I
103D CONGRESS
2D SESSION
H. R. 4690
To provide assistance for the establishment of community rural health net-
works in chronically underserved areas, to provide incentives for providers
of health care services to furnish services in such areas, to assist provid-
ers of emergency medical services in such areas, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
JUNE 30, 1994
Mr. BEREUTER introduced the following bill; which was referred jointly to the
Committees on Energy and Commerce, Ways and Means, Education and
Labor, and the Judiciary
A BILL
To provide assistance for the establishment of community
rural health networks in chronically underserved areas,
to provide incentives for providers of health care services
to furnish services in such areas, to assist providers
of emergency medical services in such areas, 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
‘‘Rural Health Care Improvement Act of 1994’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I—GRANTS TO ENCOURAGE ESTABLISHMENT OF
COMMUNITY RURAL HEALTH NETWORKS
Sec. 101. Assistance for implementation of access plans for chronically under-
served areas.
Sec. 102. Technical assistance grants for networks.
Sec. 103. Development grants for networks.
Sec. 104. Definitions.
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 repayments excluded from gross in-
come.
Sec. 202. Modification in criteria for designation as health professional short-
age area.
Sec. 203. Other provisions regarding national health service corps.
Subtitle B—Incentives Under Other Programs
Sec. 211. Extension of additional payment under medicare for physicians’ serv-
ices furnished in former shortage areas.
Sec. 212. Refinement of geographic adjustment factor for medicare physicians’
services.
Sec. 213. Extension of student loan deferments.
Sec. 214. Development of model State scope of practice law.
TITLE III—ASSISTANCE FOR INSTITUTIONAL PROVIDERS
Subtitle A—Emergency Medical Systems
Sec. 301. Emergency medical services.
Sec. 302. Grants to states regarding aircraft for transporting rural victims of
medical emergencies.
Subtitle B—Assistance to Rural Providers Under Medicare
PART 1—MEDICARE ESSENTIAL ACCESS COMMUNITY HOSPITALS
Sec. 311. Amendments to essential access community hospital (EACH) pro-
gram under medicare.
PART 2—ESTABLISHMENT OF RURAL EMERGENCY ACCESS CARE HOSPITALS
Sec. 321. Rural emergency access care hospitals described.
Sec. 322. Coverage of and payment for services.
Sec. 323. Effective date.
Subtitle D—Demonstration Projects to Encourage Primary
Care and Rural-Based Graduate Medical Education
Sec. 331. State and consortium demonstration projects.
Sec. 332. Goals for projects.
Sec. 333. Definitions.
TITLE IV—HOSPITAL ANTITRUST FAIRNESS
Sec. 401. Antitrust exemption.
Sec. 402. Requirements.
Sec. 403. Definition.
TITLE I—GRANTS TO ENCOUR-
AGE 
ESTABLISHMENT 
OF
COMMUNITY RURAL HEALTH
NETWORKS
SEC. 101. ASSISTANCE FOR DEVELOPMENT OF ACCESS
PLANS FOR CHRONICALLY UNDERSERVED
AREAS.
(a) AVAILABILITY OF FINANCIAL ASSISTANCE TO IM-
PLEMENT ACTION PLANS TO INCREASE ACCESS.—
(1) IN GENERAL.—The Secretary shall provide
grants (in amounts determined in accordance with
paragraph (3)) over a 3-year period to an eligible
State for the development of plans to increase access
to health care services during such period for resi-
dents of areas in the State that are designated as
chronically underserved areas in accordance with
subsection (b).
(2) ELIGIBILITY REQUIREMENTS.—A State is
eligible to receive grants under this section if the
State submits to the Secretary (at such time and in
such form as the Secretary may require) assurances
that the State has developed (or is in the process of
developing) a plan to increase the access of residents
of a chronically underserved area to health care serv-
ices that meets the requirements of subsection (c),
together with such other information and assurances
as the Secretary may require.
(3) AMOUNT OF ASSISTANCE.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), the amount of assistance provided to
a State under this subsection with respect to
any plan during a 3-year period shall be equal
to—
(i) for the first year of the period, an
amount equal to 100% of the amounts ex-
pended by the State during the year to im-
plement the plan described in paragraph
(1) (as reported to the Secretary in accord-
ance with such requirements as the Sec-
retary may impose);
(ii) for the second year of the period,
an amount equal to 50% of the amounts
expended by the State during the year to
implement the plan; and
(iii) for the third year of the period,
an amount equal to 33% of the amounts
expended by the State during the year to
implement the plan.
(B) AGGREGATE
PER
PLAN
LIMIT.—The
amount of assistance provided to a State under
this subsection with respect to any plan may
not exceed $100,000 during any year of the 3-
year period for which the State receives assist-
ance.
(b) DESIGNATION OF AREAS.—
(1) DESIGNATION BY GOVERNOR.—In accord-
ance with the guidelines developed under paragraph
(2), the Governor of a State may designate an area
in the State as a chronically underserved area for
purposes of this section upon the request of a local
official of the area or upon the Governor’s initiative.
