of primary care (including general internal
medicine, general pediatrics, family medi-
cine, and osteopathy) or in obstetrics and
gynecology;’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to on and after the date of the
enactment of this Act with respect to loans made under
the Higher Education Act of 1965 before, on, or after that
date.
SEC. 203. CLARIFICATION OF PERMISSIBLE SUBSTITUTE
BILLING ARRANGEMENTS FOR PHYSICIANS’
SERVICES UNDER THE MEDICARE AND MED-
ICAID PROGRAMS.
(a) MEDICARE PROGRAM.—
(1) IN
GENERAL.—Clause (D) of section
1842(b)(6) of the Social Security Act (42 U.S.C.
1395u(b)(6)) is amended to read as follows: ‘‘(D)(i)
payment may be made to a physician for physicians’
services (and services incident to such services) to be
provided by a second physician on a reciprocal basis
to individuals who are patients of the first physician
if (I) the first physician is unavailable to provide the
services, (II) the services are not provided by the
second physician over a continuous period of longer
than 60 days, and (III) the claim form submitted to
the carrier includes the second physician’s unique
identifier (provided under the system established
under subsection (r)) and indicates that the claim
meets the requirements of this clause for payment to
the first physician; and (ii) payment may be made
to a physician for physicians’ services (and services
incident to such services) which that physician pays
a second physician on a per diem or other fee-for-
time basis to provide to individuals who are patients
of the first physician if (I) the first physician is un-
available to provide the services, (II) the services are
not provided by the second physician over a continu-
ous period of longer than 90 days (or such longer
period as the Secretary may provide), and (III) the
claim form submitted to the carrier includes the sec-
ond physician’s unique identifier (provided under the
system established under subsection (r)) and indi-
cates that the claim meets the requirements of this
clause for payment to the first physician’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to services furnished on
or after the first day of the first month beginning
more than 60 days after the date of the enactment
of this Act.
(b) MEDICAID PROGRAM.—
(1) IN
GENERAL.—Section 1902(a)(32)(C) of
the Social Security Act (42 U.S.C. 1396a(a)(32)(C))
is amended to read as follows:
‘‘(C) payment may be made to a physician
for services furnished by a substitute physician
under the circumstances described in subpara-
graph (D) of section 1842(b)(6), except that,
for purposes of this subparagraph, any ref-
erence in such subparagraph to ‘a carrier’ or
‘the system established under subsection (r)’ is
deemed a reference to the State (or other fiscal
agent under the State plan) and to the system
established under subsection (x) of this section,
respectively.’’.
(2) EFFECTIVE
DATE.—(A) The amendment
made by paragraph (1) shall apply to services fur-
nished on or after the date of the enactment of this
Act.
(B) Until the first day of the first calendar
quarter beginning more than 60 days after the date
the Secretary of Health and Human Services estab-
lishes the physician identifier system under section
1902(x) of the Social Security Act, the requirement
under section 1902(a)(32)(C) of such Act that a
claim form submitted must include the second physi-
cian’s unique identifier is deemed to be satisfied if
the claim form identifies (in a manner specified by
the Secretary of Health and Human Services) the
second physician.
TITLE III—PRIMARY CARE PHY-
SICIANS UNDER APPROVED
MEDICAL RESIDENCY TRAIN-
ING PROGRAMS
SEC. 301. DISTRIBUTION OF PRIMARY CARE PHYSICIANS
UNDER 
APPROVED 
MEDICAL 
RESIDENCY
TRAINING PROGRAMS.
(a) ESTABLISHMENT OF 50/50 RULE AS NATIONAL
POLICY.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall establish a national policy pro-
viding that, after a 3-year transition period begin-
ning on June 1, 1995, the number of entry positions
in all approved medical residency training programs
in a State or region for residents who begin an ini-
tial residency period on or after June 1, 1998, who
are not primary care residents may not exceed 50
percent of the total number of entry positions in all
such programs in a State for all residents who are
medical graduates.
