I 
110TH CONGRESS 
2D SESSION 
H. R. 7192 
To amend the Public Health Service Act and the Social Security Act to 
increase the number of primary care physicians and to improve patient 
access to primary care services, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 27, 2008 
Ms. SCHWARTZ introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committees on 
the Judiciary, Education and Labor, and Ways and Means, for a period 
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee 
concerned 
A BILL 
To amend the Public Health Service Act and the Social 
Security Act to increase the number of primary care 
physicians and to improve patient access to primary care 
services, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Preserving Patient Access to Primary Care Act’’. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(b) TABLE OF CONTENTS.—The table of contents is 
as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Findings. 
Sec. 3. Definitions. 
TITLE I—MEDICAL EDUCATION 
Sec. 101. Recruitment incentives. 
Sec. 102. Debt forgiveness, scholarships, and service obligations. 
Sec. 103. Deferment of loans during residency and internships. 
Sec. 104. Immigration and Nationality provisions. 
Sec. 105. Educating Medical Students about Primary Care Careers. 
TITLE II—MEDICAID RELATED PROVISIONS 
Sec. 201. Transformation grants to support patient centered medical homes 
under Medicaid and SCHIP. 
Sec. 202. Promoting Children’s Access to Covered Health Services. 
TITLE III—MEDICARE PROVISIONS 
Subtitle A—Primary Care 
Sec. 301. Reforming payment systems under Medicare to support primary care. 
Sec. 302. Coverage of patient-centered medical home services. 
Sec. 303. Medicare primary care payment equity and access provision. 
Sec. 304. Additional incentive payment program for primary care services fur-
nished in health professional shortage areas. 
Sec. 305. Permanent extension of floor on Medicare work geographic adjust-
ment under the Medicare physician fee schedule. 
Sec. 306. Permanent extension of Medicare incentive payment program for phy-
sician scarcity areas. 
Sec. 307. HHS study and report on the process for determining relative value 
under the Medicare physician fee schedule. 
Subtitle B—Preventive Services 
Sec. 311. Eliminating time restriction for initial preventive physical examina-
tion. 
Sec. 312. Elimination of cost-sharing for preventive benefits under the Medi-
care program. 
Sec. 313. HHS study and report on facilitating the receipt of Medicare preven-
tive services by Medicare beneficiaries. 
Subtitle C—Other Provisions 
Sec. 321. HHS study and report on improving the ability of physicians to assist 
Medicare beneficiaries in obtaining needed prescriptions under 
Medicare part D. 
Sec. 322. Quality Improvement Organization Assistance for Physician Practices 
seeking to be patient-centered medical home practices. 
Sec. 323. HHS study and report on improved patient care through increased 
caregiver and physician interaction. 
VerDate Aug 31 2005 
03:48 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6211
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
Sec. 324. Improved patient care through expanded support for Limited English 
Proficiency services. 
Sec. 325. HHS study and report on use of real-time Medicare claims adjudica-
tion. 
TITLE IV—STUDIES 
Sec. 401. Study concerning the designation of primary care as a shortage pro-
fession. 
Sec. 402. Study concerning the education debt of medical school graduates. 
Sec. 403. Study on minority representation in primary care. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) Approximately 21 percent of physicians who 
were board certified in general internal medicine 
during the early 1990s have left internal medicine, 
compared to a 5 percent departure rate for those 
who were certified in subspecialties of internal medi-
cine. 
(2) The number of United States medical grad-
uates going into family medicine has fallen by more 
than 50 percent from 1997 to 2005. 
(3) In 2007, only 88 percent of the available 
medicine residency positions were filled and only 42 
percent of those were filled by United States medical 
school graduates. 
(4) In 2006, only 24 percent of third-year inter-
nal medicine resident intended to pursue careers in 
general internal medicine, down from 54 percent in 
1998. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(5) Primary care physicians serve as the point 
of first contact for most patients and are able to co-
ordinate the care of the whole person, reducing un-
necessary care and duplicative testing. 
(6) Primary care physicians practicing preven-
tive care, including screening for illness and treating 
diseases, can help prevent complications that result 
in more costly care. 
(7) Patients with primary care physicians have 
lower health care expenditures and primary care is 
correlated with better health status, lower overall 
mortality, and longer life expectancy. 
(8) Higher proportions of primary care physi-
cians are associated with significantly reduced utili-
zation. 
(9) The United States has a higher ratio of spe-
cialists to primary care physicians than other indus-
trialized nations and the population of the United 
States is growing faster than the expected rate of 
growth in the supply of primary care physicians. 
