I

106TH CONGRESS

1ST SESSION H. R. 1224

To amend the Internal Revenue Code of 1986 and title XVIII of the Social

Security Act to provide for comprehensive financing for graduate medical

education.

IN THE HOUSE OF REPRESENTATIVES

MARCH 23, 1999

Mr. CARDIN (for himself, Mr. STARK, Mr. KLECZKA, Mr. LEWIS of Georgia,

Mr. LEVIN, and Mr. BENTSEN) introduced the following bill; which was

referred to the Committee on Ways and Means, and in addition to the

Committee on 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 the Internal Revenue Code of 1986 and title

XVIII of the Social Security Act to provide for comprehensive financing for graduate medical education.

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; TABLE OF CONTENTS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘All-Payer Graduate Medical Education Act’’.

6 (b) TABLE OF CONTENTS.—The table of contents of

7 this Act is as follows:
2

•HR 1224 IH

Sec. 1. Short title; table of contents.

TITLE I—HEALTH CARE WORKFORCE TRUST FUND; PAYMENTS

TO TEACHING HOSPITALS

Subtitle A—Establishment and Financing of Fund

Sec. 101. Establishment.

Sec. 102. Financing for fund; fees on insured and self-insured health plans.

Subtitle B—Additional Payments to Teaching Hospitals

Sec. 111. Formula payments regarding private-sector share of costs of graduate

medical education.

Sec. 112. Application for payments.

Sec. 113. Annual amount of payments.

Sec. 114. Definitions.

Sec. 115. Study.

Subtitle C—Conforming Changes in Medicare Payment for Direct Costs of

Graduate Medical Education

Sec. 121. Changes in medicare formula for payment of direct GME costs.

Sec. 122. Exception from limitation on number of residents for rural and underserved urban areas.

Sec. 123. Study on appropriate levels of documentation for professional services

of teaching physicians.

TITLE II—HEALTH WORKFORCE PRIORITIES

Sec. 201. Plan to reduce residency training positions.

TITLE III—MODIFICATION IN MEDICARE PAYMENT FOR IME AND

DSH

Sec. 301. Modification regarding payments for indirect costs of graduate medical education.

Sec. 302. Modification of DSH.

TITLE IV—ADDITIONAL PAYMENTS FOR GRADUATE EDUCATION

FOR NON-PHYSICIAN HEALTH PROFESSIONALS

Sec. 401. Payments for graduate education for non-physician health professionals.
3

•HR 1224 IH

1 TITLE I—HEALTH CARE WORK2 FORCE TRUST FUND; PAY3 MENTS TO TEACHING HOS4 PITALS

5 Subtitle A—Establishment and

6 Financing of Fund

7 SEC. 101. ESTABLISHMENT.

8 (a) IN GENERAL.—Subchapter A of chapter 98 of the

9 Internal Revenue Code of 1986 (relating to trust fund

10 code) is amended by adding at the end the following new

11 section:

12 ‘‘SEC. 9511. HEALTH CARE WORKFORCE TRUST FUND.

13 ‘‘(a) CREATION OF TRUST FUND.—There is estab14 lished in the Treasury of the United States a trust fund

15 to be known as the ‘Health Care Workforce Trust Fund’,

16 consisting of such amounts as may be appropriated or

17 credited to such Trust Fund as provided in this section

18 and section 9602(b).

19 ‘‘(b) TRANSFERS TO FUND.—

20 ‘‘(1) IN GENERAL.—There are hereby appro21 priated to the Health Care Workforce Trust Fund—

22 ‘‘(A) amounts equivalent to the net reve23 nues received in the Treasury from the fees im24 posed under subchapter B of chapter 34 (relat-
4

•HR 1224 IH

1 ing to fees on health insurance and health-re2 lated administrative services);

3 ‘‘(B) subject to paragraph (2), from the

4 Federal Hospital Insurance Trust Fund (estab5 lished under section 1817 of the Social Security

6 Act) amounts determined by the Secretary of

7 Health and Human Services to be equivalent to

8 the reductions in payments made from such

9 Trust Fund by virtue of the amendments made

10 by the All-Payer Graduate Medical Education

11 Act; and

12 ‘‘(C) subject to paragraph (2), from the

13 Federal Supplementary Medical Insurance

14 Trust Fund (established under section 1841 of

15 the Social Security Act) amounts determined by

16 the Secretary of Health and Human Services to

17 be equivalent to the reductions in payments

18 made from such Trust Fund by virtue of the

19 amendments made by the All-Payer Graduate

20 Medical Education Act.

21 (2) LIMITATION ON TRANSFERS FROM MEDI22 CARE TRUST FUNDS.—If the sum of the amounts

23 otherwise transferred (but for this paragraph) under

24 subparagraph (B) and (C) of paragraph (1) for a

25 fiscal year would exceed $300,000,000, the amounts
5

•HR 1224 IH

1 so transferred under each respective subparagraph

2 shall be reduced in a pro-rated manner so that the

3 total so transferred is equal to $300,000,000.

4 ‘‘(c) EXPENDITURES FROM FUND.—Amounts in the

5 Health Care Workforce Trust Fund are available to the

6 Secretary of Health and Human Services for making pay7 ments under sections 111 and 401 of the All-Payer Grad8 uate Medical Education Act.

9 ‘‘(d) NET REVENUES.—For purposes of this section,

10 the term ‘net revenues’ means the amount estimated by

11 the Secretary based on the excess of—

12 ‘‘(1) the fees received in the Treasury under

13 subchapter B of chapter 34, over

14 ‘‘(2) the decrease in the tax imposed by chapter

15 1 resulting from the fees imposed by such sub16 chapter.’’.

17 (b) CLERICAL AMENDMENT.—The table of sections

18 for such subchapter A is amended by adding at the end

19 thereof the following new item:

‘‘Sec. 9511. Health Care Workforce Trust Fund.’’.

20 SEC. 102. FINANCING FOR FUND; FEES ON INSURED AND

21 SELF-INSURED HEALTH PLANS.

22 (a) GENERAL RULE.—Chapter 34 of the Internal

23 Revenue Code of 1986 is amended by adding at the end

24 the following new subchapter:
6

•HR 1224 IH

1 ‘‘Subchapter B—Insured and Self-Insured

2 Health Plans

‘‘Sec. 4375. Health insurance and health-related administrative

services.

‘‘Sec. 4376. Self-insured health plans.

‘‘Sec. 4377. Definitions and special rules.