(2) WAIVER FOR CERTAIN STATES.—The Sec-
retary may waive the application of the general rule
described in paragraph (1) to a State if the Sec-
retary finds that the application of the rule to the
State is not practicable.
(3) TIMETABLE.—
(A) PUBLICATION OF INTERIM FINAL REG-
ULATION.—The Secretary shall publish an in-
terim final regulation carrying out the national
policy referred to in paragraph (1) not later
than 60 days after the National Health Profes-
sional Workforce Advisory Board submits its
recommendations to the Secretary regarding
such national policy pursuant to subsection
(c)(2).
(B) USE OF BOARD’S RECOMMENDATIONS
AS
DEFAULT
POLICY.—If the Secretary does
not meet the requirements of subparagraph (A),
the recommendations of the National Health
Professional Workforce Advisory Board submit-
ted to the Secretary pursuant to subsection
(c)(2) shall, for purposes of this section and the
amendments made by this section, be deemed to
be the national policy established by the Sec-
retary under paragraph (1) respecting the num-
ber of positions in each State or region in the
approved medical residency training programs
of the different medical specialties conducted in
the State.
(b) ASSURING CONFORMITY
OF MEDICARE PAY-
MENTS FOR MEDICAL EDUCATION WITH NATIONAL POL-
ICY.—
(1) PAYMENT
FOR
DIRECT
MEDICAL
EDU-
CATION.—Section 1886(h)(5)(A) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)(5)(A)) is amended—
(A) by striking ‘‘means’’ and inserting
‘‘means, with respect to a hospital,’’; and
(B) by striking the period at the end and
inserting the following: ‘‘, but only if (with re-
spect to residents who begin an initial residency
period on or after June 1, 1995) entry positions
in each such program of the hospital are in ac-
cordance with the national policy established by
the Secretary under section 301(a) of the Fam-
ily Medicine and Primary Care Research Act of
1993 respecting the number of positions in such
program.’’.
(2) PAYMENT
FOR
INDIRECT
MEDICAL
EDU-
CATION.—Section 1886(d)(5)(B) of such Act (42
U.S.C. 1395ww(d)(5)(B)) is amended by adding at
the end the following new clauses:
‘‘(v) In determining such adjustment, the Sec-
retary may not take into account the services of any
interns and residents in a medical residency training
program for a specialty or subspecialty unless, with
respect to interns and residents who begin an initial
residency period (as defined in subsection (h)(5)(F))
on or after June 1, 1995, entry positions in each
such program of the hospital are in accordance with
the national policy established by the Secretary
under section 301(a) of the Family Medicine and
Primary Care Research Act of 1993 respecting the
number of positions in such program.
‘‘(vi) With respect to payments during each of
the first 5 fiscal years for which clause (v) is in ef-
fect, the application of such clause may not result in
a reduction of the additional payment amount made
to the hospital under this subparagraph during the
fiscal year to an amount that is less than—
‘‘(I) in the case of a hospital receiving an
additional payment amount under subpara-
graph (F) during the fiscal year that is com-
puted under clause (vii)(I) of such subpara-
graph, 95 percent of the additional payment
(D) at least 1 shall be the chief executive
officer of a hospital that operates an approved
medical residency training program;
(E) at least 1 shall be the vice-president or
vice-chancellor for health affairs of a multi-dis-
ciplinary academic health center; and
(F) at least 1 shall represent the general
public.
(2) DUTIES.—
(A) IN GENERAL.—The Board shall—
(i) prepare initial recommendations
regarding the national policy referred to in
subsection (a)(1) regarding the distribution
of entry positions in approved medical resi-
dency training programs of the different
medical specialties among primary care
and non-primary care residents at various
sites, and submit such recommendations to
the Secretary not later than 1 year after
the date of the enactment of this Act;
(ii) submit recommendations to the
Secretary regarding the supply and role of
providers of primary care services who are
not physicians;
(iii) with respect to funds available
pursuant to title XVIII of the Social Secu-
rity Act for direct graduate medical edu-
cation for the clinical training of physi-
cians and nurses, study the appropriate-
ness of expending such funds to make re-
imbursements under such title for the clin-
ical training in primary care of additional
practitioners;
(iv) submit annual reports to Con-
gress and the Secretary on the implemen-
tation of such national policy; and
(v) provide the Secretary with such
technical and other assistance regarding
such national policy as the Secretary may
request.
