I 
114TH CONGRESS 
2D SESSION 
H. R. 4774 
To amend title XVIII of the Social Security Act to provide for the distribution 
of additional residency positions, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 17, 2016 
Ms. CASTOR of Florida introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on En-
ergy 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 title XVIII of the Social Security Act to provide 
for the distribution of additional residency positions, and 
for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Training Tomorrow’s Doctors Today Act’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Distribution of additional residency positions. 
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Sec. 3. Additional rules relating to application of 3-year rolling average for re-
distributed residency positions. 
Sec. 4. Rules for determining full-time equivalent residents. 
Sec. 5. Medicare GME treatment of hospitals establishing new medical resi-
dency training programs after hosting medical resident rotators 
for short durations. 
Sec. 6. Aggregation rules relating to applying limitation on number of resi-
dents. 
Sec. 7. Period of board eligibility for residents who change programs. 
Sec. 8. Medicare indirect medical education performance adjustment. 
Sec. 9. Increasing graduate medical education transparency. 
Sec. 10. GAO studies and reports. 
SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI-
TIONS. 
(a) DGME.—Section 1886(h) of the Social Security 
Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 
(8), and (9)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘para-
graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 
(8), and (9)’’; 
(3) in paragraph (7)(E), by inserting ‘‘para-
graph (9),’’ after ‘‘paragraph (8),’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY 
POSITIONS.— 
‘‘(A) 
ADDITIONAL
RESIDENCY
POSI-
TIONS.— 
‘‘(i) IN GENERAL.—For each of fiscal 
years 2017 through 2021 (and succeeding 
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fiscal years if the Secretary determines 
that there are additional residency posi-
tions available to distribute under clause 
(iv)(II)), the Secretary shall, subject to 
clause (ii) and subparagraph (D), increase 
the otherwise applicable resident limit for 
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). 
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‘‘(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. 
‘‘(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 
2017 through 2021. 
‘‘(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 
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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. 
‘‘(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 2021.—If the aggregate number 
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of positions distributed under this 
paragraph during the 5-year period of 
fiscal years 2017 through 2021 is less 
than 15,000, the Secretary shall, in 
accordance with the provisions of 
clause (ii) and subparagraph (D) and 
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 
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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— 
‘‘(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 
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is not less than 10 and the hospital 
trains at least 30 percent of the full- 
time equivalent residents of the hos-
pital in primary care and general sur-
gery (as of the date of enactment of 
this paragraph); and 
‘‘(II) shall continue to train at 
least 30 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 
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are not reserved for distribution under this 
subparagraph. 
‘‘(C) DISTRIBUTION
OF
OTHER
POSI-
TIONS.—For purposes of determining an in-
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: 
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‘‘(I) First, to hospitals with ap-
proved medical residency programs af-
filiated with medical schools that have 
at least 40 percent of graduates 
matched in primary care residency 
program in the 5 years prior. 
‘‘(II) Second, to hospitals in 
States with (aa) new medical schools 
that received Candidate School status 
from the Liaison Committee on Med-
ical Education or that received Pre- 
Accreditation status from the Amer-
ican Osteopathic Association Commis-
sion on Osteopathic College Accredita-
tion on or after January 1, 2000, and 
that have achieved or continue to 
progress toward Full Accreditation 
status (as such term is defined by the 
Liaison Committee on Medical Edu-
cation) or toward Accreditation status 
(as such term is defined by the Amer-
ican Osteopathic Association Commis-
sion on Osteopathic College Accredita-
tion), or (bb) additional locations and 
branch campuses established on or 
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after January 1, 2000, by medical 
schools with Full Accreditation status 
(as such term is defined by the Liai-
son Committee on Medical Education) 
or Accreditation status (as such term 
is defined by the American Osteo-
pathic Association Commission on Os-
teopathic College Accreditation). 
‘‘(III) Third, to hospitals with 
which the Secretary cooperates under 
section 7302(d) of title 38, United 
States Code. 
‘‘(IV) Fourth, to all other hos-
pitals. 
‘‘(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 
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. 
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‘‘(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)(v)), 
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 
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-
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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-
clause. In the case that the Secretary 
determines that such a hospital does 
not meet such requirements, the Sec-
retary shall— 
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‘‘(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 
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 
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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) PRIMARY CARE.—The term ‘pri-
mary care’ means family medicine, general 
internal medicine, general pediatrics, geri-
atrics, preventive medicine, obstetrics and 
gynecology, general surgery, and psychi-
atry. 