(2) GUIDELINES FOR DESIGNATION.—
(A) DEVELOPMENT BY SECRETARY.—Not
later than 1 year after the date of the enact-
ment of this Act, the Secretary shall develop
guidelines for the designation of areas as chron-
ically underserved areas under this section.
(B) FACTORS CONSIDERED IN DEVELOP-
MENT
OF
GUIDELINES.—In developing guide-
lines under paragraph (1), the Secretary shall
consider the following factors:
(v) The percentage of residents of the
area who are age 65 or older.
(vi) The existence of cultural or geo-
graphic barriers to access to health care
services in the area, including weather con-
ditions.
(3) REVIEW BY SECRETARY.—No designation
under paragraph (1) shall take effect under this sec-
tion unless the Secretary—
(A) has been notified of the proposed des-
ignation; and
(B) has not, within 60 days after the date
of receipt of the notice, disapproved the des-
ignation.
(4) PERIOD OF DESIGNATION.—A designation
under this section shall be effective during a period
specified by the Governor of not longer than 3 years.
The Governor may extend the designation for addi-
tional 3-year periods, except that a State may not
receive assistance under subsection (a)(3) for
amounts expended during any such additional peri-
ods.
(c) REQUIREMENTS FOR STATE ACCESS PLANS.—A
State plan to increase the access of residents of chronically
underserved areas to health care services meets the re-
quirements of this section if the Secretary finds that the
plan was developed with the participation of health care
providers and facilities and residents of the area that is
the subject of the plan, together with such other require-
ments as the Secretary may impose.
(d) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated for assistance under this
section $10,000,000 for each of the first 3 fiscal years
beginning after the date on which the Secretary develops
guidelines for the designation of areas as chronically un-
derserved areas under subsection (b)(2).
SEC. 102. TECHNICAL ASSISTANCE GRANTS FOR NET-
WORKS.
(a) IN GENERAL.—The Secretary shall make funds
available under this section to provide technical assistance
(including information regarding eligibility for other Fed-
eral programs) and advice for entities described in sub-
section (b) seeking to establish or enhance a community
rural health network in an underserved rural area.
(b) ENTITIES ELIGIBLE TO RECEIVE FUNDS.—The
following entities are eligible to receive funds for technical
assistance under this section:
(1) An entity receiving a grant under section
103.
(2) A State or unit of local government.
(3) An entity providing health care services (in-
cluding health professional education services) in the
area involved.
(c) USE OF FUNDS.—
(1) IN GENERAL.—Funds made available under
this section may be used—
(A) for planning a community health net-
work and the submission of the plan for the
network to the Secretary under section 103(c)
(subject to the limitation described in para-
graph (2));
(B) to provide assistance in conducting
community-based needs and prioritization, iden-
tifying existing regional health resources, and
developing networks, utilizing existing local pro-
viders and facilities where appropriate;
(C) to provide advice on obtaining the
proper balance of primary and secondary facili-
ties for the population served by the network;
(D) to provide assistance in coordinating
arrangements for tertiary care;
(E) to provide assistance in recruitment
and retention of health care professionals;
(F) to provide assistance in coordinating
the delivery of emergency services with the pro-
vision of other health care services in the area
served by the network;
(G) to provide assistance in coordinating
arrangements for mental health and substance
abuse treatment services; and
(H) to provide information regarding the
area or proposed network’s eligibility for Fed-
eral and State assistance for health care-related
activities, together with information on funds
available through private sources.
(2) LIMITATION ON AMOUNT AVAILABLE FOR
DEVELOPMENT OF NETWORK.—The amount of fi-
nancial assistance available for activities described in
paragraph (1) may not exceed $50,000 and may not
be available for a period of time exceeding 1 year.
(d) USE OF RURAL HEALTH OFFICES.—In carrying
out this section with respect to entities in rural areas, the
Secretary shall make funds available through—
(1) not more than 10 regional centers acting as
clearinghouses for the distribution of such funds;
(2) State Offices of Rural Health,
or any combination of such centers and Offices.
(e) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated $10,000,000 for each
of fiscal years 1995 through 1999 to carry out this sec-
tion. Amounts appropriated under this section shall be
available until expended.
SEC. 103. DEVELOPMENT GRANTS FOR NETWORKS.
(a) IN GENERAL.—The Secretary shall provide finan-
cial assistance to eligible entities in order to provide for
the development and implementation of community rural
health networks.
(b) ELIGIBLE ENTITIES.—
(1) IN GENERAL.—An entity is eligible to re-
ceive financial assistance under this section only if
the entity—
(A) is (i) based in a rural area or (ii) is
described in paragraph (2), (3), or (4) of sec-
tion 102(b),
(B) is undertaking to develop and imple-
ment a community rural health network in an
underserved rural area (or underserved rural
areas) with the active participation of at least
3 health care providers or facilities in the area,
and
(C) has consulted with the local govern-
ments of the area to be served by the network
and with individuals who reside in the area.
(2) COORDINATION WITH PROVIDERS OUTSIDE
OF AREA PERMITTED.—Nothing in this section shall
be construed as preventing an entity that coordi-
nates the delivery of services in an underserved rural
area with an entity outside the area from qualifying
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—Emergency Medical
Systems
SEC. 301. 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—
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.