I

106TH CONGRESS

1ST SESSION H. R. 1344

To promote and improve access to health care services in rural areas.

IN THE HOUSE OF REPRESENTATIVES

MARCH 25, 1999

Mr. NUSSLE (for himself, Mr. MCINTYRE, Mrs. EMERSON, Mr. STENHOLM,

Mr. BEREUTER, Mr. KIND, Mr. MORAN of Kansas, Mr. OBERSTAR, Mr.

THORNBERRY, Mr. STUPAK, Mr. HILL of Montana, Mr. DEFAZIO, Mr.

PETERSON of Pennsylvania, Mr. HILLIARD, Mr. BERRY, Mr. HERGER,

Mr. LEACH, Mr. LATHAM, Mr. MCHUGH, Mr. NEY, Mr. NORWOOD, Mr.

MASCARA, Mr. WALSH, Mr. FROST, Mr. BOSWELL, Mr. SKELTON, Mr.

BAIRD, Mr. FALEOMAVAEGA, Mr. PHELPS, Mr. BARRETT of Nebraska,

Mr. BOUCHER, and Mr. RAHALL) introduced the following bill; which was

referred to the Committee on Ways and Means, and in addition to the

Committee on Commerce, for a period to be subsequently determined by

the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To promote and improve access to health care services in

rural areas.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

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

5 ‘‘Triple-A Rural Health Improvement Act of 1999’’.
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1 (b) TABLE OF CONTENTS.—The table of contents for

2 this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Findings.

TITLE I—PROMOTING ACCESS TO HEALTH CARE SERVICES IN

RURAL AREAS UNDER THE MEDICARE PROGRAM

Subtitle A—Hospital-Related Payment Provisions

Sec. 101. Establishing payment floor for medicare hospital outpatient prospective payment system.

Sec. 102. Repeal of restriction on medicare payment for certain hospital discharges to post-acute care.

Sec. 103. Sole community hospitals.

Sec. 104. Critical access hospitals.

Sec. 105. Graduate medical education technical amendments.

Sec. 106. Medicare-dependent, small rural hospitals.

Sec. 107. Geographic reclassification for purposes of DSH payments.

Sec. 108. Revision of guidelines for geographic reclassification by wage index.

Sec. 109. Hospital geographic reclassification for labor costs for all items and

services reimbursed under prospective payment systems.

Subtitle B—Medicare+Choice

Sec. 111. Payments to Medicare+Choice organizations.

Sec. 112. Repeal of phase out of medicare reasonable cost reimbursement contracts.

Sec. 113. Medicare+Choice rural demonstration project.

Subtitle C—General Payment Provisions

Sec. 121. Direct medicare payment for physician assistants, nurse practitioners,

and clinical nurse specialists practicing in underserved rural

areas.

Sec. 122. Coverage of qualified mental health professional services under medicare.

Sec. 123. Medicare waivers for providers in rural areas.

Sec. 124. Safe harbor under the anti-kickback statute for hospital restocking of

certain ambulance drugs and supplies.

TITLE II—PROMOTING ACCESS TO HEALTH CARE SERVICES IN

RURAL AREAS UNDER THE MEDICAID PROGRAM

Sec. 201. Continuation of pre-BBA medicaid reimbursement rules for federally

qualified health centers and rural health clinics.

Sec. 202. Medicaid coverage of physicians’ assistants.

TITLE III—PROMOTING ACCESS TO HEALTH CARE SERVICES IN

RURAL AREAS UNDER THE INTERNAL REVENUE CODE

Sec. 301. Exclusion of certain amounts received under the National Health

Service Corps Scholarship Program.

Sec. 302. Issuance of tax-exempt bonds by organizations providing rescue and

emergency medical services.
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Sec. 303. Bank deductibility of small, tax-exempt debts.

TITLE IV—ADDITIONAL PROVISIONS TO ADDRESS SHORTAGES OF

HEALTH PROFESSIONALS IN RURAL AREAS

Sec. 401. Requirement for rural impact Statements for health care regulations.

Sec. 402. Health professional shortage areas.

Sec. 403. Access to data.

Sec. 404. Designation of underserved areas under health care contracts administered by the Office of Personnel Management.

Sec. 405. Revision of methodology for designation of health professional shortage areas.

Sec. 406. Sense of Congress regarding the reserve corps of the commissioned

corps of the public health service.

TITLE V—TELEMEDICINE

Subtitle A—Improvements to the Medicare Program

Sec. 501. Improvement of telehealth services.

Sec. 502. Joint working group on telehealth.

Subtitle B—Development of Telehealth Networks

Sec. 511. Development.

Sec. 512. Administration.

Sec. 513. Guidelines.

Sec. 514. Authorization of appropriations.

1 SEC. 2. FINDINGS.

2 Congress makes the following findings:

3 (1) Rural communities have long had great dif4 ficulty recruiting and retaining health care providers

5 to serve the needs of their residents.

6 (2) Despite great increases in the production of

7 providers in this country (the number of individuals

8 per physician fell from 724 in 1965 to 375 in 1995),

9 individuals living in rural areas have not shared eq10 uitably in the benefits of this expansion.

11 (3) Over 51,000,000 Americans live in rural

12 areas, making up approximately 20 percent of the

13 population. Further, 22,000,000 rural Americans
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1 live in a federally designated Health Professional

2 Shortage Area.

3 (4) The following conditions are characteristic

4 of rural populations:

5 (A) The relative lack of health care re6 sources as compared to urban areas.

7 (B) The uneven pattern of disease burden.

8 (C) The idiosyncratic distribution of pro9 grams and resources resulting from policy vari10 ations across the nation.

11 (5) Of the non-metropolitan counties in the

12 United States, 20 percent are considered frontier

13 counties, with six or fewer people per square mile.

14 Seven million Americans live in frontier areas.

15 TITLE I—PROMOTING ACCESS

16 TO HEALTH CARE SERVICES

17 IN RURAL AREAS UNDER THE

18 MEDICARE PROGRAM

19 Subtitle A—Hospital-Related

20 Payment Provisions

21 SEC. 101. ESTABLISHING PAYMENT FLOOR FOR MEDICARE

22 HOSPITAL OUTPATIENT PROSPECTIVE PAY23 MENT SYSTEM.

24 (a) IN GENERAL.—Section 1833(t)(1) of the Social

25 Security Act (42 U.S.C. 1395l(t)(1)) is amended—
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1 (1) in subparagraph (B), by striking ‘‘For pur2 poses of this’’ and inserting ‘‘Subject to subpara3 graph (C), for purposes of this’’; and

4 (2) by adding at the end the following new sub5 paragraph:

6 ‘‘(C) EXCLUSION FOR SERVICES FURNISHED BY

7 SMALL RURAL PROVIDERS.—Such term does not in8 clude services furnished by any of the following:

9 ‘‘(i) A medicare-dependent, small rural

10 hospital, as defined in section

11 1886(d)(5)(G)(iv).

12 ‘‘(ii) A critical access hospital, as defined

13 in section 1861(mm)(1).

14 ‘‘(iii) A sole community hospital, as de15 fined in section 1886(d)(5)(D)(iii).’’.

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

17 subsection (a) applies to payment for covered OPD serv18 ices furnished on or after January 1, 2000.

19 SEC. 102. REPEAL OF RESTRICTION ON MEDICARE PAY20 MENT FOR CERTAIN HOSPITAL DISCHARGES

21 TO POST-ACUTE CARE.

22 (a) IN GENERAL.—Section 1886(d)(5) of the Social

23 Security Act (42 U.S.C. 1395ww(d)(5)) is amended—
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1 (1) in subparagraph (I)(ii), by striking ‘‘not

2 taking in account the effect of subparagraph (J),’’,

3 and

4 (2) by striking subparagraph (J).

5 (b) EFFECTIVE DATE.—The amendments made by

6 subsection (a) apply to discharges occurring on or after

7 January 1, 2000.

8 SEC. 103. SOLE COMMUNITY HOSPITALS.

9 (a) IN GENERAL.—Section 1886(b)(3)(C) of the So10 cial Security Act (42 U.S.C. 1395ww(b)(3)(C)) is

11 amended—

12 (1) in clause (i), by redesignating subclauses (I)

13 and (II) as items (aa) and (bb), respectively;

14 (2) by redesignating clauses (i), (ii), (iii), and

15 (iv) as subclauses (I), (II), (III), and (IV), respec16 tively;

17 (3) by striking ‘‘(C) In’’ and inserting ‘‘(C)(i)

18 Subject to clause (ii), in’’; and

19 (4) by striking the last sentence and inserting

20 the following new clause:

21 ‘‘(ii)(I) There shall be substituted for the base cost

22 reporting period described in clause (i)(I) a hospital’s cost

23 reporting period (if any) beginning during fiscal year 1987

24 if such substitution results in an increase in the target

25 amount for the hospital.
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1 ‘‘(II) Beginning with discharges occurring in cost re2 porting periods beginning in fiscal year 2000, there shall

3 be substituted for the base cost reporting period described

4 in clause (i)(I) either—

5 ‘‘(aa) the allowable operating costs of inpatient

6 hospital services (as defined in subsection (a)(4))

7 recognized under this title for the hospital’s cost re8 porting period (if any) beginning during fiscal year

9 1995 increased (in a compounded manner) by the

10 applicable percentage increases applied to the hos11 pital under this paragraph for discharges occurring

12 in fiscal years 1996, 1997, 1998, and 1999, or

13 ‘‘(bb) the allowable operating costs of inpatient

14 hospital services (as defined in subsection (a)(4))

15 recognized under this title for the hospital’s cost re16 porting period (if any) beginning during fiscal year

17 1996 increased (in a compounded manner) by the

18 applicable percentage increases applied to the hos19 pital under this paragraph for discharges occurring

20 in fiscal years 1997, 1998, and 1999,

21 if such substitution results in an increase in the target

22 amount for the hospital.’’.