3 ‘‘SEC. 4375. HEALTH INSURANCE AND HEALTH-RELATED

4 ADMINISTRATIVE SERVICES.

5 ‘‘(a) IMPOSITION OF FEE.—There is hereby

6 imposed—

7 ‘‘(1) on each specified health insurance policy,

8 a fee equal to 1 percent of the premiums received

9 under such policy, and

10 ‘‘(2) on each amount received for health-related

11 administrative services, a fee equal to 1 percent of

12 the amount so received.

13 ‘‘(b) LIABILITY FOR FEE.—

14 ‘‘(1) HEALTH INSURANCE.—The fee imposed by

15 subsection (a)(1) shall be paid by the issuer of the

16 policy.

17 ‘‘(2) HEALTH-RELATED ADMINISTRATIVE SERV18 ICES.—The fee imposed by subsection (a)(2) shall be

19 paid by the person providing the health-related ad20 ministrative services.

21 ‘‘(c) SPECIFIED HEALTH INSURANCE POLICY.—For

22 purposes of this section—
7

•HR 1224 IH

1 ‘‘(1) IN GENERAL.—Except as otherwise pro2 vided in this section, the term ‘specified health in3 surance policy’ means any accident or health insur4 ance policy issued with respect to individuals resid5 ing in the United States.

6 ‘‘(2) EXEMPTION OF CERTAIN POLICIES.—The

7 term ‘specified health insurance policy’ does not in8 clude any insurance policy if substantially all of the

9 coverage provided under such policy relates to—

10 ‘‘(A) liabilities incurred under workers’

11 compensation laws,

12 ‘‘(B) tort liabilities,

13 ‘‘(C) liabilities relating to ownership or use

14 of property,

15 ‘‘(D) credit insurance, or

16 ‘‘(E) such other similar liabilities as the

17 Secretary may specify by regulations.

18 ‘‘(3) SPECIAL RULE WHERE POLICY PROVIDES

19 OTHER COVERAGE.—In the case of any specified

20 health insurance policy under which amounts are

21 payable other than for accident and health coverage,

22 in determining the amount of the fee imposed by

23 subsection (a)(1) on any premium received under

24 such policy, there shall be excluded the amount of
8

•HR 1224 IH

1 the charge for the non-accident and health coverage

2 if—

3 ‘‘(A) the charge for such non-accident and

4 health coverage is either separately stated in

5 the policy, or furnished to the policyholder in a

6 separate statement, and

7 ‘‘(B) such charge is reasonable in relation

8 to the total charges under the policy.

9 In any other case, the entire amount of the premium

10 received under such a policy shall be subject to the

11 fees under subsection (a)(1).

12 ‘‘(4) TREATMENT OF PREPAID HEALTH COV13 ERAGE ARRANGEMENTS.—

14 ‘‘(A) IN GENERAL.—In the case of any ar15 rangement described in subparagraph (B)—

16 ‘‘(i) such arrangement shall be treated

17 as a specified health insurance policy,

18 ‘‘(ii) the payments or premiums re19 ferred to in subparagraph (B)(i) shall be

20 treated as premiums received for a speci21 fied health insurance policy, and

22 ‘‘(iii) the person referred to in sub23 paragraph (B)(i) shall be treated as the

24 issuer.
9

•HR 1224 IH

1 ‘‘(B) DESCRIPTION OF ARRANGEMENTS.—

2 An arrangement is described in this subpara3 graph if under such arrangement—

4 ‘‘(i) fixed payments or premiums are

5 received as consideration for any person’s

6 agreement to provide or arrange for the

7 provision of accident or health coverage to

8 residents of the United States, regardless

9 of how such coverage is provided or ar10 ranged to be provided, and

11 ‘‘(ii) substantially all of the risks of

12 the rates of utilization of services is as13 sumed by such person or the provider of

14 such services.

15 ‘‘(d) HEALTH-RELATED ADMINISTRATIVE SERV16 ICES.—For purposes of this section, the term ‘health-re17 lated administrative services’ means—

18 ‘‘(1) the processing of claims or performance of

19 other administrative services in connection with acci20 dent or health coverage under a specified health in21 surance policy if the charge for such services is not

22 included in the premiums under such policy, and

23 ‘‘(2) processing claims, arranging for provision

24 of accident or health coverage, or performing other

25 administrative services in connection with an appli-
10

•HR 1224 IH

1 cable self-insured health plan (as defined in section

2 4376(c)) established or maintained by another per3 son.

4 ‘‘SEC. 4376. SELF-INSURED HEALTH PLANS.

5 ‘‘(a) IMPOSITION OF FEE.—In the case of any appli6 cable self-insured health plan, there is hereby imposed a

7 fee for each month equal to 1 percent of the sum of—

8 ‘‘(1) the accident and health coverage expendi9 tures for such month under such plan, and

10 ‘‘(2) the direct administrative expenditures for

11 such month under such plan.

12 ‘‘(b) LIABILITY FOR FEE.—

13 ‘‘(1) IN GENERAL.—The fee imposed by sub14 section (a) shall be paid by the plan sponsor.

15 ‘‘(2) PLAN SPONSOR.—For purposes of para16 graph (1) the term ‘plan sponsor’ means—

17 ‘‘(A) the employer in the case of a plan es18 tablished or maintained by a single employer,

19 ‘‘(B) the employee organization in the case

20 of a plan established or maintained by an em21 ployee organization,

22 ‘‘(C) in the case of—

23 ‘‘(i) a plan established or maintained

24 by 2 or more employers or jointly by 1 or
11

•HR 1224 IH

1 more employers and 1 or more employee

2 organizations,

3 ‘‘(ii) a multiple employer welfare ar4 rangement, or

5 ‘‘(iii) a voluntary employees’ bene6 ficiary association described in section

7 501(c)(9),

8 the association, committee, joint board of trust9 ees, or other similar group of representatives of

10 the parties who establish or maintain the plan,

11 or

12 ‘‘(D) the cooperative or association de13 scribed in subsection (c)(2)(F) in the case of a

14 plan established or maintained by such a coop15 erative or association.

16 ‘‘(c) APPLICABLE SELF-INSURED HEALTH PLAN.—

17 For purposes of this section, the term ‘applicable self-in18 sured health plan’ means any plan for providing accident

19 or health coverage if—

20 ‘‘(1) any portion of such coverage is provided

21 other than through an insurance policy, and

22 ‘‘(2) such plan is established or maintained—

23 ‘‘(A) by one or more employers for the

24 benefit of their employees or former employees,
12

•HR 1224 IH

1 ‘‘(B) by one or more employee organiza2 tions for the benefit of their members or former

3 members,

4 ‘‘(C) jointly by 1 or more employers and 1

5 or more employee organizations for the benefit

6 of employees or former employees,

7 ‘‘(D) by a voluntary employees’ beneficiary

8 association described in section 501(c)(9),

9 ‘‘(E) by any organization described in sec10 tion 501(c)(6), or

11 ‘‘(F) in the case of a plan not described in

12 the preceding subparagraphs, by a multiple em13 ployer welfare arrangement (as defined in sec14 tion 3(40) of Employee Retirement Income Se15 curity Act of 1974), a rural electric cooperative

16 (as defined in section 3(40)(B)(iv) of such Act),

17 or a rural telephone cooperative association (as

18 defined in section 3(40)(B)(v) of such Act).

