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‘‘(B) total payments may not exceed 
$80,000 during the 2010 and 2011 fiscal years 
(adjusted for subsequent fiscal years as provided 
for in the same manner as in paragraph (2)(B)). 
‘‘(d) BREACH OF AGREEMENT.— 
‘‘(1) IN GENERAL.—In the case of any agreement 
made under subsection (b), the individual is liable to 
the Federal Government for the total amount paid by 
the Secretary under such agreement, and for interest 
on such amount at the maximum legal prevailing 
rate, if the individual fails to meet the agreement 
terms required under such subsection. 
‘‘(2) WAIVER OR SUSPENSION OF LIABILITY.—In 
the case of an individual making an agreement for 
purposes of paragraph (1), the Secretary shall provide 
for the waiver or suspension of liability under such 
paragraph if compliance by the individual with the 
agreement involved is impossible or would involve ex-
treme hardship to the individual or if enforcement of 
the agreement with respect to the individual would be 
unconscionable. 
‘‘(3) DATE CERTAIN FOR RECOVERY.—Subject to 
paragraph (2), any amount that the Federal Govern-
ment is entitled to recover under paragraph (1) shall 
be paid to the United States not later than the expi-
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ration of the 3-year period beginning on the date the 
United States becomes so entitled. 
‘‘(4) AVAILABILITY.—Amounts recovered under 
paragraph (1) shall be available to the Secretary for 
making loan repayments under this section and shall 
remain available for such purpose until expended. 
‘‘(e) ELIGIBLE INDIVIDUAL DEFINED.—For purposes 
of this section, the term ‘eligible individual’ means an indi-
vidual who— 
‘‘(1) is a United States citizen, national, or law-
ful permanent resident; 
‘‘(2) holds an unencumbered license as a reg-
istered nurse; and 
‘‘(3) has either already completed a master’s or 
doctorate nursing program at an accredited school of 
nursing or is currently enrolled on a full-time or 
part-time basis in such a program. 
‘‘(f) PRIORITY.—For the purposes of this section and 
section 846A, funding priority will be awarded to School 
of Nursing Student Loans that support doctoral nursing 
students or Individual Student Loan Repayment that sup-
port doctoral nursing students. 
‘‘(g) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section
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such sums as may be necessary for each of fiscal years 2010 
through 2014.’’. 
SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR 
PARTS B THROUGH D OF TITLE VIII. 
Section 871 of the Public Health Service Act, as redes-
ignated and moved by section 5310, is amended to read as 
follows: 
‘‘SEC. 871. AUTHORIZATION OF APPROPRIATIONS. 
‘‘For the purpose of carrying out parts B, C, and D 
(subject to section 851(g)), there are authorized to be appro-
priated $338,000,000 for fiscal year 2010, and such sums 
as may be necessary for each of the fiscal years 2011 
through 2016.’’. 
SEC. 5313. GRANTS TO PROMOTE THE COMMUNITY HEALTH 
WORKFORCE. 
(a) IN GENERAL.—Part P of title III of the Public 
Health Service Act (42 U.S.C. 280g et seq.) is amended by 
adding at the end the following: 
‘‘SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BE-
HAVIORS AND OUTCOMES. 
‘‘(a) GRANTS AUTHORIZED.—The Director of the Cen-
ters for Disease Control and Prevention, in collaboration 
with the Secretary, shall award grants to eligible entities 
to promote positive health behaviors and outcomes for popu-
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lations in medically underserved communities through the 
use of community health workers. 
‘‘(b) USE OF FUNDS.—Grants awarded under sub-
section (a) shall be used to support community health work-
ers— 
‘‘(1) to educate, guide, and provide outreach in 
a community setting regarding health problems prev-
alent in medically underserved communities, particu-
larly racial and ethnic minority populations; 
‘‘(2) to educate and provide guidance regarding 
effective strategies to promote positive health behav-
iors and discourage risky health behaviors; 
‘‘(3) to educate and provide outreach regarding 
enrollment in health insurance including the Chil-
dren’s Health Insurance Program under title XXI of 
the Social Security Act, Medicare under title XVIII 
of such Act and Medicaid under title XIX of such Act; 
‘‘(4) to identify, educate, refer, and enroll under-
served populations to appropriate healthcare agencies 
and community-based programs and organizations in 
order to increase access to quality healthcare services 
and to eliminate duplicative care; or 
‘‘(5) to educate, guide, and provide home visita-
tion services regarding maternal health and prenatal 
care.
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‘‘(c) APPLICATION.—Each eligible entity that desires 
to receive a grant under subsection (a) shall submit an ap-
plication to the Secretary, at such time, in such manner, 
and accompanied by such information as the Secretary 
may require. 
‘‘(d) PRIORITY.—In awarding grants under subsection 
(a), the Secretary shall give priority to applicants that— 
‘‘(1) propose to target geographic areas— 
‘‘(A) with a high percentage of residents 
who are eligible for health insurance but are un-
insured or underinsured; 
‘‘(B) with a high percentage of residents 
who suffer from chronic diseases; or 
‘‘(C) with a high infant mortality rate; 
‘‘(2) have experience in providing health or 
health-related social services to individuals who are 
underserved with respect to such services; and 
‘‘(3) have documented community activity and 
experience with community health workers. 
‘‘(e) COLLABORATION WITH ACADEMIC INSTITUTIONS 
AND THE ONE-STOP DELIVERY SYSTEM.—The Secretary 
shall encourage community health worker programs receiv-
ing funds under this section to collaborate with academic 
institutions and one-stop delivery systems under section 
134(c) of the Workforce Investment Act of 1998. Nothing
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in this section shall be construed to require such collabora-
tion. 
‘‘(f) EVIDENCE-BASED
INTERVENTIONS.—The Sec-
retary shall encourage community health worker programs 
receiving funding under this section to implement a process 
or an outcome-based payment system that rewards commu-
nity health workers for connecting underserved populations 
with the most appropriate services at the most appropriate 
time. Nothing in this section shall be construed to require 
such a payment. 
‘‘(g) QUALITY ASSURANCE
AND COST EFFECTIVE-
NESS.—The Secretary shall establish guidelines for assuring 
the quality of the training and supervision of community 
health workers under the programs funded under this sec-
tion and for assuring the cost-effectiveness of such programs. 
‘‘(h) MONITORING.—The Secretary shall monitor com-
munity health worker programs identified in approved ap-
plications under this section and shall determine whether 
such programs are in compliance with the guidelines estab-
lished under subsection (g). 
‘‘(i) TECHNICAL ASSISTANCE.—The Secretary may 
provide technical assistance to community health worker 
programs identified in approved applications under this 
section with respect to planning, developing, and operating 
programs under the grant.
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‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—There are 
authorized to be appropriated, such sums as may be nec-
essary to carry out this section for each of fiscal years 2010 
through 2014. 
‘‘(k) DEFINITIONS.—In this section: 
‘‘(1) COMMUNITY HEALTH WORKER.—The term 
‘community health worker’, as defined by the Depart-
ment of Labor as Standard Occupational Classifica-
tion [21–1094] means an individual who promotes 
health or nutrition within the community in which 
the individual resides— 
‘‘(A) by serving as a liaison between com-
munities and healthcare agencies; 
‘‘(B) by providing guidance and social as-
sistance to community residents; 
‘‘(C) by enhancing community residents’ 
ability 
to 
effectively 
communicate 
with 
healthcare providers; 
‘‘(D) by providing culturally and linguis-
tically appropriate health or nutrition edu-
cation; 
‘‘(E) by advocating for individual and com-
munity health; 
‘‘(F) by providing referral and follow-up 
services or otherwise coordinating care; and
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‘‘(G) by proactively identifying and enroll-
ing eligible individuals in Federal, State, local, 
private or nonprofit health and human services 
programs. 
‘‘(2) COMMUNITY SETTING.—The term ‘commu-
nity setting’ means a home or a community organiza-
tion located in the neighborhood in which a partici-
pant in the program under this section resides. 
‘‘(3) ELIGIBLE ENTITY.—The term ‘eligible enti-
ty’ means a public or nonprofit private entity (in-
cluding a State or public subdivision of a State, a 
public health department, a free health clinic, a hos-
pital, or a Federally-qualified health center (as de-
fined in section 1861(aa) of the Social Security Act)), 
or a consortium of any such entities. 
‘‘(4) MEDICALLY UNDERSERVED COMMUNITY.— 
The term ‘medically underserved community’ means a 
community identified by a State— 
‘‘(A) that has a substantial number of indi-
viduals who are members of a medically under-
served 
population, 
as 
defined 
by 
section 
330(b)(3); and 
‘‘(B) a significant portion of which is a 
health professional shortage area as designated 
under section 332.’’.
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SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH. 
Part E of title VII of the Public Health Service Act 
(42 U.S.C. 294n et seq.), as amended by section 5206, is 
further amended by adding at the end the following: 
‘‘SEC. 778. FELLOWSHIP TRAINING IN APPLIED PUBLIC 
HEALTH 
EPIDEMIOLOGY, 
PUBLIC 
HEALTH 
LABORATORY 
SCIENCE, 
PUBLIC 
HEALTH 
INFORMATICS, AND EXPANSION OF THE EPI-
DEMIC INTELLIGENCE SERVICE. 
‘‘(a) IN GENERAL.—The Secretary may carry out ac-
tivities to address documented workforce shortages in State 
and local health departments in the critical areas of applied 
public health epidemiology and public health laboratory 
science and informatics and may expand the Epidemic In-
telligence Service. 
‘‘(b) SPECIFIC USES.—In carrying out subsection (a), 
the Secretary shall provide for the expansion of existing fel-
lowship programs operated through the Centers for Disease 
Control and Prevention in a manner that is designed to 
alleviate shortages of the type described in subsection (a). 
‘‘(c) OTHER PROGRAMS.—The Secretary may provide 
for the expansion of other applied epidemiology training 
programs that meet objectives similar to the objectives of 
the programs described in subsection (b). 
‘‘(d) WORK OBLIGATION.—Participation in fellowship 
training programs under this section shall be deemed to be
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service for purposes of satisfying work obligations stipulated 
in contracts under section 338I(j). 
‘‘(e) GENERAL SUPPORT.—Amounts may be used from 
grants awarded under this section to expand the Public 
Health Informatics Fellowship Program at the Centers for 
Disease Control and Prevention to better support all public 
health systems at all levels of government. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are 
authorized to be appropriated to carry out this section 
$39,500,000 for each of fiscal years 2010 through 2013, of 
which— 
‘‘(1) $5,000,000 shall be made available in each 
such fiscal year for epidemiology fellowship training 
program activities under subsections (b) and (c); 
‘‘(2) $5,000,000 shall be made available in each 
such fiscal year for laboratory fellowship training 
programs under subsection (b); 
‘‘(3) $5,000,000 shall be made available in each 
such fiscal year for the Public Health Informatics 
Fellowship Program under subsection (e); and 
‘‘(4) $24,500,000 shall be made available for ex-
panding the Epidemic Intelligence Service under sub-
section (a).’’.
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SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES 
TRACK. 
Title II of the Public Health Service Act (42 U.S.C. 
202 et seq.) is amended by adding at the end the following: 
‘‘PART D—UNITED STATES PUBLIC HEALTH 
SCIENCES TRACK 
‘‘SEC. 271. ESTABLISHMENT. 
‘‘(a) UNITED STATES PUBLIC HEALTH SERVICES 
TRACK.— 
‘‘(1) IN GENERAL.—There is hereby authorized to 
be established a United States Public Health Sciences 
Track (referred to in this part as the ‘Track’), at sites 
to be selected by the Secretary, with authority to 
grant appropriate advanced degrees in a manner that 
uniquely emphasizes team-based service, public health, 
epidemiology, and emergency preparedness and re-
sponse. It shall be so organized as to graduate not less 
than— 
‘‘(A) 150 medical students annually, 10 of 
whom shall be awarded studentships to the Uni-
formed Services University of Health Sciences; 
‘‘(B) 100 dental students annually; 
‘‘(C) 250 nursing students annually; 
‘‘(D) 100 public health students annually; 
‘‘(E) 100 behavioral and mental health pro-
fessional students annually;
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‘‘(F) 100 physician assistant or nurse prac-
titioner students annually; and 
‘‘(G) 50 pharmacy students annually. 
‘‘(2) LOCATIONS.—The Track shall be located at 
existing and accredited, affiliated health professions 
education training programs at academic health cen-
ters located in regions of the United States deter-
mined appropriate by the Surgeon General, in con-
sultation with the National Health Care Workforce 
Commission established in section 5101 of the Patient 
Protection and Affordable Care Act. 
‘‘(b) NUMBER OF GRADUATES.—Except as provided in 
subsection (a), the number of persons to be graduated from 
the Track shall be prescribed by the Secretary. In so pre-
scribing the number of persons to be graduated from the 
Track, the Secretary shall institute actions necessary to en-
sure the maximum number of first-year enrollments in the 
Track consistent with the academic capacity of the affili-
ated sites and the needs of the United States for medical, 
dental, and nursing personnel. 
‘‘(c) DEVELOPMENT.—The development of the Track 
may be by such phases as the Secretary may prescribe sub-
ject to the requirements of subsection (a). 
‘‘(d) INTEGRATED LONGITUDINAL PLAN.—The Sur-
geon General shall develop an integrated longitudinal plan
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for health professions continuing education throughout the 
continuum of health-related education, training, and prac-
tice. Training under such plan shall emphasize patient-cen-
tered, interdisciplinary, and care coordination skills. Expe-
rience with deployment of emergency response teams shall 
be included during the clinical experiences. 
‘‘(e) FACULTY DEVELOPMENT.—The Surgeon General 
shall develop faculty development programs and curricula 
in decentralized venues of health care, to balance urban, ter-
tiary, and inpatient venues. 
‘‘SEC. 272. ADMINISTRATION. 
‘‘(a) IN GENERAL.—The business of the Track shall be 
conducted by the Surgeon General with funds appropriated 
for and provided by the Department of Health and Human 
Services. The National Health Care Workforce Commission 
shall assist the Surgeon General in an advisory capacity. 
‘‘(b) FACULTY.— 
‘‘(1) IN GENERAL.—The Surgeon General, after 
considering the recommendations of the National 
Health Care Workforce Commission, shall obtain the 
services of such professors, instructors, and adminis-
trative and other employees as may be necessary to 
operate the Track, but utilize when possible, existing 
affiliated health professions training institutions. 
Members of the faculty and staff shall be employed
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under salary schedules and granted retirement and 
other related benefits prescribed by the Secretary so as 
to place the employees of the Track faculty on a com-
parable basis with the employees of fully accredited 
schools of the health professions within the United 
States. 
‘‘(2) TITLES.—The Surgeon General may confer 
academic titles, as appropriate, upon the members of 
the faculty. 
‘‘(3) NONAPPLICATION OF PROVISIONS.—The lim-
itations in section 5373 of title 5, United States Code, 
shall not apply to the authority of the Surgeon Gen-
eral under paragraph (1) to prescribe salary schedules 
and other related benefits. 
‘‘(c) AGREEMENTS.—The Surgeon General may nego-
tiate agreements with agencies of the Federal Government 
to utilize on a reimbursable basis appropriate existing Fed-
eral medical resources located in the United States (or loca-
tions selected in accordance with section 271(a)(2)). Under 
such agreements the facilities concerned will retain their 
identities and basic missions. The Surgeon General may ne-
gotiate affiliation agreements with accredited universities 
and health professions training institutions in the United 
States. Such agreements may include provisions for pay-
ments for educational services provided students partici-
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pating in Department of Health and Human Services edu-
cational programs. 
‘‘(d) PROGRAMS.—The Surgeon General may establish 
the following educational programs for Track students: 
‘‘(1) Postdoctoral, postgraduate, and techno-
logical programs. 
‘‘(2) A cooperative program for medical, dental, 
physician assistant, pharmacy, behavioral and men-
tal health, public health, and nursing students. 
‘‘(3) Other programs that the Surgeon General 
determines necessary in order to operate the Track in 
a cost-effective manner. 
‘‘(e) CONTINUING MEDICAL EDUCATION.—The Sur-
geon General shall establish programs in continuing med-
ical education for members of the health professions to the 
end that high standards of health care may be maintained 
within the United States. 
‘‘(f) AUTHORITY OF THE SURGEON GENERAL.— 
‘‘(1) IN GENERAL.—The Surgeon General is au-
thorized— 
‘‘(A) to enter into contracts with, accept 
grants from, and make grants to any nonprofit 
entity for the purpose of carrying out cooperative 
enterprises in medical, dental, physician assist-
ant, pharmacy, behavioral and mental health,
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public health, and nursing research, consulta-
tion, and education; 
‘‘(B) to enter into contracts with entities 
under which the Surgeon General may furnish 
the services of such professional, technical, or 
clerical personnel as may be necessary to fulfill 
cooperative enterprises undertaken by the Track; 
‘‘(C) to accept, hold, administer, invest, and 
spend any gift, devise, or bequest of personal 
property made to the Track, including any gift, 
devise, or bequest for the support of an academic 
chair, teaching, research, or demonstration 
project; 
‘‘(D) to enter into agreements with entities 
that may be utilized by the Track for the purpose 
of enhancing the activities of the Track in edu-
cation, research, and technological applications 
of knowledge; and 
‘‘(E) to accept the voluntary services of 
guest scholars and other persons. 
‘‘(2) LIMITATION.—The Surgeon General may 
not enter into any contract with an entity if the con-
tract would obligate the Track to make outlays in ad-
vance of the enactment of budget authority for such 
outlays.
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‘‘(3) SCIENTISTS.—Scientists or other medical, 
dental, or nursing personnel utilized by the Track 
under an agreement described in paragraph (1) may 
be appointed to any position within the Track and 
may be permitted to perform such duties within the 
Track as the Surgeon General may approve. 
‘‘(4) VOLUNTEER SERVICES.—A person who pro-
vides voluntary services under the authority of sub-
paragraph (E) of paragraph (1) shall be considered 
to be an employee of the Federal Government for the 
purposes of chapter 81 of title 5, relating to com-
pensation for work-related injuries, and to be an em-
ployee of the Federal Government for the purposes of 
chapter 171 of title 28, relating to tort claims. Such 
a person who is not otherwise employed by the Fed-
eral Government shall not be considered to be a Fed-
eral employee for any other purpose by reason of the 
provision of such services. 
‘‘SEC. 273. STUDENTS; SELECTION; OBLIGATION. 
‘‘(a) STUDENT SELECTION.— 
‘‘(1) IN GENERAL.—Medical, dental, physician 
assistant, pharmacy, behavioral and mental health, 
public health, and nursing students at the Track shall 
be selected under procedures prescribed by the Sur-
geon General. In so prescribing, the Surgeon General
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shall consider the recommendations of the National 
Health Care Workforce Commission. 
‘‘(2) PRIORITY.—In developing admissions pro-
cedures under paragraph (1), the Surgeon General 
shall ensure that such procedures give priority to ap-
plicant medical, dental, physician assistant, phar-
macy, behavioral and mental health, public health, 
and nursing students from rural communities and 
underrepresented minorities. 
‘‘(b) CONTRACT AND SERVICE OBLIGATION.— 
‘‘(1) CONTRACT.—Upon being admitted to the 
Track, a medical, dental, physician assistant, phar-
macy, behavioral and mental health, public health, or 
nursing student shall enter into a written contract 
with the Surgeon General that shall contain— 
‘‘(A) an agreement under which— 
‘‘(i) subject to subparagraph (B), the 
Surgeon General agrees to provide the stu-
dent with tuition (or tuition remission) and 
a student stipend (described in paragraph 
(2)) in each school year for a period of 
years (not to exceed 4 school years) deter-
mined by the student, during which period 
the student is enrolled in the Track at an 
affiliated or other participating health pro-
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fessions institution pursuant to an agree-
ment between the Track and such institu-
tion; and 
‘‘(ii) subject to subparagraph (B), the 
student agrees— 
‘‘(I) to accept the provision of 
such tuition and student stipend to the 
student; 
‘‘(II) to maintain enrollment at 
the Track until the student completes 
the course of study involved; 
‘‘(III) while enrolled in such 
course of study, to maintain an accept-
able level of academic standing (as de-
termined by the Surgeon General); 
‘‘(IV) if pursuing a degree from a 
school of medicine or osteopathic medi-
cine, dental, public health, or nursing 
school or a physician assistant, phar-
macy, or behavioral and mental health 
professional program, to complete a 
residency or internship in a specialty 
that the Surgeon General determines is 
appropriate; and
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‘‘(V) to serve for a period of time 
(referred to in this part as the ‘period 
of obligated service’) within the Com-
missioned Corps of the Public Health 
Service equal to 2 years for each school 
year during which such individual was 
enrolled at the College, reduced as pro-
vided for in paragraph (3); 
‘‘(B) a provision that any financial obliga-
tion of the United States arising out of a con-
tract entered into under this part and any obli-
gation of the student which is conditioned there-
on, is contingent upon funds being appropriated 
to carry out this part; 
‘‘(C) a statement of the damages to which 
the United States is entitled for the student’s 
breach of the contract; and 
‘‘(D) such other statements of the rights and 
liabilities of the Secretary and of the individual, 
not inconsistent with the provisions of this part. 
‘‘(2) TUITION AND STUDENT STIPEND.— 
‘‘(A) TUITION REMISSION RATES.—The Sur-
geon General, based on the recommendations of 
the National Health Care Workforce Commis-
sion, shall establish Federal tuition remission
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rates to be used by the Track to provide reim-
bursement to affiliated and other participating 
health professions institutions for the cost of edu-
cational services provided by such institutions to 
Track students. The agreement entered into by 
such participating institutions under paragraph 
(1)(A)(i) shall contain an agreement to accept as 
payment in full the established remission rate 
under this subparagraph. 
‘‘(B) 
STIPEND.—The 
Surgeon 
General, 
based on the recommendations of the National 
Health Care Workforce Commission, shall estab-
lish and update Federal stipend rates for pay-
ment to students under this part. 
‘‘(3) REDUCTIONS IN THE PERIOD OF OBLIGATED 
SERVICE.—The period of obligated service under 
paragraph (1)(A)(ii)(V) shall be reduced— 
‘‘(A) in the case of a student who elects to 
participate in a high-needs speciality residency 
(as determined by the National Health Care 
Workforce Commission), by 3 months for each 
year of such participation (not to exceed a total 
of 12 months); and 
‘‘(B) in the case of a student who, upon 
completion of their residency, elects to practice
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in a Federal medical facility (as defined in sec-
tion 781(e)) that is located in a health profes-
sional shortage area (as defined in section 332), 
by 3 months for year of full-time practice in 
such a facility (not to exceed a total of 12 
months). 
‘‘(c) SECOND 2 YEARS OF SERVICE.—During the third 
and fourth years in which a medical, dental, physician as-
sistant, pharmacy, behavioral and mental health, public 
health, or nursing student is enrolled in the Track, training 
should be designed to prioritize clinical rotations in Federal 
medical facilities in health professional shortage areas, and 
emphasize a balance of hospital and community-based expe-
riences, and training within interdisciplinary teams. 
