[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1143 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                S. 1143

   To improve the delivery of health care services in rural areas by 
creating an Assistant Secretary for Rural Health, to amend title XVIII 
     of the Social Security Act to provide that medical assistance 
facilities be reimbursed based on reasonable cost, to establish a grant 
 program for the use of interactive telecommunications systems, and to 
adjust the payments made for certain direct graduate medical education 
                               expenses.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 22, 1993

 Mr. Baucus (for himself, Mr. Conrad, Mrs. Murray, Mr. Inouye, and Mr. 
    Dorgan) introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
   To improve the delivery of health care services in rural areas by 
creating an Assistant Secretary for Rural Health, to amend title XVIII 
     of the Social Security Act to provide that medical assistance 
facilities be reimbursed based on reasonable cost, to establish a grant 
 program for the use of interactive telecommunications systems, and to 
adjust the payments made for certain direct graduate medical education 
                               expenses.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Rural Health Improvement Act of 
1993''.

SEC. 2. OFFICE OF RURAL HEALTH POLICY.

    (a) Appointment of Assistant Secretary.--
            (1) In general.--Section 711(a) of the Social Security Act 
        (42 U.S.C. 912(a)) is amended--
                    (A) by striking ``by a Director, who shall advise 
                the Secretary'' and inserting ``by an Assistant 
                Secretary for Rural Health (in this section referred to 
                as the `Assistant Secretary'), who shall report 
                directly to the Secretary''; and
                    (B) by adding at the end the following new 
                sentence: ``The Office shall not be a component of any 
                other office, service, or component of the 
                Department.''.
            (2) Conforming amendments.--(A) Section 711(b) of the 
        Social Security Act (42 U.S.C. 912(b)) is amended by striking 
        ``the Director'' and inserting ``the Assistant Secretary''.
            (B) Section 338J(a) of the Public Health Service Act (42 
        U.S.C. 254r(a)) is amended by striking ``Director of the Office 
        of Rural Health Policy'' and inserting ``Assistant Secretary 
        for Rural Health''.
            (C) Section 464T(b) of the Public Health Service Act (42 
        U.S.C. 285p-2(b)) is amended in the matter preceding paragraph 
        (1) by striking ``Director of the Office of Rural Health 
        Policy'' and inserting ``Assistant Secretary for Rural 
        Health''.
            (D) Section 6213 of the Omnibus Budget Reconciliation Act 
        of 1989 (42 U.S.C. 1395x note) is amended in subsection (e)(1) 
        by striking ``Director of the Office of Rural Health Policy'' 
        and inserting ``Assistant Secretary for Rural Health''.
            (E) Section 403 of the Ryan White Comprehensive AIDS 
        Resources Emergency Act of 1990 (42 U.S.C. 300ff-11 note) is 
        amended in the matter preceding paragraph (1) of subsection (a) 
        by striking ``Director of the Office of Rural Health Policy'' 
        and inserting ``Assistant Secretary for Rural Health''.
            (3) Amendment to the executive schedule.--Section 5315 of 
        title 5, United States Code, is amended by striking ``Assistant 
        Secretaries of Health and Human Services (5)'' and inserting 
        ``Assistant Secretaries of Health and Human Services (6)''.
    (b) Expansion of Duties.--Section 711(a) of the Social Security Act 
(42 U.S.C. 912(a)) is amended by striking ``and access to (and the 
quality of) health care in rural areas'' and inserting ``access to, and 
quality of, health care in rural areas, and reforms to the health care 
system and the implications of such reforms for rural areas''.

SEC. 3. COVERAGE OF, AND PAYMENT FOR, MEDICAL ASSISTANCE FACILITY 
              SERVICES.

