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•AMDT. NO. 2786 
‘‘SEC. 274. FUNDING. 
‘‘Beginning with fiscal year 2010, the Secretary shall 
transfer from the Public Health and Social Services Emer-
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— 
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•AMDT. NO. 2786 
‘‘(I) 60 percent of such amount 
for grants under subsection (a) to 
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) 
percent 
of 
such 
excess 
amounts shall be made available for grants 
under subsection (a) to health professions 
schools that meet the requirements de-
scribed in paragraph (3) or (4) of sub-
section (c) (including meeting conditions 
pursuant to subsection (e)); and 
‘‘(ii) 20 percent of such excess 
amount shall be made available for grants 
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•AMDT. NO. 2786 
under subsection (a) to health professions 
schools that meet the conditions described 
in subsection (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 available— 
‘‘(i) not less than $12,000,000 for 
grants under subsection (a) to health pro-
fessions schools that meet the conditions 
described in subsection (c)(2)(A); 
‘‘(ii) not less than $12,000,000 for 
grants under subsection (a) to health pro-
fessions schools that meet the conditions 
described 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 pro-
fessions schools that meet the conditions 
described in subsection (c)(5); and 
‘‘(iv) after grants are made with 
funds under clauses (i) through (iii), any 
remaining excess amount for grants under 
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•AMDT. NO. 2786 
subsection (a) to health professions schools 
that meet the conditions described in para-
graph (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 Secretary shall make available— 
‘‘(i) not less than $16,000,000 for 
grants under subsection (a) to health pro-
fessions schools that meet the conditions 
described in subsection (c)(2)(A); 
‘‘(ii) not less than $16,000,000 for 
grants under subsection (a) to health pro-
fessions schools that meet the conditions 
described 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 pro-
fessions schools that meet the conditions 
described in subsection (c)(5); and 
‘‘(iv) after grants are made with 
funds under clauses (i) through (iii), any 
remaining funds for grants under sub-
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•AMDT. NO. 2786 
section (a) to health professions schools 
that meet the conditions described in para-
graph (2)(A), (3), (4), or (5) of subsection 
(c). 
‘‘(2) NO
LIMITATION.—Nothing in this sub-
section shall be construed as limiting the centers of 
excellence referred to in this section to the des-
ignated 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 
maintain expenditures of non-Federal amounts 
for such activities at a level that is not less 
than the level of such expenditures maintained 
by the center 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 
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•AMDT. NO. 2786 
authorized to be expended, the center shall, be-
fore expending the grant, expend the Federal 
amounts obtained from sources other than the 
grant, unless given prior approval from the Sec-
retary. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this sec-
tion— 
‘‘(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 Pub-
lic Health Service Act (42 U.S.C. 293b(a)(1)) is amended 
by striking ‘‘$20,000 of the principal and interest of the 
educational 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 
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•AMDT. NO. 2786 
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.—Sec-
tion 740(b) of such Act (42 U.S.C. 293d(b)) is amended 
by striking ‘‘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 INDI-
VIDUALS FROM A DISADVANTAGED BACKGROUND.—Sec-
tion 740(c) of such Act (42 U.S.C. 293d(c)) is amended 
by striking 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: 
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•AMDT. NO. 2786 
‘‘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 eligi-
ble entities to enable such entities to initiate health 
care workforce educational programs or to continue 
to carry out comparable programs that are operating 
at the time the award is made by planning, devel-
oping, operating, and evaluating an area health edu-
cation center program. 
‘‘(2) POINT
OF
SERVICE
MAINTENANCE
AND 
ENHANCEMENT 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.— 
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•AMDT. NO. 2786 
‘‘(A) INFRASTRUCTURE DEVELOPMENT.— 
For purposes of subsection (a)(1), the term ‘eli-
gible entity’ means a school of medicine or os-
teopathic 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, 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 sub-
section (a)(2), the term ‘eligible entity’ means 
an entity that has received funds under this 
section, is operating an area health education 
center program, including an area health edu-
cation center or centers, and has a center or 
centers that are no longer eligible to receive fi-
nancial 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.— 
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•AMDT. NO. 2786 
‘‘(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 Work-
force Investment Act of 1998, to recruit indi-
viduals from underrepresented minority popu-
lations or from disadvantaged or rural back-
grounds 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 
development programs, the State workforce 
agency, and local workforce investment boards, 
and in health care safety net sites. 