‘‘(d) DENTIST, PHYSICIAN ASSISTANT, PHARMACIST, 
BEHAVIORAL AND MENTAL HEALTH PROFESSIONAL, PUB-
LIC HEALTH PROFESSIONAL, AND NURSE TRAINING.—The 
Surgeon General shall establish provisions applicable with 
respect to dental, physician assistant, pharmacy, behavioral 
and mental health, public health, and nursing students that 
are comparable to those for medical students under this sec-
tion, including service obligations, tuition support, and sti-
pend support. The Surgeon General shall give priority to 
health professions training institutions that train medical, 
dental, physician assistant, pharmacy, behavioral and
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mental health, public health, and nursing students for some 
significant period of time together, but at a minimum have 
a discrete and shared core curriculum. 
‘‘(e) ELITE FEDERAL DISASTER TEAMS.—The Sur-
geon General, in consultation with the Secretary, the Direc-
tor of the Centers for Disease Control and Prevention, and 
other appropriate military and Federal government agen-
cies, shall develop criteria for the appointment of highly 
qualified Track faculty, medical, dental, physician assist-
ant, pharmacy, behavioral and mental health, public health, 
and nursing students, and graduates to elite Federal dis-
aster preparedness teams to train and to respond to public 
health emergencies, natural disasters, bioterrorism events, 
and other emergencies. 
‘‘(f) STUDENT DROPPED FROM TRACK IN AFFILIATE 
SCHOOL.—A medical, dental, physician assistant, phar-
macy, behavioral and mental health, public health, or nurs-
ing student who, under regulations prescribed by the Sur-
geon General, is dropped from the Track in an affiliated 
school for deficiency in conduct or studies, or for other rea-
sons, shall be liable to the United States for all tuition and 
stipend support provided to the student. 
‘‘SEC. 274. FUNDING. 
‘‘Beginning with fiscal year 2010, the Secretary shall 
transfer from the Public Health and Social Services Emer-
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gency Fund such sums as may be necessary to carry out 
this part.’’. 
Subtitle E—Supporting the Existing 
Health Care Workforce 
SEC. 5401. CENTERS OF EXCELLENCE. 
Section 736 of the Public Health Service Act (42 
U.S.C. 293) is amended by striking subsection (h) and in-
serting the following: 
‘‘(h) FORMULA FOR ALLOCATIONS.— 
‘‘(1) ALLOCATIONS.—Based on the amount ap-
propriated under subsection (i) for a fiscal year, the 
following subparagraphs shall apply as appropriate: 
‘‘(A) IN GENERAL.—If the amounts appro-
priated under subsection (i) for a fiscal year are 
$24,000,000 or less— 
‘‘(i) the Secretary shall make available 
$12,000,000 for grants under subsection (a) 
to health professions schools that meet the 
conditions described in subsection (c)(2)(A); 
and 
‘‘(ii) and available after grants are 
made with funds under clause (i), the Sec-
retary shall make available— 
‘‘(I) 60 percent of such amount 
for grants under subsection (a) to
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health professions schools that meet the 
conditions described in paragraph (3) 
or (4) of subsection (c) (including 
meeting the conditions under sub-
section (e)); and 
‘‘(II) 40 percent of such amount 
for grants under subsection (a) to 
health professions schools that meet the 
conditions 
described 
in 
subsection 
(c)(5). 
‘‘(B) FUNDING IN EXCESS OF $24,000,000.— 
If amounts appropriated under subsection (i) for 
a fiscal year exceed $24,000,000 but are less than 
$30,000,000— 
‘‘(i) 80 percent of such excess amounts 
shall be made available for grants under 
subsection (a) to health professions schools 
that meet the requirements described in 
paragraph (3) or (4) of subsection (c) (in-
cluding meeting conditions pursuant to sub-
section (e)); and 
‘‘(ii) 20 percent of such excess amount 
shall be made available for grants under 
subsection (a) to health professions schools
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that meet the conditions described in sub-
section (c)(5). 
‘‘(C) FUNDING IN EXCESS OF $30,000,000.— 
If amounts appropriated under subsection (i) for 
a fiscal year exceed $30,000,000 but are less than 
$40,000,000, the Secretary shall make avail-
able— 
‘‘(i) not less than $12,000,000 for 
grants under subsection (a) to health profes-
sions schools that meet the conditions de-
scribed in subsection (c)(2)(A); 
‘‘(ii) not less than $12,000,000 for 
grants under subsection (a) to health profes-
sions schools that meet the conditions de-
scribed in paragraph (3) or (4) of sub-
section (c) (including meeting conditions 
pursuant to subsection (e)); 
‘‘(iii) not less than $6,000,000 for 
grants under subsection (a) to health profes-
sions schools that meet the conditions de-
scribed in subsection (c)(5); and 
‘‘(iv) after grants are made with funds 
under clauses (i) through (iii), any remain-
ing excess amount for grants under sub-
section (a) to health professions schools that
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meet the conditions described in paragraph 
(2)(A), (3), (4), or (5) of subsection (c). 
‘‘(D) FUNDING IN EXCESS OF $40,000,000.— 
If amounts appropriated under subsection (i) for 
a fiscal year are $40,000,000 or more, the Sec-
retary shall make available— 
‘‘(i) not less than $16,000,000 for 
grants under subsection (a) to health profes-
sions schools that meet the conditions de-
scribed in subsection (c)(2)(A); 
‘‘(ii) not less than $16,000,000 for 
grants under subsection (a) to health profes-
sions schools that meet the conditions de-
scribed in paragraph (3) or (4) of sub-
section (c) (including meeting conditions 
pursuant to subsection (e)); 
‘‘(iii) not less than $8,000,000 for 
grants under subsection (a) to health profes-
sions schools that meet the conditions de-
scribed in subsection (c)(5); and 
‘‘(iv) after grants are made with funds 
under clauses (i) through (iii), any remain-
ing funds for grants under subsection (a) to 
health professions schools that meet the con-
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ditions described in paragraph (2)(A), (3), 
(4), or (5) of subsection (c). 
‘‘(2) NO LIMITATION.—Nothing in this subsection 
shall be construed as limiting the centers of excellence 
referred to in this section to the designated amount, 
or to preclude such entities from competing for grants 
under this section. 
‘‘(3) MAINTENANCE OF EFFORT.— 
‘‘(A) IN GENERAL.—With respect to activi-
ties for which a grant made under this part are 
authorized to be expended, the Secretary may not 
make such a grant to a center of excellence for 
any fiscal year unless the center agrees to main-
tain expenditures of non-Federal amounts for 
such activities at a level that is not less than the 
level of such expenditures maintained by the cen-
ter for the fiscal year preceding the fiscal year 
for which the school receives such a grant. 
‘‘(B) USE OF FEDERAL FUNDS.—With re-
spect to any Federal amounts received by a cen-
ter of excellence and available for carrying out 
activities for which a grant under this part is 
authorized to be expended, the center shall, before 
expending the grant, expend the Federal amounts
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obtained from sources other than the grant, un-
less given prior approval from the Secretary. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There are 
authorized to be appropriated to carry out this section— 
‘‘(1) $50,000,000 for each of the fiscal years 2010 
through 2015; and 
‘‘(2) and such sums as are necessary for each 
subsequent fiscal year.’’. 
SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR 
DIVERSITY. 
(a) LOAN REPAYMENTS AND FELLOWSHIPS REGARD-
ING FACULTY POSITIONS.—Section 738(a)(1) of the Public 
Health Service Act (42 U.S.C. 293b(a)(1)) is amended by 
striking ‘‘$20,000 of the principal and interest of the edu-
cational loans of such individuals.’’ and inserting ‘‘$30,000 
of the principal and interest of the educational loans of such 
individuals.’’. 
(b) 
SCHOLARSHIPS
FOR
DISADVANTAGED
STU-
DENTS.—Section 740(a) of such Act (42 U.S.C. 293d(a)) 
is amended by striking ‘‘$37,000,000’’ and all that follows 
through ‘‘2002’’ and inserting ‘‘$51,000,000 for fiscal year 
2010, and such sums as may be necessary for each of the 
fiscal years 2011 through 2014’’. 
(c) REAUTHORIZATION FOR LOAN REPAYMENTS AND 
FELLOWSHIPS REGARDING FACULTY POSITIONS.—Section
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740(b) of such Act (42 U.S.C. 293d(b)) is amended by strik-
ing ‘‘appropriated’’ and all that follows through the period 
at the end and inserting ‘‘appropriated, $5,000,000 for each 
of the fiscal years 2010 through 2014.’’. 
(d) REAUTHORIZATION
FOR EDUCATIONAL ASSIST-
ANCE IN THE HEALTH PROFESSIONS REGARDING INDIVID-
UALS FROM
A DISADVANTAGED BACKGROUND.—Section 
740(c) of such Act (42 U.S.C. 293d(c)) is amended by strik-
ing the first sentence and inserting the following: ‘‘For the 
purpose of grants and contracts under section 739(a)(1), 
there is authorized to be appropriated $60,000,000 for fiscal 
year 2010 and such sums as may be necessary for each of 
the fiscal years 2011 through 2014.’’ 
SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINK-
AGES. 
(a) AREA HEALTH EDUCATION CENTERS.—Section 
751 of the Public Health Service Act (42 U.S.C. 294a) is 
amended to read as follows: 
‘‘SEC. 751. AREA HEALTH EDUCATION CENTERS. 
‘‘(a) ESTABLISHMENT
OF AWARDS.—The Secretary 
shall make the following 2 types of awards in accordance 
with this section: 
‘‘(1) INFRASTRUCTURE DEVELOPMENT AWARD.— 
The Secretary shall make awards to eligible entities 
to enable such entities to initiate health care work-
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force educational programs or to continue to carry 
out comparable programs that are operating at the 
time the award is made by planning, developing, op-
erating, and evaluating an area health education cen-
ter program. 
‘‘(2) POINT OF SERVICE MAINTENANCE AND EN-
HANCEMENT
AWARD.—The Secretary shall make 
awards to eligible entities to maintain and improve 
the effectiveness and capabilities of an existing area 
health education center program, and make other 
modifications to the program that are appropriate 
due to changes in demographics, needs of the popu-
lations served, or other similar issues affecting the 
area health education center program. For the pur-
poses of this section, the term ‘Program’ refers to the 
area health education center program. 
‘‘(b) ELIGIBLE ENTITIES; APPLICATION.— 
‘‘(1) ELIGIBLE ENTITIES.— 
‘‘(A) INFRASTRUCTURE
DEVELOPMENT.— 
For purposes of subsection (a)(1), the term ‘eligi-
ble entity’ means a school of medicine or osteo-
pathic medicine, an incorporated consortium of 
such schools, or the parent institutions of such a 
school. With respect to a State in which no area 
health education center program is in operation,
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the Secretary may award a grant or contract 
under subsection (a)(1) to a school of nursing. 
‘‘(B) POINT OF SERVICE MAINTENANCE AND 
ENHANCEMENT.—For 
purposes 
of 
subsection 
(a)(2), the term ‘eligible entity’ means an entity 
that has received funds under this section, is op-
erating an area health education center program, 
including an area health education center or 
centers, and has a center or centers that are no 
longer eligible to receive financial assistance 
under subsection (a)(1). 
‘‘(2) APPLICATION.—An eligible entity desiring 
to receive an award under this section shall submit 
to the Secretary an application at such time, in such 
manner, and containing such information as the Sec-
retary may require. 
‘‘(c) USE OF FUNDS.— 
‘‘(1) REQUIRED ACTIVITIES.—An eligible entity 
shall use amounts awarded under a grant under sub-
section (a)(1) or (a)(2) to carry out the following ac-
tivities: 
‘‘(A) Develop and implement strategies, in 
coordination with the applicable one-stop deliv-
ery system under section 134(c) of the Workforce 
Investment Act of 1998, to recruit individuals
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from underrepresented minority populations or 
from disadvantaged or rural backgrounds into 
health professions, and support such individuals 
in attaining such careers. 
‘‘(B) Develop and implement strategies to 
foster and provide community-based training 
and education to individuals seeking careers in 
health professions within underserved areas for 
the purpose of developing and maintaining a di-
verse health care workforce that is prepared to 
deliver high-quality care, with an emphasis on 
primary care, in underserved areas or for health 
disparity populations, in collaboration with 
other Federal and State health care workforce de-
velopment programs, the State workforce agency, 
and local workforce investment boards, and in 
health care safety net sites. 
‘‘(C) Prepare individuals to more effectively 
provide health services to underserved areas and 
health disparity populations through field place-
ments or preceptorships in conjunction with 
community-based organizations, accredited pri-
mary care residency training programs, Feder-
ally qualified health centers, rural health clinics,
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public health departments, or other appropriate 
facilities. 
‘‘(D) Conduct and participate in inter-
disciplinary training that involves physicians, 
physician assistants, nurse practitioners, nurse 
midwives, dentists, psychologists, pharmacists, 
optometrists, community health workers, public 
and allied health professionals, or other health 
professionals, as practicable. 
‘‘(E) Deliver or facilitate continuing edu-
cation and information dissemination programs 
for health care professionals, with an emphasis 
on individuals providing care in underserved 
areas and for health disparity populations. 
‘‘(F) Propose and implement effective pro-
gram and outcomes measurement and evaluation 
strategies. 
‘‘(G) Establish a youth public health pro-
gram to expose and recruit high school students 
into health careers, with a focus on careers in 
public health. 
‘‘(2) INNOVATIVE
OPPORTUNITIES.—An eligible 
entity may use amounts awarded under a grant 
under subsection (a)(1) or subsection (a)(2) to carry 
out any of the following activities:
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‘‘(A) Develop and implement innovative 
curricula in collaboration with community-based 
accredited primary care residency training pro-
grams, Federally qualified health centers, rural 
health clinics, behavioral and mental health fa-
cilities, public health departments, or other ap-
propriate facilities, with the goal of increasing 
the number of primary care physicians and 
other primary care providers prepared to serve 
in underserved areas and health disparity popu-
lations. 
‘‘(B) 
Coordinate 
community-based 
participatory research with academic health cen-
ters, and facilitate rapid flow and dissemination 
of evidence-based health care information, re-
search results, and best practices to improve 
quality, efficiency, and effectiveness of health 
care and health care systems within community 
settings. 
‘‘(C) Develop and implement other strate-
gies to address identified workforce needs and in-
crease and enhance the health care workforce in 
the area served by the area health education cen-
ter program. 
‘‘(d) REQUIREMENTS.—
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‘‘(1) AREA
HEALTH
EDUCATION
CENTER
PRO-
GRAM.—In carrying out this section, the Secretary 
shall ensure the following: 
‘‘(A) An entity that receives an award 
under this section shall conduct at least 10 per-
cent of clinical education required for medical 
students in community settings that are removed 
from the primary teaching facility of the con-
tracting institution for grantees that operate a 
school of medicine or osteopathic medicine. In 
States in which an entity that receives an award 
under this section is a nursing school or its par-
ent institution, the Secretary shall alternatively 
ensure that— 
‘‘(i) the nursing school conducts at 
least 10 percent of clinical education re-
quired for nursing students in community 
settings that are remote from the primary 
teaching facility of the school; and 
‘‘(ii) the entity receiving the award 
maintains a written agreement with a 
school of medicine or osteopathic medicine 
to place students from that school in train-
ing sites in the area health education center 
program area.
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‘‘(B) An entity receiving funds under sub-
section (a)(2) does not distribute such funding to 
a center that is eligible to receive funding under 
subsection (a)(1). 
‘‘(2) AREA HEALTH EDUCATION CENTER.—The 
Secretary shall ensure that each area health education 
center program includes at least 1 area health edu-
cation center, and that each such center— 
‘‘(A) is a public or private organization 
whose structure, governance, and operation is 
independent from the awardee and the parent 
institution of the awardee; 
‘‘(B) is not a school of medicine or osteo-
pathic medicine, the parent institution of such a 
school, or a branch campus or other subunit of 
a school of medicine or osteopathic medicine or 
its parent institution, or a consortium of such 
entities; 
‘‘(C) designates an underserved area or pop-
ulation to be served by the center which is in a 
location removed from the main location of the 
teaching facilities of the schools participating in 
the program with such center and does not du-
plicate, in whole or in part, the geographic area 
or population served by any other center;
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‘‘(D) fosters networking and collaboration 
among communities and between academic 
health centers and community-based centers; 
‘‘(E) serves communities with a dem-
onstrated need of health professionals in partner-
ship with academic medical centers; 
‘‘(F) addresses the health care workforce 
needs of the communities served in coordination 
with the public workforce investment system; and 
‘‘(G) has a community-based governing or 
advisory board that reflects the diversity of the 
communities involved. 
‘‘(e) MATCHING FUNDS.—With respect to the costs of 
operating a program through a grant under this section, 
to be eligible for financial assistance under this section, an 
entity shall make available (directly or through contribu-
tions from State, county or municipal governments, or the 
private sector) recurring non-Federal contributions in cash 
or in kind, toward such costs in an amount that is equal 
to not less than 50 percent of such costs. At least 25 percent 
of the total required non-Federal contributions shall be in 
cash. An entity may apply to the Secretary for a waiver 
of not more than 75 percent of the matching fund amount 
required by the entity for each of the first 3 years the entity 
is funded through a grant under subsection (a)(1).
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‘‘(f) LIMITATION.—Not less than 75 percent of the total 
amount provided to an area health education center pro-
gram under subsection (a)(1) or (a)(2) shall be allocated 
to the area health education centers participating in the 
program under this section. To provide needed flexibility 
to newly funded area health education center programs, the 
Secretary may waive the requirement in the sentence for 
the first 2 years of a new area health education center pro-
gram funded under subsection (a)(1). 
‘‘(g) AWARD.—An award to an entity under this sec-
tion shall be not less than $250,000 annually per area 
health education center included in the program involved. 
If amounts appropriated to carry out this section are not 
sufficient to comply with the preceding sentence, the Sec-
retary may reduce the per center amount provided for in 
such sentence as necessary, provided the distribution estab-
lished in subsection (j)(2) is maintained. 
‘‘(h) PROJECT TERMS.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), the period during which payments may be 
made under an award under subsection (a)(1) may 
not exceed— 
‘‘(A) in the case of a program, 12 years; or 
‘‘(B) in the case of a center within a pro-
gram, 6 years.
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‘‘(2) EXCEPTION.—The periods described in 
paragraph (1) shall not apply to programs receiving 
point of service maintenance and enhancement 
awards under subsection (a)(2) to maintain existing 
centers and activities. 
‘‘(i) 
INAPPLICABILITY
OF
PROVISION.—Notwith-
standing any other provision of this title, section 791(a) 
shall not apply to an area health education center funded 
under this section. 
‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— 
‘‘(1) IN GENERAL.—There is authorized to be ap-
propriated to carry out this section $125,000,000 for 
each of the fiscal years 2010 through 2014. 
‘‘(2) REQUIREMENTS.—Of the amounts appro-
priated for a fiscal year under paragraph (1)— 
‘‘(A) not more than 35 percent shall be used 
for awards under subsection (a)(1); 
‘‘(B) not less than 60 percent shall be used 
for awards under subsection (a)(2); 
‘‘(C) not more than 1 percent shall be used 
for grants and contracts to implement outcomes 
evaluation for the area health education centers; 
and 
‘‘(D) not more than 4 percent shall be used 
for grants and contracts to provide technical as-
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sistance to entities receiving awards under this 
section. 
‘‘(3) CARRYOVER
FUNDS.—An entity that re-
ceives an award under this section may carry over 
funds from 1 fiscal year to another without obtaining 
approval from the Secretary. In no case may any 
funds be carried over pursuant to the preceding sen-
tence for more than 3 years. 
‘‘(k) SENSE OF CONGRESS.—It is the sense of the Con-
gress that every State have an area health education center 
program in effect under this section.’’. 
(b) CONTINUING EDUCATIONAL SUPPORT FOR HEALTH 
PROFESSIONALS
SERVING
IN
UNDERSERVED
COMMU-
NITIES.—Part D of title VII of the Public Health Service 
Act (42 U.S.C. 294 et seq.) is amended by striking section 
752 and inserting the following: 
‘‘SEC. 752. CONTINUING EDUCATIONAL SUPPORT FOR 
HEALTH PROFESSIONALS SERVING IN UN-
DERSERVED COMMUNITIES. 
‘‘(a) IN GENERAL.—The Secretary shall make grants 
to, and enter into contracts with, eligible entities to improve 
health care, increase retention, increase representation of 
minority faculty members, enhance the practice environ-
ment, and provide information dissemination and edu-
cational support to reduce professional isolation through the
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timely dissemination of research findings using relevant re-
sources. 
‘‘(b) ELIGIBLE ENTITIES.—For purposes of this sec-
tion, the term ‘eligible entity’ means an entity described 
in section 799(b). 
‘‘(c) APPLICATION.—An eligible entity desiring to re-
ceive an award under this section shall submit to the Sec-
retary an application at such time, in such manner, and 
containing such information as the Secretary may require. 
‘‘(d) USE OF FUNDS.—An eligible entity shall use 
amounts awarded under a grant or contract under this sec-
tion to provide innovative supportive activities to enhance 
education through distance learning, continuing edu-
cational activities, collaborative conferences, and electronic 
and telelearning activities, with priority for primary care. 
‘‘(e) AUTHORIZATION.—There is authorized to be ap-
propriated to carry out this section $5,000,000 for each of 
the fiscal years 2010 through 2014, and such sums as may 
be necessary for each subsequent fiscal year.’’. 
SEC. 5404. WORKFORCE DIVERSITY GRANTS. 
Section 821 of the Public Health Service Act (42 
U.S.C. 296m) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘The Secretary may’’ and 
inserting the following:
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‘‘(1) AUTHORITY.—The Secretary may’’; 
(B) by striking ‘‘pre-entry preparation, and 
retention activities’’ and inserting the following: 
‘‘stipends for diploma or associate degree nurses 
to enter a bridge or degree completion program, 
student scholarships or stipends for accelerated 
nursing degree programs, pre-entry preparation, 
advanced education preparation, and retention 
activities’’; and 
(2) in subsection (b)— 
(A) by striking ‘‘First’’ and all that follows 
through ‘‘including the’’ and inserting ‘‘National 
Advisory Council on Nurse Education and Prac-
tice and consult with nursing associations in-
cluding the National Coalition of Ethnic Minor-
ity Nurse Associations,’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘, and other organizations determined 
appropriate by the Secretary’’. 
SEC. 5405. PRIMARY CARE EXTENSION PROGRAM. 
Part P of title III of the Public Health Service Act 
(42 U.S.C. 280g et seq.), as amended by section 5313, is 
further amended by adding at the end the following: 
‘‘SEC. 399W. PRIMARY CARE EXTENSION PROGRAM. 
‘‘(a) ESTABLISHMENT, PURPOSE AND DEFINITION.—
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‘‘(1) 
IN
GENERAL.—The 
Secretary, 
acting 
through the Director of the Agency for Healthcare Re-
search and Quality, shall establish a Primary Care 
Extension Program. 
