I 
111TH CONGRESS 
1ST SESSION H. R. 2251 
To amend title XVIII of the Social Security Act to provide for the distribution 
of additional residency positions, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 5, 2009 
Mr. CROWLEY (for himself, Mr. MEEK of Florida, Ms. CASTOR of Florida, and 
Mr. ENGEL) introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for the distribution of additional residency positions, and 
for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Resident Physician 
Shortage Reduction Act of 2009’’. 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI-
TIONS. 
(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)’’; 
and 
(3) by adding at the end the following new 
paragraph: 
‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY 
POSITIONS.— 
‘‘(A) 
ADDITIONAL
RESIDENCY
POSI-
TIONS.— 
‘‘(i) REDUCTION IN LIMIT BASED ON 
UNUSED POSITIONS.— 
‘‘(I) IN
GENERAL.—The Sec-
retary shall reduce the otherwise ap-
plicable resident limit for a hospital 
that the Secretary determines had 
residency positions that were unused 
for all 5 of the most recent cost re-
porting periods ending prior to the 
date of enactment of this paragraph 
by an amount that is equal to the 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
number of such unused residency po-
sitions. 
‘‘(II) EXCEPTION
FOR
RURAL 
HOSPITALS AND CERTAIN OTHER HOS-
PITALS.—This subparagraph shall not 
apply to a hospital— 
‘‘(aa) located in a rural area 
(as 
defined 
in 
subsection 
(d)(2)(D)(ii)); 
‘‘(bb) that has participated 
in a voluntary reduction plan 
under paragraph (6); or 
‘‘(cc) that has participated 
in a demonstration project ap-
proved as of October 31, 2003, 
under the authority of section 
402 of Public Law 90–248. 
‘‘(ii) NUMBER
AVAILABLE
FOR
DIS-
TRIBUTION.—The number of additional 
residency positions available for distribu-
tion under subparagraph (B) shall be an 
amount that the Secretary determines 
would result in a 15 percent increase in 
the aggregate number of full-time equiva-
lent residents in approved medical training 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
programs (as determined based on the 
most recent cost reports available at the 
time of distribution). One-third of such 
number shall only be available for distribu-
tion to hospitals described in subclause (I) 
of subparagraph (B)(ii) under such sub-
paragraph. 
‘‘(B) DISTRIBUTION.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall increase the otherwise applicable resi-
dent limit for each qualifying hospital that 
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 the date of 
enactment of this paragraph. The aggre-
gate number of increases in the otherwise 
applicable resident limit under this sub-
paragraph shall be equal to the number of 
additional residency positions available for 
distribution under subparagraph (A)(ii). 
‘‘(ii) DISTRIBUTION
TO
HOSPITALS 
ALREADY
OPERATING
OVER
RESIDENT 
LIMIT.— 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), in the case of a hos-
pital in which the reference resident 
level of the hospital (as specified in 
clause (iii)) is greater than the other-
wise applicable resident limit, the in-
crease in the otherwise applicable resi-
dent limit under this subparagraph 
shall be an amount equal to the prod-
uct of the total number of additional 
residency positions available for dis-
tribution under subparagraph (A)(ii) 
and the quotient of— 
‘‘(aa) the number of resident 
positions by which the reference 
resident level of the hospital ex-
ceeds the otherwise applicable 
resident limit for the hospital; 
and 
‘‘(bb) the number of resident 
positions by which the reference 
resident level of all such hospitals 
with respect to which an applica-
tion is approved under this sub-
paragraph exceeds the otherwise 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
applicable resident limit for such 
hospitals. 
‘‘(II) REQUIREMENTS.—A hos-
pital described in subclause (I)— 
‘‘(aa) is not eligible for an 
increase in the otherwise applica-
ble resident limit under this sub-
paragraph unless the amount by 
which the reference resident level 
of the hospital exceeds the other-
wise applicable resident limit is 
not less than 10 and the hospital 
trains at least 25 percent of the 
full-time equivalent residents of 
the hospital in primary care and 
general surgery (as of the date of 
enactment of this paragraph); 
and 
‘‘(bb) shall continue to train 
at least 25 percent of the full- 
time equivalent residents of the 
hospital in primary care and gen-
eral surgery for the 10-year pe-
riod beginning on such date. 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
In the case where the Secretary deter-
mines that a hospital no longer meets 
the requirement of item (bb), the Sec-
retary may reduce the otherwise appli-
cable resident limit of the hospital by 
the amount by which such limit was 
increased under this clause. 
‘‘(III) CLARIFICATION
REGARD-
ING
ELIGIBILITY
FOR
OTHER
ADDI-
TIONAL
RESIDENCY
POSITIONS.— 
Nothing in this clause shall be con-
strued as preventing a hospital de-
scribed in subclause (I) from applying 
for 
additional 
residency 
positions 
under this paragraph that are not re-
served for distribution under this 
clause. 