19 ‘‘(d) ACCIDENT AND HEALTH COVERAGE EXPENDI20 TURES.—For purposes of this section—

21 ‘‘(1) IN GENERAL.—The accident and health

22 coverage expenditures of any applicable self-insured

23 health plan for any month is the aggregate expendi24 tures for such month for accident and health cov25 erage provided under such plan to the extent such
13

•HR 1224 IH

1 expenditures are not subject to the fees under sec2 tion 4375.

3 ‘‘(2) TREATMENT OF REIMBURSEMENTS.—In

4 determining accident and health coverage expendi5 tures during any month of any applicable self-in6 sured health plan, reimbursements (by insurance or

7 otherwise) received during such month for accident

8 and health coverage expenditures shall be taken into

9 account as a reduction in accident and health cov10 erage expenditures.

11 ‘‘(3) CERTAIN EXPENDITURES DISREGARDED.—

12 Paragraph (1) shall not apply to any expenditure for

13 the acquisition or improvement of land or for the ac14 quisition or improvement of any property to be used

15 in connection with the provision of accident and

16 health coverage which is subject to the allowance

17 under section 167, except that, for purposes of para18 graph (1), allowances under section 167 shall be

19 considered as expenditures.

20 ‘‘(e) DIRECT ADMINISTRATIVE EXPENDITURES.—

21 For purposes of this section, the term ‘direct administra22 tive expenditures’ means the administrative expenditures

23 under the plan to the extent such expenditures are not

24 subject to the fees under section 4375. In determining the
14

•HR 1224 IH

1 amount of such expenditures, rules similar to the rules of

2 subsection (d)(3) shall apply.

3 ‘‘SEC. 4377. DEFINITIONS AND SPECIAL RULES.

4 ‘‘(a) DEFINITIONS.—For purposes of this

5 subchapter—

6 ‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The

7 term ‘accident and health coverage’ means any cov8 erage which, if provided by an insurance policy,

9 would cause such policy to be a specified health in10 surance policy (as defined in section 4375(c)).

11 ‘‘(2) INSURANCE POLICY.—The term ‘insurance

12 policy’ means any policy or other instrument where13 by a contract of insurance is issued, renewed, or ex14 tended.

15 ‘‘(3) PREMIUM.—The term ‘premium’ means

16 the gross amount of premiums and other consider17 ation (including advance premiums, deposits, fees,

18 and assessments) arising from policies issued by a

19 person acting as the primary insurer, adjusted for

20 any return or additional premiums paid as a result

21 of endorsements, cancellations, audits, or retrospec22 tive rating.

23 ‘‘(4) UNITED STATES.—The term ‘United

24 States’ includes any possession of the United States.

25 ‘‘(b) TREATMENT OF GOVERNMENTAL ENTITIES.—
15

•HR 1224 IH

1 ‘‘(1) IN GENERAL.—For purposes of this

2 subchapter—

3 ‘‘(A) the term ‘person’ includes any gov4 ernmental entity, and

5 ‘‘(B) notwithstanding any other law or rule

6 of law, governmental entities shall not be ex7 empt from the fees imposed by this subchapter

8 except as provided in paragraph (2).

9 ‘‘(2) TREATMENT OF EXEMPT GOVERNMENTAL

10 PROGRAMS.—In the case of an exempt governmental

11 program—

12 ‘‘(A) no fee shall be imposed under section

13 4375 on any premium received pursuant to

14 such program or on any amount received for

15 health-related administrative services pursuant

16 to such program, and

17 ‘‘(B) no fee shall be imposed under section

18 4376 on any expenditures pursuant to such

19 program.

20 ‘‘(3) EXEMPT GOVERNMENTAL PROGRAM DE21 FINED.—For purposes of this subchapter, the term

22 ‘exempt governmental program’ means—

23 ‘‘(A) the insurance programs established

24 by parts A, B, and C of title XVIII of the So25 cial Security Act,
16

•HR 1224 IH

1 ‘‘(B) the medical assistance program es2 tablished by title XIX or XXI of the Social Se3 curity Act,

4 ‘‘(C) any program established by Federal

5 law for providing medical care (other than

6 through insurance policies) to individuals (or

7 the spouses and dependents thereof) by reason

8 of such individuals being—

9 ‘‘(i) members of the Armed Forces of

10 the United States, or

11 ‘‘(ii) veterans, and

12 ‘‘(D) any program established by Federal

13 law for providing medical care (other than

14 through insurance policies) to members of In15 dian tribes (as defined in section 4(d) of the In16 dian Health Care Improvement Act).

17 ‘‘(c) TREATMENT AS TAX.—For purposes of subtitle

18 F, the fees imposed by this subchapter shall be treated

19 as if they were taxes.

20 ‘‘(d) NO COVER OVER TO POSSESSIONS.—Notwith21 standing any other provision of law, no amount collected

22 under this subchapter shall be covered over to any posses23 sion of the United States.’’
17

•HR 1224 IH

1 (b) CLERICAL AMENDMENT.—Chapter 34 of such

2 Code is amended by striking the chapter heading and in3 serting the following:

4 ‘‘CHAPTER 34—TAXES ON CERTAIN

5 INSURANCE POLICIES

‘‘Subchapter A. Policies issued by foreign insurers.

‘‘Subchapter B. Insured and self-insured health plans.

6 ‘‘Subchapter A—Policies Issued By Foreign

7 Insurers’’.

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

9 this section shall apply with respect to premiums received

10 and expenses incurred after December 31, 1999.

11 Subtitle B—Additional Payments to

12 Teaching Hospitals

13 SEC. 111. FORMULA PAYMENTS REGARDING PRIVATE-SEC14 TOR SHARE OF COSTS OF GRADUATE MED15 ICAL EDUCATION.

16 (a) IN GENERAL.—In the case of each teaching hos17 pital that in accordance with section 112 submits to the

18 Secretary an application for calendar year 2002 or any

19 subsequent calendar year (referred to in this title as an

20 ‘‘eligible hospital’’ for the year involved), the Secretary

21 shall in accordance with section 113 make payments for

22 such year to the hospital.
18

•HR 1224 IH

1 (b) DEFINITIONS.—For purposes of this subtitle, the

2 term ‘‘teaching hospital’’ means any hospital that operates

3 an approved medical residency training program (as de4 fined in section 1886(h)(5)(A) of the Social Security Act).

