I 
117TH CONGRESS 
1ST SESSION H. R. 2256 
To amend title XVIII of the Social Security Act to provide for the distribution 
of additional residency positions, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 26, 2021 
Ms. SEWELL (for herself, Mr. KATKO, Mr. SUOZZI, Mr. RODNEY DAVIS of Illi-
nois, Ms. BARRAGA´N, Mrs. BEATTY, Mr. BRENDAN F. BOYLE of Pennsyl-
vania, Mr. CARBAJAL, Mr. CICILLINE, Mr. COHEN, Mr. CONNOLLY, Mr. 
CROW, Mr. DANNY K. DAVIS of Illinois, Ms. DEGETTE, Mr. MICHAEL 
F. DOYLE of Pennsylvania, Mr. FITZPATRICK, Ms. HOULAHAN, Mr. 
JOHNSON of Georgia, Mr. LAWSON of Florida, Ms. LEE of California, 
Mrs. LEE of Nevada, Ms. MCCOLLUM, Mr. MEEKS, Ms. MENG, Mr. NAD-
LER, Mr. PAYNE, Ms. PINGREE, Ms. ROSS, Ms. SCANLON, Ms. 
STEFANIK, Mr. STEUBE, Ms. STEVENS, Ms. TITUS, Mr. TONKO, Mr. VAN 
DREW, Ms. VELA´ZQUEZ, Mr. WELCH, Ms. BASS, and Miss RICE of New 
York) introduced the following bill; which was referred to the Committee 
on Ways and Means, and in addition to the Committee on Energy and 
Commerce, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for the distribution of additional residency positions, and 
for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Resident Physician 
Shortage Reduction Act of 2021’’. 
SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI-
TIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graphs (7), (8), and (9)’’ and inserting ‘‘paragraphs 
(7), (8), (9), and (10)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘para-
graphs (7), (8), and (9)’’ and inserting ‘‘paragraphs 
(7), (8), (9), and (10)’’; 
(3) in paragraph (7)(E), by inserting ‘‘para-
graph (10),’’ after ‘‘paragraph (8),’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(10) DISTRIBUTION
OF
ADDITIONAL
RESI-
DENCY POSITIONS.— 
‘‘(A) 
ADDITIONAL
RESIDENCY
POSI-
TIONS.— 
‘‘(i) IN GENERAL.—For each of fiscal 
years 2023 through 2029 (and succeeding 
fiscal years if the Secretary determines 
that there are additional residency posi-
tions available to distribute under clause 
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(iv)(II)), the Secretary shall, subject to 
clause (ii) and subparagraph (D), increase 
the otherwise applicable resident limit for 
each qualifying hospital (as defined in sub-
paragraph (H)) that submits a timely ap-
plication under this subparagraph by such 
number as the Secretary may approve for 
portions of cost reporting periods occurring 
on or after July 1 of the fiscal year of the 
increase. 
‘‘(ii) NUMBER
AVAILABLE
FOR
DIS-
TRIBUTION.—For each such fiscal year, 
the Secretary shall determine the total 
number of additional residency positions 
available for distribution under clause (i) 
in accordance with the following: 
‘‘(I) ALLOCATION TO HOSPITALS 
ALREADY OPERATING OVER RESIDENT 
LIMIT.—One-third of such number 
shall be available for distribution only 
to hospitals described in subparagraph 
(B). 
‘‘(II) AGGREGATE LIMITATION.— 
Except as provided in clause (iv)(I), 
the aggregate number of increases in 
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the otherwise applicable resident limit 
under this subparagraph shall be 
equal to 2,000 in each such year. 
‘‘(iii) PROCESS
FOR
DISTRIBUTING 
POSITIONS.— 
‘‘(I) 
ROUNDS
OF
APPLICA-
TIONS.—The Secretary shall initiate 7 
separate rounds of applications for an 
increase under clause (i), 1 round 
with respect to each of fiscal years 
2023 through 2029. 
‘‘(II) NUMBER
AVAILABLE.—In 
each of such rounds, the aggregate 
number of positions available for dis-
tribution in the fiscal year under 
clause (ii) shall be distributed, plus 
any 
additional 
positions 
available 
under clause (iv). 
‘‘(III) TIMING.—The Secretary 
shall notify hospitals of the number of 
positions distributed to the hospital 
under this paragraph as a result of an 
increase in the otherwise applicable 
resident limit by January 1 of the fis-
cal year of the increase. Such increase 
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shall be effective for portions of cost 
reporting periods beginning on or 
after July 1 of that fiscal year. 
‘‘(iv) POSITIONS
NOT
DISTRIBUTED 
DURING THE FISCAL YEAR.— 
‘‘(I) IN GENERAL.—If the num-
ber of resident full-time equivalent po-
sitions distributed under this para-
graph in a fiscal year is less than the 
aggregate number of positions avail-
able for distribution in the fiscal year 
(as described in clause (ii), including 
after application of this subclause), 
the difference between such number 
distributed and such number available 
for distribution shall be added to the 
aggregate number of positions avail-
able for distribution in the following 
fiscal year. 
