H. R. 3590—535 
‘‘(I) is a physician (as described in section 
1861(r)(1)) who has a primary specialty designa-
tion of family medicine, internal medicine, geriatric 
medicine, or pediatric medicine; or 
‘‘(II) is a nurse practitioner, clinical nurse spe-
cialist, or physician assistant (as those terms are 
defined in section 1861(aa)(5)); and 
‘‘(ii) for whom primary care services accounted for 
at least 60 percent of the allowed charges under this 
part for such physician or practitioner in a prior period 
as determined appropriate by the Secretary. 
‘‘(B) PRIMARY CARE SERVICES.—The term ‘primary care 
services’ means services identified, as of January 1, 2009, 
by the following HCPCS codes (and as subsequently modi-
fied by the Secretary): 
‘‘(i) 99201 through 99215. 
‘‘(ii) 99304 through 99340. 
‘‘(iii) 99341 through 99350. 
‘‘(3) COORDINATION WITH OTHER PAYMENTS.—The amount 
of the additional payment for a service under this subsection 
and subsection (m) shall be determined without regard to any 
additional payment for the service under subsection (m) and 
this subsection, respectively. 
‘‘(4) LIMITATION ON REVIEW.—There shall be no administra-
tive or judicial review under section 1869, 1878, or otherwise, 
respecting the identification of primary care practitioners under 
this subsection.’’. 
(2) CONFORMING AMENDMENT.—Section 1834(g)(2)(B) of the 
Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by 
adding at the end the following sentence: ‘‘Section 1833(x) shall 
not be taken into account in determining the amounts that 
would otherwise be paid pursuant to the preceding sentence.’’. 
(b) INCENTIVE PAYMENT PROGRAM FOR MAJOR SURGICAL PROCE-
DURES FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.— 
(1) IN GENERAL.—Section 1833 of the Social Security Act 
(42 U.S.C. 1395l), as amended by subsection (a)(1), is amended 
by adding at the end the following new subsection: 
‘‘(y) INCENTIVE PAYMENTS FOR MAJOR SURGICAL PROCEDURES 
FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.— 
‘‘(1) IN GENERAL.—In the case of major surgical procedures 
furnished on or after January 1, 2011, and before January 
1, 2016, by a general surgeon in an area that is designated 
(under section 332(a)(1)(A) of the Public Health Service Act) 
as a health professional shortage area as identified by the 
Secretary prior to the beginning of the year involved, in addition 
to the amount of payment that would otherwise be made for 
such services under this part, there also shall be paid (on 
a monthly or quarterly basis) an amount equal to 10 percent 
of the payment amount for the service under this part. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) GENERAL SURGEON.—In this subsection, the term 
‘general surgeon’ means a physician (as described in section 
1861(r)(1)) who has designated CMS specialty code 02– 
General Surgery as their primary specialty code in the 
physician’s enrollment under section 1866(j). 
‘‘(B) MAJOR SURGICAL PROCEDURES.—The term ‘major 
surgical procedures’ means physicians’ services which are
H. R. 3590—536 
surgical procedures for which a 10-day or 90-day global 
period is used for payment under the fee schedule under 
section 1848(b). 
‘‘(3) COORDINATION WITH OTHER PAYMENTS.—The amount 
of the additional payment for a service under this subsection 
and subsection (m) shall be determined without regard to any 
additional payment for the service under subsection (m) and 
this subsection, respectively. 
‘‘(4) APPLICATION.—The provisions of paragraph (2) and 
(4) of subsection (m) shall apply to the determination of addi-
tional payments under this subsection in the same manner 
as such provisions apply to the determination of additional 
payments under subsection (m).’’. 
(2) CONFORMING AMENDMENT.—Section 1834(g)(2)(B) of the 
Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended 
by subsection (a)(2), is amended by striking ‘‘Section 1833(x)’’ 
and inserting ‘‘Subsections (x) and (y) of section 1833’’ in the 
last sentence. 