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‘‘(iii) 
REFERENCE
RESIDENT 
LEVEL.—Except as otherwise provided in 
subclause (II), the term ‘reference resident 
level’ means, with respect to a hospital, the 
resident level for the most recent cost re-
porting period of the hospital ending on or 
before 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. 
‘‘(iv) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i). 
‘‘(v) 
SHORTAGE
SPECIALTY
RESI-
DENCY
PROGRAM.—The term ‘shortage 
specialty residency program’ means the fol-
lowing: 
‘‘(I) 
PRIOR
TO
REPORT
ON 
SHORTAGE
SPECIALTIES.—Prior 
to 
the date on which the report is sub-
mitted under section 10(a) of the 
Training Tomorrow’s Doctors Today 
Act, any approved residency training 
program in a specialty identified in 
the report entitled ‘The Physician 
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Workforce: Projections and Research 
into Current Issues Affecting Supply 
and Demand’, issued in December 
2008 by the Health Resources and 
Services Administration, as a specialty 
whose baseline physician requirements 
projections exceed the projected sup-
ply of total active physicians for the 
period of 2005 through 2020. 
‘‘(II) AFTER REPORT ON SHORT-
AGE SPECIALITIES.—On or after the 
date on which the report is submitted 
under such section 5, any approved 
residency training program in a physi-
cian specialty identified in such report 
as a specialty for which there is a 
shortage.’’. 
(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 second sentence, by 
striking ‘‘subsections (h)(7) and (h)(8)’’ and insert-
ing ‘‘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-
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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, 2016, insofar as an additional payment amount 
under this subparagraph is attributable to resident 
positions distributed 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. ADDITIONAL RULES RELATING TO APPLICATION OF 
3-YEAR ROLLING AVERAGE FOR REDISTRIB-
UTED RESIDENCY POSITIONS. 
(a) ELIMINATION OF 3-YEAR ROLLING AVERAGE RE-
LATING
TO
REDISTRIBUTIONS
AFTER
A
HOSPITAL 
CLOSES AND UNDER PPACA REDISTRIBUTIONS.— 
(1) DGME.— 
(A) 
REDISTRIBUTION
OF
RESIDENCY 
SLOTS AFTER A HOSPITAL CLOSES.— 
(i) 
IN
GENERAL.—Section 
1886(h)(4)(H)(vi) of the Social Security 
Act (42 U.S.C. 1395ww(h)(4)(H)(vi)) is 
amended by adding at the end the fol-
lowing new subclause: 
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‘‘(VI) THREE-YEAR ROLLING AV-
ERAGE
INAPPLICABLE.—In applying 
subparagraph (G), in the case of addi-
tional residency positions in a hospital 
attributable to the increase in the oth-
erwise applicable resident limit pro-
vided under this paragraph pursuant 
to this clause, the reference to ‘the av-
erage of the actual full-time equiva-
lent resident counts for the cost re-
porting period and the preceding two 
cost 
reporting 
periods’ 
shall 
be 
deemed to be a reference to ‘the ac-
tual full-time equivalent residents 
count for the cost reporting period’.’’. 
(ii) EFFECTIVE
DATE.—The amend-
ment made by clause (i) shall apply with 
respect to hospitals with an approved med-
ical residency program that closes on or 
after March 23, 2008. 
(B) DISTRIBUTION OF ADDITIONAL RESI-
DENCY SLOTS UNDER PPACA.— 
(i) IN GENERAL.—Section 1886(h)(8) 
of the Social Security Act (42 U.S.C. 
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1395ww(h)(8)) is amended by adding at 
the end the following new subparagraph: 
‘‘(J) THREE-YEAR ROLLING AVERAGE IN-
APPLICABLE.—In applying paragraph (4)(G), in 
the case of additional residency positions in a 
hospital attributable to the increase in the oth-
erwise applicable resident limit provided under 
this paragraph, the reference to ‘the average of 
the actual full-time equivalent resident counts 
for the cost reporting period and the preceding 
two cost reporting periods’ shall be deemed to 
be a reference to ‘the actual full-time equivalent 
residents count for the cost reporting period’.’’. 
