II 115th CONGRESS 2d Session S. 2843 IN THE SENATE OF THE UNITED STATES May 15, 2018 Mr. Nelson (for himself and Mr. Heller ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to provide for the distribution of additional residency positions to help combat the opioid crisis.

1. Short title This Act may be cited as the Opioid Workforce Act of 2018 . 2. Distribution of additional residency positions to help combat opioid crisis (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 paragraphs (7) and (8) and inserting paragraphs (7), (8), and (9) ; (2) in paragraph (4)(H)(i), by striking paragraphs (7) and (8) and inserting paragraphs (7), (8), and (9) ; (3) in paragraph (7)(E), by inserting paragraph (9), after paragraph (8), ; and (4) by adding at the end the following new paragraph: (9) Distribution of additional residency positions to help combat opioid crisis (A) Additional residency positions For each of fiscal years 2019 through 2023 (and succeeding fiscal years if the Secretary determines that there are additional residency positions available to distribute under subparagraph (D)), the Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits a timely application 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. Except as provided in subparagraph (B)(iv) or (D), the aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to 500 in fiscal year 2019 and 500 over the period of fiscal years 2020 through 2023, distributed in accordance with the succeeding subparagraphs of this paragraph. (B) Distribution for fiscal year 2019 (i) In general For fiscal year 2019, the positions available for distribution with respect to the fiscal year as described in subparagraph (A) shall be distributed to hospitals that have existing established approved programs in addiction medicine, addiction psychiatry, or pain management as determined by the Secretary. (ii) Number of positions hospital eligible to receive Subject to clauses (iii) and (iv), the aggregate number of positions a hospital may receive under this subparagraph with respect to fiscal year 2019 is equal to the sum of the following: (I) The number of full-time-equivalent residents that will be training in addiction medicine, addiction psychiatry, or pain management as determined by the Secretary with respect to the fiscal year. (II) The associated number of residents training in a pre-requisite program, such as internal medicine, necessary for the number of full-time residents for the programs described in subclause (I). (iii) Additional positions for expansion of existing program If a hospital demonstrates to the Secretary that the hospital is planning to increase the number of full-time-equivalent residents in existing programs described in clause (i), the Secretary may increase the number of positions a hospital is eligible to receive under clause (ii) in order to accommodate that expansion, as determined by the Secretary. (iv) Considerations in distribution The Secretary shall distribute additional residency positions under this subparagraph based on— (I) in the case of positions made available under clause (ii), the demonstrated likelihood of the hospital filling such positions by July 1, 2019; and (II) in the case of positions made available under clause (iii), the demonstrated likelihood of the hospital filling such positions within the first three cost reporting periods beginning on or after July 1, 2019. (v) Limitation Notwithstanding clauses (ii) and (iv), an individual hospital may not receive more than 25 full-time-equivalent residency positions under this subparagraph. (vi) Clarification regarding availability of additional positions in subsequent fiscal years Nothing in this subparagraph shall preclude a hospital from receiving additional residency positions under subparagraph (C). (vii) Positions not distributed during the fiscal year If the number of resident full-time-equivalent positions distributed under this subparagraph is less than the aggregate number of positions available for distribution in the fiscal year (as described in subparagraph (A)), the difference between such number distributed and such number available for distribution shall be added to the aggregate number of positions available for distribution under subparagraph (C). (C) Distribution for fiscal years 2020 through 2023 (i) In general For the period of fiscal years 2020 through 2023, the positions available for distribution with respect to such period (as described in subparagraph (A), including after application of subparagraph (B)(vi)) shall be distributed to hospitals which demonstrate to the Secretary that the hospital— (I) will establish an approved program in addiction medicine, addiction psychiatry, or pain management; and (II) will use all of the additional positions made available under this subparagraph in such program or a prerequisite residency program for such program within the first four cost reporting periods after the increase would be effective. (ii) Requirements Subject to clause (iii), a hospital that receives an increase in the otherwise applicable resident limit under this subparagraph shall ensure, during the 5-year period beginning after the date of such increase, that the hospital uses the positions received under clauses (i)(I) and (i)(II) for the programs for which the positions were distributed, or similar programs (as determined by the Secretary). 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 the requirements 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 subparagraph; and (II) provide for the distribution of positions attributable to such reduction in accordance with the requirements of this paragraph. (iv) Limitation An individual hospital may not receive more than 25 full-time-equivalent residency positions under this subparagraph. (D) Distribution of remaining positions If the aggregate number of positions distributed under subparagraphs (B) and (C) during the period of fiscal years 2019 through 2023 is less than 1,000, the Secretary shall distribute the remaining residency positions in succeeding fiscal years according to criteria consistent with this paragraph until such time as the aggregate amount of positions distributed under this paragraph is equal to 1,000. (E) Notification 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 fiscal year of the increase. Such increase shall be effective for portions of cost reporting periods beginning on or after July 1 of that fiscal year. (F) Application of per resident amounts for primary care and non-primary care With respect to additional 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 non-primary care computed 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 aggregated pursuant to paragraph (4)(H) among members of the same affiliated group. (H) Definitions In this paragraph: (i) 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 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) . (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 redesignated by subparagraph (A), the following new clause: (xii) For discharges occurring on or after July 1, 2019, 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. .