I 

117TH CONGRESS 

1ST SESSION H. R. 2256 

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 

MARCH 26, 2021 

Ms. SEWELL (for herself, Mr. KATKO, Mr. SUOZZI, Mr. RODNEY DAVIS of Illinois, Ms. BARRAGA ́N, Mrs. BEATTY, Mr. BRENDAN F. BOYLE of Pennsylvania, Mr. CARBAJAL, Mr. CICILLINE, Mr. COHEN, Mr. CONNOLLY, Mr. 

CROW, Mr. DANNY K. DAVIS of Illinois, Ms. DEGETTE, Mr. MICHAEL

F. DOYLE of Pennsylvania, Mr. FITZPATRICK, Ms. HOULAHAN, Mr. 

JOHNSON of Georgia, Mr. LAWSON of Florida, Ms. LEE of California, 

Mrs. LEE of Nevada, Ms. MCCOLLUM, Mr. MEEKS, Ms. MENG, Mr. NADLER, Mr. PAYNE, Ms. PINGREE, Ms. ROSS, Ms. SCANLON, Ms. 

STEFANIK, Mr. STEUBE, Ms. STEVENS, Ms. TITUS, Mr. TONKO, Mr. VAN

DREW, Ms. VELA ́ZQUEZ, Mr. WELCH, Ms. BASS, and Miss RICE 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 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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Resident Physician 

3 Shortage Reduction Act of 2021’’. 

4 SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI5 TIONS. 

6 (a) IN GENERAL.—Section 1886(h) of the Social Se7 curity Act (42 U.S.C. 1395ww(h)) is amended— 

8 (1) in paragraph (4)(F)(i), by striking ‘‘para9 graphs (7), (8), and (9)’’ and inserting ‘‘paragraphs 

10 (7), (8), (9), and (10)’’; 

11 (2) in paragraph (4)(H)(i), by striking ‘‘para12 graphs (7), (8), and (9)’’ and inserting ‘‘paragraphs 

13 (7), (8), (9), and (10)’’; 

14 (3) in paragraph (7)(E), by inserting ‘‘para15 graph (10),’’ after ‘‘paragraph (8),’’; and 

16 (4) by adding at the end the following new 

17 paragraph: 

18 ‘‘(10) DISTRIBUTION OF ADDITIONAL RESI19 DENCY POSITIONS.— 

20 ‘‘(A) ADDITIONAL RESIDENCY POSI21 TIONS.— 

22 ‘‘(i) IN GENERAL.—For each of fiscal 

23 years 2023 through 2029 (and succeeding 

24 fiscal years if the Secretary determines 

25 that there are additional residency posi26 tions available to distribute under clause 


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1 (iv)(II)), the Secretary shall, subject to 

2 clause (ii) and subparagraph (D), increase 

3 the otherwise applicable resident limit for 

4 each qualifying hospital (as defined in sub5 paragraph (H)) that submits a timely ap6 plication under this subparagraph by such 

7 number as the Secretary may approve for 

8 portions of cost reporting periods occurring 

9 on or after July 1 of the fiscal year of the 

10 increase. 

11 ‘‘(ii) NUMBER AVAILABLE FOR DIS12 TRIBUTION.—For each such fiscal year, 

13 the Secretary shall determine the total 

14 number of additional residency positions 

15 available for distribution under clause (i) 

16 in accordance with the following: 

17 ‘‘(I) ALLOCATION TO HOSPITALS

18 ALREADY OPERATING OVER RESIDENT

19 LIMIT.—One-third of such number 

20 shall be available for distribution only 

21 to hospitals described in subparagraph 

22 (B). 

23 ‘‘(II) AGGREGATE LIMITATION.— 

24 Except as provided in clause (iv)(I), 

25 the aggregate number of increases in 


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1 the otherwise applicable resident limit 

2 under this subparagraph shall be 

3 equal to 2,000 in each such year. 

4 ‘‘(iii) PROCESS FOR DISTRIBUTING

5 POSITIONS.— 

6 ‘‘(I) ROUNDS OF APPLICA7 TIONS.—The Secretary shall initiate 7 

8 separate rounds of applications for an 

9 increase under clause (i), 1 round 

10 with respect to each of fiscal years 

11 2023 through 2029. 