(ii) EFFECTIVE
DATE.—The amend-
ment made by clause (i) shall apply with 
respect to cost reporting periods occurring 
on or after July 1, 2011. 
(2) 3-YEAR
ROLLING
AVERAGE
AND
INTERN 
AND
RESIDENT
BED
RATIO
CAP
INAPPLICABLE 
UNDER IME.— 
(A) IN GENERAL.—Section 1886(d)(5)(B) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(d)(5)(B)), as amended by section 2(b), 
is further amended— 
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(i) in subclause (I) of clause (xi), as 
redesignated by section 2(b)(2), by striking 
‘‘The provisions’’ and inserting ‘‘Subject to 
clauses (xiii) and (xiv)’’; and 
(ii) by adding at the end the following 
new clauses: 
‘‘(xiii) In the case of additional resi-
dency positions in a hospital attributable 
to the increase in the otherwise applicable 
resident limit provided under subsection 
(h)(4)(H)(vi) or (h)(8), the provisions of 
clause (vi)(II) shall be applied by deeming 
the reference to ‘the average of the actual 
full-time equivalent resident count for the 
cost reporting period and the preceding 
two cost reporting periods’ to be a ref-
erence to ‘the actual full-time equivalent 
resident count for the cost reporting pe-
riod’. 
‘‘(xiv) In the case of additional resi-
dency positions in a hospital attributable 
to the increase in the otherwise applicable 
resident limit provided under subsection 
(h)(4)(H)(vi) or (h)(8), the ratio of the 
hospital’s full-time equivalent interns and 
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residents to beds shall be equal to the ratio 
for the hospital’s current cost reporting pe-
riod.’’. 
(B) EFFECTIVE DATE.—The amendments 
made by subparagraph (A) shall apply— 
(i) to the extent such amendments re-
late to section 1886(h)(4)(H)(vi) of the So-
cial Security Act, as if included in the en-
actment of section 5506 of the Patient 
Protection and Affordable Care Act; and 
(ii) to the extent such amendments re-
late to section 1886(h)(8) of the Social Se-
curity Act, as if included in the enactment 
of section 5503 of the Patient Protection 
and Affordable Care Act. 
(b) ELIMINATION
OF 3-YEAR ROLLING AVERAGE 
AND INTERN AND RESIDENT BED RATIO CAP BEGINNING 
IN 2015.— 
(1) DGME.—Section 1886(h)(4)(G) of the So-
cial Security Act (42 U.S.C. 1395ww(h)(4)(G)) is 
amended— 
(A) in clause (i), by inserting ‘‘and before 
December 31, 2014,’’ after ‘‘October 1, 1997,’’; 
and 
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(B) by adding at the end the following new 
clause: 
‘‘(iv) CURRENT YEAR COUNT USED TO 
DETERMINE FULL-TIME EQUIVALENT RESI-
DENT COUNT.—For cost reporting periods 
beginning on or after December 31, 2014, 
subject to the limit described in subpara-
graph (F), the total number of full-time 
equivalent residents for determining a hos-
pital’s graduate medical education payment 
shall equal the actual full-time equivalent 
residents count for the hospital’s cost re-
porting period.’’. 
(2) IME.—Section 1886(d)(5)(B) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(B)), as 
amended by subsection (b), is further amended by 
adding at the end the following new clauses: 
‘‘(xv) For cost reporting periods be-
ginning on or after December 31, 2014, 
subject to the limits described in clauses 
(iv) and (v), the total number of full-time 
equivalent residents for payment purposes 
shall equal the actual full-time equivalent 
resident count for the hospital’s cost re-
porting period. 
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‘‘(xvi) For cost reporting periods be-
ginning on or after December 31, 2014, 
the ratio of the hospital’s full-time equiva-
lent interns and residents to beds shall be 
equal to the ratio for the hospital’s cost re-
porting period.’’. 
SEC. 4. RULES FOR DETERMINING FULL-TIME EQUIVALENT 
RESIDENTS. 
