Rural Health’’.

25 (C) Section 464T(b) of the Public Health Serv26 ice Act (42 U.S.C. 285p–2(b)) is amended in the
3

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1 matter preceding paragraph (1) by striking ‘‘Direc2 tor of the Office of Rural Health Policy’’ and insert3 ing ‘‘Assistant Secretary for Rural Health’’.

4 (D) Section 6213 of the Omnibus Budget Rec5 onciliation Act of 1989 (42 U.S.C. 1395x note) is

6 amended in subsection (e)(1) by striking ‘‘Director

7 of the Office of Rural Health Policy’’ and inserting

8 ‘‘Assistant Secretary for Rural Health’’.

9 (E) Section 403 of the Ryan White Comprehen10 sive AIDS Resources Emergency Act of 1990 (42

11 U.S.C. 300ff–11 note) is amended in the matter pre12 ceding paragraph (1) of subsection (a) by striking

13 ‘‘Director of the Office of Rural Health Policy’’ and

14 inserting ‘‘Assistant Secretary for Rural Health’’.

15 (3) AMENDMENT TO THE EXECUTIVE SCHED16 ULE.—Section 5315 of title 5, United States Code,

17 is amended by striking ‘‘Assistant Secretaries of

18 Health and Human Services (5)’’ and inserting ‘‘As19 sistant Secretaries of Health and Human Services

20 (6)’’.

21 (b) EXPANSION OF DUTIES.—Section 711(a) of the

22 Social Security Act (42 U.S.C. 912(a)) is amended by

23 striking ‘‘and access to (and the quality of) health care

24 in rural areas’’ and inserting ‘‘access to, and quality of,

25 health care in rural areas, and reforms to the health care
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1 system and the implications of such reforms for rural

2 areas’’.

3 SEC. 3. COVERAGE OF, AND PAYMENT FOR, MEDICAL AS4 SISTANCE FACILITY SERVICES.

5 (a) AMENDMENTS TO PART A.—

6 (1) DEFINITIONS.—Section 1861 of the Social

7 Security Act (42 U.S.C. 1395x) is amended by add8 ing at the end the following new subsection:

9 ‘‘Medical Assistance Facility; Medical Assistance Facility

10 Services

11 ‘‘(oo)(1) The term ‘medical assistance facility’ means

12 a facility which—

13 ‘‘(A) is located in a county (or equivalent unit

14 of local government) with fewer than 6 residents per

15 square mile or is located more than a 35 mile drive

16 from a hospital, a rural primary care hospital, or an17 other facility described in this subsection;

18 ‘‘(B) furnishes services to ill or injured individ19 uals prior to the transportation of such individuals

20 to a hospital or furnishes inpatient care to individ21 uals needing such care for a period not longer than

22 96 hours;

23 ‘‘(C) permits a physician assistant or nurse

24 practitioner to admit and treat patients under the
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1 supervision of a physician not present in such facil2 ity;

3 ‘‘(D) meets the requirements of section 1861(e)

4 that are applicable to a hospital located in a rural

5 area except that—

6 ‘‘(i) with respect to any requirements relat7 ing to the number of hours that the facility

8 must be open on a daily or weekly basis, the fa9 cility is only required to meet the requirement

10 to provide emergency care on a 24-hour basis;

11 ‘‘(ii) with respect to any services required

12 under such section to be furnished by a dieti13 cian, pharmacist, laboratory technician, medical

14 technologist, and radiological technologist, the

15 facility may furnish such services on a part16 time, off-site basis; and

17 ‘‘(iii) the inpatient care described in sub18 paragraph (B) may be furnished by a physician

19 assistant or nurse practitioner as provided in

20 subparagraph (C);

21 ‘‘(E) receives a certification of medical necessity

22 and appropriateness by a peer review organization

23 (or the equivalent of a peer review organization)

24 upon admitting each patient on an inpatient basis

25 or, in the case of admissions that do not occur dur-
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1 ing regular business hours, receives such a certifi2 cation at the earliest possible time; and

3 ‘‘(F) may enter into an agreement with the Sec4 retary under section 1883 under which the facility’s

5 inpatient hospital facilities may be used for the fur6 nishing of services of the type which, if furnished by

7 a skilled nursing facility, would constitute extended

8 care services.

9 ‘‘(2) The term ‘inpatient medical assistance facility

10 services’ means items and services furnished to an inpa11 tient of a medical assistance facility by such facility that

12 would be inpatient hospital services if furnished to an in13 patient of a hospital by a hospital.’’.