(c) BUDGET-NEUTRALITY ADJUSTMENT.—Section 1848(c)(2)(B) of 
the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended 
by adding at the end the following new clause: 
‘‘(vii) ADJUSTMENT FOR CERTAIN PHYSICIAN INCEN-
TIVE
PAYMENTS.—Fifty percent of the additional 
expenditures under this part attributable to sub-
sections (x) and (y) of section 1833 for a year (as 
estimated by the Secretary) shall be taken into account 
in applying clause (ii)(II) for 2011 and subsequent 
years. In lieu of applying the budget-neutrality adjust-
ments required under clause (ii)(II) to relative value 
units to account for such costs for the year, the Sec-
retary shall apply such budget-neutrality adjustments 
to the conversion factor otherwise determined for the 
year. For 2011 and subsequent years, the Secretary 
shall 
increase 
the 
incentive 
payment 
otherwise 
applicable under section 1833(m) by a percent esti-
mated to be equal to the additional expenditures esti-
mated under the first sentence of this clause for such 
year that is applicable to physicians who primarily 
furnish services in areas designated (under section 
332(a)(1)(A) of the Public Health Service Act) as health 
professional shortage areas.’’. 
SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CENTER 
IMPROVEMENTS. 
(a) EXPANSION OF MEDICARE-COVERED PREVENTIVE SERVICES 
AT FEDERALLY QUALIFIED HEALTH CENTERS.— 
(1) IN GENERAL.—Section 1861(aa)(3)(A) of the Social Secu-
rity Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read as 
follows: 
‘‘(A) services of the type described subparagraphs (A) 
through (C) of paragraph (1) and preventive services (as 
defined in section 1861(ddd)(3)); and’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply to services furnished on or after January 1, 
2011. 
(b) PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY QUALIFIED 
HEALTH CENTERS.—Section 1834 of the Social Security Act (42
H. R. 3590—537 
U.S.C. 1395m) is amended by adding at the end the following 
new subsection: 
‘‘(n) DEVELOPMENT AND IMPLEMENTATION OF PROSPECTIVE PAY-
MENT SYSTEM.— 
‘‘(1) DEVELOPMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall develop a 
prospective payment system for payment for Federally 
qualified health services furnished by Federally qualified 
health centers under this title. Such system shall include 
a process for appropriately describing the services fur-
nished by Federally qualified health centers. 
‘‘(B) COLLECTION OF DATA AND EVALUATION.—The Sec-
retary shall require Federally qualified health centers to 
submit to the Secretary such information as the Secretary 
may require in order to develop and implement the prospec-
tive payment system under this paragraph and paragraph 
(2), respectively, including the reporting of services using 
HCPCS codes. 
‘‘(2) IMPLEMENTATION.— 
‘‘(A) 
IN
GENERAL.—Notwithstanding 
section 
1833(a)(3)(B), the Secretary shall provide, for cost reporting 
periods beginning on or after October 1, 2014, for payments 
for Federally qualified health services furnished by Feder-
ally qualified health centers under this title in accordance 
with the prospective payment system developed by the 
Secretary under paragraph (1). 
‘‘(B) PAYMENTS.— 
‘‘(i) INITIAL PAYMENTS.—The Secretary shall imple-
ment such prospective payment system so that the 
estimated amount of expenditures under this title for 
Federally qualified health services in the first year 
that the prospective payment system is implemented 
is equal to 103 percent of the estimated amount of 
expenditures under this title that would have occurred 
for such services in such year if the system had not 
been implemented. 
‘‘(ii) PAYMENTS IN SUBSEQUENT YEARS.—In the year 
after the first year of implementation of such system, 
and in each subsequent year, the payment rate for 
Federally qualified health services furnished in the 
year shall be equal to the payment rate established 
for such services furnished in the preceding year under 
this subparagraph increased by the percentage increase 
in the MEI (as defined in 1842(i)(3)) for the year 
involved.’’. 
SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Security Act 
(42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘paragraph (7)’’ and 
inserting ‘‘paragraphs (7) and (8)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘paragraph (7)’’ and 
inserting ‘‘paragraphs (7) and (8)’’; 
(3) in paragraph (7)(E), by inserting ‘‘or paragraph (8)’’ 
before the period at the end; and 
(4) by adding at the end the following new paragraph: 
‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.—
H. R. 3590—538 
‘‘(A) REDUCTIONS
IN
LIMIT
BASED
ON
UNUSED
POSI-
TIONS.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), if a hospital’s reference resident level (as defined 
in subparagraph (H)(i)) is less than the otherwise 
applicable resident limit (as defined in subparagraph 
(H)(iii)), effective for portions of cost reporting periods 
occurring on or after July 1, 2011, the otherwise 
applicable resident limit shall be reduced by 65 percent 
of the difference between such otherwise applicable 
resident limit and such reference resident level. 