    (a) Amendments to Part A.--
            (1) Definitions.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x) is amended by adding at the end the following 
        new subsection:

  ``Medical Assistance Facility; Medical Assistance Facility Services

    ``(oo)(1) The term `medical assistance facility' means a facility 
which--
            ``(A) is located in a county (or equivalent unit of local 
        government) with fewer than 6 residents per square mile or is 
        located more than a 35 mile drive from a hospital, a rural 
        primary care hospital, or another facility described in this 
        subsection;
            ``(B) furnishes services to ill or injured individuals 
        prior to the transportation of such individuals to a hospital 
        or furnishes inpatient care to individuals needing such care 
        for a period not longer than 96 hours;
            ``(C) permits a physician assistant or nurse practitioner 
        to admit and treat patients under the supervision of a 
        physician not present in such facility;
            ``(D) meets the requirements of section 1861(e) that are 
        applicable to a hospital located in a rural area except that--
                    ``(i) with respect to any requirements relating to 
                the number of hours that the facility must be open on a 
                daily or weekly basis, the facility is only required to 
                meet the requirement to provide emergency care on a 24-
                hour basis;
                    ``(ii) with respect to any services required under 
                such section to be furnished by a dietician, 
                pharmacist, laboratory technician, medical 
                technologist, and radiological technologist, the 
                facility may furnish such services on a part-time, off-
                site basis; and
                    ``(iii) the inpatient care described in 
                subparagraph (B) may be furnished by a physician 
                assistant or nurse practitioner as provided in 
                subparagraph (C);
            ``(E) receives a certification of medical necessity and 
        appropriateness by a peer review organization (or the 
        equivalent of a peer review organization) upon admitting each 
        patient on an inpatient basis or, in the case of admissions 
        that do not occur during regular business hours, receives such 
        a certification at the earliest possible time; and
            ``(F) may enter into an agreement with the Secretary under 
        section 1883 under which the facility's inpatient hospital 
        facilities may be used for the furnishing of services of the 
        type which, if furnished by a skilled nursing facility, would 
        constitute extended care services.
    ``(2) The term `inpatient medical assistance facility services' 
means items and services furnished to an inpatient of a medical 
assistance facility by such facility that would be inpatient hospital 
services if furnished to an inpatient of a hospital by a hospital.''.
            (2) Coverage and payment.--(A) Section 1812(a)(1) of such 
        Act (42 U.S.C. 1395d(a)(1)) is amended by striking ``and 
        inpatient rural primary care hospital services'' and inserting 
        ``, inpatient rural primary care hospital services, and 
        inpatient medical assistance facility services''.
            (B) Section 1814 of such Act (42 U.S.C. 1395f) is amended--
                    (i) in subsection (a)--
                            (I) by striking ``and'' at the end of 
                        paragraph (7),
                            (II) by striking the period at the end of 
                        paragraph (8) and inserting ``; and'', and
                            (III) by inserting after paragraph (8) the 
                        following new paragraph:
            ``(9) in the case of inpatient medical assistance facility 
        services, a physician certifies that such services were 
        required to be immediately furnished on a temporary, inpatient 
        basis.'';
                    (ii) in subsection (b), by striking ``inpatient 
                rural primary care hospital services,'' and inserting 
                ``inpatient rural primary care hospital services, other 
                than a medical assistance facility providing inpatient 
                medical assistance facility services,''; and
                    (iii) by adding at the end the following new 
                subsection:

