I

107TH CONGRESS

1ST SESSION H. R. 2178

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

JUNE 14, 2001

Mr. CARDIN (for himself, Mr. STARK, Mr. KLECZKA, Mr. LEVIN, Mrs. THURMAN, Mr. COYNE, Mr. TOWNS, Mr. LEWIS of Georgia, Mr. BENTSEN, Ms.

HOOLEY of Oregon, Mr JEFFERSON, and Mr. WAXMAN) 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 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 of 2001’’.
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1 (b) TABLE OF CONTENTS.—The table of contents of

2 this Act is as follows:

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.

Sec. 124. No impact on support of graduate medical education programs in

children’s hospitals.

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.
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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-
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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 of 2001; 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 of 2001.

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
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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 of 2001.

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:
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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—
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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
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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.
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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-
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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
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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,
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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
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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
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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.—
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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,
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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.’’
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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, 2001.

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 2004 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.

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

24 term ‘‘teaching hospital’’ means any hospital that operates
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1 an approved medical residency training program (as de2 fined in section 1886(h)(5)(A) of the Social Security Act).

3 SEC. 112. APPLICATION FOR PAYMENTS.

4 For purposes of section 111(a), an application for

5 payments under such section for a calendar year is in ac6 cordance with this section if—

7 (1) the application is submitted not later than

8 the date specified by the Secretary;

9 (2) the application contains the agreements re10 quired in this subtitle; and

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

12 such manner, and contains such agreements, assur13 ances, and information as the Secretary determines

14 to be necessary to carry out this subtitle.

15 SEC. 113. ANNUAL AMOUNT OF PAYMENTS.

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

17 Workforce Trust Fund under section 9511 of the Internal

18 Revenue Code of 1986, the Secretary shall make payments

19 under section 111 to an eligible hospital for a calendar

20 year as follows:

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

22 sum is equal to the amount determined under sub23 section (c) for the hospital for the year (which

24 amount relates to the direct costs for graduate med25 ical education attributable to certain individuals).
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1 (2) Payments (in addition to payments under

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

3 is equal to the amount determined under subsection

4 (d) for the hospital for the year (which amount re5 lates to the per-discharge indirect costs of the hos6 pital for graduate medical education attributable to

7 certain individuals).

8 (b) EFFECTIVE DATES FOR PAYMENTS.—Payments

9 under paragraph (1) of subsection (a) are effective for por10 tions of cost reporting periods occurring on or after Janu11 ary 1, 2003. Payments under paragraph (2) of such sub12 section are effective for patient discharges occurring on

13 or after such date.

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

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

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

17 this subsection for an eligible hospital for a calendar

18 year is the product of—

19 (A) the aggregate nonmedicare training

20 amount for the hospital, as defined in para21 graph (2); and

22 (B) the direct-cost Fund payout percent23 age, as defined in paragraph (4).

24 (2) AGGREGATE NONMEDICARE TRAINING

25 AMOUNT.—For purposes of this subtitle, the term
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1 ‘‘aggregate nonmedicare training amount’’, with re2 spect to the eligible hospital involved, means (subject

3 to paragraph (3)(D)) an amount equal to the prod4 uct of subparagraphs (A) and (B), as follows:

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

6 training participants in the approved physician

7 training programs of the hospital for the aca8 demic year in which the calendar year begins,

9 not to exceed the maximum total number per10 mitted under section 1886(h)(4)(F) of the So11 cial Security Act.

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

13 (i) the national average FTE wage-re14 lated compensation, as defined in para15 graph (3); and

16 (ii) a percentage equal to the fraction

17 of the total inpatient hospital and out18 patient hospital revenues (as established by

19 the Secretary) during the cost reporting

20 period which are attributable to patients

21 with respect to whom payment may be

22 made under health insurance coverage

23 (whether through a group health plan or

24 otherwise) or under a group health plan.
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1 For purposes of clause (ii), payment made

2 under the medicare or medicaid programs

3 (under titles XVIII or XIX of the Social Secu4 rity Act) shall not be treated as payment under

5 health insurance coverage.

6 (3) NATIONAL AVERAGE FTE WAGE-RELATED

7 COMPENSATION.—

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

9 subtitle, the term ‘‘national average FTE wage10 related compensation’’ means the national aver11 age of the costs of resident salaries and related

12 fringe benefits per training participant for all

13 approved physician training programs and all

14 medical specialities, as adjusted under subpara15 graphs (B) and (C). Such national average shall

16 be based upon a national resident wage survey

17 for salaries and related fringe benefits as of

18 July 1, 2000, as determined by the Secretary

19 and shall not include costs of overhead or su20 pervision.