‘‘(ii) EXCEPTIONS.—This subparagraph shall not 
apply to— 
‘‘(I) a hospital located in a rural area (as 
defined in subsection (d)(2)(D)(ii)) with fewer than 
250 acute care inpatient beds; 
‘‘(II) a hospital that was part of a qualifying 
entity which had a voluntary residency reduction 
plan approved under paragraph (6)(B) or under 
the authority of section 402 of Public Law 90– 
248, if the hospital demonstrates to the Secretary 
that it has a specified plan in place for filling 
the unused positions by not later than 2 years 
after the date of enactment of this paragraph; 
or 
‘‘(III) a hospital described in paragraph 
(4)(H)(v). 
‘‘(B) DISTRIBUTION.— 
‘‘(i) IN GENERAL.—The Secretary shall increase the 
otherwise applicable resident limit for each qualifying 
hospital that submits an application under this 
subparagraph by such number as the Secretary may 
approve for portions of cost reporting periods occurring 
on or after July 1, 2011. The aggregate number of 
increases in the otherwise applicable resident limit 
under this subparagraph shall be equal to the aggre-
gate reduction in such limits attributable to subpara-
graph (A) (as estimated by the Secretary). 
‘‘(ii) REQUIREMENTS.—Subject to clause (iii), a hos-
pital that receives an increase in the otherwise 
applicable resident limit under this subparagraph shall 
ensure, during the 5-year period beginning on the date 
of such increase, that— 
‘‘(I) the number of full-time equivalent primary 
care residents, as defined in paragraph (5)(H) (as 
determined by the Secretary), excluding any addi-
tional positions under subclause (II), is not less 
than the average number of full-time equivalent 
primary care residents (as so determined) during 
the 3 most recent cost reporting periods ending 
prior to the date of enactment of this paragraph; 
and 
‘‘(II) not less than 75 percent of the positions 
attributable to such increase are in a primary care 
or general surgery residency (as determined by 
the Secretary).
H. R. 3590—539 
The Secretary may determine whether a hospital has 
met the requirements under this clause during such 
5-year period in such manner and at such time as 
the Secretary determines appropriate, including at the 
end of such 5-year period. 
‘‘(iii) REDISTRIBUTION
OF
POSITIONS
IF
HOSPITAL 
NO
LONGER
MEETS
CERTAIN
REQUIREMENTS.—In the 
case where the Secretary determines that a hospital 
described in clause (ii) does not meet either of the 
requirements under subclause (I) or (II) of such clause, 
the Secretary shall— 
‘‘(I) reduce the otherwise applicable resident 
limit of the hospital by the amount by which such 
limit was increased under this paragraph; and 
‘‘(II) provide for the distribution of positions 
attributable to such reduction in accordance with 
the requirements of this paragraph. 
‘‘(C) CONSIDERATIONS
IN
REDISTRIBUTION.—In deter-
mining for which hospitals the increase in the otherwise 
applicable resident limit is provided under subparagraph 
(B), the Secretary shall take into account— 
‘‘(i) the demonstration likelihood of the hospital 
filling the positions made available under this para-
graph within the first 3 cost reporting periods begin-
ning on or after July 1, 2011, as determined by the 
Secretary; and 
‘‘(ii) whether the hospital has an accredited rural 
training track (as described in paragraph (4)(H)(iv)). 
‘‘(D) PRIORITY FOR CERTAIN AREAS.—In determining for 
which hospitals the increase in the otherwise applicable 
resident limit is provided under subparagraph (B), subject 
to subparagraph (E), the Secretary shall distribute the 
increase to hospitals based on the following factors: 
‘‘(i) Whether the hospital is located in a State 
with a resident-to-population ratio in the lowest quar-
tile (as determined by the Secretary). 
‘‘(ii) Whether the hospital is located in a State, 
a territory of the United States, or the District of 
Columbia that is among the top 10 States, territories, 
or Districts in terms of the ratio of— 
‘‘(I) the total population of the State, territory, 
or District living in an area designated (under 
such section 332(a)(1)(A)) as a health professional 
shortage area (as of the date of enactment of this 
paragraph); to 
‘‘(II) the total population of the State, territory, 
or District (as determined by the Secretary based 
on the most recent available population data pub-
lished by the Bureau of the Census). 