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•AMDT. NO. 2786 
‘‘(C) Prepare individuals to more effec-
tively provide health services to underserved 
areas and health disparity populations through 
field placements or preceptorships in conjunc-
tion with community-based organizations, ac-
credited primary care residency training pro-
grams, Federally qualified health centers, rural 
health clinics, 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 evalua-
tion strategies. 
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•AMDT. NO. 2786 
‘‘(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: 
‘‘(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 
centers, and facilitate rapid flow and dissemina-
tion of evidence-based health care information, 
research results, and best practices to improve 
quality, efficiency, and effectiveness of health 
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•AMDT. NO. 2786 
care and health care systems within community 
settings. 
‘‘(C) Develop and implement other strate-
gies to address identified workforce needs and 
increase and enhance the health care workforce 
in the area served by the area health education 
center program. 
‘‘(d) REQUIREMENTS.— 
‘‘(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 re-
moved from the primary teaching facility of the 
contracting 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 parent institution, the Secretary shall alter-
natively ensure that— 
‘‘(i) the nursing school conducts at 
least 10 percent of clinical education re-
quired for nursing students in community 
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•AMDT. NO. 2786 
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 cen-
ter program area. 
‘‘(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 edu-
cation center program includes at least 1 area health 
education 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 
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•AMDT. NO. 2786 
or its parent institution, or a consortium of 
such entities; 
‘‘(C) designates an underserved area or 
population to be served by the center which is 
in a location removed from the main location of 
the teaching facilities of the schools partici-
pating in the program with such center and 
does not duplicate, in whole or in part, the geo-
graphic area or population served by any other 
center; 
‘‘(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 part-
nership 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, 
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•AMDT. NO. 2786 
to be eligible for financial assistance under this section, 
an entity shall make available (directly or through con-
tributions 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 sub-
section (a)(1). 
‘‘(f) LIMITATION.—Not less than 75 percent of the 
total amount provided to an area health education center 
program under subsection (a)(1) or (a)(2) shall be allo-
cated to the area health education centers participating 
in the program under this section. To provide needed flexi-
bility to newly funded area health education center pro-
grams, the Secretary may waive the requirement in the 
sentence for the first 2 years of a new area health edu-
cation center program 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 
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•AMDT. NO. 2786 
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 es-
tablished 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. 
‘‘(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.— 
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•AMDT. NO. 2786 
‘‘(1) IN GENERAL.—There is authorized to be 
appropriated 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 cen-
ters; and 
‘‘(D) not more than 4 percent shall be 
used for grants and contracts to provide tech-
nical assistance 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 obtain-
ing approval from the Secretary. In no case may any 
funds be carried over pursuant to the preceding sen-
tence for more than 3 years. 
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•AMDT. NO. 2786 
‘‘(k) SENSE OF CONGRESS.—It is the sense of the 
Congress 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 
COMMUNITIES.—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 im-
prove health care, increase retention, increase representa-
tion of minority faculty members, enhance the practice en-
vironment, and provide information dissemination and 
educational support to reduce professional isolation 
through the timely dissemination of research findings 
using relevant resources. 
‘‘(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-
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•AMDT. NO. 2786 
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 
section to provide innovative supportive activities to en-
hance education through distance learning, continuing 
educational activities, collaborative conferences, and elec-
tronic 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: 
‘‘(1) AUTHORITY.—The Secretary may’’; 
(B) by striking ‘‘pre-entry preparation, 
and retention activities’’ and inserting the fol-
lowing: ‘‘stipends for diploma or associate de-
gree nurses to enter a bridge or degree comple-
tion program, student scholarships or stipends 
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•AMDT. NO. 2786 
for accelerated nursing degree programs, pre- 
entry preparation, advanced education prepara-
tion, and retention activities’’; and 
(2) in subsection (b)— 
(A) by striking ‘‘First’’ and all that follows 
through ‘‘including the’’ and inserting ‘‘Na-
tional Advisory Council on Nurse Education 
and Practice and consult with nursing associa-
tions including the National Coalition of Ethnic 
Minority 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
DEFINI-
TION.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Director of the Agency for Healthcare 
Research and Quality, shall establish a Primary 
Care Extension Program. 