21 (B) ANNUAL ADJUSTMENTS PER CON22 SUMER PRICE INDEX.—The national average

23 applicable under subparagraph (A) for a cal24 endar year for such programs is, subject to sub25 paragraph (C), the amount determined under
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1 subparagraph (A) increased by the estimated

2 percentage change in the Consumer Price Index

3 for All Urban Consumers (United States city

4 average) from January 2001 through the mid5 point of the year involved, with appropriate ad6 justments to reflect previous under- or over-es7 timations under this subparagraph in the pro8 jected percentage change in such consumer

9 price index.

10 (C) INDIVIDUAL ADJUSTMENTS PER AREA

11 WAGE INDEX.—The national average deter12 mined under subparagraph (A) and adjusted

13 under subparagraph (B) for a calendar year

14 shall, in the case of the approved physician

15 training programs of the eligible hospital in16 volved, be adjusted by a factor to reflect re17 gional differences in wage and wage-related

18 costs, as determined in accordance with the

19 area wage index applicable (as of the beginning

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

21 area involved, as determined under section

22 1886(d)(3)(E) of the Social Security Act.

23 (D) ALTERNATIVE RULE FOR CERTAIN

24 HOSPITALS.—
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1 (i) ELECTION FOR APPLICABILITY OF

2 RULE.—In the case of an eligible hospital

3 for which the election under section

4 1861(b)(7) of the Social Security Act was

5 in effect on July 1, 2000, and has re6 mained in effect continuously from such

7 date, the following applies:

8 (I) The hospital may, with re9 spect to the determination under

10 paragraph (2) of the aggregate non11 medicare training amount for the hos12 pital, elect to have the alternative rule

13 described in clause (ii) applied to the

14 hospital.

15 (II) If the election under such

16 section 1861(b)(7) ceases to be in ef17 fect, any election made by the hospital

18 under subclause (I) is terminated.

19 (III) If the hospital has made the

20 election under subclause (I) and sub21 sequently requests that the election be

22 terminated, the Secretary shall ap23 prove the request. Upon the approval

24 of the request, the hospital may not
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1 subsequently elect to have the alter2 native rule applied to the hospital.

3 (ii) DESCRIPTION OF ALTERNATIVE

4 RULE.—With respect to a determination

5 under paragraph (2) of the aggregate non6 medicare training amount for an eligible

7 hospital that has made the election under

8 clause (i), the alternative rule described in

9 this clause is as follows:

10 (I) In lieu of the applicability of

11 the national FTE training amount

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

13 the Secretary shall apply an amount

14 equal to the approved FTE resident

15 amount in effect for the hospital

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

17 Security Act.

18 (II) Subject to the modification

19 applied under subclause (I), the Sec20 retary shall determine an amount

21 under paragraph (2).

22 (III) The Secretary shall deter23 mine an amount equal to the product

24 of the fraction determined under

25 paragraph (2)(B)(ii) and the amount
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1 of the physician costs of services rec2 ognized under section 1861(v)(1) of

3 the Social Security Act pursuant to

4 the election of the hospital under sec5 tion 1861(b)(7) of such Act.

6 (IV) In lieu of the applicability of

7 the aggregate nonmedicare training

8 amount (for purposes of paragraph

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

10 amount equal to the sum of the

11 amount determined under subclause

12 (II) and the amount determined under

13 subclause (III).

14 (4) DIRECT-COST FUND PAYOUT PERCENT15 AGE.—For purposes of this subtitle, the term ‘‘di16 rect-cost Fund payout percentage’’, with respect to

17 the calendar year involved, means a percentage equal

18 to the ratio of—

19 (A) the amount available in the Health

20 Care Workforce Trust Fund for such year (as

21 estimated by the Secretary); to

22 (B) an amount equal to the total amount

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

24 be made to eligible hospitals for such year if

25 each hospital received, pursuant to paragraph
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1 (1), 100 percent of the aggregate nonmedicare

2 training amount determined for the hospital.

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

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

5 (2) 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) an amount equal to the sum of the

9 nonmedicare per-discharge supplemental pay10 ments, as defined in paragraph (2); and

11 (B) the indirect-cost Fund payout percent12 age, as defined in paragraph (3).