‘‘(iii) Whether the hospital is located in a rural 
area (as defined in subsection (d)(2)(D)(ii)). 
‘‘(E) RESERVATION
OF
POSITIONS
FOR
CERTAIN
HOS-
PITALS.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the Sec-
retary shall reserve the positions available for distribu-
tion under this paragraph as follows:
H. R. 3590—540 
‘‘(I) 70 percent of such positions for distribu-
tion to hospitals described in clause (i) of subpara-
graph (D). 
‘‘(II) 30 percent of such positions for distribu-
tion to hospitals described in clause (ii) and (iii) 
of such subparagraph. 
‘‘(ii) EXCEPTION IF POSITIONS NOT REDISTRIBUTED 
BY JULY 1, 2011.—In the case where the Secretary does 
not distribute positions to hospitals in accordance with 
clause (i) by July 1, 2011, the Secretary shall distribute 
such positions to other hospitals in accordance with 
the considerations described in subparagraph (C) and 
the priority described in subparagraph (D). 
‘‘(F) LIMITATION.—A hospital may not receive more 
than 75 full-time equivalent additional residency positions 
under this paragraph. 
‘‘(G) APPLICATION OF PER RESIDENT AMOUNTS FOR PRI-
MARY CARE AND NONPRIMARY CARE.—With respect to addi-
tional residency positions in a hospital attributable to the 
increase provided under this paragraph, the approved FTE 
per resident amounts are deemed to be equal to the hospital 
per resident amounts for primary care and nonprimary 
care computed under paragraph (2)(D) for that hospital. 
‘‘(H) DEFINITIONS.—In this paragraph: 
‘‘(i) REFERENCE RESIDENT LEVEL.—The term ‘ref-
erence resident level’ means, with respect to a hospital, 
the highest resident level for any of the 3 most recent 
cost reporting periods (ending before the date of the 
enactment of this paragraph) of the hospital for which 
a cost report has been settled (or, if not, submitted 
(subject to audit)), as determined by the Secretary. 
‘‘(ii) RESIDENT
LEVEL.—The term ‘resident level’ 
has the meaning given such term in paragraph 
(7)(C)(i). 
‘‘(iii) OTHERWISE APPLICABLE RESIDENT LIMIT.—The 
term ‘otherwise applicable resident limit’ means, with 
respect to a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of paragraph (4) 
on the resident level for the hospital determined with-
out regard to this paragraph but taking into account 
paragraph (7)(A).’’. 
(b) IME.— 
(1) IN
GENERAL.—Section 1886(d)(5)(B)(v) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sen-
tence, is amended— 
(A) by striking ‘‘subsection (h)(7)’’ and inserting ‘‘sub-
sections (h)(7) and (h)(8)’’; and 
(B) by striking ‘‘it applies’’ and inserting ‘‘they apply’’. 
(2) CONFORMING AMENDMENT.—Section 1886(d)(5)(B) of the 
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended 
by adding at the end the following clause: 
‘‘(x) For discharges occurring on or after July 1, 2011, 
insofar as an additional payment amount under this subpara-
graph is attributable to resident positions distributed to a hos-
pital under subsection (h)(8)(B), the indirect teaching adjust-
ment factor shall be computed in the same manner as provided 
under clause (ii) with respect to such resident positions.’’.
H. R. 3590—541 
(c) CONFORMING AMENDMENT.—Section 422(b)(2) of the Medi-
care Prescription Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173) is amended by striking ‘‘section 
1886(h)(7)’’ and all that follows and inserting ‘‘paragraphs (7) and 
(8) of subsection (h) of section 1886 of the Social Security Act’’. 
SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER SETTINGS. 
