I 
118TH CONGRESS 
1ST SESSION H. R. 3623 
To amend title XVIII of the Social Security Act to establish a national 
graduate nurse education program. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 24, 2023 
Ms. UNDERWOOD (for herself, Ms. BONAMICI, and Mr. HORSFORD) 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 jurisdiction of the com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to establish 
a national graduate nurse education program. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Educating Future 
Nurses Act’’. 
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SEC. 2. NATIONAL GRADUATE NURSE EDUCATION PRO-
GRAM. 
Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by inserting after section 1866G 
the following new section: 
‘‘SEC. 1866H. NATIONAL GRADUATE NURSE EDUCATION 
PROGRAM. 
‘‘(a) IN GENERAL.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a national graduate nurse education 
program under this title under which an eligible 
hospital may receive payment for the hospital’s 
reasonable costs (described in paragraph (2)) 
for the provision of qualified clinical education 
to advanced practice registered nurses. 
‘‘(B) 
WRITTEN
AGREEMENTS.—Eligible 
hospitals participating in the program shall 
enter into written agreements pursuant to sub-
section (b)(1) in order to reimburse the eligible 
partners of the hospital the share of the costs 
attributable to each partner. 
‘‘(2) COSTS DESCRIBED.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the costs described in this para-
graph are the reasonable costs (as described in 
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section 1861(v)) of each eligible hospital for the 
clinical education costs (as determined by the 
Secretary) that are attributable to providing ad-
vanced practice registered nurses with qualified 
clinical education. 
‘‘(B) LIMITATION.—With respect to a 
year, the amount reimbursed under subpara-
graph (A) may not exceed the amount of costs 
described in subparagraph (A) that are attrib-
utable to an increase in the number of advanced 
practice registered nurses enrolled in an accred-
ited school of nursing that provides qualified 
clinical education during the year and for which 
the hospital is being reimbursed under the pro-
gram, as compared to the average number of 
advanced practice registered nurses who grad-
uated in each year during the period beginning 
on January 1, 2021, and ending on December 
31, 2022 (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 program. 
‘‘(3) ESTABLISHMENT OF REGIONS.— 
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‘‘(A) IN
GENERAL.—The Secretary shall 
establish regions for Graduate Nurse Education 
Hubs described in subsection (b) under the pro-
gram based on hospital referral regions. 
‘‘(B) LIMITATIONS.— 
‘‘(i) ONE
HUB
PER
REGION.—Only 
one Graduate Nurse Education Hub may 
participate in the program with respect to 
each region established by the Secretary 
under subparagraph (A). 
‘‘(ii) ELIGIBLE HOSPITALS AND ELIGI-
BLE PARTNERS.—An eligible hospital or el-
igible partner may only participate in one 
Graduate Nurse Education Hub under the 
program. 
‘‘(4) SUPPLEMENT NOT SUPPLANT.—Payments 
under this section in any given year shall supple-
ment, not supplant, other Federal funds that have 
been made available in the year for advanced prac-
tice registered nurse clinical education or training. 
‘‘(5) WAIVER AUTHORITY.—The Secretary may 
waive such requirements of title XI and this title as 
may be necessary to carry out the program. 
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‘‘(6) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to the imple-
mentation of this section. 
‘‘(b) REQUIREMENTS.—No payment shall be made 
under this section to an eligible hospital unless such hos-
pital meets the following requirements: 
‘‘(1) The hospital has in effect a written agree-
ment with the eligible partners of the hospital. Such 
written agreement shall describe, at a minimum— 
‘‘(A) the obligations of the eligible partners 
with respect to the provision of qualified clinical 
education; and 
‘‘(B) the obligation of the eligible hospital 
to reimburse such eligible partners (in a timely 
manner) for the costs of such qualified clinical 
education that are attributable to such partner. 
‘‘(2) The hospital demonstrates to the Secretary 
that it is leading a Graduate Nurse Education 
(GNE) Hub which has established and will maintain 
the following in order to provide qualified clinical 
education to advanced practice registered nurses: 
‘‘(A) Partnerships with one or more— 
‘‘(i) applicable schools of nursing; 
‘‘(ii) hospitals or health systems in a 
regional area; and 
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‘‘(iii) applicable non-hospital commu-
nity-based care settings. 