14 (2) COVERAGE AND PAYMENT.—(A) Section

15 1812(a)(1) of such Act (42 U.S.C. 1395d(a)(1)) is

16 amended by striking ‘‘and inpatient rural primary

17 care hospital services’’ and inserting ‘‘, inpatient

18 rural primary care hospital services, and inpatient

19 medical assistance facility services’’.

20 (B) Section 1814 of such Act (42 U.S.C.

21 1395f) is amended—

22 (i) in subsection (a)—

23 (I) by striking ‘‘and’’ at the end of

24 paragraph (7),
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1 (II) by striking the period at the end

2 of paragraph (8) and inserting ‘‘; and’’,

3 and

4 (III) by inserting after paragraph (8)

5 the following new paragraph:

6 ‘‘(9) in the case of inpatient medical assistance

7 facility services, a physician certifies that such serv8 ices were required to be immediately furnished on a

9 temporary, inpatient basis.’’;

10 (ii) in subsection (b), by striking ‘‘inpa11 tient rural primary care hospital services,’’ and

12 inserting ‘‘inpatient rural primary care hospital

13 services, other than a medical assistance facility

14 providing inpatient medical assistance facility

15 services,’’; and

16 (iii) by adding at the end the following new

17 subsection:

18 ‘‘Payment for Inpatient Medical Assistance Facility

19 Services

20 ‘‘(m) The amount of payment under this part for in21 patient medical assistance facility services is the reason22 able costs of the medical assistance facility in providing

23 such services.’’.

24 (3) TREATMENT OF MEDICAL ASSISTANCE FA25 CILITIES AS PROVIDERS OF SERVICES.—(A) Section
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1 1861(u) of such Act (42 U.S.C. 1395x(u)) is amend2 ed by inserting ‘‘medical assistance facility,’’ after

3 ‘‘rural primary care hospital,’’.

4 (B) The first sentence of section 1864(a) of

5 such Act (42 U.S.C. 1395aa(a)) is amended by in6 serting ‘‘a medical assistance facility, as defined in

7 section 1861(oo)(1),’’ after ‘‘1861(mm)(1),’’.

8 (C) The third sentence of section 1865(a) of

9 such Act (42 U.S.C. 1395bb(a)) is amended by

10 striking ‘‘or 1861(mm)(1)’’ and inserting

11 ‘‘1861(mm)(1), or 1861(oo)(1),’’.

12 (4) CONFORMING AMENDMENTS.—(A) Section

13 1128A(b)(1) of such Act (42 U.S.C. 1320a–

14 7a(b)(1)) is amended—

15 (i) by striking ‘‘or a rural primary care

16 hospital’’ the first place it appears and insert17 ing ‘‘, a rural primary care hospital, or a medi18 cal assistance facility’’; and

19 (ii) by striking ‘‘or a rural primary care

20 hospital’’ the second place it appears and in21 serting ‘‘, the rural primary care hospital, or

22 the medical assistance facility’’.

23 (B) Section 1128B(c) of such Act (42 U.S.C.

24 1320a–7b(c)) is amended by inserting ‘‘medical as-
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1 sistance facility,’’ after ‘‘rural primary care hos2 pital,’’.

3 (C) Section 1134 of such Act (42 U.S.C.

4 1320b–4) is amended by striking ‘‘or rural primary

5 care hospitals’’ each place it appears and inserting

6 ‘‘, rural primary care hospitals, or medical assist7 ance facilities’’.

8 (D) Section 1138(a)(1) of such Act (42 U.S.C.

9 1320b–8(a)(1)) is amended—

10 (i) in the matter preceding subparagraph

11 (A), by striking ‘‘or rural primary care hos12 pital’’ and inserting ‘‘, rural primary care hos13 pital, or medical assistance facility’’, and

14 (ii) in the matter preceding clause (i) of

15 subparagraph (A), by striking ‘‘or rural pri16 mary care hospital’’ and inserting ‘‘, rural pri17 mary care hospital, or medical assistance facil18 ity’’.

19 (E) Section 1164(e) of such Act (42 U.S.C.

20 1320c–13(e)) is amended by inserting ‘‘medical as21 sistance facilities,’’ after ‘‘rural primary care hos22 pitals,’’.