(a) GME.—Section 1886(h)(4)(E) of the Social Security Act (42 
U.S.C. 1395ww(h)(4)(E)) is amended— 
(1) by striking ‘‘shall be counted and that all the time’’ 
and inserting ‘‘shall be counted and that— 
‘‘(i) effective for cost reporting periods beginning 
before July 1, 2010, all the time;’’; 
(2) in clause (i), as inserted by paragraph (1), by striking 
the period at the end and inserting ‘‘; and’’; 
(3) by inserting after clause (i), as so inserted, the following 
new clause: 
‘‘(ii) effective for cost reporting periods beginning 
on or after July 1, 2010, all the time so spent by 
a resident shall be counted towards the determination 
of full-time equivalency, without regard to the setting 
in which the activities are performed, if a hospital 
incurs the costs of the stipends and fringe benefits 
of the resident during the time the resident spends 
in that setting. If more than one hospital incurs these 
costs, either directly or through a third party, such 
hospitals shall count a proportional share of the time, 
as determined by written agreement between the hos-
pitals, that a resident spends training in that setting.’’; 
and 
(4) by adding at the end the following flush sentence: 
‘‘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 Security Act 
(42 U.S.C. 1395ww(d)(5)) is amended— 
(1) by striking ‘‘(iv) Effective for discharges occurring on 
or after October 1, 1997’’ and inserting ‘‘(iv)(I) Effective for 
discharges occurring on or after October 1, 1997, and before 
July 1, 2010’’; and 
(2) by inserting after clause (I), as inserted by paragraph 
(1), the following new subparagraph: 
‘‘(II) Effective for discharges occurring on or after July 
1, 2010, all the time spent by an intern or resident in patient 
care activities in a nonprovider setting shall be counted towards 
the determination of full-time equivalency if a hospital incurs 
the costs of the stipends and fringe benefits of the intern 
or resident during the time the intern or resident spends in 
that setting. If more than one hospital 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 resident spends 
training in that setting.’’.
H. R. 3590—542 
(c) APPLICATION.—The amendments made by this section shall 
not be applied in a manner that requires reopening 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)). 
SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC 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 subpara-
graphs: 
‘‘(J) 
TREATMENT
OF
CERTAIN
NONPROVIDER
AND 
DIDACTIC ACTIVITIES.—Such rules shall provide that all time 
spent by an intern or resident in an approved medical 
residency training 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 associated with the treatment or diagnosis 
of a particular patient, as such time and activities are 
defined by the Secretary, shall be counted toward the deter-
mination of full-time equivalency. 
‘‘(K) TREATMENT
OF
CERTAIN
OTHER
ACTIVITIES.—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 
residency training program on vacation, sick leave, or other 
approved leave, as such time is defined by the Secretary, 
and that does not prolong the total time the resident is 
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
PRIMARILY 
ENGAGED IN FURNISHING PATIENT CARE.—The term ‘nonpro-
vider setting that is primarily engaged in furnishing patient 
care’ means a nonprovider setting in which the primary 
activity is the care and treatment of patients, as defined 
by the Secretary.’’. 
(b) IME DETERMINATIONS.—Section 1886(d)(5)(B) of such Act 
(42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the 
following new clause: 
‘‘(x)(I) The provisions of subparagraph (K) of sub-
section (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 subpara-
graph, all the time spent by an intern or resident
H. R. 3590—543 
in an approved medical residency training program 
in non-patient care activities, such as didactic con-
ferences and seminars, as such time and activities 
are defined by the Secretary, 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 reimbursement 
system authorized under section 1814(b)(3); or 
‘‘(dd) is a provider-based hospital outpatient 
department. 
‘‘(III) In determining the hospital’s number of full- 
time equivalent residents for purposes of this subpara-
graph, all the time spent by an intern or resident 
in an approved medical residency training program 
in research activities that are not associated with the 
treatment or diagnosis of a particular 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 Sec-
retary of Health and Human Services shall implement the 
amendments made by this section in a manner so as to apply 
to cost reporting periods beginning on or after January 1, 
1983. 
(2) GME.—Section 1886(h)(4)(J) of the Social Security Act, 
as added by subsection (a)(1)(B), shall apply to cost reporting 
periods beginning on or after July 1, 2009. 
(3) IME.—Section 1886(d)(5)(B)(x)(III) of the Social Security 
Act, as added by subsection (b), shall apply to cost reporting 
periods beginning on or after October 1, 2001. Such section, 
as so added, shall not give rise to any inference as to how 
the law in effect prior to such date should be interpreted. 
SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM 
CLOSED HOSPITALS. 
(a) GME.—Section 1886(h)(4)(H) of the Social Security 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 approved 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 hospitals in accordance with this clause. 
‘‘(II) PRIORITY
FOR
HOSPITALS
IN
CERTAIN 
AREAS.—Subject to the succeeding provisions of 
this clause, in determining for which hospitals the
H. R. 3590—544 
increase in the otherwise applicable resident limit 
is provided under such process, 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 hospital): 
‘‘(aa) First, to hospitals located in the 
same core-based statistical area as, or a core- 
based statistical area contiguous to, the hos-
pital that closed. 
