I 

111TH CONGRESS 

1ST SESSION H. R. 2251 

To amend title XVIII of the Social Security Act to provide for the distribution 

of additional residency positions, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 5, 2009 

Mr. CROWLEY (for himself, Mr. MEEK of Florida, Ms. CASTOR of Florida, and 

Mr. ENGEL) 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 to provide 

for the distribution of additional residency positions, and 

for other purposes. 

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 ‘‘Resident Physician 

5 Shortage Reduction Act of 2009’’. 


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1 SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI2 TIONS. 

3 (a) IN GENERAL.—Section 1886(h) of the Social Se4 curity Act (42 U.S.C. 1395ww(h)) is amended— 

5 (1) in paragraph (4)(F)(i), by striking ‘‘para6 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

7 (2) in paragraph (4)(H)(i), by striking ‘‘para8 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

9 and 

10 (3) by adding at the end the following new 

11 paragraph: 

12 ‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY

13 POSITIONS.— 

14 ‘‘(A) ADDITIONAL RESIDENCY POSI15 TIONS.— 

16 ‘‘(i) REDUCTION IN LIMIT BASED ON

17 UNUSED POSITIONS.— 

18 ‘‘(I) IN GENERAL.—The Sec19 retary shall reduce the otherwise ap20 plicable resident limit for a hospital 

21 that the Secretary determines had 

22 residency positions that were unused 

23 for all 5 of the most recent cost re24 porting periods ending prior to the 

25 date of enactment of this paragraph 

26 by an amount that is equal to the 


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1 number of such unused residency po2 sitions. 

3 ‘‘(II) EXCEPTION FOR RURAL

4 HOSPITALS AND CERTAIN OTHER HOS5 PITALS.—This subparagraph shall not 

6 apply to a hospital— 

7 ‘‘(aa) located in a rural area 

8 (as defined in subsection 

9 (d)(2)(D)(ii)); 

10 ‘‘(bb) that has participated 

11 in a voluntary reduction plan 

12 under paragraph (6); or 

13 ‘‘(cc) that has participated 

14 in a demonstration project ap15 proved as of October 31, 2003, 

16 under the authority of section 

17 402 of Public Law 90–248. 

18 ‘‘(ii) NUMBER AVAILABLE FOR DIS19 TRIBUTION.—The number of additional 

20 residency positions available for distribu21 tion under subparagraph (B) shall be an 

22 amount that the Secretary determines 

23 would result in a 15 percent increase in 

24 the aggregate number of full-time equiva25 lent residents in approved medical training 


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1 programs (as determined based on the 

2 most recent cost reports available at the 

3 time of distribution). One-third of such 

4 number shall only be available for distribu5 tion to hospitals described in subclause (I) 

6 of subparagraph (B)(ii) under such sub7 paragraph. 

8 ‘‘(B) DISTRIBUTION.— 

9 ‘‘(i) IN GENERAL.—The Secretary 

10 shall increase the otherwise applicable resi11 dent limit for each qualifying hospital that 

12 submits an application under this subpara13 graph by such number as the Secretary 

14 may approve for portions of cost reporting 

15 periods occurring on or after the date of 

16 enactment of this paragraph. The aggre17 gate number of increases in the otherwise 

18 applicable resident limit under this sub19 paragraph shall be equal to the number of 

20 additional residency positions available for 

21 distribution under subparagraph (A)(ii). 

22 ‘‘(ii) DISTRIBUTION TO HOSPITALS

23 ALREADY OPERATING OVER RESIDENT

24 LIMIT.— 


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1 ‘‘(I) IN GENERAL.—Subject to 

2 subclause (II), in the case of a hos3 pital in which the reference resident 

4 level of the hospital (as specified in 

5 clause (iii)) is greater than the other6 wise applicable resident limit, the in7 crease in the otherwise applicable resi8 dent limit under this subparagraph 

9 shall be an amount equal to the prod10 uct of the total number of additional 

11 residency positions available for dis12 tribution under subparagraph (A)(ii) 

13 and the quotient of— 

14 ‘‘(aa) the number of resident 

15 positions by which the reference 

16 resident level of the hospital ex17 ceeds the otherwise applicable 

18 resident limit for the hospital; 

19 and 

20 ‘‘(bb) the number of resident 

21 positions by which the reference 

22 resident level of all such hospitals 

23 with respect to which an applica24 tion is approved under this sub25 paragraph exceeds the otherwise 


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1 applicable resident limit for such 

2 hospitals. 