‘‘(iii) 
REFERENCE
RESIDENT 
LEVEL.— 
‘‘(I) IN
GENERAL.—Except as 
otherwise provided in subclause (II), 
the reference resident level specified in 
this clause for a hospital is the resi-
dent level for the most recent cost re-
porting period of the hospital ending 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
on or before the date of enactment of 
this paragraph, for which a cost re-
port has been settled (or, if not, sub-
mitted (subject to audit)), as deter-
mined by the Secretary. 
‘‘(II) USE OF MOST RECENT AC-
COUNTING PERIOD TO RECOGNIZE EX-
PANSION OF EXISTING PROGRAM OR 
ESTABLISHMENT
OF
NEW
PRO-
GRAM.—If a hospital submits a timely 
request to increase its resident level 
due to an expansion of an existing 
residency training program or the es-
tablishment of a new residency train-
ing program that is not reflected on 
the most recent cost report that has 
been settled (or, if not, submitted 
(subject to audit)), subject to the dis-
cretion of the Secretary, the reference 
resident level for such hospital is the 
resident level for the cost reporting 
period that includes the additional 
residents attributable to such expan-
sion or establishment, as determined 
by the Secretary. 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
‘‘(C) CONSIDERATIONS
IN
REDISTRIBU-
TION.—In determining for which hospitals the 
increase in the otherwise applicable resident 
limit is provided under subparagraph (B) (other 
than an increase under subparagraph (B)(ii)), 
the Secretary shall take into account the dem-
onstrated likelihood of the hospital filling the 
positions within the first 3 cost reporting peri-
ods beginning on or after July 1, 2010, made 
available under this paragraph, as determined 
by the Secretary. 
‘‘(D) PRIORITY FOR CERTAIN AREAS.—In 
determining for which hospitals the increase in 
the otherwise applicable resident limit is pro-
vided under subparagraph (B) (other than an 
increase under subparagraph (B)(ii)), the Sec-
retary shall distribute the increase to hospitals 
based on the following criteria: 
‘‘(i) The Secretary shall give pref-
erence to hospitals that submit applica-
tions for new primary care and general 
surgery residency positions. In the case of 
any increase based on such preference, a 
hospital shall ensure that— 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
‘‘(I) the position made available 
as a result of such increase remains a 
primary care or general surgery resi-
dency position for not less than 10 
years after the date on which the posi-
tion is filled; and 
‘‘(II) the total number of primary 
care and general surgery residency po-
sitions in the hospital (determined 
based on the number of such positions 
as of the date of such increase, includ-
ing any position added as a result of 
such increase) is not decreased during 
such 10-year period. 
In the case where the Secretary determines 
that a hospital no longer meets the re-
quirement of subclause (II), the Secretary 
may reduce the otherwise applicable resi-
dent limit of the hospital by the amount by 
which such limit was increased under this 
paragraph. 
‘‘(ii) The Secretary shall give pref-
erence to hospitals that emphasize training 
in community health centers and other 
community-based clinical settings. 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
‘‘(iii) The Secretary shall give pref-
erence to hospitals in States that have 
more medical students than residency posi-
tions available (including a greater pref-
erence for those States with smaller resi-
dent-to-medical-student ratios). In deter-
mining the number of medical students in 
a State for purposes of the preceding sen-
tence, the Secretary shall include planned 
students at medical schools which have 
provisional accreditation by the Liaison 
Committee on Medical Education or the 
American Osteopathic Association. 
‘‘(iv) The Secretary shall give pref-
erence to hospitals in States that have low 
resident-to-population ratios (including a 
greater preference for those States with 
lower resident-to-population ratios). 
‘‘(E) LIMITATION.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), in no case may a hos-
pital (other than a hospital described in 
subparagraph (B)(ii)(I), subject to the lim-
itation under subparagraph (B)(ii)(III)) 
apply for more than 50 full-time equivalent 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS
additional residency positions under this 
paragraph. 
‘‘(ii) INCREASE IN NUMBER OF ADDI-
TIONAL
POSITIONS
AVAILABLE
FOR
DIS-
TRIBUTION.—The Secretary shall increase 
the number of full-time equivalent addi-
tional residency positions a hospital may 
apply for under this paragraph if the Sec-
retary determines that the number of addi-
tional residency positions available for dis-
tribution under subparagraph (A)(ii) ex-
ceeds the number of such applications ap-
proved. 
‘‘(F) 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 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. 
‘‘(G) DISTRIBUTION.—The Secretary shall 
distribute the increase to hospitals under this 
VerDate Nov 24 2008 
22:45 May 06, 2009
Jkt 079200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H2251.IH
H2251
hsrobinson on PROD1PC76 with BILLS