23 (b) ELIGIBILITY FOR GEOGRAPHIC RECLASSIFICA24 TION WITHOUT REGARD TO WAGE INDEX THRESHOLD.—
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1 (1) IN GENERAL.—Section 1886(d)(10)(D)(iii)

2 of such Act (42 U.S.C. 1395ww(d)(10)(D)(iii)) is

3 amended by inserting ‘‘or a sole community hospital

4 under paragraph (5)(D)’’ after ‘‘a rural referral cen5 ter under paragraph (5)(C)’’.

6 (2) EFFECTIVE DATE.—The amendment made

7 by paragraph (1) shall take effect on January 1,

8 2000, and apply with respect to applications sub9 mitted for geographic reclassification for cost report10 ing periods beginning on or after such date.

11 SEC. 104. CRITICAL ACCESS HOSPITALS.

12 (a) CONVERSION OF RECENTLY CLOSED HOSPITALS

13 TO CRITICAL ACCESS HOSPITALS.—

14 (1) IN GENERAL.—Section 1820(c)(2) of the

15 Social Security Act (42 U.S.C. 1395i–4(c)(2)) is

16 amended by adding at the end the following new

17 subparagraph:

18 ‘‘(C) RECENTLY CLOSED FACILITIES.—A

19 State may designate a facility as a critical ac20 cess hospital if the facility—

21 ‘‘(i) within the 3-year period ending

22 on the date of enactment of this

23 subparagraph—

24 ‘‘(I) ceased operations; or
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1 ‘‘(II) was a nonprofit or public

2 hospital that was downsized to a clin3 ic; and

4 ‘‘(ii) would, after being designated as

5 a critical access hospital, meet the require6 ments of subparagraph (B).’’.

7 (2) EFFECTIVE DATE.—The amendment made

8 by paragraph (1) shall take effect on the date of en9 actment of this Act.

10 (b) ALL-INCLUSIVE PAYMENT OPTION FOR OUT11 PATIENT CRITICAL ACCESS HOSPITAL SERVICES.—

12 (1) IN GENERAL.—Section 1834(g) of the So13 cial Security Act (42 U.S.C. 1395m(g)) is amended

14 to read as follows:

15 ‘‘(g) PAYMENT FOR OUTPATIENT CRITICAL ACCESS

16 HOSPITAL SERVICES.—The amount of payment under

17 this part for outpatient critical access hospital services is

18 the amount determined under one of the two following

19 methods, as elected by the critical access hospital:

20 ‘‘(1) REASONABLE COSTS.—There shall be paid

21 amounts equal to the reasonable costs of the critical

22 access hospital in providing such services.

23 ‘‘(2) ALL-INCLUSIVE RATE.—With respect to

24 both facility services and professional medical serv25 ices, there shall be paid amounts equal to the costs
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1 which are reasonable and related to the cost of fur2 nishing such services or which are based on such

3 other tests of reasonableness as the Secretary may

4 prescribe in regulations, less the amount the hospital

5 may charge as described in clause (i) of section

6 1866(a)(2)(A), but in no case may the payment for

7 such services (other than for items and services de8 scribed in section 1861(s)(10)(A)) exceed 80 percent

9 of such costs.

10 The amount of payment shall be determined under either

11 method without regard to the amount of the customary

12 or other charge.’’.

13 (2) EFFECTIVE DATE.—The amendment made

14 by paragraph (1) shall take effect as if included in

15 the enactment of the Balanced Budget Act of 1997.

16 (c) ELIGIBILITY FOR PAYMENTS UNDER THE MED17 ICAID PROGRAM.—

18 (1) IN GENERAL.—Section 1905(a) of the So19 cial Security Act (42 U.S.C. 1396d(a)) is

20 amended—

21 (A) by striking ‘‘and’’ at the end of para22 graph (26);

23 (B) by redesignating paragraph (27) as

24 paragraph (28); and
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1 (C) by inserting after paragraph (26) the

2 following new paragraph:

3 ‘‘(27) services furnished by a critical access

4 hospital (as defined section 1861(mm)(1); and’’.

5 (2) EFFECTIVE DATE.—The amendments made

6 by paragraph (1) apply with respect to items and

7 services furnished on or after January 1, 2000.

8 (d) ACCREDITATION.—The last sentence of section

9 1861(e) of such Act (42 U.S.C. 1395x(e)) is amended to

10 read as follows:

11 ‘‘The term ‘hospital’ does not include a critical access hos12 pital (as defined in section 1861(mm)(1)), unless the con13 text otherwise requires, or unless a critical access hospital

14 applies for accreditation by the Joint Commission on Ac15 creditation of Hospitals.’’.

16 SEC. 105. GRADUATE MEDICAL EDUCATION TECHNICAL

17 AMENDMENTS.

18 (a) INDIRECT GRADUATE MEDICAL EDUCATION AD19 JUSTMENT.—

20 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of

21 the Social Security Act (42 U.S.C.

22 1395ww(d)(5)(B)(v)) is amended to read as follows:

23 ‘‘(v)(I) In determining the adjustment with re24 spect to a hospital that sponsors more than one

25 allopathic or osteopathic residency training program
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1 for discharges occurring on or after October 1,

2 1997, the total number of full-time equivalent in3 terns and residents in the fields of allopathic and os4 teopathic medicine in either a hospital or nonhos5 pital setting may not exceed the number of such full6 time equivalent interns and residents who partici7 pated, or who but for an approved leave would have

8 participated, in the hospital’s approved medical resi9 dency training programs for the hospital’s most re10 cent cost reporting period ending on or before De11 cember 31, 1996.

12 ‘‘(II) In determining the adjustment with re13 spect to a hospital that sponsors only one allopathic

14 or osteopathic residency program for discharges oc15 curring on or after October 1, 1997, the total num16 ber of full-time equivalent interns and residents in

17 the fields of allopathic and osteopathic medicine who

18 participated, or who but for an approved leave would

19 have participated, in the hospital’s medical residency

20 training program may be increased by not more

21 than one for any calendar year, and may not exceed

22 a total of three more than the number appointed in

23 either a hospital or nonhospital setting for the hos24 pital’s most recent cost reporting period ending on

25 or before December 31, 1996.’’.
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1 (2) TECHNICAL AMENDMENTS.—Section

2 1886(d)(5)(B) of such Act (42 U.S.C.

3 1395ww(d)(5)(B)) is amended by moving clauses (ii)

4 and (vi) two ems to the left.

5 (b) DIRECT GRADUATE MEDICAL EDUCATION AD6 JUSTMENT.—

7 (1) LIMITATION ON NUMBER OF RESIDENTS.—

8 Section 1886(h)(4)(F) of the Social Security Act (42

9 U.S.C. 1395ww(h)(4)(F)) is amended by inserting

10 ‘‘who participated, or who but for an approved leave

11 would have participated, in the hospital’s medical

12 residency training programs’’ after ‘‘may not exceed

13 the number of such full-time equivalent residents’’.

14 (2) FUNDING.—

15 (A) NEW PROGRAMS.—The first sentence

16 of section 1886(h)(4)(H)(i) of such Act (42

17 U.S.C. 1935ww(h)(4)(H)(i)) is amended by in18 serting ‘‘and before September 30, 1999’’ after

19 ‘‘January 1, 1995’’.

20 (B) PROGRAMS MEETING RURAL NEEDS.—

21 The second sentence of such section is amended

22 by striking the period at the end and inserting

23 ‘‘, including facilities that are not located in an

24 underserved rural area but have established
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1 separately accredited approved medical resi2 dency training programs in such an area.’’.

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

4 this section shall take effect as if included in the enact5 ment of the Balanced Budget Act of 1997.

6 SEC. 106. MEDICARE-DEPENDENT SMALL RURAL HOS7 PITALS.

8 (a) REDUCTION IN ELIGIBILITY DISCHARGE PER9 CENTAGE.—Section 1886(d)(5)(G)(iv)(IV) of the Social

10 Security Act (42 U.S.C. 1395ww(d)(5)(G)(iv)(IV)) is

11 amended by striking ‘‘60’’ and inserting ‘‘50’’.

12 (b) REBASING FOR DISCHARGES DURING THE MOST

13 CURRENT AUDITED FISCAL YEAR.—Section

14 1886(b)(3)(D) of the Social Security Act (42 U.S.C.

15 1395ww(b)(3)(D) is amended—

16 (1) in the second sentence, by striking ‘‘begin17 ning during fiscal year 1987’’ and inserting ‘‘ending

18 during fiscal year 1998’’; and

19 (2) by adding at the end the following new sen20 tence: ‘‘An increase in the target amount by reason

21 of the previous sentence shall have no effect on the

22 classification of a hospital as a medicare-dependent,

23 small rural hospital.’’.
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1 (c) EFFECTIVE DATE.—The amendments made by

2 this section shall apply with respect to discharges occur3 ring on or after October 1, 1999.

