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1 dent positions provided to the hospital
2 under this subparagraph. For pur-
3 poses of this subparagraph, the ‘base
4 level of primary care residents’ for a
5 hospital is the level of such residents
6 as of a base period (specified by the
7 Secretary), determined without regard
8 to whether such positions were in ex-
9 cess of the otherwise applicable resi-
10 dent limit for such period but taking
11 into account the application of sub-
12 clauses (II) and (III) of subparagraph
13 (A)(ii).
14 ‘‘(II) DEDICATED ASSIGNMENT

15 OF ADDITIONAL RESIDENT POSITIONS

16 TO PRIMARY CARE.—The hospital as-

17 signs all such additional resident posi-
18 tions for primary care residents.
19 ‘‘(III) ACCREDITATION.—The
20 hospital’s residency programs in pri-
21 mary care are fully accredited or, in
22 the case of a residency training pro-
23 gram not in operation as of the base
24 year, the hospital is actively applying
25 for such accreditation for the program

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1 for such additional resident positions
2 (as determined by the Secretary).
3 ‘‘(iii) CONSIDERATIONS IN REDIS-

4 TRIBUTION.—In determining for which

5 qualifying hospitals the increase in the oth-
6 erwise applicable resident limit is provided
7 under this subparagraph, the Secretary
8 shall take into account the demonstrated
9 likelihood of the hospital filling the posi-
10 tions within the first 3 cost reporting peri-
11 ods beginning on or after July 1, 2011,
12 made available under this subparagraph,
13 as determined by the Secretary.
14 ‘‘(iv) PRIORITY FOR CERTAIN HOS-

15 PITALS.—In determining for which quali-

16 fying hospitals the increase in the other-
17 wise applicable resident limit is provided
18 under this subparagraph, the Secretary
19 shall distribute the increase to qualifying
20 hospitals based on the following criteria:
21 ‘‘(I) The Secretary shall give
22 preference to hospitals that had a re-
23 duction in resident training positions
24 under subparagraph (A).

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1 ‘‘(II) The Secretary shall give
2 preference to hospitals with 3-year
3 primary care residency training pro-
4 grams, such as family practice and
5 general internal medicine.
6 ‘‘(III) The Secretary shall give
7 preference to hospitals insofar as they
8 have in effect formal arrangements
9 (as determined by the Secretary) that
10 place greater emphasis upon training
11 in Federally qualified health centers,
12 rural health clinics, and other nonpro-
13 vider settings, and to hospitals that
14 receive additional payments under
15 subsection (d)(5)(F) and emphasize
16 training in an outpatient department.
17 ‘‘(IV) The Secretary shall give
18 preference to hospitals with a number
19 of positions (as of July 1, 2009) in
20 excess of the otherwise applicable resi-
21 dent limit for such period.
22 ‘‘(V) The Secretary shall give
23 preference to hospitals that place
24 greater emphasis upon training in a
25 health professional shortage area (des-

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668
1 ignated under section 332 of the Pub-
2 lic Health Service Act) or a health
3 professional needs area (designated
4 under section 2211 of such Act).
5 ‘‘(VI) The Secretary shall give
6 preference to hospitals in States that
7 have low resident-to-population ratios
8 (including a greater preference for
9 those States with lower resident-to-
10 population ratios).
11 ‘‘(v) LIMITATION.—In no case shall
12 more than 20 full-time equivalent addi-
13 tional residency positions be made available
14 under this subparagraph with respect to
15 any hospital.
16 ‘‘(vi) APPLICATION OF PER RESIDENT

17 AMOUNTS FOR PRIMARY CARE.—With re-

18 spect to additional residency positions in a
19 hospital attributable to the increase pro-
20 vided under this subparagraph, the ap-
21 proved FTE resident amounts are deemed
22 to be equal to the hospital per resident
23 amounts for primary care and nonprimary
24 care computed under paragraph (2)(D) for
25 that hospital.