      ``Payment for Inpatient Medical Assistance Facility Services

    ``(m) The amount of payment under this part for inpatient medical 
assistance facility services is the reasonable costs of the medical 
assistance facility in providing such services.''.
            (3) Treatment of medical assistance facilities as providers 
        of services.--(A) Section 1861(u) of such Act (42 U.S.C. 
        1395x(u)) is amended by inserting ``medical assistance 
        facility,'' after ``rural primary care hospital,''.
            (B) The first sentence of section 1864(a) of such Act (42 
        U.S.C. 1395aa(a)) is amended by inserting ``a medical 
        assistance facility, as defined in section 1861(oo)(1),'' after 
        ``1861(mm)(1),''.
            (C) The third sentence of section 1865(a) of such Act (42 
        U.S.C. 1395bb(a)) is amended by striking ``or 1861(mm)(1)'' and 
        inserting ``1861(mm)(1), or 1861(oo)(1),''.
            (4) Conforming amendments.--(A) Section 1128A(b)(1) of such 
        Act (42 U.S.C. 1320a-7a(b)(1)) is amended--
                    (i) by striking ``or a rural primary care 
                hospital'' the first place it appears and inserting ``, 
                a rural primary care hospital, or a medical assistance 
                facility''; and
                    (ii) by striking ``or a rural primary care 
                hospital'' the second place it appears and inserting 
                ``, the rural primary care hospital, or the medical 
                assistance facility''.
            (B) Section 1128B(c) of such Act (42 U.S.C. 1320a-7b(c)) is 
        amended by inserting ``medical assistance facility,'' after 
        ``rural primary care hospital,''.
            (C) Section 1134 of such Act (42 U.S.C. 1320b-4) is amended 
        by striking ``or rural primary care hospitals'' each place it 
        appears and inserting ``, rural primary care hospitals, or 
        medical assistance facilities''.
            (D) Section 1138(a)(1) of such Act (42 U.S.C. 1320b-
        8(a)(1)) is amended--
                    (i) in the matter preceding subparagraph (A), by 
                striking ``or rural primary care hospital'' and 
                inserting ``, rural primary care hospital, or medical 
                assistance facility'', and
                    (ii) in the matter preceding clause (i) of 
                subparagraph (A), by striking ``or rural primary care 
                hospital'' and inserting ``, rural primary care 
                hospital, or medical assistance facility''.
            (E) Section 1164(e) of such Act (42 U.S.C. 1320c-13(e)) is 
        amended by inserting ``medical assistance facilities,'' after 
        ``rural primary care hospitals,''.
            (F) Section 1816(c)(2)(C) of such Act (42 U.S.C. 
        1395h(c)(2)(C)) is amended by inserting ``medical assistance 
        facility,'' after ``rural primary care hospital,''.
            (G) Section 1833 of such Act (42 U.S.C. 1395l) is amended--
                    (i) in subsection (h)(5)(A)(iii)--
                            (I) by striking ``or rural primary care 
                        hospital'' and inserting ``rural primary care 
                        hospital, or medical assistance facility''; and
                            (II) by striking ``to the hospital'' and 
                        inserting ``to the hospital or the facility'';
                    (ii) in subsection (i)(1)(A), by inserting 
                ``medical assistance facility,'' after ``rural primary 
                care hospital,'';
                    (iii) in subsection (i)(3)(A), by striking ``or 
                rural primary care hospital services'' and inserting 
                ``rural primary care hospital services, or medical 
                assistance facility services'';
                    (iv) in subsection (l)(5)(A), by inserting 
                ``medical assistance facility,'' after ``rural primary 
                care hospital,'' each place it appears; and
                    (v) in subsection (l)(5)(C), by striking ``or rural 
                primary care hospital'' each place it appears and 
                inserting ``, rural primary care hospital, or medical 
                assistance facility''.
            (H) Section 1835(c) of such Act (42 U.S.C. 1395n(c)) is 
        amended by adding at the end the following: ``A medical 
        assistance facility shall be considered a hospital for purposes 
        of this subsection.''.
            (I) Section 1842(b)(6)(A)(ii) of such Act (42 U.S.C. 
        1395u(b)(6)(A)(ii)) is amended by inserting ``medical 
        assistance facility,'' after ``rural primary care hospital,''.
            (J) Section 1861 of such Act (42 U.S.C. 1395x) is amended--
                    (i) in the last sentence of subsection (e), by 
                striking ``1861(mm)(1))'' and inserting ``1861(mm)(1)) 
                or a medical assistance facility (as defined in section 
                1861(oo)(1)).'',
                    (ii) in subsection (w)(1) by inserting ``medical 
                assistance facility,'' after ``rural primary care 
                hospital,'', and
                    (iii) in subsection (w)(2), by striking ``or rural 
                primary care hospital'' each place it appears and 
                inserting ``, rural primary care hospital, or medical 
                assistance facility''.
            (K) Section 1862(a)(14) of such Act (42 U.S.C. 
        1395y(a)(14)) is amended by striking ``or rural primary care 
        hospital'' each place it appears and inserting ``, rural 
        primary care hospital, or medical assistance facility''.
            (L) Section 1866(a)(1) of such Act (42 U.S.C 1395cc(a)(1)) 
        is amended--
                    (i) in subparagraph (F)(ii), by inserting ``medical 
                assistance facilities,'' after ``rural primary care 
                hospitals,'';
                    (ii) in subparagraph (H)--
                            (I) in the matter preceding clause (i), by 
                        inserting ``and in the case of medical 
                        assistance facilities which provide inpatient 
                        medical assistance facility services'' after 
                        ``rural primary care hospital services''; and
                            (II) in clauses (i) and (ii), by striking 
                        ``hospital'' each place it appears and 
                        inserting ``hospital or facility'';
                    (iii) in subparagraph (I)--
                            (I) in the matter preceding clause (i), by 
                        striking ``or rural primary care hospital'' and 
                        inserting ``, a rural primary care hospital, or 