13 (2) NONMEDICARE PER-DISCHARGE SUPPLE14 MENTAL PAYMENT.—

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

16 subtitle, the term ‘‘nonmedicare per-discharge

17 supplemental payment’’, with respect to a cal18 endar year, means a payment made to an eligi19 ble hospital for a discharge during the year of

20 a patient described in subparagraph (B), the

21 amount of which payment is determined in ac22 cordance with subparagraph (C).

23 (B) RELEVANT PATIENTS.—For purposes

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

25 subparagraph is a patient who is not—
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1 (i) entitled to benefits under part A of

2 title XVIII of the Social Security Act; or

3 (ii) eligible for medical assistance

4 under title XIX of such Act.

5 (C) AMOUNT OF PER-DISCHARGE PAY6 MENT.—For purposes of subparagraph (A), the

7 amount of the payment under such subpara8 graph for the discharge of a patient described

9 in subparagraph (B) is the product of—

10 (i) the amount which would be deter11 mined with respect to the discharge under

12 section 1886(d)(1)(A)(iii) of the Social Se13 curity Act if the patient were entitled to

14 benefits under part A of title XVIII of

15 such Act, adjusted by the Secretary to take

16 into account differences in health status,

17 utilization of services, and other demo18 graphic characteristics among individuals

19 entitled to benefits under part A of title

20 XVIII of such Act and individuals who are

21 not so entitled; and

22 (ii) the percentage applicable to the

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

24 such Act.
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1 (D) SPECIAL RULE FOR CERTAIN HOS2 PITALS.—In the case of a hospital that is lo3 cated in a State for which a demonstration pro4 gram under section 1814(b)(3) of the Social Se5 curity Act is in effect, the Secretary shall, for

6 purposes of applying subparagraph (C) to dis7 charges from the hospital, make determinations

8 under such subparagraph as if paragraphs

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

10 such Act applied to the hospital.

11 (3) INDIRECT-COST FUND PAYOUT PERCENT12 AGE.—For purposes of this subtitle, the term ‘‘indi13 rect-cost Fund payout percentage’’, with respect the

14 calendar year involved, means a percentage equal to

15 the ratio of—

16 (A) the amount available in the Health

17 Care Workforce Trust Fund for such year re18 maining after payments for the year have been

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

20 is estimated by the Secretary); to

21 (B) the total amount of payments under

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

23 hospitals for such year if each hospital received,

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

25 amount equal to the sum of the nonmedicare
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1 per-discharge supplemental payments deter2 mined for the hospital.

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

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

5 full-time equivalent resident of the hospital as determined

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

7 the cost reporting period involved.

8 SEC. 114. DEFINITIONS.

9 For purposes of this subtitle:

10 (1) The term ‘‘aggregate nonmedicare training

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

12 113(c)(2).

13 (2) The term ‘‘direct-cost Fund payout percent14 age’’ has the meaning given such term in section

15 113(c)(4).

16 (3) The term ‘‘full-time-equivalent training par17 ticipant’’ has the meaning given such term in section

18 113(e).

19 (4) The term ‘‘indirect-cost Fund payout per20 centage’’ has the meaning given such term in section

21 113(d)(3).

22 (5) The term ‘‘national average FTE wage-re23 lated compensation’’ has the meaning given such

24 term in section 113(c)(3).
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1 (6) The term ‘‘nonmedicare per-discharge sup2 plemental payment’’ has the meaning given such

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

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

5 of Health and Human Services, unless the context of

6 usage indicates otherwise.

7 (8) The term ‘‘teaching hospital’’ has the mean8 ing given such term in section 111(b).

9 SEC. 115. STUDY.

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

11 Services shall conduct a study of the impact of this sub12 title.

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

14 that payments are first made under this subtitle, the Sec15 retary shall submit to Congress a report on such study

16 and shall include such recommendations on the continu17 ation of payments under this subtitle, and such changes

18 in such payments, as the Secretary deems appropriate.
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1 Subtitle C—Conforming Changes in

2 Medicare Payment for Direct

3 Costs of Graduate Medical Edu4 cation

5 SEC. 121. CHANGES IN MEDICARE FORMULA FOR PAYMENT

6 OF DIRECT GME COSTS.

7 (a) USE OF NATIONAL AVERAGE FTE WAGE-RE8 LATED COMPENSATION AS BASIS FOR PAYMENT.—Sec9 tion 1886(h)(3)(B)(i) of the Social Security Act (42

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

11 for portions of cost reporting periods occurring on or after

12 January 1, 2003, in the case of a hospital that does not

13 have in effect the election described in section

14 113(c)(3)(D)(i) of the All-Payer Graduate Medical Edu15 cation Act of 2001, the applicable national average FTE

16 wage-related compensation, as determined under section

17 113(c)(3) of such Act)’’ after ‘‘for that period’’.

