I 
108TH CONGRESS 
2D SESSION 
H. R. 4578
To reauthorize the Children’s Hospitals Graduate Medical Education 
Program. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 15, 2004
Mrs. JOHNSON of Connecticut (for herself, Ms. PRYCE of Ohio, Mr. BROWN 
of Ohio, Mr. GREENWOOD, Mr. RAMSTAD, Mr. BURR, Ms. ESHOO, Mrs. 
BONO, Mr. MCINNIS, Mr. SHAYS, Mr. NORWOOD, Mr. CAMP, Ms. DUNN, 
and Mr. WAXMAN) introduced the following bill; which was referred to 
the Committee on Energy and Commerce 
A BILL 
To reauthorize the Children’s Hospitals Graduate Medical 
Education Program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Children’s Hospitals 
Education Equity and Research (CHEER) Act of 2004’’.
‘‘(A) the product of—
‘‘(i) the updated per resident’’; 
(C) by redesignating subparagraph (B) as 
clause (ii) and indenting appropriately; 
(D) in subparagraph (A)(ii) (as so redesig-
nated)—
(i) by inserting ‘‘, but without giving 
effect to section 1886(h)(7) of such Act)’’ 
after ‘‘section 1886(h)(4) of the Social Se-
curity Act’’; and 
(ii) by striking the period and insert-
ing ‘‘; and’’; and 
(E) by inserting after subparagraph (A) 
the following: 
‘‘(B) amounts for other approved edu-
cation programs that are provider-operated, as 
defined for purposes of Medicare payment, lim-
ited to not more than 30 percent of costs that 
would be allowed for such programs under 
Medicare rules for hospitals reimbursed under 
section 1886(d) of the Social Security Act.’’; 
and 
(2) in paragraph (2)(B), by inserting before the 
period at the end ‘‘, without giving effect to section 
1886(d)(3)(E)(ii) of the Social Security Act’’.
(d) INDIRECT GRADUATE MEDICAL EDUCATION.—
Section 340E(d) of the Public Health Service Act (42 
U.S.C. 256e(d)) is amended—
(1) in paragraph (1), by striking ‘‘related to’’ 
and inserting ‘‘associated with’’; and 
(2) in paragraph (2)(A)—
(A) by inserting ‘‘ratio of the’’ after ‘‘hos-
pitals and the’’; and 
(B) by inserting at the end before the 
semicolon ‘‘to beds (but excluding beds or bassi-
nets assigned to healthy newborn infants)’’. 
(e) NATURE OF PAYMENTS.—Section 340E(e) of the 
Public Health Service Act (42 U.S.C. 256e(e)) is amend-
ed—
(1) in paragraph (2), by striking the first sen-
tence; 
(2) in paragraph (3), by striking ‘‘recoup any 
overpayments made to pay any balance due to the 
extent possible’’ and all that follows through the end 
of the paragraph and inserting the following: ‘‘re-
coup any overpayments made and pay any balance 
due. To the greatest extent possible, amounts re-
couped from a hospital are to be distributed to other 
hospitals in the same fiscal year. Amounts recouped 
from a hospital and not disbursed to other hospitals
in the same fiscal year shall remain available for dis-
tribution during the subsequent fiscal year. Unless 
there is fraud, amounts paid to a hospital without 
a demand for recoupment by the end of the fiscal 
year shall be final and not subject to recoupment.’’; 
and 
(3) by adding at the end the following: 
‘‘(4) APPEALS.—
‘‘(A) IN
GENERAL.—A decision affecting 
the amount payable to a hospital pursuant to 
this section shall—
‘‘(i) be subject to review under section 
1878 of the Social Security Act in the 
same manner as final determinations of a 
fiscal intermediary of the amount of pay-
ment under section 1886(d) of such Act 
are subject to review; and 
‘‘(ii) be handled expeditiously so that 
the review decision is reflected in the final 
reconciliation for the year in which the ap-
peal is made. 
‘‘(B) LIMITATION.—A review decision pur-
suant to this section shall not affect payments 
for a fiscal year prior to the fiscal year in which 
the review decision is rendered.
‘‘(C) APPLICATION TO SUBSEQUENT FIS-
CAL YEARS.—The Secretary shall apply a re-
view decision in determining the amount of pay-
ment for the appealing hospital in the fiscal 
year in which the decision is rendered and in 
subsequent years, unless the law at issue in the 
review decision is amended or there are mate-
rial differences between the facts for the fiscal 
year for which the review decision is rendered 
and the year for which payment is made. Noth-
ing in this section shall be construed to prohibit 
a hospital from appealing similar determina-
tions in subsequent periods.’’. 
(f) AUTHORIZATION OF APPROPRIATIONS.—Section 
340E(f) of the Public Health Service Act (42 U.S.C. 
256e(f)) is amended—
(1) in paragraph (1)—
(A) in subparagraph (A)—
(i) in clause (ii), by striking ‘‘and’’; 
(ii) in clause (iii), by striking the pe-
riod at the end and inserting a semicolon; 
and 
(iii) by adding at the end the fol-
lowing:
‘‘(iv) 
for 
fiscal 
year 
2006, 
$110,000,000; and 
‘‘(v) for each of fiscal years 2007 
through 2010, such sums as may be nec-
essary, including an annual adjustment to 
reflect increases in the Consumer Price 
Index.’’; and 
(B) in subparagraph (B), by striking ‘‘for 
fiscal year 2000’’ and all that follows and in-
serting ‘‘for fiscal year 2006 and each subse-
quent fiscal year shall remain available for obli-
gation for the year appropriated and the subse-
quent fiscal year.’’; and 
(2) in paragraph (2)—
(A) by redesignating subparagraphs (A), 
(B), and (C) as clauses (i), (ii), and (iii), re-
spectively, and indenting appropriately; 
(B) by striking ‘‘There are hereby author-
ized’’ and inserting the following: 
‘‘(A) IN
GENERAL.—There are author-
ized’’; 
(C) in clause (ii) (as redesignated by this 
paragraph), by striking ‘‘and’’;
(D) in clause (iii) (as redesignated by this 
paragraph), by striking the period at the end 
and inserting a semicolon; 
(E) by adding at the end of subparagraph 
(A) (as designated by this paragraph), the fol-
lowing: 
‘‘(iv) 
for 
fiscal 
year 
2006, 
$220,000,000; and 
‘‘(v) for each of fiscal years 2007 
through 2010, such sums as may be nec-
essary, including an annual adjustment to 
reflect increases in the Consumer Price 
Index.’’; and 
(F) at the end of paragraph (2), by adding 
the following: 
‘‘(B) CARRYOVER OF EXCESS.—To the ex-
tent that amounts are not expended in the year 
for which they are appropriated, the amounts 
appropriated under subparagraph (A) for fiscal 
year 2006 and each subsequent fiscal year shall 
remain available for obligation through the end 
of the following fiscal year.’’. 
(g) 
DEFINITIONS.—Paragraph 
(3) 
of 
section 
340E(g) of the Public Health Service Act (42 U.S.C.
256e(g)) is amended by striking ‘‘has’’ and all that follows 
through the end of the sentence and inserting ‘‘—
‘‘(A) has the meaning given such term in 
section 1886(h)(5)(C) of the Social Security 
Act; and 
‘‘(B) includes costs of approved edu-
cational activities, as such term is used in sec-
tion 1886(a)(4) of the Social Security Act.’’.
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