II 118th CONGRESS 1st Session S. 1586 IN THE SENATE OF THE UNITED STATES May 11, 2023 Ms. Stabenow (for herself, Mr. Casey , and Ms. Hassan ) 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 establish a national graduate nurse education program.

1. Short title This Act may be cited as the Educating Future Nurses Act . 2. National graduate nurse education program 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: 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 subsection (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 subparagraph (B), the costs described in this paragraph are the reasonable costs (as described in section 1861(v)) of each eligible hospital for the clinical education costs (as determined by the Secretary) that are attributable to providing advanced practice registered nurses with qualified clinical education. (B) Limitation With respect to a year, the amount reimbursed under subparagraph (A) may not exceed the amount of costs described in subparagraph (A) that are attributable to an increase in the number of advanced practice registered nurses enrolled in an accredited school of nursing that provides qualified clinical education during the year and for which the hospital is being reimbursed under the program, as compared to the average number of advanced practice registered nurses who graduated 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 (A) In general The Secretary shall establish regions for Graduate Nurse Education Hubs described in subsection (b) under the program 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 eligible partners An eligible hospital or eligible 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 supplement, not supplant, other Federal funds that have been made available in the year for advanced practice 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. (6) Administration Chapter 35 of title 44, United States Code, shall not apply to the implementation of this section. (b) Requirements No payment shall be made under this section to an eligible hospital unless such hospital meets the following requirements: (1) The hospital has in effect a written agreement 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 (iii) applicable non-hospital community-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 developed and approved by the hospital, participating 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 qualified 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 consideration 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 payment 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 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 eligible 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 Education 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 consumer price index for all urban consumers (all items; United States city average) from the last year of the Graduate Nurse Education Demonstration established under section 5509 for which such data is available to the June preceding such first year of the program under this section; and (B) for a subsequent year, the amount determined under this paragraph for the preceding year, increased or decreased by the percentage change in the consumer price index for all urban consumers (all items; United States 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 determines 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 subparagraph of such paragraph. (B) Notice and opportunity to provide missing information Before imposing a reduction under subparagraph (A) on the basis of a hospital's failure to provide information described in subparagraph (A)(ii), the Secretary shall provide notice to the hospital of such failure and the Secretary's intention to impose such reduction and shall provide the hospital with the opportunity to provide the required information within a period of 30 days beginning on the date of such notice. If the hospital provides such information within such period, no reduction shall be made under subparagraph (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 corresponding 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 education 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 Education (GNE) Hub. (C) The number of advanced practice registered nurse students receiving qualified clinical education through the eligible hospital under the program. (D) Any changes in qualified clinical education 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 hospital received payment under this section), including— (i) changes in curricula, clinical education experiences, and types of clinical education, and benefits that have resulted from such changes; and (ii) changes for purposes of measuring and improving the quality and safety of patient care. (E) The numbers of advanced practice registered nurses who graduated from their program 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. (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 program at the end of such academic year, the number and percentage of such advanced practice registered nurses who entered practice at a health care facility— (i) primarily serving a health professional shortage area with a designation in effect under section 332 of the Public Health Service Act or a medically underserved community (as defined in section 799B of such Act); or (ii) located in a rural area (as defined in section 1886(d)(2)(D)). (I) Other information as deemed appropriate 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— (A) summarizing the information submitted in reports to the Secretary under paragraph (2); (B) describing the results of the program carried out under this section; and (C) making recommendations for improvements to the program. (e) Funding For purposes of carrying the program 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). (C) A certified registered nurse anesthetist (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 entered into a written agreement (as described in subsection (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 retail clinics), accountable care organizations, physician 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 accredited 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 (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 nursing; 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 regional area. (C) An applicable non-hospital community-based care setting. (7) Qualified clinical education (A) In general The term qualified clinical education means education— (i) that provides an advanced practice registered nurse with the clinical skills necessary to provide primary care, preventive care, transitional care, acute care, chronic care management, and other services 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. .