23 (F) Section 1816(c)(2)(C) of such Act (42

24 U.S.C. 1395h(c)(2)(C)) is amended by inserting
10

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1 ‘‘medical assistance facility,’’ after ‘‘rural primary

2 care hospital,’’.

3 (G) Section 1833 of such Act (42 U.S.C. 1395l)

4 is amended—

5 (i) in subsection (h)(5)(A)(iii)—

6 (I) by striking ‘‘or rural primary care

7 hospital’’ and inserting ‘‘rural primary

8 care hospital, or medical assistance facil9 ity’’; and

10 (II) by striking ‘‘to the hospital’’ and

11 inserting ‘‘to the hospital or the facility’’;

12 (ii) in subsection (i)(1)(A), by inserting

13 ‘‘medical assistance facility,’’ after ‘‘rural pri14 mary care hospital,’’;

15 (iii) in subsection (i)(3)(A), by striking ‘‘or

16 rural primary care hospital services’’ and in17 serting ‘‘rural primary care hospital services, or

18 medical assistance facility services’’;

19 (iv) in subsection (l)(5)(A), by inserting

20 ‘‘medical assistance facility,’’ after ‘‘rural pri21 mary care hospital,’’ each place it appears; and

22 (v) in subsection (l)(5)(C), by striking ‘‘or

23 rural primary care hospital’’ each place it ap24 pears and inserting ‘‘, rural primary care hos25 pital, or medical assistance facility’’.
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1 (H) Section 1835(c) of such Act (42 U.S.C.

2 1395n(c)) is amended by adding at the end the fol3 lowing: ‘‘A medical assistance facility shall be con4 sidered a hospital for purposes of this subsection.’’.

5 (I) Section 1842(b)(6)(A)(ii) of such Act (42

6 U.S.C. 1395u(b)(6)(A)(ii)) is amended by inserting

7 ‘‘medical assistance facility,’’ after ‘‘rural primary

8 care hospital,’’.

9 (J) Section 1861 of such Act (42 U.S.C.

10 1395x) is amended—

11 (i) in the last sentence of subsection (e), by

12 striking ‘‘1861(mm)(1))’’ and inserting

13 ‘‘1861(mm)(1)) or a medical assistance facility

14 (as defined in section 1861(oo)(1)).’’,

15 (ii) in subsection (w)(1) by inserting ‘‘med16 ical assistance facility,’’ after ‘‘rural primary

17 care hospital,’’, and

18 (iii) in subsection (w)(2), by striking ‘‘or

19 rural primary care hospital’’ each place it ap20 pears and inserting ‘‘, rural primary care hos21 pital, or medical assistance facility’’.

22 (K) Section 1862(a)(14) of such Act (42 U.S.C.

23 1395y(a)(14)) is amended by striking ‘‘or rural pri24 mary care hospital’’ each place it appears and in-
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1 serting ‘‘, rural primary care hospital, or medical as2 sistance facility’’.

3 (L) Section 1866(a)(1) of such Act (42 U.S.C

4 1395cc(a)(1)) is amended—

5 (i) in subparagraph (F)(ii), by inserting

6 ‘‘medical assistance facilities,’’ after ‘‘rural pri7 mary care hospitals,’’;

8 (ii) in subparagraph (H)—

9 (I) in the matter preceding clause (i),

10 by inserting ‘‘and in the case of medical

11 assistance facilities which provide inpatient

12 medical assistance facility services’’ after

13 ‘‘rural primary care hospital services’’; and

14 (II) in clauses (i) and (ii), by striking

15 ‘‘hospital’’ each place it appears and in16 serting ‘‘hospital or facility’’;

17 (iii) in subparagraph (I)—

18 (I) in the matter preceding clause (i),

19 by striking ‘‘or rural primary care hos20 pital’’ and inserting ‘‘, a rural primary

21 care hospital, or a medical assistance facil22 ity’’; and

23 (II) in clause (ii), by striking ‘‘the

24 hospital’’ and inserting ‘‘the hospital or the

25 facility’’; and
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1 (iv) in subparagraph (N)—

2 (I) in the matter preceding clause (i),

3 by striking ‘‘and rural primary hospitals’’

4 and inserting ‘‘, rural primary care hos5 pitals, and medical assistance facilities’’;

6 (II) in clause (i), by striking ‘‘or rural

7 primary care hospital,’’ and inserting ‘‘,

8 rural primary care hospital, or medical as9 sistance facility,’’; and

10 (III) in clause (ii), by striking ‘‘hos11 pital’’ and inserting ‘‘hospital or facility’’.

