To amend title XVIII of the Social Security Act with respect to treatment of didactic and scholarly activities and training in outpatient settings for purposes of payment for graduate medical education under the Medicare Program.

Summary: Graduate Medical Education Advancement Act of 2009 - Amends title XVIII (Medicare) of the Social Security Act with respect to rules for the computation of the number of full-time-equivalent residents in an approved medical residency training program, particularly the counting of time spent in outpatient settings, for purposes of calculating payments to: (1) hospitals for direct graduate medical education (GME) costs; and (2) subsection (d) hospitals with indirect medical education (IME) costs.

(Generally, a subsection (d) hospital is an acute care hospital, particularly one that receives payments under Medicare's inpatient prospective payment system [IPPS] when providing covered inpatient services to eligible beneficiaries.)

Requires the counting of hours spent by an intern or resident in a nonhospital setting (that is primarily engaged in furnishing patient care) in non-patient care activities, such as didactic conferences and seminars (but excluding research not associated with the treatment or diagnosis of a particular patient).

Requires the counting as well of all the time spent on vacation, sick leave, or other approved leave that does not prolong the total time the resident is participating in the approved program beyond its normal duration.

Revises rules for counting resident time in outpatient settings with respect to GME and IME costs to include the costs of the residents' stipends and fringe benefits during the time residents spend in such a setting.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Graduate Medical Education 
Advancement Act of 2009''.

SEC. 2. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY 
              ACTIVITIES AND OTHER ACTIVITIES.

    (a) Direct GME.--Section 1886(h) of the Social Security Act (42 
U.S.C. 1395ww(h)) is amended--
            (1) in paragraph (4)(E)--
                    (A) by designating the first sentence as a clause 
                (i) with the heading ``In general'' and appropriate 
                indentation and by striking ``Such rules'' and 
                inserting ``Subject to clause (ii), such rules''; and
                    (B) by adding at the end the following new clause:
                            ``(ii) Treatment of certain nonhospital and 
                        didactic activities.--Such rules shall provide 
                        that all time spent by an intern or resident in 
                        an approved medical residency training program 
                        in a nonhospital setting that is primarily 
                        engaged in furnishing patient care (as defined 
                        in paragraph (5)(K)) in non-patient care 
                        activities, such as didactic conferences and 
                        seminars, but not including research not 
                        associated with the treatment or diagnosis of a 
                        particular patient, as such time and activities 
                        are defined by the Secretary, shall be counted 
                        toward the determination of full-time 
                        equivalency.'';
            (2) in paragraph (4), by adding at the end the following 
        new subparagraph:
                    ``(I) Treatment of certain leave time.--In 
                determining the hospital's number of full-time 
                equivalent residents for purposes of this subsection, 
                all the time that is spent by an intern or resident in 
                an approved medical residency training program on 
                vacation, sick leave, or other approved leave, as such 
                time is defined by the Secretary, and that does not 
                prolong the total time the resident is participating in 
                the approved program beyond the normal duration of the 
                program shall be counted toward the determination of 
                full-time equivalency.''; and
            (3) in paragraph (5), by adding at the end the following 
        new subparagraph:
                    ``(K) Nonhospital setting that is primarily engaged 
                in furnishing patient care.--The term `nonhospital 
                setting that is primarily engaged in furnishing patient 
                care' means a nonhospital setting in which the primary 
                activity is the care and treatment of patients, as 
                defined by the Secretary.''.
    (b) IME Determinations.--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 clause:
            ``(x)(I) The provisions of subparagraph (I) of subsection 
        (h)(4) shall apply under this subparagraph in the same manner 
        as they apply under such subsection.
            ``(II) In determining the hospital's number of full-time 
        equivalent residents for purposes of this subparagraph, all the 
        time spent by an intern or resident in an approved medical 
        residency training program in non-patient care activities, such 
        as didactic conferences and seminars, as such time and 
        activities are defined by the Secretary, that occurs in the 
        hospital shall be counted toward the determination of full-time 
        equivalency if the hospital--
                    ``(aa) is recognized as a subsection (d) hospital;
                    ``(bb) is recognized as a subsection (d) Puerto 
                Rico hospital;
                    ``(cc) is reimbursed under a reimbursement system 
                authorized under section 1814(b)(3); or
                    ``(dd) is a provider-based hospital outpatient 
                department.
            ``(III) In determining the hospital's number of full-time 
        equivalent residents for purposes of this subparagraph, all the 
        time spent by an intern or resident in an approved medical 
        residency training program in research activities that are not 
        associated with the treatment or diagnosis of a particular 
        patient, as such time and activities are defined by the 
        Secretary, shall not be counted toward the determination of 
        full-time equivalency.''.
    (c) Effective Dates; Application.--
            (1) In general.--Except as otherwise provided, the 
        Secretary of Health and Human Services shall implement the 
        amendments made by this section in a manner so as to apply to 
        cost reporting periods beginning on or after January 1, 1983.
            (2) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social 
        Security Act, as added by subsection (a)(1)(B), shall apply to 
        cost reporting periods beginning on or after July 1, 2009.
            (3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social 
        Security Act, as added by subsection (b), shall apply to cost 
        reporting periods beginning on or after October 1, 2001. Such 
        section, as so added, shall not give rise to any inference on 
        how the law in effect prior to such date should be interpreted.
            (4) Application.--The amendments made by this section shall 
        not be applied in a manner that requires reopening of any 
        settled hospital cost reports as to which there is not a 
        jurisdictionally proper appeal pending as of the date of the 
        enactment of this Act on the issue of payment for indirect 
        costs of medical education under section 1886(d)(5)(B) of the 
        Social Security Act or for direct graduate medical education 
        costs under section 1886(h) of such Act.

SEC. 3. RULES FOR COUNTING RESIDENT TIME IN OUTPATIENT SETTINGS.

    (a) Direct GME.--Section 1886(h)(4)(E) of the Social Security Act 
(42 U.S.C. 1395ww(h)(4)(E)) is amended--
            (1) by striking ``under an approved medical residency 
        program''; and
            (2) by striking ``if the hospital incurs all, or 
        substantially all, of the costs for the training program in 
        that setting'' and inserting ``if the hospital or hospitals 
        continue to incur the costs of the residents' stipends and 
        fringe benefits during the time the residents spend in that 
        setting.''
    (b) IME Determinations.--Section 1886(d)(5)(B)(iv) of such Act (42 
U.S.C. 1395ww(d)(5)(B)(iv)) is amended--
            (1) by striking ``under an approved medical residency 
        training program''; and
            (2) by striking ``if the hospital incurs all, or 
        substantially all, of the costs for the training program in 
        that setting'' and inserting ``if the hospital or hospitals 
        continue to incur the costs of the residents' stipends and 
        fringe benefits during the time the residents spend in that 
        setting.''
    (c) Effective Dates; Application.--
            (1) In general.--Except as otherwise provided, the 
        Secretary of Health and Human Services shall implement the 
        amendments made by this section in a manner so as to apply to 
        cost reporting periods beginning on or after July 1, 2009.
            (2) Application.--The amendments made by this section shall 
        not be applied in a manner that requires reopening of any 
        settled hospital cost reports as to which there is not a 
        jurisdictionally proper appeal pending as of the date of the 
        enactment of this Act on the issue of payment for indirect 
        costs of medical education under section 1886(d)(5)(B) of the 
        Social Security Act or for direct graduate medical education 
        costs under section 1886(h) of such Act.