                        a medical assistance facility''; and
                            (II) in clause (ii), by striking ``the 
                        hospital'' and inserting ``the hospital or the 
                        facility''; and
                    (iv) in subparagraph (N)--
                            (I) in the matter preceding clause (i), by 
                        striking ``and rural primary hospitals'' and 
                        inserting ``, rural primary care hospitals, and 
                        medical assistance facilities'';
                            (II) in clause (i), by striking ``or rural 
                        primary care hospital,'' and inserting ``, 
                        rural primary care hospital, or medical 
                        assistance facility,''; and
                            (III) in clause (ii), by striking 
                        ``hospital'' and inserting ``hospital or 
                        facility''.
            (M) Section 1866(a)(3) of such Act (42 U.S.C 1395cc(a)(3)) 
        is amended--
                    (i) by striking ``rural primary care hospital,'' 
                each place it appears in subparagraphs (A) and (B) and 
                inserting ``rural primary care hospital, medical 
                assistance facility,'', and
                    (ii) in subparagraph (C)(ii)(II), by striking 
                ``rural primary care hospitals,'' each place it appears 
                and inserting ``rural primary care hospitals, medical 
                assistance facilities''.
            (N) Section 1867(e)(5) of such Act (42 U.S.C. 1395dd(e)(5)) 
        is amended by striking ``1861(mm)(1))'' and inserting 
        ``1861(mm)(1)) or a medical assistance facility (as defined in 
        section 1861(oo)(1)).''.
    (b) Amendments to Part B.--
            (1) Coverage.--(A) Section 1861(oo) of the Social Security 
        Act (42 U.S.C. 1395x(oo)), as added by section 1, is amended by 
        adding at the end the following new paragraph:
    ``(3) The term `outpatient medical assistance facility services' 
means medical and other health services furnished by a medical 
assistance facility on an outpatient basis.''.
            (B) Section 1832(a)(2) of such Act (42 U.S.C. 1395k(a)(2)) 
        is amended--
                    (i) in subparagraph (I), by striking ``and'' at the 
                end;
                    (ii) in subparagraph (J), by striking the period at 
                the end and inserting ``; and''; and
                    (iii) by adding at the end the following new 
                subparagraph:
                    ``(K) outpatient medical assistance facility 
                services (as defined in section 1861(oo)(3)).''.
            (2) Payment.--(A) Section 1833(a) of such Act (42 U.S.C. 
        1395l(a)) is amended--
                    (i) in paragraph (2), in the matter preceding 
                subparagraph (A), by striking ``and (I)'' and inserting 
                ``(I), and (K)'';
                    (ii) in paragraph (6), by striking ``and'' at the 
                end;
                    (iii) in paragraph (7), by striking the period at 
                the end and inserting ``; and''; and
                    (iv) by adding at the end the following new 
                paragraph:
            ``(8) in the case of outpatient medical assistance facility 
        services, the amounts described in section 1834(i).''.
            (B) Section 1834 of such Act (42 U.S.C. 1395m) is amended 
        by adding at the end the following new subsection:
    ``(i) Payment for Outpatient Medical Assistance Facility 
Services.--The amount of payment for outpatient medical assistance 
facility services provided in a medical assistance facility under this 
part shall be determined by one of the two following methods, as 
elected by the medical assistance facility:
            ``(1) Cost-based facility fee plus professional charges.--
                    ``(A) Facility fee.--With respect to facility 
                services, not including any services for which payment 
                may be made under subparagraph (B), there shall be paid 
                amounts equal to the amounts described in section 
                1833(a)(2)(B) (describing amounts paid for hospital 
                outpatient services).
                    ``(B) Reasonable charges for professional 
                services.--In electing treatment under this paragraph, 
                payment for professional medical services otherwise 
                included within outpatient medical assistance facility 
                services shall be made under such other provisions of 
                this part as would apply to payment for such services 
                if they were not included in outpatient medical 
                assistance facility services.
            ``(2) All-inclusive rate.--
                    ``(A) In general.--With respect to both facility 
                services and professional medical services, there shall 
                be paid amounts equal to the excess of--
                            ``(i) the costs which are reasonable and 
                        related to the cost of furnishing such services 
                        or which are based on such other tests of 
                        reasonableness as the Secretary may prescribe 
                        in regulations, over
                            ``(ii) the amount the facility may charge 
                        as described in clause (i) of section 
                        1866(a)(2)(A).
                    ``(B) Limitation.--
                            ``(i) In general.--The payment amount 
                        determined under subparagraph (A) with respect 
                        to items and services shall not exceed 80 
                        percent of the amount determined under clause 
                        (i) of such subparagraph with respect to such 
                        items and services.
                            ``(ii) Certain items and services.--Clause 
                        (i) shall not apply to--
                                    ``(I) items and services described 
                                in section 1861(s)(10)(A), and
                                    ``(II) items and services furnished 
                                in connection with obtaining a second 
                                opinion required under section 
                                1164(c)(2), or third opinion, if the 
                                second opinion was in disagreement with 
                                the first opinion.''.
    (c) Effective Date.--The amendments made by this section shall be 
effective for services provided on or after the date of the enactment 
of this section.