(10) The number of Americans age 65 and 
older, those eligible for Medicare and who use far 
more ambulatory care visits per person as those 
under age 65, is expected to double from 2000 to 
2030. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(11) A decrease in Federal spending to carry 
out programs authorized by title VII of the Public 
Health Service Act threatens the viability of one of 
the programs used to solve the problem of inad-
equate access to primary care. 
(12) The National Health Service Corps pro-
gram has a proven record of supplying physicians to 
underserved areas, and has played an important role 
in expanding access for underserved populations in 
rural and inner city communities. 
(13) Individuals in many geographic areas, es-
pecially rural areas, lack adequate access to high 
quality preventive, primary health care, contributing 
to significant health disparities that impair Amer-
ica’s public health and economic productivity. 
(14) About 20 percent of the population of the 
United States resides in primary medical care 
Health Professional Shortage Areas. 
SEC. 3. DEFINITIONS. 
(a) GENERAL DEFINITIONS.—In this Act: 
(1) CHRONIC
CARE
COORDINATION.—In this 
Act, the term ‘‘chronic care coordination’’ means the 
coordination of services that is based on the Chronic 
Care Model that provides on-going health care to pa-
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
tients with chronic diseases that may include any of 
the following services: 
(A) The development of an initial plan of 
care, and subsequent appropriate revisions to 
such plan of care. 
(B) The management of, and referral for, 
medical and other health services, including 
interdisciplinary care conferences and manage-
ment with other providers. 
(C) The monitoring and management of 
medications. 
(D) Patient education and counseling serv-
ices. 
(E) Family caregiver education and coun-
seling services. 
(F) Self-management services, including 
health education and risk appraisal to identify 
behavioral risk factors through self-assessment. 
(G) Providing access by telephone with 
physicians and other appropriate health care 
professionals, including 24-hour availability of 
such professionals for emergencies. 
(H) Management with the principal non-
professional caregiver in the home. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(I) Managing and facilitating transitions 
among health care professionals and across set-
tings of care, including the following: 
(i) Pursuing the treatment option 
elected by the individual. 
(ii) Including any advance directive 
executed by the individual in the medical 
file of the individual. 
(J) Information about, and referral to, 
hospice care, including patient and family care-
giver education and counseling about hospice 
care, and facilitating transition to hospice care 
when elected. 
(K) Information about, referral to, and 
management with, community services. 
(L) Such additional services for which pay-
ment would not otherwise be made under this 
title that the Secretary may specify that en-
courage the receipt of, or improve the effective-
ness of, the services described in this para-
graph. 
(2) CRITICAL SHORTAGE HEALTH FACILITY.— 
The term ‘‘critical shortage health facility’’ means a 
public or private nonprofit health facility that does 
not serve a health professional shortage area (as 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
designated under section 332 of the Public Health 
Service Act), but that has a critical shortage of phy-
sicians (as determined by the Secretary) in the field 
of family practice, internal medicine and pediatrics. 
(3) PRIMARY CARE.—The term ‘‘primary care’’ 
means the provision of integrated, high-quality, ac-
cessible health care services by health care providers 
who are accountable for addressing a full range of 
personal health and health care needs, developing a 
sustained partnership with patients, practicing in 
the context of family and community, and working 
to minimize disparities across population subgroups. 
(4) PRIMARY CARE PHYSICIAN.—The term ‘‘pri-
mary care physician’’ means a physician (as defined 
in section 1886 of the Social Security Act) who is 
trained in the fields of family practice, internal med-
icine, and pediatrics who provides first contact, con-
tinuous, and comprehensive care to patients. 
(5) PRINCIPAL
CARE.—The term ‘‘principal 
care’’ means integrated, accessible health care that 
is provided by medical subspecialists that addresses 
the majority of the personal health care needs of pa-
tients with chronic conditions requiring the sub-
specialist’s expertise, and for whom the subspecialist 
assumes care management, developing a sustained 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
physician-patient partnership and practicing within 
the context of family and community. 
(6) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(b) PRIMARY MEDICAL CARE SHORTAGE AREA.— 
(1) IN GENERAL.—In this Act, the term ‘‘pri-
mary medical care shortage area’’ or ‘‘PMCSA’’ 
means a geographic area with a shortage of physi-
cians (as designated by the Secretary) in the field of 
family practice, internal medicine, or pediatrics, as 
designated in accordance with paragraph (2). 
