for financial assistance under this section, or as pre-
venting an entity consisting of a consortia of mem-
bers located in adjoining States from qualifying for
such assistance.
(3) PERMITTING
ENTITIES
NOT
RECEIVING
FUNDING FOR DEVELOPMENT OF PLAN TO RECEIVE
FUNDING FOR IMPLEMENTATION.—An entity that is
eligible to receive financial assistance under this sec-
tion may receive assistance to carry out activities de-
scribed in subsection (c)(1)(B) notwithstanding that
the entity does not receive assistance to carry out
activities described in subsection (c)(1)(A).
(c) USE OF FUNDS.—
(1) IN
GENERAL.—Financial assistance made
available to eligible entities under this section may
be used only—
(A) for the development of a community
health network and the submission of the plan
for the network to the Secretary; and
(B) after the Secretary approves the plan
for the network, for activities to implement the
network, including (but not limited to)—
(i) establishing information systems,
including telecommunications,
(ii) recruiting health care providers,
(iii) providing services to enable indi-
viduals to have access to health care serv-
ices, including transportation and language
interpretation services (including interpre-
tation services for the hearing-impaired),
and
(iv) establishing and operating a com-
munity health advisor program described
in paragraph (2).
(2) COMMUNITY HEALTH ADVISOR PROGRAM.—
(A) PROGRAM DESCRIBED.—In paragraph
(1), a ‘‘community health advisor program’’ is
a program under which community health advi-
sors carry out the following activities:
(i) Collaborating efforts with health
care providers and related entities to facili-
tate the provision of health services and
health-related social services.
(ii) Providing public education on
health promotion and disease prevention
and efforts to facilitate the use of available
health services and health-related social
services.
(iii) Providing health-related counsel-
ing.
(iv) Making referrals for available
health services and health-related social
services.
(v) Improving the ability of individ-
uals to use health services and health-relat-
ed social services under Federal, State,
and local programs through assisting indi-
viduals in establishing eligibility under the
programs.
(vi) Providing outreach services to in-
form the community of the availability of
the services provided under the program.
(B) COMMUNITY
HEALTH
ADVISOR
DE-
FINED.—In subparagraph (A), the term ‘‘com-
munity health advisor’’ means, with respect to
a community health advisor program, an indi-
vidual—
(i) who has demonstrated the capacity
to carry out one or more of the activities
carried out under the program; and
(ii) who, for not less than one year,
has been a resident of the community in
which the program is to be operated.
(3) LIMITATIONS ON ACTIVITIES FUNDED.—Fi-
nancial assistance made available under this section
may not be used for any of the following:
(A) For a telecommunications system un-
less such system is coordinated with, and does
not duplicate, a system existing in the area.
(B) For construction or remodeling of
health care facilities.
(4) LIMITATION ON AMOUNT AVAILABLE FOR
DEVELOPMENT OF NETWORK.—The amount of fi-
nancial assistance available for activities described in
paragraph (1)(A) may not exceed $50,000 and may
not be made available for a period of time exceeding
1 year.
(d) APPLICATION.—
(1) IN GENERAL.—No financial assistance shall
be provided under this section to an entity unless
the entity has submitted to the Secretary, in a time
and manner specified by the Secretary, and had ap-
proved by the Secretary an application.
(2) INFORMATION
TO
BE
INCLUDED.—Each
such application shall include—
(A) a description of the community rural
health network, including service area and ca-
pacity, and
(B) a description of how the proposed net-
work will utilize existing health care facilities in
a manner that avoids unnecessary duplication.
(e) AUTHORIZATION OF APPROPRIATIONS.—
(1) IN GENERAL.—There are authorized to be
appropriated $100,000,000 for each of fiscal years
1995 through 1999 to carry out this section.
Amounts appropriated under this section shall be
available until expended.
(2) INTEGRATION
OF
OTHER
AUTHORIZA-
TIONS.—In order to provide for the authorization of
appropriations under paragraph (1), notwithstanding
any other provision of law, no funds are authorized
to be appropriated to carry out the following pro-
grams in fiscal years after fiscal year 1994:
(A) The rural health transition grant pro-
gram (under section 4005(e) of the Omnibus
Budget Reconciliation Act of 1987).
(B) The rural health outreach program
(for which appropriations were annually pro-
vided under the Departments of Labor, Health
and Human Services, and Education, and Re-
lated Agencies Appropriation Acts).
(3) ANNUAL LIMIT ON ASSISTANCE TO GRANT-
EE.—The amount of financial assistance provided to
an entity under this section during a year may not
exceed $250,000.
SEC. 104. DEFINITIONS.
For purposes of this title:
(1) COMMUNITY RURAL HEALTH NETWORK.—
The term ‘‘community rural health network’’ means
a formal cooperative arrangement between partici-
pating hospitals, physicians, and other health care
providers which—
(A) is located in an underserved rural
area;
(B) furnishes health care services to indi-
viduals residing in the area; and
(C) is governed by a board of directors se-
lected by participating health care providers
and residents of the area.
(2) RURAL AREA.—The term ‘‘rural area’’ has
the 
meaning 
given 
such 
term 
in 
section
1886(d)(2)(D) of the Social Security Act.
(3) SECRETARY.—The term ‘‘Secretary’’ means
the Secretary of Health and Human Services.
(4) STATE.—The term ‘‘State’’ means each of
the several States, the District of Columbia, Puerto
Rico, the Virgin Islands, Guam, the Northern Mari-
ana Islands, and American Samoa.
(5) UNDERSERVED
RURAL
AREA.—The term
‘‘underserved rural area’’ means a rural area des-
ignated—
(A) as a health professional shortage area
under section 332(a) of the Public Health Serv-
ice Act; or
(B) as a chronically underserved area
under section 101.
TITLE 
II—INCENTIVES 
FOR
HEALTH PROFESSIONALS TO
PRACTICE IN RURAL AREAS
Subtitle A—National Health
Service Corps Program
SEC. 201. NATIONAL HEALTH SERVICE CORPS LOAN REPAY-
MENTS EXCLUDED FROM GROSS INCOME.
(a) IN GENERAL.—Part III of subchapter B of chap-
ter 1 of the Internal Revenue Code of 1986 (relating to
items specifically excluded from gross income) is amended
by redesignating section 137 as section 138 and by insert-
ing after section 136 the following new section:
‘‘SEC. 137. NATIONAL HEALTH SERVICE CORPS LOAN RE-
PAYMENTS.
‘‘(a) GENERAL RULE.—Gross income shall not in-
clude any qualified loan repayment.
‘‘(b) QUALIFIED LOAN REPAYMENT.—For purposes
of this section, the term ‘qualified loan repayment’ means
any payment made on behalf of the taxpayer by the Na-
tional Health Service Corps Loan Repayment Program
under section 338B(g) of the Public Health Service Act.’’.
(b) CONFORMING AMENDMENT.—Paragraph (3) of
section 338B(g) of the Public Health Service Act is
amended by striking ‘‘Federal, State, or local’’ and insert-
ing ‘‘State or local’’.
(c) CLERICAL AMENDMENT.—The table of sections
for part III of subchapter B of chapter 1 of the Internal
Revenue Code of 1986 is amended by striking the item
relating to section 137 and inserting the following:
‘‘Sec. 137. National Health Service Corps loan repayments.
‘‘Sec. 138. Cross references to other Acts.’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to payments made under section
338B(g) of the Public Health Service Act after the date
of the enactment of this Act.
SEC. 202. MODIFICATION IN CRITERIA FOR DESIGNATION
AS HEALTH PROFESSIONAL SHORTAGE AREA.
(a) CONSIDERATIONS REGARDING MEDICARE AND
MEDICAID PROGRAMS AS MEANS OF PAYMENT.—Section
332(b) of the Public Health Service Act (42 U.S.C.
254e(b)) is amended by adding at the end the following
paragraph:
‘‘(4) With respect to determining the need for
health services through the indicators of need under
paragraphs (1) and (2), consideration of the follow-
ing:
‘‘(A) The number of individuals in the pop-
ulation involved whose means of payment for
health services is the program under title XVIII
of the Social Security Act.
‘‘(B) The number of individuals in the
population whose means of payment for health
services is the program under title XIX of such
Act.
‘‘(C) The number of individuals in the pop-
ulation who are uninsured with respect to
health policies or plans.
‘‘(D) The percentage of the population
constituted by the aggregate number of individ-
uals under subparagraphs (A) through (C).
‘‘(E) In the case of community-based phy-
sicians who provide primary health services and
who are accepting additional patients whose
means of payment is through the program es-
tablished in title XVIII or XIX of the Social
Security Act, the percentage constituted by the
ratio of the number of such physicians to the
number of individuals in the population.’’.
(b) RELEVANCE OF TRAVEL TIMES WITHIN FRON-
TIER AREAS.—Section 332(a) of the Public Health Service
Act (42 U.S.C. 245e(a)) is amended by adding at the end
the following new paragraph:
‘‘(4) With respect to meeting the criteria under
paragraph (1)(A) for an area to be designated as a
health professional shortage area, the Secretary
shall, in the case of a frontier area, make the deter-
mination of whether the frontier area is a rational
area for the delivery of health services without re-
gard to—
‘‘(A) the travel time between population
centers in the frontier area; or
‘‘(B) the travel time to contiguous area re-
sources in the frontier area.’’.