3 ‘‘(II) REQUIREMENTS.—A hos4 pital described in subclause (I)— 

5 ‘‘(aa) is not eligible for an 

6 increase in the otherwise applica7 ble resident limit under this sub8 paragraph unless the amount by 

9 which the reference resident level 

10 of the hospital exceeds the other11 wise applicable resident limit is 

12 not less than 10 and the hospital 

13 trains at least 25 percent of the 

14 full-time equivalent residents of 

15 the hospital in primary care and 

16 general surgery (as of the date of 

17 enactment of this paragraph); 

18 and 

19 ‘‘(bb) shall continue to train 

20 at least 25 percent of the full21 time equivalent residents of the 

22 hospital in primary care and gen23 eral surgery for the 10-year pe24 riod beginning on such date. 


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1 In the case where the Secretary deter2 mines that a hospital no longer meets 

3 the requirement of item (bb), the Sec4 retary may reduce the otherwise appli5 cable resident limit of the hospital by 

6 the amount by which such limit was 

7 increased under this clause. 

8 ‘‘(III) CLARIFICATION REGARD9 ING ELIGIBILITY FOR OTHER ADDI10 TIONAL RESIDENCY POSITIONS.— 

11 Nothing in this clause shall be con12 strued as preventing a hospital de13 scribed in subclause (I) from applying 

14 for additional residency positions 

15 under this paragraph that are not re16 served for distribution under this 

17 clause. 

18 ‘‘(iii) REFERENCE RESIDENT

19 LEVEL.— 

20 ‘‘(I) IN GENERAL.—Except as 

21 otherwise provided in subclause (II), 

22 the reference resident level specified in 

23 this clause for a hospital is the resi24 dent level for the most recent cost re25 porting period of the hospital ending 


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1 on or before the date of enactment of 

2 this paragraph, for which a cost re3 port has been settled (or, if not, sub4 mitted (subject to audit)), as deter5 mined by the Secretary. 

6 ‘‘(II) USE OF MOST RECENT AC7 COUNTING PERIOD TO RECOGNIZE EX8 PANSION OF EXISTING PROGRAM OR

9 ESTABLISHMENT OF NEW PRO10 GRAM.—If a hospital submits a timely 

11 request to increase its resident level 

12 due to an expansion of an existing 

13 residency training program or the es14 tablishment of a new residency train15 ing program that is not reflected on 

16 the most recent cost report that has 

17 been settled (or, if not, submitted 

18 (subject to audit)), subject to the dis19 cretion of the Secretary, the reference 

20 resident level for such hospital is the 

21 resident level for the cost reporting 

22 period that includes the additional 

23 residents attributable to such expan24 sion or establishment, as determined 

25 by the Secretary. 


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1 ‘‘(C) CONSIDERATIONS IN REDISTRIBU2 TION.—In determining for which hospitals the 

3 increase in the otherwise applicable resident 

4 limit is provided under subparagraph (B) (other 

5 than an increase under subparagraph (B)(ii)), 

6 the Secretary shall take into account the dem7 onstrated likelihood of the hospital filling the 

8 positions within the first 3 cost reporting peri9 ods beginning on or after July 1, 2010, made 

10 available under this paragraph, as determined 

11 by the Secretary. 