(2) DESIGNATION.—To be designated by the 
Secretary as a PMCSA, the Secretary must find 
that the geographic area involved has an established 
shortage of primary care physicians for the popu-
lation served. The Secretary shall make such a des-
ignation with respect to an urban or rural geo-
graphic area if the following criteria are met: 
(A) The area is a rational area for the de-
livery of primary medical care services. 
(B) One of the following conditions pre-
vails within the area— 
(i) the area has a population to full- 
time-equivalent primary care physician 
ratio of at least 3,500 to 1; or 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(ii) the area has a population to full- 
time-equivalent primary care physician 
ratio of less than 3,500 to 1 but greater 
than 3,000 to 1 and has unusually high 
needs for primary care services or insuffi-
cient capacity of existing primary care pro-
viders. 
(C) Primary medical care professionals in 
contiguous geographic areas are over-utilized. 
(c) MEDICALLY UNDERSERVED AREA.— 
(1) IN GENERAL.—In this Act, the term ‘‘medi-
cally underserved area’’ or ‘‘MUA’’ means a rational 
service area with a demonstrable shortage of pri-
mary healthcare resources relative to the needs of 
the entire population within the service area as de-
termined in accordance with paragraph (2) through 
the use of the Index of Medical Underservice (re-
ferred to in this subsection as the ‘‘IMU’’) with re-
spect to data on a service area. 
(2) DETERMINATIONS.—Under criteria to be 
established by the Secretary with respect to the 
IMU, if a service area is determined by the Sec-
retary to have a score of 62.0 or less, such area shall 
be eligible to be designated as a MUA. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(3) IMU VARIABLES.—In establishing criteria 
under paragraph (2), the Secretary shall ensure that 
the following variable are utilized: 
(A) The ratio of primary medical care phy-
sicians per 1,000 individuals in the population 
of the area involved. 
(B) The infant mortality rate in the area 
involved. 
(C) The percentage of the population in-
volved with incomes below the poverty level. 
(D) The percentage of the population in-
volved age 65 or over. 
The value of each of such variables for the service 
area involved shall be converted by the Secretary to 
a weighted value, according to established criteria, 
and added together to obtain the area’s IMU score. 
(d) PATIENT CENTERED MEDICAL HOME.— 
(1) IN GENERAL.—In this Act, the term ‘‘pa-
tient centered medical home’’ means a physician-di-
rected practice that has been certified by an organi-
zation under paragraph (2) as meeting the following 
standards: 
(A) The practice provides patients who 
elect to obtain care through a patient centered 
medical home (referred to as ‘‘participating pa-
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
tients’’) with direct and ongoing access to a pri-
mary or principal care physician who accepts 
responsibility for providing first contact, contin-
uous, and comprehensive care to the whole per-
son, in collaboration with teams of other health 
professionals, including nurses and specialist 
physicians, as needed and appropriate. 
(B) The practice applies standards for ac-
cess to care and communication with partici-
pating beneficiaries. 
(C) The practice has readily accessible, 
clinically useful information on participating pa-
tients that enables the practice to treat such 
patients comprehensively and systematically. 
(D) The practice maintains continuous re-
lationships with participating patients by imple-
menting evidence-based guidelines and applying 
such guidelines to the identified needs of indi-
vidual beneficiaries over time and with the in-
tensity needed by such beneficiaries. 
(E) The practice— 
(i) collaborates with participating pa-
tients to pursue their goals for optimal 
achievable health; and 
VerDate Aug 31 2005 
03:48 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(ii) assesses patient-specific barriers 
to communication and conducts activities 
to support patient self-management. 
(F) The practice has in place the resources 
and processes necessary to achieve improve-
ments in the management and coordination of 
care for participating patients. 
(G) The practice monitors its clinical proc-
ess and performance (including outcome meas-
ures) in meeting the applicable standards under 
this paragraph and provides information in a 
form and manner specified by the Secretary 
with respect to such process and performance. 
(2) STANDARD
SETTING
AND
QUALIFICATION 
PROCESS
FOR
MEDICAL
HOMES.—The Secretary 
shall establish a process for the selection of a quali-
fied standard setting and certification organiza-
tion— 
(A) to establish standards, consistent with 
this subsection, to enable medical practices to 
qualify as patient centered medical homes; and 
(B) to provide for the review and certifi-
cation of medical practices as meeting such 
standards. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
TITLE I—MEDICAL EDUCATION 
SEC. 101. RECRUITMENT INCENTIVES. 