(c) AGENCY
RECOMMENDATIONS
FOR
IMPROVE-
MENTS.—Not later than February 1, 1995, the Secretary
of Health and Human Services shall submit to the Con-
gress a report specifying the recommendations of the Sec-
retary for improving the manner of determining the extent
to which a geographic area has a need for assignments
of members of the National Health Service Corps, and for
equitably allocating such assignments among the geo-
graphic areas with a need for such assignments.
(d) EFFECTIVE DATE.—This section shall take effect
on October 1, 1994, or upon the date of the enactment
of this Act, whichever occurs later.
SEC. 203. OTHER PROVISIONS REGARDING NATIONAL
HEALTH SERVICE CORPS.
(a) SCHOLARSHIP
AND LOAN REPAYMENT PRO-
GRAMS.—
(1) AUTHORIZATION
OF
APPROPRIATIONS.—
Section 338H(b)(1) of the Public Health Service Act
(42 U.S.C. 254q(b)(1)) is amended—
(A) by striking ‘‘and’’ after ‘‘1991,’’; and
(B) by striking ‘‘through 2000.’’ and in-
serting ‘‘through 1994, $150,000,000 for fiscal
year 1995, $175,000,000 for fiscal year 1996,
$200,000,000 
for 
fiscal 
year 
1997,
$225,000,000 
for 
fiscal 
year 
1998, 
and
$250,000,000 for fiscal year 1999.’’.
(2) 
ALLOCATION
FOR
PARTICIPATION
OF
NURSES
IN
SCHOLARSHIP
PROGRAM.—Section
338H(b)(2) of the Public Health Service Act (42
U.S.C. 254q(b)(2)) is amended by adding at the end
the following subparagraph:
‘‘(C) Of the amounts appropriated under
paragraph (1) for fiscal year 1995 and subse-
quent fiscal years, the Secretary shall reserve
such amounts as may be necessary to ensure
that, of the aggregate number of individuals
who are participants in the Scholarship Pro-
gram, the total number who are being educated
as nurses or are serving as nurses, respectively,
is increased to 20 percent.’’.
(b) INCREASE
IN NUMBER
OF MENTAL HEALTH
PROFESSIONALS IN SHORTAGE AREAS.—
(1) IN GENERAL.—Section 338H(b) of the Pub-
lic Health Service Act (42 U.S.C. 254q(b)) is
amended by adding at the end the following para-
graph:
‘‘(3) MENTAL
HEALTH
PROFESSIONALS.—In
providing contracts under this subpart for scholar-
ships and loan repayments, the Secretary shall en-
sure that an appropriate number of mental health
professionals is assigned under section 333 for
health professional shortage areas.’’.
(2) APPLICABILITY.—With respect to contracts
for scholarships and loan repayments under subpart
III of part D of title III of the Public Health Service
Act, the amendment made by subsection (a) applies
with respect to contracts entered into on or after Oc-
tober 1, 1994.
Subtitle B—Incentives Under Other
Programs
SEC. 211. EXTENSION OF ADDITIONAL PAYMENT UNDER
MEDICARE FOR PHYSICIANS’ SERVICES FUR-
NISHED IN FORMER SHORTAGE AREAS.
(a) IN GENERAL.—Section 1833(m) of the Social Se-
curity Act (42 U.S.C. 1395l(m)) is amended by striking
‘‘area,’’ and inserting ‘‘area (or, in the case of an area
for which the designation as a health professional shortage
area under such section is withdrawn, in the case of physi-
cians’ services furnished to such an individual during the
3-year period beginning on the effective date of the with-
drawal of such designation),’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to physicians’ services furnished
in an area for which the designation as a health profes-
sional shortage area under section 332(a)(1)(A) of the
Public Health Service Act is withdrawn on or after Janu-
ary 1, 1995.
SEC. 212. REFINEMENT OF GEOGRAPHIC ADJUSTMENT
FACTOR FOR MEDICARE PHYSICIANS’ SERV-
ICES.
(a) DEADLINE
FOR INITIAL REVIEW
AND REVI-
SION.—Section 1848(e)(1)(C) of the Social Security Act
(42 U.S.C. 1395w–4(e)(1)(C)) is amended by adding at
the end the following: ‘‘The first such review and revision
shall apply to services furnished on or after January 1,
1997.’’.
(b) AUTHORITY TO ADJUST INDEX VALUE
FOR
INPUT COMPONENT UNDER CERTAIN CIRCUMSTANCES.—
(1) Section 1848(e)(1) of the Social Security Act (42
U.S.C. 1395w–4(e)(1)) is amended—
(A) in subparagraph (A), by striking ‘‘(B) and
(C)’’ and inserting ‘‘(B), (C), and (D)’’;
(B) by redesignating subparagraph (C) as sub-
paragraph (D); and
(C) by inserting after subparagraph (B) the fol-
lowing:
‘‘(C) SPECIAL ADJUSTMENT TO CORRECT
FOR
UNIQUE
LOCAL
CIRCUMSTANCES.—The
Secretary may adjust the value assigned to an
input component of an index in a fee schedule
area if the Secretary determines that the value
that would otherwise apply in such area does
not accurately reflect the relative costs of such
input for such area because of unique local cir-
cumstances.’’.
(2) Section 1848(i)(1)(D) of the Social Security Act
(42 U.S.C. 1395w–4(i)(1)(D)) is amended by inserting
‘‘(including any adjustment under subparagraph (C)
thereof)’’ after ‘‘subsection (e)’’.
(c) REPORT ON REVIEW PROCESS.—Not later than
April 1, 1996, the Secretary of Health and Human Serv-
ices (in this section referred to as the ‘‘Secretary’’) shall
study and report to the Committee on Finance of the Sen-
ate and the Committees on Ways and Means and Energy
and Commerce of the House of Representatives on—
(1) the data necessary to review and revise the
indices established under section 1848(e)(1)(A) of
the Social Security Act, including—
(A) the shares allocated to physicians’
work effort, practice expenses (other than mal-
practice expenses), and malpractice expenses;
(B) the weights assigned to the input com-
ponents of such shares; and
(C) the index values assigned to such com-
ponents;
(2) any limitations on the availability of data
necessary to review and revise such indices at least
every three years;
(3) ways of addressing such limitations, with
particular attention to the development of alternative
data sources for input components for which current
index values are based on data collected less fre-
quently than every three years; and
(4) the costs of developing more accurate and
timely data sources.
(d) STUDY ON LOW-VOLUME ADJUSTMENT IN ISO-
LATED AREAS.—(1) Not later than July 1, 1996, the Phy-
sician Payment Review Commission shall study and report
to the Committee on Finance of the Senate and the Com-
mittees on Ways and Means and Energy and Commerce
of the House of Representatives on the feasibility and de-
sirability of providing for a special adjustment to the index
value of the medical equipment and supplies input compo-
nent of the index used under section 1848(e) of the Social
Security Act with respect to services described in para-
graph (2).
(2) Services described in this paragraph are serv-
ices—
(A) furnished by a physician who practices in
an isolated area;
(B) requiring the presence of expensive medical
equipment and supplies in the physician’s office; and
(C) with respect to which the cost per service
of operating the equipment is increased because of
the low volume of patients of such physician.
SEC. 213. EXTENSION OF STUDENT LOAN DEFERMENTS.
(a) STAFFORD LOANS.—
(1) GSL LOANS.—Section 428(b)(1)(M) of the
Higher 
Education 
Act 
of 
1965 
(20 
U.S.C.
1078(b)(1)(M)) is amended—
(A) by striking ‘‘or’’ at the end of clause
(ii);
(B) by inserting ‘‘or’’ after the semicolon
at the end of clause (iii); and
(C) by adding at the end thereof the fol-
lowing new clause:
‘‘(iv) during which the borrower is
serving in an internship or residency pro-
gram in preparation for practice in an area
of primary care (including internal medi-
cine, pediatrics, obstetrics/gynecology, fam-
ily medicine, and osteopathy);’’.
(2) FISL LOANS.—Section 427(a)(2)(C) of
such Act (20 U.S.C. 1077(a)(2)(C)) is amended—
(A) by striking ‘‘or’’ at the end of clause
(ii);
(B) by inserting ‘‘or’’ after the semicolon
at the end of clause (iii); and
(C) by adding at the end thereof the fol-
lowing new clause:
‘‘(iv) during which the borrower is
serving in an internship or residency pro-
gram in preparation for practice in an area
of primary care (including internal medi-
cine, pediatrics, obstetrics/gynecology, fam-
ily medicine, and osteopathy);’’.
(b) PERKINS LOANS.—Section 464(c)(2)(A) of such
Act (20 U.S.C. 1087dd(c)(2)(A)) is amended—
(1) by striking ‘‘or’’ at the end of clause (iii);
(2) by inserting ‘‘or’’ after the semicolon at the
end of clause (iv); and
(3) by adding at the end thereof the following
new clause:
‘‘(v) during which the borrower is
serving in an internship or residency pro-
gram in preparation for practice in an area
of primary care (including internal medi-
cine, pediatrics, obstetrics/gynecology, fam-
ily medicine, and osteopathy);’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply on and after the date of the enact-
ment of this Act with respect to loans made under the
Higher Education Act of 1965 before, on, or after that
date.