12 ‘‘(II) NUMBER AVAILABLE.—In 

13 each of such rounds, the aggregate 

14 number of positions available for dis15 tribution in the fiscal year under 

16 clause (ii) shall be distributed, plus 

17 any additional positions available 

18 under clause (iv). 

19 ‘‘(III) TIMING.—The Secretary 

20 shall notify hospitals of the number of 

21 positions distributed to the hospital 

22 under this paragraph as a result of an 

23 increase in the otherwise applicable 

24 resident limit by January 1 of the fis25 cal year of the increase. Such increase 


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1 shall be effective for portions of cost 

2 reporting periods beginning on or 

3 after July 1 of that fiscal year. 

4 ‘‘(iv) POSITIONS NOT DISTRIBUTED

5 DURING THE FISCAL YEAR.— 

6 ‘‘(I) IN GENERAL.—If the num7 ber of resident full-time equivalent po8 sitions distributed under this para9 graph in a fiscal year is less than the 

10 aggregate number of positions avail11 able for distribution in the fiscal year 

12 (as described in clause (ii), including 

13 after application of this subclause), 

14 the difference between such number 

15 distributed and such number available 

16 for distribution shall be added to the 

17 aggregate number of positions avail18 able for distribution in the following 

19 fiscal year. 

20 ‘‘(II) EXCEPTION IF POSITIONS

21 NOT DISTRIBUTED BY END OF FISCAL

22 YEAR 2029.—If the aggregate number 

23 of positions distributed under this 

24 paragraph during the 7-year period of 

25 fiscal years 2023 through 2029 is less 


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1 than 14,000, the Secretary shall, in 

2 accordance with the provisions of 

3 clause (ii) and subparagraph (E) and 

4 the considerations and priority de5 scribed in subparagraph (C), conduct 

6 an application and distribution proc7 ess in each subsequent fiscal year 

8 until such time as the aggregate 

9 amount of positions distributed under 

10 this paragraph is equal to 14,000. 

11 ‘‘(B) ALLOCATION OF DISTRIBUTION FOR

12 POSITIONS TO HOSPITALS ALREADY OPERATING

13 OVER RESIDENT LIMIT.— 

14 ‘‘(i) IN GENERAL.—Subject to clauses 

15 (ii) and (iii), in the case of a hospital in 

16 which the reference resident level of the 

17 hospital (as specified in subparagraph 

18 (G)(iii)) is greater than the otherwise ap19 plicable resident limit, the increase in the 

20 otherwise applicable resident limit under 

21 subparagraph (A) for a fiscal year de22 scribed in such subparagraph shall be an 

23 amount equal to the product of the total 

24 number of additional residency positions 

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1 graph (A)(ii)(I) for such fiscal year and 

2 the quotient of— 

3 ‘‘(I) the number of resident posi4 tions by which the reference resident 

5 level of the hospital exceeds the other6 wise applicable resident limit for the 

7 hospital; and 

8 ‘‘(II) the number of resident po9 sitions by which the reference resident 

10 level of all such hospitals with respect 

11 to which an application is approved 

12 under this paragraph exceeds the oth13 erwise applicable resident limit for 

14 such hospitals. 

15 ‘‘(ii) REQUIREMENTS.—A hospital de16 scribed in clause (i)— 

17 ‘‘(I) is not eligible for an increase 

18 in the otherwise applicable resident 

19 limit under this subparagraph unless 

20 the amount by which the reference 

21 resident level of the hospital exceeds 

22 the otherwise applicable resident limit 

23 is not less than 10 and the hospital 

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1 pital in primary care and general sur2 gery (as of the date of enactment of 

3 this paragraph); and 

4 ‘‘(II) shall continue to train at 

5 least 25 percent of the full-time equiv6 alent residents of the hospital in pri7 mary care and general surgery for the 

8 5-year period beginning on such date. 

9 In the case where the Secretary determines 

10 that a hospital described in clause (i) no 

11 longer meets the requirement of subclause 

12 (II), the Secretary may reduce the other13 wise applicable resident limit of the hos14 pital by the amount by which such limit 

15 was increased under this subparagraph. 