‘‘(2) PURPOSE.—The Primary Care Extension 
Program shall provide support and assistance to pri-
mary care providers to educate providers about pre-
ventive medicine, health promotion, chronic disease 
management, mental and behavioral health services 
(including substance abuse prevention and treatment 
services), and evidence-based and evidence-informed 
therapies and techniques, in order to enable providers 
to incorporate such matters into their practice and to 
improve community health by working with commu-
nity-based health connectors (referred to in this sec-
tion as ‘Health Extension Agents’). 
‘‘(3) DEFINITIONS.—In this section: 
‘‘(A) HEALTH
EXTENSION
AGENT.—The 
term ‘Health Extension Agent’ means any local, 
community-based health worker who facilitates 
and provides assistance to primary care prac-
tices by implementing quality improvement or 
system redesign, incorporating the principles of 
the patient-centered medical home to provide 
high-quality, effective, efficient, and safe pri-
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mary care and to provide guidance to patients 
in culturally and linguistically appropriate 
ways, and linking practices to diverse health sys-
tem resources. 
‘‘(B) PRIMARY CARE PROVIDER.—The term 
‘primary care provider’ means a clinician who 
provides integrated, accessible health care serv-
ices and who is accountable for addressing a 
large majority of personal health care needs, in-
cluding providing preventive and health pro-
motion services for men, women, and children of 
all ages, developing a sustained partnership with 
patients, and practicing in the context of family 
and community, as recognized by a State licens-
ing or regulatory authority, unless otherwise 
specified in this section. 
‘‘(b) GRANTS TO ESTABLISH STATE HUBS AND LOCAL 
PRIMARY CARE EXTENSION AGENCIES.— 
‘‘(1) GRANTS.—The Secretary shall award com-
petitive grants to States for the establishment of 
State- or multistate-level primary care Primary Care 
Extension Program State Hubs (referred to in this 
section as ‘Hubs’). 
‘‘(2) COMPOSITION OF HUBS.—A Hub established 
by a State pursuant to paragraph (1)—
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‘‘(A) shall consist of, at a minimum, the 
State health department, the entity responsible 
for administering the State Medicaid program 
(if other than the State health department), the 
State-level entity administering the Medicare 
program, and the departments of 1 or more 
health professions schools in the State that train 
providers in primary care; and 
‘‘(B) may include entities such as hospital 
associations, primary care practice-based re-
search networks, health professional societies, 
State primary care associations, State licensing 
boards, organizations with a contract with the 
Secretary under section 1153 of the Social Secu-
rity Act, consumer groups, and other appro-
priate entities. 
‘‘(c) STATE AND LOCAL ACTIVITIES.— 
‘‘(1) HUB ACTIVITIES.—Hubs established under 
a grant under subsection (b) shall— 
‘‘(A) submit to the Secretary a plan to co-
ordinate functions with quality improvement or-
ganizations and area health education centers if 
such entities are members of the Hub not de-
scribed in subsection (b)(2)(A);
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‘‘(B) contract with a county- or local-level 
entity that shall serve as the Primary Care Ex-
tension Agency to administer the services de-
scribed in paragraph (2); 
‘‘(C) organize and administer grant funds 
to county- or local-level Primary Care Extension 
Agencies that serve a catchment area, as deter-
mined by the State; and 
‘‘(D) organize State-wide or multistate net-
works of local-level Primary Care Extension 
Agencies to share and disseminate information 
and practices. 
‘‘(2) LOCAL PRIMARY CARE EXTENSION AGENCY 
ACTIVITIES.— 
‘‘(A) 
REQUIRED
ACTIVITIES.—Primary 
Care Extension Agencies established by a Hub 
under paragraph (1) shall— 
‘‘(i) assist primary care providers to 
implement a patient-centered medical home 
to improve the accessibility, quality, and ef-
ficiency of primary care services, including 
health homes; 
‘‘(ii) develop and support primary 
care learning communities to enhance the 
dissemination of research findings for evi-
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dence-based practice, assess implementation 
of practice improvement, share best prac-
tices, and involve community clinicians in 
the generation of new knowledge and identi-
fication of important questions for research; 
‘‘(iii) participate in a national net-
work of Primary Care Extension Hubs and 
propose how the Primary Care Extension 
Agency will share and disseminate lessons 
learned and best practices; and 
‘‘(iv) develop a plan for financial sus-
tainability involving State, local, and pri-
vate contributions, to provide for the reduc-
tion in Federal funds that is expected after 
an initial 6-year period of program estab-
lishment, infrastructure development, and 
planning. 
‘‘(B) 
DISCRETIONARY
ACTIVITIES.—Pri-
mary Care Extension Agencies established by a 
Hub under paragraph (1) may— 
‘‘(i) provide technical assistance, train-
ing, and organizational support for commu-
nity health teams established under section 
3602 of the Patient Protection and Afford-
able Care Act;
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‘‘(ii) collect data and provision of pri-
mary care provider feedback from standard-
ized measurements of processes and out-
comes to aid in continuous performance im-
provement; 
‘‘(iii) collaborate with local health de-
partments, community health centers, tribes 
and tribal entities, and other community 
agencies to identify community health pri-
orities and local health workforce needs, and 
participate in community-based efforts to 
address the social and primary deter-
minants of health, strengthen the local pri-
mary care workforce, and eliminate health 
disparities; 
‘‘(iv) develop measures to monitor the 
impact of the proposed program on the 
health of practice enrollees and of the wider 
community served; and 
‘‘(v) participate in other activities, as 
determined appropriate by the Secretary. 
‘‘(d) FEDERAL PROGRAM ADMINISTRATION.— 
‘‘(1) GRANTS; TYPES.—Grants awarded under 
subsection (b) shall be—
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‘‘(A) program grants, that are awarded to 
State or multistate entities that submit fully-de-
veloped plans for the implementation of a Hub, 
for a period of 6 years; or 
‘‘(B) planning grants, that are awarded to 
State or multistate entities with the goal of de-
veloping a plan for a Hub, for a period of 2 
years. 
‘‘(2) APPLICATIONS.—To be eligible for a grant 
under subsection (b), a State or multistate entity 
shall submit to the Secretary an application, at such 
time, in such manner, and containing such informa-
tion as the Secretary may require. 
‘‘(3) EVALUATION.—A State that receives a grant 
under subsection (b) shall be evaluated at the end of 
the grant period by an evaluation panel appointed by 
the Secretary. 
‘‘(4) CONTINUING
SUPPORT.—After the sixth 
year in which assistance is provided to a State under 
a grant awarded under subsection (b), the State may 
receive additional support under this section if the 
State program has received satisfactory evaluations 
with respect to program performance and the merits 
of the State sustainability plan, as determined by the 
Secretary.
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‘‘(5) LIMITATION.—A State shall not use in ex-
cess of 10 percent of the amount received under a 
grant to carry out administrative activities under 
this section. Funds awarded pursuant to this section 
shall not be used for funding direct patient care. 
‘‘(e) REQUIREMENTS ON THE SECRETARY.—In car-
rying out this section, the Secretary shall consult with the 
heads of other Federal agencies with demonstrated experi-
ence and expertise in health care and preventive medicine, 
such as the Centers for Disease Control and Prevention, the 
Substance Abuse and Mental Health Administration, the 
Health Resources and Services Administration, the Na-
tional Institutes of Health, the Office of the National Coor-
dinator for Health Information Technology, the Indian 
Health Service, the Agricultural Cooperative Extension 
Service of the Department of Agriculture, and other entities, 
as the Secretary determines appropriate. 
‘‘(f) 
AUTHORIZATION
OF
APPROPRIATIONS.—To 
awards grants as provided in subsection (d), there are au-
thorized to be appropriated $120,000,000 for each of fiscal 
years 2011 and 2012, and such sums as may be necessary 
to carry out this section for each of fiscal years 2013 
through 2014.’’.
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Subtitle F—Strengthening Primary 
Care and Other Workforce Im-
provements 
SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERV-
ICES AND GENERAL SURGERY SERVICES. 
(a) INCENTIVE PAYMENT PROGRAM
FOR PRIMARY 
CARE SERVICES.— 
(1) IN GENERAL.—Section 1833 of the Social Se-
curity Act (42 U.S.C. 1395l) is amended by adding 
at the end the following new subsection: 
‘‘(x) INCENTIVE PAYMENTS FOR PRIMARY CARE SERV-
ICES.— 
‘‘(1) IN GENERAL.—In the case of primary care 
services furnished on or after January 1, 2011, and 
before January 1, 2016, by a primary care practi-
tioner, in addition to the amount of payment that 
would otherwise be made for such services under this 
part, there also shall be paid (on a monthly or quar-
terly basis) an amount equal to 10 percent of the pay-
ment amount for the service under this part. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) PRIMARY
CARE
PRACTITIONER.—The 
term ‘primary care practitioner’ means an indi-
vidual— 
‘‘(i) who—
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‘‘(I) is a physician (as described 
in section 1861(r)(1)) who has a pri-
mary specialty designation of family 
medicine, internal medicine, geriatric 
medicine, or pediatric medicine; or 
‘‘(II) is a nurse practitioner, clin-
ical nurse specialist, or physician as-
sistant (as those terms are defined in 
section 1861(aa)(5)); and 
‘‘(ii) for whom primary care services 
accounted for at least 60 percent of the al-
lowed charges under this part for such phy-
sician or practitioner in a prior period as 
determined appropriate by the Secretary. 
‘‘(B) PRIMARY CARE SERVICES.—The term 
‘primary care services’ means services identified, 
as of January 1, 2009, by the following HCPCS 
codes (and as subsequently modified by the Sec-
retary): 
‘‘(i) 99201 through 99215. 
‘‘(ii) 99304 through 99340. 
‘‘(iii) 99341 through 99350. 
‘‘(3) COORDINATION WITH OTHER PAYMENTS.— 
The amount of the additional payment for a service 
under this subsection and subsection (m) shall be de-
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termined without regard to any additional payment 
for the service under subsection (m) and this sub-
section, respectively. 
‘‘(4) LIMITATION ON REVIEW.—There shall be no 
administrative or judicial review under section 1869, 
1878, or otherwise, respecting the identification of 
primary care practitioners under this subsection.’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1834(g)(2)(B) of the Social Security Act (42 U.S.C. 
1395m(g)(2)(B)) is amended by adding at the end the 
following sentence: ‘‘Section 1833(x) shall not be 
taken into account in determining the amounts that 
would otherwise be paid pursuant to the preceding 
sentence.’’. 
(b) INCENTIVE PAYMENT PROGRAM FOR MAJOR SUR-
GICAL PROCEDURES FURNISHED
IN HEALTH PROFES-
SIONAL SHORTAGE AREAS.— 
(1) IN GENERAL.—Section 1833 of the Social Se-
curity Act (42 U.S.C. 1395l), as amended by sub-
section (a)(1), is amended by adding at the end the 
following new subsection: 
‘‘(y) INCENTIVE PAYMENTS
FOR MAJOR SURGICAL 
PROCEDURES
FURNISHED
IN
HEALTH
PROFESSIONAL 
SHORTAGE AREAS.—
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‘‘(1) IN GENERAL.—In the case of major surgical 
procedures furnished on or after January 1, 2011, 
and before January 1, 2016, by a general surgeon in 
an 
area 
that 
is 
designated 
(under 
section 
332(a)(1)(A) of the Public Health Service Act) as a 
health professional shortage area as identified by the 
Secretary prior to the beginning of the year involved, 
in addition to the amount of payment that would oth-
erwise be made for such services under this part, there 
also shall be paid (on a monthly or quarterly basis) 
an amount equal to 10 percent of the payment 
amount for the service under this part. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) GENERAL
SURGEON.—In this sub-
section, the term ‘general surgeon’ means a phy-
sician (as described in section 1861(r)(1)) who 
has designated CMS specialty code 02–General 
Surgery as their primary specialty code in the 
physician’s enrollment under section 1866(j). 
‘‘(B) MAJOR SURGICAL PROCEDURES.—The 
term ‘major surgical procedures’ means physi-
cians’ services which are surgical procedures for 
which a 10-day or 90-day global period is used 
for payment under the fee schedule under section 
1848(b).
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‘‘(3) COORDINATION WITH OTHER PAYMENTS.— 
The amount of the additional payment for a service 
under this subsection and subsection (m) shall be de-
termined without regard to any additional payment 
for the service under subsection (m) and this sub-
section, respectively. 
‘‘(4) APPLICATION.—The provisions of para-
graph (2) and (4) of subsection (m) shall apply to the 
determination of additional payments under this sub-
section in the same manner as such provisions apply 
to the determination of additional payments under 
subsection (m).’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1834(g)(2)(B) of the Social Security Act (42 U.S.C. 
1395m(g)(2)(B)), as amended by subsection (a)(2), is 
amended by striking ‘‘Section 1833(x)’’ and inserting 
‘‘Subsections (x) and (y) of section 1833’’ in the last 
sentence. 
(c) 
BUDGET-NEUTRALITY
ADJUSTMENT.—Section 
1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w– 
4(c)(2)(B)) is amended by adding at the end the following 
new clause: 
‘‘(vii) ADJUSTMENT FOR CERTAIN PHY-
SICIAN
INCENTIVE
PAYMENTS.—Fifty per-
cent of the additional expenditures under
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this part attributable to subsections (x) and 
(y) of section 1833 for a year (as estimated 
by the Secretary) shall be taken into ac-
count in applying clause (ii)(II) for 2011 
and subsequent years. In lieu of applying 
the budget-neutrality adjustments required 
under clause (ii)(II) to relative value units 
to account for such costs for the year, the 
Secretary shall apply such budget-neu-
trality adjustments to the conversion factor 
otherwise determined for the year. For 2011 
and subsequent years, the Secretary shall 
increase the incentive payment otherwise 
applicable under section 1833(m) by a per-
cent estimated to be equal to the additional 
expenditures estimated under the first sen-
tence of this clause for such year that is ap-
plicable to physicians who primarily fur-
nish services in areas designated (under sec-
tion 332(a)(1)(A) of the Public Health Serv-
ice Act) as health professional shortage 
areas.’’.
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SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CEN-
TER IMPROVEMENTS. 
(a) EXPANSION OF MEDICARE-COVERED PREVENTIVE 
SERVICES
AT
FEDERALLY
QUALIFIED
HEALTH
CEN-
TERS.— 
(1) IN GENERAL.—Section 1861(aa)(3)(A) of the 
Social Security Act (42 U.S.C. 1395w (aa)(3)(A)) is 
amended to read as follows: 
‘‘(A) services of the type described subpara-
graphs (A) through (C) of paragraph (1) and 
preventive 
services 
(as 
defined 
in 
section 
1861(ddd)(3)); and’’. 
(2) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply to services furnished on or 
after January 1, 2011. 
(b) PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY 
QUALIFIED HEALTH CENTERS.—Section 1834 of the Social 
Security Act (42 U.S.C. 1395m) is amended by adding at 
the end the following new subsection: 
‘‘(n) DEVELOPMENT AND IMPLEMENTATION OF PRO-
SPECTIVE PAYMENT SYSTEM.— 
‘‘(1) DEVELOPMENT.— 
‘‘(A) IN GENERAL.—The Secretary shall de-
velop a prospective payment system for payment 
for Federally qualified health services furnished 
by Federally qualified health centers under this
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title. Such system shall include a process for ap-
propriately describing the services furnished by 
Federally qualified health centers. 
‘‘(B) COLLECTION OF DATA AND EVALUA-
TION.—The Secretary shall require Federally 
qualified health centers to submit to the Sec-
retary such information as the Secretary may 
require in order to develop and implement the 
prospective payment system under this para-
graph and paragraph (2), respectively, including 
the reporting of services using HCPCS codes. 
‘‘(2) IMPLEMENTATION.— 
‘‘(A) IN
GENERAL.—Notwithstanding sec-
tion 1833(a)(3)(B), the Secretary shall provide, 
for cost reporting periods beginning on or after 
October 1, 2014, for payments for Federally 
qualified health services furnished by Federally 
qualified health centers under this title in ac-
cordance with the prospective payment system 
developed by the Secretary under paragraph (1). 
‘‘(B) PAYMENTS.— 
‘‘(i) INITIAL
PAYMENTS.—The Sec-
retary shall implement such prospective 
payment system so that the estimated 
amount of expenditures under this title for
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Federally qualified health services in the 
first year that the prospective payment sys-
tem is implemented is equal to 103 percent 
of the estimated amount of expenditures 
under this title that would have occurred for 
such services in such year if the system had 
not been implemented. 
‘‘(ii) 
PAYMENTS
IN
SUBSEQUENT 
YEARS.—In the year after the first year of 
implementation of such system, and in each 
subsequent year, the payment rate for Fed-
erally qualified health services furnished in 
the year shall be equal to the payment rate 
established for such services furnished in the 
preceding year under this subparagraph in-
creased by the percentage increase in the 
MEI (as defined in 1842(i)(3)) for the year 
involved.’’. 
SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY PO-
SITIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’;
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(2) in paragraph (4)(H)(i), by striking ‘‘para-
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 
(3) in paragraph (7)(E), by inserting ‘‘or para-
graph (8)’’ before the period at the end; and 
(4) by adding at the end the following new para-
graph: 
‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY 
POSITIONS.— 
‘‘(A) REDUCTIONS IN LIMIT BASED ON UN-
USED POSITIONS.— 
‘‘(i) IN GENERAL.—Except as provided 
in clause (ii), if a hospital’s reference resi-
dent level (as defined in subparagraph 
(H)(i)) is less than the otherwise applicable 
resident limit (as defined in subparagraph 
(H)(iii)), effective for portions of cost re-
porting periods occurring on or after July 
1, 2011, the otherwise applicable resident 
limit shall be reduced by 65 percent of the 
difference between such otherwise applicable 
resident limit and such reference resident 
level. 
‘‘(ii) 
EXCEPTIONS.—This 
subpara-
graph shall not apply to—
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‘‘(I) a hospital located in a rural 
area 
(as 
defined 
in 
subsection 
(d)(2)(D)(ii)) with fewer than 250 
acute care inpatient beds; 
‘‘(II) a hospital that was part of 
a qualifying entity which had a vol-
untary residency reduction plan ap-
proved under paragraph (6)(B) or 
under the authority of section 402 of 
Public Law 90–248, if the hospital 
demonstrates to the Secretary that it 
has a specified plan in place for filling 
the unused positions by not later than 
2 years after the date of enactment of 
this paragraph; or 
‘‘(III) a hospital described in 
paragraph (4)(H)(v). 
‘‘(B) DISTRIBUTION.— 
‘‘(i) IN GENERAL.—The Secretary shall 
increase the otherwise applicable resident 
limit for each qualifying hospital that sub-
mits an application under this subpara-
graph by such number as the Secretary may 
approve for portions of cost reporting peri-
ods occurring on or after July 1, 2011. The
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crease are in a primary care or gen-
eral surgery residency (as determined 
by the Secretary). 
The Secretary may determine whether a 
hospital has met the requirements under 
this clause during such 5-year period in 
such manner and at such time as the Sec-
retary determines appropriate, including at 
the end of such 5-year period. 
‘‘(iii) REDISTRIBUTION OF POSITIONS 
IF HOSPITAL NO LONGER MEETS CERTAIN 
REQUIREMENTS.—In the case where the Sec-
retary determines that a hospital described 
in clause (ii) does not meet either of the re-
quirements under subclause (I) or (II) of 
such clause, the Secretary shall— 
‘‘(I) reduce the otherwise applica-
ble resident limit of the hospital by the 
amount by which such limit was in-
creased under this paragraph; and 
‘‘(II) provide for the distribution 
of positions attributable to such reduc-
tion in accordance with the require-
ments of this paragraph.
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‘‘(C) 
CONSIDERATIONS
IN
REDISTRIBU-
TION.—In determining for which hospitals the 
increase in the otherwise applicable resident 
limit is provided under subparagraph (B), the 
Secretary shall take into account— 
‘‘(i) the demonstration likelihood of the 
hospital filling the positions made available 
under this paragraph within the first 3 cost 
reporting periods beginning on or after July 
1, 2011, as determined by the Secretary; 
and 
‘‘(ii) whether the hospital has an ac-
credited rural training track (as described 
in paragraph (4)(H)(iv)). 
‘‘(D) PRIORITY
FOR
CERTAIN
AREAS.—In 
determining for which hospitals the increase in 
the otherwise applicable resident limit is pro-
vided under subparagraph (B), subject to sub-
paragraph (E), the Secretary shall distribute the 
increase to hospitals based on the following fac-
tors: 
‘‘(i) Whether the hospital is located in 
a State with a resident-to-population ratio 
in the lowest quartile (as determined by the 
Secretary).
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‘‘(ii) Whether the hospital is located in 
a State, a territory of the United States, or 
the District of Columbia that is among the 
top 10 States, territories, or Districts in 
terms of the ratio of— 
‘‘(I) the total population of the 
State, territory, or District living in 
an area designated (under such section 
332(a)(1)(A)) as a health professional 
shortage area (as of the date of enact-
ment of this paragraph); to 
‘‘(II) the total population of the 
State, territory, or District (as deter-
mined by the Secretary based on the 
most recent available population data 
published by the Bureau of the Cen-
sus). 
‘‘(iii) Whether the hospital is located 
in a rural area (as defined in subsection 
(d)(2)(D)(ii)). 
‘‘(E) RESERVATION OF POSITIONS FOR CER-
TAIN HOSPITALS.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), the Secretary shall reserve the positions
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available for distribution under this para-
graph as follows: 
‘‘(I) 70 percent of such positions 
for distribution to hospitals described 
in clause (i) of subparagraph (D). 
‘‘(II) 30 percent of such positions 
for distribution to hospitals described 
in clause (ii) and (iii) of such sub-
paragraph. 
‘‘(ii) EXCEPTION
IF
POSITIONS
NOT 
REDISTRIBUTED BY JULY 1, 2011.—In the 
case where the Secretary does not distribute 
positions to hospitals in accordance with 
clause (i) by July 1, 2011, the Secretary 
shall distribute such positions to other hos-
pitals in accordance with the considerations 
described in subparagraph (C) and the pri-
ority described in subparagraph (D). 
‘‘(F) LIMITATION.—A hospital may not re-
ceive more than 75 full-time equivalent addi-
tional residency positions under this paragraph. 
‘‘(G) 
APPLICATION
OF
PER
RESIDENT 
AMOUNTS FOR PRIMARY CARE AND NONPRIMARY 
CARE.—With respect to additional residency po-
sitions in a hospital attributable to the increase
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provided under this paragraph, the approved 
FTE per resident amounts are deemed to be 
equal to the hospital per resident amounts for 
primary care and nonprimary care computed 
under paragraph (2)(D) for that hospital. 
‘‘(H) DEFINITIONS.—In this paragraph: 
‘‘(i) REFERENCE RESIDENT LEVEL.— 
The term ‘reference resident level’ means, 
with respect to a hospital, the highest resi-
dent level for any of the 3 most recent cost 
reporting periods (ending before the date of 
the enactment of this paragraph) of the hos-
pital for which a cost report has been settled 
(or, if not, submitted (subject to audit)), as 
determined by the Secretary. 