SEC. 214. DEVELOPMENT OF MODEL STATE SCOPE OF
PRACTICE LAW.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall develop and publish a model law
that may be adopted by States to increase the access of
individuals residing in underserved rural areas to health
care services by expanding the services which non-physi-
cian health care professionals may provide in such areas.
(b) DEADLINE.—The Secretary shall publish the
model law developed under subsection (a) not later than
1 year after the date of the enactment of this Act.
TITLE III—ASSISTANCE FOR
INSTITUTIONAL PROVIDERS
Subtitle A—Community and
Migrant Health Centers
SEC. 301. COMMUNITY AND MIGRANT HEALTH CENTERS.
(a) 
MIGRANT
HEALTH
CENTERS.—Section
329(h)(1)(A) of the Public Health Service Act (42 U.S.C.
254b(h)(1)(A)) is amended—
(1) by striking ‘‘and’’ after ‘‘1991,’’; and
(2) by inserting before the period the following:
‘‘, $75,000,0000 for fiscal year 1995, and such sums
as may be necessary for each of the fiscal years
1996 through 1999’’.
(b) 
COMMUNITY
HEALTH
CENTERS.—Section
330(g)(1)(A) of the Public Health Service Act (42 U.S.C.
254c(g)(1)(A)) is amended—
(1) by striking ‘‘and’’ after ‘‘1991,’’; and
(2) by inserting before the period the following:
‘‘, $650,000,0000 for fiscal year 1995, and such
sums as may be necessary for each of the fiscal
years 1996 through 1999’’.
Subtitle B—Emergency Medical
Systems
SEC. 311. EMERGENCY MEDICAL SERVICES.
(a) ESTABLISHMENT OF FEDERAL OFFICE.—Title
XII of the Public Health Service Act (42 U.S.C. 300d et
seq.) is amended—
(1) in the heading for the title, by striking
‘‘TRAUMA CARE’’ and inserting ‘‘EMERGENCY
MEDICAL SERVICES’’;
(2) in the heading for part A, by striking
‘‘GENERAL’’ and all that follows and inserting
‘‘GENERAL AUTHORITIES AND DUTIES’’; and
(3) by amending section 1201 to read as fol-
lows:
‘‘SEC. 1201. ESTABLISHMENT OF OFFICE OF EMERGENCY
MEDICAL SERVICES.
‘‘(a) IN GENERAL.—The Secretary shall establish an
office to be known as the Office of Emergency Medical
Services, which shall be headed by a director appointed
by the Secretary. The Secretary shall carry out this title
acting through the Director of such Office.
‘‘(b) GENERAL AUTHORITIES AND DUTIES.—With
respect to emergency medical services (including trauma
care), the Secretary shall—
‘‘(1) conduct and support research, training,
evaluations, and demonstration projects;
‘‘(2) foster the development of appropriate,
modern systems of such services through the sharing
of information among agencies and individuals in-
volved in the study and provision of such services;
‘‘(3) foster the development of regional systems
for the provision of such services;
‘‘(4) sponsor workshops and conferences;
‘‘(5) as appropriate, disseminate to public and
private entities information obtained in carrying out
paragraphs (1) through (4);
‘‘(6) provide technical assistance to State and
local agencies;
‘‘(7) coordinate activities of the Department of
Health and Human Services; and
‘‘(8) as appropriate, coordinate activities of
such Department with activities of other Federal
agencies.
‘‘(c) CERTAIN REQUIREMENTS.—With respect to
emergency medical services (including trauma care), the
Secretary shall ensure that activities under subsection (b)
are carried out regarding—
‘‘(1) maintaining an adequate number of health
professionals with expertise in the provision of the
services, including hospital-based professionals and
prehospital-based professionals;
‘‘(2) developing, periodically reviewing, and re-
vising as appropriate, in collaboration with appro-
priate public and private entities, guidelines for the
provision of such services (including, for various typ-
ical circumstances, guidelines on the number and va-
riety of professionals, on equipment, and on train-
ing);
‘‘(3) the appropriate use of available tech-
nologies, including communications technologies; and
‘‘(4) the unique needs of underserved inner-city
areas and underserved rural areas.
‘‘(d) GRANTS, COOPERATIVE AGREEMENTS, AND
CONTRACTS.—In carrying out subsections (b) and (c), the
Secretary may make grants and enter into cooperative
agreements and contracts.
‘‘(e) DEFINITIONS.—For purposes of this part:
‘‘(1) The term ‘hospital-based professional’
means a health professional (including an allied
health professional) who has expertise in providing
one or more emergency medical services and who
normally provides the services at a medical facility.
‘‘(2) The term ‘prehospital-based professional’
means a health professional (including an allied
health professional) who has expertise in providing
one or more emergency medical services and who
normally provides the services at the site of the med-
ical emergency or during transport to a medical fa-
cility.’’.
(b) STATE OFFICES OF EMERGENCY MEDICAL SERV-
ICES; DEMONSTRATION PROGRAM REGARDING TELE-
COMMUNICATIONS.—Part A of title XII of the Public
Health Service Act (42 U.S.C. 300d et seq.), as amended
by section 601(b) of Public Law 103–183 (107 Stat.
2238), is amended—
(1) by redesignating sections 1202 and 1203 as
sections 1203 and 1204, respectively;
(2) by inserting after section 1201 the following
section:
‘‘SEC. 1202. STATE OFFICES OF EMERGENCY MEDICAL
SERVICES.
‘‘(a) PROGRAM
OF GRANTS.—The Secretary may
make grants to States for the purpose of improving the
availability and quality of emergency medical services
through the operation of State offices of emergency medi-
cal services.
‘‘(b) REQUIREMENT OF MATCHING FUNDS.—
‘‘(1) IN
GENERAL.—The Secretary may not
make a grant under subsection (a) unless the State
involved agrees, with respect to the costs to be in-
curred by the State in carrying out the purpose de-
scribed in such subsection, to provide non-Federal
contributions toward such costs in an amount that—
‘‘(A) for the first fiscal year of payments
under the grant, is not less than $1 for each $3
of Federal funds provided in the grant;
‘‘(B) for any second fiscal year of such
payments, is not less than $1 for each $1 of
Federal funds provided in the grant; and
‘‘(C) for any third fiscal year of such pay-
ments, is not less than $3 for each $1 of Fed-
eral funds provided in the grant.
‘‘(2) DETERMINATION
OF
AMOUNT
OF
NON-
FEDERAL CONTRIBUTION.—
‘‘(A) Subject to subparagraph (B), non-
Federal contributions required in paragraph (1)
may be in cash or in kind, fairly evaluated, in-
cluding plant, equipment, or services. Amounts
provided by the Federal Government, or serv-
ices assisted or subsidized to any significant ex-
tent by the Federal Government, may not be in-
cluded in determining the amount of such non-
Federal contributions.
‘‘(B) The Secretary may not make a grant
under subsection (a) unless the State involved
agrees that—
‘‘(i) for the first fiscal year of pay-
ments under the grant, 100 percent or less
of the non-Federal contributions required
in paragraph (1) will be provided in the
form of in-kind contributions;
‘‘(ii) for any second fiscal year of such
payments, not more than 50 percent of
such non-Federal contributions will be pro-
vided in the form of in-kind contributions;
and
‘‘(iii) for any third fiscal year of such
payments, such non-Federal contributions
will be provided solely in the form of cash.
‘‘(c) CERTAIN REQUIRED ACTIVITIES.—The Sec-
retary may not make a grant under subsection (a) unless
the State involved agrees that activities carried out by an
office operated pursuant to such subsection will include—
‘‘(1) coordinating the activities carried out in
the State that relate to emergency medical services;
‘‘(2) activities regarding the matters described
in paragraphs (1) through (4) section 1201(b); and
‘‘(3) identifying Federal and State programs re-
garding emergency medical services and providing
technical assistance to public and nonprofit private
entities regarding participation in such programs.
‘‘(d) REQUIREMENT REGARDING ANNUAL BUDGET
FOR OFFICE.—The Secretary may not make a grant
under subsection (a) unless the State involved agrees that,
for any fiscal year for which the State receives such a
grant, the office operated pursuant to subsection (a) will
be provided with an annual budget of not less than
$50,000.
‘‘(e) CERTAIN USES OF FUNDS.—
‘‘(1) RESTRICTIONS.—The Secretary may not
make a grant under subsection (a) unless the State
involved agrees that—
‘‘(A) if research with respect to emergency
medical services is conducted pursuant to the
grant, not more than 10 percent of the grant
will be expended for such research; and
‘‘(B) the grant will not be expended to pro-
vide emergency medical services (including pro-
viding cash payments regarding such services).
‘‘(2) ESTABLISHMENT
OF
OFFICE.—Activities
for which a State may expend a grant under sub-
section (a) include paying the costs of establishing
an office of emergency medical services for purposes
of such subsection.
‘‘(f) REPORTS.—The Secretary may not make a
grant under subsection (a) unless the State involved
agrees to submit to the Secretary reports containing such
information as the Secretary may require regarding activi-
ties carried out under this section by the State.