12 ‘‘(D) PRIORITY FOR CERTAIN AREAS.—In 

13 determining for which hospitals the increase in 

14 the otherwise applicable resident limit is pro15 vided under subparagraph (B) (other than an 

16 increase under subparagraph (B)(ii)), the Sec17 retary shall distribute the increase to hospitals 

18 based on the following criteria: 

19 ‘‘(i) The Secretary shall give pref20 erence to hospitals that submit applica21 tions for new primary care and general 

22 surgery residency positions. In the case of 

23 any increase based on such preference, a 

24 hospital shall ensure that— 


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1 ‘‘(I) the position made available 

2 as a result of such increase remains a 

3 primary care or general surgery resi4 dency position for not less than 10 

5 years after the date on which the posi6 tion is filled; and 

7 ‘‘(II) the total number of primary 

8 care and general surgery residency po9 sitions in the hospital (determined 

10 based on the number of such positions 

11 as of the date of such increase, includ12 ing any position added as a result of 

13 such increase) is not decreased during 

14 such 10-year period. 

15 In the case where the Secretary determines 

16 that a hospital no longer meets the re17 quirement of subclause (II), the Secretary 

18 may reduce the otherwise applicable resi19 dent limit of the hospital by the amount by 

20 which such limit was increased under this 

21 paragraph. 

22 ‘‘(ii) The Secretary shall give pref23 erence to hospitals that emphasize training 

24 in community health centers and other 

25 community-based clinical settings. 


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1 ‘‘(iii) The Secretary shall give pref2 erence to hospitals in States that have 

3 more medical students than residency posi4 tions available (including a greater pref5 erence for those States with smaller resi6 dent-to-medical-student ratios). In deter7 mining the number of medical students in 

8 a State for purposes of the preceding sen9 tence, the Secretary shall include planned 

10 students at medical schools which have 

11 provisional accreditation by the Liaison 

12 Committee on Medical Education or the 

13 American Osteopathic Association. 

14 ‘‘(iv) The Secretary shall give pref15 erence to hospitals in States that have low 

16 resident-to-population ratios (including a 

17 greater preference for those States with 

18 lower resident-to-population ratios). 

19 ‘‘(E) LIMITATION.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), in no case may a hos22 pital (other than a hospital described in 

23 subparagraph (B)(ii)(I), subject to the lim24 itation under subparagraph (B)(ii)(III)) 

25 apply for more than 50 full-time equivalent 


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1 additional residency positions under this 

2 paragraph. 

3 ‘‘(ii) INCREASE IN NUMBER OF ADDI4 TIONAL POSITIONS AVAILABLE FOR DIS5 TRIBUTION.—The Secretary shall increase 

6 the number of full-time equivalent addi7 tional residency positions a hospital may 

8 apply for under this paragraph if the Sec9 retary determines that the number of addi10 tional residency positions available for dis11 tribution under subparagraph (A)(ii) ex12 ceeds the number of such applications ap13 proved. 

14 ‘‘(F) APPLICATION OF PER RESIDENT

15 AMOUNTS FOR PRIMARY CARE AND NONPRI16 MARY CARE.—With respect to additional resi17 dency positions in a hospital attributable to the 

18 increase provided under this paragraph, the ap19 proved FTE resident amounts are deemed to be 

20 equal to the hospital per resident amounts for 

21 primary care and nonprimary care computed 

22 under paragraph (2)(D) for that hospital. 

23 ‘‘(G) DISTRIBUTION.—The Secretary shall 

24 distribute the increase to hospitals under this 


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1 paragraph not later than 2 years after the date 

2 of enactment of this paragraph.’’. 

3 (b) IME.— 

4 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of 

5 the Social Security Act (42 U.S.C. 

6 1395ww(d)(5)(B)(v)), in the second sentence, is 

7 amended— 

8 (A) by striking ‘‘subsection (h)(7)’’ and in9 serting ‘‘subsections (h)(7) and (h)(8)’’; and 

10 (B) by striking ‘‘it applies’’ and inserting 

11 ‘‘they apply’’. 

12 (2) CONFORMING PROVISION.—Section 

13 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

14 1395ww(d)(5)(B)) is amended by adding at the end 

15 the following clause: 

16 ‘‘(x) For discharges occurring on or after the 

17 date of enactment of this clause, insofar as an addi18 tional payment amount under this subparagraph is 

19 attributable to resident positions distributed to a 

20 hospital under subsection (h)(8)(B), the indirect 

21 teaching adjustment factor shall be computed in the 

22 same manner as provided under clause (ii) with re23 spect to such resident positions.’’. 