4 SEC. 107. GEOGRAPHIC RECLASSIFICATION FOR PURPOSES

5 OF DSH PAYMENTS.

6 (a) IN GENERAL.—Section 1886(d)(10)(C)(i) of the

7 Social Security Act (42 U.S.C. 1395ww(d)(10)(C)(i)) is

8 amended—

9 (1) by striking ‘‘or’’ at the end of subclause (I);

10 (2) by striking the period at the end of sub11 clause (II) and inserting ‘‘, or’’; and

12 (3) by adding at the end the following new sub13 clause:

14 ‘‘(III) eligibility for and amount of additional

15 payments under paragraph (5)(F).

16 In the case of a hospital with an application approved

17 under subclause (I) to change the hospital’s geographic

18 classification for a fiscal year, such change in the hos19 pital’s geographic classification for that fiscal year shall

20 apply to such hospital for purposes of subclause (III).’’.

21 (b) APPLICABLE GUIDELINES.—Section

22 1886(d)(10)(D) of such Act (42 U.S.C.

23 1395ww(d)(10)(D)) is amended—

24 (1) in clause (i), by adding at the end the fol25 lowing new subclause:
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1 ‘‘(V) Guidelines for considering applications

2 under subparagraph (C)(i)(III) of determining eligi3 bility for and amount of additional payments under

4 paragraph (5)(F).’’;

5 (2) by redesignating clause (iv) as clause (v);

6 (3) by inserting after clause (iii) the following

7 new clause:

8 ‘‘(iv) Under the guidelines published by the Secretary

9 under clause (i)(V), the Board shall not reject an applica10 tion to change a hospital’s geographic classification under

11 subparagraph (C)(i)(I) because the change in the hos12 pital’s geographic classification for that fiscal year does

13 not result in an increase in the average standardized

14 amount for that hospital.’’; and

15 (4) in clause (v), as so redesignated by para16 graph (2)—

17 (A) by inserting ‘‘(I)’’ after ‘‘(v)’’;

18 (B) by striking ‘‘The’’ and inserting ‘‘Ex19 cept as provided in subclause (II), the’’; and

20 (C) by adding at the end the following new

21 subclause:

22 ‘‘(II) The Secretary shall publish the guidelines de23 scribed in subclause (V) of clause (i) by January 1,

24 2000.’’.
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1 (c) EFFECTIVE DATE.—The amendments made by

2 subsection (a) take effect on January 1, 2000, and apply

3 with respect to applications for geographic reclassification

4 submitted for cost reporting periods beginning on or after

5 such date.

6 SEC. 108. REVISION OF GUIDELINES FOR GEOGRAPHIC RE7 CLASSIFICATION BY WAGE INDEX.

8 (a) AVERAGE HOURLY WAGE WEIGHTED FOR OCCU9 PATIONAL MIX.—Section 1886(d)(10)(D)(i)(I) of the So10 cial Security Act (42 U.S.C. 1395ww(d)(10)(D)(i)(I)) is

11 amended to read as follows:

12 ‘‘(I) Guidelines for comparing a hospital’s aver13 age hourly wage to the average hourly wage of hos14 pitals in the area in which the hospital is classified,

15 guidelines for comparing a hospital’s average hourly

16 wage to the average hourly wage of hospitals in the

17 area in which the hospital is applying to be classi18 fied, and guidelines for comparing a hospital’s aver19 age hourly wage adjusted by the occupational mix of

20 the area in which the hospital is applying to be clas21 sified to the average hourly wage of hospitals in such

22 area.’’.

23 (b) DATA COLLECTION REQUIREMENT.—Section

24 1886(d)(10)(D) of such Act (42 U.S.C.
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1 1395ww(d)(10)(D)), as amended by section 107(b), is fur2 ther amended—

3 (1) by redesignating clause (v) as clause (vi);

4 (2) by inserting after clause (iv) the following

5 new clause:

6 ‘‘(v) For purposes of considering an application under

7 subparagraph (C)(i)(II), the Secretary shall collect and

8 update every three years such information as is necessary

9 to compare a hospital’s wages weighted by the occupa10 tional mix of hospitals in the area in which the hospital

11 is applying to be classified, or the Board shall, in consid12 ering such an application, apply the most current available

13 information with respect to such wages collected by the

14 American Hospital Association.’’; and

15 (3) in clause (vi), as so redesignated by para16 graph (1), by inserting ‘‘subclause (I), as amended

17 by the Triple-A Rural Health Improvement Act of

18 1999, and’’ before ‘‘subclause (III) of clause (i) by

19 January 1, 2000.’’.

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

21 subsections (a) and (b) take effect on January 1, 2000,

22 and apply with respect to applications for geographic re23 classification for cost reporting periods beginning on or

24 after such date.
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1 (d) REPORT TO CONGRESS.—Not later than one year

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

3 shall submit to Congress a report describing revised meth4 odology to compute hospital wage indices, for purposes of

5 adjustments in payment amounts to hospitals under the

6 medicare program, that reflect legitimate differences in

7 hospital wage rates by area, but that do not rely on aver8 age per employee expenditures.

9 (e) SENSE OF CONGRESS.—It is the Sense of the

10 Congress that the adjustment in payment amounts to hos11 pitals under the medicare program to reflect variations in

12 the costs of wages and wage-related costs of hospitals,

13 under section 1886(d)(3)(E) of the Social Security Act

14 (42 U.S.C. 1395ww(d)(3)(E)), should only be used with

15 respect to payments made on a prospective basis to such

16 hospitals for inpatient hospital services. Such adjustment

17 should not be applied to payment amounts for any other

18 item or service reimbursed under the medicare program.

19 SEC. 109. HOSPITAL GEOGRAPHIC RECLASSIFICATION FOR

20 LABOR COSTS FOR ALL ITEMS AND SERVICES

21 REIMBURSED UNDER PROSPECTIVE PAY22 MENT SYSTEMS.

23 (a) IN GENERAL.—Section 1886 of the Social Secu24 rity Act (42 U.S.C. 1395ww) is amended by adding at the

25 end the following new subsection:
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1 ‘‘(l) APPLICATION OF HOSPITAL GEOGRAPHIC RE2 CLASSIFICATION FOR INPATIENT SERVICES TO ALL HOS3 PITAL FURNISHED ITEMS AND SERVICES REIMBURSED

4 UNDER PROSPECTIVE PAYMENT SYSTEM.—

5 ‘‘(1) IN GENERAL.—In the case of a hospital

6 with an application to the Medicare Geographic

7 Classification Review Board under subsection

8 (d)(10)(C) to change the hospital’s geographic clas9 sification for a fiscal year for purposes of the factor

10 used to adjust the DRG prospective payment rate

11 for area differences in hospital wage levels that ap12 plies to such hospital under subsection (d)(3)(E)

13 that has been approved, the change in the hospital’s

14 geographic classification for such purposes shall

15 apply for purposes of adjustments to payments for

16 variations in costs which are attributable to wages

17 and wage-related costs for all pps-reimbursed items

18 and services.

19 ‘‘(2) PPS-REIMBURSED ITEMS AND SERVICES

20 DEFINED.—For purposes of paragraph (1), the term

21 ‘pps-reimbursed items and services’ means, for cost

22 reporting periods beginning during the fiscal year

23 for which such change has been approved, items and

24 services furnished by the hospital, or by an entity or

25 department of the hospital which is provider-based
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1 (as determined by the Secretary), for which

2 payments—

3 ‘‘(A) are made under this title on a pro4 spective basis; and

5 ‘‘(B) are adjusted for variations in costs

6 which are attributable to wages and wage-re7 lated costs.’’.

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

9 subsection (a) shall apply to items and services furnished

10 on or after January 1, 2000.

11 Subtitle B—Medicare+Choice

12 SEC. 111. PAYMENTS TO MEDICARE+CHOICE ORGANIZA13 TIONS.

14 (a) ADJUSTMENT TO CALCULATION OF ANNUAL

15 CAPITATION RATES.—Section 1853(c) of the Social Secu16 rity Act (42 U.S.C. 1395w–23(c)) is amended—

17 (1) in paragraph (1)—

18 (A) in subparagraph (A), by striking the

19 comma at the end of clause (ii) and all that fol20 lows before the period; and

21 (B) in subparagraph (C)(ii), by inserting

22 ‘‘multiplied by the budget neutrality adjustment

23 factor determined under paragraph (5)’’ before

24 the period at the end; and
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1 (2) in paragraph (5), by striking ‘‘paragraph

2 (1)(A)’’ and inserting ‘‘paragraph (1)(C)(ii)’’.

3 (b) EFFECTIVE DATE.—The amendments made by

4 subsection (a) shall apply to rates calculated for years

5 after 1999.

6 SEC. 112. REPEAL OF PHASE OUT OF CERTAIN MEDICARE

7 REASONABLE COST REIMBURSEMENT CON8 TRACTS.

9 Section 1876(h)(5) of the Social Security Act (42

10 U.S.C. 1395mm(h)(5)) is amended—

11 (1) by striking ‘‘(5)(A)’’ and inserting ‘‘(5)’’;

12 and

13 (2) by striking subparagraph (B).