Title VII of the Higher Education Act of 1965 (20 
U.S.C. 1133 et seq.) is amended by adding at the end 
the following: 
‘‘PART F—MEDICAL EDUCATION RECRUITMENT 
INCENTIVES 
‘‘SEC. 786. MEDICAL EDUCATION RECRUITMENT INCEN-
TIVES. 
‘‘(a) IN GENERAL.—The Secretary is authorized to 
award grants or contracts to institutions of higher edu-
cation that are graduate medical schools, to enable the 
graduate medical schools to improve primary care edu-
cation and training for medical students. 
‘‘(b) APPLICATION.—A graduate medical school that 
desires to receive a grant under this section shall submit 
to the Secretary an application at such time, in such man-
ner, and containing such information as the Secretary may 
require. 
‘‘(c) USES OF FUNDS.—A graduate medical school 
that receives a grant under this section shall use such 
grant funds to carry out 1 or more of the following: 
‘‘(1) The creation of primary care mentorship 
programs. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(2) Curriculum development for population- 
based primary care models of care, such as the pa-
tient-centered medical home. 
‘‘(3) Increased opportunities for ambulatory, 
community-based training. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 
is authorized to be appropriated to carry out this section 
$50,000,000 for each of the fiscal years 2010 through 
2012.’’. 
SEC. 102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERV-
ICE OBLIGATIONS. 
(a) PURPOSE.—It is the purpose of this section to 
encourage individuals to enter and continue in primary 
care physician careers. 
(b) AMENDMENT TO THE PUBLIC HEALTH SERVICE 
ACT.—Part D of title III of the Public Health Service Act 
(42 U.S.C. 254b et seq.) is amended by adding at the end 
the following: 
‘‘Subpart XI—Primary Care Medical Education 
‘‘SEC. 340I. SCHOLARSHIPS. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Administrator of the Health Resources and Services 
Administration, shall award grants to critical shortage 
health facilities to enable such facilities to provide scholar-
ships to individuals who agree to serve as physicians at 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
such facilities after completing a residency in the field of 
family practice, pediatrics, or internal medicine. 
‘‘(b) SCHOLARSHIPS.—A health facility shall use 
amounts received under a grant under this section to enter 
into contracts with eligible individuals under which— 
‘‘(1) the facility agrees to provide the individual 
with a scholarship for each school year (not to ex-
ceed 4 school years) in which the individual is en-
rolled as a full-time student in a school of medicine 
or a school of osteopathic medicine; and 
‘‘(2) the individual agrees— 
‘‘(A) to maintain an acceptable level of 
academic standing; 
‘‘(B) to complete a residency in the field of 
family practice, internal medicine, or pediatrics; 
and 
‘‘(C) after completing the residency, to 
serve as a primary care physician at such facil-
ity in such field for a time period equal to the 
greater of— 
‘‘(i) one year for each school year for 
which the individual was provided a schol-
arship under this section; or 
‘‘(ii) two years. 
‘‘(c) AMOUNT.— 
VerDate Aug 31 2005 
03:48 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(1) IN
GENERAL.—The amount paid by a 
health facility to an individual under a scholarship 
under this section shall not exceed $30,000 for any 
school year. 
‘‘(2) CONSIDERATIONS.—In determining the 
amount of a scholarship to be provided to an indi-
vidual under this section, a health facility may take 
into consideration the individual’s financial need, ge-
ographic differences, and educational costs. 
‘‘(3) EXCLUSION
FROM
GROSS
INCOME.—For 
purposes of the Internal Revenue Code of 1986, 
gross income shall not include any amount received 
as a scholarship under this section. 
‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 
provisions of subpart III of part D shall, except as incon-
sistent with this section, apply to the program established 
in subsection (a) in the same manner and to the same 
extent as such provisions apply to the National Health 
Service Corps Scholarship Program established in such 
subpart. 
‘‘(e) DEFINITIONS.—In this section: 
‘‘(1) CRITICAL SHORTAGE HEALTH FACILITY.— 
The term ‘critical shortage health facility’ means a 
public or private nonprofit health facility that does 
not serve a health professional shortage area (as 
VerDate Aug 31 2005 
03:48 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
designated under section 332), but has a critical 
shortage of physicians (as determined by the Sec-
retary) in the field of family practice, internal medi-
cine, or pediatrics. 
