I 

111TH CONGRESS 

1ST SESSION H. R. 2301 

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. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 7, 2009 

Mr. YARMUTH (for himself, Mr. BOUSTANY, Mr. CROWLEY, Ms. SCHWARTZ, 

and Mr. KING of New York) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the 

Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions 

as fall within the jurisdiction of the committee concerned 

A BILL 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Graduate Medical Edu5 cation Advancement Act of 2009’’. 


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1 SEC. 2. RULES FOR COUNTING RESIDENT TIME FOR DIDAC2 TIC AND SCHOLARLY ACTIVITIES AND OTHER 

3 ACTIVITIES. 

4 (a) DIRECT GME.—Section 1886(h) of the Social Se5 curity Act (42 U.S.C. 1395ww(h)) is amended— 

6 (1) in paragraph (4)(E)— 

7 (A) by designating the first sentence as a 

8 clause (i) with the heading ‘‘IN GENERAL’’ and 

9 appropriate indentation and by striking ‘‘Such 

10 rules’’ and inserting ‘‘Subject to clause (ii), 

11 such rules’’; and 

12 (B) by adding at the end the following new 

13 clause: 

14 ‘‘(ii) TREATMENT OF CERTAIN NON15 HOSPITAL AND DIDACTIC ACTIVITIES.— 

16 Such rules shall provide that all time spent 

17 by an intern or resident in an approved 

18 medical residency training program in a 

19 nonhospital setting that is primarily en20 gaged in furnishing patient care (as de21 fined in paragraph (5)(K)) in non-patient 

22 care activities, such as didactic conferences 

23 and seminars, but not including research 

24 not associated with the treatment or diag25 nosis of a particular patient, as such time 

26 and activities are defined by the Secretary, 


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1 shall be counted toward the determination 

2 of full-time equivalency.’’; 

3 (2) in paragraph (4), by adding at the end the 

4 following new subparagraph: 

5 ‘‘(I) TREATMENT OF CERTAIN LEAVE

6 TIME.—In determining the hospital’s number of 

7 full-time equivalent residents for purposes of 

8 this subsection, all the time that is spent by an 

9 intern or resident in an approved medical resi10 dency training program on vacation, sick leave, 

11 or other approved leave, as such time is defined 

12 by the Secretary, and that does not prolong the 

13 total time the resident is participating in the 

14 approved program beyond the normal duration 

15 of the program shall be counted toward the de16 termination of full-time equivalency.’’; and 

17 (3) in paragraph (5), by adding at the end the 

18 following new subparagraph: 

19 ‘‘(K) NONHOSPITAL SETTING THAT IS PRI20 MARILY ENGAGED IN FURNISHING PATIENT

21 CARE.—The term ‘nonhospital setting that is 

22 primarily engaged in furnishing patient care’ 

23 means a nonhospital setting in which the pri24 mary activity is the care and treatment of pa25 tients, as defined by the Secretary.’’. 


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1 (b) IME DETERMINATIONS.—Section 1886(d)(5)(B) 

2 of such Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 

3 adding at the end the following new clause: 

4 ‘‘(x)(I) The provisions of subparagraph (I) of 

5 subsection (h)(4) shall apply under this subpara6 graph in the same manner as they apply under such 

7 subsection. 

8 ‘‘(II) In determining the hospital’s number of 

9 full-time equivalent residents for purposes of this 

10 subparagraph, all the time spent by an intern or 

11 resident in an approved medical residency training 

12 program in non-patient care activities, such as di13 dactic conferences and seminars, as such time and 

14 activities are defined by the Secretary, that occurs in 

15 the hospital shall be counted toward the determina16 tion of full-time equivalency if the hospital— 

17 ‘‘(aa) is recognized as a subsection (d) hos18 pital; 

19 ‘‘(bb) is recognized as a subsection (d) 

20 Puerto Rico hospital; 

21 ‘‘(cc) is reimbursed under a reimbursement 

22 system authorized under section 1814(b)(3); or 

23 ‘‘(dd) is a provider-based hospital out24 patient department. 


