,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #abja  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,m>* #ad1 #bjac ,mr4  
,s*ock 7= himself & ,ms4 ,s*w>tz7       
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,ways & ,means1 & 9    
addition to ! ,committee on ,en]gy &    
,comm]ce1 = a p]iod to be subsequ5tly   
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d title ,,xviii ( !     
,social ,security ,act to provide = !   
di/ribution ( additional resid5cy       
positions1 & = o!r purposes4  #a4 ,%ort 
title2 table ( cont5ts  7a7 ,%ort title 
,?is ,act may be cit$ z ! ,tra9+        
,tomorr['s ,doctors ,today ,act4  7b7   
,table ( cont5ts ,! table ( cont5ts =   
?is ,act is z foll[s3  ,sec4 #a4 ,%ort  
title2 table ( cont5ts4 ,sec4 #b4       
,di/ribution ( additional resid5cy      
positions4 ,sec4 #c4 ,additional rules  
relat+ to application ( #c-ye> roll+    
av]age = r$i/ribut$ resid5cy positions4 

,sec4 #d4 ,rules = det]m9+ full-"t      
equival5t resid5ts4 ,sec4 #e4 ,treatm5t 
( hospitals ) rotat+ resid5ts4 ,sec4 #f4
 ,aggregation rules relat+ to apply+    
limitation on numb] ( resid5ts4 ,sec4   
#g4 ,p]iod ( bo>d eligibility = resid5ts
 :o *ange programs4 ,sec4 #h4 ,m$ic>e   
indirect m$ical education p]=mance      
adju/m5t4 ,sec4 #i4 ,increas+ graduate  
m$ical education transp>5cy4 ,sec4 #aj4 
,,gao /udies & reports4  #b4            
,di/ribution ( additional resid5cy      
positions  7a7 ,,dgme ,section #ahhf7;h7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #acieww7h77 is am5d$--  7#a7 9
 p>agraph 7#d77;,f77i71 by /rik+        
p>agraphs 7#g7 & 7#h7 & ins]t+ p>agraphs
 7#g71 7#h71 & 7#i72  7#b7 9 p>agraph   
7#d77;,h77i71 by /rik+ p>agraphs 7#g7 & 
7#h7 & ins]t+ p>agraphs 7#g71 7#h71 &   
7#i72  7#c7 9 p>agraph 7#g77;,e71 by    
ins]t+ p>agraph 7#i71 aft] p>agraph     
7#h712 &  7#d7 by add+ at ! end ! foll[+
 new p>agraph3  7#i7 ,di/ribution (     
additional resid5cy positions  7,a7     

,additional resid5cy positions  7i7 ,9  
g5]al ,= ea* ( fiscal ye>s #bjad ?r\gh  
#bjah 7& succe$+ fiscal ye>s if !       
,secret>y det]m9es t !re are additional 
resid5cy positions available to         
di/ribute "u clause 7iv77,,ii771 !      
,secret>y %all1 subject to clause 7ii7 &
 subp>agraph 7,d71 increase ! o!rwise   
applicable resid5t limit = ea* qualify+ 
hospital t submits a timely application 
"u ?is subp>agraph by su* numb] z !     
,secret>y may approve = portions ( co/  
report+ p]iods occurr+ on or aft] ,july 
#a ( ! fiscal ye> ( ! increase4  7ii7   
,numb] available = di/ribution ,= ea*   
su* fiscal ye>1 ! ,secret>y %all det]m9e
 ! total numb] ( additional resid5cy    
positions available = di/ribution "u    
clause 7i7 9 accordance ) ! foll[+3     
7,i7 ,allocation to hospitals already   
op]at+ ov] resid5t limit ,"o-?ird ( su* 
numb] %all be available = di/ribution   
only to hospitals describ$ 9 subp>agraph
 7,b74  7,,ii7 ,aggregate limitation    
,except z provid$ 9 clause 7iv77,i71 !  