5 SEC. 112. APPLICATION FOR PAYMENTS.

6 (a) IN GENERAL.—For purposes of section 111(a),

7 an application for payments under such section for a cal8 endar year is in accordance with this section if—

9 (1) the application is submitted not later than

10 the date specified by the Secretary;

11 (2) the application contains the agreements re12 quired in this subtitle; and

13 (3) the application is in such form, is made in

14 such manner, and contains such agreements, assur15 ances, and information as the Secretary determines

16 to be necessary to carry out this subtitle, including

17 the assurance described in subsection (b).

18 (b) ASSURANCE REGARDING USE OF DIRECT GRAD19 UATE MEDICAL EDUCATION FUNDS IN SUPPORT OF

20 TEACHING PHYSICIANS.—The assurance described in this

21 subsection is an assurance that at least 20 percent of the

22 funds provided to the hospital under section 113(a)(1) (re23 lating to direct graduate medical education funding) is ex24 pended to compensate physicians for their time spent in
19

•HR 1224 IH

1 teaching residents in an approved medical residency train2 ing program.

3 SEC. 113. ANNUAL AMOUNT OF PAYMENTS.

4 (a) IN GENERAL.—From amounts in the Health Care

5 Workforce Trust Fund under section 9511 of the Internal

6 Revenue Code of 1986, the Secretary shall make payments

7 under section 111 to an eligible hospital for a calendar

8 year as follows:

9 (1) Payments, made on a periodic basis, whose

10 sum is equal to the amount determined under sub11 section (c) for the hospital for the year (which

12 amount relates to the direct costs for graduate med13 ical education attributable to certain individuals).

14 (2) Payments (in addition to payments under

15 paragraph (1)), made on a periodic basis, whose sum

16 is equal to the amount determined under subsection

17 (d) for the hospital for the year (which amount re18 lates to the per-discharge indirect costs of the hos19 pital for graduate medical education attributable to

20 certain individuals).

21 (b) EFFECTIVE DATES FOR PAYMENTS.—Payments

22 under paragraph (1) of subsection (a) are effective for por23 tions of cost reporting periods occurring on or after Janu24 ary 1, 2001. Payments under paragraph (2) of such sub-
20

•HR 1224 IH

1 section are effective for patient discharges occurring on

2 or after such date.

3 (c) AMOUNT OF PAYMENTS; DIRECT COSTS.—

4 (1) IN GENERAL.—For purposes of paragraph

5 (1) of subsection (a), the amount determined under

6 this subsection for an eligible hospital for a calendar

7 year is the product of—

8 (A) the aggregate nonmedicare training

9 amount for the hospital, as defined in para10 graph (2); and

11 (B) the direct-cost Fund payout percent12 age, as defined in paragraph (4).

13 (2) AGGREGATE NONMEDICARE TRAINING

14 AMOUNT.—For purposes of this subtitle, the term

15 ‘‘aggregate nonmedicare training amount’’, with re16 spect to the eligible hospital involved, means (subject

17 to paragraph (3)(D)) an amount equal to the prod18 uct of subparagraphs (A) and (B), as follows:

19 (A) The number of full-time-equivalent

20 training participants in the approved physician

21 training programs of the hospital for the aca22 demic year in which the calendar year begins,

23 not to exceed the maximum total number per24 mitted under section 1886(h)(4)(F) of the So25 cial Security Act.
21

•HR 1224 IH

1 (B) An amount equal to the product of—

2 (i) the national average FTE wage-re3 lated compensation, as defined in para4 graph (3); and

5 (ii) a percentage equal to the fraction

6 of the total inpatient hospital and out7 patient hospital revenues (as established by

8 the Secretary) during the cost reporting

9 period which are attributable to patients

10 with respect to whom payment may be

11 made under health insurance coverage

12 (whether through a group health plan or

13 otherwise) or under a group health plan.

14 For purposes of clause (ii), payment made

15 under the medicare or medicaid programs

16 (under titles XVIII or XIX of the Social Secu17 rity Act) shall not be treated as payment under

18 health insurance coverage.

19 (3) NATIONAL AVERAGE FTE WAGE-RELATED

20 COMPENSATION.—

21 (A) IN GENERAL.—For purposes of this

22 subtitle, the term ‘‘national average FTE wage23 related compensation’’ means the national aver24 age of the costs of resident salaries and related

25 fringe benefits per training participant for all
22

•HR 1224 IH

1 approved physician training programs and all

2 medical specialities, as adjusted under subpara3 graphs (B) and (C). Such national average shall

4 be based upon a national resident wage survey

5 for salaries and related fringe benefits as of

6 July 1, 1998, as determined by the Secretary

7 and shall not include costs of overhead or su8 pervision.

9 (B) ANNUAL ADJUSTMENTS PER CON10 SUMER PRICE INDEX.—The national average

11 applicable under subparagraph (A) for a cal12 endar year for such programs is, subject to sub13 paragraph (C), the amount determined under

14 subparagraph (A) increased by the estimated

15 percentage change in the consumer price index

16 from January 1999 through the midpoint of the

17 year involved, with appropriate adjustments to

18 reflect previous under- or over-estimations

19 under this subparagraph in the projected per20 centage change in the consumer price index.

21 (C) INDIVIDUAL ADJUSTMENTS PER AREA

22 WAGE INDEX.—The national average deter23 mined under subparagraph (A) and adjusted

24 under subparagraph (B) for a calendar year

25 shall, in the case of the approved physician
23

•HR 1224 IH

1 training programs of the eligible hospital in2 volved, be adjusted by a factor to reflect re3 gional differences in wage and wage-related

4 costs, as determined in accordance with the

5 area wage index applicable (as of the beginning

6 of such year) to hospitals in the labor-market

7 area involved, as determined under section

8 1886(d)(3)(E) of the Social Security Act.

9 (D) ALTERNATIVE RULE FOR CERTAIN

10 HOSPITALS.—

11 (i) ELECTION FOR APPLICABILITY OF

12 RULE.—In the case of an eligible hospital

13 for which the election under section

14 1861(b)(7) of the Social Security Act was

15 in effect on July 1, 1998, and has re16 mained in effect continuously from such

17 date, the following applies:

18 (I) The hospital may, with re19 spect to the determination under

20 paragraph (2) of the aggregate non21 medicare training amount for the hos22 pital, elect to have the alternative rule

23 described in clause (ii) applied to the

24 hospital.
24

•HR 1224 IH

1 (II) If the election under such

2 section 1861(b)(7) ceases to be in ef3 fect, any election made by the hospital

4 under subclause (I) is terminated.