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1 SEC. 3. COUNTING RESIDENT TIME IN OUTPATIENT SET2 TINGS. 

3 (a) GME.—Section 1886(h)(4)(E) of the Social Se4 curity Act (42 U.S.C. 1395ww(h)) is amended— 

5 (1) by striking ‘‘shall be counted and that all 

6 the time’’ and inserting ‘‘shall be counted and 

7 that— 

8 ‘‘(i) effective for cost reporting peri9 ods beginning before July 1, 2009, all the 

10 time’’; 

11 (2) in clause (i), as inserted by paragraph (1), 

12 by striking the period at the end and inserting ‘‘; 

13 and’’; and 

14 (3) by inserting after clause (i), as so inserted, 

15 the following new clause: 

16 ‘‘(ii) effective for cost reporting peri17 ods beginning on or after July 1, 2009, all 

18 the time so spent by a resident shall be 

19 counted towards the determination of full20 time equivalency, without regard to the 

21 setting in which the activities are per22 formed, if the hospital continues to incur 

23 the costs of the stipends and fringe bene24 fits of the resident during the time the 

25 resident spends in that setting.’’. 


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1 (b) IME.—Section 1886(d)(5)(B)(iv) of the Social 

2 Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend3 ed— 

4 (1) by striking ‘‘(iv) Effective for discharges oc5 curring on or after October 1, 1997’’ and inserting 

6 ‘‘(iv)(A) Effective for discharges occurring on or 

7 after October 1, 1997, and before July 1, 2009’’; 

8 and 

9 (2) by inserting after subparagraph (A), as in10 serted by paragraph (1), the following new subpara11 graph: 

12 ‘‘(B) Effective for discharges occur13 ring on or after July 1, 2009, all the time 

14 spent by an intern or resident in patient 

15 care activities at an entity in a nonhospital 

16 setting shall be counted towards the deter17 mination of full-time equivalency if the 

18 hospital continues to incur the costs of the 

19 stipends and fringe benefits of the intern 

20 or resident during the time the intern or 

21 resident spends in that setting.’’. 

22 (c) APPLICATION.—The amendments made by this 

23 section shall not be applied in a manner that requires re24 opening of any settled hospital cost reports as to which 

25 there is not a jurisdictionally proper appeal pending as 


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1 of the date of the enactment of this Act on the issue of 

2 payment for indirect costs of medical education under sec3 tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

4 1395ww(d)(5)(B)) or for direct graduate medical edu5 cation costs under section 1886(h) of such Act (42 U.S.C. 

6 1395ww(h)). 

7 SEC. 4. RULES FOR COUNTING RESIDENT TIME FOR DIDAC8 TIC AND SCHOLARLY ACTIVITIES AND OTHER 

9 ACTIVITIES. 

10 (a) GME.—Section 1886(h) of the Social Security 

11 Act (42 U.S.C. 1395ww(h)), as amended by section 3, is 

12 amended— 

13 (1) in paragraph (4)(E)— 

14 (A) by designating the first sentence as a 

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

16 appropriate indentation and by striking ‘‘Such 

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

18 such rules’’; and 

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

20 clause: 

21 ‘‘(ii) TREATMENT OF CERTAIN NON22 HOSPITAL AND DIDACTIC ACTIVITIES.— 

23 Such rules shall provide that all time spent 

24 by an intern or resident in an approved 

25 medical residency training program in a 


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1 nonhospital setting that is primarily en2 gaged in furnishing patient care (as de3 fined in paragraph (5)(K)) in non-patient 

4 care activities, such as didactic conferences 

5 and seminars, but not including research 

6 not associated with the treatment or diag7 nosis of a particular patient, as such time 

8 and activities are defined by the Secretary, 

9 shall be counted toward the determination 

10 of full-time equivalency.’’; 

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

12 following new subparagraph: 

13 ‘‘(I) In determining the hospital’s number 

14 of full-time equivalent residents for purposes of 

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

16 intern or resident in an approved medical resi17 dency training program on vacation, sick leave, 

18 or other approved leave, as such time is defined 

19 by the Secretary, and that does not prolong the 

20 total time the resident is participating in the 

21 approved program beyond the normal duration 

22 of the program shall be counted toward the de23 termination of full-time equivalency.’’; and 

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

25 following new subparagraph: 


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1 ‘‘(K) NONHOSPITAL SETTING THAT IS PRI2 MARILY ENGAGED IN FURNISHING PATIENT

3 CARE.—The term ‘nonhospital setting that is 

4 primarily engaged in furnishing patient care’ 

5 means a nonhospital setting in which the pri6 mary activity is the care and treatment of pa7 tients, as defined by the Secretary.’’. 

