shall be counted toward the determination 
of full-time equivalency.’’; 
(2) in paragraph (4), by adding at the end the 
following new subparagraph: 
‘‘(I) TREATMENT
OF
CERTAIN
LEAVE 
TIME.—In determining the hospital’s number of 
full-time equivalent residents for purposes of 
this subsection, all the time that is spent by an 
intern or resident in an approved medical resi-
dency training program on vacation, sick leave, 
or other approved leave, as such time is defined 
by the Secretary, and that does not prolong the 
total time the resident is participating in the 
approved program beyond the normal duration 
of the program shall be counted toward the de-
termination of full-time equivalency.’’; and 
(3) in paragraph (5), by adding at the end the 
following new subparagraph: 
‘‘(K) NONHOSPITAL SETTING THAT IS PRI-
MARILY
ENGAGED
IN
FURNISHING
PATIENT 
CARE.—The term ‘nonhospital setting that is 
primarily engaged in furnishing patient care’ 
means a nonhospital setting in which the pri-
mary activity is the care and treatment of pa-
tients, as defined by the Secretary.’’. 
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(b) IME DETERMINATIONS.—Section 1886(d)(5)(B) 
of such Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 
adding at the end the following new clause: 
‘‘(x)(I) The provisions of subparagraph (I) of 
subsection (h)(4) shall apply under this subpara-
graph in the same manner as they apply under such 
subsection. 
‘‘(II) In determining the hospital’s number of 
full-time equivalent residents for purposes of this 
subparagraph, all the time spent by an intern or 
resident in an approved medical residency training 
program in non-patient care activities, such as di-
dactic conferences and seminars, as such time and 
activities are defined by the Secretary, that occurs in 
the hospital shall be counted toward the determina-
tion of full-time equivalency if the hospital— 
‘‘(aa) is recognized as a subsection (d) hos-
pital; 
‘‘(bb) is recognized as a subsection (d) 
Puerto Rico hospital; 
‘‘(cc) is reimbursed under a reimbursement 
system authorized under section 1814(b)(3); or 
‘‘(dd) is a provider-based hospital out-
patient department. 
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‘‘(III) In determining the hospital’s number of 
full-time equivalent residents for purposes of this 
subparagraph, all the time spent by an intern or 
resident in an approved medical residency training 
program in research activities that are not associ-
ated with the treatment or diagnosis of a particular 
patient, as such time and activities are defined by 
the Secretary, shall not be counted toward the deter-
mination of full-time equivalency.’’. 
(c) EFFECTIVE DATES; APPLICATION.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided, the Secretary of Health and Human Services 
shall implement the amendments made by this sec-
tion in a manner so as to apply to cost reporting pe-
riods beginning on or after January 1, 1983. 
(2) DIRECT GME.—Section 1886(h)(4)(E)(ii) of 
the Social Security Act, as added by subsection 
(a)(1)(B), shall apply to cost reporting periods be-
ginning on or after July 1, 2009. 
(3) IME.—Section 1886(d)(5)(B)(x)(III) of the 
Social Security Act, as added by subsection (b), shall 
apply to cost reporting periods beginning on or after 
October 1, 2001. Such section, as so added, shall 
not give rise to any inference on how the law in ef-
fect prior to such date should be interpreted. 
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(4) APPLICATION.—The amendments made by 
this section shall not be applied in a manner that re-
quires reopening of any settled hospital cost reports 
as to which there is not a jurisdictionally proper ap-
peal pending as of the date of the enactment of this 
Act on the issue of payment for indirect costs of 
medical education under section 1886(d)(5)(B) of 
the Social Security Act or for direct graduate med-
ical education costs under section 1886(h) of such 
Act. 
SEC. 3. RULES FOR COUNTING RESIDENT TIME IN OUT-
PATIENT SETTINGS. 
(a) DIRECT GME.—Section 1886(h)(4)(E) of the So-
cial Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amend-
ed— 
(1) by striking ‘‘under an approved medical 
residency program’’; and 
(2) by striking ‘‘if the hospital incurs all, or 
substantially all, of the costs for the training pro-
gram in that setting’’ and inserting ‘‘if the hospital 
or hospitals continue to incur the costs of the resi-
dents’ stipends and fringe benefits during the time 
the residents spend in that setting.’’ 
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(b) 
IME 
DETERMINATIONS.—Section 
1886(d)(5)(B)(iv) 
of 
such 
Act 
(42 
U.S.C. 
1395ww(d)(5)(B)(iv)) is amended— 
(1) by striking ‘‘under an approved medical 
residency training program’’; and 
(2) by striking ‘‘if the hospital incurs all, or 
substantially all, of the costs for the training pro-
gram in that setting’’ and inserting ‘‘if the hospital 
or hospitals continue to incur the costs of the resi-
dents’ stipends and fringe benefits during the time 
the residents spend in that setting.’’ 
(c) EFFECTIVE DATES; APPLICATION.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided, the Secretary of Health and Human Services 
shall implement the amendments made by this sec-
tion in a manner so as to apply to cost reporting pe-
riods beginning on or after July 1, 2009. 
(2) APPLICATION.—The amendments made by 
this section shall not be applied in a manner that re-
quires reopening of any settled hospital cost reports 
as to which there is not a jurisdictionally proper ap-
peal pending as of the date of the enactment of this 
Act on the issue of payment for indirect costs of 
medical education under section 1886(d)(5)(B) of 
the Social Security Act or for direct graduate med-
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ical education costs under section 1886(h) of such 
Act. 
Æ 
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