‘‘(B) A governance structure that includes 
one or more applicable schools of nursing in the 
leadership and an oversight process that is de-
veloped and approved by the hospital, partici-
pating applicable schools of nursing, and other 
hub partners, in accordance with requirements 
established by the Secretary. 
‘‘(C) A process for timely reimbursement 
of eligible partners for the costs of such quali-
fied clinical education that are attributable to 
such partner. 
‘‘(D) An adequate system for coordination 
of clinical education sites and preceptors. 
‘‘(E) A process for taking into consider-
ation local, State, and regional workforce needs 
to facilitate innovation and value-based delivery 
of health care. 
‘‘(c) PAYMENTS.— 
‘‘(1) PER-STUDENT RATE.—The amount of pay-
ment under this section to an eligible hospital shall 
for each year of the program shall be equal to the 
applicable per-student rate (as defined in paragraph 
(2)) multiplied by the total number of advanced 
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practice registered nurses receiving qualified clinical 
education through the eligible hospital under the 
program. 
‘‘(2) APPLICABLE
PER-STUDENT
RATE.—The 
applicable per-student rate, with respect to an eligi-
ble hospital, is— 
‘‘(A) for the first year of the program, a 
per-student rate determined by the Secretary 
based on data from the Graduate Nurse Edu-
cation Demonstration established under section 
5509 of the Patient Protection and Affordable 
Care Act (Public Law 111–148), increased or 
decreased by the percentage change in the con-
sumer price index for all urban consumers (all 
items; United States city average) from the last 
year of the Graduate Nurse Education Dem-
onstration established under section 5509 for 
which such data is available to the June pre-
ceding such first year of the program under this 
section; and 
‘‘(B) for a subsequent year, the amount 
determined under this paragraph for the pre-
ceding year, increased or decreased by the per-
centage change in the consumer price index for 
all urban consumers (all items; United States 
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city average) for the 12-month period ending 
with June of the previous year. 
‘‘(d) ANNUAL REPORTING REQUIRED.— 
‘‘(1) REDUCTION IN PAYMENT FOR FAILURE TO 
REPORT.— 
‘‘(A) IN GENERAL.—The amount payable 
under this section to an eligible hospital shall 
be reduced by 25 percent if the Secretary deter-
mines that— 
‘‘(i) the hospital has failed to provide 
the Secretary the report required under 
paragraph (2) for the year; or 
‘‘(ii) such report fails to provide the 
information required under any subpara-
graph of such paragraph. 
‘‘(B) NOTICE AND OPPORTUNITY TO PRO-
VIDE MISSING INFORMATION.—Before imposing 
a reduction under subparagraph (A) on the 
basis of a hospital’s failure to provide informa-
tion described in subparagraph (A)(ii), the Sec-
retary shall provide notice to the hospital of 
such failure and the Secretary’s intention to im-
pose such reduction and shall provide the hos-
pital with the opportunity to provide the re-
quired information within a period of 30 days 
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beginning on the date of such notice. If the hos-
pital provides such information within such pe-
riod, no reduction shall be made under subpara-
graph (A) on the basis of the previous failure 
to provide such information. 
‘‘(C) LIMITATION.—In the case where the 
amount payable under this section to an eligible 
hospital is reduced pursuant to subparagraph 
(A), the eligible hospital may not make any cor-
responding reductions in payment to eligible 
partners. 
‘‘(2) ANNUAL
REPORT.—The report required 
under this paragraph for an eligible hospital for a 
year is a report that includes (in a form and manner 
specified by the Secretary) the following information 
for the academic year completed immediately prior 
to such year: 
‘‘(A) The types of qualified clinical edu-
cation provided to advanced practice registered 
nurses under the program. 
‘‘(B) The type and number of academic or 
practice partnerships established as a result of 
working together in a Graduate Nurse Edu-
cation (GNE) Hub. 
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‘‘(C) The number of advanced practice reg-
istered nurse students receiving qualified clin-
ical education through the eligible hospital 
under the program. 
‘‘(D) Any changes in qualified clinical edu-
cation made during such academic year (except 
that the first report submitted by the eligible 
hospital under this paragraph shall be for such 
changes since the first year in which the hos-
pital received payment under this section), in-
cluding— 
‘‘(i) changes in curricula, clinical edu-
cation experiences, and types of clinical 
education, and benefits that have resulted 
from such changes; and 
‘‘(ii) changes for purposes of meas-
uring and improving the quality and safety 
of patient care. 
