prove, effective for portions of cost reporting 
periods occurring on or after July 1 of the fis-
cal year of the increase. The aggregate number 
of additional full-time equivalent resident posi-
tions available for distribution under this para-
graph shall be equal to 1,000, distributed in ac-
cordance with the succeeding subparagraphs of 
this paragraph. 
‘‘(B) DISTRIBUTION
FOR
FISCAL
YEAR 
2022.— 
‘‘(i) IN
GENERAL.—For fiscal year 
2022, 500 of the positions described in 
subparagraph (A) may only be distributed 
to hospitals that have established (as of 
the date of the enactment of this para-
graph) approved programs in addiction 
medicine, addiction psychiatry, or pain 
medicine, as determined by the Secretary. 
‘‘(ii) CONSIDERATIONS IN DISTRIBU-
TION.—The Secretary shall distribute addi-
tional residency positions under this sub-
paragraph based on the demonstrated like-
lihood (as determined by the Secretary) of 
the hospital filling such positions. 
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‘‘(iii) 
REQUIREMENTS.—A 
hospital 
that receives an increase in the otherwise 
applicable resident limit under this sub-
paragraph shall ensure, during the 5-year 
period beginning after the date of such in-
crease, that the hospital uses the positions 
made available under this subparagraph 
for a program described in clause (i) or a 
program that is a prerequisite (as deter-
mined by the Secretary) for such a pro-
gram so described, such as internal medi-
cine. The Secretary may determine wheth-
er a hospital has met the requirements 
under this clause during such 5-year pe-
riod in such manner and at such time as 
the Secretary determines appropriate, in-
cluding at the end of such 5-year period. 
‘‘(iv) REDISTRIBUTION OF POSITIONS 
IF HOSPITAL NO LONGER MEETS CERTAIN 
REQUIREMENTS.—In the case in which the 
Secretary determines that a hospital de-
scribed in clause (iii) does not meet the re-
quirements of such clause, the Secretary 
shall— 
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‘‘(I) reduce the otherwise applica-
ble resident limit of the hospital by 
the amount by which such limit was 
increased under this subparagraph; 
and 
‘‘(II) provide for the distribution 
of positions attributable to such re-
duction in accordance with the re-
quirements of this paragraph. 
‘‘(C) DISTRIBUTION
FOR
FISCAL
YEARS 
2023 THROUGH 2026.— 
‘‘(i) IN GENERAL.—For the period of 
fiscal years 2023 through 2026, 500 of the 
positions available for distribution under 
subparagraph (A) shall be distributed to 
hospitals which demonstrate to the Sec-
retary that the hospital has established or 
will establish an approved residency train-
ing program in addiction medicine, addic-
tion psychiatry, or pain medicine. 
‘‘(ii) CONSIDERATIONS IN DISTRIBU-
TION.—The Secretary shall distribute addi-
tional residency positions under this sub-
paragraph based on the demonstrated like-
lihood, as determined by the Secretary, of 
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the hospital filling such positions within 
the first 4 training years (as specified by 
the Secretary) after the increase would be 
effective. 
‘‘(iii) 
REQUIREMENTS.—A 
hospital 
that receives an increase in the otherwise 
applicable resident limit under this sub-
paragraph shall ensure, during the 5-year 
period beginning after the date of such in-
crease, that the hospital uses the positions 
made available under this subparagraph 
for a program described in clause (i) or a 
program that is a prerequisite (as deter-
mined by the Secretary) for such a pro-
gram so described, such as internal medi-
cine. The Secretary may determine wheth-
er a hospital has met the requirements 
under this clause during such 5-year pe-
riod in such manner and at such time as 
the Secretary determines appropriate, in-
cluding at the end of such 5-year period. 
‘‘(iv) REDISTRIBUTION OF POSITIONS 
IF HOSPITAL NO LONGER MEETS CERTAIN 
REQUIREMENTS.—In the case where the 
Secretary determines that a hospital de-
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scribed in clause (iii) does not meet the re-
quirements of such clause, the Secretary 
shall— 
‘‘(I) reduce the otherwise applica-
ble resident limit of the hospital by 
the amount by which such limit was 
increased under this subparagraph; 
and 
‘‘(II) provide for the distribution 
of positions attributable to such re-
duction in accordance with the re-
quirements of this paragraph. 
‘‘(D) DISTRIBUTION OF REMAINING POSI-
TIONS.—If the aggregate number of positions 
distributed under subparagraphs (B) and (C) 
during the period of fiscal years 2022 through 
2026 is less than 500, the Secretary shall dis-
tribute the remaining residency positions in suc-
ceeding fiscal years according to criteria con-
sistent with this paragraph until such time as 
the aggregate amount of positions distributed 
under this paragraph is equal to 500. 
‘‘(E) LIMITATION.—An individual hospital 
may not receive more than 25 full-time-equiva-
lent residency positions under this paragraph. 
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‘‘(F) NOTIFICATION.—The Secretary shall 
notify hospitals of the number of positions dis-
tributed to the hospital under this paragraph as 
a result of an increase in the otherwise applica-
ble resident limit by January 1 of the fiscal 
year of the increase. Such increase shall be ef-
fective for portions of cost reporting periods be-
ginning on or after July 1 of that fiscal year. 
‘‘(G) 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. 
‘‘(H) 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-
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gated pursuant to paragraph (4)(H) among 
members of the same affiliated group. 
‘‘(I) CLARIFICATION.—Chapter 35 of title 
44, United States Code, shall not apply to im-
plementation of this paragraph. 
‘‘(J) DEFINITIONS.—In this paragraph: 
‘‘(i) OTHERWISE
APPLICABLE
RESI-
DENT LIMIT.—The term ‘otherwise appli-
cable resident limit’ means, with respect to 
a hospital, the limit otherwise applicable 
under paragraph (4)(F)(i) on the resident 
level for the hospital determined without 
regard to this paragraph but taking into 
account paragraphs (7)(A), (7)(B), (8)(A), 
and (8)(B). 
‘‘(ii) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i).’’. 
(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 third sentence, is 
amended by striking ‘‘and (h)(8)’’ and inserting 
‘‘(h)(8), and (h)(9)’’. 
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(2) 
CONFORMING
PROVISION.—Section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) is amended— 
(A) by redesignating clause (x), as added 
by section 5505(b) of the Patient Protection 
and Affordable Care Act (Public Law 111– 
148), as clause (xi) and moving such clause 4 
ems to the left; and 
(B) by adding after clause (xi), as redesig-
nated by subparagraph (A), the following new 
clause: 
‘‘(xii) For discharges occurring on or after July 
1, 2022, insofar as an additional payment amount 
under this subparagraph is attributable to resident 
positions distributed to a hospital under subsection 
(h)(9), the indirect teaching adjustment factor shall 
be computed in the same manner as provided under 
clause (ii) with respect to such resident positions.’’. 
Æ 
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