each qualifying hospital that submits a 
timely application under this subparagraph 
by such number as the Secretary may ap-
prove for portions of cost reporting periods 
occurring on or after July 1 of the fiscal 
year of the increase. 
‘‘(ii) NUMBER
AVAILABLE
FOR
DIS-
TRIBUTION.—For each such fiscal year, 
the Secretary shall determine the total 
number of additional residency positions 
available for distribution under clause (i) 
in accordance with the following: 
‘‘(I) ALLOCATION TO HOSPITALS 
ALREADY OPERATING OVER RESIDENT 
LIMIT.—One-third of such number 
shall be available for distribution only 
to hospitals described in subparagraph 
(B). 
‘‘(II) AGGREGATE LIMITATION.— 
Except as provided in clause (iv)(I), 
the aggregate number of increases in 
the otherwise applicable resident limit 
under this subparagraph shall be 
equal to 3,000 in each such year. 
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‘‘(iii) PROCESS
FOR
DISTRIBUTING 
POSITIONS.— 
‘‘(I) 
ROUNDS
OF
APPLICA-
TIONS.—The Secretary shall initiate 5 
separate rounds of applications for an 
increase under clause (i), 1 round 
with respect to each of fiscal years 
2021 through 2025. 
‘‘(II) NUMBER
AVAILABLE.—In 
each of such rounds, the aggregate 
number of positions available for dis-
tribution in the fiscal year under 
clause (ii) shall be distributed, plus 
any 
additional 
positions 
available 
under clause (iv). 
‘‘(III) TIMING.—The Secretary 
shall notify hospitals of the number of 
positions distributed to the hospital 
under this paragraph as a result of an 
increase in the otherwise applicable 
resident limit by January 1 of the fis-
cal year of the increase. Such increase 
shall be effective for portions of cost 
reporting periods beginning on or 
after July 1 of that fiscal year. 
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‘‘(iv) POSITIONS
NOT
DISTRIBUTED 
DURING THE FISCAL YEAR.— 
‘‘(I) IN GENERAL.—If the num-
ber of resident full-time equivalent po-
sitions distributed under this para-
graph in a fiscal year is less than the 
aggregate number of positions avail-
able for distribution in the fiscal year 
(as described in clause (ii), including 
after application of this subclause), 
the difference between such number 
distributed and such number available 
for distribution shall be added to the 
aggregate number of positions avail-
able for distribution in the following 
fiscal year. 
‘‘(II) EXCEPTION
IF
POSITIONS 
NOT DISTRIBUTED BY END OF FISCAL 
YEAR 2025.—If the aggregate number 
of positions distributed under this 
paragraph during the 5-year period of 
fiscal years 2021 through 2025 is less 
than 15,000, the Secretary shall, in 
accordance with the provisions of 
clause (ii) and subparagraph (D) and 
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the considerations and priority de-
scribed in subparagraph (C), conduct 
an application and distribution proc-
ess in each subsequent fiscal year 
until such time as the aggregate 
amount of positions distributed under 
this paragraph is equal to 15,000. 
‘‘(B) ALLOCATION OF DISTRIBUTION FOR 
POSITIONS TO HOSPITALS ALREADY OPERATING 
OVER RESIDENT LIMIT.— 
‘‘(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), in the case of a hospital in 
which the reference resident level of the 
hospital (as specified in subparagraph 
(G)(iii)) is greater than the otherwise ap-
plicable resident limit, the increase in the 
otherwise applicable resident limit under 
subparagraph (A) for a fiscal year de-
scribed in such subparagraph shall be an 
amount equal to the product of the total 
number of additional residency positions 
available for distribution under subpara-
graph (A)(ii)(I) for such fiscal year and 
the quotient of— 
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‘‘(I) the number of resident posi-
tions by which the reference resident 
level of the hospital exceeds the other-
wise applicable resident limit for the 
hospital; and 
‘‘(II) the number of resident po-
sitions by which the reference resident 
level of all such hospitals with respect 
to which an application is approved 
under this paragraph exceeds the oth-
erwise applicable resident limit for 
such hospitals. 
‘‘(ii) REQUIREMENTS.—A hospital de-
scribed in clause (i)— 
‘‘(I) is not eligible for an increase 
in the otherwise applicable resident 
limit under this subparagraph unless 
the amount by which the reference 
resident level of the hospital exceeds 
the otherwise applicable resident limit 
is not less than 10 and the hospital 
trains at least 25 percent of the full- 
time equivalent residents of the hos-
pital in primary care and general sur-
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gery (as of the date of enactment of 
this paragraph); and 
‘‘(II) shall continue to train at 
least 25 percent of the full-time equiv-
alent residents of the hospital in pri-
mary care and general surgery for the 
5-year period beginning on such date. 