12 (M) Section 1866(a)(3) of such Act (42 U.S.C

13 1395cc(a)(3)) is amended—

14 (i) by striking ‘‘rural primary care hos15 pital,’’ each place it appears in subparagraphs

16 (A) and (B) and inserting ‘‘rural primary care

17 hospital, medical assistance facility,’’, and

18 (ii) in subparagraph (C)(ii)(II), by striking

19 ‘‘rural primary care hospitals,’’ each place it

20 appears and inserting ‘‘rural primary care hos21 pitals, medical assistance facilities’’.

22 (N) Section 1867(e)(5) of such Act (42 U.S.C.

23 1395dd(e)(5)) is amended by striking

24 ‘‘1861(mm)(1))’’ and inserting ‘‘1861(mm)(1)) or a
14

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1 medical assistance facility (as defined in section

2 1861(oo)(1)).’’.

3 (b) AMENDMENTS TO PART B.—

4 (1) COVERAGE.—(A) Section 1861(oo) of the

5 Social Security Act (42 U.S.C. 1395x(oo)), as added

6 by section 1, is amended by adding at the end the

7 following new paragraph:

8 ‘‘(3) The term ‘outpatient medical assistance facility

9 services’ means medical and other health services fur10 nished by a medical assistance facility on an outpatient

11 basis.’’.

12 (B) Section 1832(a)(2) of such Act (42 U.S.C.

13 1395k(a)(2)) is amended—

14 (i) in subparagraph (I), by striking ‘‘and’’

15 at the end;

16 (ii) in subparagraph (J), by striking the

17 period at the end and inserting ‘‘; and’’; and

18 (iii) by adding at the end the following new

19 subparagraph:

20 ‘‘(K) outpatient medical assistance facility

21 services (as defined in section 1861(oo)(3)).’’.

22 (2) PAYMENT.—(A) Section 1833(a) of such

23 Act (42 U.S.C. 1395l(a)) is amended—
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1 (i) in paragraph (2), in the matter preced2 ing subparagraph (A), by striking ‘‘and (I)’’

3 and inserting ‘‘(I), and (K)’’;

4 (ii) in paragraph (6), by striking ‘‘and’’ at

5 the end;

6 (iii) in paragraph (7), by striking the pe7 riod at the end and inserting ‘‘; and’’; and

8 (iv) by adding at the end the following new

9 paragraph:

10 ‘‘(8) in the case of outpatient medical assist11 ance facility services, the amounts described in sec12 tion 1834(i).’’.

13 (B) Section 1834 of such Act (42 U.S.C.

14 1395m) is amended by adding at the end the follow15 ing new subsection:

16 ‘‘(i) PAYMENT FOR OUTPATIENT MEDICAL ASSIST17 ANCE FACILITY SERVICES.—The amount of payment for

18 outpatient medical assistance facility services provided in

19 a medical assistance facility under this part shall be deter20 mined by one of the two following methods, as elected by

21 the medical assistance facility:

22 ‘‘(1) COST-BASED FACILITY FEE PLUS PROFES23 SIONAL CHARGES.—

24 ‘‘(A) FACILITY FEE.—With respect to fa25 cility services, not including any services for
16

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1 which payment may be made under subpara2 graph (B), there shall be paid amounts equal to

3 the amounts described in section 1833(a)(2)(B)

4 (describing amounts paid for hospital out5 patient services).

6 ‘‘(B) REASONABLE CHARGES FOR PROFES7 SIONAL SERVICES.—In electing treatment under

8 this paragraph, payment for professional medi9 cal services otherwise included within outpatient

10 medical assistance facility services shall be

11 made under such other provisions of this part

12 as would apply to payment for such services if

13 they were not included in outpatient medical as14 sistance facility services.

15 ‘‘(2) ALL-INCLUSIVE RATE.—

16 ‘‘(A) IN GENERAL.—With respect to both

17 facility services and professional medical serv18 ices, there shall be paid amounts equal to the

19 excess of—

20 ‘‘(i) the costs which are reasonable

21 and related to the cost of furnishing such

22 services or which are based on such other

23 tests of reasonableness as the Secretary

24 may prescribe in regulations, over
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1 ‘‘(ii) the amount the facility may

2 charge as described in clause (i) of section

3 1866(a)(2)(A).