SEC. 4. GRANT PROGRAM FOR THE USE OF INTERACTIVE TELECOMMUNICATIONS 
              SYSTEMS IN PROVIDING HEALTH CARE TO RURAL AREAS.

    Title VII of the Social Security Act (42 U.S.C. 901 et seq.) is 
amended by adding at the end the following new section:

 ``grant program for the use of interactive telecommunications systems 
                in providing health care to rural areas

    ``Sec. 712. (a) Establishment of Program.--
            ``(1) In general.--The Assistant Secretary for Rural Health 
        (hereafter referred to in this section as the ``Assistant 
        Secretary''), through the Office of Rural Health Policy, shall 
        establish a program to provide grants to rural health care 
        networks (as defined in paragraph (2)) to enhance the delivery 
        of health care in rural areas through the use of interactive 
        telecommunications systems.
            ``(2) Definition.--For purposes of this section, the term 
        ``rural health care network'' means a group of providers 
        furnishing health care services to a rural area composed of--
                    ``(A) a tertiary care facility, rural referral 
                center (as defined in section 1886(d)(5)(C)(i)), or 
                medical teaching institution; and
                    ``(B) one or more rural hospitals, clinics, medical 
                assistance facilities, mental health departments or 
                similar facilities, including community health centers 
                (as defined in section 330 of the Public Health Service 
                Act) and migrant health centers (as defined in section 
                329 of the Public Health Service Act).
    ``(b) Application Requirements.--
            ``(1) In general.--In order to be eligible to receive a 
        grant under this section, a rural health care network must 
        submit an application to the Assistant Secretary at such time 
        and in such manner as the Assistant Secretary shall require.
            ``(2) Contents of application.--An application submitted 
        under this section must contain--
                    ``(A) a plan for acquisition and operation of an 
                interactive telecommunications system;
                    ``(B) a description of the uses to be made of such 
                system;
                    ``(C) a description of how such system will 
                function in connection with existing common carrier 
                networks; and
                    ``(D) a description of a plan for evaluation of the 
                cost and effectiveness of the system and the quality of 
                the health care delivered under the system.
            ``(3) Consideration of applications.--In considering the 
        applications submitted under this subsection, the Assistant 
        Secretary shall give a preference to rural health care networks 
        that establish multiple uses for the interactive 
        telecommunications system in the rural area served by the 
        system, including uses that do not relate to the provision of 
        health care.
    ``(c) Amount of Grants; Use of Funds.--
            ``(1) Limitation on amount of grants.--The amount of any 
        grant awarded to a rural health care network under this section 
        in any fiscal year shall not exceed $500,000.
            ``(2) Number of annual grants allowed per network.--No more 
        than 3 annual grants may be awarded to any rural health care 
        network under this section.
            ``(3) Use of funds.--
                    (A) In general.--From the amounts awarded to a 
                rural health care network under this section, funds may 
                be expended to support the cost of activities involving 
                the sending and receiving of information to improve the 
                delivery of health care services to rural areas 
                including--
                            ``(i) consultations between health care 
                        providers in remote areas and providers in 
                        large facilities;
                            ``(ii) the transfer and analysis of x-rays, 
                        lab slides, and other images;
                            ``(iii) the development of innovative 
                        health education programs; and
                            ``(iv) such other related activities as the 
                        Assistant Secretary determines to be consistent 
                        with the purposes of this section.
                    ``(B) Limitation.--Each grant awarded to a rural 
                health care network under this section is subject to 
                the following limitations:
                            ``(i) No more than 35 percent of the grant 
                        funds may be used to acquire interactive 
                        telecommunications equipment.
                            ``(ii) No grant funds may be used to 
                        establish or operate a telecommunications 
                        common carrier network.
    ``(d) Evaluation and Report.--The Assistant Secretary shall provide 
for an evaluation of the grant program under this section to be 
conducted by the Office of Rural Health Policy which shall prepare and 
submit a report to the Congress not later than 4 years after the date 
on which the first grant is awarded under this section summarizing such 
evaluation.
    ``(e) Funding.--There are authorized to be appropriated $5,000,000 
for each of fiscal years 1994, 1995, and 1996 to carry out the purposes 
of this Act and such sums shall remain available until expended.''.