14 SEC. 113. MEDICARE+CHOICE RURAL DEMONSTRATION

15 PROJECT.

16 (a) ESTABLISHMENT OF PROJECT.—For purposes of

17 expanding and improving the quality of items and services

18 furnished under the medicare program to medicare bene19 ficiaries residing in rural and frontier areas, the Secretary

20 of Health and Human Services (in this section referred

21 to as the ‘‘Secretary’’) shall conduct demonstration

22 projects under which the Secretary shall establish, and

23 provide for payment for such items and services to, pro24 vider-sponsored organizations and other managed care en25 tities that are based in rural and frontier areas.
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1 (b) REQUIREMENT OF RURAL AND FRONTIER

2 AREAS.—The Secretary shall designate areas in which

3 projects under this section shall be conducted. Such

4 projects may only be conducted in rural or frontier areas,

5 as defined under title XVIII of the Social Security Act

6 and under regulations promulgated thereunder.

7 (c) PROJECT IMPLEMENTATION.—

8 (1) IN GENERAL.—The Secretary shall establish

9 a benefit design, and establish payment amounts for

10 items and services furnished by such provider-spon11 sored organizations and managed care entities to

12 medicare beneficiaries.

13 (2) DATA COLLECTION.—The Secretary shall

14 provide for the collection of information (including

15 information concerning quality and access to care),

16 for purposes of evaluating the results of the project.

17 (d) REPORT TO CONGRESS.—

18 (1) IN GENERAL.—Not later than two years

19 after the Secretary implements the demonstration

20 projects under this section, and annually thereafter,

21 the Secretary shall submit to Congress a report re22 garding such demonstration projects.

23 (2) CONTENTS OF REPORT.—The report in

24 paragraph (1) shall include the following:
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1 (A) A description of the demonstration

2 projects conducted under this section.

3 (B) An evaluation of—

4 (i) the viability of such provider-spon5 sored organizations and managed care en6 tities operating in rural and frontier areas;

7 (ii) the quality of the health care serv8 ices provided to medicare beneficiaries re9 siding in such areas under the demonstra10 tion projects; and

11 (iii) beneficiary and health care pro12 vider satisfaction under the demonstration

13 project.

14 (C) Any other information regarding the

15 demonstration projects conducted under this

16 section that the Secretary determines to be ap17 propriate.

18 (e) WAIVER AUTHORITY.—The Secretary of Health

19 and Human Services may waive such requirements of title

20 XVIII of the Social Security Act (as amended by this Act)

21 as may be necessary for the purposes of carrying out the

22 project.
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1 Subtitle C—General Payment

2 Provisions

3 SEC. 121. DIRECT MEDICARE PAYMENT FOR PHYSICIAN AS4 SISTANTS, NURSE PRACTITIONERS, AND

5 CLINICAL NURSE SPECIALISTS PRACTICING

6 IN UNDERSERVED RURAL AREAS.

7 (a) IN GENERAL.—Section 1833(a)(1)(O) of the Social

8 Security Act (42 U.S.C. 1395l(a)(1)(O)) is amended—

9 (1) by inserting ‘‘(or 100 percent in the case of

10 services furnished in an underserved rural area)’’

11 after ‘‘85 percent’’ the first place it appears.

12 (b) DIRECT REIMBURSEMENT.—Section

13 1842(b)(6)(C) of such Act (42 U.S.C. 1395u(b)(6)(C)) is

14 amended—

15 (1) by striking ‘‘clause (i) of’’;

16 (2) by inserting ‘‘, nurse practitioner, or clinical

17 nurse specialist’’ after ‘‘physician assistant’’ the first

18 place it appears; and

19 (3) by amending clause (ii) to read as follows:

20 ‘‘(ii) with respect to a physician assistant, nurse

21 practitioner, or clinical nurse specialist who is pro22 viding services in an underserved rural area, pay23 ment may be made directly to the assistant, practi24 tioner, or specialist;’’.
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1 (c) EFFECTIVE DATE.—The amendments made by

2 this section apply to services furnished on or after Janu3 ary 1, 2000.

4 SEC. 122. COVERAGE OF QUALIFIED MENTAL HEALTH PRO5 FESSIONAL SERVICES UNDER MEDICARE.

6 (a) IN GENERAL.—Section 1861(s)(2) of the Social

7 Security Act (42 U.S.C. 1395x(s)(2)) is amended—

8 (1) in subparagraph (S), by striking ‘‘and’’ at

9 the end;

10 (2) in subparagraph (T), by striking the period

11 at the end and inserting ‘‘; and’’; and

12 (3) by adding at the end the following new sub13 paragraph:

14 ‘‘(U) qualified mental health professional serv15 ices (as defined in subsection (uu));’’.

16 (b) PAYMENT RULES.—

17 (1) DETERMINATION OF AMOUNT OF PAY18 MENT.—Section 1833(a)(1) of the Social Security

19 Act (42 U.S.C. 1395l(a)(1)) is amended—

20 (A) by striking ‘‘and’’ before ‘‘(S)’’; and

21 (B) by striking the semicolon at the end

22 and inserting the following: ‘‘, and (T) with re23 spect to qualified mental health professional

24 services described in section 1861(s)(2)(U), the

25 amounts paid shall be the amount determined
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1 by a fee schedule established by the Secretary

2 for purposes of this subparagraph;’’.

3 (2) SEPARATE PAYMENT FOR

4 SERVICES OF INSTITUTIONAL PROVIDERS.—Section

5 1832(a)(2)(B)(iii) of the Social Security Act (42

6 U.S.C. 1395k(a)(2)(B)(iii)) is amended—

7 (A) by striking ‘‘and services’’ and insert8 ing ‘‘services’’; and

9 (B) by striking the semicolon at the end

10 and inserting the following: ‘‘, and qualified

11 mental health professional services described in

12 section 1861(s)(2)(U);’’.

13 (c) SERVICES DESCRIBED.—Section 1861 of the So14 cial Security Act (42 U.S.C. 1395x) is amended by adding

15 at the end the following new subsection:

16 ‘‘Qualified Mental Health Professional Services

17 ‘‘(uu)(1) The term ‘qualified mental health profes18 sional services’ means such services (with such frequency

19 limits as the Secretary determines appropriate) furnished

20 by a mental health professional (as defined in paragraph

21 (2)) and such services and supplies (with such limits) fur22 nished as an incident to services furnished by the mental

23 health professional that the mental health professional is

24 legally authorized to perform under State law (or under

25 a State regulatory mechanism provided by State law), if
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1 such services and supplies are furnished to an individual

2 who resides in an area designated as a health professional

3 shortage area in accordance with section 332 of the Public

4 Health Service Act (42 U.S.C. 254e).

5 ‘‘(2) The term ‘mental health professional’ means an

6 individual who is licensed as a mental health professional

7 for the diagnosis and treatment of mental illnesses by the

8 State (or under a State regulatory mechanism provided

9 by State law) in which the individual furnishes qualified

10 mental health professional services.’’.

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

12 this section apply to services furnished on or after Janu13 ary 1, 2000.

14 SEC. 123. MEDICARE WAIVERS FOR PROVIDERS IN RURAL

15 AREAS.

16 Notwithstanding section 1886(d)(2)(D) of the Social

17 Security Act (42 U.S.C. 1395ww(d)(2)(D)), by not later

18 than 180 days after the date of the enactment of this Act,

19 the Secretary of Health and Human Services shall estab20 lish a waiver process under which entities and individuals

21 under the medicare program that are determined by the

22 Office of Management and Budget to be located in an

23 urban or large urban area for purposes of reimbursement

24 under such program may apply to the Secretary to be con-
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1 sidered to be located in a rural area for such purposes

2 if such entity or individual is located—

3 (1) in a rural area, as defined by the Goldsmith

4 Modification as published in the Federal Register on

5 February 27, 1992;

6 (2) outside of an urbanized area, as defined by

7 the United States Census Bureau; or

8 (3) an area designated by a State as a rural

9 area.

10 SEC. 124. SAFE HARBOR UNDER THE ANTI-KICKBACK STAT11 UTE FOR HOSPITAL RESTOCKING OF CER12 TAIN AMBULANCE DRUGS AND SUPPLIES.

13 (a) IN GENERAL.—Section 1128B(b)(3) of the Social

14 Security Act (42 U.S.C. 1320a–7b(b)(3)) is amended—

15 (1) by striking ‘‘and’’ at the end of subpara16 graph (E);

17 (2) by striking the period at the end of sub18 paragraph (F) and inserting ‘‘; and’’; and

19 (3) by adding at the end the following new sub20 paragraph:

21 ‘‘(G) any remuneration from a hospital to an

22 ambulance provider if—

23 ‘‘(i) the ambulance provider is owned or

24 operated (I) by a State or local government

25 agency or (II) by an organization that is de-
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1 scribed in paragraph (3) or (4) of section

2 501(c) of the Internal Revenue Code of 1986

3 and that is exempt from taxation under section

4 501(a) of such Code;

5 ‘‘(ii) the remuneration is in the form of the

6 replenishment of drugs or supplies, or both,

7 used by the ambulance provider during the

8 transport of a patient to the hospital; and

9 ‘‘(iii) the remuneration is not determined

10 in a manner that takes into account the volume

11 or value of any referrals or business otherwise

12 generated between the parties for which pay13 ment may be made in whole or part under a

14 Federal health care program.’’.

15 (b) EFFECTIVE DATE.—The amendments made by

16 subsection (a) shall apply to remuneration provided on or

17 after the date of the enactment of this Act.
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1 TITLE II—PROMOTING ACCESS

2 TO HEALTH CARE SERVICES

3 IN RURAL AREAS UNDER THE

4 MEDICAID PROGRAM

5 SEC. 201. CONTINUATION OF PRE-BBA MEDICAID REIM6 BURSEMENT RULES FOR FEDERALLY QUALI7 FIED HEALTH CENTERS AND RURAL HEALTH

8 CLINICS.

9 (a) ELIMINATION OF PHASE-OUT OF PAYMENT

10 BASED ON REASONABLE COST.—Section 1902(a)(13)(C)

11 of the Social Security Act (42 U.S.C. 1396a(a)(13)(C))

12 is amended by striking ‘‘(or 95 percent’’ and all that fol13 lows through ‘‘70 percent for services furnished during fis14 cal year 2003)’’.