4 ‘‘(B) LIMITATION.—

5 ‘‘(i) IN GENERAL.—The payment

6 amount determined under subparagraph

7 (A) with respect to items and services shall

8 not exceed 80 percent of the amount deter9 mined under clause (i) of such subpara10 graph with respect to such items and serv11 ices.

12 ‘‘(ii) CERTAIN ITEMS AND SERV13 ICES.—Clause (i) shall not apply to—

14 ‘‘(I) items and services described

15 in section 1861(s)(10)(A), and

16 ‘‘(II) items and services fur17 nished in connection with obtaining a

18 second opinion required under section

19 1164(c)(2), or third opinion, if the

20 second opinion was in disagreement

21 with the first opinion.’’.

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

23 this section shall be effective for services provided on or

24 after the date of the enactment of this section.
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1 SEC. 4. GRANT PROGRAM FOR THE USE OF INTERACTIVE

2 TELECOMMUNICATIONS SYSTEMS IN PROVID3 ING HEALTH CARE TO RURAL AREAS.

4 Title VII of the Social Security Act (42 U.S.C. 901

5 et seq.) is amended by adding at the end the following

6 new section:

7 ‘‘GRANT PROGRAM FOR THE USE OF INTERACTIVE TELE8 COMMUNICATIONS SYSTEMS IN PROVIDING HEALTH

9 CARE TO RURAL AREAS

10 ‘‘SEC. 712. (a) ESTABLISHMENT OF PROGRAM.—

11 ‘‘(1) IN GENERAL.—The Assistant Secretary for

12 Rural Health (hereafter referred to in this section as

13 the ‘‘Assistant Secretary’’), through the Office of

14 Rural Health Policy, shall establish a program to

15 provide grants to rural health care networks (as de16 fined in paragraph (2)) to enhance the delivery of

17 health care in rural areas through the use of inter18 active telecommunications systems.

19 ‘‘(2) DEFINITION.—For purposes of this sec20 tion, the term ‘‘rural health care network’’ means a

21 group of providers furnishing health care services to

22 a rural area composed of—

23 ‘‘(A) a tertiary care facility, rural referral

24 center (as defined in section 1886(d)(5)(C)(i)),

25 or medical teaching institution; and
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1 ‘‘(B) one or more rural hospitals, clinics,

2 medical assistance facilities, mental health de3 partments or similar facilities, including com4 munity health centers (as defined in section 330

5 of the Public Health Service Act) and migrant

6 health centers (as defined in section 329 of the

7 Public Health Service Act).

8 ‘‘(b) APPLICATION REQUIREMENTS.—

9 ‘‘(1) IN GENERAL.—In order to be eligible to

10 receive a grant under this section, a rural health

11 care network must submit an application to the As12 sistant Secretary at such time and in such manner

13 as the Assistant Secretary shall require.

14 ‘‘(2) CONTENTS OF APPLICATION.—An applica15 tion submitted under this section must contain—

16 ‘‘(A) a plan for acquisition and operation

17 of an interactive telecommunications system;

18 ‘‘(B) a description of the uses to be made

19 of such system;

20 ‘‘(C) a description of how such system will

21 function in connection with existing common

22 carrier networks; and

23 ‘‘(D) a description of a plan for evaluation

24 of the cost and effectiveness of the system and
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1 the quality of the health care delivered under

2 the system.

3 ‘‘(3) CONSIDERATION OF APPLICATIONS.—In

4 considering the applications submitted under this

5 subsection, the Assistant Secretary shall give a pref6 erence to rural health care networks that establish

7 multiple uses for the interactive telecommunications

8 system in the rural area served by the system, in9 cluding uses that do not relate to the provision of

10 health care.

11 ‘‘(c) AMOUNT OF GRANTS; USE OF FUNDS.—

12 ‘‘(1) LIMITATION ON AMOUNT OF GRANTS.—

13 The amount of any grant awarded to a rural health

14 care network under this section in any fiscal year

15 shall not exceed $500,000.

16 ‘‘(2) NUMBER OF ANNUAL GRANTS ALLOWED

17 PER NETWORK.—No more than 3 annual grants

18 may be awarded to any rural health care network

19 under this section.

