I

103D CONGRESS

1ST SESSION H. R. 3294

To amend title XVIII of the Social Security Act to include services provided

at any Federally-qualified health center by interns and residents in

a medical residency training program of a hospital in determining the

amount of payment to the hospital under the medicare program for

the costs of graduate medical education if the hospital incurs any of

the costs of providing the services, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

OCTOBER 15, 1993

Mr. BARRETT of Wisconsin introduced the following bill; which was referred

jointly to the Committees on Ways and Means and Energy and Commerce

A BILL

To amend title XVIII of the Social Security Act to include

services provided at any Federally-qualified health center

by interns and residents in a medical residency training

program of a hospital in determining the amount of

payment to the hospital under the medicare program

for the costs of graduate medical education if the hospital incurs any of the costs of providing the services,

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 ‘‘Frontline Medical

3 Education Act’’.

4 SEC. 2. INCLUDING SERVICES OF INTERNS AND RESIDENTS

5 AT ANY FEDERALLY-QUALIFIED HEALTH

6 CENTER UNDER ANY PROGRAM PAID FOR BY

7 A HOSPITAL IN DETERMINING MEDICARE

8 PAYMENTS FOR GRADUATE MEDICAL EDU9 CATION.

10 (a) PAYMENT FOR DIRECT COSTS OF GRADUATE

11 MEDICAL EDUCATION.—Section 1886(h)(4)(E) of the So12 cial Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amend13 ed by striking ‘‘setting.’’ and inserting the following: ‘‘set14 ting (or, in the case of activities performed at an Feder15 ally-qualified health center described in section

16 1861(aa)(4), if the hospital incurs any of the costs for the

17 training program at such center and reimburses the center

18 for any of the costs of the program that the center in19 curs).’’.

20 (b) PAYMENT FOR INDIRECT COSTS OF GRADUATE

21 MEDICAL EDUCATION.—Section 1886(d)(5)(B)(iv) of

22 such Act (42 U.S.C. 1395ww(d)(5)(B)(iv)), as amended

23 by section 13506 of the Omnibus Budget Reconciliation

24 Act of 1993, is amended—

25 (1) by striking ‘‘entity receiving a grant’’ and

26 all that follows through ‘‘control of the hospital’’ and
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1 inserting ‘‘Federally-qualified health center described

2 in section 1861(aa)(4)’’;

3 (2) by striking ‘‘all, or substantially all, of the

4 costs’’ and inserting ‘‘any of the costs’’; and

5 (3) by striking ‘‘residents)’’ and inserting ‘‘resi6 dents and reimburses the center for any of the costs

7 of the program that the center incurs)’’.

8 (c) EFFECTIVE DATE.—The amendments made by

9 subsections (a) and (b) shall apply to services furnished

10 during cost reporting periods beginning on or after Octo11 ber 1, 1994.

12 SEC. 3. MEDICARE PAYMENT FOR DIRECT MEDICAL EDU13 CATION COSTS OF FEDERALLY-QUALIFIED

14 HEALTH CENTERS.

15 (a) IN GENERAL.—Title XVIII of the Social Security

16 Act (42 U.S.C. 1395 et seq.) is amended by inserting after

17 section 1889 the following new section:

18 ‘‘GRADUATE MEDICAL EDUCATION PAYMENTS FOR

19 FEDERALLY-QUALIFIED HEALTH CENTERS

20 ‘‘SEC. 1890. (a) IN GENERAL.—Notwithstanding any

21 other provision of this title, in the case of any Federally22 qualified health center that participates in an approved

23 medical residency training program, in addition to any

24 other payments that may be made to the center under this

25 title, the Secretary shall provide for payment to the center
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1 for direct graduate medical education costs in accordance

2 with subsection (b).

3 ‘‘(b) DETERMINATION OF AMOUNT OF PAYMENT.—

4 ‘‘(1) IN GENERAL.—Subject to paragraph (4),

5 the amount of payment made to a Federally-quali6 fied health center under this section for direct medi7 cal education for a fiscal year is equal to the product

8 of—

9 ‘‘(A) the aggregate approved amount (as

10 defined in paragraph (2)) for the year; and

11 ‘‘(B) the center’s medicare patient load (as

12 defined in subsection (d)(2)) for the year.

13 ‘‘(2) AGGREGATE APPROVED AMOUNT.—In

14 paragraph (1), the term ‘aggregate approved

15 amount’ means, for a fiscal year, the product of—

16 ‘‘(A) the approved FTE resident amount

17 (determined under paragraph (3)) for the year;

18 and

19 ‘‘(B) the weighted average number of full20 time equivalent residents (as determined by the

21 Secretary in a manner similar to the manner

22 used to determine the number of such residents

23 under section 1886(h)(4)) providing services for

24 the center under the approved medical resi-
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1 dency training program in which the center par2 ticipates during the year.