‘‘(2) ELIGIBLE INDIVIDUAL.—The term ‘eligible 
individual’ means an individual who is enrolled, or 
accepted for enrollment, as a full-time student in an 
accredited school of medicine or school of osteo-
pathic medicine. 
‘‘(f) AUTHORIZATION
OF
APPROPRIATIONS.—To 
carry out this section, there is authorized to be appro-
priated $5,000,000 for each of fiscal years 2009 through 
2013. 
‘‘SEC. 340J. LOAN REPAYMENT PROGRAM. 
‘‘(a) PURPOSE.—It is the purpose of this section to 
alleviate critical shortages of physicians in the fields of 
family practice, internal medicine, and pediatrics. 
‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 
through the Administrator of the Health Resources and 
Services Administration, shall establish a program of en-
tering into contracts with eligible individuals under 
which— 
‘‘(1) the individual agrees to serve— 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(A) as a primary care physician in the 
field of family practice, internal medicine, or 
pediatrics; and 
‘‘(B) in an area that is not a health profes-
sional shortage area (as designated under sec-
tion 332), but has a critical shortage of physi-
cians (as determined by the Secretary) in such 
field; and 
‘‘(2) the Secretary agrees to pay, for each year 
of such service, not more than $35,000 of the prin-
cipal and interest of the undergraduate or graduate 
educational loans of the individual. 
‘‘(c) SERVICE REQUIREMENT.—A contract entered 
into under this section shall allow the individual receiving 
the loan repayment to satisfy the service requirement de-
scribed in subsection (a)(1) through employment in a solo 
or group practice, a clinic, a public or private nonprofit 
hospital, or any other appropriate health care entity. 
‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 
provisions of subpart III of part D shall, except as incon-
sistent with this section, apply to the program established 
in subsection (a) in the same manner and to the same 
extent as such provisions apply to the National Health 
Service Corps Scholarship Program established in such 
subpart. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(e) DEFINITION.—In this section, the term ‘eligible 
individual’ means an individual with a degree in medicine 
or osteopathic medicine. 
‘‘(f) AUTHORIZATION
OF
APPROPRIATIONS.—To 
carry out this section, there is authorized to be appro-
priated $5,000,000 for each of fiscal years 2009 through 
2013. 
‘‘SEC. 340K. REPORTS. 
‘‘Not later than 18 months after the date of enact-
ment of this Act, and annually thereafter, the Secretary 
shall submit to Congress a report that describes the pro-
grams carried out under this subpart, including state-
ments concerning— 
‘‘(1) the number of enrollees, scholarships, loan 
repayments, and grant recipients; 
‘‘(2) the number of graduates; 
‘‘(3) the amount of scholarship payments and 
loan repayments made; 
‘‘(4) which educational institution the recipients 
attended; 
‘‘(5) the number and placement location of the 
scholarship and loan repayment recipients at health 
care facilities with a critical shortage of primary 
care physicians; 
‘‘(6) the default rate and actions required; 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00020
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(7) the amount of outstanding default funds of 
both the scholarship and loan repayment programs; 
‘‘(8) to the extent that it can be determined, 
the reason for the default; 
‘‘(9) the demographics of the individuals par-
ticipating in the scholarship and loan repayment 
programs; 
‘‘(10) the justification for the allocation of 
funds between the scholarship and loan repayment 
programs; and 
‘‘(11) an evaluation of the overall costs and 
benefits of the programs.’’. 
SEC. 103. DEFERMENT OF LOANS DURING RESIDENCY AND 
INTERNSHIPS. 
(a) LOAN REQUIREMENTS.—Section 427(a)(2)(C)(i) 
of the Higher Education Act of 1965 (20 U.S.C. 
1077(a)(2)(C)(i)) is amended by inserting ‘‘unless the 
medical internship or residency program is in family medi-
cine, internal medicine, or pediatric medicine’’ after ‘‘resi-
dency program’’. 
(b) FFEL LOANS.—Section 428(b)(1)(M)(i) of the 
Higher 
Education 
Act 
of 
1965 
(20 
U.S.C. 
1078(b)(1)(M)(i)) is amended by inserting ‘‘unless the 
medical internship or residency program is in family medi-
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00021
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
cine, internal medicine, or pediatric medicine’’ after ‘‘resi-
dency program’’. 
(c) FEDERAL DIRECT LOANS.—Section 455(f)(2)(A) 
of the Higher Education Act of 1965 (20 U.S.C. 
1087e(f)(2)(A)) is amended by inserting ‘‘unless the med-
ical internship or residency program is in family medicine, 
internal medicine, or pediatric medicine’’ after ‘‘residency 
program’’. 