In the case where the Secretary determines 
that a hospital described in clause (i) no 
longer meets the requirement of subclause 
(II), the Secretary may reduce the other-
wise applicable resident limit of the hos-
pital by the amount by which such limit 
was increased under this subparagraph. 
‘‘(iii) CLARIFICATION REGARDING ELI-
GIBILITY
FOR
OTHER
ADDITIONAL
RESI-
DENCY POSITIONS.—Nothing in this sub-
paragraph shall be construed as preventing 
a hospital described in clause (i) from ap-
plying for and receiving additional resi-
dency positions under this paragraph that 
are not reserved for distribution under this 
subparagraph. 
‘‘(C) DISTRIBUTION
OF
OTHER
POSI-
TIONS.—For purposes of determining an in-
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crease in the otherwise applicable resident limit 
under subparagraph (A) (other than such an in-
crease described in subparagraph (B)), the fol-
lowing shall apply: 
‘‘(i) CONSIDERATIONS
IN
DISTRIBU-
TION.—In determining for which hospitals 
such an increase is provided under sub-
paragraph (A), the Secretary shall take 
into account the demonstrated likelihood of 
the hospital filling the positions made 
available under this paragraph within the 
first 5 cost reporting periods beginning 
after the date the increase would be effec-
tive, as determined by the Secretary. 
‘‘(ii) PRIORITY
FOR
CERTAIN
HOS-
PITALS.—Subject to clause (iii), in deter-
mining for which hospitals such an in-
crease is provided, the Secretary shall dis-
tribute the increase in the following pri-
ority order: 
‘‘(I) First, to hospitals in States 
with— 
‘‘(aa) new medical schools 
that received ‘Candidate School’ 
status from the Liaison Com-
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Osteopathic Association Commis-
sion on Osteopathic College Ac-
creditation). 
‘‘(II) Second, to hospitals with 
which the Secretary cooperates under 
section 7302(d) of title 38, United 
States Code. 
‘‘(III) Third, to hospitals that 
emphasize training in community- 
based settings or in hospital out-
patient departments. 
‘‘(IV) Fourth, to hospitals that 
are not located in a rural area and op-
erate an approved medical residency 
training program (or rural track) in a 
rural area or an approved medical 
residency training program with an 
integrated rural track. 
‘‘(V) Fifth, to all other hospitals. 
‘‘(iii) DISTRIBUTION TO HOSPITALS IN 
HIGHER PRIORITY GROUP PRIOR TO DIS-
TRIBUTION IN LOWER PRIORITY GROUPS.— 
The Secretary may only distribute such an 
increase to a lower priority group under 
clause (ii) if all qualifying hospitals in the 
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higher priority group or groups have re-
ceived the maximum number of increases 
under such subparagraph that the hospital 
is eligible for under this paragraph for the 
fiscal year. 
‘‘(iv) REQUIREMENTS FOR USE OF AD-
DITIONAL POSITIONS.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), a hospital that receives 
such an increase shall ensure, during 
the 5-year period beginning on the ef-
fective date of such increase, that— 
‘‘(aa) not less than 50 per-
cent of the positions attributable 
to such increase that are used in 
a given year during such 5-year 
period are used to train full-time 
equivalent residents in a shortage 
specialty residency program (as 
defined in subparagraph (G)(iv)), 
as determined by the Secretary 
at the end of such 5-year period; 
‘‘(bb) the total number of 
full-time equivalent residents, ex-
cluding any additional positions 
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attributable to such increase, is 
not less than the average number 
of full-time equivalent residents 
during the 3 most recent cost re-
porting periods ending on or be-
fore the effective date of such in-
crease; and 
‘‘(cc) the ratio of full-time 
equivalent residents in a shortage 
specialty residency program (as 
so defined) is not less than the 
average ratio of full-time equiva-
lent residents in such a program 
during the 3 most recent cost re-
porting periods ending on or be-
fore the effective date of such in-
crease. 