(B) CRITERIA FOR RECOMMENDATIONS.—
In preparing its recommendations under sub-
paragraph (A), the Board shall take into con-
sideration—
(i) the quality of graduate medical
residency training programs;
(ii) the need to maintain the operation
of such programs that have demonstrated
success in recruiting, retaining, and pro-
moting minority practitioners;
(iii) the need to assure that the dis-
tribution of entry positions in such pro-
grams is not inequitable in relation to the
States and hospitals in urban and rural
areas that are qualified to offer such pro-
grams;
(iv) the need to assure the provision
of primary care and other health care serv-
ices to medically underserved communities;
and
(v) such other criteria as the Board
(in consultation with the accrediting bodies
referred to in paragraph (3)) considers ap-
propriate.
(3) ROLE OF ACCREDITING BODIES AND CER-
TIFYING
BOARDS.—In preparing its recommenda-
tions regarding the national policy referred to in
subsection (a)(1), the Board shall—
(A) request each accrediting body for ap-
proved medical residency training programs for
a specialty or subspecialty, and each certifi-
cation board for such specialty or subspecialty,
to prepare and submit a plan that provides for
the achievement of such national policy with re-
spect to approved medical residency training
programs for such specialty or subspecialty;
(B) analyze the extent to which the Board
may adopt such plans as the basis for its rec-
ommendations; and
(C) maintain close consultation with such
bodies and boards throughout the process of
preparing its recommendations.
(4) CHAIRPERSON; ADDITIONAL DUTIES.—The
President shall designate a Chairperson from among
the members, who (subject to the approval of the
Board) may—
(A) employ and fix the compensation of an
Executive Director and such other personnel
(not to exceed 25) as may be necessary to carry
out the Board’s duties;
(B) seek such assistance and support as
may be required in the performance of the
Board’s duties from appropriate Federal de-
partments and agencies;
(C) enter into contracts or make other ar-
rangements, as may be necessary for the con-
duct of the work of the Board (without regard
to section 3709 of the Revised Statutes (41
U.S.C. 5));
(D) make advance, progress, and other
payments which relate to the work of the Com-
mission;
(E) provide transportation and subsistence
for persons serving without compensation; and
(F) prescribe such rules and regulations as
the Board deems necessary with respect to its
internal organization and operation.
(5) COMPENSATION.—Members of the Board
who are full-time officers or employees of the United
States may not receive additional pay, allowances, or
benefits by reason of their service on the Board, but
may receive travel expenses, including per diem in
lieu of subsistence, in accordance with sections 5702
and 5703 of title 5, United States Code.
(6) TERMINATION.—The Board shall terminate
upon the expiration of the 6-year period that begins
on the date of the enactment of this act. Section
14(a) of the Federal Advisory Committee Act (5
U.S.C. App.; relating to the termination of advisory
committees) shall not apply to the Board.
(7) 
CONFORMING
AMENDMENT
REPEALING
COUNCIL ON GRADUATE MEDICAL EDUCATION.—Ef-
fective on the date of the enactment of this Act, sec-
tion 301 of the Health Professions Education Exten-
sion Amendments of 1992 (Public Law 102–408) is
repealed.
(d) ANNUAL PUBLICATION OF MEDICARE PAYMENTS
FOR DIRECT GRADUATE MEDICAL EDUCATION COSTS.—
Not later than March of each year (beginning with 1994),
the Secretary of Health and Human Services shall publish
in the Federal Register a list of the total amount of pay-
ments made to each hospital in the United States during
the previous year under section 1886(h) of the Social Se-
curity Act for the direct costs of graduate medical edu-
cation.
Æ
HR 3089 IH——2