19
SITIONS.
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(a) IN GENERAL.—Section 1886(h) of the Social Secu-
21
rity Act (42 U.S.C. 1395ww(h)) is amended— 22
(1) in paragraph (4)(F)(i), by striking ‘‘para- 23
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 24
(2) in paragraph (4)(H)(i), by striking ‘‘para- 1
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 2
(3) in paragraph (7)(E), by inserting ‘‘or para- 3
graph (8)’’ before the period at the end; and 4
(4) by adding at the end the following new para- 5
graph: 6
‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY
7
POSITIONS.—
8
‘‘(A) REDUCTIONS IN LIMIT BASED ON UN-
9
USED POSITIONS.—
10
‘‘(i) IN GENERAL.—Except as provided
11
in clause (ii), if a hospital’s reference resi- 12
dent level (as defined in subparagraph 13
(H)(i)) is less than the otherwise applicable 14
resident limit (as defined in subparagraph 15
(H)(iii)), effective for portions of cost re- 16
porting periods occurring on or after July 17
1, 2011, the otherwise applicable resident 18
limit shall be reduced by 65 percent of the 19
difference between such otherwise applicable 20
resident limit and such reference resident 21
level. 22
‘‘(ii) EXCEPTIONS.—This subpara-
23
graph shall not apply to— 24
‘‘(I) a hospital located in a rural 1
area (as defined in subsection 2
(d)(2)(D)(ii)) with fewer than 250 3
acute care inpatient beds; 4
‘‘(II) a hospital that was part of 5
a qualifying entity which had a vol- 6
untary residency reduction plan ap- 7
proved under paragraph (6)(B) or 8
under the authority of section 402 of 9
Public Law 90–248, if the hospital 10
demonstrates to the Secretary that it 11
has a specified plan in place for filling 12
the unused positions by not later than 13
2 years after the date of enactment of 14
this paragraph; or 15
‘‘(III) a hospital described in 16
paragraph (4)(H)(v). 17
‘‘(B) DISTRIBUTION.—
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‘‘(i) IN GENERAL.—The Secretary shall
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increase the otherwise applicable resident 20
limit for each qualifying hospital that sub- 21
mits an application under this subpara- 22
graph by such number as the Secretary may 23
approve for portions of cost reporting peri- 24
ods occurring on or after July 1, 2011. The 25
aggregate number of increases in the other- 1
wise applicable resident limit under this 2
subparagraph shall be equal to the aggregate 3
reduction in such limits attributable to sub- 4
paragraph (A) (as estimated by the Sec- 5
retary). 6
‘‘(ii) REQUIREMENTS.—Subject to
7
clause (iii), a hospital that receives an in- 8
crease in the otherwise applicable resident 9
limit under this subparagraph shall ensure, 10
during the 5-year period beginning on the 11
date of such increase, that— 12
‘‘(I) the number of full-time equiv- 13
alent primary care residents, as de- 14
fined in paragraph (5)(H) (as deter- 15
mined by the Secretary), excluding any 16
additional positions under subclause 17
(II), is not less than the average num- 18
ber of full-time equivalent primary 19
care residents (as so determined) dur- 20
ing the 3 most recent cost reporting pe- 21
riods ending prior to the date of enact- 22
ment of this paragraph; and 23
‘‘(II) not less than 75 percent of 24
the positions attributable to such in- 25
crease are in a primary care or gen- 1
eral surgery residency (as determined 2
by the Secretary). 3
The Secretary may determine whether a 4
hospital has met the requirements under 5
this clause during such 5-year period in 6
such manner and at such time as the Sec- 7
retary determines appropriate, including at 8
the end of such 5-year period. 9
‘‘(iii) REDISTRIBUTION OF POSITIONS
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IF HOSPITAL NO LONGER MEETS CERTAIN
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REQUIREMENTS.—In the case where the Sec-
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retary determines that a hospital described 13
in clause (ii) does not meet either of the re- 14
quirements under subclause (I) or (II) of 15
such clause, the Secretary shall— 16
‘‘(I) reduce the otherwise applica- 17
ble resident limit of the hospital by the 18
amount by which such limit was in- 19
creased under this paragraph; and 20
‘‘(II) provide for the distribution 21
of positions attributable to such reduc- 22
tion in accordance with the require- 23
ments of this paragraph. 24
‘‘(C) CONSIDERATIONS IN REDISTRIBU-
1
TION.—In determining for which hospitals the
2
increase in the otherwise applicable resident 3
limit is provided under subparagraph (B), the 4
Secretary shall take into account— 5
‘‘(i) the demonstration likelihood of the 6
hospital filling the positions made available 7
under this paragraph within the first 3 cost 8
reporting periods beginning on or after July 9
1, 2011, as determined by the Secretary; 10
and 11
‘‘(ii) whether the hospital has an ac- 12
credited rural training track (as described 13
in paragraph (4)(H)(iv)). 14
‘‘(D) PRIORITY FOR CERTAIN AREAS.—In
15
determining for which hospitals the increase in 16
the otherwise applicable resident limit is pro- 17
vided under subparagraph (B), subject to sub- 18