(d) 
FEDERAL
PERKINS
LOANS.—Section 
464(c)(2)(A)(i) of the Higher Education Act of 1965 (20 
U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting ‘‘un-
less the medical internship or residency program is in fam-
ily medicine, internal medicine, or pediatric medicine’’ 
after ‘‘residency program’’. 
SEC. 104. IMMIGRATION AND NATIONALITY PROVISIONS. 
(a) CONRAD STATE 30 J–1 VISA WAIVER PRO-
GRAM.—Section 220(c) of the Immigration and Nation-
ality Technical Corrections Act of 1994 (8 U.S.C. 1182 
note) is amended by striking ‘‘and before June 1, 2008’’. 
(b) EXEMPTION TO H–1B VISA LIMITATION.—Sec-
tion 214(g)(5) of the Immigration and Nationality Act (8 
U.S.C. 1184(g)(5)) is amended— 
(1) in subparagraph (B), by striking ‘‘or’’ at 
the end; 
VerDate Aug 31 2005 
03:48 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00022
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
(2) in subparagraph (C), by striking the period 
at the end and inserting ‘‘; or’’; and 
(3) by adding at the end the following: 
‘‘(D) has been awarded a medical specialty cer-
tification in internal medicine, pediatrics, or family 
medicine by the appropriate medical board based on 
post-doctoral training and experience in the United 
States.’’. 
SEC. 105. EDUCATING MEDICAL STUDENTS ABOUT PRI-
MARY CARE CAREERS. 
Part C of title VII of the Public Health Service Act 
(42 U.S.C. 293k) is amended by adding at the end the 
following: 
‘‘SEC. 749. EDUCATING MEDICAL STUDENTS ABOUT PRI-
MARY CARE CAREERS. 
‘‘(a) IN
GENERAL.—The Secretary shall award 
grants to eligible State and local government entities for 
the development of informational materials that promote 
careers in primary care by highlighting the advantages 
and rewards of primary care, and that encourage medical 
students, particularly students from disadvantaged back-
grounds, to become primary care physicians. 
‘‘(b) ANNOUNCEMENT.—The grants described in sub-
section (a) shall be announced through a publication in 
the Federal Register and through appropriate media out-
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00023
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
lets in a manner intended to reach medical education insti-
tutions, associations, physician groups, and others who 
communicate with medical students. 
‘‘(c) ELIGIBILITY.—To be eligible to receive a grant 
under this section an entity shall— 
‘‘(1) be a State or local entity; and 
‘‘(2) submit to the Secretary an application at 
such time, in such manner, and containing such in-
formation as the Secretary may require. 
‘‘(d) USE OF FUNDS.— 
‘‘(1) 
IN
GENERAL.—An 
entity 
shall 
use 
amounts received under a grant under this section to 
support State and local campaigns through appro-
priate media outlets to promote careers in primary 
care and to encourage individuals from disadvan-
taged backgrounds to enter and pursue careers in 
primary care. 
‘‘(2) SPECIFIC USES.—In carrying out activities 
under paragraph (1), an entity shall use grants 
funds to develop informational materials in a man-
ner intended to reach as wide and diverse an audi-
ence of medical students as possible, in order to— 
‘‘(A) advertise and promote careers in pri-
mary care; 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00024
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(B) promote primary care medical edu-
cation programs; 
‘‘(C) inform the public of financial assist-
ance regarding such education programs; 
‘‘(D) highlight individuals in the commu-
nity who are practicing primary care physicians 
in order to recruit physicians; or 
‘‘(E) provide any other information to re-
cruit individuals for careers in primary care. 
‘‘(e) LIMITATION.—An entity shall not use amounts 
received under a grant under this section to advertise par-
ticular employment opportunities. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 
is authorized to be appropriated to carry out this section, 
such sums as may be necessary for each of fiscal years 
2009 through 2012.’’. 
TITLE II—MEDICAID RELATED 
PROVISIONS 
SEC. 201. TRANSFORMATION GRANTS TO SUPPORT PA-
TIENT CENTERED MEDICAL HOMES UNDER 
MEDICAID AND SCHIP. 
