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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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‘‘(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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‘‘(e) CLARIFICATION REGARDING RELATIONSHIP TO 
OTHER
PAYMENTS
FOR
GRADUATE
MEDICAL
EDU-
CATION.—Payments under this section— 
‘‘(1) shall be in addition to any payments— 
‘‘(A) for the indirect costs of medical edu-
cation under section 1886(d)(5)(B) of the Social 
Security Act; 
‘‘(B) for direct graduate medical education 
costs under section 1886(h) of such Act; and 
‘‘(C) for direct costs of medical education 
under section 1886(k) of such Act; 
‘‘(2) shall not be taken into account in applying 
the limitation on the number of total full-time equiva-
lent residents under subparagraphs (F) and (G) of 
section 1886(h)(4) of such Act and clauses (v), (vi)(I), 
and (vi)(II) of section 1886(d)(5)(B) of such Act for 
the portion of time that a resident rotates to a hos-
pital; and 
‘‘(3) shall not include the time in which a resi-
dent is counted toward full-time equivalency by a hos-
pital 
under 
paragraph 
(2) 
or 
under 
section 
1886(d)(5)(B)(iv) of the Social Security Act, section 
1886(h)(4)(E) of such Act, or section 340E of this 
Act. 
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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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