‘‘(g) REQUIREMENT
OF APPLICATION.—The Sec-
retary may not make a grant under subsection (a) unless
an application for the grant is submitted to the Secretary
and the application is in such form, is made in such man-
ner, and contains such agreements, assurances, and infor-
mation as the Secretary determines to be necessary to
carry out this section.’’; and
(3) in section 1204 (as redesignated by para-
graph (1) of this subsection)—
(A) by redesignating subsection (c) as sub-
section (d); and
(B) by inserting after subsection (b) the
following new subsection:
‘‘(c) DEMONSTRATION PROGRAM REGARDING TELE-
COMMUNICATIONS.—
‘‘(1) LINKAGES
FOR
RURAL
FACILITIES.—
Projects under subsection (a)(1) shall include dem-
onstration projects to establish telecommunications
between rural medical facilities and medical facilities
that have expertise or equipment that can be utilized
by the rural facilities through the telecommuni-
cations.
‘‘(2) MODES
OF
COMMUNICATION.—The Sec-
retary shall ensure that the telecommunications
technologies demonstrated under paragraph (1) in-
clude interactive video telecommunications, static
video imaging transmitted through the telephone
system, and facsimiles transmitted through such sys-
tem.’’.
(c) FUNDING.—Section 1232 of the Public Health
Service Act (42 U.S.C. 300d–32) is amended by striking
subsections (a) and (b) and inserting the following:
‘‘(a) 
EMERGENCY
MEDICAL
SERVICES
GEN-
ERALLY.—
‘‘(1) IN GENERAL.—For the purpose of carry-
ing out section 1201 other than with respect to trau-
ma care, and for the purpose of carrying out section
1204(c), there are authorized to be appropriated
$2,000,000 for fiscal year 1995, and such sums as
may be necessary for each of the fiscal years 1996
and 1997.
‘‘(2) STATE OFFICES.—For the purpose of car-
rying out section 1202, there are authorized to be
appropriated $3,000,000 for fiscal year 1995, and
such sums as may be necessary for each of the fiscal
years 1996 and 1997.
‘‘(b) TRAUMA CARE AND CERTAIN OTHER ACTIVI-
TIES.—
‘‘(1) IN GENERAL.—For the purpose of carry-
ing out part A with respect to trauma care, and for
the purpose of carrying out part B, there are au-
thorized to be appropriated $60,000,000 for fiscal
year 1995, and such sums as may be necessary for
each of the fiscal years 1996 and 1997.
‘‘(2) ALLOCATION OF FUNDS BY SECRETARY.—
‘‘(A) For the purpose of carrying out part
A with respect to trauma care, the Secretary
shall make available 10 percent of the amounts
appropriated for a fiscal year under paragraph
(1).
‘‘(B) For the purpose of carrying out sec-
tion 1204 (other than subsection (c) of such
section), the Secretary shall make available 10
percent of the amounts appropriated for a fiscal
year under paragraph (1).
‘‘(C)(i) For the purpose of making allot-
ments under section 1211(a), the Secretary
shall, subject to subsection (c), make available
80 percent of the amounts appropriated for a
fiscal year under paragraph (1).
‘‘(ii) Amounts paid to a State under sec-
tion 1211(a) for a fiscal year shall, for the pur-
poses for which the amounts were paid, remain
available for obligation until the end of the fis-
cal year immediately following the fiscal year
for which the amounts were paid.’’.
SEC. 312. GRANTS TO STATES REGARDING AIRCRAFT FOR
TRANSPORTING RURAL VICTIMS OF MEDICAL
EMERGENCIES.
Part E of title XII of the Public Health Service Act
(42 U.S.C. 300d–51 et seq.) is amended by adding at the
end the following new section:
‘‘SEC. 1252. GRANTS FOR SYSTEMS TO TRANSPORT RURAL
VICTIMS OF MEDICAL EMERGENCIES.
‘‘(a) IN GENERAL.—The Secretary shall make grants
to States to assist such States in the creation or enhance-
ment of air medical transport systems that provide victims
of medical emergencies in rural areas with access to treat-
ments for the injuries or other conditions resulting from
such emergencies.
‘‘(b) APPLICATION AND PLAN.—
‘‘(1) APPLICATION.—To be eligible to receive a
grant under subsection (a), a State shall prepare
and submit to the Secretary an application in such
form, made in such manner, and containing such
agreements, assurances, and information, including
a State plan as required in paragraph (2), as the
Secretary determines to be necessary to carry out
this section.
‘‘(2) STATE PLAN.—An application submitted
under paragraph (1) shall contain a State plan that
shall—
‘‘(A) describe the intended uses of the
grant proceeds and the geographic areas to be
served;
‘‘(B) demonstrate that the geographic
areas to be served, as described under subpara-
graph (A), are rural in nature;
‘‘(C) demonstrate that there is a lack of
facilities available and equipped to deliver ad-
vanced levels of medical care in the geographic
areas to be served;
‘‘(D) demonstrate that in utilizing the
grant proceeds for the establishment or en-
hancement of air medical services the State
would be making a cost-effective improvement
to existing ground-based or air emergency medi-
cal service systems;
‘‘(E) demonstrate that the State will not
utilize the grant proceeds to duplicate the capa-
bilities of existing air medical systems that are
effectively meeting the emergency medical needs
of the populations they serve;
‘‘(F) demonstrate that in utilizing the
grant proceeds the State is likely to achieve a
reduction in the morbidity and mortality rates
of the areas to be served, as determined by the
Secretary;
‘‘(G) demonstrate that the State, in utiliz-
ing the grant proceeds, will—
‘‘(i) maintain the expenditures of the
State for air and ground medical transport
systems at a level equal to not less than
the level of such expenditures maintained
by the State for the fiscal year preceding
the fiscal year for which the grant is re-
ceived; and
‘‘(ii) ensure that recipients of direct
financial assistance from the State under
such grant will maintain expenditures of
such recipients for such systems at a level
at least equal to the level of such expendi-
tures maintained by such recipients for the
fiscal year preceding the fiscal year for
which the financial assistance is received;
‘‘(H) demonstrate that persons experienced
in the field of air medical service delivery were
consulted in the preparation of the State plan;
and
‘‘(I) contain such other information as the
Secretary may determine appropriate.
‘‘(c) CONSIDERATIONS IN AWARDING GRANTS.—In
determining whether to award a grant to a State under
this section, the Secretary shall—
‘‘(1) consider the rural nature of the areas to
be served with the grant proceeds and the services
to be provided with such proceeds, as identified in
the State plan submitted under subsection (b); and
‘‘(2) give preference to States with State plans
that demonstrate an effective integration of the pro-
posed air medical transport systems into a com-
prehensive network or plan for regional or statewide
emergency medical service delivery.
‘‘(d) 
STATE
ADMINISTRATION
AND
USE
OF
GRANT.—
‘‘(1) IN
GENERAL.—The Secretary may not
make a grant to a State under subsection (a) unless
the State agrees that such grant will be adminis-
tered by the State agency with principal responsibil-
ity for carrying out programs regarding the provi-
sion of medical services to victims of medical emer-
gencies or trauma.
‘‘(2) PERMITTED
USES.—A State may use
amounts received under a grant awarded under this
section to award subgrants to public and private en-
tities operating within the State.
‘‘(3) OPPORTUNITY FOR PUBLIC COMMENT.—
The Secretary may not make a grant to a State
under subsection (a) unless that State agrees that,
in developing and carrying out the State plan under
subsection (b)(2), the State will provide public notice
with respect to the plan (including any revisions
thereto) and facilitate comments from interested
persons.
‘‘(e) NUMBER
OF GRANTS.—The Secretary shall
award grants under this section to not less than 7 States.
‘‘(f) REPORTS.—
‘‘(1) REQUIREMENT.—A State that receives a
grant under this section shall annually (during each
year in which the grant proceeds are used) prepare
and submit to the Secretary a report that shall con-
tain—
‘‘(A) a description of the manner in which
the grant proceeds were utilized;
‘‘(B) a description of the effectiveness of
the air medical transport programs assisted
with grant proceeds; and
‘‘(C) such other information as the Sec-
retary may require.
‘‘(2) TERMINATION OF FUNDING.—In reviewing
reports submitted under paragraph (1), if the Sec-
retary determines that a State is not using amounts
provided under a grant awarded under this section
in accordance with the State plan submitted by the
State under subsection (b), the Secretary may termi-
nate the payment of amounts under such grant to
the State until such time as the Secretary deter-
mines that the State comes into compliance with
such plan.
‘‘(g) DEFINITION.—As used in this section, the term
‘rural areas’ means geographic areas that are located out-
side of standard metropolitan statistical areas, as identi-
fied by the Secretary.
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—There
are authorized to be appropriated to make grants under
this section, $15,000,000 for fiscal year 1995, and such
sums as may be necessary for each of the fiscal years 1996
and 1997.’’.
Subtitle C—Assistance to Rural
Providers Under Medicare
PART 1—MEDICARE ESSENTIAL ACCESS
COMMUNITY HOSPITALS
SEC. 321. AMENDMENTS TO ESSENTIAL ACCESS COMMU-
NITY HOSPITAL (EACH) PROGRAM UNDER
MEDICARE.