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•AMDT. NO. 2786 
‘‘(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 pro-
viders to incorporate such matters into their practice 
and to improve community health by working with 
community-based health connectors (referred to in 
this section 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-
mary care and to provide guidance to patients 
in culturally and linguistically appropriate ways, 
and linking practices to diverse health system 
resources. 
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•AMDT. NO. 2786 
‘‘(B) PRIMARY
CARE
PROVIDER.—The 
term ‘primary care provider’ means a clinician 
who provides integrated, accessible health care 
services and who is accountable for addressing 
a large majority of personal health care needs, 
including 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 
licensing or regulatory authority, unless other-
wise 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 estab-
lished by a State pursuant to paragraph (1)— 
‘‘(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 
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•AMDT. NO. 2786 
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 Se-
curity 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); 
‘‘(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); 
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•AMDT. NO. 2786 
‘‘(C) organize and administer grant funds 
to county- or local-level Primary Care Exten-
sion Agencies that serve a catchment area, as 
determined 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 
efficiency of primary care services, includ-
ing health homes; 
‘‘(ii) develop and support primary care 
learning communities to enhance the dis-
semination of research findings for evi-
dence-based practice, assess implementa-
tion of practice improvement, share best 
practices, and involve community clinicians 
in the generation of new knowledge and 
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•AMDT. NO. 2786 
identification of important questions for 
research; 
‘‘(iii) participate in a national network 
of Primary Care Extension Hubs and pro-
pose 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 re-
duction in Federal funds that is expected 
after an initial 6-year period of program 
establishment, infrastructure development, 
and planning. 
‘‘(B) DISCRETIONARY
ACTIVITIES.—Pri-
mary Care Extension Agencies established by a 
Hub under paragraph (1) may— 
‘‘(i) 
provide 
technical 
assistance, 
training, and organizational support for 
community health teams established under 
section 3602 of the Patient Protection and 
Affordable Care Act; 
‘‘(ii) collect data and provision of pri-
mary care provider feedback from stand-
ardized measurements of processes and 
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•AMDT. NO. 2786 
outcomes to aid in continuous performance 
improvement; 
‘‘(iii) collaborate with local health de-
partments, 
community 
health 
centers, 
tribes and tribal entities, and other com-
munity agencies to identify community 
health priorities and local health workforce 
needs, and participate in community-based 
efforts to address the social and primary 
determinants of health, strengthen the 
local primary 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— 
‘‘(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 
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•AMDT. NO. 2786 
‘‘(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 ap-
pointed 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. 
‘‘(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 
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•AMDT. NO. 2786 
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 
National Institutes of Health, the Office of the National 
Coordinator for Health Information Technology, the In-
dian Health Service, the Agricultural Cooperative Exten-
sion 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 fis-
cal years 2011 and 2012, and such sums as may be nec-
essary to carry out this section for each of fiscal years 
2013 through 2014.’’. 
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•AMDT. NO. 2786 
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 
Security Act (42 U.S.C. 1395l) is amended by add-
ing at the end the following new subsection: 
‘‘(x) INCENTIVE PAYMENTS
FOR PRIMARY CARE 
SERVICES.— 
‘‘(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 
payment 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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•AMDT. NO. 2786 
‘‘(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 
physician or practitioner in a prior period 
as determined appropriate by the Sec-
retary. 
‘‘(B) PRIMARY CARE SERVICES.—The term 
‘primary care services’ means services identi-
fied, as of January 1, 2009, by the following 
HCPCS codes (and as subsequently modified by 
the Secretary): 
‘‘(i) 99201 through 99215. 
‘‘(ii) 99304 through 99340. 
‘‘(iii) 99341 through 99350. 
‘‘(3) 
COORDINATION
WITH
OTHER
PAY-
MENTS.—The amount of the additional payment for 
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•AMDT. NO. 2786 
a service under this subsection and subsection (m) 
shall be determined without regard to any additional 
payment for the service under subsection (m) and 
this subsection, respectively. 
‘‘(4) LIMITATION ON REVIEW.—There shall be 
no administrative or judicial review under section 
1869, 1878, or otherwise, respecting the identifica-
tion of primary care practitioners under this sub-
section.’’. 
