established not later than 18 months after the date of the 
enactment of this title, and shall be based on the study 
conducted under subsection (b). 
‘‘(b) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
search and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in 
hospitals. The Director may contract with a qualified enti-
ty or organization to carry out such study under this para-
graph. The Director shall consult with licensed practical 
nurses and organizations representing licensed practical 
nurses regarding the design and conduct of the study. 
‘‘(c) APPLICATION OF REGISTERED NURSE PROVI-
SIONS TO LICENSED PRACTICAL NURSE STAFFING RE-
QUIREMENTS.—Paragraphs (2), (3), (4)(A), and (5) of 
section 2901(b), section 2901(c), and section 2902 shall 
apply to the establishment and application of direct care 
licensed practical nurse staffing requirements under this 
section in the same manner that they apply to the estab-
lishment and application of direct care registered nurse- 
to-patient ratios under section 2901. 
‘‘(d) EFFECTIVE DATE.—The requirements of this 
section shall take effect as soon as practicable, as deter-
mined by the Secretary, but not later than 2 years after
the date of the enactment of this title, or in the case of 
a hospital in a rural area (as defined in section 
1886(d)(2)(D) of the Social Security Act (42 U.S.C. 
1395ww(d)(2)(D)), not later than 4 years after the date 
of the enactment of this title. 
‘‘SEC. 2904. ADJUSTMENT IN REIMBURSEMENT. 
‘‘(a) MEDICARE REIMBURSEMENT.—The Secretary 
shall adjust payments made to hospitals (other than feder-
ally operated hospitals) under title XVIII of the Social Se-
curity Act in an amount equal to the net amount of addi-
tional costs incurred in providing services to medicare 
beneficiaries that are attributable to compliance with re-
quirements imposed under sections 2901 through 2903. 
The amount of such payment adjustments shall take into 
account recommendations contained in the report sub-
mitted by the Medicare Payment Advisory Commission 
under subsection (c). 
‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED-
ERALLY OPERATED HOSPITALS.—There are authorized to 
be appropriated such additional sums as are required for 
federally operated hospitals to comply with the additional 
requirements established under sections 2901 through 
2903. 
‘‘(c) MEDPAC REPORT.—Not later than 2 years after 
the date of the enactment of this title, the Medicare Pay-
ment Advisory Commission (established under section 
1805 of the Social Security Act (42 U.S.C. 1395b–6)) 
shall submit to Congress and the Secretary a report esti-
mating total costs and savings attributable to compliance 
with requirements imposed under sections 2901 through 
2903. Such report shall include recommendations on the 
need, if any, to adjust reimbursement for Medicare pay-
ments under subsection (a). 
‘‘SEC. 2905. PROTECTION OF NURSES AND OTHER INDIVID-
UALS. 
‘‘(a) REFUSAL
OF
ASSIGNMENT.—A nurse may 
refuse to accept an assignment as a nurse in a hospital 
if— 
‘‘(1) the assignment would violate section 2901 
or 2903; or 
‘‘(2) the nurse is not prepared by education, 
training, or experience to fulfill the assignment with-
out compromising the safety of any patient or jeop-
ardizing the license of the nurse. 
‘‘(b) RETALIATION FOR REFUSAL OF ASSIGNMENT 
BARRED.— 
‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE-
TALIATION.—No hospital shall discharge, discrimi-
nate, or retaliate in any manner with respect to any 
aspect of employment (as defined in section