18 (b) ALLOCATION BASED ON MEDICARE REVE19 NUES.—Section 1886(h)(3) of such Act (42 U.S.C.

20 1395ww(h)(3)) is amended—

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

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

23 of a cost reporting period occurring on or after Jan24 uary 1, 2003, in the case of a hospital that does not

25 have in effect the election described in section
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1 113(c)(3)(D)(i) of the All-Payer Graduate Medical

2 Education Act of 2001, the fraction of the total in3 patient hospital and outpatient hospital revenues (as

4 established by the Secretary) during the reporting

5 period which is attributable to patients with respect

6 to whom payment may be made under this title’’;

7 and

8 (2) in subparagraph (D)(i)(II), by inserting be9 fore the period at the end the following: ‘‘or, for por10 tions of a cost reporting period occurring on or after

11 January 1, 2003, in the case of a hospital that does

12 not have in effect the election described in section

13 113(c)(3)(D)(i) of the All-Payer Graduate Medical

14 Education Act of 2001, the fraction of the total in15 patient hospital and outpatient hospital revenues (as

16 established by the Secretary) during the reporting

17 period which is attributable to such enrolled individ18 uals’’.

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

20 this section apply to portions of cost reporting periods oc21 curring on or after January 1, 2003.
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1 SEC. 122. EXCEPTION FROM LIMITATION ON NUMBER OF

2 RESIDENTS FOR RURAL AND UNDERSERVED

3 URBAN AREAS.

4 (a) IN GENERAL.—Section 1886 of the Social Secu5 rity Act (42 U.S.C. 1395ww) is amended—

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

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

8 reasonable exemptions and exceptions from the pre9 vious sentence in the case of a hospital that has resi10 dents who are assigned to serve a rural area or an

11 urban underserved area.’’; and

12 (2) in subsection (h)(4)(F)(i), 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.’’.

18 (b) EFFECTIVE DATES.—The amendments made

19 by—

20 (1) subsection (a)(1) apply to discharges occur21 ring on or after January 1, 2002; or

22 (2) subsection (a)(2) apply to cost reporting pe23 riods beginning on or after January 1, 2002.
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1 SEC. 123. STUDY ON APPROPRIATE LEVELS OF DOCU2 MENTATION FOR PROFESSIONAL SERVICES

3 OF TEACHING PHYSICIANS.

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

5 Human Services shall, in collaboration with the Institute

6 of Medicine, the Association of American Medical Colleges,

7 and the American Association of Colleges of Osteopathic

8 Medicine, conduct a study of the appropriateness of the

9 level of documentation that should be required, as a condi10 tion of payment under part B of the medicare program

11 for professional services of a teaching physician, in a pa12 tient’s medical record of the services provided by that phy13 sician.

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

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

16 a report on the study under subsection (a) to the Commit17 tees on Ways and Means and Commerce of the House of

18 Representatives and the Committee on Finance of the

19 Senate.

20 SEC. 124. NO IMPACT ON SUPPORT OF GRADUATE MEDICAL

21 EDUCATION PROGRAMS IN CHILDREN’S HOS22 PITALS.

23 Nothing in this Act shall be construed as applying

24 to, or as affecting, payment for graduate medical edu25 cation programs in children’s hospitals under section

26 340E of the Public Health Service Act (42 U.S.C. 256e).
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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, 2007,

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 physicians to fulfill

17 the country’s needs and to ensure access to health care

18 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.
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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, the American Asso7 ciation of Colleges of Osteopathic Medicine, and other or8 ganizations deemed appropriate by the Secretary.

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

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

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

12 House of Representatives, and to the Committee on Fi13 nance in the Senate, a report on the plan developed under

14 this section.

15 (f) ENFORCEMENT.—

16 (1) IN GENERAL.—Notwithstanding any other

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

18 purposes of computing the amount of payment to be

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

20 1886 of the Social Security Act (42 U.S.C. 1395ww)

21 for any hospital that the Secretary determines has

22 a medical residency training program in which the

23 number of first year residents exceeds the maximum

24 number permitted for such program under the plan

25 implemented under subsection (a), the number of
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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, 2000.