3 ‘‘(3) DETERMINATION OF APPROVED FTE RESI4 DENT AMOUNT.—

5 ‘‘(A) IN GENERAL.—For each approved

6 medical residency training program, the Sec7 retary shall determine an approved FTE resi8 dent amount for each fiscal year (beginning

9 with fiscal year 1995) equal to 250 percent of

10 the national average salary for the year (as de11 fined in subparagraph (B)(ii)).

12 ‘‘(B) DETERMINATION OF NATIONAL AV13 ERAGE SALARY.—

14 ‘‘(i) DETERMINATION OF BASE

15 AMOUNT.—The Secretary shall determine a

16 base salary amount equal to the Sec17 retary’s estimate (using the most recent

18 available audited cost reports) of the na19 tional average salary, including fringe ben20 efits, for a full-time-equivalent resident in

21 an approved medical residency training

22 program during fiscal year 1990, increased

23 (in a compounded manner) by the sum of

24 the estimated percentage changes in the

25 consumer price index during the 12-month
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1 periods between the midpoint of fiscal year

2 1990 and the midpoint of fiscal year 1994.

3 ‘‘(ii) NATIONAL AVERAGE SALARY DE4 FINED.—In this paragraph, the ‘national

5 average salary’ for a fiscal year is equal

6 to—

7 ‘‘(I) for fiscal year 1995, the

8 base amount determined under clause

9 (i) updated through the midpoint of

10 the year by projecting the estimated

11 percentage change in the consumer

12 price index during the 12-month pe13 riod ending at that midpoint (with ap14 propriate adjustments to reflect pre15 vious under- or over-estimations under

16 this subparagraph in the projected

17 percentage change in the consumer

18 price index); and

19 ‘‘(II) for a subsequent fiscal year,

20 the amount determined under this

21 clause for the previous fiscal year up22 dated through the midpoint of the

23 year by projecting the estimated per24 centage change in the consumer price

25 index during the 12-month period
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1 ending at that midpoint (with appro2 priate adjustments to reflect previous

3 under- or over-estimations under this

4 subparagraph in the projected per5 centage change in the consumer price

6 index).

7 ‘‘(4) OFFSET FOR REIMBURSEMENT RECEIVED

8 DIRECTLY THROUGH HOSPITALS.—The amount of

9 payment made to a Federally-qualified health center

10 under this subsection with respect to costs incurred

11 by the center shall be reduced by the amount of any

12 payment received by the center from a hospital

13 under section 1886(d)(5)(B)(iv) or section

14 1886(h)(4)(E) as reimbursement for such costs.

15 ‘‘(c) ALLOCATION OF PAYMENTS AMONG TRUST

16 FUNDS.—In providing for payments under this section,

17 the Secretary shall provide for an allocation of such pay18 ments between part A and part B (and the trust funds

19 established under the respective parts) as reasonably re20 flects the proportion of direct graduate medical costs of

21 Federally-qualified health centers associated with the pro22 vision of services under each respective part.

23 ‘‘(d) DEFINITIONS.—In this section:

24 ‘‘(1) The terms ‘approved medical residency

25 training program’, ‘consumer price index’, ‘direct
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1 graduate medical education costs’, and ‘resident’

2 have the meaning given such terms under section

3 1886(h)(5).

4 ‘‘(2) The term ‘Federally-qualified health cen5 ter’ has the meaning given such term under section

6 1861(aa)(4).

7 ‘‘(3) The term ‘medicare patient load’ means,

8 with respect to a Federally-qualified health center

9 for a year, the fraction of the center’s services dur10 ing the year which are attributable to individuals en11 titled to benefits under this title (based on such

12 measure of services as the Secretary determines to

13 be appropriate for purposes of this section).’’.

14 (b) EFFECTIVE DATE.—The amendment made by

15 subsection (a) shall apply to services furnished during cost

16 reporting periods beginning on or after October 1, 1994.

17 SEC. 4. REPEAL OF APPLICATION OF PRODUCTIVITY

18 SCREENS FOR CENTERS RECEIVING PAY19 MENTS FOR MEDICAL EDUCATION.

20 Section 1861(aa) of the Social Security Act (42

21 U.S.C. 1395x(aa)) is amended by adding at the end the

22 following new paragraph:

23 ‘‘(8)(A) In the case of a Federally-qualified health

24 center receiving any medical education payment described

25 in subparagraph (B) during a cost reporting period, the
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1 Secretary shall waive the application of any screening

2 guideline used to determine the productivity of practition3 ers providing services at the center for purposes of para4 graph (3) or (4).

5 ‘‘(B) A medical education payment described in this

6 subparagraph is a payment made to a Federally-qualified

7 health center—

8 ‘‘(i) by a hospital as reimbursement to the cen9 ter for medical education costs, as described in sec10 tion 1886(d)(5)(B)(iv) or section 1886(h)(4)(E); or

11 ‘‘(ii) by the Secretary under section 1890.’’.

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