15 (b) ELIMINATION OF TRANSITIONAL SUPPLEMENTAL

16 PAYMENT FOR SERVICES FURNISHED UNDER CERTAIN

17 MANAGED CARE CONTRACTS.—

18 (1) IN GENERAL.—Section 1902(a)(13)(C) of

19 such Act (42 U.S.C. 1396a(a)(13)(C)) is further

20 amended—

21 (A) by striking ‘‘(C)(i)’’ and inserting

22 ‘‘(C); and

23 (B) by striking ‘‘and (ii)’’ and all that fol24 lows up to the semicolon at the end.
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1 (2) CONFORMING AMENDMENT TO MANAGED

2 CARE CONTRACT REQUIREMENT.—Clause (ix) of sec3 tion 1903(m)(2)(A) of such Act (42 U.S.C.

4 1396b(m)(2)(A)) is amended to read as follows:

5 ‘‘(ix) such contract provides, in the case of an

6 entity that has entered into a contract for the provi7 sion of services with a Federally-qualified health cen8 ter or a rural health clinic, that (I) rates of prepay9 ment from the State are adjusted to reflect fully the

10 rates of payment specified in section

11 1902(a)(13)(C), and (II) at the election of such cen12 ter or clinic, payments made by the entity to such

13 center or clinic for services described in section

14 1905(a)(2)(C) are made at the rates of payment

15 specified in section 1902(a)(13)(C);’’.

16 (3) ELIMINATION OF REPEAL.—Section 4712(c)

17 of the Balanced Budget Act of 1997 is repealed and

18 the provisions of the Social Security Act shall be im19 plemented as through such section had never been

20 enacted.

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

22 subsections (a) and (b) apply to services furnished on or

23 after January 1, 2000.
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1 SEC. 202. MEDICAID COVERAGE OF PHYSICIANS’ ASSIST2 ANTS.

3 (a) IN GENERAL.—Section 1905(a)(5)(A) of the So4 cial Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended

5 by inserting ‘‘and services which would be physicians’ serv6 ices if furnished by such a physician and which are per7 formed by a physician assistant or a nurse practitioner

8 (as defined in section 1861(aa)(5)(A)) under the super9 vision of a physician (as so defined) and which the physi10 cian assistant or the nurse practitioner is legally author11 ized to perform by the State in which the services are per12 formed’’ after ‘‘section 1861(r)(1))’’.

13 (b) EFFECTIVE DATE.—(1) Except as provided in

14 paragraph (2), the amendment made by subsection (a)

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

16 2000, without regard to whether or not final regulations

17 to carry out such amendment have been promulgated by

18 such date.

19 (2) In the case of a State plan for medical assistance

20 under title XIX of the Social Security Act which the Sec21 retary of Health and Human Services determines requires

22 State legislation (other than legislation appropriating

23 funds) in order for the plan to meet the additional require24 ment imposed by the amendment made by subsection (a),

25 the State plan shall not be regarded as failing to comply

26 with the requirements of such title solely on the basis of
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1 its failure to meet this additional requirement before the

2 first day of the first calendar quarter beginning after the

3 close of the first regular session of the State legislature

4 that begins after the date of the enactment of this Act.

5 For purposes of the previous sentence, in the case of a

6 State that has a 2-year legislative session, each year of

7 such session shall be deemed to be a separate regular ses8 sion of the State legislature.

9 TITLE III—PROMOTING ACCESS

10 TO HEALTH CARE SERVICES

11 IN RURAL AREAS UNDER THE

12 INTERNAL REVENUE CODE

13 SEC. 301. EXCLUSION OF CERTAIN AMOUNTS RECEIVED

14 UNDER THE NATIONAL HEALTH SERVICE

15 CORPS SCHOLARSHIP PROGRAM.

16 (a) IN GENERAL.—Subsection (c) of section 117 of

17 the Internal Revenue Code of 1986 (relating to the exclu18 sion from gross income amounts received as a qualified

19 scholarship) is amended—

20 (1) by striking ‘‘Subsections (a)’’ and inserting

21 the following:

22 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

23 subsections (a)’’; and

24 (2) by adding at the end the following:
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1 ‘‘(2) NATIONAL HEALTH CORPS SCHOLARSHIP

2 PROGRAM.—Paragraph (1) shall not apply to any

3 amount received by an individual under the National

4 Health Corps Scholarship Program under section

5 338A(g)(1)(A) of the Public Health Service Act.’’

6 (b) EFFECTIVE DATE.—The amendments made by

7 subsection (a) shall apply to amounts received in taxable

8 years beginning after December 31, 1999.

9 SEC. 302. ISSUANCE OF TAX-EXEMPT BONDS BY ORGANIZA10 TIONS PROVIDING RESCUE AND EMERGENCY

11 MEDICAL SERVICES.

12 (a) GENERAL RULE.—Subsection (e) of section 150

13 of the Internal Revenue Code of 1986 is amended to read

14 as follows:

15 ‘‘(e) BONDS OF CERTAIN VOLUNTEER FIRE DEPART16 MENTS OR EMERGENCY SERVICE ORGANIZATIONS.—For

17 purposes of this part and section 103—

18 ‘‘(1) IN GENERAL.—A bond of a volunteer fire

19 or other emergency services organization shall be

20 treated as a bond of a political subdivision of a State

21 if—

22 ‘‘(A) such organization is a qualified volun23 teer fire or other emergency services organiza24 tion with respect to an area within the jurisdic25 tion of such political subdivision, and
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1 ‘‘(B) such bond is issued as part of an

2 issue 95 percent or more of the net proceeds of

3 which are to be used for the acquisition, con4 struction, reconstruction, or improvement of—

5 ‘‘(i) a firehouse or other building used

6 or to be used by such organization in pro7 viding qualified services (including land

8 which is functionally related and subordi9 nate thereto), or

10 ‘‘(ii) a firetruck, ambulance, or other

11 vehicle used or to be used by such organi12 zation in providing qualified services.

13 ‘‘(2) QUALIFIED VOLUNTEER FIRE OR OTHER

14 EMERGENCY SERVICES ORGANIZATION.—For pur15 poses of this subsection, the term ‘qualified volun16 teer fire or other emergency services organization’

17 means, with respect to a political subdivision of a

18 State, any organization—

19 ‘‘(A) which is organized and operated to

20 provide qualified services for persons in an area

21 (within the jurisdiction of such political subdivi22 sion) which is not provided with any other

23 qualified services of the type provided by such

24 organization, and
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1 ‘‘(B) which is required (by written agree2 ment) by the political subdivision to furnish

3 qualified services in such area.

4 For purposes of subparagraph (A), other qualified

5 services provided in an area shall be disregarded in

6 determining whether an organization is a qualified

7 volunteer fire or other emergency services organiza8 tion if such other qualified services are provided by

9 a qualified volunteer fire or other emergency services

10 organization (determined with the application of this

11 sentence) and such organization and the provider of

12 such other services have been continuously providing

13 qualified services to such area since January 1,

14 1997.

15 ‘‘(3) TREATMENT AS PRIVATE ACTIVITY BONDS

16 ONLY FOR CERTAIN PURPOSES.—Bonds which are

17 part of an issue which meets the requirements of

18 paragraph (1) shall not be treated as private activity

19 bonds except for purposes of sections 147(f) and

20 149(d).

21 ‘‘(4) QUALIFIED SERVICES.—For purposes of

22 this subsection, the term ‘qualified services’ means

23 any firefighting, rescue, or emergency medical serv24 ices.’’
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1 (b) EFFECTIVE DATE.—The amendment made by

2 subsection (a) shall apply to obligations issued on or after

3 January 1, 2000.

4 SEC. 303. BANK DEDUCTIBILITY OF SMALL, TAX-EXEMPT

5 DEBTS.

6 (a) IN GENERAL.—Section 265(b)(3) of the Internal

7 Revenue Code of 1986 (relating to exception for certain

8 tax-exempt obligations) is amended by adding at the end

9 the following:

10 ‘‘(G) ELECTION TO APPLY LIMITATION ON

11 AMOUNT OF OBLIGATIONS AT BORROWER

12 LEVEL.—

13 ‘‘(i) IN GENERAL.—An issuer, the

14 proceeds of the obligations of which are to

15 be used to make or finance eligible loans,

16 may elect to apply subparagraphs (C) and

17 (D) by treating each borrower as the issuer

18 of a separate issue.

19 ‘‘(ii) ELIGIBLE LOAN.—For purposes

20 of this subparagraph—

21 ‘‘(I) IN GENERAL.—The term ‘el22 igible loan’ means one or more loans

23 to a qualified borrower the proceeds of

24 which are used by the borrower for

25 health care or educational purposes
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1 and the outstanding balance of which

2 in the aggregate does not exceed

3 $5,000,000.

4 ‘‘(II) QUALIFIED BORROWER.—

5 The term ‘qualified borrower’ means a

6 borrower which is an organization de7 scribed in section 501(c)(3) and ex8 empt from taxation under section

9 501(a).