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669
1 ‘‘(vi) DISTRIBUTION.—The Secretary
2 shall distribute the increase in resident
3 training positions to qualifying hospitals
4 under this subparagraph not later than
5 July 1, 2011.
6 ‘‘(C) RESIDENT LEVEL AND LIMIT DE-

7 FINED.—In this paragraph:

8 ‘‘(i) The term ‘resident level’ has the
9 meaning given such term in paragraph
10 (7)(C)(i).
11 ‘‘(ii) The term ‘otherwise applicable
12 resident limit’ means, with respect to a
13 hospital, the limit otherwise applicable
14 under subparagraphs (F)(i) and (H) of
15 paragraph (4) on the resident level for the
16 hospital determined without regard to this
17 paragraph but taking into account para-
18 graph (7)(A).
19 ‘‘(D) MAINTENANCE OF PRIMARY CARE

20 RESIDENT LEVEL.—In carrying out this para-

21 graph, the Secretary shall require hospitals that
22 receive additional resident positions under sub-
23 paragraph (B)—
24 ‘‘(i) to maintain records, and periodi-
25 cally report to the Secretary, on the num-

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1 ber of primary care residents in its resi-
2 dency training programs; and
3 ‘‘(ii) as a condition of payment for a
4 cost reporting period under this subsection
5 for such positions, to maintain the level of
6 such positions at not less than the sum
7 of—
8 ‘‘(I) the base level of primary
9 care resident positions (as determined
10 under subparagraph (B)(ii)(I)) before
11 receiving such additional positions;
12 and
13 ‘‘(II) the number of such addi-
14 tional positions.’’.
15 (b) IME.—
16 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of
17 the Social Security Act (42 U.S.C.
18 1395ww(d)(5)(B)(v)), in the second sentence, is
19 amended—
20 (A) by striking ‘‘subsection (h)(7)’’ and in-
21 serting ‘‘subsections (h)(7) and (h)(8)’’; and
22 (B) by striking ‘‘it applies’’ and inserting
23 ‘‘they apply’’.
24 (2) CONFORMING PROVISION.—Section

25 1886(d)(5)(B) of the Social Security Act (42 U.S.C.

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1 1395ww(d)(5)(B)) is amended by adding at the end
2 the following clause:
3 ‘‘(x) For discharges occurring on or after July 1,
4 2011, insofar as an additional payment amount under this
5 subparagraph is attributable to resident positions distrib-
6 uted to a hospital under subsection (h)(8)(B), the indirect
7 teaching adjustment factor shall be computed in the same
8 manner as provided under clause (ii) with respect to such
9 resident positions.’’.
10 (c) CONFORMING AMENDMENT.—Section 422(b)(2)
11 of the Medicare Prescription Drug, Improvement, and
12 Modernization Act of 2003 (Public Law 108–173) is
13 amended by striking ‘‘section 1886(h)(7)’’ and all that fol-
14 lows and inserting ‘‘paragraphs (7) and (8) of subsection
15 (h) of section 1886 of the Social Security Act’’.
16 SEC. 1502. INCREASING TRAINING IN NONPROVIDER SET-

17 TINGS.

18 (a) DIRECT GME.—Section 1886(h)(4)(E) of the So-

19 cial Security Act (42 U.S.C. 1395ww(h)) is amended—
20 (1) by designating the first sentence as a clause
21 (i) with the heading ‘‘IN GENERAL’’ and appropriate
22 indentation;
23 (2) by striking ‘‘shall be counted and that all
24 the time’’ and inserting ‘‘shall be counted and
25 that—

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1 ‘‘(I) effective for cost reporting
2 periods beginning before July 1, 2009,
3 all the time’’;
4 (3) in subclause (I), as inserted by paragraph
5 (1), by striking the period at the end and inserting
6 ‘‘; and’’; and
7 (A) by inserting after subclause (I), as so
8 inserted, the following:
9 ‘‘(II) effective for cost reporting
10 periods beginning on or after July 1,
11 2009, all the time so spent by a resi-
12 dent shall be counted towards the de-
13 termination of full-time equivalency,
14 without regard to the setting in which
15 the activities are performed, if the
16 hospital incurs the costs of the sti-
17 pends and fringe benefits of the resi-
18 dent during the time the resident
19 spends in that setting.
20 Any hospital claiming under this subpara-
21 graph for time spent in a nonprovider set-
22 ting shall maintain and make available to
23 the Secretary records regarding the
24 amount of such time and such amount in
25 comparison with amounts of such time in

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