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 PERCENT TO 4.8 PER15 CENT.—Section 1886(d)(5)(B)(ii) of the Social Security

16 Act (42 U.S.C. 1395ww(d)(5)(B)(ii)), as amended by sec17 tion 302(a) of Medicare, Medicaid, and SCHIP Benefits

18 Improvement and Protection Act of 2000 (113 Stat.

19 2763A–493), as enacted into law by section 1(a)(6) of

20 Public Law 106–554, is amended—

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

22 (IV),

23 (2) by amending subclause (VII) to read as fol24 lows:
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1 ‘‘(V) during fiscal year 2003, ‘c’ is

2 equal to 1.35; and’’; and

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

4 ‘‘(VI) on or after October 1, 2003, ‘c’

5 is equal to 1.18.’’.

6 (b) REPORTING OF IME PAYMENTS.—The Secretary

7 of Health and Human Services, in collaboration with the

8 Institute of Medicine, the Council on Graduate Medical

9 Education, the Association of American Medical Colleges,

10 the American Hospital Association, the American Osteo11 pathic Association, the American Association of Colleges

12 of Osteopathic Medicine, and other organizations deemed

13 appropriate by the Secretary, shall develop and implement

14 a plan for hospitals that receive additional payments

15 under section 1886(d)(5)(B) of the Social Security Act to

16 report annually to the Secretary information on how such

17 hospitals contributed to education, improvements in clin18 ical services and research infrastructure, and community

19 services operated by or in such hospitals. The first such

20 report shall be submitted for cost reporting periods begin21 ning during fiscal year 2004.

22 (c) REPORT ON STRATEGIES TO REDUCE MEDICAL

23 ERRORS AND LOWER HEALTH CARE COSTS IN ACADEMIC

24 MEDICAL CENTERS.—The Director of the Agency for

25 Healthcare Research and Quality shall develop, in close
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1 cooperation with the medical community and health plans,

2 a plan of strategies that can be tested in academic medical

3 centers to reduce the number of medical errors and lower

4 health care costs in such centers. Not later than January

5 1, 2004, the Director shall submit a report to Congress

6 on the plan so developed.

7 SEC. 302. MODIFICATION OF DSH.

8 (a) COLLECTION OF CHARGE DATA.—Section

9 1886(d)(5)(F) of the Social Security Act (42 U.S.C.

10 1395ww(d)(5)(F)) is amended by adding at the end the

11 following new clause:

12 ‘‘(xiv) The Secretary shall collect from all subsection

13 (d) hospitals annual data on inpatient and outpatient

14 charges, including all such charges—

15 ‘‘(I) for all patients;

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

17 (excluding any State supplementation) under the

18 supplemental security income program under title

19 XVI and entitled to benefits under part A;

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

21 they applied, would be eligible for) medical assist22 ance under title XIX;

23 ‘‘(IV) for patients who are beneficiaries of indi24 gent care programs sponsored by State or local gov25 ernments; and
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1 ‘‘(V) to the extent that payment is not made

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

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

4 charges.’’.

5 (b) REVISION OF FORMULA FOR DISPROPORTIONATE

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

7 amended to read as follows:

8 ‘‘(vi) In this subparagraph, the term ‘dispropor9 tionate patient percentage’ means, with respect to a cost

10 reporting period of a hospital—

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

12 through (V) of clause (xiv) for such period; divided

13 by

14 ‘‘(II) the charges described in clause (xiv)(I) for

15 such period.’’.

16 (c) CARVING OUT DSH PAYMENTS FROM PAYMENTS

17 TO MEDICARE+CHOICE ORGANIZATIONS AND PAYING

18 THE AMOUNTS DIRECTLY TO DSH HOSPITALS TREATING

19 MEDICARE+CHOICE ENROLLEES.—

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

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

22 amended—

23 (A) in subparagraph (A), by striking ‘‘sub24 paragraph (B)’’ and inserting ‘‘subparagraphs

25 (B) and (D)’’;
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1 (B) by redesignating subparagraph (D) as

2 subparagraph (E); and

3 (C) by inserting after subparagraph (C)

4 the following new subparagraph:

5 ‘‘(D) REMOVAL OF PAYMENTS ATTRIB6 UTABLE TO DISPROPORTIONATE SHARE PAY7 MENTS FROM CALCULATION OF ADJUSTED AV8 ERAGE PER CAPITA COST.—

9 ‘‘(i) IN GENERAL.—In determining

10 the area-specific Medicare+Choice capita11 tion rate under subparagraph (A) for a