10 ‘‘(iii) MANNER OF ELECTION.—The

11 election described in clause (i) may be

12 made by an issuer for any calendar year at

13 any time prior to its first issuance during

14 such year of obligations the proceeds of

15 which will be used to make or finance one

16 or more eligible loans.

17 ‘‘(iv) MODIFICATION OF RULE FOR

18 COMPOSITE ISSUES.—In the case of an ob19 ligation which is issued by any issuer

20 which has made the election described in

21 clause (i), subparagraph (F) shall be ap22 plied without regard to clause (i) of such

23 subparagraph.’’
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1 (b) EFFECTIVE DATE.—The amendment made by

2 subsection (a) shall apply to taxable years beginning after

3 December 31, 1999.

4 TITLE IV—ADDITIONAL PROVI5 SIONS TO ADDRESS SHORT6 AGES OF HEALTH PROFES7 SIONALS IN RURAL AREAS

8 SEC. 401. REQUIREMENT FOR RURAL IMPACT STATEMENTS

9 FOR HEALTH CARE REGULATIONS.

10 (a) IN GENERAL.—Whenever the Secretary of Health

11 and Human Services promulgates a regulation (or pro12 posed regulation) relating to a health care program, in13 cluding the medicare or medicaid programs, the Secretary

14 shall include with the promulgation of the regulation an

15 analysis of the likely impact of the implementation of the

16 regulation on rural areas, including its impact on—

17 (1) rural safety net providers;

18 (2) rural primary care providers;

19 (3) rural hospitals;

20 (4) Federally qualified health centers and rural

21 health clinics;

22 (5) the economies in rural areas; and

23 (6) rural residents.
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1 (b) EFFECTIVE DATE.—Subsection (a) shall apply to

2 regulations promulgated on or after the date of the enact3 ment of this Act.

4 SEC. 402. HEALTH PROFESSIONAL SHORTAGE AREAS.

5 (a) EFFECTIVE DATE.—Section 332 of the Public

6 Health Service Act (42 U.S.C. 254e) is amended—

7 (1) in subsection (a)(1)(A), by inserting after

8 ‘‘services)’’ the following: ‘‘, or a frontier area (an

9 area that has six or fewer residents per square

10 mile),’’; and

11 (2) by adding at the end of subsection (c), the

12 following new paragraph:

13 ‘‘(3) Any pending retirements or resignations of

14 physicians available within the area involved. In im15 plementing this paragraph, the Secretary shall waive

16 the requirements of this section with respect to the

17 number of physicians serving the area for the 12-

18 month period beginning on the date on which the

19 area was designated as a health professional short20 age area.’’.

21 (b) EFFECTIVE DATE.—The amendments made by

22 subsection (a) shall take effect on the date of enactment

23 of this Act.
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1 SEC. 403. ACCESS TO DATA.

2 (a) REQUIREMENT.—The heads of the agencies de3 scribed in subsection (b) shall negotiate and enter into

4 interagency agreements with agencies and offices of the

5 Department of Health and Human Services under which

6 such agencies and offices will be provided access to data

7 sets for intramural and extramural research conducted or

8 supported by such agencies or offices.

9 (b) AGENCY HEADS.—The agencies described in this

10 section are the following:

11 (1) The National Health Service Corps.

12 (2) The Centers for Disease Control and Pre13 vention.

14 (3) The Agency for Health Care Policy and Re15 search.

16 (4) The Bureau of the Census.

17 (c) INFORMATION.—The information that is to be

18 made available under interagency agreements under this

19 section shall include all information that is necessary for

20 scholarly and policy research. Such information shall be

21 made available in a manner that includes a description of

22 the geographic area or location of the individuals who are

23 the subject of such information.

24 (d) AVAILABILITY.—Information that is subject to an

25 interagency agreement under this section shall be made
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1 available to bona fide researchers as determined appro2 priate by the Secretary of Health and Human Services.

3 (e) CONFIDENTIALITY.—Each interagency agreement

4 entered into under this section shall contain provisions

5 that protect the confidentiality of the individuals who are

6 the subjects of such information.

7 SEC. 404. DESIGNATION OF UNDERSERVED AREAS UNDER

8 HEALTH CARE CONTRACTS ADMINISTERED

9 BY THE OFFICE OF PERSONNEL MANAGE10 MENT.

11 Section 8902(m)(2)(A) of title 5, United States Code,

12 is amended by striking ‘‘a State where 25 percent’’ and

13 all that follows through the period and inserting ‘‘an area

14 designated as a health professional shortage area by the

15 Department of Health and Human Services in accordance

16 with section 332 of the Public Health Service Act (42

17 U.S.C. 254e).’’.

18 SEC. 405. REVISION OF METHODOLOGY FOR DESIGNATION

19 OF HEALTH PROFESSIONAL SHORTAGE

20 AREAS.

21 (a) REVISION OF METHODOLOGY.—

22 (1) IN GENERAL.—The Secretary of Health and

23 Human Services shall establish, on an expedited

24 basis and using a negotiated rulemaking process

25 under subchapter III of chapter 5 of title 5, United
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1 States Code, revised standards for the designation of

2 a health professional shortage area under section

3 332(a)(1) of the Public Health Service Act (42

4 U.S.C. 254e(a)(1)).

5 (2) CONSIDERATIONS.—In developing standards

6 under subsection (a), the Secretary shall—

7 (A) promote the needs of medically under8 served populations (as defined in section

9 330(b)(3) of the Public Health Service Act (42

10 U.S.C. 254c(b)(3))) and the needs of individ11 uals residing in health professional shortage

12 areas located in rural, frontier, and urban

13 areas; and

14 (B) consider the percentage of population

15 over the age of 65 years residing in such health

16 professional shortage areas.

17 (b) DEVELOPMENT OF DEFINITION OF FRONTIER.—

18 For purposes of subsection (a) and for purposes of pay19 ment under title XVIII of the Social Security Act, the Sec20 retary of Health and Human Services shall, by regulation,

21 define the term ‘‘frontier’’. Such definition shall take into

22 account population density and distance in miles, and time

23 in minutes, to the nearest medical facility.
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1 SEC. 406. SENSE OF CONGRESS REGARDING THE RESERVE

2 CORPS OF THE COMMISSIONED CORPS OF

3 THE PUBLIC HEALTH SERVICE.

4 (a) FINDINGS.—Congress makes the following find5 ings:

6 (1) Improving the Reserve Corps of the Com7 missioned Corps of the Public Health Service would

8 significantly enhance access to quality health care in

9 rural areas.

10 (2) Use of inactive members of the Reserve

11 Corps to fill vacancies in staffing of health care pro12 viders under the Public Health Service Act is an ef13 fective and cost efficient manner of providing in14 creased and improved health care services in rural

15 areas and to Public Health Service agencies.

16 (3) The use of inactive members of the Reserve

17 Corps to fill such vacancies is impeded because of an

18 inability to identify such members.

19 (4) Better overall management of the Reserve

20 Corps may save several million dollars annually.

21 (b) SENSE OF CONGRESS.—It is the sense on Con22 gress that the Secretary of Health and Human Services

23 should establish within the Public Health Service of the

24 Department of Health and Human Services an Office of

25 Reserve Corps Coordination for the Commissioned Corps

26 of the Public Health Service. Such Office should oversee
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1 the management of the Reserve Corps and take such steps

2 as are necessary, including using inactive members to fill

3 temporary vacancies in staffing of health care providers

4 under the Public Health Service Act, to efficiently utilize

5 the Reserve Corps to increase and improve health care

6 services furnished in rural areas.

7 TITLE V—TELEMEDICINE

8 Subtitle A—Improvements to the

9 Medicare Program

10 SEC. 501. IMPROVEMENT OF TELEHEALTH SERVICES.

11 (a) MEDICARE COVERAGE OF TELEHEALTH SERV12 ICES.—

13 (1) ALL SERVICES FURNISHED UNDER MEDI14 CARE.—Section 4206(a) of the Balanced Budget Act

15 of 1997 (42 U.S.C. 1395l note) is amended by strik16 ing ‘‘furnishing a service for which payment may be

17 made under such part’’ and inserting ‘‘furnishing a

18 service for which payment may be made under such

19 title’’.

20 (2) PHYSICAL, OCCUPATIONAL, AND SPEECH

21 THERAPY.—Subsections (a) and (d)(1) of section

22 4206 of the Balanced Budget Act of 1997 (42

23 U.S.C. 1395l note) are each amended by adding at

24 the end the following new sentence: ‘‘For purposes

25 of the preceding sentence, the term ‘practitioner’
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1 shall include physical, occupational, and speech

2 therapists.’’.

3 (3) TELEHEALTH CONSULTATION USING STORE

4 AND FORWARD TECHNOLOGY.—Section 4206(a) of

5 the Balanced Budget Act of 1997 (42 U.S.C. 1395l

6 note), as amended by paragraph (2), is further

7 amended by adding at the end the following new

8 sentence: ‘‘Payment shall also be made under this

9 section for professional consultations utilizing tech10 nology that provides for the asynchronous trans11 mission of health care information, in single or

12 multimedia formats, for the objective of any or all

13 of the following:

14 (1) Medical diagnosis.

15 (2) Medical treatment.

16 (3) Medical education.’’.