paragraph (E), the Secretary shall distribute the 19
increase to hospitals based on the following fac- 20
tors: 21
‘‘(i) Whether the hospital is located in 22
a State with a resident-to-population ratio 23
in the lowest quartile (as determined by the 24
Secretary). 25
‘‘(ii) Whether the hospital is located in 1
a State, a territory of the United States, or 2
the District of Columbia that is among the 3
top 10 States, territories, or Districts in 4
terms of the ratio of— 5
‘‘(I) the total population of the 6
State, territory, or District living in 7
an area designated (under such section 8
332(a)(1)(A)) as a health professional 9
shortage area (as of the date of enact- 10
ment of this paragraph); to 11
‘‘(II) the total population of the 12
State, territory, or District (as deter- 13
mined by the Secretary based on the 14
most recent available population data 15
published by the Bureau of the Cen- 16
sus). 17
‘‘(iii) Whether the hospital is located 18
in a rural area (as defined in subsection 19
(d)(2)(D)(ii)). 20
‘‘(E) RESERVATION OF POSITIONS FOR CER-
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TAIN HOSPITALS.—
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‘‘(i) IN GENERAL.—Subject to clause
23
(ii), the Secretary shall reserve the positions 24
available for distribution under this para- 1
graph as follows: 2
‘‘(I) 70 percent of such positions 3
for distribution to hospitals described 4
in clause (i) of subparagraph (D). 5
‘‘(II) 30 percent of such positions 6
for distribution to hospitals described 7
in clause (ii) and (iii) of such sub- 8
paragraph. 9
‘‘(ii) EXCEPTION IF POSITIONS NOT
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REDISTRIBUTED BY JULY 1, 2011.—In the
11
case where the Secretary does not distribute 12
positions to hospitals in accordance with 13
clause (i) by July 1, 2011, the Secretary 14
shall distribute such positions to other hos- 15
pitals in accordance with the considerations 16
described in subparagraph (C) and the pri- 17
ority described in subparagraph (D). 18
‘‘(F) LIMITATION.—A hospital may not re-
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ceive more than 75 full-time equivalent addi- 20
tional residency positions under this paragraph. 21
‘‘(G) APPLICATION OF PER RESIDENT
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AMOUNTS FOR PRIMARY CARE AND NONPRIMARY
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CARE.—With respect to additional residency po-
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sitions in a hospital attributable to the increase 25
provided under this paragraph, the approved 1
FTE per resident amounts are deemed to be 2
equal to the hospital per resident amounts for 3
primary care and nonprimary care computed 4
under paragraph (2)(D) for that hospital. 5
‘‘(H) DEFINITIONS.—In this paragraph:
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‘‘(i) REFERENCE RESIDENT LEVEL.—
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The term ‘reference resident level’ means, 8
with respect to a hospital, the highest resi- 9
dent level for any of the 3 most recent cost 10
reporting periods (ending before the date of 11
the enactment of this paragraph) of the hos- 12
pital for which a cost report has been settled 13
(or, if not, submitted (subject to audit)), as 14
determined by the Secretary. 15
‘‘(ii) RESIDENT LEVEL.—The term
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‘resident level’ has the meaning given such 17
term in paragraph (7)(C)(i). 18
‘‘(iii) OTHERWISE APPLICABLE RESI-
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DENT LIMIT.—The term ‘otherwise applica-
20
ble resident limit’ means, with respect to a 21
hospital, the limit otherwise applicable 22
under subparagraphs (F)(i) and (H) of 23
paragraph (4) on the resident level for the 24
hospital determined without regard to this 25
paragraph but taking into account para- 1 graph (7)(A).’’. 2 (b) IME.— 3 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of 4
the Social Security Act (42 U.S.C. 5
1395ww(d)(5)(B)(v)), in the second sentence, is 6
amended— 7
(A) by striking ‘‘subsection (h)(7)’’ and in- 8
serting ‘‘subsections (h)(7) and (h)(8)’’; and 9
(B) by striking ‘‘it applies’’ and inserting 10
‘‘they apply’’. 11
(2) CONFORMING AMENDMENT.—Section
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1886(d)(5)(B) of the Social Security Act (42 U.S.C. 13
1395ww(d)(5)(B)) is amended by adding at the end 14
the following clause: 15
‘‘(x) For discharges occurring on or after July 1, 16
2011, insofar as an additional payment amount 17
under this subparagraph is attributable to resident 18
positions distributed to a hospital under subsection 19
(h)(8)(B), the indirect teaching adjustment factor 20
shall be computed in the same manner as provided 21
under clause (ii) with respect to such resident posi- 22
tions.’’. 23
(c) CONFORMING AMENDMENT.—Section 422(b)(2) of
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the Medicare Prescription Drug, Improvement, and Mod- 25
ernization Act of 2003 (Public Law 108–173) is amended 1
by striking ‘‘section 1886(h)(7)’’ and all that follows and 2
inserting ‘‘paragraphs (7) and (8) of subsection (h) of sec- 3
tion 1886 of the Social Security Act’’. 4