(a) 
INCREASING
NUMBER
OF
PARTICIPATING
STATES.—Section 1820(a)(1) of the Social Security Act
(42 U.S.C. 1395i–4(a)(1)) is amended by striking ‘‘7’’ and
inserting ‘‘9’’.
(b) TREATMENT OF INPATIENT HOSPITAL SERVICES
PROVIDED IN RURAL PRIMARY CARE HOSPITALS.—
(1) IN
GENERAL.—Section 1820(f)(1)(F) of
such Act (42 U.S.C. 1395i–4(f)(1)(F)) is amended
to read as follows:
‘‘(F) subject to paragraph (4), provides not
more than 6 inpatient beds (meeting such con-
ditions as the Secretary may establish) for pro-
viding inpatient care to patients requiring sta-
bilization before discharge or transfer to a hos-
pital, except that the facility may not provide
any inpatient hospital services—
‘‘(i) to any patient whose attending
physician does not certify that the patient
may reasonably be expected to be dis-
charged or transferred to a hospital within
72 hours of admission to the facility; or
‘‘(ii) consisting of surgery or any
other service requiring the use of general
anesthesia (other than surgical procedures
specified by the Secretary under section
1833(i)(1)(A)), unless the attending physi-
cian certifies that the risk associated with
transferring the patient to a hospital for
such services outweighs the benefits of
transferring the patient to a hospital for
such services.’’.
(2) LIMITATION
ON
AVERAGE
LENGTH
OF
STAY.—Section 1820(f) of such Act (42 U.S.C.
1395i–4(f)) is amended by adding at the end the fol-
lowing new paragraph:
‘‘(4) LIMITATION ON AVERAGE LENGTH OF IN-
PATIENT STAYS.—The Secretary may terminate a
designation of a rural primary care hospital under
paragraph (1) if the Secretary finds that the average
length of stay for inpatients at the facility during
the previous year in which the designation was in ef-
fect exceeded 72 hours. In determining the compli-
ance of a facility with the requirement of the pre-
vious sentence, there shall not be taken into account
periods of stay of inpatients in excess of 72 hours
to the extent such periods exceed 72 hours because
transfer to a hospital is precluded because of inclem-
ent weather or other emergency conditions.’’.
(3) 
CONFORMING
AMENDMENT.—Section
1814(a)(8) of such Act (42 U.S.C. 1395f(a)(8)) is
amended by striking ‘‘such services’’ and all that fol-
lows and inserting ‘‘the individual may reasonably be
expected to be discharged or transferred to a hos-
pital within 72 hours after admission to the rural
primary care hospital.’’.
(4) GAO REPORTS.—Not later than 2 years
after the date of the enactment of this Act, the
Comptroller General shall submit reports to Con-
gress on—
(A) the application of the requirements
under section 1820(f) of the Social Security Act
(as amended by this subsection) that rural pri-
mary care hospitals provide inpatient care only
to those individuals whose attending physicians
certify may reasonably be expected to be dis-
charged within 72 hours after admission and
maintain an average length of inpatient stay
during a year that does not exceed 72 hours;
and
(B) the extent to which such requirements
have resulted in such hospitals providing inpa-
tient care beyond their capabilities or have lim-
ited the ability of such hospitals to provide
needed services.
(c) DESIGNATION OF HOSPITALS.—
(1) PERMITTING DESIGNATION OF HOSPITALS
LOCATED IN URBAN AREAS.—
(A) IN GENERAL.—Section 1820 of such
Act (42 U.S.C. 1395i–4) is amended—
(i) by striking paragraph (1) of sub-
section (e) and redesignating paragraphs
(2) through (6) as paragraphs (1) through
(5);
(ii) in subsection (e)(1)(A) (as redes-
ignated by subparagraph (A))—
(I) by striking ‘‘is located’’ and
inserting ‘‘except in the case of a hos-
pital located in an urban area, is lo-
cated’’,
(II) by striking ‘‘, (ii)’’ and in-
serting ‘‘or (ii)’’, and
(III) by striking ‘‘or (iii)’’ and all
that follows through ‘‘section,’’; and
(iii) in subsection (i)(1)(B), by strik-
ing ‘‘paragraph (3)’’ and inserting ‘‘para-
graph (2)’’.
(B) NO CHANGE IN MEDICARE PROSPEC-
TIVE
PAYMENT.—Section 1886(d)(5)(D) of
such Act (42 U.S.C. 1395ww(d)(5)(D)) is
amended—
(i) in clause (iii)(III), by inserting ‘‘lo-
cated in a rural area and’’ after ‘‘that is’’,
and
(ii) in clause (v), by inserting ‘‘located
in a rural area and’’ after ‘‘in the case of
a hospital’’.
(2) PERMITTING HOSPITALS LOCATED IN AD-
JOINING STATES TO PARTICIPATE IN STATE PRO-
GRAM.—
(A) IN GENERAL.—Section 1820 of such
Act (42 U.S.C. 1395i–4) is amended—
(i) by redesignating subsection (k) as
subsection (l); and
(ii) by inserting after subsection (j)
the following new subsection:
‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN
PARTICIPATING
STATES.—Notwithstanding any other
provision of this section—
‘‘(1) for purposes of including a hospital or fa-
cility as a member institution of a rural health net-
work, a State may designate a hospital or facility
that is not located in the State as an essential access
community hospital or a rural primary care hospital
if the hospital or facility is located in an adjoining
State and is otherwise eligible for designation as
such a hospital;
‘‘(2) the Secretary may designate a hospital or
facility that is not located in a State receiving a
grant under subsection (a)(1) as an essential access
community hospital or a rural primary care hospital
if the hospital or facility is a member institution of
a rural health network of a State receiving a grant
under such subsection; and
‘‘(3) a hospital or facility designated pursuant
to this subsection shall be eligible to receive a grant
under subsection (a)(2).’’.
(B) CONFORMING AMENDMENTS.—(i) Sec-
tion 1820(c)(1) of such Act (42 U.S.C. 1395i–
4(c)(1)) is amended by striking ‘‘paragraph
(3)’’ and inserting ‘‘paragraph (3) or subsection
(k)’’.
(ii) Paragraphs (1)(A) and (2)(A) of sec-
tion 1820(i) of such Act (42 U.S.C. 1395i–4(i))
are each amended—
(I) in clause (i), by striking ‘‘(a)(1)’’
and inserting ‘‘(a)(1) (except as provided
in subsection (k))’’, and
(II) in clause (ii), by striking ‘‘sub-
paragraph (B)’’ and inserting ‘‘subpara-
graph (B) or subsection (k)’’.
(d) SKILLED NURSING SERVICES IN RURAL PRIMARY
CARE HOSPITALS.—Section 1820(f)(3) of such Act (42
U.S.C. 1395i–4(f)(3)) is amended by striking ‘‘because
the facility’’ and all that follows and inserting the follow-
ing: ‘‘because, at the time the facility applies to the State
for designation as a rural primary care hospital, there is
in effect an agreement between the facility and the Sec-
retary under section 1883 under which the facility’s inpa-
tient hospital facilities are used for the furnishing of ex-
tended care services, except that the number of beds used
for the furnishing of such services may not exceed the total
number of licensed inpatient beds at the time the facility
applies to the State for such designation (minus the num-
ber of inpatient beds used for providing inpatient care pur-
suant to paragraph (1)(F)). For purposes of the previous
sentence, the number of beds of the facility used for the
furnishing of extended care services shall not include any
beds of a unit of the facility that is licensed as a distinct-
part skilled nursing facility at the time the facility applies
to the State for designation as a rural primary care hos-
pital.’’.
(e) DEADLINE FOR DEVELOPMENT OF PROSPECTIVE
PAYMENT SYSTEM
FOR INPATIENT RURAL PRIMARY
CARE HOSPITAL SERVICES.—Section 1814(l)(2) of such
Act (42 U.S.C. 1395f(l)(2)) is amended by striking ‘‘Jan-
uary 1, 1993’’ and inserting ‘‘January 1, 1996’’.
(f) PAYMENT
FOR OUTPATIENT RURAL PRIMARY
CARE HOSPITAL SERVICES.—
(1) IMPLEMENTATION
OF
PROSPECTIVE
PAY-
MENT SYSTEM.—Section 1834(g) of such Act (42
U.S.C. 1395m(g)) is amended—
(A) in paragraph (1), by striking ‘‘during
a year before 1993’’ and inserting ‘‘during a
year before the prospective payment system de-
scribed in paragraph (2) is in effect’’; and
(B) in paragraph (2), by striking ‘‘January
1, 1993,’’ and inserting ‘‘January 1, 1996,’’.
(2) NO USE OF CUSTOMARY CHARGE IN DETER-
MINING PAYMENT.—Section 1834(g)(1) of such Act
(42 U.S.C. 1395m(g)(1)) is amended by adding at
the end the following new flush sentence:
‘‘The amount of payment shall be determined under
either method without regard to the amount of the
customary or other charge.’’.