(a) IN GENERAL.—Section 1903(z) of the Social Se-
curity Act (42 U.S.C. 1396b(z)) is amended— 
(1) in paragraph (2), by adding at the end the 
following new subparagraph: 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00025
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(G) Methods for improving the effective-
ness and efficiency of medical assistance pro-
vided under this title and child health assist-
ance provided under title XXI by encouraging 
the adoption of medical practices that satisfy 
the standards established by the Secretary 
under paragraph (2) of section 3(d) of the Pre-
serving Patient Access to Primary Care Act for 
medical practices to qualify as patient centered 
medical homes (as defined subsection (d)(1) of 
such section).’’; and 
(2) in paragraph (4)— 
(A) in subparagraph (A)— 
(i) in clause (i), by striking ‘‘and’’ at 
the end; 
(ii) in clause (ii), by striking the pe-
riod at the end and inserting ‘‘; and’’; and 
(iii) by inserting after clause (ii), the 
following new clause: 
‘‘(iii) $25,000,000 for each of fiscal 
years 2010, 2011, and 2012.’’; and 
(B) in subparagraph (B), by striking the 
second and third sentences and inserting the 
following: ‘‘Such method shall provide that 100 
percent of such funds for each of fiscal years 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00026
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
2010, 2011, and 2012 shall be allocated among 
States that design programs to adopt the inno-
vative methods described in paragraph (2)(G), 
with preference given to States that design pro-
grams involving multipayers (including under 
title XVIII and private health plans) test 
projects for implementation of the elements nec-
essary to be recognized as a patient centered 
medical home practice under the National Com-
mittee for Quality Assurance Physicians Prac-
tice Connection-PCMH module (or any other 
equivalent process, as determined by the Sec-
retary).’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section take effect on October 1, 2009. 
SEC. 202. PROMOTING CHILDREN’S ACCESS TO COVERED 
HEALTH SERVICES. 
(a) MEDICAID AND CHIP PAYMENT AND ACCESS 
COMMISSION.—Title XIX (42 U.S.C. 1396 et seq.) is 
amended by inserting before section 1901 the following 
new section: 
‘‘MEDICAID AND CHIP PAYMENT AND ACCESS 
COMMISSION 
‘‘SEC. 1900. (a) ESTABLISHMENT.—There is hereby 
established the Medicaid and CHIP Payment and Access 
Commission (in this section referred to as ‘MACPAC’). 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00027
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(b) DUTIES.— 
‘‘(1) REVIEW
OF
ACCESS
POLICIES
AND
AN-
NUAL REPORTS.—MACPAC shall— 
‘‘(A) review policies of the Medicaid pro-
gram established under this title (in this section 
referred to as ‘Medicaid’) and the State Chil-
dren’s Health Insurance Program established 
under title XXI (in this section referred to as 
‘CHIP’) affecting access to covered items and 
services, including topics described in paragraph 
(2); 
‘‘(B) make recommendations to Congress 
concerning such access policies; 
‘‘(C) by not later than March 1 of each 
year (beginning with 2009), submit a report to 
Congress containing the results of such reviews 
and MACPAC’s recommendations concerning 
such policies; and 
‘‘(D) by not later than June 1 of each year 
(beginning with 2009), submit a report to Con-
gress containing an examination of issues af-
fecting Medicaid and CHIP, including the im-
plications of changes in health care delivery in 
the United States and in the market for health 
care services on such programs. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00028
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(2) SPECIFIC TOPICS TO BE REVIEWED.—Spe-
cifically, MACPAC shall review and assess the fol-
lowing: 
‘‘(A) MEDICAID AND CHIP PAYMENT POLI-
CIES.—Payment policies under Medicaid and 
CHIP, including— 
‘‘(i) the factors affecting expenditures 
for items and services in different sectors, 
including the process for updating hospital, 
skilled nursing facility, physician, federally 
qualified health center, rural health center, 
and other fees; 
‘‘(ii) payment methodologies; and 
‘‘(iii) the relationship of such factors 
and methodologies to access and quality of 
care for Medicaid and CHIP beneficiaries. 
‘‘(B) INTERACTION
OF
MEDICAID
AND 
CHIP PAYMENT POLICIES WITH HEALTH CARE 
DELIVERY GENERALLY.—The effect of Medicaid 
and CHIP payment policies on access to items 
and services for children and other Medicaid 
and CHIP populations other than under this 
title or title XXI and the implications of 
changes in health care delivery in the United 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00029
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
States and in the general market for health 
care items and services on Medicaid and CHIP. 
‘‘(C) OTHER ACCESS POLICIES.—The ef-
fect of other Medicaid and CHIP policies on ac-
cess to covered items and services, including 
policies relating to transportation and language 
barriers. 