17 (b) MEDICARE REIMBURSEMENT FOR TELEHEALTH

18 SERVICES IN ALL RURAL AREAS.—Section 4206 of the

19 Balanced Budget Act of 1997 (42 U.S.C. 1395l note) is

20 amended—

21 (1) in subsection (a), by striking ‘‘that is des22 ignated as a health professional shortage area under

23 section 332(a)(1)(A) of the Public Health Service

24 Act (42 U.S.C. 254e(a)(1)(A))’’ and inserting ‘‘or a
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1 county that is not otherwise included in a Metropoli2 tan Statistical Area’’; and

3 (2) in subsection (d), by striking ‘‘who does not

4 reside in a rural area (as so defined) that is des5 ignated as a health professional shortage area under

6 section 332(a)(1)(A) of the Public Health Service

7 Act (42 U.S.C. 254e(a)(1)(A))’’ and inserting ‘‘who

8 resides in a county in a rural area (as so defined)

9 or a county that is not otherwise included in a Met10 ropolitan Statistical Area’’.

11 (c) PERMITTING PRESENTATION OF PATIENT BY

12 HEALTH CARE PROVIDERS.—Section 4206(a) of the

13 Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as

14 amended by subsection (a), is further amended—

15 (1) by inserting ‘‘(1)’’ after ‘‘(a) IN GEN16 ERAL.—’’; and

17 (2) by adding at the end the following new

18 paragraph:

19 ‘‘(2)(A) In the case of telehomecare (as described in

20 subparagraph (D)) a registered nurse, acting under the

21 directions of a physician or practitioner, may present the

22 beneficiary for the professional consultation. In the case

23 of such a presentation the presence of a referring or con24 sulting physician or practitioner is not required.
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1 ‘‘(B) Telehomecare may be furnished in areas other

2 than in rural areas.

3 ‘‘(C) In this section, the term ‘‘registered nurse’’

4 means a registered nurse who is licensed to practice nurs5 ing in the State in which the professional consultation is

6 performed and is operating within the scope of such li7 cense.

8 ‘‘(D) For purposes of subparagraph (A),

9 telehomecare consists of certain home health services fur10 nished using a electronic device capable of two-way audio

11 and video transmissions, and capable of monitoring and

12 transmitting vital statistics of a patient, including meas13 uring blood pressure and temperature of a patient.’’.

14 (d) REVISION OF PAYMENT METHODOLOGY.—Sec15 tion 4206(b) of the Balanced Budget Act of 1997 (42

16 U.S.C. 1395l note) is amended—

17 (1) by redesignating paragraphs (1), (2), (3),

18 and (4) as subparagraphs (A), (B), (C), and (D), re19 spectively;

20 (2) by inserting ‘‘(1)’’ before ‘‘Taking into ac21 count’’;

22 (3) in subparagraph (A), as so redesignated, to

23 read as follows:

24 ‘‘(A) The payment shall be made under a fee

25 schedule established by the Secretary that provides
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1 for payment for the referring physician or practi2 tioner and for the consulting physician or practi3 tioner. If the referring physician or practitioner de4 termines it appropriate, such referring physician or

5 practitioner may be present during the professional

6 consultation. The amount of the payment to the

7 physicians or practitioners shall not be greater than

8 the current fee schedule of such consulting physician

9 or practitioner for the health care services pro10 vided.’’;

11 (2) in subparagraph (B), to read as follows:

12 ‘‘(B) The payment shall include payment to a

13 provider of services for the costs associated with pro14 fessional consultation via telecommunications sys15 tems. Such costs shall include facility fees, costs of

16 maintenance of telehealth equipment and of tele17 communications facilities, and costs of staff incurred

18 in furnishing such professional consultations. In no

19 case may a beneficiary be billed for any such charges

20 or fees.’’; and

21 (3) by adding at the end the following new

22 paragraphs:

23 ‘‘(2) The Secretary shall permit the imposition of

24 beneficiary cost sharing in the form of a copayment, not

25 to exceed $15 per visit. In the case of any copayment im-
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1 posed under the preceding sentence, the Secretary shall

2 require the provision of notice to the individual requesting

3 such services prior to the furnishing of such services.

4 ‘‘(3) The Secretary shall establish a separate code (or

5 codes) for purposes of claims for payment for items and

6 services furnished under this section.’’.

7 (e) REPORTS TO CONGRESS.—Section 4206 of the

8 Balanced Budget Act of 1997 (42 U.S.C. 1395l note) is

9 amended by adding at the end the following new sub10 section:

11 ‘‘(e) ADDITIONAL REPORTS TO CONGRESS.—

12 ‘‘(1) INITIAL REPORT.—Not later than August

13 1, 2003, the Secretary of Health and Human Serv14 ices shall prepare and submit to the appropriate

15 committees of Congress a report concerning—

16 ‘‘(A) the number, percentage, and types of

17 health care providers licensed to provide tele18 health services across State lines, including the

19 number and types of health care providers li20 censed to provide such services in more than

21 three States;

22 ‘‘(B) the status of any reciprocal, mutual

23 recognition, fast-track, or other licensure agree24 ments between or among various States;
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1 ‘‘(C) the status of any efforts to develop

2 uniform national sets of standards for the licen3 sure of health care providers to provide tele4 health services across State lines;

5 ‘‘(D) a projection of future utilization of

6 telehealth consultations across State lines;

7 ‘‘(E) State efforts to increase or reduce li8 censure as a burden to interstate telehealth

9 practice; and

10 ‘‘(F) any State licensure requirements that

11 appear to constitute unnecessary barriers to the

12 provision of telehealth services across State

13 lines.

14 ‘‘(2) ANNUAL REPORT.—

15 ‘‘(A) IN GENERAL.—Not later than August

16 1, 2004, and each July 1 thereafter, the Sec17 retary of Health and Human Services shall pre18 pare and submit to the appropriate committees

19 of Congress, an annual report on relevant devel20 opments concerning the matters referred to in

21 subparagraphs (A) through (F) of paragraph

22 (1).

23 ‘‘(B) RECOMMENDATIONS.—If, with re24 spect to a report submitted under subparagraph

25 (A), the Secretary of Health and Human Serv-
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1 ices determines that States are not making

2 progress in facilitating the provision of tele3 health services across State lines by eliminating

4 unnecessary requirements, adopting reciprocal

5 licensing arrangements for telehealth services,

6 implementing uniform requirements for tele7 health licensure, or other means, the Secretary

8 shall include in the report recommendations

9 concerning the scope and nature of Federal ac10 tions required to reduce licensure as a barrier

11 to the interstate provision of telehealth services.

12 (f) EFFECTIVE DATE.—The amendments made by

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

14 this Act.

15 SEC. 502. JOINT WORKING GROUP ON TELEHEALTH.

16 (a) IN GENERAL.—

17 (1) REDESIGNATION.—The Joint Working

18 Group on Telemedicine, established by the Secretary

19 of Health and Human Services, shall hereafter be

20 known as the ‘‘Joint Working Group on Telehealth’’

21 with the chairperson being designated by the Office

22 for the Advancement on Telehealth.

23 (2) REPRESENTATION OF RURAL AREAS.—The

24 Joint Working Group on Telehealth shall ensure
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1 that individuals that represent the interests of rural

2 areas are members of the Group.

3 (3) MISSION.—The mission of the Joint Work4 ing Group on Telehealth is—

5 (A) to identify, monitor, and coordinate

6 Federal telehealth projects, data sets, and pro7 grams;

8 (B) to analyze—

9 (i) how telehealth systems are expand10 ing access to health care services, edu11 cation, and information;

12 (ii) the clinical, educational, or admin13 istrative efficacy and cost-effectiveness of

14 telehealth applications; and

15 (iii) the quality of the telehealth serv16 ices delivered; and

17 (C) to make further recommendations for

18 coordinating Federal and State efforts to in19 crease access to health services, education, and

20 information in rural and underserved areas.

21 (4) ANNUAL REPORTS.—Not later than two

22 years after the date of enactment of this Act and

23 each January 1 thereafter the Joint Working Group

24 on Telehealth shall report to Congress on the status
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1 of the Group’s mission and the state of the tele2 health field generally.

3 (b) REPORT SPECIFICS.—The annual report required

4 under subsection (a)(3) shall provide—

5 (1) an analysis of—

6 (A) the matters described in subsection

7 (a)(3)(B);

8 (B) the Federal activities with respect to

9 telehealth; and

10 (C) the progress of the Joint Working

11 Group on Telehealth’s efforts to coordinate

12 Federal telehealth programs; and

13 (2) recommendations for a coordinated Federal

14 strategy to increase health care access through tele15 health.

16 (c) AUTHORIZATION OF APPROPRIATIONS.—There

17 are authorized to be appropriated such sums as are nec18 essary for the Joint Working Group on Telehealth to carry

19 out this section.

20 Subtitle B—Development of

21 Telehealth Networks

22 SEC. 511. DEVELOPMENT.

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

24 Human Services (in this subtitle referred to as the ‘‘Sec25 retary’’), acting through the Director of the Office for the
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1 Advancement of Telehealth (of the Health Resources and

2 Services Administration), shall provide financial assistance

3 (as described in subsection (b)(1)) to recipients (as de4 scribed in subsection (c)(1)) for the purpose of expanding

5 access to health care services for individuals in rural and

6 frontier areas through the use of telehealth.

7 (b) FINANCIAL ASSISTANCE.—

8 (1) IN GENERAL.—Financial assistance shall

9 consist of grants or cost of money loans, or both.