12 year (beginning with 2004), the annual per

13 capita rate of payment for 2000 deter14 mined under section 1876(a)(1)(C) shall be

15 adjusted, subject to clause (ii) to exclude

16 from the rate the additional payments that

17 the Secretary estimates were payment dur18 ing 1999 for additional payments described

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

20 ‘‘(ii) TREATMENT OF PAYMENTS COV21 ERED UNDER STATE HOSPITAL REIM22 BURSEMENT SYSTEM.—To the extent that

23 the Secretary estimates that an annual per

24 capita rate of payment for 2000 described

25 in clause (i) reflects payments to hospitals
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1 reimbursed under section 1814(b)(3), the

2 Secretary shall estimate a payment adjust3 ment that is comparable to the payment

4 adjustment that would have been made

5 under clause (i) if the hospitals had not

6 been reimbursed under such section.’’.

7 (2) ADDITIONAL PAYMENTS FOR MANAGED

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

9 Act (42 U.S.C. 1395ww(d)(5)(F)), as amended by

10 211(b) of Medicare, Medicaid, and SCHIP Benefits

11 Improvement and Protection Act of 2000 (113 Stat.

12 2763A–484), as enacted into law by section 1(a)(6)

13 of Public Law 106–554 and by section 302 of this

14 Act, is amended—

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

16 and inserting ‘‘clauses (ix) and (xv)’’, and

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

18 ‘‘(xv)(I) For portions of cost reporting periods occur19 ring on or after January 1, 2004, the Secretary shall pro20 vide for an additional payment amount for each applicable

21 discharge of any subsection (d) hospital that is a dis22 proportionate share hospital (as described in clause (i)).

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

24 discharge’ means the discharge of any individual who is

25 enrolled under a risk-sharing contract with an eligible or-
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1 ganization under section 1876 and who is entitled to bene2 fits under part A or any individual who is enrolled with

3 a Medicare+Choice organization under part C.

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

5 with respect to any applicable discharge shall be equal to

6 the estimated average per discharge amount that would

7 otherwise have been paid under this subparagraph if the

8 individuals had not been enrolled as described in subclause

9 (II).

10 ‘‘(IV) The Secretary shall establish rules for an addi11 tional payment amount, for any hospital reimbursed under

12 a reimbursement system authorized under section

13 1814(b)(3) if such hospital would qualify as a dispropor14 tionate share hospital under clause (i) were it not so reim15 bursed. Such payment shall be determined in the same

16 manner as the amount of payment is determined under

17 this clause for disproportionate share hospitals.’’.

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

19 this section apply to payments for discharges occurring on

20 or after January 1, 2004.
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1 TITLE IV—ADDITIONAL PAY2 MENTS FOR GRADUATE EDU3 CATION FOR NON-PHYSICIAN

4 HEALTH PROFESSIONALS

5 SEC. 401. PAYMENTS FOR GRADUATE EDUCATION FOR

6 NON-PHYSICIAN HEALTH PROFESSIONALS.

7 (a) DEVELOPMENT OF PLAN.—

8 (1) IN GENERAL.—Not later than 2 years after

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

10 of Health and Human Services shall develop (and

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

12 support to institutions that provide graduate health

13 care education for non-physician health profes14 sionals.

15 (2) CONSULTATION.—The Secretary shall de16 velop the plan in consultation with the Council on

17 Graduate Medical Education, the Institute of Medi18 cine, the American Hospital Association, the Asso19 ciation of American Medical Colleges, the American

20 Association of Colleges of Nursing, the American

21 Nurses Association, the American Physical Therapy

22 Association, the American Occupational Therapy As23 sociation, the American Speech-Language-Hearing

24 Association, the Association of Schools of Allied

25 Health Professions, the National Association of Chil-
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1 dren’s Hospitals, the American Osteopathic Associa2 tion, the American Association of Colleges of Osteo3 pathic Medicine, and other organizations as deemed

4 appropriate by the Secretary.

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

6 first fiscal year that begins after the report under sub7 section (a) has been submitted to Congress, the Secretary

8 of Health and Human Services shall provide from the

9 Health Care Workforce Trust Fund (established under

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

11 support in the aggregate amount of $300,000,000 for in12 stitutions providing graduate health care education for

13 non-physician health professionals. Such support shall be

14 provided under such terms and conditions as the Secretary

15 establishes in order to carry out the plan developed under

16 subsection (a).

Æ