‘‘(ii) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i). 
‘‘(iii) OTHERWISE
APPLICABLE
RESI-
DENT LIMIT.—The term ‘otherwise applica-
ble 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
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paragraph but taking into account para-
graph (7)(A).’’. 
(b) IME.— 
(1) IN
GENERAL.—Section 1886(d)(5)(B)(v) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(d)(5)(B)(v)), in the second sentence, is 
amended— 
(A) by striking ‘‘subsection (h)(7)’’ and in-
serting ‘‘subsections (h)(7) and (h)(8)’’; and 
(B) by striking ‘‘it applies’’ and inserting 
‘‘they apply’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) is amended by adding at the end 
the following clause: 
‘‘(x) For discharges occurring on or after July 1, 
2011, insofar as an additional payment amount 
under this subparagraph is attributable to resident 
positions distributed to a hospital under subsection 
(h)(8)(B), the indirect teaching adjustment factor 
shall be computed in the same manner as provided 
under clause (ii) with respect to such resident posi-
tions.’’. 
(c) CONFORMING AMENDMENT.—Section 422(b)(2) of 
the Medicare Prescription Drug, Improvement, and Mod-
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ernization Act of 2003 (Public Law 108–173) is amended 
by striking ‘‘section 1886(h)(7)’’ and all that follows and 
inserting ‘‘paragraphs (7) and (8) of subsection (h) of sec-
tion 1886 of the Social Security Act’’. 
SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER 
SETTINGS. 
(a) GME.—Section 1886(h)(4)(E) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)(4)(E)) is amended— 
(1) by striking ‘‘shall be counted and that all the 
time’’ and inserting ‘‘shall be counted and that— 
‘‘(i) effective for cost reporting periods 
beginning before July 1, 2010, all the 
time;’’; 
(2) in clause (i), as inserted by paragraph (1), 
by striking the period at the end and inserting ‘‘; 
and’’; 
(3) by inserting after clause (i), as so inserted, 
the following new clause: 
‘‘(ii) effective for cost reporting periods 
beginning on or after July 1, 2010, all the 
time so spent by a resident shall be counted 
towards the determination of full-time 
equivalency, without regard to the setting in 
which the activities are performed, if a hos-
pital incurs the costs of the stipends and
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fringe benefits of the resident during the 
time the resident spends in that setting. If 
more than one hospital incurs these costs, 
either directly or through a third party, 
such hospitals shall count a proportional 
share of the time, as determined by written 
agreement between the hospitals, that a resi-
dent spends training in that setting.’’; and 
(4) by adding at the end the following flush sen-
tence: 
‘‘Any hospital claiming under this subparagraph 
for time spent in a nonprovider setting shall 
maintain and make available to the Secretary 
records regarding the amount of such time and 
such amount in comparison with amounts of 
such time in such base year as the Secretary 
shall specify.’’. 
(b) IME.—Section 1886(d)(5)(B)(iv) of the Social Se-
curity Act (42 U.S.C. 1395ww(d)(5)) is amended— 
(1) by striking ‘‘(iv) Effective for discharges oc-
curring on or after October 1, 1997’’ and inserting 
‘‘(iv)(I) Effective for discharges occurring on or after 
October 1, 1997, and before July 1, 2010’’; and 
(2) by inserting after clause (I), as inserted by 
paragraph (1), the following new subparagraph:
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‘‘(II) Effective for discharges occurring on or 
after July 1, 2010, all the time spent by an intern 
or resident in patient care activities in a nonprovider 
setting shall be counted towards the determination of 
full-time equivalency if a hospital incurs the costs of 
the stipends and fringe benefits of the intern or resi-
dent during the time the intern or resident spends in 
that setting. If more than one hospital incurs these 
costs, either directly or through a third party, such 
hospitals shall count a proportional share of the time, 
as determined by written agreement between the hos-
pitals, that a resident spends training in that set-
ting.’’. 
(c) APPLICATION.—The amendments made by this sec-
tion shall not be applied in a manner that requires reopen-
ing of any settled hospital cost reports as to which there 
is not a jurisdictionally proper appeal 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 (42 U.S.C. 
1395ww(d)(5)(B)) or for direct graduate medical education 
costs under section 1886(h) of such Act (42 U.S.C. 
1395ww(h)).
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SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DI-
DACTIC AND SCHOLARLY ACTIVITIES AND 
OTHER ACTIVITIES. 
(a) GME.—Section 1886(h) of the Social Security Act 
(42 U.S.C. 1395ww(h)), as amended by section 5504, is 
amended— 
(1) in paragraph (4)— 
(A) in subparagraph (E), by striking ‘‘Such 
rules’’ and inserting ‘‘Subject to subparagraphs 
(J) and (K), such rules’’; and 
(B) by adding at the end the following new 
subparagraphs: 
‘‘(J) TREATMENT
OF
CERTAIN
NONPRO-
VIDER
AND
DIDACTIC
ACTIVITIES.—Such rules 
shall provide that all time spent by an intern or 
resident in an approved medical residency train-
ing program in a nonprovider setting that is 
primarily engaged in furnishing patient care (as 
defined in paragraph (5)(K)) in non-patient 
care activities, such as didactic conferences and 
seminars, but not including research not associ-
ated with the treatment or diagnosis of a par-
ticular patient, as such time and activities are 
defined by the Secretary, shall be counted toward 
the determination of full-time equivalency.
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‘‘(K) TREATMENT OF CERTAIN OTHER AC-
TIVITIES.—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 deter-
mination of full-time equivalency.’’; and 
(2) in paragraph (5), by adding at the end the 
following new subparagraph: 
‘‘(K) NONPROVIDER SETTING THAT IS PRI-
MARILY
ENGAGED
IN
FURNISHING
PATIENT 
CARE.—The term ‘nonprovider setting that is 
primarily engaged in furnishing patient care’ 
means a nonprovider setting in which the pri-
mary activity is the care and treatment of pa-
tients, as defined by the Secretary.’’. 
(b) IME DETERMINATIONS.—Section 1886(d)(5)(B) of 
such Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by add-
ing at the end the following new clause:
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‘‘(x)(I) The provisions of subparagraph 
(K) of subsection (h)(4) shall apply under 
this subparagraph 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 ap-
proved 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 Sec-
retary, that occurs in the hospital shall be 
counted toward the determination of full- 
time equivalency if the hospital— 
‘‘(aa) is recognized as a subsection 
(d) hospital; 
‘‘(bb) is recognized as a subsection 
(d) Puerto Rico hospital; 
‘‘(cc) is reimbursed under a reim-
bursement system authorized under sec-
tion 1814(b)(3); or 
‘‘(dd) is a provider-based hospital 
outpatient 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 ap-
proved medical residency training program 
in research activities that are not associated 
with the treatment or diagnosis of a par-
ticular patient, as such time and activities 
are defined by the Secretary, shall not be 
counted toward the determination of full- 
time equivalency.’’. 
(c) EFFECTIVE DATES.— 
(1) IN GENERAL.—Except as otherwise provided, 
the Secretary of Health and Human Services shall 
implement the amendments made by this section in a 
manner so as to apply to cost reporting periods begin-
ning on or after January 1, 1983. 
(2) GME.—Section 1886(h)(4)(J) of the Social 
Security Act, as added by subsection (a)(1)(B), shall 
apply to cost reporting periods beginning 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
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give rise to any inference as to how the law in effect 
prior to such date should be interpreted. 
SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS 
FROM CLOSED HOSPITALS. 
(a) GME.—Section 1886(h)(4)(H) of the Social Secu-
rity Act (42 U.S.C. Section 1395ww(h)(4)(H)) is amended 
by adding at the end the following new clause: 
‘‘(vi) REDISTRIBUTION OF RESIDENCY 
SLOTS AFTER A HOSPITAL CLOSES.— 
‘‘(I) IN GENERAL.—Subject to the 
succeeding provisions of this clause, the 
Secretary shall, by regulation, establish 
a process under which, in the case 
where a hospital (other than a hospital 
described in clause (v)) with an ap-
proved medical residency program 
closes on or after a date that is 2 years 
before the date of enactment of this 
clause, the Secretary shall increase the 
otherwise applicable resident limit 
under this paragraph for other hos-
pitals in accordance with this clause. 
‘‘(II) PRIORITY FOR HOSPITALS IN 
CERTAIN AREAS.—Subject to the suc-
ceeding provisions of this clause, in de-
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termining for which hospitals the in-
crease in the otherwise applicable resi-
dent limit is provided under such proc-
ess, the Secretary shall distribute the 
increase to hospitals in the following 
priority order (with preference given 
within each category to hospitals that 
are members of the same affiliated 
group (as defined by the Secretary 
under clause (ii)) as the closed hos-
pital): 
‘‘(aa) First, to hospitals lo-
cated in the same core-based sta-
tistical area as, or a core-based 
statistical area contiguous to, the 
hospital that closed. 
‘‘(bb) Second, to hospitals lo-
cated in the same State as the 
hospital that closed. 
‘‘(cc) Third, to hospitals lo-
cated in the same region of the 
country as the hospital that 
closed. 
‘‘(dd) Fourth, only if the Sec-
retary is not able to distribute the
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increase to hospitals described in 
item (cc), to qualifying hospitals 
in accordance with the provisions 
of paragraph (8). 
‘‘(III) REQUIREMENT
HOSPITAL 
LIKELY TO FILL POSITION WITHIN CER-
TAIN
TIME
PERIOD.—The Secretary 
may only increase the otherwise appli-
cable resident limit of a hospital under 
such process if the Secretary deter-
mines the hospital has demonstrated a 
likelihood of filling the positions made 
available under this clause within 3 
years. 
‘‘(IV) LIMITATION.—The aggre-
gate number of increases in the other-
wise applicable resident limits for hos-
pitals under this clause shall be equal 
to the number of resident positions in 
the approved medical residency pro-
grams that closed on or after the date 
described in subclause (I). 
‘‘(V) ADMINISTRATION.—Chapter 
35 of title 44, United States Code, shall
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not apply to the implementation of 
this clause.’’. 
(b) IME.—Section 1886(d)(5)(B)(v) of the Social Se-
curity Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 
sentence, as amended by section 5503, is amended by strik-
ing ‘‘subsections (h)(7) and (h)(8)’’ and inserting ‘‘sub-
sections (h)(4)(H)(vi), (h)(7), and (h)(8)’’. 
(c) APPLICATION.—The amendments made by this sec-
tion shall not be applied in a manner that requires reopen-
ing of any settled hospital cost reports as to which there 
is not a jurisdictionally proper appeal 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 (42 U.S.C. 
1395ww(d)(5)(B)) or for direct graduate medical education 
costs under section 1886(h) of such Act (42 U.S.C. Section 
1395ww(h)). 
(d) EFFECT
ON TEMPORARY FTE CAP ADJUST-
MENTS.—The Secretary of Health and Human Services 
shall give consideration to the effect of the amendments 
made by this section on any temporary adjustment to a 
hospital’s FTE cap under section 413.79(h) of title 42, Code 
of Federal Regulations (as in effect on the date of enactment 
of this Act) in order to ensure that there is no duplication 
of FTE slots. Such amendments shall not affect the applica-
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tion of section 1886(h)(4)(H)(v) of the Social Security Act 
(42 U.S.C. 1395ww(h)(4)(H)(v)). 
(e) 
CONFORMING
AMENDMENT.—Section 
1886(h)(7)(E) of the Social Security Act (42 U.S.C. 
1395ww(h)(7)(E)), as amended by section 5503(a), is 
amended by striking ‘‘paragraph or paragraph (8)’’ and 
inserting ‘‘this paragraph, paragraph (8), or paragraph 
(4)(H)(vi)’’. 
SEC. 
5507. 
DEMONSTRATION 
PROJECTS 
TO 
ADDRESS 
HEALTH PROFESSIONS WORKFORCE NEEDS; 
EXTENSION OF FAMILY-TO-FAMILY HEALTH 
INFORMATION CENTERS. 
(a) 
AUTHORITY
TO
CONDUCT
DEMONSTRATION 
PROJECTS.—Title XX of the Social Security Act (42 U.S.C. 
1397 et seq.) is amended by adding at the end the following: 
‘‘SEC. 2008. DEMONSTRATION PROJECTS TO ADDRESS 
HEALTH PROFESSIONS WORKFORCE NEEDS. 
‘‘(a) DEMONSTRATION PROJECTS TO PROVIDE LOW- 
INCOME INDIVIDUALS WITH OPPORTUNITIES
FOR EDU-
CATION, TRAINING, AND CAREER ADVANCEMENT TO AD-
DRESS HEALTH PROFESSIONS WORKFORCE NEEDS.— 
‘‘(1) AUTHORITY TO AWARD GRANTS.—The Sec-
retary, in consultation with the Secretary of Labor, 
shall award grants to eligible entities to conduct dem-
onstration projects that are designed to provide eligi-
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ble individuals with the opportunity to obtain edu-
cation and training for occupations in the health care 
field that pay well and are expected to either experi-
ence labor shortages or be in high demand. 
‘‘(2) REQUIREMENTS.— 
‘‘(A) AID AND SUPPORTIVE SERVICES.— 
‘‘(i) IN
GENERAL.—A demonstration 
project conducted by an eligible entity 
awarded a grant under this section shall, if 
appropriate, provide eligible individuals 
participating in the project with financial 
aid, child care, case management, and other 
supportive services. 
‘‘(ii) TREATMENT.—Any aid, services, 
or incentives provided to an eligible bene-
ficiary participating in a demonstration 
project under this section shall not be con-
sidered income, and shall not be taken into 
account for purposes of determining the in-
dividual’s eligibility for, or amount of, ben-
efits under any means-tested program. 
‘‘(B) CONSULTATION AND COORDINATION.— 
An eligible entity applying for a grant to carry 
out a demonstration project under this section 
shall demonstrate in the application that the en-
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tity has consulted with the State agency respon-
sible for administering the State TANF program, 
the local workforce investment board in the area 
in which the project is to be conducted (unless 
the applicant is such board), the State workforce 
investment board established under section 111 of 
the Workforce Investment Act of 1998, and the 
State Apprenticeship Agency recognized under 
the Act of August 16, 1937 (commonly known as 
the ‘National Apprenticeship Act’) (or if no 
agency has been recognized in the State, the Of-
fice of Apprenticeship of the Department of 
Labor) and that the project will be carried out 
in coordination with such entities. 
‘‘(C) ASSURANCE OF OPPORTUNITIES FOR 
INDIAN
POPULATIONS.—The 
Secretary 
shall 
award at least 3 grants under this subsection to 
an eligible entity that is an Indian tribe, tribal 
organization, or Tribal College or University. 
‘‘(3) REPORTS AND EVALUATION.— 
‘‘(A) ELIGIBLE ENTITIES.—An eligible enti-
ty awarded a grant to conduct a demonstration 
project under this subsection shall submit in-
terim reports to the Secretary on the activities 
carried out under the project and a final report
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on such activities upon the conclusion of the en-
tities’ participation in the project. Such reports 
shall include assessments of the effectiveness of 
such activities with respect to improving out-
comes for the eligible individuals participating 
in the project and with respect to addressing 
health professions workforce needs in the areas in 
which the project is conducted. 
‘‘(B) EVALUATION.—The Secretary shall, by 
grant, contract, or interagency agreement, evalu-
ate the demonstration projects conducted under 
this subsection. Such evaluation shall include 
identification of successful activities for creating 
opportunities for developing and sustaining, par-
ticularly with respect to low-income individuals 
and other entry-level workers, a health profes-
sions workforce that has accessible entry points, 
that meets high standards for education, train-
ing, certification, and professional development, 
and that provides increased wages and affordable 
benefits, including health care coverage, that are 
responsive to the workforce’s needs. 
‘‘(C) REPORT
TO
CONGRESS.—The Sec-
retary shall submit interim reports and, based 
on the evaluation conducted under subparagraph
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(B), a final report to Congress on the demonstra-
tion projects conducted under this subsection. 
‘‘(4) DEFINITIONS.—In this subsection: 
‘‘(A) ELIGIBLE ENTITY.—The term ‘eligible 
entity’ means a State, an Indian tribe or tribal 
organization, an institution of higher education, 
a local workforce investment board established 
under section 117 of the Workforce Investment 
Act of 1998, a sponsor of an apprenticeship pro-
gram registered under the National Apprentice-
ship Act or a community-based organization. 
‘‘(B) ELIGIBLE INDIVIDUAL.— 
‘‘(i) IN GENERAL.—The term ‘eligible 
individual’ means a individual receiving 
assistance under the State TANF program. 
‘‘(ii) OTHER
LOW-INCOME
INDIVID-
UALS.—Such term may include other low- 
income individuals described by the eligible 
entity in its application for a grant under 
this section. 
‘‘(C) INDIAN
TRIBE; 
TRIBAL
ORGANIZA-
TION.—The terms ‘Indian tribe’ and ‘tribal orga-
nization’ have the meaning given such terms in 
section 4 of the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450b).
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‘‘(D) 
INSTITUTION
OF
HIGHER
EDU-
CATION.—The term ‘institution of higher edu-
cation’ has the meaning given that term in sec-
tion 101 of the Higher Education Act of 1965 
(20 U.S.C. 1001). 
‘‘(E) STATE.—The term ‘State’ means each 
of the 50 States, the District of Columbia, the 
Commonwealth of Puerto Rico, the United States 
Virgin Islands, Guam, and American Samoa. 
‘‘(F) STATE
TANF
PROGRAM.—The term 
‘State TANF program’ means the temporary as-
sistance for needy families program funded 
under part A of title IV. 
‘‘(G) TRIBAL COLLEGE OR UNIVERSITY.— 
The term ‘Tribal College or University’ has the 
meaning given that term in section 316(b) of the 
Higher Education Act of 1965 (20 U.S.C. 
1059c(b)). 
‘‘(b) DEMONSTRATION PROJECT TO DEVELOP TRAIN-
ING AND CERTIFICATION PROGRAMS FOR PERSONAL OR 
HOME CARE AIDES.— 
‘‘(1) AUTHORITY TO AWARD GRANTS.—Not later 
than 18 months after the date of enactment of this 
section, the Secretary shall award grants to eligible 
entities that are States to conduct demonstration
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projects for purposes of developing core training com-
petencies and certification programs for personal or 
home care aides. The Secretary shall— 
‘‘(A) evaluate the efficacy of the core train-
ing competencies described in paragraph (3)(A) 
for newly hired personal or home care aides and 
the methods used by States to implement such 
core training competencies in accordance with 
the issues specified in paragraph (3)(B); and 
‘‘(B) ensure that the number of hours of 
training provided by States under the dem-
onstration project with respect to such core 
training competencies are not less than the num-
ber of hours of training required under any ap-
plicable State or Federal law or regulation. 
‘‘(2) DURATION.—A demonstration project shall 
be conducted under this subsection for not less than 
3 years. 
‘‘(3) CORE TRAINING COMPETENCIES FOR PER-
SONAL OR HOME CARE AIDES.— 
‘‘(A) IN GENERAL.—The core training com-
petencies for personal or home care aides de-
scribed in this subparagraph include com-
petencies with respect to the following areas:
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‘‘(i) The role of the personal or home 
care aide (including differences between a 
personal or home care aide employed by an 
agency and a personal or home care aide 
employed directly by the health care con-
sumer or an independent provider). 
‘‘(ii) Consumer rights, ethics, and con-
fidentiality (including the role of proxy de-
cision-makers in the case where a health 
care consumer has impaired decision-mak-
ing capacity). 
‘‘(iii) Communication, cultural and 
linguistic competence and sensitivity, prob-
lem solving, behavior management, and re-
lationship skills. 
‘‘(iv) Personal care skills. 
‘‘(v) Health care support. 
‘‘(vi) Nutritional support. 
‘‘(vii) Infection control. 
‘‘(viii) Safety and emergency training. 
‘‘(ix) Training specific to an indi-
vidual consumer’s needs (including older in-
dividuals, younger individuals with disabil-
ities, individuals with developmental dis-
abilities, individuals with dementia, and
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individuals with mental and behavioral 
health needs). 
‘‘(x) Self-Care. 
‘‘(B) IMPLEMENTATION.—The implementa-
tion issues specified in this subparagraph in-
clude the following: 
‘‘(i) The length of the training. 
‘‘(ii) The appropriate trainer to stu-
dent ratio. 
‘‘(iii) The amount of instruction time 
spent in the classroom as compared to on- 
site in the home or a facility. 
‘‘(iv) Trainer qualifications. 
‘‘(v) Content for a ‘hands-on’ and writ-
ten certification exam. 
‘‘(vi) Continuing education require-
ments. 
‘‘(4) APPLICATION AND SELECTION CRITERIA.— 
‘‘(A) IN GENERAL.— 
‘‘(i) NUMBER
OF
STATES.—The Sec-
retary shall enter into agreements with not 
more than 6 States to conduct demonstra-
tion projects under this subsection.
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‘‘(ii) REQUIREMENTS
FOR
STATES.— 
An agreement entered into under clause (i) 
shall require that a participating State— 
‘‘(I) implement the core training 
competencies described in paragraph 
(3)(A); and 
‘‘(II) develop written materials 
and protocols for such core training 
competencies, including the develop-
ment of a certification test for personal 
or home care aides who have completed 
such training competencies. 
‘‘(iii) CONSULTATION AND COLLABORA-
TION
WITH
COMMUNITY
AND
VOCATIONAL 
COLLEGES.—The Secretary shall encourage 
participating States to consult with com-
munity and vocational colleges regarding 
the development of curricula to implement 
the project with respect to activities, as ap-
plicable, which may include consideration 
of such colleges as partners in such imple-
mentation. 
‘‘(B) APPLICATION
AND
ELIGIBILITY.—A 
State seeking to participate in the project 
shall—
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‘‘(i) submit an application to the Sec-
retary containing such information and at 
such time as the Secretary may specify; 
‘‘(ii) meet the selection criteria estab-
lished under subparagraph (C); and 
‘‘(iii) meet such additional criteria as 
the Secretary may specify. 
‘‘(C) SELECTION
CRITERIA.—In selecting 
States to participate in the program, the Sec-
retary shall establish criteria to ensure (if appli-
cable with respect to the activities involved)— 
‘‘(i) geographic and demographic di-
versity; 
‘‘(ii) that participating States offer 
medical assistance for personal care services 
under the State Medicaid plan; 
‘‘(iii) that the existing training stand-
ards for personal or home care aides in each 
participating State— 
‘‘(I) are different from such stand-
ards in the other participating States; 
and 
‘‘(II) are different from the core 
training competencies described in 
paragraph (3)(A);
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‘‘(iv) that participating States do not 
reduce the number of hours of training re-
quired under applicable State law or regu-
lation after being selected to participate in 
the project; and 
‘‘(v) that participating States recruit a 
minimum number of eligible health and 
long-term care providers to participate in 
the project. 
‘‘(D) TECHNICAL
ASSISTANCE.—The Sec-
retary shall provide technical assistance to 
States in developing written materials and pro-
tocols for such core training competencies. 
