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’’;
(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. 323. EFFECTIVE DATE.
The amendments made by this part shall apply to fis-
cal years beginning on or after October 1, 1994.
Subtitle 
D—Demonstration 
Proj-
ects to Encourage Primary Care
and Rural-Based Graduate Med-
ical Education
SEC. 331. 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.
(2) APPROVAL OF APPLICATIONS.—A State or
consortium that submits an application under para-
graph (1) may begin a demonstration project under
this subsection—
(A) upon approval of such application by
the Secretary; or
(B) at the end of the 60-day period begin-
ning on the date such application is submitted,
unless the Secretary denies the application dur-
ing such period.
(3) NOTICE AND COMMENT.—A State or con-
sortium shall issue a public notice on the date it
submits an application under paragraph (1) which
contains a general description of the proposed dem-
onstration project. Any interested party may com-
ment on the proposed demonstration project to the
State or consortium or the Secretary during the 30-
day period beginning on the date the public notice
is issued.
(c) SPECIFIC REQUIREMENTS FOR PARTICIPANTS.—
(1) REQUIREMENTS FOR STATES.—Each State
participating in the demonstration project under this
subtitle shall use the payments provided under sub-
section (d) to test and evaluate either of the follow-
ing mechanisms to increase the number and percent-
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.