5 (III) If the hospital has made the

6 election under subclause (I) and sub7 sequently requests that the election be

8 terminated, the Secretary shall ap9 prove the request. Upon the approval

10 of the request, the hospital may not

11 subsequently elect to have the alter12 native rule applied to the hospital.

13 (ii) DESCRIPTION OF ALTERNATIVE

14 RULE.—With respect to a determination

15 under paragraph (2) of the aggregate non16 medicare training amount for an eligible

17 hospital that has made the election under

18 clause (i), the alternative rule described in

19 this clause is as follows:

20 (I) In lieu of the applicability of

21 the national FTE training amount

22 (for purposes of paragraph (2)(B)(i)),

23 the Secretary shall apply an amount

24 equal to the approved FTE resident

25 amount in effect for the hospital
25

•HR 1224 IH

1 under section 1886(h)(2) of the Social

2 Security Act.

3 (II) Subject to the modification

4 applied under subclause (I), the Sec5 retary shall determine an amount

6 under paragraph (2).

7 (III) The Secretary shall deter8 mine an amount equal to the product

9 of the fraction determined under

10 paragraph (2)(B)(ii) and the amount

11 of the physician costs of services rec12 ognized under section 1861(v)(1) of

13 the Social Security Act pursuant to

14 the election of the hospital under sec15 tion 1861(b)(7) of such Act.

16 (IV) In lieu of the applicability of

17 the aggregate nonmedicare training

18 amount (for purposes of paragraph

19 (1)(A)), the Secretary shall apply an

20 amount equal to the sum of the

21 amount determined under subclause

22 (II) and the amount determined under

23 subclause (III).

24 (4) DIRECT-COST FUND PAYOUT PERCENT25 AGE.—For purposes of this subtitle, the term ‘‘di-
26

•HR 1224 IH

1 rect-cost Fund payout percentage’’, with respect to

2 the calendar year involved, means a percentage equal

3 to the ratio of—

4 (A) the amount available in the Health

5 Care Workforce Trust Fund for such year (as

6 estimated by the Secretary); to

7 (B) an amount equal to the total amount

8 of payments under subsection (a)(1) that would

9 be made to eligible hospitals for such year if

10 each hospital received, pursuant to paragraph

11 (1), 100 percent of the aggregate nonmedicare

12 training amount determined for the hospital.

13 (d) AMOUNT OF PAYMENTS; INDIRECT COSTS.—

14 (1) IN GENERAL.—For purposes of paragraph

15 (2) of subsection (a), the amount determined under

16 this subsection for an eligible hospital for a calendar

17 year is the product of—

18 (A) an amount equal to the sum of the

19 nonmedicare per-discharge supplemental pay20 ments, as defined in paragraph (2); and

21 (B) the indirect-cost Fund payout percent22 age, as defined in paragraph (3).

23 (2) NONMEDICARE PER-DISCHARGE SUPPLE24 MENTAL PAYMENT.—
27

•HR 1224 IH

1 (A) IN GENERAL.—For purposes of this

2 subtitle, the term ‘‘nonmedicare per-discharge

3 supplemental payment’’, with respect to a cal4 endar year, means a payment made to an eligi5 ble hospital for a discharge during the year of

6 a patient described in subparagraph (B), the

7 amount of which payment is determined in ac8 cordance with subparagraph (C).

9 (B) RELEVANT PATIENTS.—For purposes

10 of subparagraph (A), a patient described in this

11 subparagraph is a patient who is not—

12 (i) entitled to benefits under part A of

13 title XVIII of the Social Security Act; or

14 (ii) eligible for medical assistance

15 under title XIX of such Act.

16 (C) AMOUNT OF PER-DISCHARGE PAY17 MENT.—For purposes of subparagraph (A), the

18 amount of the payment under such subpara19 graph for the discharge of a patient described

20 in subparagraph (B) is the product of—

21 (i) the amount which would be deter22 mined with respect to the discharge under

23 section 1886(d)(1)(A)(iii) of the Social Se24 curity Act if the patient were entitled to

25 benefits under part A of title XVIII of
28

•HR 1224 IH

1 such Act, adjusted by the Secretary to take

2 into account differences in health status,

3 utilization of services, and other demo4 graphic characteristics among individuals

5 entitled to benefits under part A of title

6 XVIII of such Act and individuals who are

7 not so entitled; and

8 (ii) the percentage applicable to the

9 hospital under section 1886(d)(5)(B)(ii) of

10 such Act.

11 (D) SPECIAL RULE FOR CERTAIN HOS12 PITALS.—In the case of a hospital that is lo13 cated in a State for which a demonstration pro14 gram under section 1814(b)(3) of the Social Se15 curity Act is in effect, the Secretary shall, for

16 purposes of applying subparagraph (C) to dis17 charges from the hospital, make determinations

18 under such subparagraph as if paragraphs

19 (1)(A)(iii) and (5)(B)(ii) of section 1886(d) of

20 such Act applied to the hospital.

21 (3) INDIRECT-COST FUND PAYOUT PERCENT22 AGE.—For purposes of this subtitle, the term ‘‘indi23 rect-cost Fund payout percentage’’, with respect the

24 calendar year involved, means a percentage equal to

25 the ratio of—
29

•HR 1224 IH

1 (A) the amount available in the Health

2 Care Workforce Trust Fund for such year re3 maining after payments for the year have been

4 made under subsection (a)(1) (as such amount

5 is estimated by the Secretary); to

6 (B) the total amount of payments under

7 subsection (a)(2) that would be made to eligible

8 hospitals for such year if each hospital received,

9 pursuant to paragraph (1), 100 percent of an

10 amount equal to the sum of the nonmedicare

11 per-discharge supplemental payments deter12 mined for the hospital.

13 (e) DEFINITIONS.—For purposes of this subtitle, the

14 term ‘‘full-time-equivalent training participant’’ means a

15 full-time equivalent resident of the hospital as determined

16 under section 1886(h)(4) of the Social Security Act for

17 the cost reporting period involved.

18 SEC. 114. DEFINITIONS.

19 For purposes of this subtitle:

20 (1) The term ‘‘aggregate nonmedicare training

21 amount’’ has the meaning given such term in section

22 113(c)(2).

23 (2) The term ‘‘direct-cost Fund payout percent24 age’’ has the meaning given such term in section

25 113(c)(4).
30

•HR 1224 IH

1 (3) The term ‘‘full-time-equivalent training par2 ticipant’’ has the meaning given such term in section

3 113(e).

4 (4) The term ‘‘indirect-cost Fund payout per5 centage’’ has the meaning given such term in section

6 113(d)(3).