(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 
SURGICAL PROCEDURES FURNISHED IN HEALTH PRO-
FESSIONAL SHORTAGE AREAS.— 
(1) IN GENERAL.—Section 1833 of the Social 
Security Act (42 U.S.C. 1395l), as amended by sub-
section (a)(1), is amended by adding at the end the 
following new subsection: 
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•AMDT. NO. 2786 
‘‘(y) INCENTIVE PAYMENTS FOR MAJOR SURGICAL 
PROCEDURES FURNISHED
IN HEALTH PROFESSIONAL 
SHORTAGE AREAS.— 
‘‘(1) IN GENERAL.—In the case of major sur-
gical procedures furnished on or after January 1, 
2011, and before January 1, 2016, by a general sur-
geon 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 
otherwise 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 pay-
ment 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 
physician (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 
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•AMDT. NO. 2786 
physicians’ services which are surgical proce-
dures for which a 10-day or 90-day global pe-
riod is used for payment under the fee schedule 
under section 1848(b). 
‘‘(3) 
COORDINATION
WITH
OTHER
PAY-
MENTS.—The amount of the additional payment for 
a service under this subsection and subsection (m) 
shall be determined without regard to any additional 
payment for the service under subsection (m) and 
this subsection, respectively. 
‘‘(4) APPLICATION.—The provisions of para-
graph (2) and (4) of subsection (m) shall apply to 
the determination of additional payments under this 
subsection 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 in-
serting ‘‘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. 
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•AMDT. NO. 2786 
1395w–4(c)(2)(B)) is amended by adding at the end the 
following new clause: 
‘‘(vii) ADJUSTMENT
FOR
CERTAIN 
PHYSICIAN
INCENTIVE
PAYMENTS.—Fifty 
percent of the additional expenditures 
under this part attributable to subsections 
(x) and (y) of section 1833 for a year (as 
estimated by the Secretary) shall be taken 
into account in applying clause (ii)(II) for 
2011 and subsequent years. In lieu of ap-
plying 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-neutrality adjustments to the con-
version factor otherwise determined for the 
year. For 2011 and subsequent years, the 
Secretary shall increase the incentive pay-
ment otherwise applicable under section 
1833(m) by a percent estimated to be 
equal to the additional expenditures esti-
mated under the first sentence of this 
clause for such year that is applicable to 
physicians who primarily furnish services 
in 
areas 
designated 
(under 
section 
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•AMDT. NO. 2786 
332(a)(1)(A) of the Public Health Service 
Act) 
as 
health 
professional 
shortage 
areas.’’. 
SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH 
CENTER IMPROVEMENTS. 
(a) EXPANSION OF MEDICARE-COVERED PREVEN-
TIVE SERVICES
AT FEDERALLY QUALIFIED HEALTH 
CENTERS.— 
(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 sub-
paragraphs (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 FEDER-
ALLY 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.— 
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•AMDT. NO. 2786 
‘‘(A) IN
GENERAL.—The Secretary shall 
develop a prospective payment system for pay-
ment for Federally qualified health services fur-
nished by Federally qualified health centers 
under this title. Such system shall include a 
process for appropriately 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). 
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•AMDT. NO. 2786 
‘‘(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 
Federally qualified health services in the 
first year that the prospective payment 
system is implemented is equal to 103 per-
cent of the estimated amount of expendi-
tures under this title that would have oc-
curred 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 
Federally qualified health services fur-
nished in the year shall be equal to the 
payment rate established for such services 
furnished in the preceding year under this 
subparagraph increased by the percentage 
increase in the MEI (as defined in 
1842(i)(3)) for the year involved.’’. 
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•AMDT. NO. 2786 
SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY PO-
SITIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Se-
curity 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)’’; 
(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 
paragraph: 
‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY 
POSITIONS.— 
‘‘(A) REDUCTIONS IN LIMIT BASED ON UN-
USED POSITIONS.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), if a hospital’s reference 
resident level (as defined in subparagraph 
(H)(i)) is less than the otherwise applica-
ble resident limit (as defined in subpara-
graph (H)(iii)), effective for portions of 
cost reporting periods occurring on or after 
July 1, 2011, the otherwise applicable resi-
dent limit shall be reduced by 65 percent 
of the difference between such otherwise 
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•AMDT. NO. 2786 
applicable resident limit and such reference 
resident level. 