(g) CLARIFICATION OF PHYSICIAN STAFFING RE-
QUIREMENT FOR RURAL PRIMARY CARE HOSPITALS.—
Section 1820(f)(1)(H) of such Act (42 U.S.C. 1395i–
4(f)(1)(H)) is amended by striking the period and insert-
ing the following: ‘‘, except that in determining whether
a facility meets the requirements of this subparagraph,
subparagraphs (E) and (F) of that paragraph shall be ap-
plied as if any reference to a ‘physician’ is a reference
to a physician as defined in section 1861(r)(1).’’.
(h) TECHNICAL AMENDMENTS RELATING TO PART
A DEDUCTIBLE, COINSURANCE, AND SPELL
OF ILL-
NESS.—(1) Section 1812(a)(1) of such Act (42 U.S.C.
1395d(a)(1)) is amended—
(A) by striking ‘‘inpatient hospital services’’ the
first place it appears and inserting ‘‘inpatient hos-
pital services or inpatient rural primary care hos-
pital services’’;
(B) by striking ‘‘inpatient hospital services’’ the
second place it appears and inserting ‘‘such serv-
ices’’; and
(C) by striking ‘‘and inpatient rural primary
care hospital services’’.
(2) Sections 1813(a) and 1813(b)(3)(A) of such Act
(42 U.S.C. 1395e(a), 1395e(b)(3)(A)) are each amended
by striking ‘‘inpatient hospital services’’ each place it ap-
pears and inserting ‘‘inpatient hospital services or inpa-
tient rural primary care hospital services’’.
(3) Section 1813(b)(3)(B) of such Act (42 U.S.C.
1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos-
pital services’’ and inserting ‘‘inpatient hospital services,
inpatient rural primary care hospital services’’.
(4) Section 1861(a) of such Act (42 U.S.C. 1395x(a))
is amended—
(A) in paragraph (1), by striking ‘‘inpatient
hospital services’’ and inserting ‘‘inpatient hospital
services, inpatient rural primary care hospital serv-
ices’’; and
(B) in paragraph (2), by striking ‘‘hospital’’
and inserting ‘‘hospital or rural primary care hos-
pital’’.
(i) AUTHORIZATION OF APPROPRIATIONS.—Section
1820(l) of such Act (42 U.S.C. 1395i–4(l)), as redesig-
nated by subsection (c)(2)(A), is amended by striking
‘‘1990, 1991, and 1992’’ and inserting ‘‘1990 through
1995’’.
(j) EFFECTIVE DATE.—The amendments made by
this section shall take effect on the date of the enactment
of this Act.
PART 2—ESTABLISHMENT OF RURAL
EMERGENCY ACCESS CARE HOSPITALS
SEC. 331. RURAL EMERGENCY ACCESS CARE HOSPITALS
DESCRIBED.
(a) IN GENERAL.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x) is amended by adding at the
end the following new subsection:
‘‘Rural Emergency Access Care Hospital; Rural
Emergency Access Care Hospital Services
‘‘(oo)(1) The term ‘rural emergency access care hos-
pital’ means, for a fiscal year, a facility with respect to
which the Secretary finds the following:
‘‘(A) The facility is located in a rural area (as
defined in section 1886(d)(2)(D)).
‘‘(B) The facility was a hospital under this title
at any time during the 5-year period that ends on
the date of the enactment of this subsection.
‘‘(C) The facility is in danger of closing due to
low inpatient utilization rates and negative operating
losses, and the closure of the facility would limit the
access of individuals residing in the facility’s service
area to emergency services.
‘‘(D) The facility has entered into (or plans to
enter into) an agreement with a hospital with a par-
ticipation agreement in effect under section 1866(a),
and under such agreement the hospital shall accept
patients transferred to the hospital from the facility
and receive data from and transmit data to the facil-
ity.
‘‘(E) There is a practitioner who is qualified to
provide advanced cardiac life support services (as de-
termined by the State in which the facility is lo-
cated) on-site at the facility on a 24-hour basis.
‘‘(F) A physician is available on-call to provide
emergency medical services on a 24-hour basis.
‘‘(G) The facility meets such staffing require-
ments as would apply under section 1861(e) to a
hospital located in a rural area, except that—
‘‘(i) the facility need not meet hospital
standards relating to the number of hours dur-
ing a day, or days during a week, in which the
facility must be open, except insofar as the fa-
cility is required to provide emergency care on
a 24-hour basis under subparagraphs (E) and
(F); and
‘‘(ii) the facility may provide any services
otherwise required to be provided by a full-time,
on-site dietician, pharmacist, laboratory techni-
cian, medical technologist, or radiological tech-
nologist on a part-time, off-site basis.
‘‘(H) The facility meets the requirements appli-
cable to clinics and facilities under subparagraphs
(C) through (J) of paragraph (2) of section
1861(aa) and of clauses (ii) and (iv) of the second
sentence of such paragraph (or, in the case of the
requirements of subparagraph (E), (F), or (J) of
such paragraph, would meet the requirements if any
reference in such subparagraph to a ‘nurse practi-
tioner’ or to ‘nurse practitioners’ was deemed to be
a reference to a ‘nurse practitioner or nurse’ or to
‘nurse practitioners or nurses’); except that in deter-
mining whether a facility meets the requirements of
this subparagraph, subparagraphs (E) and (F) of
that paragraph shall be applied as if any reference
to a ‘physician’ is a reference to a physician as de-
fined in section 1861(r)(1).
‘‘(2) The term ‘rural emergency access care hospital
services’ means the following services provided by a rural
emergency access care hospital:
‘‘(A) An appropriate medical screening exam-
ination (as described in section 1867(a)).
‘‘(B) Necessary stabilizing examination and
treatment services for an emergency medical condi-
tion and labor (as described in section 1867(b)).’’.
(b) REQUIRING RURAL EMERGENCY ACCESS CARE
HOSPITALS
TO MEET HOSPITAL ANTI-DUMPING RE-
QUIREMENTS.—Section 1867(e)(5) of such Act (42 U.S.C.
1395dd(e)(5)) is amended by striking ‘‘1861(mm)(1))’’
and inserting ‘‘1861(mm)(1)) and a rural emergency ac-
cess care hospital (as defined in section 1861(oo)(1))’’.
SEC. 332. COVERAGE OF AND PAYMENT FOR SERVICES.
(a) COVERAGE UNDER PART B.—Section 1832(a)(2)
of the Social Security Act (42 U.S.C. 1395k(a)(2)) is
amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (I);
(2) by striking the period at the end of sub-
paragraph (J) and inserting ‘‘; and’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(K) rural emergency access care hospital
services (as defined in section 1861(oo)(2)).’’.
(b) PAYMENT BASED ON PAYMENT FOR OUTPATIENT
RURAL PRIMARY CARE HOSPITAL SERVICES.—
(1) IN GENERAL.—Section 1833(a)(6) of the
Social Security Act (42 U.S.C. 1395l(a)(6)) is
amended by striking ‘‘services,’’ and inserting ‘‘serv-
ices and rural emergency access care hospital serv-
ices,’’.
(2) PAYMENT
METHODOLOGY
DESCRIBED.—
Section 1834(g) of such Act (42 U.S.C. 1395m(g))
is amended—
(A) in the heading, by striking ‘‘SERV-
ICES’’ and inserting ‘‘SERVICES
AND RURAL
EMERGENCY ACCESS CARE HOSPITAL SERV-
ICES’’; and
(B) in paragraph (1), by striking ‘‘during
a year before 1993’’ and inserting ‘‘during a
year before the prospective payment system de-
scribed in paragraph (2) is in effect’’;
(C) in paragraph (1), by adding at the end
the following:
‘‘The amount of payment shall be determined under
either method without regard to the amount of the
customary or other charge.’’;
(D) in paragraph (2), by striking ‘‘Janu-
ary 1, 1993,’’ and inserting ‘‘January 1,
1996,’’; and
(E) by adding at the end the following new
paragraph:
‘‘(3) APPLICATION OF METHODS TO PAYMENT
FOR
RURAL
EMERGENCY
ACCESS
CARE
HOSPITAL
SERVICES.—The amount of payment for rural emer-
gency access care hospital services provided during
a year shall be determined using the applicable
method provided under this subsection for determin-
ing payment for outpatient rural primary care hos-
pital services during the year.’’.
SEC. 333. EFFECTIVE DATE.
The amendments made by this part shall apply to fis-
cal years beginning on or after October 1, 1994.
Subtitle 
D—Demonstration
Projects to Encourage Primary
Care and Rural-Based Graduate
Medical Education
SEC. 341. STATE AND CONSORTIUM DEMONSTRATION
PROJECTS.
(a) IN GENERAL.—
(1) PARTICIPATION OF STATES AND CONSOR-
TIA.—The Secretary shall establish and conduct a
demonstration project to increase the number and
percentage of medical students entering primary
care practice relative to those entering nonprimary
care practice under which the Secretary shall make
payments in accordance with subsection (d)—
(A) to not more than 10 States for the
purpose of testing and evaluating mechanisms
to meet the goals described in section 342; and
(B) to not more than 10 health care train-
ing consortia for the purpose of testing and
evaluating mechanisms to meet such goals.