16 ‘‘(iii) CLARIFICATION REGARDING ELI17 GIBILITY FOR OTHER ADDITIONAL RESI18 DENCY POSITIONS.—Nothing in this sub19 paragraph shall be construed as preventing 

20 a hospital described in clause (i) from ap21 plying for and receiving additional resi22 dency positions under this paragraph that 

23 are not reserved for distribution under this 

24 subparagraph. 


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1 ‘‘(C) DISTRIBUTION OF OTHER POSI2 TIONS.—For purposes of determining an in3 crease in the otherwise applicable resident limit 

4 under subparagraph (A) (other than such an in5 crease described in subparagraph (B)), the fol6 lowing shall apply: 

7 ‘‘(i) CONSIDERATIONS IN DISTRIBU8 TION.—In determining for which hospitals 

9 such an increase is provided under sub10 paragraph (A), the Secretary shall take 

11 into account the demonstrated likelihood of 

12 the hospital filling the positions made 

13 available under this paragraph within the 

14 first 5 cost reporting periods beginning 

15 after the date the increase would be effec16 tive, as determined by the Secretary. 

17 ‘‘(ii) MINIMUM DISTRIBUTION FOR

18 CERTAIN CATEGORIES OF HOSPITALS.— 

19 With respect to the aggregate number of 

20 such positions available for distribution 

21 under this paragraph, the Secretary shall 

22 distribute not less than 10 percent of such 

23 aggregate number to each of the following 

24 categories of hospitals: 


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1 ‘‘(I) Hospitals that are located in 

2 a rural area (as defined in subsection 

3 (d)(2)(D)) or are treated as being lo4 cated in a rural area pursuant to sub5 section (d)(8)(E). 

6 ‘‘(II) Hospitals in which the ref7 erence resident level of the hospital 

8 (as specified in subparagraph (F)(iii)) 

9 is greater than the otherwise applica10 ble resident limit. 

11 ‘‘(III) Hospitals in States with— 

12 ‘‘(aa) new medical schools 

13 that received ‘Candidate School’ 

14 status from the Liaison Com15 mittee on Medical Education or 

16 that received ‘Pre-Accreditation’ 

17 status from the American Osteo18 pathic Association Commission 

19 on Osteopathic College Accredita20 tion on or after January 1, 2000, 

21 and that have achieved or con22 tinue to progress toward ‘Full 

23 Accreditation’ status (as such 

24 term is defined by the Liaison 

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1 cation) or toward ‘Accreditation’ 

2 status (as such term is defined 

3 by the American Osteopathic As4 sociation Commission on Osteo5 pathic College Accreditation); or 

6 ‘‘(bb) additional locations 

7 and branch campuses established 

8 on or after January 1, 2000, by 

9 medical schools with ‘Full Ac10 creditation’ status (as such term 

11 is defined by the Liaison Com12 mittee on Medical Education) or 

13 ‘Accreditation’ status (as such 

14 term is defined by the American 

15 Osteopathic Association Commis16 sion on Osteopathic College Ac17 creditation). 

18 ‘‘(IV) Hospitals that serve areas 

19 designated as health professional 

20 shortage areas under section 

21 332(a)(1)(A) of the Public Health 

22 Service Act, as determined by the Sec23 retary. 

24 ‘‘(D) PROHIBITION ON DISTRIBUTION TO

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1 MENT.—No increase in the otherwise applicable 

2 resident limit of a hospital may be made under 

3 subparagraph (C) unless such hospital agrees to 

4 increase the total number of full-time equivalent 

5 residency positions under the approved medical 

6 residency training program of such hospital by 

7 the number of such positions made available by 

8 such increase under the subparagraph. 

9 ‘‘(E) LIMITATION.— 

10 ‘‘(i) IN GENERAL.—Except as pro11 vided in clause (ii), a hospital may not re12 ceive more than 75 full-time equivalent ad13 ditional residency positions in the aggre14 gate under this paragraph and paragraph 

15 (9) over the period of fiscal years 2023 

16 through 2029. 