‘‘(ii) 
EXCEPTIONS.—This 
subpara-
graph shall not apply to— 
‘‘(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 resi-
dent limit for each qualifying hospital that 
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•AMDT. NO. 2786 
submits an application under this subpara-
graph by such number as the Secretary 
may approve for portions of cost reporting 
periods occurring on or after July 1, 2011. 
The aggregate number of increases in the 
otherwise applicable resident limit under 
this subparagraph shall be equal to the ag-
gregate reduction in such limits attrib-
utable to subparagraph (A) (as estimated 
by the Secretary). 
‘‘(ii) 
REQUIREMENTS.—Subject 
to 
clause (iii), a hospital that receives an in-
crease in the otherwise applicable resident 
limit under this subparagraph shall ensure, 
during the 5-year period beginning on the 
date of such increase, that— 
‘‘(I) the number of full-time 
equivalent primary care residents, as 
defined in paragraph (5)(H) (as de-
termined by the Secretary), excluding 
any additional positions under sub-
clause (II), is not less than the aver-
age number of full-time equivalent 
primary care residents (as so deter-
mined) during the 3 most recent cost 
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•AMDT. NO. 2786 
reporting periods ending prior to the 
date of enactment of this paragraph; 
and 
‘‘(II) not less than 75 percent of 
the positions attributable to such in-
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 
Secretary determines that a hospital de-
scribed in clause (ii) does not meet either 
of the requirements 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 
increased under this paragraph; and 
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•AMDT. NO. 2786 
‘‘(II) provide for the distribution 
of positions attributable to such re-
duction in accordance with the re-
quirements of this paragraph. 
‘‘(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 
factors: 
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•AMDT. NO. 2786 
‘‘(i) Whether the hospital is located in 
a State with a resident-to-population ratio 
in the lowest quartile (as determined by 
the Secretary). 
‘‘(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 sec-
tion 332(a)(1)(A)) as a health profes-
sional shortage area (as of the date of 
enactment 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)). 
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•AMDT. NO. 2786 
‘‘(E) RESERVATION
OF
POSITIONS
FOR 
CERTAIN HOSPITALS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the Secretary shall reserve the posi-
tions available for distribution under this 
paragraph 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 dis-
tribute positions to hospitals in accordance 
with clause (i) by July 1, 2011, the Sec-
retary shall distribute such positions to 
other hospitals in accordance with the con-
siderations described in subparagraph (C) 
and the priority described in subparagraph 
(D). 
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•AMDT. NO. 2786 
‘‘(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
NONPRI-
MARY CARE.—With respect to additional resi-
dency positions in a hospital attributable to the 
increase provided under this paragraph, the ap-
proved FTE per resident amounts are deemed 
to be equal to the hospital per resident amounts 
for primary care and nonprimary care com-
puted under paragraph (2)(D) for that hospital. 
‘‘(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 
hospital 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). 
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•AMDT. NO. 2786 
‘‘(iii) OTHERWISE APPLICABLE RESI-
DENT LIMIT.—The term ‘otherwise appli-
cable resident limit’ means, with respect to 
a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
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 
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•AMDT. NO. 2786 
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 
Modernization Act of 2003 (Public Law 108–173) is 
amended by striking ‘‘section 1886(h)(7)’’ and all that fol-
lows and inserting ‘‘paragraphs (7) and (8) of subsection 
(h) of section 1886 of the Social Security Act’’. 
SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER 
SETTINGS. 
(a) GME.—Section 1886(h)(4)(E) of the Social Se-
curity 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 peri-
ods 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’’; 
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•AMDT. NO. 2786 
(3) by inserting after clause (i), as so inserted, 
the following new clause: 
‘‘(ii) effective for cost reporting peri-
ods 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 per-
formed, if a hospital incurs the costs of the 
stipends and 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 deter-
mined by written agreement between the 
hospitals, that a resident spends training 
in that setting.’’; and 
(4) by adding at the end the following flush 
sentence: 
‘‘Any hospital claiming under this subpara-
graph for time spent in a nonprovider setting 
shall maintain and make available to the Sec-
retary records regarding the amount of such 
time and such amount in comparison with 
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•AMDT. NO. 2786 
amounts of such time in such base year as the 
Secretary shall specify.’’. 