‘‘(E) The numbers of advanced practice 
registered nurses who graduated from their pro-
gram at the end of such academic year and care 
for individuals within the borders of the service 
area of the hospital or within the borders of the 
State in which the hospital is located. 
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‘‘(F) The number of patients treated by 
advanced practice registered nurses under the 
program. 
‘‘(G) The number of visits by patients 
treated by such advanced practice registered 
nurses. 
‘‘(H) Of the number of advanced practice 
registered nurses who graduated from their pro-
gram at the end of such academic year, the 
number and percentage of such advanced prac-
tice registered nurses who entered practice at a 
health care facility— 
‘‘(i) primarily serving a health profes-
sional shortage area with a designation in 
effect under section 332 of the Public 
Health Service Act or a medically under-
served community (as defined in section 
799B of such Act); or 
‘‘(ii) located in a rural area (as de-
fined in section 1886(d)(2)(D)). 
‘‘(I) Other information as deemed appro-
priate by the Secretary. 
‘‘(3) REPORT TO CONGRESS.—Not later than 2 
years after the date of the enactment of this section, 
the Secretary shall submit to Congress a report— 
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‘‘(A) summarizing the information sub-
mitted in reports to the Secretary under para-
graph (2); 
‘‘(B) describing the results of the program 
carried out under this section; and 
‘‘(C) making recommendations for im-
provements to the program. 
‘‘(e) FUNDING.—For purposes of carrying the pro-
gram under this section, the Secretary shall provide for 
the transfer, from the Federal Hospital Insurance Trust 
Fund under section 1817 and the Federal Supplementary 
Medical Insurance Trust Fund under section 1841, in 
such proportion as the Secretary determines appropriate, 
of such sums as the Secretary determines necessary, to 
the Centers for Medicare & Medicaid Services Program 
Management Account. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) 
ADVANCED
PRACTICE
REGISTERED 
NURSE.—The term ‘advanced practice registered 
nurse’ includes the following: 
‘‘(A) A clinical nurse specialist (as defined 
in subsection (aa)(5) of section 1861). 
‘‘(B) A nurse practitioner (as defined in 
such subsection). 
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‘‘(C) A certified registered nurse anes-
thetist (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)(1)) with the eligible hospital participating 
in the program. Such settings include Federally 
qualified health centers, rural health clinics, nurse 
managed clinics, ambulatory practices (including re-
tail clinics), accountable care organizations, physi-
cian or practitioner offices, schools, nursing homes, 
hospice programs, long-term care facilities, home 
health agencies, 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 
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(b)(1)) with the eligible hospital participating in the 
program. 
‘‘(4) PROGRAM.—The term ‘program’ means 
the graduate nurse education program established 
under subsection (a). 
‘‘(5) ELIGIBLE HOSPITAL.—The term ‘eligible 
hospital’ means a hospital (as defined in subsection 
(e) of section 1861) or a critical access hospital (as 
defined in subsection (mm)(1) of such section) that 
has a written agreement in place with— 
‘‘(A) 1 or more applicable schools of nurs-
ing; and 
‘‘(B) 2 or more applicable non-hospital 
community-based care settings. 
‘‘(6) ELIGIBLE PARTNERS.—The term ‘eligible 
partners’ includes the following: 
‘‘(A) An applicable school of nursing. 
‘‘(B) A hospital or health system in a re-
gional area. 
‘‘(C) An applicable non-hospital commu-
nity-based care setting. 
‘‘(7) QUALIFIED CLINICAL EDUCATION.— 
‘‘(A) IN
GENERAL.—The term ‘qualified 
clinical education’ means education— 
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‘‘(i) that provides an advanced prac-
tice registered nurse with the clinical skills 
necessary to provide primary care, preven-
tive care, transitional care, acute care, 
chronic care management, and other serv-
ices appropriate for individuals entitled to, 
or enrolled for, benefits under part A, or 
enrolled under part B; and 
‘‘(ii) subject to subparagraph (B), at 
least half of which is provided in a non- 
hospital community-based care setting. 
‘‘(B) WAIVER OF REQUIREMENT HALF OF 
QUALIFIED EDUCATION BE PROVIDED IN NON- 
HOSPITAL COMMUNITY-BASED CARE SETTING IN 
CERTAIN AREAS.—The Secretary may waive the 
requirement under subparagraph (A)(ii) with 
respect to eligible hospitals located in rural or 
medically underserved areas.’’. 
Æ 
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