20 ‘‘(3) USE OF FUNDS.—

21 (A) IN GENERAL.—From the amounts

22 awarded to a rural health care network under

23 this section, funds may be expended to support

24 the cost of activities involving the sending and

25 receiving of information to improve the delivery
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1 of health care services to rural areas includ2 ing—

3 ‘‘(i) consultations between health care

4 providers in remote areas and providers in

5 large facilities;

6 ‘‘(ii) the transfer and analysis of x7 rays, lab slides, and other images;

8 ‘‘(iii) the development of innovative

9 health education programs; and

10 ‘‘(iv) such other related activities as

11 the Assistant Secretary determines to be

12 consistent with the purposes of this sec13 tion.

14 ‘‘(B) LIMITATION.—Each grant awarded

15 to a rural health care network under this sec16 tion is subject to the following limitations:

17 ‘‘(i) No more than 35 percent of the

18 grant funds may be used to acquire inter19 active telecommunications equipment.

20 ‘‘(ii) No grant funds may be used to

21 establish or operate a telecommunications

22 common carrier network.

23 ‘‘(d) EVALUATION AND REPORT.—The Assistant Sec24 retary shall provide for an evaluation of the grant program

25 under this section to be conducted by the Office of Rural
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1 Health Policy which shall prepare and submit a report to

2 the Congress not later than 4 years after the date on

3 which the first grant is awarded under this section sum4 marizing such evaluation.

5 ‘‘(e) FUNDING.—There are authorized to be appro6 priated $5,000,000 for each of fiscal years 1994, 1995,

7 and 1996 to carry out the purposes of this Act and such

8 sums shall remain available until expended.’’.

9 SEC. 5. DIRECT GRADUATE MEDICAL EDUCATION.

10 (a) PUBLICLY FUNDED FAMILY PRACTICE RESI11 DENCY PROGRAMS.—

12 (1) IN GENERAL.—Section 1886(h)(5) (42

13 U.S.C. 1395ww(h)(5)) is amended by adding at the

14 end the following new subparagraph:

15 ‘‘(H) ADJUSTMENTS FOR CERTAIN FAMILY

16 PRACTICE RESIDENCY PROGRAMS.—

17 ‘‘(i) IN GENERAL.—In the case of an

18 approved medical residency training pro19 gram (meeting the requirements of clause

20 (ii)) of a hospital which received payments

21 from the United States, a State, or a polit22 ical subdivision of a State or an instrumen23 tality of such a State or political subdivi24 sion (other than payments under this title

25 or a State plan under title XIX) during
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1 the cost reporting period that began during

2 fiscal year 1984, the Secretary shall—

3 ‘‘(I) provide for an average

4 amount under paragraph (2)(A) that

5 takes into account the Secretary’s es6 timate of the amount that would have

7 been recognized as reasonable under

8 this title if the hospital had not re9 ceived such payments, and

10 ‘‘(II) reduce the payment amount

11 otherwise provided under this sub12 section in an amount equal to the pro13 portion of such program payments

14 during the cost reporting period in15 volved that is allocable to this title.

16 ‘‘(ii) ADDITIONAL REQUIREMENTS.—

17 A hospital’s approved medical residency

18 program meets the requirements of this

19 clause if—

20 ‘‘(I) the program is limited to

21 training for family and community

22 medicine;

23 ‘‘(II) the program is the only ap24 proved medical residency program of

25 the hospital; and
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1 ‘‘(III) the average amount deter2 mined under paragraph (2)(A) for the

3 hospital (as determined without re4 gard to the increase in such amount

5 described in clause (i)(I)) does not ex6 ceed $10,000.’’.

7 (2) EFFECTIVE DATE.—The amendment made

8 by paragraph (1) shall apply to payments under sec9 tion 1886(h) of the Social Security Act for cost re10 porting periods beginning on or after October 1,

11 1990.

12 (b) PREVENTIVE CARE SERVICES AS PART OF INI13 TIAL RESIDENCY PERIOD.—

14 (1) ELIGIBILITY OF PREVENTIVE CARE RESI15 DENCY PROGRAMS FOR EXPANDED INITIAL RESI16 DENCY PERIODS.—Section 1886(h)(5)(F)(ii) (42

17 U.S.C. 1395ww(h)(5)(F)(ii)) is amended by insert18 ing after ‘‘fellowship program’’ the following: ‘‘or a

19 preventive care residency or fellowship program’’.

20 (2) EFFECTIVE DATE.—The amendment made

21 by paragraph (1) shall apply to cost reporting peri22 ods beginning on or after October 1, 1993.

Æ

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