10 (2) FORM.—The Secretary shall determine the

11 portion of the financial assistance provided to a re12 cipient that consists of grants and the portion that

13 consists of cost of money loans so as to result in the

14 maximum feasible repayment to the Federal Govern15 ment of the financial assistance, based on the ability

16 of the recipient to repay and full utilization of funds

17 made available to carry out this subtitle.

18 (3) LOAN FORGIVENESS PROGRAM.—

19 (A) ESTABLISHMENT.—With respect to

20 cost of money loans provided under this section,

21 the Secretary shall establish a loan forgiveness

22 program under which recipients of such loans

23 may apply to have all or a portion of such loans

24 forgiven.
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1 (B) REQUIREMENTS.—A recipient de2 scribed in subparagraph (A) that desires to

3 have a loan forgiven under the program estab4 lished under such paragraph shall—

5 (i) within 180 days of the end of the

6 loan cycle, submit an application to the

7 Secretary requesting forgiveness of the

8 loan involved;

9 (ii) demonstrate that the recipient has

10 a financial need for such forgiveness;

11 (iii) demonstrate that the recipient

12 has met the quality and cost-appropriate13 ness criteria developed under subparagraph

14 (C); and

15 (iv) provide any other information de16 termined appropriate by the Secretary.

17 (C) CRITERIA.—As part of the program

18 established under subparagraph (A), the Sec19 retary shall establish criteria for determining

20 the cost-effectiveness and quality of programs

21 operated with loans provided under this section.

22 (c) RECIPIENTS.—

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

24 grant or loan under this section an entity described

25 in paragraph (2) shall, in consultation with the
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1 State office of rural health or other appropriate

2 State entity, prepare and submit to the Secretary an

3 application, at such time, in such manner, and con4 taining such information as the Secretary may re5 quire, including—

6 (A) a description of the anticipated need

7 for the grant or loan;

8 (B) a description of the activities which the

9 entity intends to carry out using amounts pro10 vided under the grant or loan;

11 (C) a plan for continuing the project after

12 Federal support under this section is ended;

13 (D) a description of the manner in which

14 the activities funded under the grant or loan

15 will meet health care needs of underserved rural

16 populations within the State;

17 (E) a description of how the local commu18 nity or region to be served by the network or

19 proposed network will be involved in the devel20 opment and ongoing operations of the network;

21 (F) the source and amount of non-Federal

22 funds the entity would pledge for the project;

23 and
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1 (G) a showing of the long-term viability of

2 the project and evidence of health care provider

3 commitment to the network.

4 The application should demonstrate the manner in

5 which the project will promote the integration of

6 telehealth in the community so as to avoid redun7 dancy of technology and achieve economies of scale.

8 (2) ELIGIBLE ENTITIES.—An entity described

9 in this paragraph is a hospital or other health care

10 provider in a health care network of community11 based health care providers that includes at least—

12 (A) two of the following:

13 (i) community or migrant health cen14 ters;

15 (ii) local health departments;

16 (iii) nonprofit hospitals;

17 (iv) private practice health profes18 sionals, including rural health clinics;

19 (v) other publicly funded health or so20 cial services agencies;

21 (vi) skilled nursing facilities;

22 (vii) county mental health and other

23 publicly funded mental health facilities;

24 and
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1 (viii) providers of home health serv2 ices; and

3 (B) one of the following, which must dem4 onstrate use of the network for purposes of

5 education and economic development (as re6 quired by the Secretary):

7 (i) a public school;

8 (ii) a public library;

9 (iii) a university or college;

10 (iv) a local government entity; or

11 (v) a local nonhealth-related business

12 entity.

13 An eligible entity may include for-profit entities so

14 long as the network grantee is a nonprofit entity.

15 (d) PRIORITY.—The Secretary shall establish proce16 dures to prioritize financial assistance under this subtitle

17 considering whether or not the applicant—

18 (1) is a health care provider in a rural health

19 care network or a health care provider that proposes

20 to form such a network, and the majority of the

21 health care providers in such a network are located

22 in a medically underserved, health professional

23 shortage area, or mental health professional short24 age areas;
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1 (2) can demonstrate broad geographic coverage

2 in the rural areas of the State, or States in which

3 the applicant is located;

4 (3) proposes to use Federal funds to develop

5 plans for, or to establish, telehealth systems that will

6 link rural hospitals and rural health care providers

7 to other hospitals, health care providers, and pa8 tients;

9 (4) will use the amounts provided for a range

10 of health care applications and to promote greater

11 efficiency in the use of health care resources;

12 (5) can demonstrate the long-term viability of

13 projects through cost participation (cash or in-kind);

14 (6) can demonstrate financial, institutional, and

15 community support for the long-term viability of the

16 network; and

17 (7) can demonstrate a detailed plan for coordi18 nating system use by eligible entities so that health

19 care services are given a priority over non-clinical

20 uses.

21 (e) MAXIMUM AMOUNT OF ASSISTANCE TO INDI22 VIDUAL RECIPIENTS.—The Secretary may establish the

23 maximum amount of financial assistance to be made avail24 able to an individual recipient for each fiscal year under

25 this subtitle, and establish the term of the loan or grant,
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1 by publishing notice of the maximum amount in the Fed2 eral Register.

3 (f) USE OF AMOUNTS.—

4 (1) IN GENERAL.—Financial assistance pro5 vided under this subtitle shall be used—

6 (A) with respect to cost of money loans, to

7 encourage the initial development of rural tele8 health networks, expand existing networks, or

9 link existing networks together; and

10 (B) with respect to grants, as described in

11 paragraph (2).

12 (2) GRANTS AND LOANS.—The recipient of a

13 grant or loan under this subtitle may use financial

14 assistance received under such grant or loan for the

15 acquisition of telehealth equipment and modifica16 tions or improvements of telecommunications facili17 ties including—

18 (A) the development and acquisition

19 through lease or purchase of computer hard20 ware and software, audio and video equipment,

21 computer network equipment, interactive equip22 ment, data terminal equipment, and other fa23 cilities and equipment that would further the

24 purposes of this section;
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1 (B) the provision of technical assistance

2 and instruction for the development and use of

3 such programming equipment or facilities;

4 (C) the development and acquisition of in5 structional programming;

6 (D) demonstration projects for teaching or

7 training medical students, residents, and other

8 health profession students in rural training

9 sites about the application of telehealth;

10 (E) transmission costs, maintenance of

11 equipment, and compensation of specialists and

12 referring health care providers;

13 (F) development of projects to use tele14 health to facilitate collaboration between health

15 care providers;

16 (G) electronic archival of patient records;

17 (H) collection and analysis of usage statis18 tics and data that can be used to document the

19 cost-effectiveness of the telehealth services; or

20 (I) such other uses that are consistent with

21 achieving the purposes of this section as ap22 proved by the Secretary.

23 (3) EXPENDITURES IN RURAL AREAS.—In

24 awarding a grant or cost of money loan under this

25 section, the Secretary shall ensure that not less than
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1 50 percent of the grant or loan award is expended

2 in a rural area or to provide services to residents of

3 rural areas.

4 (g) PROHIBITED USES.—Financial assistance re5 ceived under this section may not be used for any of the

6 following:

7 (1) To build or acquire real property.

8 (2) In the case of the grant program, expendi9 tures to purchase or lease equipment to the extent

10 the expenditures would exceed more than 40 percent

11 of the total grant funds.

12 (3) To purchase or install transmission equip13 ment (such as laying cable or telephone lines, micro14 wave towers, satellite dishes, amplifiers, and digital

15 switching equipment).

16 (4) For construction, except that such funds

17 may be expended for minor renovations relating to

18 the installation of equipment.

19 (5) Expenditures for indirect costs (as deter20 mined by the Secretary) to the extent the expendi21 tures would exceed more than 20 percent of the total

22 grant or loan.

23 SEC. 512. ADMINISTRATION.

24 (a) NONDUPLICATION.—The Secretary shall ensure

25 that facilities constructed using financial assistance pro-
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1 vided under this subtitle do not duplicate adequately es2 tablished telehealth networks.

3 (b) LOAN MATURITY.—The maturities of cost of

4 money loans shall be determined by the Secretary, based

5 on the useful life of the facility being financed, except that

6 the loan shall not be for a period of more than 10 years.

7 (c) LOAN SECURITY AND FEASIBILITY.—The Sec8 retary shall make a cost of money loan only if the Sec9 retary determines that the security for the loan is reason10 ably adequate and that the loan will be repaid within the

11 period of the loan.

12 (d) COORDINATION WITH OTHER AGENCIES.—The

13 Secretary shall coordinate, to the extent practicable, with

14 other Federal and State agencies with similar grant or

15 loan programs to pool resources for funding meritorious

16 proposals in rural areas.

17 (e) INFORMATIONAL EFFORTS.—The Secretary shall

18 establish and implement procedures to carry out informa19 tional efforts to advise potential end users located in rural

20 areas of each State about the program authorized by this

21 subtitle.

22 SEC. 513. GUIDELINES.

23 Not later than 180 days after the date of enactment

24 of this Act, the Secretary shall issue guidelines to carry

25 out this subtitle.
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1 SEC. 514. AUTHORIZATION OF APPROPRIATIONS.

2 There are authorized to be appropriated to carry out

3 this subtitle, $25,000,000 for fiscal year 2000, and such

4 sums as may be necessary for each of the fiscal years 2001

5 through 2006.

Æ