17 ‘‘(ii) INCREASE IN NUMBER OF ADDI18 TIONAL POSITIONS A HOSPITAL MAY RE19 CEIVE.—The Secretary shall increase the 

20 aggregate number of full-time equivalent 

21 additional residency positions a hospital 

22 may receive under this paragraph over 

23 such period if the Secretary estimates that 

24 the number of positions available for dis25 tribution under subparagraph (A) exceeds 


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1 the number of applications approved under 

2 such subparagraph over such period. 

3 ‘‘(F) APPLICATION OF PER RESIDENT

4 AMOUNTS FOR PRIMARY CARE AND NONPRI5 MARY CARE.—With respect to additional resi6 dency positions in a hospital attributable to the 

7 increase provided under this paragraph, the ap8 proved FTE per resident amounts are deemed 

9 to be equal to the hospital per resident amounts 

10 for primary care and nonprimary care com11 puted under paragraph (2)(D) for that hospital. 

12 ‘‘(G) PERMITTING FACILITIES TO APPLY

13 AGGREGATION RULES.—The Secretary shall 

14 permit hospitals receiving additional residency 

15 positions attributable to the increase provided 

16 under this paragraph to, beginning in the fifth 

17 year after the effective date of such increase, 

18 apply such positions to the limitation amount 

19 under paragraph (4)(F) that may be aggre20 gated pursuant to paragraph (4)(H) among 

21 members of the same affiliated group. 

22 ‘‘(H) DEFINITIONS.—In this paragraph: 

23 ‘‘(i) OTHERWISE APPLICABLE RESI24 DENT LIMIT.—The term ‘otherwise appli25 cable resident limit’ means, with respect to 


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1 a hospital, the limit otherwise applicable 

2 under subparagraphs (F)(i) and (H) of 

3 paragraph (4) on the resident level for the 

4 hospital determined without regard to this 

5 paragraph but taking into account para6 graphs (7)(A), (7)(B), (8)(A), and (8)(B). 

7 ‘‘(ii) REFERENCE RESIDENT LEVEL.— 

8 Except as otherwise provided in subclause 

9 (II), the term ‘reference resident level’ 

10 means, with respect to a hospital, the resi11 dent level for the most recent cost report12 ing period of the hospital ending on or be13 fore the date of enactment of this para14 graph, for which a cost report has been 

15 settled (or, if not, submitted (subject to 

16 audit)), as determined by the Secretary. 

17 ‘‘(iii) RESIDENT LEVEL.—The term 

18 ‘resident level’ has the meaning given such 

19 term in paragraph (7)(C)(i). 

20 ‘‘(iv) QUALIFYING HOSPITAL.—The 

21 term ‘qualifying hospital’ means a hospital 

22 described in subparagraph (B)(i) or any of 

23 subclauses (I) through (IV) of subpara24 graph (C)(ii).’’. 


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1 (b) IME.—Section 1886(d)(5)(B) of the Social Secu2 rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 

3 (1) in clause (v), in the third sentence, by strik4 ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’ and in5 serting ‘‘subsections (h)(7), (h)(8), (h)(9), and 

6 (h)(10)’’; and 

7 (2) by adding after clause (xii), as redesignated 

8 by subparagraph (A), the following new clause: 

9 ‘‘(xiii) For discharges occurring on or 

10 after July 1, 2023, insofar as an additional 

11 payment amount under this subparagraph 

12 is attributable to resident positions distrib13 uted to a hospital under subsection 

14 (h)(10), the indirect teaching adjustment 

15 factor shall be computed in the same man16 ner as provided under clause (ii) with re17 spect to such resident positions.’’. 

18 SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREAS19 ING DIVERSITY. 

20 (a) STUDY.—The Comptroller General of the United 

21 States (in this section referred to as the ‘‘Comptroller 

22 General’’) shall conduct a study on strategies for increas23 ing the diversity of the health professional workforce. Such 

24 study shall include an analysis of strategies for increasing 

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1 come, and underrepresented minority communities, includ2 ing which strategies are most effective for achieving such 

3 goal. 

4 (b) REPORT.—Not later than 2 years after the date 

5 of enactment of this Act, the Comptroller General shall 

6 submit to Congress a report on the study conducted under 

7 subsection (a), together with recommendations for such 

8 legislation and administrative action as the Comptroller 

9 General determines appropriate. 

Æ 


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