‘‘(bb) Second, to hospitals located in the 
same State as the hospital that closed. 
‘‘(cc) Third, to hospitals located in the 
same region of the country as the hospital 
that closed. 
‘‘(dd) Fourth, only if the Secretary is not 
able to distribute the increase to hospitals 
described in item (cc), to qualifying hospitals 
in accordance with the provisions of paragraph 
(8). 
‘‘(III) REQUIREMENT HOSPITAL LIKELY TO FILL 
POSITION WITHIN CERTAIN TIME PERIOD.—The Sec-
retary may only increase the otherwise applicable 
resident limit of a hospital under such process 
if the Secretary determines the hospital has dem-
onstrated a likelihood of filling the positions made 
available under this clause within 3 years. 
‘‘(IV) LIMITATION.—The aggregate number of 
increases in the otherwise applicable resident 
limits for hospitals under this clause shall be equal 
to the number of resident positions in the approved 
medical residency programs that closed on or after 
the date described in subclause (I). 
‘‘(V) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to the 
implementation of this clause.’’. 
(b) IME.—Section 1886(d)(5)(B)(v) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended 
by section 5503, is amended by striking ‘‘subsections (h)(7) and 
(h)(8)’’ and inserting ‘‘subsections (h)(4)(H)(vi), (h)(7), and (h)(8)’’. 
(c) APPLICATION.—The amendments made by this section shall 
not be applied in a manner that requires reopening 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 ADJUSTMENTS.—The Sec-
retary 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
H. R. 3590—545 
application of section 1886(h)(4)(H)(v) of the Social Security Act 
(42 U.S.C. 1395ww(h)(4)(H)(v)). 
(e) CONFORMING AMENDMENT.—Section 1886(h)(7)(E) of the 
Social Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended by 
section 5503(a), is amended by striking ‘‘paragraph or paragraph 
(8)’’ and inserting ‘‘this paragraph, paragraph (8), or paragraph 
(4)(H)(vi)’’. 
SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFES-
SIONS 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 EDUCATION, TRAINING, AND 
CAREER
ADVANCEMENT
TO
ADDRESS
HEALTH
PROFESSIONS 
WORKFORCE NEEDS.— 
‘‘(1) AUTHORITY TO AWARD GRANTS.—The Secretary, in con-
sultation with the Secretary of Labor, shall award grants to 
eligible entities to conduct demonstration projects that are 
designed to provide eligible individuals with the opportunity 
to obtain education and training for occupations in the health 
care field that pay well and are expected to either experience 
labor shortages or be in high demand. 
‘‘(2) REQUIREMENTS.— 
‘‘(A) AID AND SUPPORTIVE SERVICES.— 
‘‘(i) IN
GENERAL.—A demonstration project con-
ducted 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 beneficiary participating in a 
demonstration project under this section shall not be 
considered income, and shall not be taken into account 
for purposes of determining the individual’s eligibility 
for, or amount of, benefits 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 applica-
tion that the entity has consulted with the State agency 
responsible for administering the State TANF program, 
the local workforce investment board in the area in which 
the project is to be conducted (unless the applicant is 
such board), the State workforce investment board estab-
lished 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 Office of Apprenticeship 
of the Department of Labor) and that the project will 
be carried out in coordination with such entities.
H. R. 3590—546 
‘‘(C) ASSURANCE OF OPPORTUNITIES FOR INDIAN POPU-
LATIONS.—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 entity awarded 
a grant to conduct a demonstration project under this sub-
section shall submit interim reports to the Secretary on 
the activities carried out under the project and a final 
report on such activities upon the conclusion of the entities’ 
participation in the project. Such reports shall include 
assessments of the effectiveness of such activities with 
respect to improving outcomes for the eligible individuals 
participating in the project and with respect to addressing 
health professions workforce needs in the areas in which 
the project is conducted. 
‘‘(B) EVALUATION.—The Secretary shall, by grant, con-
tract, or interagency agreement, evaluate the demonstra-
tion projects conducted under this subsection. Such evalua-
tion shall include identification of successful activities for 
creating opportunities for developing and sustaining, 
particularly with respect to low-income individuals and 
other entry-level workers, a health professions workforce 
that has accessible entry points, that meets high standards 
for education, training, certification, and professional 
development, and that provides increased wages and afford-
able benefits, including health care coverage, that are 
responsive to the workforce’s needs. 