‘‘(II) EXCEPTION
IF
POSITIONS 
NOT DISTRIBUTED BY END OF FISCAL 
YEAR 2029.—If the aggregate number 
of positions distributed under this 
paragraph during the 7-year period of 
fiscal years 2023 through 2029 is less 
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than 14,000, the Secretary shall, in 
accordance with the provisions of 
clause (ii) and subparagraph (E) and 
the considerations and priority de-
scribed in subparagraph (C), conduct 
an application and distribution proc-
ess in each subsequent fiscal year 
until such time as the aggregate 
amount of positions distributed under 
this paragraph is equal to 14,000. 
‘‘(B) ALLOCATION OF DISTRIBUTION FOR 
POSITIONS TO HOSPITALS ALREADY OPERATING 
OVER RESIDENT LIMIT.— 
‘‘(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), in the case of a hospital in 
which the reference resident level of the 
hospital (as specified in subparagraph 
(G)(iii)) is greater than the otherwise ap-
plicable resident limit, the increase in the 
otherwise applicable resident limit under 
subparagraph (A) for a fiscal year de-
scribed in such subparagraph shall be an 
amount equal to the product of the total 
number of additional residency positions 
available for distribution under subpara-
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graph (A)(ii)(I) for such fiscal year and 
the quotient of— 
‘‘(I) the number of resident posi-
tions by which the reference resident 
level of the hospital exceeds the other-
wise applicable resident limit for the 
hospital; and 
‘‘(II) the number of resident po-
sitions by which the reference resident 
level of all such hospitals with respect 
to which an application is approved 
under this paragraph exceeds the oth-
erwise applicable resident limit for 
such hospitals. 
‘‘(ii) REQUIREMENTS.—A hospital de-
scribed in clause (i)— 
‘‘(I) is not eligible for an increase 
in the otherwise applicable resident 
limit under this subparagraph unless 
the amount by which the reference 
resident level of the hospital exceeds 
the otherwise applicable resident limit 
is not less than 10 and the hospital 
trains at least 25 percent of the full- 
time equivalent residents of the hos-
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pital in primary care and general sur-
gery (as of the date of enactment of 
this paragraph); and 
‘‘(II) shall continue to train at 
least 25 percent of the full-time equiv-
alent residents of the hospital in pri-
mary care and general surgery for the 
5-year period beginning on such date. 
In the case where the Secretary determines 
that a hospital described in clause (i) no 
longer meets the requirement of subclause 
(II), the Secretary may reduce the other-
wise applicable resident limit of the hos-
pital by the amount by which such limit 
was increased under this subparagraph. 
‘‘(iii) CLARIFICATION REGARDING ELI-
GIBILITY
FOR
OTHER
ADDITIONAL
RESI-
DENCY POSITIONS.—Nothing in this sub-
paragraph shall be construed as preventing 
a hospital described in clause (i) from ap-
plying for and receiving additional resi-
dency positions under this paragraph that 
are not reserved for distribution under this 
subparagraph. 
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‘‘(C) DISTRIBUTION
OF
OTHER
POSI-
TIONS.—For purposes of determining an in-
crease in the otherwise applicable resident limit 
under subparagraph (A) (other than such an in-
crease described in subparagraph (B)), the fol-
lowing shall apply: 
‘‘(i) CONSIDERATIONS
IN
DISTRIBU-
TION.—In determining for which hospitals 
such an increase is provided under sub-
paragraph (A), the Secretary shall take 
into account the demonstrated likelihood of 
the hospital filling the positions made 
available under this paragraph within the 
first 5 cost reporting periods beginning 
after the date the increase would be effec-
tive, as determined by the Secretary. 
‘‘(ii) MINIMUM
DISTRIBUTION
FOR 
CERTAIN
CATEGORIES
OF
HOSPITALS.— 
With respect to the aggregate number of 
such positions available for distribution 
under this paragraph, the Secretary shall 
distribute not less than 10 percent of such 
aggregate number to each of the following 
categories of hospitals: 
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‘‘(I) Hospitals that are located in 
a rural area (as defined in subsection 
(d)(2)(D)) or are treated as being lo-
cated in a rural area pursuant to sub-
section (d)(8)(E). 
‘‘(II) Hospitals in which the ref-
erence resident level of the hospital 
(as specified in subparagraph (F)(iii)) 
is greater than the otherwise applica-
ble resident limit. 
‘‘(III) Hospitals in States with— 
‘‘(aa) new medical schools 
that received ‘Candidate School’ 
status from the Liaison Com-
mittee on Medical Education or 
that received ‘Pre-Accreditation’ 
status from the American Osteo-
pathic Association Commission 
on Osteopathic College Accredita-
tion on or after January 1, 2000, 
and that have achieved or con-
tinue to progress toward ‘Full 
Accreditation’ status (as such 
term is defined by the Liaison 
Committee 
on 
Medical 
Edu-
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cation) or toward ‘Accreditation’ 
status (as such term is defined 
by the American Osteopathic As-
sociation Commission on Osteo-
pathic College Accreditation); or 
‘‘(bb) 
additional 
locations 
and branch campuses established 
on or after January 1, 2000, by 
medical schools with ‘Full Ac-
creditation’ status (as such term 
is defined by the Liaison Com-
mittee on Medical Education) or 
‘Accreditation’ status (as such 
term is defined by the American 
Osteopathic Association Commis-
sion on Osteopathic College Ac-
creditation). 