‘‘(3) CREATION OF EARLY-WARNING SYSTEM.— 
MACPAC shall create an early-warning system to 
identify provider shortage areas or any other prob-
lems that threaten access to care or the health care 
status of Medicaid and CHIP beneficiaries. 
‘‘(4) COMMENTS ON CERTAIN SECRETARIAL RE-
PORTS.—If the Secretary submits to Congress (or a 
committee of Congress) a report that is required by 
law and that relates to access policies, including with 
respect to payment policies, under Medicaid or 
CHIP, the Secretary shall transmit a copy of the re-
port to MACPAC. MACPAC shall review the report 
and, not later than 6 months after the date of sub-
mittal of the Secretary’s report to Congress, shall 
submit to the appropriate committees of Congress 
written comments on such report. Such comments 
may include such recommendations as MACPAC 
deems appropriate. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00030
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(5) AGENDA
AND
ADDITIONAL
REVIEWS.— 
MACPAC shall consult periodically with the chair-
men and ranking minority members of the appro-
priate committees of Congress regarding MACPAC’s 
agenda and progress towards achieving the agenda. 
MACPAC may conduct additional reviews, and sub-
mit additional reports to the appropriate committees 
of Congress, from time to time on such topics relat-
ing to the program under this title or title XXI as 
may be requested by such chairmen and members 
and as MACPAC deems appropriate. 
‘‘(6) AVAILABILITY
OF
REPORTS.—MACPAC 
shall transmit to the Secretary a copy of each report 
submitted under this subsection and shall make such 
reports available to the public. 
‘‘(7) 
APPROPRIATE
COMMITTEE
OF
CON-
GRESS.—For purposes of this section, the term ‘ap-
propriate committees of Congress’ means the Com-
mittee on Energy and Commerce of the House of 
Representatives and the Committee on Finance of 
the Senate. 
‘‘(8) 
VOTING
AND
REPORTING
REQUIRE-
MENTS.—With respect to each recommendation con-
tained in a report submitted under paragraph (1), 
each member of MACPAC shall vote on the rec-
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00031
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘(B) DESIGNATED PRIMARY CARE SERV-
ICES.—The term ‘designated primary care serv-
ice’ means a service which the Secretary deter-
mines has a procedure code which involves a 
clinical interaction with an individual enrolled 
under this part that is inherent to care coordi-
nation, including interactions outside of a face- 
to-face encounter. Such term includes the fol-
lowing: 
‘‘(i) Care plan oversight. 
‘‘(ii) Evaluation and management pro-
vided by phone. 
‘‘(iii) Evaluation and management 
provided using internet resources. 
‘‘(iv) Collection and review of physio-
logic data, such as from a remote moni-
toring device. 
‘‘(v) Education and training for pa-
tient self management. 
‘‘(vi) 
Anticoagulation 
management 
services. 
‘‘(vii) Any other service determined 
appropriate by the Secretary.’’. 
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00043
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS
‘‘Patient-Centered Medical Home Services 
‘‘(hhh)(1) The term ‘patient-centered medical home 
services’ means care coordination services furnished by a 
qualified patient-centered medical home. 
‘‘(2) The term ‘qualified patient-centered medical 
home’ means a patient-centered medical home which has 
been recognized as a patient-centered medical home 
through an appropriate process, including a patient-cen-
tered medical home which is recognized through the Physi-
cian Practice Connections—Patient-Centered Medical 
Home (‘PPC–PCMH’) voluntary recognition process of 
the National Committee for Quality Assurance (or any 
other equivalent process, as determined by the Sec-
retary).’’. 
(c) MONTHLY FEE FOR PATIENT-CENTERED MED-
ICAL HOME SERVICES.—Section 1848 of the Social Secu-
rity Act (42 U.S.C. 1395w–4), as amended by section 131 
of the Medicare Improvements for Patients and Providers 
Act of 2008 (Public Law 110–275), is amended by adding 
at the end the following new subsection: 
‘‘(o) MONTHLY FEE FOR PATIENT-CENTERED MED-
ICAL HOME SERVICES.— 
‘‘(1) MONTHLY FEE.— 
‘‘(A) IN GENERAL.—Not later than Janu-
ary 1, 2012, the Secretary shall establish a pay-
VerDate Aug 31 2005 
02:21 Oct 04, 2008
Jkt 069200
PO 00000
Frm 00045
Fmt 6652
Sfmt 6201
E:\BILLS\H7192.IH
H7192
rfrederick on PROD1PC67 with BILLS