(2) EXCLUSION OF CONSORTIA IN PARTICIPAT-
ING STATES.—A consortia may not receive payments
under the demonstration project under paragraph
(1)(B) if any of its members is located in a State
receiving payments under the project under para-
graph (1)(A).
(b) APPLICATIONS.—
(1) IN GENERAL.—Each State and consortium
desiring to conduct a demonstration project under
this section shall prepare and submit to the Sec-
retary an application, at such time, in such manner,
and containing such information as the Secretary
may require to assure that the State or consortium
will meet the goals described in section 342. In the
case of an application of a State, the application
shall include—
(A) information demonstrating that the
State has consulted with interested parties with
respect to the project, including State medical
associations, State hospital associations, and
medical schools located in the State;
(B) an assurance that no hospital conduct-
ing an approved medical residency training pro-
gram in the State will lose more than 10 per-
cent of such hospital’s approved medical resi-
dency positions in any year as a result of the
project; and
(C) an explanation of a plan for evaluating
the impact of the project in the State.
age of medical students entering primary care prac-
tice relative to those entering nonprimary care prac-
tice:
(A) USE
OF
ALTERNATIVE
WEIGHTING
FACTORS.—
(i) IN
GENERAL.—The State may
make payments to hospitals in the State
for direct graduate medical education costs
in amounts determined under the meth-
odology provided under section 1886(h) of
the Social Security Act, except that the
State shall apply weighting factors that are
different than the weighting factors other-
wise set forth in section 1886(h)(4)(C) of
the Social Security Act.
(ii) USE OF PAYMENTS FOR PRIMARY
CARE
RESIDENTS.—In applying different
weighting factors under clause (i), the
State shall ensure that the amount of pay-
ment made to hospitals for costs attrib-
utable to primary care residents shall be
greater than the amount that would have
been paid to hospitals for costs attributable
to such residents if the State had applied
the weighting factors otherwise set forth in
section 1886(h)(4)(C) of the Social Secu-
rity Act.
(B) PAYMENTS FOR MEDICAL EDUCATION
THROUGH CONSORTIUM.—The State may make
payments for graduate medical education costs
through payments to a health care training con-
sortium (or through any entity identified by
such a consortium as appropriate for receiving
payments on behalf of the consortium) that is
established in the State but that is not other-
wise participating in the demonstration project.
(2) REQUIREMENTS FOR CONSORTIUM.—
(A) IN GENERAL.—In the case of a consor-
tium participating in the demonstration project
under this subtitle, the Secretary shall make
payments for graduate medical education costs
through a health care training consortium
whose members provide medical residency train-
ing (or through any entity identified by such a
consortium as appropriate for receiving pay-
ments on behalf of the consortium).
(B) USE OF PAYMENTS.—
(i) IN
GENERAL.—Each consortium
receiving payments under subparagraph
(A) shall use such funds to conduct activi-
ties which test and evaluate mechanisms to
increase the number and percentage of
medical students entering primary care
practice 
relative 
to 
those 
entering
nonprimary care practice, and may use
such funds for the operation of the consor-
tium.
(ii) PAYMENTS
TO
PARTICIPATING
PROGRAMS.—The consortium shall ensure
that the majority of the payments received
under subparagraph (A) are directed to
consortium members for primary care resi-
dency programs, and shall designate for
each resident assigned to the consortium a
hospital operating an approved medical
residency training program for purposes of
enabling the Secretary to calculate the con-
sortium’s payment amount under the
project. Such hospital shall be the hospital
where the resident receives the majority of
the 
resident’s 
hospital-based, 
non-
ambulatory training experience.
(d) ALLOCATION OF PORTION OF MEDICARE GME
PAYMENTS FOR ACTIVITIES UNDER PROJECT.—Notwith-
standing any provision of title XVIII of the Social Security
Act, the following rules apply with respect to each State
and each health care training consortium participating in
the demonstration project established under this section
during a year:
(1) In the case of a State—
(A) the Secretary shall reduce the amount
of each payment made to hospitals in the State
during the year for direct graduate medical
education costs under section 1886(h) of the
Social Security Act by 3 percent; and
(B) the Secretary shall pay the State an
amount equal to the Secretary’s estimate of the
sum of the reductions made during the year
under subparagraph (A) (as adjusted by the
Secretary in subsequent years for over- or
under-estimations in the amount estimated
under this subparagraph in previous years).
(2) In the case of a consortium—
(A) the Secretary shall reduce the amount
of each payment made to hospitals who are
members of the consortium during the year for
direct graduate medical education costs under
section 1886(h) of the Social Security Act by 3
percent; and
(B) the Secretary shall pay the consortium
an amount equal to the Secretary’s estimate of
the sum of the reductions made during the year
under subparagraph (A) (as adjusted by the
Secretary in subsequent years for over- or
under-estimations in the amount estimated
under this subparagraph in previous years).
(e) ADDITIONAL GRANT FOR PLANNING AND EVAL-
UATION.—
(1) IN GENERAL.—The Secretary may award
grants to States and consortia participating in the
demonstration project under this section for the pur-
pose of developing and evaluating such projects. A
State or consortia may conduct such an evaluation
or contract with a private entity to conduct the eval-
uation. Each State and consortia desiring to receive
a grant under this paragraph shall prepare and sub-
mit to the Secretary an application, at such time, in
such manner, and containing such information as
the Secretary may require.
(2) AUTHORIZATION
OF
APPROPRIATIONS.—
There are authorized to be appropriated such sums
as may be necessary for grants under this paragraph
for fiscal years 1995 through 2000.
(f) DURATION.—A demonstration project under this
section shall be conducted for a period not to exceed 5
years. The Secretary may terminate a project if the Sec-
retary determines that the State or consortium conducting
the project is not in substantial compliance with the terms
of the application approved by the Secretary.
(g) EVALUATIONS AND REPORTS.—
(1) EVALUATIONS.—Each State or consortium
participating in the demonstration project shall sub-
mit to the Secretary a final evaluation within 360
days of the termination of the State or consortium’s
participation and such interim evaluations as the
Secretary may require.
(2) REPORTS TO CONGRESS.—Not later than
360 days after the first demonstration project under
this subtitle begins, and annually thereafter for each
year in which such a project is conducted, the Sec-
retary shall submit a report to Congress which eval-
uates the effectiveness of the State and consortium
activities conducted under such projects and includes
any legislative recommendations determined appro-
priate by the Secretary.
(h) MAINTENANCE OF EFFORT.—Any funds available
for the activities covered by a demonstration project under
this subtitle shall supplement, and shall not supplant,
funds that are expended for similar purposes under any
State, regional, or local program.
SEC. 342. GOALS FOR PROJECTS.
The goals referred to in this section for a State or
consortium participating in the demonstration project
under this subtitle are as follows:
(1) The training of an equal number of physi-
cian and non-physician primary care providers.
(2) The recruiting of residents for graduate
medical education training programs who received a
portion of undergraduate training in a rural area.
(3) The allocation of not less than 50 percent
of the training spent in a graduate medical residency
training program at sites at which acute care inpa-
tient hospital services are not furnished.
(4) The rotation of residents in approved medi-
cal residency training programs among practices
that serve residents of rural areas.
(5) The development of a plan under which,
after a 5-year transition period, not less than 50
percent of the residents who begin an initial resi-
dency period in an approved medical residency train-
ing program shall be primary care residents.
SEC. 343. DEFINITIONS.
In this subtitle:
(1) APPROVED MEDICAL RESIDENCY TRAINING
PROGRAM.—The term ‘‘approved medical residency
training program’’ has the meaning given such term
in section 1886(h)(5)(A) of the Social Security Act.
(2) HEALTH
CARE
TRAINING
CONSORTIUM.—
The term ‘‘health care training consortium’’ means
a State, regional, or local entity consisting of at
least one of each of the following:
(A) A hospital operating an approved med-
ical residency training program at which resi-
dents receive training at ambulatory training
sites located in rural areas.
(B) A school of medicine or osteopathic
medicine.
(C) A school of allied health or a program
for the training of physician assistants (as such
terms are defined in section 799 of the Public
Health Service Act).
(D) A school of nursing (as defined in sec-
tion 853 of the Public Health Service Act).
(3) PRIMARY CARE.—The term ‘‘primary care’’
means family practice, general internal medicine,
general pediatrics, and obstetrics and gynecology.
(4) RESIDENT.—The term ‘‘resident’’ has the
meaning given such term in section 1886(h)(5)(H)
of the Social Security Act.
(5) RURAL AREA.—The term ‘‘rural area’’ has
the 
meaning 
given 
such 
term 
in 
section
1886(d)(2)(D) of the Social Security Act.
TITLE IV—UNITED STATES-MEX-
ICO BORDER HEALTH COM-
MISSION
SEC. 401. AGREEMENT TO ESTABLISH BINATIONAL COM-
MISSION.
The President is authorized and encouraged to con-
clude an agreement with Mexico to establish a binational
commission to be known as the United States-Mexico Bor-
der Health Commission.
SEC. 402. DUTIES.