(b) IME.—Section 1886(d)(5)(B)(iv) of the Social 
Security 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: 
‘‘(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 
resident during the time the intern or resident 
spends in that setting. If more than one hospital in-
curs these costs, either directly or through a third 
party, such hospitals shall count a proportional 
share of the time, as determined by written agree-
ment between the hospitals, that a resident spends 
training in that setting.’’. 
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•AMDT. NO. 2786 
(c) APPLICATION.—The amendments made by this 
section shall not be applied in a manner that requires re-
opening 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 sec-
tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) or for direct graduate medical edu-
cation costs under section 1886(h) of such Act (42 U.S.C. 
1395ww(h)). 
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 sub-
paragraphs (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 
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•AMDT. NO. 2786 
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 to-
ward the determination of full-time equivalency. 
‘‘(K) TREATMENT OF CERTAIN OTHER AC-
TIVITIES.—In determining the hospital’s num-
ber of full-time equivalent residents for pur-
poses of this subsection, all the time that is 
spent by an intern or resident in an approved 
medical residency 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 partici-
pating in the approved program beyond the nor-
mal duration of the program shall be counted 
toward the determination of full-time equiva-
lency.’’; and 
(2) in paragraph (5), by adding at the end the 
following new subparagraph: 
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•AMDT. NO. 2786 
‘‘(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 
adding at the end the following new clause: 
‘‘(x)(I) The provisions of subpara-
graph (K) of subsection (h)(4) shall apply 
under this subparagraph in the same man-
ner as they apply under such subsection. 
‘‘(II) In determining the hospital’s 
number of full-time equivalent residents 
for purposes of this subparagraph, all the 
time spent by an intern or resident in an 
approved medical residency training pro-
gram in non-patient care activities, such as 
didactic 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— 
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•AMDT. NO. 2786 
‘‘(aa) is recognized as a sub-
section (d) hospital; 
‘‘(bb) is recognized as a sub-
section (d) Puerto Rico hospital; 
‘‘(cc) is reimbursed under a reim-
bursement system authorized under 
section 1814(b)(3); or 
‘‘(dd) is a provider-based hospital 
outpatient department. 
‘‘(III) In determining the hospital’s 
number of full-time equivalent residents 
for purposes of this subparagraph, all the 
time spent by an intern or resident in an 
approved medical residency training pro-
gram in research activities that are not as-
sociated with the treatment or diagnosis of 
a particular patient, as such time and ac-
tivities 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 pro-
vided, the Secretary of Health and Human Services 
shall implement the amendments made by this sec-
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•AMDT. NO. 2786 
tion in a manner so as to apply to cost reporting pe-
riods beginning 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 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 Se-
curity 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 regula-
tion, establish a process under which, 
in the case where a hospital (other 
than a hospital described in clause 
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1466 
•AMDT. NO. 2786 
(v)) with an approved medical resi-
dency program closes on or after a 
date that is 2 years before the date of 
enactment of this clause, the Sec-
retary shall increase the otherwise ap-
plicable resident limit under this para-
graph for other hospitals in accord-
ance with this clause. 
‘‘(II) PRIORITY FOR HOSPITALS 
IN
CERTAIN
AREAS.—Subject to the 
succeeding provisions of this clause, in 
determining for which hospitals the 
increase in the otherwise applicable 
resident limit is provided under such 
process, the Secretary shall distribute 
the increase to hospitals in the fol-
lowing priority order (with preference 
given within each category to hos-
pitals that are members of the same 
affiliated group (as defined by the 
Secretary under clause (ii)) as the 
closed hospital): 
‘‘(aa) First, to hospitals lo-
cated in the same core-based sta-
tistical area as, or a core-based 
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•AMDT. NO. 2786 
statistical area contiguous to, the 
hospital that closed. 
‘‘(bb) Second, to hospitals 
located 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 
Secretary is not able to distribute 
the increase to hospitals de-
scribed in item (cc), to qualifying 
hospitals in accordance with the 
provisions of paragraph (8). 