‘‘(C) REPORT TO CONGRESS.—The Secretary shall submit 
interim reports and, based on the evaluation conducted 
under subparagraph (B), a final report to Congress on 
the demonstration 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 institu-
tion of higher education, a local workforce investment board 
established under section 117 of the Workforce Investment 
Act of 1998, a sponsor of an apprenticeship program reg-
istered under the National Apprenticeship Act or a commu-
nity-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 INDIVIDUALS.—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 ORGANIZATION.—The terms 
‘Indian tribe’ and ‘tribal organization’ have the meaning 
given such terms in section 4 of the Indian Self-Determina-
tion and Education Assistance Act (25 U.S.C. 450b). 
‘‘(D) INSTITUTION
OF
HIGHER
EDUCATION.—The term 
‘institution of higher education’ has the meaning given 
that term in section 101 of the Higher Education Act of 
1965 (20 U.S.C. 1001).
H. R. 3590—547 
‘‘(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 assistance for needy fami-
lies 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 TRAINING AND CER-
TIFICATION 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 projects for purposes of developing core training 
competencies and certification programs for personal or home 
care aides. The Secretary shall— 
‘‘(A) evaluate the efficacy of the core training com-
petencies described in paragraph (3)(A) for newly hired 
personal or home care aides and the methods used by 
States to implement such core training competencies in 
accordance with the issues specified in paragraph (3)(B); 
and 
‘‘(B) ensure that the number of hours of training pro-
vided by States under the demonstration project with 
respect to such core training competencies are not less 
than the number of hours of training required under any 
applicable State or Federal law or regulation. 
‘‘(2) DURATION.—A demonstration project shall be con-
ducted under this subsection for not less than 3 years. 
‘‘(3) CORE TRAINING COMPETENCIES FOR PERSONAL OR HOME 
CARE AIDES.— 
‘‘(A) IN GENERAL.—The core training competencies for 
personal or home care aides described in this subparagraph 
include competencies with respect to the following areas: 
‘‘(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 confidentiality 
(including the role of proxy decision-makers in the 
case where a health care consumer has impaired deci-
sion-making capacity). 
‘‘(iii) Communication, cultural and linguistic com-
petence and sensitivity, problem solving, behavior 
management, and relationship 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 individual consumer’s 
needs (including older individuals, younger individuals 
with 
disabilities, 
individuals 
with 
developmental
H. R. 3590—548 
disabilities, individuals with dementia, and individuals 
with mental and behavioral health needs). 
‘‘(x) Self-Care. 
‘‘(B) IMPLEMENTATION.—The implementation issues 
specified in this subparagraph include the following: 
‘‘(i) The length of the training. 
‘‘(ii) The appropriate trainer to student 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 written certifi-
cation exam. 
‘‘(vi) Continuing education requirements. 
‘‘(4) APPLICATION AND SELECTION CRITERIA.— 
‘‘(A) IN GENERAL.— 
‘‘(i) NUMBER OF STATES.—The Secretary shall enter 
into agreements with not more than 6 States to conduct 
demonstration projects under this subsection. 
‘‘(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 
development of a certification test for personal or 
home care aides who have completed such training 
competencies. 
‘‘(iii) CONSULTATION
AND
COLLABORATION
WITH 
COMMUNITY
AND
VOCATIONAL
COLLEGES.—The Sec-
retary shall encourage participating States to consult 
with community and vocational colleges regarding the 
development of curricula to implement the project with 
respect to activities, as applicable, which may include 
consideration of such colleges as partners in such 
implementation. 
‘‘(B) APPLICATION AND ELIGIBILITY.—A State seeking 
to participate in the project shall— 
‘‘(i) submit an application to the Secretary con-
taining such information and at such time as the Sec-
retary may specify; 
‘‘(ii) meet the selection criteria established 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 Secretary shall establish 
criteria to ensure (if applicable with respect to the activities 
involved)— 
‘‘(i) geographic and demographic diversity; 
‘‘(ii) that participating States offer medical assist-
ance for personal care services under the State Med-
icaid plan; 
‘‘(iii) that the existing training standards for per-
sonal or home care aides in each participating State—