7 (5) The term ‘‘national average FTE wage-re8 lated compensation’’ has the meaning given such

9 term in section 113(c)(3).

10 (6) The term ‘‘nonmedicare per-discharge sup11 plemental payment’’ has the meaning given such

12 term in section 113(d)(2).

13 (7) The term ‘‘Secretary’’ means the Secretary

14 of Health and Human Services, unless the context of

15 usage indicates otherwise.

16 (8) The term ‘‘teaching hospital’’ has the mean17 ing given such term in section 111(b).

18 SEC. 115. STUDY.

19 (a) STUDY.—The Secretary of Health and Human

20 Services shall conduct a study of the impact of this sub21 title.

22 (b) REPORT.—Not later than 5 years after the date

23 that payments are first made under this subtitle, the Sec24 retary shall submit to Congress a report on such study

25 and shall include such recommendations on the continu-
31

•HR 1224 IH

1 ation of payments under this subtitle, and such changes

2 in such payments, as the Secretary deems appropriate.

3 Subtitle C—Conforming Changes in

4 Medicare Payment for Direct

5 Costs of Graduate Medical Edu6 cation

7 SEC. 121. CHANGES IN MEDICARE FORMULA FOR PAYMENT

8 OF DIRECT GME COSTS.

9 (a) USE OF NATIONAL AVERAGE FTE WAGE-RE10 LATED COMPENSATION AS BASIS FOR PAYMENT.—Sec11 tion 1886(h)(3)(B)(i) of the Social Security Act (42

12 U.S.C. 1395ww(h)(3)(B)(i)) is amended by inserting ‘‘(or,

13 for portions of cost reporting periods occurring on or after

14 January 1, 2001, in the case of a hospital that does not

15 have in effect the election described in section

16 113(c)(3)(D)(i) of the All-Payer Graduate Medical Edu17 cation Act, the applicable national average FTE wage-re18 lated compensation, as determined under section

19 113(c)(3) of such Act)’’ after ‘‘for that period’’.

20 (b) ALLOCATION BASED ON MEDICARE REVE21 NUES.—Section 1886(h)(3) of such Act (42 U.S.C.

22 1395ww(h)(3)) is amended—

23 (1) in subparagraph (C), by inserting before the

24 period at the end the following: ‘‘, or, for portions

25 of a cost reporting period occurring on or after Jan-
32

•HR 1224 IH

1 uary 1, 2001, in the case of a hospital that does not

2 have in effect the election described in section

3 113(c)(3)(D)(i) of the All-Payer Graduate Medical

4 Education Act, the fraction of the total inpatient

5 hospital and outpatient hospital revenues (as estab6 lished by the Secretary) during the reporting period

7 which is attributable to patients with respect to

8 whom payment may be made under this title’’; and

9 (2) in subparagraph (D)(i)(II), by inserting be10 fore the period at the end the following: ‘‘or, for por11 tions of a cost reporting period occurring on or after

12 January 1, 2001, in the case of a hospital that does

13 not have in effect the election described in section

14 113(c)(3)(D)(i) of the All-Payer Graduate Medical

15 Education Act, the fraction of the total inpatient

16 hospital and outpatient hospital revenues (as estab17 lished by the Secretary) during the reporting period

18 which is attributable to such enrolled individuals’’.

19 (c) REQUIREMENT FOR ASSURANCE REGARDING USE

20 OF DIRECT GRADUATE MEDICAL EDUCATION FUNDS IN

21 SUPPORT OF TEACHING PHYSICIANS.—Section

22 1886(h)(1) of the Social Security Act (42 U.S.C.

23 1395ww(h)(1)) is amended by adding at the end the fol24 lowing: ‘‘The Secretary shall not make any payments to

25 a hospital under this subsection unless the Secretary re-
33

•HR 1224 IH

1 ceives satisfactory assurances that at least 20 percent of

2 the payments so made are expended to compensate physi3 cians for their time spent in teaching residents.’’.

4 (d) EFFECTIVE DATE.—The amendments made by

5 this section apply to portions of cost reporting periods oc6 curring on or after January 1, 2001.

7 SEC. 122. EXCEPTION FROM LIMITATION ON NUMBER OF

8 RESIDENTS FOR RURAL AND UNDERSERVED

9 URBAN AREAS.

10 (a) IN GENERAL.—Section 1886 of the Social Secu11 rity Act (42 U.S.C. 1395ww) is amended—

12 (1) in subsection (d)(5)(B), by adding at the

13 end the following: ‘‘The Secretary shall provide for

14 reasonable exemptions and exceptions from the pre15 vious sentence in the case of a hospital that has resi16 dents who are assigned to serve a rural area or an

17 urban underserved area.’’; and

18 (2) in subsection (h)(4)(F), by adding at the

19 end the following: ‘‘The Secretary shall provide for

20 reasonable exemptions and exceptions from the pre21 vious sentence in the case of a hospital that has resi22 dents who are assigned to serve a rural area or an

23 urban underserved area.’’.

24 (b) EFFECTIVE DATES.—The amendments made

25 by—
34

•HR 1224 IH

1 (1) subsection (a)(1) apply to discharges occur2 ring on or after January 1, 2000; or

3 (2) subsection (a)(2) apply to cost reporting pe4 riods beginning on or after January 1, 2000.

5 SEC. 123. STUDY ON APPROPRIATE LEVELS OF DOCU6 MENTATION FOR PROFESSIONAL SERVICES

7 OF TEACHING PHYSICIANS.

8 (a) IN GENERAL.—The Secretary of Health and

9 Human Services shall, in collaboration with the Institute

10 of Medicine and the Association of American Medical Col11 leges, conduct a study of the appropriateness of the level

12 of documentation that should be required, as a condition

13 of payment under part B of the medicare program for pro14 fessional services of a teaching physician, in a patient’s

15 medical record of the services provided by that physician.

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

17 of the enactment of this Act, the Secretary shall submit

18 a report on the study under subsection (a) to the Commit19 tees on Ways and Means and Commerce of the House of

20 Representatives and the Committee on Finance of the

21 Senate.
35

•HR 1224 IH

1 TITLE II—HEALTH WORKFORCE

2 PRIORITIES

3 SEC. 201. PLAN TO REDUCE RESIDENCY TRAINING POSI4 TIONS.

5 (a) IN GENERAL.—Not later than 1 year after the

6 date of the enactment of this Act, the Secretary of Health

7 and Human Services shall develop a plan to reduce, begin8 ning with the residency year that begins July 1, 2005,

9 the number of first year training positions in medical resi10 dency training programs in the United States to 110 per11 cent of the annual number of students graduating from

12 a medical school in the United States.