‘‘(II) REDISTRIBUTION OF POSI-
TIONS
IF
HOSPITAL
NO
LONGER 
MEETS
CERTAIN
REQUIREMENTS.— 
With respect to each fiscal year de-
scribed in subparagraph (A), the Sec-
retary shall determine whether or not 
a hospital described in subclause (I) 
meets the requirements of such sub-
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clause. In the case that the Secretary 
determines that such a hospital does 
not meet such requirements, the Sec-
retary shall— 
‘‘(aa) reduce the otherwise 
applicable resident limit of the 
hospital by the amount by which 
such limit was increased under 
this paragraph; and 
‘‘(bb) provide for the dis-
tribution of positions attributable 
to such reduction in accordance 
with the requirements of this 
paragraph. 
‘‘(D) LIMITATION.—A hospital may not re-
ceive more than 75 full-time equivalent addi-
tional residency positions under this paragraph 
for any fiscal year. 
‘‘(E) APPLICATION
OF
PER
RESIDENT 
AMOUNTS
FOR
PRIMARY
CARE
AND
NONPRI-
MARY CARE.—With respect to additional resi-
dency positions in a hospital attributable to the 
increase provided under this paragraph, the ap-
proved FTE per resident amounts are deemed 
to be equal to the hospital per resident amounts 
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for primary care and nonprimary care com-
puted under paragraph (2)(D) for that hospital. 
‘‘(F) PERMITTING
FACILITIES
TO
APPLY 
AGGREGATION
RULES.—The Secretary shall 
permit hospitals receiving additional residency 
positions attributable to the increase provided 
under this paragraph to, beginning in the fifth 
year after the effective date of such increase, 
apply such positions to the limitation amount 
under paragraph (4)(F) that may be aggre-
gated pursuant to paragraph (4)(H) among 
members of the same affiliated group. 
‘‘(G) DEFINITIONS.—In this paragraph: 
‘‘(i) OTHERWISE
APPLICABLE
RESI-
DENT LIMIT.—The term ‘otherwise appli-
cable resident limit’ means, with respect to 
a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
graphs (7)(A), (7)(B), (8)(A), and (8)(B). 
‘‘(ii) REFERENCE RESIDENT LEVEL.— 
Except as otherwise provided in subclause 
(II), the term ‘reference resident level’ 
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means, with respect to a hospital, the resi-
dent level for the most recent cost report-
ing period of the hospital ending on or be-
fore the date of enactment of this para-
graph, for which a cost report has been 
settled (or, if not, submitted (subject to 
audit)), as determined by the Secretary. 
‘‘(iii) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i). 
‘‘(iv) SHORTAGE
SPECIALTY
RESI-
DENCY
PROGRAM.—The term ‘shortage 
specialty residency program’ means any 
approved residency training program in a 
specialty identified in the report entitled 
‘The Physician Workforce: Projections and 
Research into Current Issues Affecting 
Supply and Demand’, issued in December 
2008 by the Health Resources and Serv-
ices Administration, as a specialty whose 
baseline physician requirements projections 
exceed the projected supply of total active 
physicians for the period of 2005 through 
2020.’’. 
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(b) IME.—Section 1886(d)(5)(B) of the Social Secu-
rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 
(1) in clause (v), in the third sentence, by strik-
ing ‘‘subsections (h)(7) and (h)(8)’’ and inserting 
‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 
(2) by redesignating clause (x), as added by 
section 5505(b) of the Patient Protection and Af-
fordable Care Act (Public Law 111–148), as clause 
(xi) and moving such clause 4 ems to the left; and 
(3) by adding after clause (xi), as redesignated 
by subparagraph (A), the following new clause: 
‘‘(xii) For discharges occurring on or 
after July 1, 2021, insofar as an additional 
payment amount under this subparagraph 
is attributable to resident positions distrib-
uted to a hospital under subsection (h)(9), 
the indirect teaching adjustment factor 
shall be computed in the same manner as 
provided under clause (ii) with respect to 
such resident positions.’’. 
SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREAS-
ING DIVERSITY. 
(a) STUDY.—The Comptroller General of the United 
States (in this section referred to as the ‘‘Comptroller 
General’’) shall conduct a study on strategies for increas-
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ing the diversity of the health professional workforce. Such 
study shall include an analysis of strategies for increasing 
the number of health professionals from rural, lower in-
come, and underrepresented minority communities, includ-
ing which strategies are most effective for achieving such 
goal. 
(b) REPORT.—Not later than 2 years after the date 
of enactment of this Act, the Comptroller General shall 
submit to Congress a report on the study conducted under 
subsection (a), together with recommendations for such 
legislation and administrative action as the Comptroller 
General determines appropriate. 
Æ 
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