It should be the duty of the Commission—
(1) to conduct a comprehensive needs assess-
ment in the United States-Mexico border area for
the purposes of identifying, evaluating, preventing,
and resolving health problems that affect the general
population of the area;
(2) to implement the actions recommended by
the needs assessment by—
(A) assisting in the coordination of the ef-
forts of public and private persons to prevent
and resolve such health problems,
(B) assisting in the coordination of the ef-
forts of public and private persons to educate
such population concerning such health prob-
lems, and
(C) developing and implementing programs
to prevent and resolve such health problems
and to educate such population concerning such
health problems where a program is necessary
to meet a need that is not being met by the ef-
forts of other public or private persons; and
(3) to formulate recommendations to the Gov-
ernments of the United States and Mexico concern-
ing a fair and reasonable method by which the gov-
ernment of one country would reimburse a public or
private person in the other country for the cost of
a health care service that the person furnishes to a
citizen or resident alien of the first country who is
unable, through insurance or otherwise, to pay for
the service.
SEC. 403. OTHER AUTHORIZED FUNCTIONS.
In addition to the duties described in section 402, the
Commission should be authorized to perform the following
additional functions as the Commission determines to be
appropriate:
(1) To conduct or sponsor investigations, re-
search, or studies designed to identify, study, and
monitor health problems that affect the general pop-
ulation in the United States-Mexico border area.
(2) To provide financial, technical, or adminis-
trative assistance to public or private persons who
act to prevent, resolve, or educate such population
concerning such health problems.
SEC. 404. MEMBERSHIP.
(a) NUMBER AND APPOINTMENT OF UNITED STATES
SECTION.—The United States section of the Commission
should be composed of 13 members. The section should
consist of the following members:
(1) The Secretary of Health and Human Serv-
ices or such individual’s delegate.
(2) The commissioners of health from the
States of Texas, New Mexico, California, and Ari-
zona or such individuals’ delegates.
(3) 2 individuals from each of the States of
Texas, New Mexico, California, and Arizona who are
nominated by the chief executive officer of one of
such States and are appointed by the President from
among individuals—
(A) who have a demonstrated interest in
health issues of the United States-Mexico bor-
der area; and
(B) whose name appears on a list of 6
nominees submitted to the President by the
chief executive officer of the State where the
nominee resides.
(b) COMMISSIONER.—The Commissioner of the
United States section of the Commission should be the
Secretary of Health and Human Services or such individ-
ual’s delegate to the Commission. The Commissioner
should be the leader of the section.
SEC. 405. REGIONAL OFFICES.
The Commission should establish no fewer than 2 re-
gional border offices in locations selected by the Commis-
sion.
SEC. 406. REPORTS.
Not later than February 1 of each year that occurs
more than 1 year after the date of the establishment of
the Commission, the Commission should submit an annual
report to both the United States Government and the Gov-
ernment of Mexico regarding all activities of the Commis-
sion during the preceding calendar year.
SEC. 407. DEFINITIONS.
For purposes of this Act:
(1) COMMISSION.—The term ‘‘Commission’’
means the United States-Mexico Border Health
Commission authorized in section 401.
(2) HEALTH
PROBLEM.—The term ‘‘health
problem’’ means a disease or medical ailment or an
environmental condition that poses the risk of dis-
ease or medical ailment. The term includes diseases,
ailments, or risks of disease or ailment caused by or
related to environmental factors, control of animals
and rabies, control of insect and rodent vectors, dis-
posal of solid and hazardous waste, and control and
monitoring of air and water quality.
(3) RESIDENT
ALIEN.—The term ‘‘resident
alien’’, when used in reference to a country, means
an alien lawfully admitted for permanent residence
to the country or otherwise permanently residing in
the country under color of law (including residence
as an asylee, refugee, or parolee).
(4) UNITED STATES-MEXICO BORDER AREA.—
The term ‘‘United States-Mexico border area’’
means the area located in the United States and
Mexico within 100 kilometers of the border between
the United States and Mexico.
TITLE V—HOSPITAL ANTITRUST
FAIRNESS
SEC. 501. ANTITRUST EXEMPTION.
The antitrust laws shall not apply with respect to—
(1) the merger of, or the attempt to merge, 2
or more hospitals,
(2) a contract entered into solely by 2 or more
hospitals to allocate hospital services, or
(3) the attempt by only 2 or more hospitals to
enter into a contract to allocate hospital services,
if each of such hospitals satisfies all of the requirements
of section 503 at the time such hospitals engage in the
conduct described in paragraph (1), (2), or (3), as the case
may be.
SEC. 502. REQUIREMENTS.
The requirements referred to in section 501 are as
follows:
(1) The hospital is located outside of a city, or
in a city that has less than 150,000 inhabitants, as
determined in accordance with the most recent data
available from the Bureau of the Census.
(2) In the most recently concluded calendar
year, the hospital received more than 40 percent of
its gross revenue from payments made under Fed-
eral programs.
(3) There is in effect with respect to the hos-
pital a certificate issued by the Health Care Financ-
ing Administration specifying that such Administra-
tion has determined that Federal expenditures would
be reduced, consumer costs would not increase, and
access to health care services would not be reduced,
if the hospital and the other hospitals that requested
such certificate merge, or allocate the hospital serv-
ices specified in such request, as the case may be.
SEC. 503. DEFINITION.
For purposes of this title, the term ‘‘antitrust laws’’
has the meaning given such term in subsection (a) of the
first section of the Clayton Act (15 U.S.C. 12), except that
such term includes section 5 of the Federal Trade Com-
mission Act (15 U.S.C. 45) to the extent that such section
5 applies with respect to unfair methods of competition.
TITLE VI—FINANCING
SEC. 601. INCREASE IN MEDICARE PART B PREMIUM FOR
INDIVIDUALS WITH HIGH INCOME.
(a) IN GENERAL.—Subchapter A of chapter 1 of the
Internal Revenue Code of 1986 is amended by adding at
the end thereof the following new part:
‘‘PART VIII—MEDICARE PART B PREMIUMS FOR
HIGH-INCOME INDIVIDUALS
‘‘Sec. 59B. Medicare part B premium tax.
‘‘SEC. 59B. MEDICARE PART B PREMIUM TAX.
‘‘(a) IMPOSITION OF TAX.—In the case of an individ-
ual to whom this section applies for the taxable year, there
is hereby imposed (in addition to any other tax imposed
by this subtitle) a tax for such taxable year equal to the
aggregate of the Medicare part B premium taxes for each
of the months during such year that such individual is
covered by Medicare part B.
‘‘(b) INDIVIDUALS TO WHOM SECTION APPLIES.—
This section shall apply to any individual for any taxable
year if—
‘‘(1) such individual is covered under Medicare
part B for any month during such year, and
‘‘(2) the modified adjusted gross income of the
taxpayer for such taxable year exceeds the threshold
amount.
‘‘(c) MEDICARE
PART
B PREMIUM
TAX
FOR
MONTH.—
‘‘(1) IN GENERAL.—The Medicare part B pre-
mium tax for any month is 2⁄3 the amount equal to
the excess of—
‘‘(A) 200 percent of the monthly actuarial
rate for enrollees age 65 and over determined
for that calendar year under section 1839(b) of
the Social Security Act, over
‘‘(B) the total monthly premium under sec-
tion 1839 of the Social Security Act (deter-
mined without regard to subsections (b) and (f)
of section 1839 of such Act).
‘‘(2) PHASEIN
OF
TAX.—If the modified ad-
justed gross income of the taxpayer for any taxable
years exceeds the threshold amount by less than
$25,000, the Medicare part B premium tax for any
month during such taxable year shall be an amount
which bears the same ratio to the amount deter-
mined under paragraph (1) (without regard to this
paragraph) as such excess bears to $25,000. The
preceding sentence shall not apply to any individual
whose threshold amount is zero.
‘‘(d) OTHER DEFINITIONS AND SPECIAL RULES.—
For purposes of this section—
‘‘(1) THRESHOLD AMOUNT.—The term ‘thresh-
old amount’ means—
‘‘(A) except as otherwise provided in this
paragraph, $100,000,
‘‘(B) $125,000 in the case of a joint re-
turn, and
‘‘(C) zero in the case of a taxpayer who—
‘‘(i) is married at the close of the tax-
able year but does not file a joint return
for such year, and
‘‘(ii) does not live apart from his
spouse at all times during the taxable year.
‘‘(2) MODIFIED
ADJUSTED
GROSS
INCOME.—
The term ‘modified adjusted gross income’ means
adjusted gross income—
‘‘(A) determined without regard to sections
135, 911, 931, and 933, and
‘‘(B) increased by the amount of interest
received or accrued by the taxpayer during the
taxable year which is exempt from tax.
‘‘(3) MEDICARE PART B COVERAGE.—An indi-
vidual shall be treated as covered under Medicare
part B for any month if a premium is paid under
part B of title XVIII of the Social Security Act for
the coverage of the individual under such part for
the month.
‘‘(4) MARRIED
INDIVIDUAL.—The determina-
tion of whether an individual is married shall be
made in accordance with section 7703.’’
(b) CLERICAL AMENDMENT.—The table of parts for
subchapter A of chapter 1 of such Code is amended by
adding at the end thereof the following new item:
‘‘Part VIII. Medicare Part B Premiums For High-Income Individ-
uals.’’
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to months after December 1994
in taxable years ending after December 31, 1994.
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