13 (b) MONITORING DISTRIBUTION.—In implementing

14 the plan under this section, the Secretary shall monitor

15 the distribution of resident specialties in order to assure

16 that there is an adequate proportion of primary care phy17 sicians to fulfill the country’s needs and to ensure access

18 to health care for underserved populations.

19 (c) IMPLEMENTATION.—In implementing the plan

20 under this section, the Secretary shall take into consider21 ation the reduced revenues to affected hospitals and shall

22 develop a formula to restore to such hospitals a portion

23 of the funds that would have been expended had the plan

24 under this section not been in effect.
36

•HR 1224 IH

1 (d) CONSULTATION.—The plan under this section

2 shall be developed in conjunction with the Institute of

3 Medicine, the Council on Graduate Medical Education, the

4 Association of American Medical Colleges, the American

5 Hospital Association, the American Medical Association,

6 the American Osteopathic Association, and other organi7 zations deemed appropriate by the Secretary.

8 (e) REPORT TO CONGRESS.—Not later than 1 year

9 after the date of the enactment of this Act, the Secretary

10 shall submit to the Committee on Ways and Means in the

11 House of Representatives, and to the Committee on Fi12 nance in the Senate, a report on the plan developed under

13 this section.

14 (f) ENFORCEMENT.—

15 (1) IN GENERAL.—Notwithstanding any other

16 provision of law, but subject to paragraph (2), for

17 purposes of computing the amount of payment to be

18 made under subsection (d)(5)(B) or (h) of section

19 1886 of the Social Security Act (42 U.S.C. 1395ww)

20 for any hospital that the Secretary determines has

21 a medical residency training program in which the

22 number of first year residents exceeds the maximum

23 number permitted for such program under the plan

24 implemented under subsection (a), the number of
37

•HR 1224 IH

1 residents counted shall be reduced by 5 multiplied by

2 the number of such excess.

3 (2) EXCEPTION FOR HOSPITALS ELECTIVE AL4 TERNATIVE TREATMENT.—Paragraph (1) does not

5 apply to a hospital for which the election under sec6 tion 1861(b)(7) of the Social Security Act was in ef7 fect on July 1, 1998.

8 TITLE III—MODIFICATION IN

9 MEDICARE PAYMENT FOR

10 IME AND DSH

11 SEC. 301. MODIFICATION REGARDING PAYMENTS FOR INDI12 RECT COSTS OF GRADUATE MEDICAL EDU13 CATION.

14 (a) MODIFICATION FROM 5.5% TO 4.8%.—Section

15 1886(d)(5)(B)(ii) of the Social Security Act (42 U.S.C.

16 1395ww(d)(5)(B)(ii)) is amended—

17 (1) by striking ‘‘and’’ at the end of subclause

18 (IV),

19 (2) by amending subclause (V) to read as fol20 lows:

21 ‘‘(V) during fiscal year 2001, ‘c’ is

22 equal to 1.35; and’’; and

23 (3) by adding at the end the following:

24 ‘‘(VI) on or after October 1, 2001, ‘c’

25 is equal to 1.18.’’.
38

•HR 1224 IH

1 (B) REPORTING OF IME PAYMENTS.—The Secretary

2 of Health and Human Services, in collaboration with the

3 Institute of Medicine, the Council on Graduate Medical

4 Education, the Association of American Medical Colleges,

5 the American Hospital Association, and other organiza6 tions deemed appropriate by the Secretary, shall develop

7 and implement a plan for hospitals that receive additional

8 payments under section 1886(d)(5)(B) of the Social Secu9 rity Act to report annually to the Secretary information

10 on how such hospitals contributed to education, improve11 ments in clinical services and research infrastructure, and

12 community services operated by or in such hospitals. The

13 first such report shall be submitted for cost reporting peri14 ods beginning during fiscal year 2002.

15 SEC. 302. MODIFICATION OF DSH.

16 (a) COLLECTION OF CHARGE DATA.—Section

17 1886(d)(5)(F) of the Social Security Act (42 U.S.C.

18 1395ww(d)(5)(F)) is amended by adding at the end the

19 following new clause:

20 ‘‘(x) The Secretary shall collect from all subsection

21 (d) hospitals annual data on inpatient and outpatient

22 charges, including all such charges—

23 ‘‘(I) for all patients;

24 ‘‘(II) for patients who are eligible for benefits

25 (excluding any State supplementation) under the
39

•HR 1224 IH

1 supplemental security income program under title

2 XVI and entitled to benefits under part A;

3 ‘‘(III) for patients who are entitled to (or, if

4 they applied, would be eligible for) medical assist5 ance under title XIX;

6 ‘‘(IV) for patients who are beneficiaries of indi7 gent care programs sponsored by State or local gov8 ernments; and

9 ‘‘(V) to the extent that payment is not made

10 because of an inability of the patient to pay (or have

11 payment made on the patient’s behalf for) such

12 charges.’’.

13 (b) REVISION OF FORMULA FOR DISPROPORTIONATE

14 PATIENT PERCENTAGE.—Clause (vi) of such section is

15 amended to read as follows:

16 ‘‘(vi) In this subparagraph, the term ‘dispropor17 tionate patient percentage’ means, with respect to a cost

18 reporting period of a hospital—

19 ‘‘(I) the charges described in subclauses (II)

20 through (V) of clause (x) for such period; divided by

21 (II) the charges described in clause (x)(I) for

22 such period.’’.

23 (c) ESTABLISHING GENERAL QUALIFYING DIS24 PROPORTIONATE PATIENT PERCENTAGE THRESHOLD TO

25 COVER HALF OF PPS HOSPITALS.—Clause (v) of such
40

•HR 1224 IH

1 section is amended by striking ‘‘equals, or exceeds—’’ and

2 all that follows and inserting ‘‘equals or exceeds a thresh3 old percentage, which is established by the Secretary in

4 a manner so that, if the amendments made by section 302

5 of the All-Payer Graduate Medical Education Act had

6 been in effect for cost reporting periods ending in fiscal

7 year 2000, 50 percent of subsection (d) hospitals would

8 have been eligible for an additional payment under this

9 subparagraph for such periods. The Secretary shall estab10 lish such threshold percentage based upon data collected

11 by the Secretary under clause (x) for such cost reporting

12 periods.’’.