SEC. 5. DIRECT GRADUATE MEDICAL EDUCATION.

    (a) Publicly Funded Family Practice Residency Programs.--
            (1) In general.--Section 1886(h)(5) (42 U.S.C. 
        1395ww(h)(5)) is amended by adding at the end the following new 
        subparagraph:
                    ``(H) Adjustments for certain family practice 
                residency programs.--
                            ``(i) In general.--In the case of an 
                        approved medical residency training program 
                        (meeting the requirements of clause (ii)) of a 
                        hospital which received payments from the 
                        United States, a State, or a political 
                        subdivision of a State or an instrumentality of 
                        such a State or political subdivision (other 
                        than payments under this title or a State plan 
                        under title XIX) during the cost reporting 
                        period that began during fiscal year 1984, the 
                        Secretary shall--
                                    ``(I) provide for an average amount 
                                under paragraph (2)(A) that takes into 
                                account the Secretary's estimate of the 
                                amount that would have been recognized 
                                as reasonable under this title if the 
                                hospital had not received such 
                                payments, and
                                    ``(II) reduce the payment amount 
                                otherwise provided under this 
                                subsection in an amount equal to the 
                                proportion of such program payments 
                                during the cost reporting period 
                                involved that is allocable to this 
                                title.
                            ``(ii) Additional requirements.--A 
                        hospital's approved medical residency program 
                        meets the requirements of this clause if--
                                    ``(I) the program is limited to 
                                training for family and community 
                                medicine;
                                    ``(II) the program is the only 
                                approved medical residency program of 
                                the hospital; and
                                    ``(III) the average amount 
                                determined under paragraph (2)(A) for 
                                the hospital (as determined without 
                                regard to the increase in such amount 
                                described in clause (i)(I)) does not 
                                exceed $10,000.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to payments under section 1886(h) of the Social 
        Security Act for cost reporting periods beginning on or after 
        October 1, 1990.
    (b) Preventive Care Services as Part of Initial Residency Period.--
            (1) Eligibility of preventive care residency programs for 
        expanded initial residency periods.--Section 1886(h)(5)(F)(ii) 
        (42 U.S.C. 1395ww(h)(5)(F)(ii)) is amended by inserting after 
        ``fellowship program'' the following: ``or a preventive care 
        residency or fellowship program''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to cost reporting periods beginning on or after 
        October 1, 1993.

                                 <all>

S 1143 IS----2