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

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

10 adding at the end the following new clause: 

11 ‘‘(x)(I) The provisions of subpara12 graph (I) of subsection (h)(4) shall apply 

13 under this subparagraph in the same man14 ner as they apply under such subsection. 

15 ‘‘(II) In determining the hospital’s 

16 number of full-time equivalent residents 

17 for purposes of this subparagraph, all the 

18 time spent by an intern or resident in an 

19 approved medical residency training pro20 gram in non-patient care activities, such as 

21 didactic conferences and seminars, as such 

22 time and activities are defined by the Sec23 retary, that occurs in the hospital shall be 

24 counted toward the determination of full25 time equivalency if the hospital— 


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1 ‘‘(aa) is recognized as a sub2 section (d) hospital; 

3 ‘‘(bb) is recognized as a sub4 section (d) Puerto Rico hospital; 

5 ‘‘(cc) is reimbursed under a reim6 bursement system authorized under 

7 section 1814(b)(3); or 

8 ‘‘(dd) is a provider-based hospital 

9 outpatient department. 

10 ‘‘(III) In determining the hospital’s 

11 number of full-time equivalent residents 

12 for purposes of this subparagraph, all the 

13 time spent by an intern or resident in an 

14 approved medical residency training pro15 gram in research activities that are not as16 sociated with the treatment or diagnosis of 

17 a particular patient, as such time and ac18 tivities are defined by the Secretary, shall 

19 not be counted toward the determination of 

20 full-time equivalency.’’. 

21 (c) EFFECTIVE DATES; APPLICATION.— 

22 (1) IN GENERAL.—Except as otherwise pro23 vided, the Secretary of Health and Human Services 

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1 tion in a manner so as to apply to cost reporting pe2 riods beginning on or after January 1, 1983. 

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

4 the Social Security Act, as added by subsection 

5 (a)(1)(B), shall apply to cost reporting periods be6 ginning on or after July 1, 2008. 

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

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

9 apply to cost reporting periods beginning on or after 

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

11 not give rise to any inference on how the law in ef12 fect prior to such date should be interpreted. 

13 (4) APPLICATION.—The amendments made by 

14 this section shall not be applied in a manner that re15 quires reopening of any settled hospital cost reports 

16 as to which there is not a jurisdictionally proper ap17 peal pending as of the date of the enactment of this 

18 Act on the issue of payment for indirect costs of 

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

20 the Social Security Act or for direct graduate med21 ical education costs under section 1886(h) of such 

22 Act. 


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1 SEC. 5. PRESERVATION OF RESIDENT CAP POSITIONS 

2 FROM CLOSED AND ACQUIRED HOSPITALS. 

3 (a) GME.—Section 1886(h)(4)(H) of the Social Se4 curity Act (42 U.S.C. Section 1395ww(h)(4)(H)) is 

5 amended by adding at the end the following new clauses: 

6 ‘‘(vi) REDISTRIBUTION OF RESIDENCY

7 SLOTS AFTER A HOSPITAL CLOSES.— 

8 ‘‘(I) IN GENERAL.—Subject to 

9 the succeeding provisions of this 

10 clause, the Secretary shall, by regula11 tion, establish a process under which, 

12 in the case where a hospital with an 

13 approved medical residency program 

14 closes on or after the date of enact15 ment of the Balanced Budget Act of 

16 1997, the Secretary shall increase the 

17 otherwise applicable resident limit 

18 under this paragraph for other hos19 pitals in accordance with this clause. 