13 (d) ESTABLISHING UNIFORM GENERAL PAYMENT

14 FORMULA.—Such section is further amended—

15 (1) in clause (iv), by striking ‘‘and that—’’ and

16 all that follows and inserting ‘‘is equal to (P–

17 T)(CF), where—

18 ‘‘(I) ‘P’ is the hospital’s disproportionate pa19 tient percentage (as defined in clause (vi));

20 ‘‘(II) ‘T’ is equal to the threshold percentage

21 established by the Secretary under clause (v); and

22 ‘‘(III) ‘CF’ is equal to such conversion factor as

23 the Secretary may establish so that, applying such

24 conversion factor as if the amendments made by sec25 tion 302 of the All-Payer Graduate Medical Edu-
41

•HR 1224 IH

1 cation Act had been in effect for cost reporting peri2 ods ending in fiscal year 2000, the total of the addi3 tional payments that would have been made under

4 this subparagraph is equal to the total of the pay5 ments actually made under this subparagraph (not

6 taking into account such amendments).

7 The Secretary shall establish the conversion factor under

8 subclause (III) based upon data collected by the Secretary

9 under clause (x) for cost reporting periods ending in fiscal

10 year 2000.’’; and

11 (2) by striking clauses (vii) and (viii).

12 (e) CARVING OUT DSH PAYMENTS FROM PAYMENTS

13 TO MEDICARE+CHOICE ORGANIZATIONS AND PAYING

14 THE AMOUNTS DIRECTLY TO DSH HOSPITALS TREATING

15 MEDICARE+CHOICE ENROLLEES.—

16 (1) IN GENERAL.—Section 1853(c)(3) of the

17 Social Security Act (42 U.S.C. 1395w–23(c)(3)) is

18 amended—

19 (A) in subparagraph (A), by striking ‘‘sub20 paragraph (B)’’ and inserting ‘‘subparagraphs

21 (B) and (D)’’;

22 (B) by redesignating subparagraph (D) as

23 subparagraph (E); and

24 (C) by inserting after subparagraph (C)

25 the following new subparagraph:
42

•HR 1224 IH

1 ‘‘(D) REMOVAL OF PAYMENTS ATTRIB2 UTABLE TO DISPROPORTIONATE SHARE PAY3 MENTS FROM CALCULATION OF ADJUSTED AV4 ERAGE PER CAPITA COST.—

5 ‘‘(i) IN GENERAL.—In determining

6 the area-specific Medicare+Choice capita7 tion rate under subparagraph (A) for a

8 year (beginning with 2002), the annual per

9 capita rate of payment for 1998 deter10 mined under section 1876(a)(1)(C) shall be

11 adjusted, subject to clause (ii) to exclude

12 from the rate the additional payments that

13 the Secretary estimates were payment dur14 ing 1997 for additional payments described

15 in section 1886(d)(5)(F).

16 ‘‘(ii) TREATMENT OF PAYMENTS COV17 ERED UNDER STATE HOSPITAL REIM18 BURSEMENT SYSTEM.—To the extent that

19 the Secretary estimates that an annual per

20 capita rate of payment for 1997 described

21 in clause (i) reflects payments to hospitals

22 reimbursed under section 1814(b)(3), the

23 Secretary shall estimate a payment adjust24 ment that is comparable to the payment

25 adjustment that would have been made
43

•HR 1224 IH

1 under clause (i) if the hospitals had not

2 been reimbursed under such section.’’.

3 (2) ADDITIONAL PAYMENTS FOR MANAGED

4 CARE ENROLLEES.—Section 1886(d)(5)(F) of such

5 Act ((42 U.S.C. 1395ww(d)(5)(F)) is amended—

6 (A) in clause (ii), by striking ‘‘clause (ix)’’

7 and inserting ‘‘clauses (ix) and (x)’’, and

8 (B) by adding at the end the following:

9 ‘‘(ix)(I) For portions of cost reporting periods occur10 ring on or after January 1, 2002, the Secretary shall pro11 vide for an additional payment amount for each applicable

12 discharge of any subsection (d) hospital that is a dis13 proportionate share hospital (as described in clause (i)).

14 ‘‘(II) For purposes of this clause, the term ‘applicable

15 discharge’ means the discharge of any individual who is

16 enrolled under a risk-sharing contract with an eligible or17 ganization under section 1876 and who is entitled to bene18 fits under part A or any individual who is enrolled with

19 a Medicare+Choice organization under part C.

20 ‘‘(III) The amount of the payment under this clause

21 with respect to any applicable discharge shall be equal to

22 the estimated average per discharge amount that would

23 otherwise have been paid under this subparagraph if the

24 individuals had not been enrolled as described in subclause

25 (II).
44

•HR 1224 IH

1 ‘‘(IV) The Secretary shall establish rules for an addi2 tional payment amount, for any hospital reimbursed under

3 a reimbursement system authorized under section

4 1814(b)(3) if such hospital would qualify as a dispropor5 tionate share hospital under clause (i) were it not so reim6 bursed. Such payment shall be determined in the same

7 manner as the amount of payment is determined under

8 this clause for disproportionate share hospitals.’’.

9 (e) EFFECTIVE DATE.—The amendments made by

10 subsections (a) through (d) of this section apply to pay11 ments for discharges occurring on or after January 1,

12 2002.

13 TITLE IV—ADDITIONAL PAY14 MENTS FOR GRADUATE EDU15 CATION FOR NON-PHYSICIAN

16 HEALTH PROFESSIONALS

17 SEC. 401. PAYMENTS FOR GRADUATE EDUCATION FOR

18 NON-PHYSICIAN HEALTH PROFESSIONALS.

19 (a) DEVELOPMENT OF PLAN.—

20 (1) IN GENERAL.—Not later than 3 years after

21 the date of the enactment of this Act, the Secretary

22 of Health and Human Services shall develop (and

23 submit to Congress a report on) a plan to provide

24 support to institutions that provide graduate health
45

•HR 1224 IH

1 care education for non-physician health profes2 sionals.

3 (2) CONSULTATION.—The Secretary shall de4 velop the plan in consultation with the Council on

5 Graduate Medical Education, the Institute of Medi6 cine, the American Hospital Association, the Asso7 ciation of American Medical Colleges, the American

8 Association of Colleges of Nursing, the American

9 Nurses Association, the American Physical Therapy

10 Association, the American Occupational Therapy As11 sociation, the American Speech-Language-Hearing

12 Association, and other organizations as deemed ap13 propriate by the Secretary.

14 (b) PAYMENTS.—For each fiscal year, beginning with

15 first fiscal year that begins after the report under sub16 section (a) has been submitted to Congress, the Secretary

17 of Health and Human Services shall provide from the

18 Health Care Workforce Trust Fund (established under

19 section 9511 of the Internal Revenue Code of 1986) for

20 support in the aggregate amount of $300,000,000 for in21 stitutions providing graduate health care education for

22 non-physician health professionals. Such support shall be

23 provided under such terms and conditions as the Secretary
46

•HR 1224 IH

1 establishes in order to carry out the plan developed under

2 subsection (a).

Æ