‘‘(III) REQUIREMENT
HOSPITAL 
LIKELY
TO
FILL
POSITION
WITHIN 
CERTAIN
TIME
PERIOD.—The Sec-
retary may only increase the otherwise 
applicable resident limit of a hospital 
under such process if the Secretary 
determines the hospital has dem-
onstrated a likelihood of filling the po-
sitions made available under this 
clause within 3 years. 
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•AMDT. NO. 2786 
‘‘(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 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 
striking ‘‘subsections (h)(7) and (h)(8)’’ and inserting 
‘‘subsections (h)(4)(H)(vi), (h)(7), and (h)(8)’’. 
(c) APPLICATION.—The amendments made by this 
section shall not be applied in a manner that requires re-
opening 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 sec-
tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) or for direct graduate medical edu-
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•AMDT. NO. 2786 
cation 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 application 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 
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•AMDT. NO. 2786 
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 
Secretary, in consultation with the Secretary of 
Labor, shall award grants to eligible entities to con-
duct demonstration projects that are designed to 
provide eligible individuals with the opportunity to 
obtain education and training for occupations in the 
health care field that pay well and are expected to 
either experience labor shortages or be in high de-
mand. 
‘‘(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 
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•AMDT. NO. 2786 
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
COORDINA-
TION.—An eligible entity applying for a grant 
to carry out a demonstration project under this 
section shall demonstrate in the application that 
the entity has consulted with the State agency 
responsible for administering the State TANF 
program, the local workforce investment board 
in the area in which the project is to be con-
ducted (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 Ap-
prenticeship Act’) (or if no agency has been rec-
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ognized in the State, the Office of Apprentice-
ship 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 en-
tity awarded a grant to conduct a demonstra-
tion project under this subsection shall submit 
interim reports to the Secretary on the activi-
ties carried out under the project and a final 
report on such activities upon the conclusion of 
the entities’ participation in the project. Such 
reports shall include assessments of the effec-
tiveness of such activities with respect to im-
proving outcomes 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, 
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evaluate the demonstration projects conducted 
under this subsection. Such evaluation shall in-
clude identification of successful activities for 
creating opportunities for developing and sus-
taining, particularly with respect to low-income 
individuals and other entry-level workers, a 
health professions workforce that has accessible 
entry points, that meets high standards for edu-
cation, training, 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 subpara-
graph (B), a final report to Congress on the 
demonstration projects conducted under this 
subsection. 
‘‘(4) DEFINITIONS.—In this subsection: 
‘‘(A) ELIGIBLE ENTITY.—The term ‘eligi-
ble entity’ means a State, an Indian tribe or 
tribal organization, an institution of higher edu-
cation, a local workforce investment board es-
tablished under section 117 of the Workforce 
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crow account under the direction 
of the Secretary on the earlier of 
the date on which the informal 
dispute resolution process under 
item (aa) is completed or the 
date that is 90 days after the 
date of the imposition of the pen-
alty; 
‘‘(dd) may provide that such 
amounts collected are kept in 
such account pending the resolu-
tion of any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
benefit residents, including as-
sistance to support and protect 
residents of a facility that closes 
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of elder justice and to make recommendations to the Elder 
Justice Coordinating Council established under section 
2021. 
‘‘(b) COMPOSITION.—The Advisory Board shall be 
composed of 27 members appointed by the Secretary from 
among members of the general public who are individuals 
with experience and expertise in elder abuse, neglect, and 
exploitation prevention, detection, treatment, intervention, 
or prosecution. 
‘‘(c) SOLICITATION
OF NOMINATIONS.—The Sec-
retary shall publish a notice in the Federal Register solic-
iting nominations for the appointment of members of the 
Advisory Board under subsection (b). 
‘‘(d) TERMS.— 
‘‘(1) IN GENERAL.—Each member of the Advi-
sory Board shall be appointed for a term of 3 years, 
except that, of the members first appointed— 
‘‘(A) 9 shall be appointed for a term of 3 
years; 
‘‘(B) 9 shall be appointed for a term of 2 
years; and 
‘‘(C) 9 shall be appointed for a term of 1 
year. 
‘‘(2) VACANCIES.— 
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