20 ‘‘(II) PRIORITY FOR HOSPITALS

21 IN CERTAIN AREAS.—Subject to the 

22 succeeding provisions of this clause, in 

23 determining for which hospitals the 

24 increase in the otherwise applicable 

25 resident limit is provided under such 

26 process, the Secretary shall distribute 


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1 the increase to hospitals located in the 

2 following priority order (with pref3 erence given within each category to 

4 hospitals that are members of the 

5 same affiliated group (as defined by 

6 the Secretary under clause (ii)) as the 

7 closed hospital): 

8 ‘‘(aa) First, to hospitals lo9 cated in the same core-based sta10 tistical area as, or a core-based 

11 statistical area contiguous to, the 

12 hospital that closed. 

13 ‘‘(bb) Second, to hospitals 

14 located in the same State as the 

15 hospital that closed. 

16 ‘‘(cc) Third, to hospitals lo17 cated in the same region of the 

18 country as the hospital that 

19 closed. 

20 ‘‘(dd) Fourth, to all other 

21 hospitals. 

22 ‘‘(III) REQUIREMENT HOSPITAL

23 LIKELY TO FILL POSITION WITHIN

24 CERTAIN TIME PERIOD.—The Sec25 retary may only increase the otherwise 


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1 applicable resident limit of a hospital 

2 under such process if the Secretary 

3 determines the hospital has dem4 onstrated a likelihood of filling the po5 sitions made available under this 

6 clause within 3 years. 

7 ‘‘(IV) LIMITATION.—The aggre8 gate number of increases in the other9 wise applicable resident limits for hos10 pitals under this clause shall be equal 

11 to the number of resident positions in 

12 the approved medical residency pro13 grams that closed on or after the date 

14 described in subclause (I). 

15 ‘‘(vii) SPECIAL RULE FOR ACQUIRED

16 HOSPITALS.— 

17 ‘‘(I) IN GENERAL.—In the case 

18 of a hospital that is acquired (through 

19 any mechanism) by another entity 

20 with the approval of a bankruptcy 

21 court, during a period determined by 

22 the Secretary (but not less than 3 

23 years), the applicable resident limit of 

24 the acquired hospital shall, except as 

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1 plicable resident limit of the hospital 

2 that was acquired (as of the date im3 mediately before the acquisition), 

4 without regard to whether the acquir5 ing entity accepts assignment of the 

6 Medicare provider agreement of the 

7 hospital that was acquired, so long as 

8 the acquiring entity continues to oper9 ate the hospital that was acquired and 

10 to furnish services, medical residency 

11 programs, and volume of patients 

12 similar to the services, medical resi13 dency programs, and volume of pa14 tients of the hospital that was ac15 quired (as determined by the Sec16 retary) during such period. 

17 ‘‘(II) LIMITATION.—Subclause 

18 (I) shall only apply in the case where 

19 an acquiring entity waives the right as 

20 a new provider under the program 

21 under this title to have the otherwise 

22 applicable resident limit of the ac23 quired hospital re-established or in24 creased.’’. 


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1 (b) IME.—Section 1886(d)(5)(B)(v) of the Social Se2 curity Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 

3 sentence, as amended by section 3, is amended by striking 

4 ‘‘subsections (h)(7) and (h)(8)’’ and inserting ‘‘sub5 sections (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and (h)(8)’’. 

6 (c) APPLICATION.—The amendments made by this 

7 section shall not be applied in a manner that requires re8 opening of any settled hospital cost reports as to which 

9 there is not a jurisdictionally proper appeal pending as 

10 of the date of the enactment of this Act on the issue of 

11 payment for indirect costs of medical education under sec12 tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

13 1395ww(d)(5)(B)) or for direct graduate medical edu14 cation costs under section 1886(h) of such Act (42 U.S.C. 

15 Section 1395ww(h)). 

16 (d) NO EFFECT ON TEMPORARY FTE CAP ADJUST17 MENTS.—The amendments made by this section shall not 

18 effect any temporary adjustment to a hospital’s FTE cap 

19 under section 413.79(h) of title 42, Code of Federal Regu20 lations (as in effect on the date of enactment of this Act). 

Æ 


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