‘‘(IV) Hospitals that serve areas 
designated 
as 
health 
professional 
shortage 
areas 
under 
section 
332(a)(1)(A) of the Public Health 
Service Act, as determined by the Sec-
retary. 
‘‘(D) PROHIBITION ON DISTRIBUTION TO 
HOSPITALS
WITHOUT
AN
INCREASE
AGREE-
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MENT.—No increase in the otherwise applicable 
resident limit of a hospital may be made under 
subparagraph (C) unless such hospital agrees to 
increase the total number of full-time equivalent 
residency positions under the approved medical 
residency training program of such hospital by 
the number of such positions made available by 
such increase under the subparagraph. 
‘‘(E) LIMITATION.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), a hospital may not re-
ceive more than 75 full-time equivalent ad-
ditional residency positions in the aggre-
gate under this paragraph and paragraph 
(9) over the period of fiscal years 2023 
through 2029. 
‘‘(ii) INCREASE IN NUMBER OF ADDI-
TIONAL POSITIONS A HOSPITAL MAY RE-
CEIVE.—The Secretary shall increase the 
aggregate number of full-time equivalent 
additional residency positions a hospital 
may receive under this paragraph over 
such period if the Secretary estimates that 
the number of positions available for dis-
tribution under subparagraph (A) exceeds 
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the number of applications approved under 
such subparagraph over such period. 
‘‘(F) APPLICATION
OF
PER
RESIDENT 
AMOUNTS
FOR
PRIMARY
CARE
AND
NONPRI-
MARY CARE.—With respect to additional resi-
dency positions in a hospital attributable to the 
increase provided under this paragraph, the ap-
proved FTE per resident amounts are deemed 
to be equal to the hospital per resident amounts 
for primary care and nonprimary care com-
puted under paragraph (2)(D) for that hospital. 
‘‘(G) PERMITTING
FACILITIES
TO
APPLY 
AGGREGATION
RULES.—The Secretary shall 
permit hospitals receiving additional residency 
positions attributable to the increase provided 
under this paragraph to, beginning in the fifth 
year after the effective date of such increase, 
apply such positions to the limitation amount 
under paragraph (4)(F) that may be aggre-
gated pursuant to paragraph (4)(H) among 
members of the same affiliated group. 
‘‘(H) DEFINITIONS.—In this paragraph: 
‘‘(i) OTHERWISE
APPLICABLE
RESI-
DENT LIMIT.—The term ‘otherwise appli-
cable resident limit’ means, with respect to 
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a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
graphs (7)(A), (7)(B), (8)(A), and (8)(B). 
‘‘(ii) REFERENCE RESIDENT LEVEL.— 
Except as otherwise provided in subclause 
(II), the term ‘reference resident level’ 
means, with respect to a hospital, the resi-
dent level for the most recent cost report-
ing period of the hospital ending on or be-
fore the date of enactment of this para-
graph, for which a cost report has been 
settled (or, if not, submitted (subject to 
audit)), as determined by the Secretary. 
‘‘(iii) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i). 
‘‘(iv) QUALIFYING
HOSPITAL.—The 
term ‘qualifying hospital’ means a hospital 
described in subparagraph (B)(i) or any of 
subclauses (I) through (IV) of subpara-
graph (C)(ii).’’. 
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(b) IME.—Section 1886(d)(5)(B) of the Social Secu-
rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 
(1) in clause (v), in the third sentence, by strik-
ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’ and in-
serting ‘‘subsections (h)(7), (h)(8), (h)(9), and 
(h)(10)’’; and 
(2) by adding after clause (xii), as redesignated 
by subparagraph (A), the following new clause: 
‘‘(xiii) For discharges occurring on or 
after July 1, 2023, insofar as an additional 
payment amount under this subparagraph 
is attributable to resident positions distrib-
uted to a hospital under subsection 
(h)(10), the indirect teaching adjustment 
factor shall be computed in the same man-
ner as provided under clause (ii) with re-
spect to such resident positions.’’. 
SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREAS-
ING DIVERSITY. 
(a) STUDY.—The Comptroller General of the United 
States (in this section referred to as the ‘‘Comptroller 
General’’) shall conduct a study on strategies for increas-
ing the diversity of the health professional workforce. Such 
study shall include an analysis of strategies for increasing 
the number of health professionals from rural, lower in-
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come, and underrepresented minority communities, includ-
ing which strategies are most effective for achieving such 
goal. 
(b) REPORT.—Not later than 2 years after the date 
of enactment of this Act, the Comptroller General shall 
submit to Congress a report on the study conducted under 
subsection (a), together with recommendations for such 
legislation and administrative action as the Comptroller 
General determines appropriate. 
Æ 
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