‘‘(5) EVALUATION AND REPORT.— 
‘‘(A) EVALUATION.—The Secretary shall de-
velop an experimental or control group testing 
protocol in consultation with an independent 
evaluation contractor selected by the Secretary. 
Such contractor shall evaluate— 
‘‘(i) the impact of core training com-
petencies described in paragraph (3)(A), in-
cluding curricula developed to implement 
such core training competencies, for per-
sonal or home care aides within each par-
ticipating State on job satisfaction, mastery
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of job skills, beneficiary and family care-
giver satisfaction with services, and addi-
tional measures determined by the Secretary 
in consultation with the expert panel; 
‘‘(ii) the impact of providing such core 
training competencies on the existing train-
ing infrastructure and resources of States; 
and 
‘‘(iii) whether a minimum number of 
hours of initial training should be required 
for personal or home care aides and, if so, 
what minimum number of hours should be 
required. 
‘‘(B) REPORTS.— 
‘‘(i) REPORT ON INITIAL IMPLEMENTA-
TION.—Not later than 2 years after the date 
of enactment of this section, the Secretary 
shall submit to Congress a report on the ini-
tial implementation of activities conducted 
under the demonstration project, including 
any available results of the evaluation con-
ducted under subparagraph (A) with respect 
to such activities, together with such rec-
ommendations for legislation or administra-
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tive action as the Secretary determines ap-
propriate. 
‘‘(ii) FINAL REPORT.—Not later than 1 
year after the completion of the demonstra-
tion project, the Secretary shall submit to 
Congress a report containing the results of 
the evaluation conducted under subpara-
graph (A), together with such recommenda-
tions for legislation or administrative ac-
tion as the Secretary determines appro-
priate. 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ELIGIBLE
HEALTH
AND
LONG-TERM 
CARE PROVIDER.—The term ‘eligible health and 
long-term care provider’ means a personal or 
home care agency (including personal or home 
care public authorities), a nursing home, a home 
health agency (as defined in section 1861(o)), or 
any other health care provider the Secretary de-
termines appropriate which— 
‘‘(i) is licensed or authorized to provide 
services in a participating State; and 
‘‘(ii) receives payment for services 
under title XIX.
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‘‘(B) PERSONAL CARE SERVICES.—The term 
‘personal care services’ has the meaning given 
such term for purposes of title XIX. 
‘‘(C) PERSONAL OR HOME CARE AIDE.—The 
term ‘personal or home care aide’ means an in-
dividual who helps individuals who are elderly, 
disabled, ill, or mentally disabled (including an 
individual with Alzheimer’s disease or other de-
mentia) to live in their own home or a residen-
tial care facility (such as a nursing home, as-
sisted living facility, or any other facility the 
Secretary determines appropriate) by providing 
routine personal care services and other appro-
priate services to the individual. 
‘‘(D) STATE.—The term ‘State’ has the 
meaning given that term for purposes of title 
XIX. 
‘‘(c) FUNDING.— 
‘‘(1) IN
GENERAL.—Subject to paragraph (2), 
out of any funds in the Treasury not otherwise appro-
priated, there are appropriated to the Secretary to 
carry out subsections (a) and (b), $85,000,000 for 
each of fiscal years 2010 through 2014. 
‘‘(2) TRAINING AND CERTIFICATION PROGRAMS 
FOR PERSONAL AND HOME CARE AIDES.—With re-
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spect to the demonstration projects under subsection 
(b), the Secretary shall use $5,000,000 of the amount 
appropriated under paragraph (1) for each of fiscal 
years 2010 through 2012 to carry out such projects. 
No funds appropriated under paragraph (1) shall be 
used to carry out demonstration projects under sub-
section (b) after fiscal year 2012. 
‘‘(d) NONAPPLICATION.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), the preceding sections of this title shall not 
apply to grant awarded under this section. 
‘‘(2) LIMITATIONS ON USE OF GRANTS.—Section 
2005(a) (other than paragraph (6)) shall apply to a 
grant awarded under this section to the same extent 
and in the same manner as such section applies to 
payments to States under this title.’’. 
(b) EXTENSION OF FAMILY-TO-FAMILY HEALTH IN-
FORMATION CENTERS.—Section 501(c)(1)(A)(iii) of the So-
cial Security Act (42 U.S.C. 701(c)(1)(A)(iii)) is amended 
by striking ‘‘fiscal year 2009’’ and inserting ‘‘each of fiscal 
years 2009 through 2012’’. 
SEC. 5508. INCREASING TEACHING CAPACITY. 
(a) TEACHING HEALTH CENTERS TRAINING AND EN-
HANCEMENT.—Part C of title VII of the Public Health 
Service Act (42 U.S.C. 293k et. seq.), as amended by section
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5303, is further amended by inserting after section 749 the 
following: 
‘‘SEC. 749A. TEACHING HEALTH CENTERS DEVELOPMENT 
GRANTS. 
‘‘(a) PROGRAM AUTHORIZED.—The Secretary may 
award grants under this section to teaching health centers 
for the purpose of establishing new accredited or expanded 
primary care residency programs. 
‘‘(b) AMOUNT AND DURATION.—Grants awarded under 
this section shall be for a term of not more than 3 years 
and the maximum award may not be more than $500,000. 
‘‘(c) USE
OF FUNDS.—Amounts provided under a 
grant under this section shall be used to cover the costs of— 
‘‘(1) establishing or expanding a primary care 
residency training program described in subsection 
(a), including costs associated with— 
‘‘(A) curriculum development; 
‘‘(B) recruitment, training and retention of 
residents and faculty: 
‘‘(C) accreditation by the Accreditation 
Council 
for 
Graduate 
Medical 
Education 
(ACGME), the American Dental Association 
(ADA), or the American Osteopathic Association 
(AOA); and
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‘‘(D) faculty salaries during the develop-
ment phase; and 
‘‘(2) technical assistance provided by an eligible 
entity. 
‘‘(d) APPLICATION.—A teaching health center seeking 
a grant under this section shall submit an application to 
the Secretary at such time, in such manner, and containing 
such information as the Secretary may require. 
‘‘(e) PREFERENCE FOR CERTAIN APPLICATIONS.—In 
selecting recipients for grants under this section, the Sec-
retary shall give preference to any such application that 
documents an existing affiliation agreement with an area 
health education center program as defined in sections 751 
and 799B. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible enti-
ty’ means an organization capable of providing tech-
nical assistance including an area health education 
center program as defined in sections 751 and 799B. 
‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.—The 
term ‘primary care residency program’ means an ap-
proved graduate medical residency training program 
(as defined in section 340H) in family medicine, in-
ternal medicine, pediatrics, internal medicine-pediat-
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rics, obstetrics and gynecology, psychiatry, general 
dentistry, pediatric dentistry, and geriatrics. 
‘‘(3) TEACHING HEALTH CENTER.— 
‘‘(A) IN
GENERAL.—The term ‘teaching 
health center’ means an entity that— 
‘‘(i) is a community based, ambulatory 
patient care center; and 
‘‘(ii) operates a primary care residency 
program. 
‘‘(B) INCLUSION OF CERTAIN ENTITIES.— 
Such term includes the following: 
‘‘(i) A Federally qualified health center 
(as defined in section 1905(l)(2)(B), of the 
Social Security Act). 
‘‘(ii) A community mental health cen-
ter (as defined in section 1861(ff)(3)(B) of 
the Social Security Act). 
‘‘(iii) A rural health clinic, as defined 
in section 1861(aa) of the Social Security 
Act. 
‘‘(iv) A health center operated by the 
Indian Health Service, an Indian tribe or 
tribal organization, or an urban Indian or-
ganization (as defined in section 4 of the 
Indian Health Care Improvement Act).
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‘‘(v) An entity receiving funds under 
title X of the Public Health Service Act. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated, $25,000,000 for fiscal year 
2010, $50,000,000 for fiscal year 2011, $50,000,000 for fis-
cal year 2012, and such sums as may be necessary for each 
fiscal year thereafter to carry out this section. Not to exceed 
$5,000,000 annually may be used for technical assistance 
program grants.’’. 
(b) NATIONAL HEALTH SERVICE CORPS TEACHING 
CAPACITY.—Section 338C(a) of the Public Health Service 
Act (42 U.S.C. 254m(a)) is amended to read as follows: 
‘‘(a) SERVICE IN FULL-TIME CLINICAL PRACTICE.— 
Except as provided in section 338D, each individual who 
has entered into a written contract with the Secretary 
under section 338A or 338B shall provide service in the full- 
time clinical practice of such individual’s profession as a 
member of the Corps for the period of obligated service pro-
vided in such contract. For the purpose of calculating time 
spent in full-time clinical practice under this subsection, 
up to 50 percent of time spent teaching by a member of 
the Corps may be counted toward his or her service obliga-
tion.’’. 
(c) PAYMENTS
TO QUALIFIED TEACHING HEALTH 
CENTERS.—Part D of title III of the Public Health Service
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Act (42 U.S.C. 254b et seq.) is amended by adding at the 
end the following: 
‘‘Subpart XI—Support of Graduate Medical 
Education in Qualified Teaching Health Centers 
‘‘SEC. 
340H. 
PROGRAM 
OF 
PAYMENTS 
TO 
TEACHING 
HEALTH CENTERS THAT OPERATE GRADUATE 
MEDICAL EDUCATION PROGRAMS. 
‘‘(a) PAYMENTS.—Subject to subsection (h)(2), the Sec-
retary shall make payments under this section for direct 
expenses and for indirect expenses to qualified teaching 
health centers that are listed as sponsoring institutions by 
the relevant accrediting body for expansion of existing or 
establishment of new approved graduate medical residency 
training programs. 
‘‘(b) AMOUNT OF PAYMENTS.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), the 
amounts payable under this section to qualified teach-
ing health centers for an approved graduate medical 
residency training program for a fiscal year are each 
of the following amounts: 
‘‘(A) 
DIRECT
EXPENSE
AMOUNT.—The 
amount determined under subsection (c) for di-
rect expenses associated with sponsoring ap-
proved graduate medical residency training pro-
grams.
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‘‘(B) INDIRECT
EXPENSE
AMOUNT.—The 
amount determined under subsection (d) for in-
direct expenses associated with the additional 
costs relating to teaching residents in such pro-
grams. 
‘‘(2) CAPPED AMOUNT.— 
‘‘(A) IN GENERAL.—The total of the pay-
ments made to qualified teaching health centers 
under paragraph (1)(A) or paragraph (1)(B) in 
a fiscal year shall not exceed the amount of 
funds appropriated under subsection (g) for such 
payments for that fiscal year. 
‘‘(B) LIMITATION.—The Secretary shall 
limit the funding of full-time equivalent resi-
dents in order to ensure the direct and indirect 
payments as determined under subsection (c) 
and (d) do not exceed the total amount of funds 
appropriated in a fiscal year under subsection 
(g). 
‘‘(c) AMOUNT OF PAYMENT FOR DIRECT GRADUATE 
MEDICAL EDUCATION.— 
‘‘(1) IN
GENERAL.—The amount determined 
under this subsection for payments to qualified teach-
ing health centers for direct graduate expenses relat-
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ing to approved graduate medical residency training 
programs for a fiscal year is equal to the product of— 
‘‘(A) the updated national per resident 
amount for direct graduate medical education, 
as determined under paragraph (2); and 
‘‘(B) the average number of full-time equiv-
alent residents in the teaching health center’s 
graduate approved medical residency training 
programs 
as 
determined 
under 
section 
1886(h)(4) of the Social Security Act (without 
regard to the limitation under subparagraph (F) 
of such section) during the fiscal year. 
‘‘(2) 
UPDATED
NATIONAL
PER
RESIDENT 
AMOUNT
FOR
DIRECT
GRADUATE
MEDICAL
EDU-
CATION.—The updated per resident amount for direct 
graduate medical education for a qualified teaching 
health center for a fiscal year is an amount deter-
mined as follows: 
‘‘(A) 
DETERMINATION
OF
QUALIFIED 
TEACHING
HEALTH
CENTER
PER
RESIDENT 
AMOUNT.—The Secretary shall compute for each 
individual qualified teaching health center a per 
resident amount— 
‘‘(i) by dividing the national average 
per resident amount computed under section
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340E(c)(2)(D) into a wage-related portion 
and a non-wage related portion by applying 
the proportion determined under subpara-
graph (B); 
‘‘(ii) by multiplying the wage-related 
portion by the factor applied under section 
1886(d)(3)(E) of the Social Security Act 
(but without application of section 4410 of 
the Balanced Budget Act of 1997 (42 U.S.C. 
1395ww note)) during the preceding fiscal 
year for the teaching health center’s area; 
and 
‘‘(iii) by adding the non-wage-related 
portion to the amount computed under 
clause (ii). 
‘‘(B) UPDATING RATE.—The Secretary shall 
update such per resident amount for each such 
qualified teaching health center as determined 
appropriate by the Secretary. 
‘‘(d) AMOUNT OF PAYMENT FOR INDIRECT MEDICAL 
EDUCATION.— 
‘‘(1) IN
GENERAL.—The amount determined 
under this subsection for payments to qualified teach-
ing health centers for indirect expenses associated 
with the additional costs of teaching residents for a
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fiscal year is equal to an amount determined appro-
priate by the Secretary. 
‘‘(2) FACTORS.—In determining the amount 
under paragraph (1), the Secretary shall— 
‘‘(A) evaluate indirect training costs rel-
ative to supporting a primary care residency 
program in qualified teaching health centers; 
and 
‘‘(B) based on this evaluation, assure that 
the aggregate of the payments for indirect ex-
penses under this section and the payments for 
direct graduate medical education as determined 
under subsection (c) in a fiscal year do not ex-
ceed the amount appropriated for such expenses 
as determined in subsection (g). 
‘‘(3) INTERIM PAYMENT.—Before the Secretary 
makes a payment under this subsection pursuant to 
a determination of indirect expenses under paragraph 
(1), the Secretary may provide to qualified teaching 
health centers a payment, in addition to any pay-
ment made under subsection (c), for expected indirect 
expenses associated with the additional costs of teach-
ing residents for a fiscal year, based on an estimate 
by the Secretary.
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‘‘(f) RECONCILIATION.—The Secretary shall determine 
any changes to the number of residents reported by a hos-
pital in the application of the hospital for the current fiscal 
year to determine the final amount payable to the hospital 
for the current fiscal year for both direct expense and indi-
rect expense amounts. Based on such determination, the 
Secretary shall recoup any overpayments made to pay any 
balance due to the extent possible. The final amount so de-
termined shall be considered a final intermediary deter-
mination for the purposes of section 1878 of the Social Se-
curity Act and shall be subject to administrative and judi-
cial review under that section in the same manner as the 
amount of payment under section 1186(d) of such Act is 
subject to review under such section. 
‘‘(g) FUNDING.—To carry out this section, there are 
appropriated such sums as may be necessary, not to exceed 
$230,000,000, for the period of fiscal years 2011 through 
2015. 
‘‘(h) ANNUAL REPORTING REQUIRED.— 
‘‘(1) ANNUAL
REPORT.—The report required 
under this paragraph for a qualified teaching health 
center for a fiscal year is a report that includes (in 
a form and manner specified by the Secretary) the 
following information for the residency academic year 
completed immediately prior to such fiscal year:
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‘‘(A) The types of primary care resident ap-
proved training programs that the qualified 
teaching health center provided for residents. 
‘‘(B) The number of approved training posi-
tions for residents described in paragraph (4). 
‘‘(C) The number of residents described in 
paragraph (4) who completed their residency 
training at the end of such residency academic 
year and care for vulnerable populations living 
in underserved areas. 
‘‘(D) Other information as deemed appro-
priate by the Secretary. 
‘‘(2) AUDIT
AUTHORITY; LIMITATION
ON
PAY-
MENT.— 
‘‘(A) AUDIT
AUTHORITY.—The Secretary 
may audit a qualified teaching health center to 
ensure the accuracy and completeness of the in-
formation submitted in a report under para-
graph (1). 
‘‘(B) LIMITATION ON PAYMENT.—A teaching 
health center may only receive payment in a cost 
reporting period for a number of such resident 
positions that is greater than the base level of 
primary care resident positions, as determined 
by the Secretary. For purposes of this subpara-
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graph, the ‘base level of primary care residents’ 
for a teaching health center is the level of such 
residents as of a base period. 
‘‘(3) REDUCTION IN PAYMENT FOR FAILURE TO 
REPORT.— 
‘‘(A) IN
GENERAL.—The amount payable 
under this section to a qualified teaching health 
center for a fiscal year shall be reduced by at 
least 25 percent if the Secretary determines 
that— 
‘‘(i) the qualified teaching health center 
has failed to provide the Secretary, as an 
addendum to the qualified teaching health 
center’s application under this section for 
such fiscal year, the report required under 
paragraph (1) for the previous fiscal year; 
or 
‘‘(ii) such report fails to provide com-
plete and accurate information required 
under any subparagraph of such paragraph. 
‘‘(B) NOTICE AND OPPORTUNITY TO PRO-
VIDE ACCURATE AND MISSING INFORMATION.— 
Before imposing a reduction under subparagraph 
(A) on the basis of a qualified teaching health 
center’s failure to provide complete and accurate
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information described in subparagraph (A)(ii), 
the Secretary shall provide notice to the teaching 
health center of such failure and the Secretary’s 
intention to impose such reduction and shall 
provide the teaching health center with the op-
portunity to provide the required information 
within the period of 30 days beginning on the 
date of such notice. If the teaching health center 
provides such information within such period, no 
reduction shall be made under subparagraph (A) 
on the basis of the previous failure to provide 
such information. 
‘‘(4) RESIDENTS.—The residents described in 
this paragraph are those who are in part-time or full- 
time equivalent resident training positions at a quali-
fied teaching health center in any approved graduate 
medical residency training program. 
‘‘(i) REGULATIONS.—The Secretary shall promulgate 
regulations to carry out this section. 
‘‘(j) DEFINITIONS.—In this section: 
‘‘(1) APPROVED GRADUATE MEDICAL RESIDENCY 
TRAINING PROGRAM.—The term ‘approved graduate 
medical residency training program’ means a resi-
dency or other postgraduate medical training pro-
gram—
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‘‘(A) participation in which may be counted 
toward certification in a specialty or sub-
specialty and includes formal postgraduate 
training programs in geriatric medicine ap-
proved by the Secretary; and 
‘‘(B) that meets criteria for accreditation 
(as established by the Accreditation Council for 
Graduate Medical Education, the American Os-
teopathic Association, or the American Dental 
Association). 
‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.—The 
term ‘primary care residency program’ has the mean-
ing given that term in section 749A. 
‘‘(3) QUALIFIED TEACHING HEALTH CENTER.— 
The term ‘qualified teaching health center’ has the 
meaning given the term ‘teaching health center’ in 
section 749A.’’. 
SEC. 5509. GRADUATE NURSE EDUCATION DEMONSTRA-
TION. 
(a) IN GENERAL.— 
(1) ESTABLISHMENT.— 
(A) IN GENERAL.—The Secretary shall es-
tablish a graduate nurse education demonstra-
tion under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.) under which an eligible
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hospital may receive payment for the hospital’s 
reasonable costs (described in paragraph (2)) for 
the provision of qualified clinical training to ad-
vance practice nurses. 
(B) NUMBER.—The demonstration shall in-
clude up to 5 eligible hospitals. 
(C) WRITTEN AGREEMENTS.—Eligible hos-
pitals selected to participate in the demonstra-
tion shall enter into written agreements pursu-
ant to subsection (b) in order to reimburse the el-
igible partners of the hospital the share of the 
costs attributable to each partner. 
(2) COSTS DESCRIBED.— 
(A) IN GENERAL.—Subject to subparagraph 
(B) and subsection (d), the costs described in this 
paragraph are the reasonable costs (as described 
in section 1861(v) of the Social Security Act (42 
U.S.C. 1395x(v))) of each eligible hospital for the 
clinical training costs (as determined by the Sec-
retary) that are attributable to providing ad-
vanced practice registered nurses with qualified 
training. 
(B) LIMITATION.—With respect to a year, 
the amount reimbursed under subparagraph (A) 
may not exceed the amount of costs described in
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subparagraph (A) that are attributable to an in-
crease in the number of advanced practice reg-
istered nurses enrolled in a program that pro-
vides qualified training during the year and for 
which the hospital is being reimbursed under the 
demonstration, as compared to the average num-
ber of advanced practice registered nurses who 
graduated in each year during the period begin-
ning on January 1, 2006, and ending on Decem-
ber 31, 2010 (as determined by the Secretary) 
from the graduate nursing education program 
operated by the applicable school of nursing that 
is an eligible partner of the hospital for purposes 
of the demonstration. 
(3) WAIVER
AUTHORITY.—The Secretary may 
waive such requirements of titles XI and XVIII of the 
Social Security Act as may be necessary to carry out 
the demonstration. 
(4) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to the implemen-
tation of this section. 
(b) WRITTEN AGREEMENTS WITH ELIGIBLE PART-
NERS.—No payment shall be made under this section to an 
eligible hospital unless such hospital has in effect a written
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agreement with the eligible partners of the hospital. Such 
written agreement shall describe, at a minimum— 
(1) the obligations of the eligible partners with 
respect to the provision of qualified training; and 
(2) the obligation of the eligible hospital to reim-
burse such eligible partners applicable (in a timely 
manner) for the costs of such qualified training at-
tributable to partner. 
(c) EVALUATION.—Not later than October 17, 2017, the 
Secretary shall submit to Congress a report on the dem-
onstration. Such report shall include an analysis of the fol-
lowing: 
(1) The growth in the number of advanced prac-
tice registered nurses with respect to a specific base 
year as a result of the demonstration. 
(2) The growth for each of the specialties de-
scribed in subparagraphs (A) through (D) of sub-
section (e)(1). 
(3) The costs to the Medicare program under 
title XVIII of the Social Security Act as a result of 
the demonstration. 
(4) Other items the Secretary determines appro-
priate and relevant. 
(d) FUNDING.—
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(1) IN GENERAL.—There is hereby appropriated 
to the Secretary, out of any funds in the Treasury not 
otherwise appropriated, $50,000,000 for each of fiscal 
years 2012 through 2015 to carry out this section, in-
cluding the design, implementation, monitoring, and 
evaluation of the demonstration. 
(2) PRORATION.—If the aggregate payments to 
eligible hospitals under the demonstration exceed 
$50,000,000 for a fiscal year described in paragraph 
(1), the Secretary shall prorate the payment amounts 
to each eligible hospital in order to ensure that the 
aggregate payments do not exceed such amount. 
(3) 
WITHOUT
FISCAL
YEAR
LIMITATION.— 
Amounts appropriated under this subsection shall re-
main available without fiscal year limitation. 
(e) DEFINITIONS.—In this section: 
(1) ADVANCED PRACTICE REGISTERED NURSE.— 
The term ‘‘advanced practice registered nurse’’ in-
cludes the following: 
(A) A clinical nurse specialist (as defined 
in subsection (aa)(5) of section 1861 of the So-
cial Security Act (42 U.S.C. 1395x)). 