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1 ‘‘(III) In determining the hospital’s number of 

2 full-time equivalent residents for purposes of this 

3 subparagraph, all the time spent by an intern or 

4 resident in an approved medical residency training 

5 program in research activities that are not associ6 ated with the treatment or diagnosis of a particular 

7 patient, as such time and activities are defined by 

8 the Secretary, shall not be counted toward the deter9 mination of full-time equivalency.’’. 

10 (c) EFFECTIVE DATES; APPLICATION.— 

11 (1) IN GENERAL.—Except as otherwise pro12 vided, the Secretary of Health and Human Services 

13 shall implement the amendments made by this sec14 tion in a manner so as to apply to cost reporting pe15 riods beginning on or after January 1, 1983. 

16 (2) DIRECT GME.—Section 1886(h)(4)(E)(ii) of 

17 the Social Security Act, as added by subsection 

18 (a)(1)(B), shall apply to cost reporting periods be19 ginning on or after July 1, 2009. 

20 (3) IME.—Section 1886(d)(5)(B)(x)(III) of the 

21 Social Security Act, as added by subsection (b), shall 

22 apply to cost reporting periods beginning on or after 

23 October 1, 2001. Such section, as so added, shall 

24 not give rise to any inference on how the law in ef25 fect prior to such date should be interpreted. 


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1 (4) APPLICATION.—The amendments made by 

2 this section shall not be applied in a manner that re3 quires reopening of any settled hospital cost reports 

4 as to which there is not a jurisdictionally proper ap5 peal pending as of the date of the enactment of this 

6 Act on the issue of payment for indirect costs of 

7 medical education under section 1886(d)(5)(B) of 

8 the Social Security Act or for direct graduate med9 ical education costs under section 1886(h) of such 

10 Act. 

11 SEC. 3. RULES FOR COUNTING RESIDENT TIME IN OUT12 PATIENT SETTINGS. 

13 (a) DIRECT GME.—Section 1886(h)(4)(E) of the So14 cial Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amend15 ed— 

16 (1) by striking ‘‘under an approved medical 

17 residency program’’; and 

18 (2) by striking ‘‘if the hospital incurs all, or 

19 substantially all, of the costs for the training pro20 gram in that setting’’ and inserting ‘‘if the hospital 

21 or hospitals continue to incur the costs of the resi22 dents’ stipends and fringe benefits during the time 

23 the residents spend in that setting.’’ 


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1 (b) IME DETERMINATIONS.—Section 

2 1886(d)(5)(B)(iv) of such Act (42 U.S.C. 

3 1395ww(d)(5)(B)(iv)) is amended— 

4 (1) by striking ‘‘under an approved medical 

5 residency training program’’; and 

6 (2) by striking ‘‘if the hospital incurs all, or 

7 substantially all, of the costs for the training pro8 gram in that setting’’ and inserting ‘‘if the hospital 

9 or hospitals continue to incur the costs of the resi10 dents’ stipends and fringe benefits during the time 

11 the residents spend in that setting.’’ 

12 (c) EFFECTIVE DATES; APPLICATION.— 

13 (1) IN GENERAL.—Except as otherwise pro14 vided, the Secretary of Health and Human Services 

15 shall implement the amendments made by this sec16 tion in a manner so as to apply to cost reporting pe17 riods beginning on or after July 1, 2009. 

18 (2) APPLICATION.—The amendments made by 

19 this section shall not be applied in a manner that re20 quires reopening of any settled hospital cost reports 

21 as to which there is not a jurisdictionally proper ap22 peal pending as of the date of the enactment of this 

23 Act on the issue of payment for indirect costs of 

24 medical education under section 1886(d)(5)(B) of 

25 the Social Security Act or for direct graduate medVerDate Nov 24 2008 06:47 May 08, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H2301.IH H2301

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1 ical education costs under section 1886(h) of such 

2 Act. 

Æ 


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