(a) DGME.—Section 1886(h)(4) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)(4)) is amended— 
(1) in subparagraph (E), by striking ‘‘Subject 
to subparagraphs (J) and (K), such rules’’ and in-
serting ‘‘Subject to subparagraphs (J), (K), and (L), 
such rules’’; 
(2) in subparagraph (J), by striking ‘‘Such 
rules’’ and inserting ‘‘Subject to subparagraph (L), 
such rules’’; 
(3) in subparagraph (K), by striking ‘‘In deter-
mining’’ and inserting ‘‘Subject to subparagraph 
(L), in determining’’; and 
(4) by adding at the end the following new sub-
paragraph: 
‘‘(L) TREATMENT OF TIME SPENT IN AP-
PROVED MEDICAL RESIDENCY TRAINING PRO-
GRAM
WITH
RESPECT
TO
CERTAIN
HOS-
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PITALS.—For purposes of cost reporting peri-
ods beginning on or after July 1, 2017, in de-
termining the number of full-time equivalent 
residents of the hospital for purposes of this 
paragraph, all the time spent by an intern or 
resident in an approved medical residency train-
ing program, regardless of setting, shall be 
counted toward the determination of full-time 
equivalency, and subparagraphs (J) and (K) 
shall not apply, if the hospital— 
‘‘(i) is recognized as a subsection (d) 
hospital; 
‘‘(ii) is recognized as a subsection (d) 
Puerto Rico hospital; 
‘‘(iii) is reimbursed under a reim-
bursement system authorized under section 
1814(b)(3); or 
‘‘(iv) is a provider-based hospital out-
patient department.’’. 
(b) IME.—The second clause (x) of section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) is amended— 
(1) in subclause (II), by striking ‘‘In deter-
mining’’ and inserting ‘‘Subject to subclause (x)(IV), 
in determining’’; 
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(2) in subclause (III), by striking ‘‘In deter-
mining’’ and inserting ‘‘Subject to subclause (x)(IV), 
in determining’’; and 
(3) by adding at the end the following new sub-
clause: 
‘‘(IV) The provisions of subpara-
graph (L) of subsection (h)(4) shall 
apply under this subparagraph in the 
same manner as they apply under 
such subsection.’’. 
SEC. 5. MEDICARE GME TREATMENT OF HOSPITALS ESTAB-
LISHING NEW MEDICAL RESIDENCY TRAIN-
ING PROGRAMS AFTER HOSTING MEDICAL 
RESIDENT ROTATORS FOR SHORT DURA-
TIONS. 
(a) REDETERMINATION OF APPROVED FTE RESI-
DENT AMOUNT.—Section 1886(h)(2)(F) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)(2)(F)) is amended— 
(1) by inserting ‘‘(i)’’ before ‘‘In the case of’’; 
and 
(2) by adding at the end the following: 
‘‘(ii) In applying this subparagraph to 
a hospital that has not entered into a 
GME affiliation agreement (as defined by 
the Secretary for purposes of paragraph 
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(4)(H)(ii)), the Secretary shall not provide 
for the establishment of an FTE resident 
amount until such time as the Secretary 
determines that the hospital has a medical 
residency training program that trains 
more than 1.0 full-time-equivalent resident 
in a cost reporting period. 
‘‘(iii) In the case of a hospital with an 
approved FTE resident amount— 
‘‘(I) based on the training of less 
than 1.0 full-time-equivalent resident 
before October 1, 1997, or 
‘‘(II) based on the training of no 
more than 3.0 full-time-equivalent 
residents in a new medical residency 
training program in any cost report-
ing period beginning on or after Octo-
ber 1, 1997, and before the date of 
the enactment of this clause, 
the Secretary shall provide the hospital an 
opportunity to have a new FTE resident 
amount established when the hospital be-
gins training at least 1.0 full-time equiva-
lent resident (in the case of a hospital de-
scribed in subclause (I)) or more than 3.0 
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resented minority communities, including which 
strategies are most effective for achieving such goal. 
(2) REPORT.—Not later than 2 years after the 
date of enactment of this Act, the Comptroller Gen-
eral shall submit to Congress a report on the study 
conducted under subsection (a), together with rec-
ommendations for such legislation and administra-
tive action as the Comptroller General determines 
appropriate. 
(c) ON PROTECTING OLDER ADULTS.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study that addresses 
the competency of the physician workforce to care 
for older adults upon the completion of such 
workforce’s residency training. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report on such 
study, including such recommendations for legisla-
tion and administrative action as the Comptroller 
General determines appropriate based on such study. 
Æ 
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