(B) A nurse practitioner (as defined in such 
subsection).
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(C) A certified registered nurse anesthetist 
(as defined in subsection (bb)(2) of such section). 
(D) A certified nurse-midwife (as defined in 
subsection (gg)(2) of such section). 
(2) APPLICABLE
NON-HOSPITAL
COMMUNITY- 
BASED CARE SETTING.—The term ‘‘applicable non- 
hospital community-based care setting’’ means a non- 
hospital community-based care setting which has en-
tered into a written agreement (as described in sub-
section (b)) with the eligible hospital participating in 
the demonstration. Such settings include Federally 
qualified health centers, rural health clinics, and 
other non-hospital settings as determined appropriate 
by the Secretary. 
(3) APPLICABLE
SCHOOL
OF
NURSING.—The 
term ‘‘applicable school of nursing’’ means an accred-
ited school of nursing (as defined in section 801 of the 
Public Health Service Act) which has entered into a 
written agreement (as described in subsection (b)) 
with the eligible hospital participating in the dem-
onstration. 
(4) DEMONSTRATION.—The term ‘‘demonstra-
tion’’ means the graduate nurse education demonstra-
tion established under subsection (a).
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(5) ELIGIBLE
HOSPITAL.—The term ‘‘eligible 
hospital’’ means a hospital (as defined in subsection 
(e) of section 1861 of the Social Security Act (42 
U.S.C. 1395x)) or a critical access hospital (as de-
fined in subsection (mm)(1) of such section) that has 
a written agreement in place with— 
(A) 1 or more applicable schools of nursing; 
and 
(B) 2 or more applicable non-hospital com-
munity-based care settings. 
(6) ELIGIBLE
PARTNERS.—The term ‘‘eligible 
partners’’ includes the following: 
(A) An applicable non-hospital community- 
based care setting. 
(B) An applicable school of nursing. 
(7) QUALIFIED TRAINING.— 
(A) IN
GENERAL.—The term ‘‘qualified 
training’’ means training— 
(i) that provides an advanced practice 
registered nurse with the clinical skills nec-
essary to provide primary care, preventive 
care, transitional care, chronic care man-
agement, and other services appropriate for 
individuals entitled to, or enrolled for, bene-
fits under part A of title XVIII of the Social
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Security Act, or enrolled under part B of 
such title; and 
(ii) subject to subparagraph (B), at 
least half of which is provided in a non-hos-
pital community-based care setting. 
(B) WAIVER
OF
REQUIREMENT
HALF
OF 
TRAINING BE PROVIDED IN NON-HOSPITAL COM-
MUNITY-BASED
CARE
SETTING
IN
CERTAIN 
AREAS.—The Secretary may waive the require-
ment under subparagraph (A)(ii) with respect to 
eligible hospitals located in rural or medically 
underserved areas. 
(8) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
Subtitle G—Improving Access to 
Health Care Services 
SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH 
CENTERS (FQHCS). 
(a) IN GENERAL.—Section 330(r) of the Public Health 
Service Act (42 U.S.C. 254b(r)) is amended by striking 
paragraph (1) and inserting the following: 
‘‘(1) GENERAL AMOUNTS FOR GRANTS.—For the 
purpose of carrying out this section, in addition to 
the amounts authorized to be appropriated under sub-
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section (d), there is authorized to be appropriated the 
following: 
‘‘(A) For fiscal year 2010, $2,988,821,592. 
‘‘(B) For fiscal year 2011, $3,862,107,440. 
‘‘(C) For fiscal year 2012, $4,990,553,440. 
‘‘(D) For fiscal year 2013, $6,448,713,307. 
‘‘(E) For fiscal year 2014, $7,332,924,155. 
‘‘(F) For fiscal year 2015, $8,332,924,155. 
‘‘(G) For fiscal year 2016, and each subse-
quent fiscal year, the amount appropriated for 
the preceding fiscal year adjusted by the product 
of— 
‘‘(i) one plus the average percentage 
increase in costs incurred per patient 
served; and 
‘‘(ii) one plus the average percentage 
increase in the total number of patients 
served.’’. 
(b) RULE OF CONSTRUCTION.—Section 330(r) of the 
Public Health Service Act (42 U.S.C. 254b(r)) is amended 
by adding at the end the following: 
‘‘(4) RULE OF CONSTRUCTION WITH RESPECT TO 
RURAL HEALTH CLINICS.— 
‘‘(A) IN GENERAL.—Nothing in this section 
shall be construed to prevent a community health
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center from contracting with a Federally cer-
tified rural health clinic (as defined in section 
1861(aa)(2) of the Social Security Act), a low- 
volume hospital (as defined for purposes of sec-
tion 1886 of such Act), a critical access hospital, 
a sole community hospital (as defined for pur-
poses of section 1886(d)(5)(D)(iii) of such Act), 
or a medicare-dependent share hospital (as de-
fined for purposes of section 1886(d)(5)(G)(iv) of 
such Act) for the delivery of primary health care 
services that are available at the clinic or hos-
pital to individuals who would otherwise be eli-
gible for free or reduced cost care if that indi-
vidual were able to obtain that care at the com-
munity health center. Such services may be lim-
ited in scope to those primary health care serv-
ices available in that clinic or hospitals. 
‘‘(B) ASSURANCES.—In order for a clinic or 
hospital to receive funds under this section 
through a contract with a community health cen-
ter under subparagraph (A), such clinic or hos-
pital shall establish policies to ensure— 
‘‘(i) nondiscrimination based on the 
ability of a patient to pay; and
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‘‘(ii) the establishment of a sliding fee 
scale for low-income patients.’’. 
SEC. 5602. NEGOTIATED RULEMAKING FOR DEVELOPMENT 
OF METHODOLOGY AND CRITERIA FOR DES-
IGNATING MEDICALLY UNDERSERVED POPU-
LATIONS AND HEALTH PROFESSIONS SHORT-
AGE AREAS. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the 
‘‘Secretary’’) shall establish, through a negotiated 
rulemaking process under subchapter 3 of chapter 5 
of title 5, United States Code, a comprehensive meth-
odology and criteria for designation of— 
(A) medically underserved populations in 
accordance with section 330(b)(3) of the Public 
Health Service Act (42 U.S.C. 254b(b)(3)); 
(B) health professions shortage areas under 
section 332 of the Public Health Service Act (42 
U.S.C. 254e). 
(2) FACTORS TO CONSIDER.—In establishing the 
methodology and criteria under paragraph (1), the 
Secretary— 
(A) shall consult with relevant stakeholders 
who will be significantly affected by a rule (such
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as national, State and regional organizations 
representing affected entities), State health of-
fices, community organizations, health centers 
and other affected entities, and other interested 
parties; and 
(B) shall take into account— 
(i) the timely availability and appro-
priateness of data used to determine a des-
ignation to potential applicants for such 
designations; 
(ii) the impact of the methodology and 
criteria on communities of various types 
and on health centers and other safety net 
providers; 
(iii) the degree of ease or difficulty that 
will face potential applicants for such des-
ignations in securing the necessary data; 
and 
(iv) the extent to which the method-
ology accurately measures various barriers 
that confront individuals and population 
groups in seeking health care services. 
(b) PUBLICATION OF NOTICE.—In carrying out the 
rulemaking process under this subsection, the Secretary 
shall publish the notice provided for under section 564(a)
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of title 5, United States Code, by not later than 45 days 
after the date of the enactment of this Act. 
(c) TARGET DATE FOR PUBLICATION OF RULE.—As 
part of the notice under subsection (b), and for purposes 
of this subsection, the ‘‘target date for publication’’, as re-
ferred to in section 564(a)(5) of title 5, United Sates Code, 
shall be July 1, 2010. 
(d) APPOINTMENT OF NEGOTIATED RULEMAKING COM-
MITTEE AND FACILITATOR.—The Secretary shall provide 
for— 
(1) the appointment of a negotiated rulemaking 
committee under section 565(a) of title 5, United 
States Code, by not later than 30 days after the end 
of the comment period provided for under section 
564(c) of such title; and 
(2) the nomination of a facilitator under section 
566(c) of such title 5 by not later than 10 days after 
the date of appointment of the committee. 
(e) PRELIMINARY COMMITTEE REPORT.—The nego-
tiated rulemaking committee appointed under subsection 
(d) shall report to the Secretary, by not later than April 
1, 2010, regarding the committee’s progress on achieving 
a consensus with regard to the rulemaking proceeding and 
whether such consensus is likely to occur before one month 
before the target date for publication of the rule. If the com-
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mittee reports that the committee has failed to make signifi-
cant progress toward such consensus or is unlikely to reach 
such consensus by the target date, the Secretary may termi-
nate such process and provide for the publication of a rule 
under this section through such other methods as the Sec-
retary may provide. 
(f) FINAL COMMITTEE REPORT.—If the committee is 
not terminated under subsection (e), the rulemaking com-
mittee shall submit a report containing a proposed rule by 
not later than one month before the target publication date. 
(g) INTERIM FINAL EFFECT.—The Secretary shall 
publish a rule under this section in the Federal Register 
by not later than the target publication date. Such rule 
shall be effective and final immediately on an interim basis, 
but is subject to change and revision after public notice and 
opportunity for a period (of not less than 90 days) for pub-
lic comment. In connection with such rule, the Secretary 
shall specify the process for the timely review and approval 
of applications for such designations pursuant to such rules 
and consistent with this section. 
(h) PUBLICATION
OF RULE AFTER PUBLIC COM-
MENT.—The Secretary shall provide for consideration of 
such comments and republication of such rule by not later 
than 1 year after the target publication date.
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SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMER-
GENCY MEDICAL SERVICES FOR CHILDREN 
PROGRAM. 
Section 1910 of the Public Health Service Act (42 
U.S.C. 300w–9) is amended— 
(1) in subsection (a), by striking ‘‘3-year period 
(with an optional 4th year’’ and inserting ‘‘4-year 
period (with an optional 5th year’’; and 
(2) in subsection (d)— 
(A) by striking ‘‘and such sums’’ and in-
serting ‘‘such sums’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘, $25,000,000 for fiscal year 2010, 
$26,250,000 for fiscal year 2011, $27,562,500 for 
fiscal year 2012, $28,940,625 for fiscal year 
2013, and $30,387,656 for fiscal year 2014’’. 
SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN 
COMMUNITY-BASED MENTAL HEALTH SET-
TINGS. 
Subpart 3 of part B of title V of the Public Health 
Service Act (42 U.S.C. 290bb–31 et seq.) is amended by 
adding at the end the following: 
‘‘SEC. 520K. AWARDS FOR CO-LOCATING PRIMARY AND SPE-
CIALTY CARE IN COMMUNITY-BASED MENTAL 
HEALTH SETTINGS. 
‘‘(a) DEFINITIONS.—In this section:
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‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible enti-
ty’ means a qualified community mental health pro-
gram defined under section 1913(b)(1). 
‘‘(2) SPECIAL POPULATIONS.—The term ‘special 
populations’ means adults with mental illnesses who 
have co-occurring primary care conditions and chron-
ic diseases. 
‘‘(b) PROGRAM AUTHORIZED.—The Secretary, acting 
through the Administrator shall award grants and coopera-
tive agreements to eligible entities to establish demonstra-
tion projects for the provision of coordinated and integrated 
services to special populations through the co-location of 
primary and specialty care services in community-based 
mental and behavioral health settings. 
‘‘(c) APPLICATION.—To be eligible to receive a grant 
or cooperative agreement under this section, an eligible enti-
ty shall submit an application to the Administrator at such 
time, in such manner, and accompanied by such informa-
tion as the Administrator may require, including a descrip-
tion of partnerships, or other arrangements with local pri-
mary care providers, including community health centers, 
to provide services to special populations. 
‘‘(d) USE OF FUNDS.—
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‘‘(1) IN
GENERAL.—For the benefit of special 
populations, an eligible entity shall use funds award-
ed under this section for— 
‘‘(A) the provision, by qualified primary 
care professionals, of on site primary care serv-
ices; 
‘‘(B) reasonable costs associated with medi-
cally necessary referrals to qualified specialty 
care professionals, other coordinators of care or, 
if permitted by the terms of the grant or coopera-
tive agreement, by qualified specialty care pro-
fessionals on a reasonable cost basis on site at 
the eligible entity; 
‘‘(C) information technology required to ac-
commodate the clinical needs of primary and 
specialty care professionals; or 
‘‘(D) facility modifications needed to bring 
primary and specialty care professionals on site 
at the eligible entity. 
‘‘(2) LIMITATION.—Not to exceed 15 percent of 
grant or cooperative agreement funds may be used for 
activities described in subparagraphs (C) and (D) of 
paragraph (1). 
‘‘(e) EVALUATION.—Not later than 90 days after a 
grant or cooperative agreement awarded under this section
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expires, an eligible entity shall submit to the Secretary the 
results of an evaluation to be conducted by the entity con-
cerning the effectiveness of the activities carried out under 
the grant or agreement. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are 
authorized to be appropriated to carry out this section, 
$50,000,000 for fiscal year 2010 and such sums as may be 
necessary for each of fiscal years 2011 through 2014.’’. 
SEC. 5605. KEY NATIONAL INDICATORS. 
(a) DEFINITIONS.—In this section: 
(1) ACADEMY.—The term ‘‘Academy’’ means the 
National Academy of Sciences. 
(2) 
COMMISSION.—The 
term 
‘‘Commission’’ 
means the Commission on Key National Indicators 
established under subsection (b). 
(3) INSTITUTE.—The term ‘‘Institute’’ means a 
Key National Indicators Institute as designated 
under subsection (c)(3). 
(b) COMMISSION ON KEY NATIONAL INDICATORS.— 
(1) ESTABLISHMENT.—There is established a 
‘‘Commission on Key National Indicators’’. 
(2) MEMBERSHIP.— 
(A) 
NUMBER
AND
APPOINTMENT.—The 
Commission shall be composed of 8 members, to 
be appointed equally by the majority and minor-
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ity leaders of the Senate and the Speaker and 
minority leader of the House of Representatives. 
(B) PROHIBITED APPOINTMENTS.—Members 
of the Commission shall not include Members of 
Congress or other elected Federal, State, or local 
government officials. 
(C) QUALIFICATIONS.—In making appoint-
ments under subparagraph (A), the majority and 
minority leaders of the Senate and the Speaker 
and minority leader of the House of Representa-
tives shall appoint individuals who have shown 
a dedication to improving civic dialogue and de-
cision-making through the wide use of scientific 
evidence and factual information. 
(D) PERIOD OF APPOINTMENT.—Each mem-
ber of the Commission shall be appointed for a 
2-year term, except that 1 initial appointment 
shall be for 3 years. Any vacancies shall not af-
fect the power and duties of the Commission but 
shall be filled in the same manner as the original 
appointment and shall last only for the remain-
der of that term. 
(E) DATE.—Members of the Commission 
shall be appointed by not later than 30 days 
after the date of enactment of this Act.
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(F) INITIAL
ORGANIZING
PERIOD.—–Not 
later than 60 days after the date of enactment of 
this Act, the Commission shall develop and im-
plement a schedule for completion of the review 
and reports required under subsection (d). 
(G) CO-CHAIRPERSONS.—The Commission 
shall select 2 Co-Chairpersons from among its 
members. 
(c) DUTIES OF THE COMMISSION.— 
(1) IN GENERAL.—The Commission shall— 
(A) conduct comprehensive oversight of a 
newly established key national indicators system 
consistent with the purpose described in this sub-
section; 
(B) make recommendations on how to im-
prove the key national indicators system; 
(C) coordinate with Federal Government 
users and information providers to assure access 
to relevant and quality data; and 
(D) enter into contracts with the Academy. 
(2) REPORTS.— 
(A) ANNUAL REPORT TO CONGRESS.—Not 
later than 1 year after the selection of the 2 Co- 
Chairpersons of the Commission, and each subse-
quent year thereafter, the Commission shall pre-
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pare and submit to the appropriate Committees 
of Congress and the President a report that con-
tains a detailed statement of the recommenda-
tions, findings, and conclusions of the Commis-
sion on the activities of the Academy and a des-
ignated Institute related to the establishment of 
a Key National Indicator System. 
(B) ANNUAL REPORT TO THE ACADEMY.— 
(i) IN
GENERAL.—Not later than 6 
months after the selection of the 2 Co-Chair-
persons of the Commission, and each subse-
quent year thereafter, the Commission shall 
prepare and submit to the Academy and a 
designated Institute a report making rec-
ommendations concerning potential issue 
areas and key indicators to be included in 
the Key National Indicators. 
(ii) 
LIMITATION.—The 
Commission 
shall not have the authority to direct the 
Academy or, if established, the Institute, to 
adopt, modify, or delete any key indicators. 
(3) CONTRACT WITH THE NATIONAL ACADEMY OF 
SCIENCES.— 
(A) IN GENERAL.—–As soon as practicable 
after the selection of the 2 Co-Chairpersons of the
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Commission, the Co-Chairpersons shall enter 
into an arrangement with the National Academy 
of Sciences under which the Academy shall— 
(i) review available public and private 
sector research on the selection of a set of 
key national indicators; 
(ii) determine how best to establish a 
key national indicator system for the 
United States, by either creating its own 
institutional capability or designating an 
independent private nonprofit organization 
as an Institute to implement a key national 
indicator system; 
(iii) if the Academy designates an 
independent Institute under clause (ii), pro-
vide scientific and technical advice to the 
Institute and create an appropriate govern-
ance mechanism that balances Academy in-
volvement and the independence of the In-
stitute; and 
(iv) provide an annual report to the 
Commission addressing scientific and tech-
nical issues related to the key national indi-
cator system and, if established, the Insti-
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tute, and governance of the Institute’s budg-
et and operations. 
(B) PARTICIPATION.—In executing the ar-
rangement under subparagraph (A), the Na-
tional Academy of Sciences shall convene a 
multi-sector, multi-disciplinary process to define 
major scientific and technical issues associated 
with developing, maintaining, and evolving a 
Key National Indicator System and, if an Insti-
tute is established, to provide it with scientific 
and technical advice. 
(C) ESTABLISHMENT OF A KEY NATIONAL 
INDICATOR SYSTEM.— 
(i) IN GENERAL.—In executing the ar-
rangement under subparagraph (A), the Na-
tional Academy of Sciences shall enable the 
establishment of a key national indicator 
system by— 
(I) creating its own institutional 
capability; or 
(II) partnering with an inde-
pendent private nonprofit organization 
as an Institute to implement a key na-
tional indicator system.
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(ii) INSTITUTE.—If the Academy des-
ignates an Institute under clause (i)(II), 
such Institute shall be a non-profit entity 
(as defined for purposes of section 501(c)(3) 
of the Internal Revenue Code of 1986) with 
an educational mission, a governance struc-
ture that emphasizes independence, and 
characteristics that make such entity appro-
priate for establishing a key national indi-
cator system. 
(iii) RESPONSIBILITIES.—Either the 
Academy or the Institute designated under 
clause (i)(II) shall be responsible for the fol-
lowing: 
(I) Identifying and selecting issue 
areas to be represented by the key na-
tional indicators. 
(II) Identifying and selecting the 
measures used for key national indica-
tors within the issue areas under sub-
clause (I). 
(III) Identifying and selecting 
data to populate the key national indi-
cators described under subclause (II).
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(IV) Designing, publishing, and 
maintaining a public website that con-
tains a freely accessible database allow-
ing public access to the key national 
indicators. 
(V) Developing a quality assur-
ance framework to ensure rigorous and 
independent processes and the selection 
of quality data. 
(VI) Developing a budget for the 
construction and management of a sus-
tainable, adaptable, and evolving key 
national indicator system that reflects 
all Commission funding of Academy 
and, if an Institute is established, In-
stitute activities. 
(VII) Reporting annually to the 
Commission regarding its selection of 
issue areas, key indicators, data, and 
progress toward establishing a web-ac-
cessible database. 
(VIII) Responding directly to the 
Commission in response to any Com-
mission recommendations and to the
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Academy regarding any inquiries by 
the Academy. 
(iv) GOVERNANCE.—Upon the estab-
lishment of a key national indicator system, 
the Academy shall create an appropriate 
governance mechanism that incorporates 
advisory and control functions. If an Insti-
tute is designated under clause (i)(II), the 
governance mechanism shall balance appro-
priate Academy involvement and the inde-
pendence of the Institute. 
(v) MODIFICATION
AND
CHANGES.— 
The Academy shall retain the sole discre-
tion, at any time, to alter its approach to 
the establishment of a key national indi-
cator system or, if an Institute is designated 
under clause (i)(II), to alter any aspect of 
its relationship with the Institute or to des-
ignate a different non-profit entity to serve 
as the Institute. 
(vi) CONSTRUCTION.—Nothing in this 
section shall be construed to limit the abil-
ity of the Academy or the Institute des-
ignated under clause (i)(II) to receive pri-
vate funding for activities related to the es-
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tablishment of a key national indicator sys-
tem. 
(D) ANNUAL REPORT.—As part of the ar-
rangement under subparagraph (A), the Na-
tional Academy of Sciences shall, not later than 
270 days after the date of enactment of this Act, 
and annually thereafter, submit to the Co-Chair-
persons of the Commission a report that contains 
the findings and recommendations of the Acad-
emy. 
(d) GOVERNMENT ACCOUNTABILITY OFFICE STUDY 
AND REPORT.— 
(1) GAO STUDY.—The Comptroller General of 
the United States shall conduct a study of previous 
work conducted by all public agencies, private organi-
zations, or foreign countries with respect to best prac-
tices for a key national indicator system. The study 
shall be submitted to the appropriate authorizing 
committees of Congress. 
(2) GAO FINANCIAL AUDIT.—If an Institute is 
established under this section, the Comptroller Gen-
eral shall conduct an annual audit of the financial 
statements of the Institute, in accordance with gen-
erally accepted government auditing standards and
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submit a report on such audit to the Commission and 
the appropriate authorizing committees of Congress. 
(3) GAO PROGRAMMATIC REVIEW.—The Comp-
troller General of the United States shall conduct pro-
grammatic assessments of the Institute established 
under this section as determined necessary by the 
Comptroller General and report the findings to the 
Commission and to the appropriate authorizing com-
mittees of Congress. 
(e) AUTHORIZATION OF APPROPRIATIONS.— 
(1) IN GENERAL.—–There are authorized to be 
appropriated to carry out the purposes of this section, 
$10,000,000 for fiscal year 2010, and $7,500,000 for 
each of fiscal year 2011 through 2018. 
(2) 
AVAILABILITY.—–Amounts 
appropriated 
under paragraph (1) shall remain available until ex-
pended. 
Subtitle H—General Provisions 
SEC. 5701. REPORTS. 
(a) REPORTS BY SECRETARY OF HEALTH AND HUMAN 
SERVICES.—On an annual basis, the Secretary of Health 
and Human Services shall submit to the appropriate Com-
mittees of Congress a report on the activities carried out 
under the amendments made by this title, and the effective-
ness of such activities.
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(b) REPORTS BY RECIPIENTS OF FUNDS.—The Sec-
retary of Health and Human Services may require, as a 
condition of receiving funds under the amendments made 
by this title, that the entity receiving such award submit 
to such Secretary such reports as the such Secretary may 
require on activities carried out with such award, and the 
effectiveness of such activities. 
TITLE VI—TRANSPARENCY AND 
PROGRAM INTEGRITY 
Subtitle A—Physician Ownership 
and Other Transparency 
SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE 
PROHIBITION ON CERTAIN PHYSICIAN RE-
FERRALS FOR HOSPITALS. 
(a) IN GENERAL.—Section 1877 of the Social Security 
Act (42 U.S.C. 1395nn) is amended— 
(1) in subsection (d)(2)— 
(A) in subparagraph (A), by striking ‘‘and’’ 
at the end; 
(B) in subparagraph (B), by striking the 
period at the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subparagraph:
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‘‘(C) in the case where the entity is a hos-
pital, the hospital meets the requirements of 
paragraph (3)(D).’’; 
(2) in subsection (d)(3)— 
(A) in subparagraph (B), by striking ‘‘and’’ 
at the end; 
(B) in subparagraph (C), by striking the 
period at the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(D) the hospital meets the requirements de-
scribed in subsection (i)(1) not later than 18 
months after the date of the enactment of this 
subparagraph.’’; and 
(3) by adding at the end the following new sub-
section: 
‘‘(i) REQUIREMENTS FOR HOSPITALS TO QUALIFY FOR 
RURAL PROVIDER AND HOSPITAL EXCEPTION TO OWNER-
SHIP OR INVESTMENT PROHIBITION.— 
‘‘(1) REQUIREMENTS DESCRIBED.—For purposes 
of subsection (d)(3)(D), the requirements described in 
this paragraph for a hospital are as follows: 
‘‘(A) PROVIDER AGREEMENT.—The hospital 
had—
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‘‘(i) physician ownership or investment 
on February 1, 2010; and 
‘‘(ii) a provider agreement under sec-
tion 1866 in effect on such date. 
‘‘(B) LIMITATION ON EXPANSION OF FACIL-
ITY
CAPACITY.—Except as provided in para-
graph (3), the number of operating rooms, proce-
dure rooms, and beds for which the hospital is li-
censed at any time on or after the date of the en-
actment of this subsection is no greater than the 
number of operating rooms, procedure rooms, 
and beds for which the hospital is licensed as of 
such date. 
‘‘(C) PREVENTING
CONFLICTS
OF
INTER-
EST.— 
‘‘(i) The hospital submits to the Sec-
retary an annual report containing a de-
tailed description of— 
‘‘(I) the identity of each physician 
owner or investor and any other own-
ers or investors of the hospital; and 
‘‘(II) the nature and extent of all 
ownership and investment interests in 
the hospital.
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‘‘(ii) The hospital has procedures in 
place to require that any referring physi-
cian owner or investor discloses to the pa-
tient being referred, by a time that permits 
the patient to make a meaningful decision 
regarding the receipt of care, as determined 
by the Secretary— 
‘‘(I) the ownership or investment 
interest, as applicable, of such referring 
physician in the hospital; and 
‘‘(II) if applicable, any such own-
ership or investment interest of the 
treating physician. 
‘‘(iii) The hospital does not condition 
any physician ownership or investment in-
terests either directly or indirectly on the 
physician owner or investor making or in-
fluencing referrals to the hospital or other-
wise generating business for the hospital. 
‘‘(iv) The hospital discloses the fact 
that the hospital is partially owned or in-
vested in by physicians— 
‘‘(I) on any public website for the 
hospital; and
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‘‘(II) in any public advertising 
for the hospital. 
‘‘(D) ENSURING BONA FIDE INVESTMENT.— 
‘‘(i) The percentage of the total value of 
the ownership or investment interests held 
in the hospital, or in an entity whose assets 
include the hospital, by physician owners or 
investors in the aggregate does not exceed 
such percentage as of the date of enactment 
of this subsection. 
‘‘(ii) Any ownership or investment in-
terests that the hospital offers to a physician 
owner or investor are not offered on more 
favorable terms than the terms offered to a 
person who is not a physician owner or in-
vestor. 
‘‘(iii) The hospital (or any owner or 
investor in the hospital) does not directly or 
indirectly provide loans or financing for 
any investment in the hospital by a physi-
cian owner or investor. 
‘‘(iv) The hospital (or any owner or in-
vestor in the hospital) does not directly or 
indirectly guarantee a loan, make a pay-
ment toward a loan, or otherwise subsidize
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a loan, for any individual physician owner 
or investor or group of physician owners or 
investors that is related to acquiring any 
ownership or investment interest in the hos-
pital. 
‘‘(v) Ownership or investment returns 
are distributed to each owner or investor in 
the hospital in an amount that is directly 
proportional to the ownership or investment 
interest of such owner or investor in the 
hospital. 
‘‘(vi) Physician owners and investors 
do not receive, directly or indirectly, any 
guaranteed receipt of or right to purchase 
other business interests related to the hos-
pital, including the purchase or lease of any 
property under the control of other owners 
or investors in the hospital or located near 
the premises of the hospital. 
‘‘(vii) The hospital does not offer a 
physician owner or investor the opportunity 
to purchase or lease any property under the 
control of the hospital or any other owner 
or investor in the hospital on more favor-
able terms than the terms offered to an indi-
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vidual who is not a physician owner or in-
vestor. 
‘‘(E) PATIENT SAFETY.— 
‘‘(i) Insofar as the hospital admits a 
patient and does not have any physician 
available on the premises to provide services 
during all hours in which the hospital is 
providing services to such patient, before 
admitting the patient— 
‘‘(I) the hospital discloses such 
fact to a patient; and 
‘‘(II) following such disclosure, the 
hospital receives from the patient a 
signed acknowledgment that the pa-
tient understands such fact. 
‘‘(ii) The hospital has the capacity 
to— 
‘‘(I) provide assessment and ini-
tial treatment for patients; and 
‘‘(II) refer and transfer patients 
to hospitals with the capability to treat 
the needs of the patient involved. 
‘‘(F) LIMITATION ON APPLICATION TO CER-
TAIN CONVERTED FACILITIES.—The hospital was 
not converted from an ambulatory surgical cen-
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ter to a hospital on or after the date of enact-
ment of this subsection. 
‘‘(2) 
PUBLICATION
OF
INFORMATION
RE-
PORTED.—The Secretary shall publish, and update on 
an annual basis, the information submitted by hos-
pitals under paragraph (1)(C)(i) on the public Inter-
net website of the Centers for Medicare & Medicaid 
Services. 
‘‘(3) EXCEPTION TO PROHIBITION ON EXPANSION 
OF FACILITY CAPACITY.— 
‘‘(A) PROCESS.— 
‘‘(i) ESTABLISHMENT.—The Secretary 
shall establish and implement a process 
under which an applicable hospital (as de-
fined in subparagraph (E)) may apply for 
an exception from the requirement under 
paragraph (1)(B). 
‘‘(ii) OPPORTUNITY
FOR
COMMUNITY 
INPUT.—The process under clause (i) shall 
provide individuals and entities in the com-
munity in which the applicable hospital ap-
plying for an exception is located with the 
opportunity to provide input with respect to 
the application.
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‘‘(iii) TIMING FOR IMPLEMENTATION.— 
The Secretary shall implement the process 
under clause (i) on August 1, 2011. 
‘‘(iv) REGULATIONS.—Not later than 
July 1, 2011, the Secretary shall promul-
gate regulations to carry out the process 
under clause (i). 
‘‘(B) FREQUENCY.—The process described 
in subparagraph (A) shall permit an applicable 
hospital to apply for an exception up to once 
every 2 years. 
‘‘(C) PERMITTED INCREASE.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii) and subparagraph (D), an applicable 
hospital granted an exception under the 
process described in subparagraph (A) may 
increase the number of operating rooms, 
procedure rooms, and beds for which the ap-
plicable hospital is licensed above the base-
line number of operating rooms, procedure 
rooms, and beds of the applicable hospital 
(or, if the applicable hospital has been 
granted a previous exception under this 
paragraph, above the number of operating 
rooms, procedure rooms, and beds for which
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the hospital is licensed after the application 
of the most recent increase under such an 
exception). 
‘‘(ii) 100 PERCENT INCREASE LIMITA-
TION.—The Secretary shall not permit an 
increase in the number of operating rooms, 
procedure rooms, and beds for which an ap-
plicable hospital is licensed under clause (i) 
to the extent such increase would result in 
the number of operating rooms, procedure 
rooms, and beds for which the applicable 
hospital is licensed exceeding 200 percent of 
the baseline number of operating rooms, 
procedure rooms, and beds of the applicable 
hospital. 
‘‘(iii) BASELINE
NUMBER
OF
OPER-
ATING
ROOMS, PROCEDURE
ROOMS, AND 
BEDS.—In this paragraph, the term ‘base-
line number of operating rooms, procedure 
rooms, and beds’ means the number of oper-
ating rooms, procedure rooms, and beds for 
which the applicable hospital is licensed as 
of the date of enactment of this subsection. 
‘‘(D) INCREASE LIMITED TO FACILITIES ON 
THE MAIN CAMPUS OF THE HOSPITAL.—Any in-
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crease in the number of operating rooms, proce-
dure rooms, and beds for which an applicable 
hospital is licensed pursuant to this paragraph 
may only occur in facilities on the main campus 
of the applicable hospital. 
‘‘(E) APPLICABLE HOSPITAL.—In this para-
graph, the term ‘applicable hospital’ means a 
hospital— 
‘‘(i) that is located in a county in 
which the percentage increase in the popu-
lation during the most recent 5-year period 
(as of the date of the application under sub-
paragraph (A)) is at least 150 percent of 
the percentage increase in the population 
growth of the State in which the hospital is 
located during that period, as estimated by 
Bureau of the Census; 
‘‘(ii) whose annual percent of total in-
patient admissions that represent inpatient 
admissions under the program under title 
XIX is equal to or greater than the average 
percent with respect to such admissions for 
all hospitals located in the county in which 
the hospital is located;
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‘‘(iii) 
that 
does 
not 
discriminate 
against beneficiaries of Federal health care 
programs and does not permit physicians 
practicing at the hospital to discriminate 
against such beneficiaries; 
‘‘(iv) that is located in a State in 
which the average bed capacity in the State 
is less than the national average bed capac-
ity; and 
‘‘(v) that has an average bed occu-
pancy rate that is greater than the average 
bed occupancy rate in the State in which 
the hospital is located. 
‘‘(F) PROCEDURE
ROOMS.—In this sub-
section, the term ‘procedure rooms’ includes 
rooms in which catheterizations, angiographies, 
angiograms, and endoscopies are performed, ex-
cept such term shall not include emergency 
rooms or departments (exclusive of rooms in 
which 
catheterizations, 
angiographies, 
angiograms, and endoscopies are performed). 
‘‘(G) PUBLICATION OF FINAL DECISIONS.— 
Not later than 60 days after receiving a complete 
application under this paragraph, the Secretary
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shall publish in the Federal Register the final de-
cision with respect to such application. 
‘‘(H) LIMITATION ON REVIEW.—There shall 
be no administrative or judicial review under 
section 1869, section 1878, or otherwise of the 
process under this paragraph (including the es-
tablishment of such process). 
‘‘(4) COLLECTION OF OWNERSHIP AND INVEST-
MENT INFORMATION.—For purposes of subparagraphs 
(A)(i) and (D)(i) of paragraph (1), the Secretary 
shall collect physician ownership and investment in-
formation for each hospital. 
‘‘(5) PHYSICIAN
OWNER
OR
INVESTOR
DE-
FINED.—For purposes of this subsection, the term 
‘physician owner or investor’ means a physician (or 
an immediate family member of such physician) with 
a direct or an indirect ownership or investment inter-
est in the hospital. 
‘‘(6) CLARIFICATION.—Nothing in this subsection 
shall be construed as preventing the Secretary from 
revoking a hospital’s provider agreement if not in 
compliance with regulations implementing section 
1866.’’. 
(b) ENFORCEMENT.—
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(1) ENSURING COMPLIANCE.—The Secretary of 
Health and Human Services shall establish policies 
and procedures to ensure compliance with the require-
ments described in subsection (i)(1) of section 1877 of 
the Social Security Act, as added by subsection 
(a)(3), beginning on the date such requirements first 
apply. Such policies and procedures may include un-
announced site reviews of hospitals. 
(2) AUDITS.—Beginning not later than Novem-
ber 1, 2011, the Secretary of Health and Human 
Services shall conduct audits to determine if hospitals 
violate the requirements referred to in paragraph (1). 
SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF 
PHYSICIAN OWNERSHIP OR INVESTMENT IN-
TERESTS. 
Part A of title XI of the Social Security Act (42 U.S.C. 
1301 et seq.) is amended by inserting after section 1128F 
the following new section: 
‘‘SEC. 1128G. TRANSPARENCY REPORTS AND REPORTING OF 
PHYSICIAN OWNERSHIP OR INVESTMENT IN-
TERESTS. 
‘‘(a) TRANSPARENCY REPORTS.— 
‘‘(1) PAYMENTS
OR
OTHER
TRANSFERS
OF 
VALUE.—
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‘‘(A) IN
GENERAL.—On March 31, 2013, 
and on the 90th day of each calendar year begin-
ning thereafter, any applicable manufacturer 
that provides a payment or other transfer of 
value to a covered recipient (or to an entity or 
individual at the request of or designated on be-
half of a covered recipient), shall submit to the 
Secretary, in such electronic form as the Sec-
retary shall require, the following information 
with respect to the preceding calendar year: 
‘‘(i) The name of the covered recipient. 
‘‘(ii) The business address of the cov-
ered recipient and, in the case of a covered 
recipient who is a physician, the specialty 
and National Provider Identifier of the cov-
ered recipient. 
‘‘(iii) The amount of the payment or 
other transfer of value. 
‘‘(iv) The dates on which the payment 
or other transfer of value was provided to 
the covered recipient. 
‘‘(v) A description of the form of the 
payment or other transfer of value, indi-
cated (as appropriate for all that apply) 
as—
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‘‘(I) cash or a cash equivalent; 
‘‘(II) in-kind items or services; 
‘‘(III) stock, a stock option, or 
any other ownership interest, dividend, 
profit, or other return on investment; 
or 
‘‘(IV) any other form of payment 
or other transfer of value (as defined 
by the Secretary). 
‘‘(vi) A description of the nature of the 
payment or other transfer of value, indi-
cated (as appropriate for all that apply) 
as— 
‘‘(I) consulting fees; 
‘‘(II) compensation for services 
other than consulting; 
‘‘(III) honoraria; 
‘‘(IV) gift; 
‘‘(V) entertainment; 
‘‘(VI) food; 
‘‘(VII) travel (including the speci-
fied destinations); 
‘‘(VIII) education; 
‘‘(IX) research; 
‘‘(X) charitable contribution;
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‘‘(XI) royalty or license; 
‘‘(XII) 
current 
or 
prospective 
ownership or investment interest; 
‘‘(XIII) direct compensation for 
serving as faculty or as a speaker for 
a medical education program; 
‘‘(XIV) grant; or 
‘‘(XV) any other nature of the 
payment or other transfer of value (as 
defined by the Secretary). 
‘‘(vii) If the payment or other transfer 
of value is related to marketing, education, 
or research specific to a covered drug, de-
vice, biological, or medical supply, the name 
of that covered drug, device, biological, or 
medical supply. 
‘‘(viii) Any other categories of informa-
tion regarding the payment or other trans-
fer of value the Secretary determines appro-
priate. 
‘‘(B) SPECIAL
RULE
FOR
CERTAIN
PAY-
MENTS OR OTHER TRANSFERS OF VALUE.—In 
the case where an applicable manufacturer pro-
vides a payment or other transfer of value to an 
entity or individual at the request of or des-
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ignated on behalf of a covered recipient, the ap-
plicable manufacturer shall disclose that pay-
ment or other transfer of value under the name 
of the covered recipient. 
‘‘(2) PHYSICIAN OWNERSHIP.—In addition to the 
requirement under paragraph (1)(A), on March 31, 
2013, and on the 90th day of each calendar year be-
ginning thereafter, any applicable manufacturer or 
applicable group purchasing organization shall sub-
mit to the Secretary, in such electronic form as the 
Secretary shall require, the following information re-
garding any ownership or investment interest (other 
than an ownership or investment interest in a pub-
licly traded security and mutual fund, as described in 
section 1877(c)) held by a physician (or an imme-
diate family member of such physician (as defined for 
purposes of section 1877(a))) in the applicable manu-
facturer or applicable group purchasing organization 
during the preceding year: 
‘‘(A) The dollar amount invested by each 
physician holding such an ownership or invest-
ment interest. 
‘‘(B) The value and terms of each such own-
ership or investment interest.
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‘‘(C) Any payment or other transfer of 
value provided to a physician holding such an 
ownership or investment interest (or to an entity 
or individual at the request of or designated on 
behalf of a physician holding such an ownership 
or investment interest), including the informa-
tion described in clauses (i) through (viii) of 
paragraph (1)(A), except that in applying such 
clauses, ‘physician’ shall be substituted for ‘cov-
ered recipient’ each place it appears. 
‘‘(D) Any other information regarding the 
ownership or investment interest the Secretary 
determines appropriate. 
‘‘(b) PENALTIES FOR NONCOMPLIANCE.— 
‘‘(1) FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B) except as provided in paragraph (2), 
any applicable manufacturer or applicable group 
purchasing organization that fails to submit in-
formation required under subsection (a) in a 
timely manner in accordance with rules or regu-
lations promulgated to carry out such subsection, 
shall be subject to a civil money penalty of not 
less than $1,000, but not more than $10,000, for 
each payment or other transfer of value or own-
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ership or investment interest not reported as re-
quired under such subsection. Such penalty shall 
be imposed and collected in the same manner as 
civil money penalties under subsection (a) of sec-
tion 1128A are imposed and collected under that 
section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) by an 
applicable manufacturer or applicable group 
purchasing 
organization 
shall 
not 
exceed 
$150,000. 
‘‘(2) KNOWING FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), any applicable manufacturer or ap-
plicable group purchasing organization that 
knowingly fails to submit information required 
under subsection (a) in a timely manner in ac-
cordance with rules or regulations promulgated 
to carry out such subsection, shall be subject to 
a civil money penalty of not less than $10,000, 
but not more than $100,000, for each payment or 
other transfer of value or ownership or invest-
ment interest not reported as required under
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such subsection. Such penalty shall be imposed 
and collected in the same manner as civil money 
penalties under subsection (a) of section 1128A 
are imposed and collected under that section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) by an 
applicable manufacturer or applicable group 
purchasing 
organization 
shall 
not 
exceed 
$1,000,000. 
‘‘(3) USE
OF
FUNDS.—Funds collected by the 
Secretary as a result of the imposition of a civil 
money penalty under this subsection shall be used to 
carry out this section. 
‘‘(c) PROCEDURES FOR SUBMISSION OF INFORMATION 
AND PUBLIC AVAILABILITY.— 
‘‘(1) IN GENERAL.— 
‘‘(A) ESTABLISHMENT.—Not later than Oc-
tober 1, 2011, the Secretary shall establish proce-
dures— 
‘‘(i) for applicable manufacturers and 
applicable group purchasing organizations 
to submit information to the Secretary 
under subsection (a); and
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‘‘(ii) for the Secretary to make such in-
formation submitted available to the public. 
‘‘(B) DEFINITION
OF
TERMS.—The proce-
dures established under subparagraph (A) shall 
provide for the definition of terms (other than 
those terms defined in subsection (e)), as appro-
priate, for purposes of this section. 
‘‘(C) PUBLIC
AVAILABILITY.—Except as 
provided in subparagraph (E), the procedures es-
tablished under subparagraph (A)(ii) shall en-
sure that, not later than September 30, 2013, 
and on June 30 of each calendar year beginning 
thereafter, the information submitted under sub-
section (a) with respect to the preceding calendar 
year is made available through an Internet 
website that— 
‘‘(i) is searchable and is in a format 
that is clear and understandable; 
‘‘(ii) contains information that is pre-
sented by the name of the applicable manu-
facturer or applicable group purchasing or-
ganization, the name of the covered recipi-
ent, the business address of the covered re-
cipient, the specialty of the covered recipi-
ent, the value of the payment or other trans-
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fer of value, the date on which the payment 
or other transfer of value was provided to 
the covered recipient, the form of the pay-
ment or other transfer of value, indicated 
(as 
appropriate) 
under 
subsection 
(a)(1)(A)(v), the nature of the payment or 
other transfer of value, indicated (as appro-
priate) under subsection (a)(1)(A)(vi), and 
the name of the covered drug, device, bio-
logical, or medical supply, as applicable; 
‘‘(iii) contains information that is able 
to be easily aggregated and downloaded; 
‘‘(iv) contains a description of any en-
forcement actions taken to carry out this 
section, including any penalties imposed 
under subsection (b), during the preceding 
year; 
‘‘(v) contains background information 
on industry-physician relationships; 
‘‘(vi) in the case of information sub-
mitted with respect to a payment or other 
transfer of value described in subparagraph 
(E)(i), lists such information separately 
from the other information submitted under 
subsection (a) and designates such sepa-
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rately listed information as funding for 
clinical research; 
‘‘(vii) contains any other information 
the Secretary determines would be helpful to 
the average consumer; 
‘‘(viii) does not contain the National 
Provider Identifier of the covered recipient, 
and 
‘‘(ix) subject to subparagraph (D), pro-
vides the applicable manufacturer, applica-
ble group purchasing organization, or cov-
ered recipient an opportunity to review and 
submit corrections to the information sub-
mitted with respect to the applicable manu-
facturer, applicable group purchasing orga-
nization, or covered recipient, respectively, 
for a period of not less than 45 days prior 
to such information being made available to 
the public. 
‘‘(D) CLARIFICATION OF TIME PERIOD FOR 
REVIEW AND CORRECTIONS.—In no case may the 
45-day period for review and submission of cor-
rections to information under subparagraph 
(C)(ix) prevent such information from being 
made available to the public in accordance with
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the dates described in the matter preceding 
clause (i) in subparagraph (C). 
‘‘(E) DELAYED
PUBLICATION
FOR
PAY-
MENTS MADE PURSUANT TO PRODUCT RESEARCH 
OR DEVELOPMENT AGREEMENTS AND CLINICAL 
INVESTIGATIONS.— 
‘‘(i) IN GENERAL.—In the case of in-
formation submitted under subsection (a) 
with respect to a payment or other transfer 
of value made to a covered recipient by an 
applicable manufacturer pursuant to a 
product research or development agreement 
for services furnished in connection with re-
search on a potential new medical tech-
nology or a new application of an existing 
medical technology or the development of a 
new drug, device, biological, or medical sup-
ply, or by an applicable manufacturer in 
connection with a clinical investigation re-
garding a new drug, device, biological, or 
medical supply, the procedures established 
under subparagraph (A)(ii) shall provide 
that such information is made available to 
the public on the first date described in the
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matter preceding clause (i) in subparagraph 
(C) after the earlier of the following: 
‘‘(I) The date of the approval or 
clearance of the covered drug, device, 
biological, or medical supply by the 
Food and Drug Administration. 
‘‘(II) Four calendar years after 
the date such payment or other trans-
fer of value was made. 
‘‘(ii) CONFIDENTIALITY
OF
INFORMA-
TION PRIOR TO PUBLICATION.—Information 
described in clause (i) shall be considered 
confidential and shall not be subject to dis-
closure under section 552 of title 5, United 
States Code, or any other similar Federal, 
State, or local law, until on or after the 
date on which the information is made 
available to the public under such clause. 
‘‘(2) CONSULTATION.—In establishing the proce-
dures under paragraph (1), the Secretary shall con-
sult with the Inspector General of the Department of 
Health and Human Services, affected industry, con-
sumers, consumer advocates, and other interested par-
ties in order to ensure that the information made
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available to the public under such paragraph is pre-
sented in the appropriate overall context. 
‘‘(d) ANNUAL REPORTS
AND RELATION
TO STATE 
LAWS.— 
‘‘(1) ANNUAL REPORT TO CONGRESS.—Not later 
than April 1 of each year beginning with 2013, the 
Secretary shall submit to Congress a report that in-
cludes the following: 
‘‘(A) The information submitted under sub-
section (a) during the preceding year, aggregated 
for each applicable manufacturer and applicable 
group purchasing organization that submitted 
such information during such year (except, in 
the case of information submitted with respect to 
a payment or other transfer of value described in 
subsection (c)(1)(E)(i), such information shall be 
included in the first report submitted to Congress 
after the date on which such information is made 
available to the public under such subsection). 
‘‘(B) A description of any enforcement ac-
tions taken to carry out this section, including 
any penalties imposed under subsection (b), dur-
ing the preceding year. 
‘‘(2) ANNUAL REPORTS TO STATES.—Not later 
than September 30, 2013 and on June 30 of each cal-
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endar year thereafter, the Secretary shall submit to 
States a report that includes a summary of the infor-
mation submitted under subsection (a) during the 
preceding year with respect to covered recipients in 
the State (except, in the case of information submitted 
with respect to a payment or other transfer of value 
described in subsection (c)(1)(E)(i), such information 
shall be included in the first report submitted to 
States after the date on which such information is 
made available to the public under such subsection). 
‘‘(3) RELATION TO STATE LAWS.— 
‘‘(A) IN GENERAL.—In the case of a pay-
ment or other transfer of value provided by an 
applicable manufacturer that is received by a 
covered recipient (as defined in subsection (e)) 
on or after January 1, 2012, subject to subpara-
graph (B), the provisions of this section shall 
preempt any statute or regulation of a State or 
of a political subdivision of a State that requires 
an applicable manufacturer (as so defined) to 
disclose or report, in any format, the type of in-
formation (as described in subsection (a)) re-
garding such payment or other transfer of value. 
‘‘(B) NO PREEMPTION OF ADDITIONAL RE-
QUIREMENTS.—Subparagraph (A) shall not pre-
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empt any statute or regulation of a State or of 
a political subdivision of a State that requires 
the disclosure or reporting of information— 
‘‘(i) not of the type required to be dis-
closed or reported under this section; 
‘‘(ii) described in subsection (e)(10)(B), 
except in the case of information described 
in clause (i) of such subsection; 
‘‘(iii) by any person or entity other 
than an applicable manufacturer (as so de-
fined) or a covered recipient (as defined in 
subsection (e)); or 
‘‘(iv) to a Federal, State, or local gov-
ernmental agency for public health surveil-
lance, investigation, or other public health 
purposes or health oversight purposes. 
‘‘(C) Nothing in subparagraph (A) shall be 
construed to limit the discovery or admissibility 
of information described in such subparagraph 
in a criminal, civil, or administrative pro-
ceeding. 
‘‘(4) CONSULTATION.—The Secretary shall con-
sult with the Inspector General of the Department of 
Health and Human Services on the implementation 
of this section.
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‘‘(e) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE GROUP PURCHASING ORGANI-
ZATION.—The term ‘applicable group purchasing or-
ganization’ means a group purchasing organization 
(as defined by the Secretary) that purchases, arranges 
for, or negotiates the purchase of a covered drug, de-
vice, biological, or medical supply which is operating 
in the United States, or in a territory, possession, or 
commonwealth of the United States. 
‘‘(2) APPLICABLE
MANUFACTURER.—The term 
‘applicable manufacturer’ means a manufacturer of a 
covered drug, device, biological, or medical supply 
which is operating in the United States, or in a terri-
tory, possession, or commonwealth of the United 
States. 
‘‘(3) CLINICAL INVESTIGATION.—The term ‘clin-
ical investigation’ means any experiment involving 1 
or more human subjects, or materials derived from 
human subjects, in which a drug or device is admin-
istered, dispensed, or used. 
‘‘(4) COVERED DEVICE.—The term ‘covered de-
vice’ means any device for which payment is avail-
able under title XVIII or a State plan under title 
XIX or XXI (or a waiver of such a plan).
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‘‘(i) A transfer of anything the value of 
which is less than $10, unless the aggregate 
amount transferred to, requested by, or des-
ignated on behalf of the covered recipient by 
the applicable manufacturer during the cal-
endar year exceeds $100. For calendar years 
after 2012, the dollar amounts specified in 
the preceding sentence shall be increased by 
the same percentage as the percentage in-
crease in the consumer price index for all 
urban consumers (all items; U.S. city aver-
age) for the 12-month period ending with 
June of the previous year. 
‘‘(ii) Product samples that are not in-
tended to be sold and are intended for pa-
tient use. 
‘‘(iii) Educational materials that di-
rectly benefit patients or are intended for 
patient use. 
‘‘(iv) The loan of a covered device for 
a short-term trial period, not to exceed 90 
days, to permit evaluation of the covered de-
vice by the covered recipient. 
‘‘(v) Items or services provided under a 
contractual warranty, including the re-
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placement of a covered device, where the 
terms of the warranty are set forth in the 
purchase or lease agreement for the covered 
device. 
‘‘(vi) A transfer of anything of value to 
a covered recipient when the covered recipi-
ent is a patient and not acting in the pro-
fessional capacity of a covered recipient. 
‘‘(vii) Discounts (including rebates). 
‘‘(viii) In-kind items used for the pro-
vision of charity care. 
‘‘(ix) A dividend or other profit dis-
tribution from, or ownership or investment 
interest in, a publicly traded security and 
mutual fund (as described in section 
1877(c)). 
‘‘(x) In the case of an applicable man-
ufacturer who offers a self-insured plan, 
payments for the provision of health care to 
employees under the plan. 
‘‘(xi) In the case of a covered recipient 
who is a licensed non-medical professional, 
a transfer of anything of value to the cov-
ered recipient if the transfer is payment 
solely for the non-medical professional serv-
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ices of such licensed non-medical profes-
sional. 
‘‘(xii) In the case of a covered recipient 
who is a physician, a transfer of anything 
of value to the covered recipient if the trans-
fer is payment solely for the services of the 
covered recipient with respect to a civil or 
criminal action or an administrative pro-
ceeding. 
‘‘(11) PHYSICIAN.—The term ‘physician’ has the 
meaning given that term in section 1861(r).’’. 
SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE AN-
CILLARY SERVICES EXCEPTION TO THE PRO-
HIBITION 
ON 
PHYSICIAN 
SELF-REFERRAL 
FOR CERTAIN IMAGING SERVICES. 
(a) IN GENERAL.—Section 1877(b)(2) of the Social Se-
curity Act (42 U.S.C. 1395nn(b)(2)) is amended by adding 
at the end the following new sentence: ‘‘Such requirements 
shall, with respect to magnetic resonance imaging, com-
puted tomography, positron emission tomography, and any 
other designated health services specified under subsection 
(h)(6)(D) that the Secretary determines appropriate, in-
clude a requirement that the referring physician inform the 
individual in writing at the time of the referral that the 
individual may obtain the services for which the individual
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is being referred from a person other than a person de-
scribed in subparagraph (A)(i) and provide such individual 
with a written list of suppliers (as defined in section 
1861(d)) who furnish such services in the area in which 
such individual resides.’’. 
(b) EFFECTIVE DATE.—The amendment made by this 
section shall apply to services furnished on or after January 
1, 2010. 
SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY. 
Part A of title XI of the Social Security Act (42 U.S.C. 
1301 et seq.), as amended by section 6002, is amended by 
inserting after section 1128G the following new section: 
‘‘SEC. 1128H. REPORTING OF INFORMATION RELATING TO 
DRUG SAMPLES. 
‘‘(a) IN GENERAL.—Not later than April 1 of each 
year (beginning with 2012), each manufacturer and author-
ized distributor of record of an applicable drug shall submit 
to the Secretary (in a form and manner specified by the 
Secretary) the following information with respect to the pre-
ceding year: 
‘‘(1) In the case of a manufacturer or authorized 
distributor of record which makes distributions by 
mail or common carrier under subsection (d)(2) of 
section 503 of the Federal Food, Drug, and Cosmetic 
Act (21 U.S.C. 353), the identity and quantity of
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drug samples requested and the identity and quantity 
of drug samples distributed under such subsection 
during that year, aggregated by— 
‘‘(A) the name, address, professional des-
ignation, and signature of the practitioner mak-
ing the request under subparagraph (A)(i) of 
such subsection, or of any individual who makes 
or signs for the request on behalf of the practi-
tioner; and 
‘‘(B) any other category of information de-
termined appropriate by the Secretary. 
‘‘(2) In the case of a manufacturer or authorized 
distributor of record which makes distributions by 
means other than mail or common carrier under sub-
section (d)(3) of such section 503, the identity and 
quantity of drug samples requested and the identity 
and quantity of drug samples distributed under such 
subsection during that year, aggregated by— 
‘‘(A) the name, address, professional des-
ignation, and signature of the practitioner mak-
ing the request under subparagraph (A)(i) of 
such subsection, or of any individual who makes 
or signs for the request on behalf of the practi-
tioner; and
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‘‘(B) any other category of information de-
termined appropriate by the Secretary. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE DRUG.—The term ‘applicable 
drug’ means a drug— 
‘‘(A) which is subject to subsection (b) of 
such section 503; and 
‘‘(B) for which payment is available under 
title XVIII or a State plan under title XIX or 
XXI (or a waiver of such a plan). 
‘‘(2) AUTHORIZED DISTRIBUTOR OF RECORD.— 
The term ‘authorized distributor of record’ has the 
meaning given that term in subsection (e)(3)(A) of 
such section. 
‘‘(3) MANUFACTURER.—The term ‘manufacturer’ 
has the meaning given that term for purposes of sub-
section (d) of such section.’’. 
SEC. 6005. PHARMACY BENEFIT MANAGERS TRANSPARENCY 
REQUIREMENTS. 
Part A of title XI of the Social Security Act (42 U.S.C. 
1301 et seq.) is amended by inserting after section 1150 
the following new section:
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‘‘SEC. 
1150A. 
PHARMACY 
BENEFIT 
MANAGERS 
TRANS-
PARENCY REQUIREMENTS. 
‘‘(a) PROVISION OF INFORMATION.—A health benefits 
plan or any entity that provides pharmacy benefits man-
agement services on behalf of a health benefits plan (in this 
section referred to as a ‘PBM’) that manages prescription 
drug coverage under a contract with— 
‘‘(1) a PDP sponsor of a prescription drug plan 
or an MA organization offering an MA–PD plan 
under part D of title XVIII; or 
‘‘(2) a qualified health benefits plan offered 
through an exchange established by a State under sec-
tion 1311 of the Patient Protection and Affordable 
Care Act, 
shall provide the information described in subsection (b) to 
the Secretary and, in the case of a PBM, to the plan with 
which the PBM is under contract with, at such times, and 
in such form and manner, as the Secretary shall specify. 
‘‘(b) INFORMATION DESCRIBED.—The information de-
scribed in this subsection is the following with respect to 
services provided by a health benefits plan or PBM for a 
contract year: 
‘‘(1) The percentage of all prescriptions that were 
provided through retail pharmacies compared to mail 
order pharmacies, and the percentage of prescriptions 
for which a generic drug was available and dispensed
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(generic dispensing rate), by pharmacy type (which 
includes an independent pharmacy, chain pharmacy, 
supermarket pharmacy, or mass merchandiser phar-
macy that is licensed as a pharmacy by the State and 
that dispenses medication to the general public), that 
is paid by the health benefits plan or PBM under the 
contract. 
‘‘(2) The aggregate amount, and the type of re-
bates, discounts, or price concessions (excluding bona 
fide service fees, which include but are not limited to 
distribution service fees, inventory management fees, 
product stocking allowances, and fees associated with 
administrative services agreements and patient care 
programs (such as medication compliance programs 
and patient education programs)) that the PBM ne-
gotiates that are attributable to patient utilization 
under the plan, and the aggregate amount of the re-
bates, discounts, or price concessions that are passed 
through to the plan sponsor, and the total number of 
prescriptions that were dispensed. 
‘‘(3) The aggregate amount of the difference be-
tween the amount the health benefits plan pays the 
PBM and the amount that the PBM pays retail phar-
macies, and mail order pharmacies, and the total 
number of prescriptions that were dispensed.
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‘‘(c) CONFIDENTIALITY.—Information disclosed by a 
health benefits plan or PBM under this section is confiden-
tial and shall not be disclosed by the Secretary or by a plan 
receiving the information, except that the Secretary may 
disclose the information in a form which does not disclose 
the identity of a specific PBM, plan, or prices charged for 
drugs, for the following purposes: 
‘‘(1) As the Secretary determines to be necessary 
to carry out this section or part D of title XVIII. 
‘‘(2) To permit the Comptroller General to re-
view the information provided. 
‘‘(3) To permit the Director of the Congressional 
Budget Office to review the information provided. 
‘‘(4) To States to carry out section 1311 of the 
Patient Protection and Affordable Care Act. 
‘‘(d) 
PENALTIES.—The 
provisions 
of 
subsection 
(b)(3)(C) of section 1927 shall apply to a health benefits 
plan or PBM that fails to provide information required 
under subsection (a) on a timely basis or that knowingly 
provides false information in the same manner as such pro-
visions apply to a manufacturer with an agreement under 
that section.’’.
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Subtitle B—Nursing Home 
Transparency and Improvement 
PART I—IMPROVING TRANSPARENCY OF 
INFORMATION 
SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND AD-
DITIONAL DISCLOSABLE PARTIES INFORMA-
TION. 
(a) IN GENERAL.—Section 1124 of the Social Security 
Act (42 U.S.C. 1320a–3) is amended by adding at the end 
the following new subsection: 
‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP AND AD-
DITIONAL DISCLOSABLE PARTIES INFORMATION.— 
‘‘(1) DISCLOSURE.—A facility shall have the in-
formation described in paragraph (2) available— 
‘‘(A) during the period beginning on the 
date of the enactment of this subsection and end-
ing on the date such information is made avail-
able to the public under section 6101(b) of the 
Patient Protection and Affordable Care Act for 
submission to the Secretary, the Inspector Gen-
eral of the Department of Health and Human 
Services, the State in which the facility is lo-
cated, and the State long-term care ombudsman 
in the case where the Secretary, the Inspector
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General, the State, or the State long-term care 
ombudsman requests such information; and 
‘‘(B) beginning on the effective date of the 
final regulations promulgated under paragraph 
(3)(A), for reporting such information in accord-
ance with such final regulations. 
Nothing in subparagraph (A) shall be construed as 
authorizing a facility to dispose of or delete informa-
tion described in such subparagraph after the effective 
date of the final regulations promulgated under para-
graph (3)(A). 
‘‘(2) INFORMATION DESCRIBED.— 
‘‘(A) IN GENERAL.—The following informa-
tion is described in this paragraph: 
‘‘(i) The information described in sub-
sections (a) and (b), subject to subpara-
graph (C). 
‘‘(ii) The identity of and information 
on— 
‘‘(I) each member of the governing 
body of the facility, including the 
name, title, and period of service of 
each such member; 
‘‘(II) each person or entity who is 
an officer, director, member, partner,
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trustee, or managing employee of the 
facility, including the name, title, and 
period of service of each such person or 
entity; and 
‘‘(III) each person or entity who 
is an additional disclosable party of 
the facility. 
‘‘(iii) The organizational structure of 
each additional disclosable party of the fa-
cility and a description of the relationship 
of each such additional disclosable party to 
the facility and to one another. 
‘‘(B) SPECIAL RULE WHERE INFORMATION 
IS ALREADY REPORTED OR SUBMITTED.—To the 
extent that information reported by a facility to 
the Internal Revenue Service on Form 990, in-
formation submitted by a facility to the Securi-
ties and Exchange Commission, or information 
otherwise submitted to the Secretary or any other 
Federal agency contains the information de-
scribed in clauses (i), (ii), or (iii) of subpara-
graph (A), the facility may provide such Form 
or such information submitted to meet the re-
quirements of paragraph (1).
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‘‘(C) SPECIAL
RULE.—In applying sub-
paragraph (A)(i)— 
‘‘(i) with respect to subsections (a) and 
(b), ‘ownership or control interest’ shall in-
clude direct or indirect interests, including 
such interests in intermediate entities; and 
‘‘(ii) subsection (a)(3)(A)(ii) shall in-
clude the owner of a whole or part interest 
in any mortgage, deed of trust, note, or 
other obligation secured, in whole or in 
part, by the entity or any of the property 
or assets thereof, if the interest is equal to 
or exceeds 5 percent of the total property or 
assets of the entirety. 
‘‘(3) REPORTING.— 
‘‘(A) IN GENERAL.—Not later than the date 
that is 2 years after the date of the enactment of 
this subsection, the Secretary shall promulgate 
final regulations requiring, effective on the date 
that is 90 days after the date on which such 
final regulations are published in the Federal 
Register, a facility to report the information de-
scribed in paragraph (2) to the Secretary in a 
standardized format, and such other regulations 
as are necessary to carry out this subsection.
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Such final regulations shall ensure that the facil-
ity certifies, as a condition of participation and 
payment under the program under title XVIII or 
XIX, that the information reported by the facil-
ity in accordance with such final regulations is, 
to the best of the facility’s knowledge, accurate 
and current. 
‘‘(B) GUIDANCE.—The Secretary shall pro-
vide guidance and technical assistance to States 
on how to adopt the standardized format under 
subparagraph (A). 
‘‘(4) NO EFFECT ON EXISTING REPORTING RE-
QUIREMENTS.—Nothing in this subsection shall re-
duce, diminish, or alter any reporting requirement 
for a facility that is in effect as of the date of the en-
actment of this subsection. 
‘‘(5) DEFINITIONS.—In this subsection: 
‘‘(A) ADDITIONAL
DISCLOSABLE
PARTY.— 
The term ‘additional disclosable party’ means, 
with respect to a facility, any person or entity 
who— 
‘‘(i) exercises operational, financial, or 
managerial control over the facility or a 
part thereof, or provides policies or proce-
dures for any of the operations of the facil-
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ity, or provides financial or cash manage-
ment services to the facility; 
‘‘(ii) leases or subleases real property 
to the facility, or owns a whole or part in-
terest equal to or exceeding 5 percent of the 
total value of such real property; or 
‘‘(iii) provides management or admin-
istrative services, management or clinical 
consulting services, or accounting or finan-
cial services to the facility. 
‘‘(B) FACILITY.—The term ‘facility’ means 
a disclosing entity which is— 
‘‘(i) a skilled nursing facility (as de-
fined in section 1819(a)); or 
‘‘(ii) a nursing facility (as defined in 
section 1919(a)). 
‘‘(C) MANAGING
EMPLOYEE.—The 
term 
‘managing employee’ means, with respect to a fa-
cility, an individual (including a general man-
ager, business manager, administrator, director, 
or consultant) who directly or indirectly man-
ages, advises, or supervises any element of the 
practices, finances, or operations of the facility.
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‘‘(D) ORGANIZATIONAL
STRUCTURE.—The 
term ‘organizational structure’ means, in the 
case of— 
‘‘(i) a corporation, the officers, direc-
tors, and shareholders of the corporation 
who have an ownership interest in the cor-
poration which is equal to or exceeds 5 per-
cent; 
‘‘(ii) a limited liability company, the 
members and managers of the limited liabil-
ity company (including, as applicable, what 
percentage each member and manager has 
of the ownership interest in the limited li-
ability company); 
‘‘(iii) a general partnership, the part-
ners of the general partnership; 
‘‘(iv) a limited partnership, the general 
partners and any limited partners of the 
limited partnership who have an ownership 
interest in the limited partnership which is 
equal to or exceeds 10 percent; 
‘‘(v) a trust, the trustees of the trust; 
‘‘(vi) an individual, contact informa-
tion for the individual; and
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‘‘(vii) any other person or entity, such 
information as the Secretary determines ap-
propriate.’’. 
(b) PUBLIC AVAILABILITY
OF INFORMATION.—Not 
later than the date that is 1 year after the date on which 
the 
final 
regulations 
promulgated 
under 
section 
1124(c)(3)(A) of the Social Security Act, as added by sub-
section (a), are published in the Federal Register, the Sec-
retary of Health and Human Services shall make the infor-
mation reported in accordance with such final regulations 
available to the public in accordance with procedures estab-
lished by the Secretary. 
(c) CONFORMING AMENDMENTS.— 
(1) IN GENERAL.— 
(A) SKILLED
NURSING
FACILITIES.—Sec-
tion 1819(d)(1) of the Social Security Act (42 
U.S.C. 1395i–3(d)(1)) is amended by striking 
subparagraph (B) and redesignating subpara-
graph (C) as subparagraph (B). 
(B) 
NURSING
FACILITIES.—Section 
1919(d)(1) of the Social Security Act (42 U.S.C. 
1396r(d)(1)) is amended by striking subpara-
graph (B) and redesignating subparagraph (C) 
as subparagraph (B).
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HR 3590 EAS/PP 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall take effect on the date on 
which the Secretary makes the information described 
in subsection (b)(1) available to the public under such 
subsection. 
SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED 
NURSING FACILITIES AND NURSING FACILI-
TIES. 
Part A of title XI of the Social Security Act (42 U.S.C. 
1301 et seq.), as amended by sections 6002 and 6004, is 
amended by inserting after section 1128H the following new 
section: 
‘‘SEC. 1128I. ACCOUNTABILITY REQUIREMENTS FOR FACILI-
TIES. 
‘‘(a) DEFINITION OF FACILITY.—In this section, the 
term ‘facility’ means— 
‘‘(1) a skilled nursing facility (as defined in sec-
tion 1819(a)); or 
‘‘(2) a nursing facility (as defined in section 
1919(a)). 
‘‘(b) EFFECTIVE COMPLIANCE
AND ETHICS PRO-
GRAMS.— 
‘‘(1) REQUIREMENT.—On or after the date that 
is 36 months after the date of the enactment of this 
section, a facility shall, with respect to the entity that