aggregate numb] ( increases 9 ! o!rwise 
applicable resid5t limit "u ?is         
subp>agraph %all be equal to #c1jjj 9   
ea* su* ye>4  7iii7 ,process = di/ribut+
 positions  7,i7 ,r\nds ( applications  
,! ,secret>y %all initiate #e sep>ate   
r\nds ( applications = an increase "u   
clause 7i71 #a r\nd ) respect to ea* (  
fiscal ye>s #bjad ?r\gh #bjah4  7,,ii7  
,numb] available ,9 ea* ( su* r\nds1 !  
aggregate numb] ( positions available = 
di/ribution 9 ! fiscal ye> "u clause    
7ii7 %all be di/ribut$1 plus any        
additional positions available "u clause
 7iv74  7,,iii7 ,tim+ ,! ,secret>y %all 
notify hospitals ( ! numb] ( positions  
di/ribut$ to ! hospital "u ?is p>agraph 
z a result ( an increase 9 ! o!rwise    
applicable resid5t limit by ,janu>y #a (
 ! fiscal ye> ( ! increase4 ,su*        
increase %all be effective = portions ( 
co/ report+ p]iods beg9n+ on or aft]    
,july #a ( t fiscal ye>4  7iv7          
,positions n di/ribut$ dur+ ! fiscal ye>
  7,i7 ,9 g5]al ,if ! numb] ( resid5t   

full-"t equival5t positions di/ribut$ "u
 ?is p>agraph 9 a fiscal ye> is less ?an
 ! aggregate numb] ( positions available
 = di/ribution 9 ! fiscal ye> 7z        
describ$ 9 clause 7ii71 includ+ aft]    
application ( ?is subclause71 ! diff]5ce
 betwe5 su* numb] di/ribut$ & su* numb] 
available = di/ribution %all be add$ to 
! aggregate numb] ( positions available 
= di/ribution 9 ! foll[+ fiscal ye>4    
7,,ii7 ,exception if positions n        
di/ribut$ by end ( fiscal ye> #bjah ,if 
! aggregate numb] ( positions di/ribut$ 
"u ?is p>agraph dur+ ! #e-ye> p]iod (   
fiscal ye>s #bjad ?r\gh #bjah is less   
?an #ae1jjj1 ! ,secret>y %all1 9        
accordance ) ! provisions ( clause 7ii7 
& subp>agraph 7,d7 & ! consid]ations &  
priority describ$ 9 subp>agraph 7,c71   
conduct an application & di/ribution    
process 9 ea* subsequ5t fiscal ye> until
 su* "t z ! aggregate am\nt ( positions 
di/ribut$ "u ?is p>agraph is equal to   
#ae1jjj4  7,b7 ,allocation ( di/ribution
 = positions to hospitals already op]at+

 ov] resid5t limit  7i7 ,9 g5]al        
,subject to clauses 7ii7 & 7iii71 9 !   
case ( a hospital 9 :i* ! ref]5ce       
resid5t level ( ! hospital 7z specifi$ 9
 subp>agraph 7,g77iii77 is great] ?an ! 
o!rwise applicable resid5t limit1 !     
increase 9 ! o!rwise applicable resid5t 
limit "u subp>agraph 7,a7 = a fiscal ye>
 describ$ 9 su* subp>agraph %all be an  
am\nt equal to ! product ( ! total numb]
 ( additional resid5cy positions        
available = di/ribution "u subp>agraph  
7,a77ii77,i7 = su* fiscal ye> & !       
quoti5t (--  7,i7 ! numb] ( resid5t     
positions by :i* ! ref]5ce resid5t level
 ( ! hospital exce$s ! o!rwise          
applicable resid5t limit = ! hospital2 &
  7,,ii7 ! numb] ( resid5t positions by 
:i* ! ref]5ce resid5t level ( all su*   
hospitals ) respect to :i* an           
application is approv$ "u ?is p>agraph  
exce$s ! o!rwise applicable resid5t     
limit = su* hospitals4  7ii7            
,requirem5ts ,a hospital describ$ 9     
clause 7i7--  7,i7 is n eligible = an   

increase 9 ! o!rwise applicable resid5t 
limit "u ?is subp>agraph unless ! am\nt 
by :i* ! ref]5ce resid5t level ( !      
hospital exce$s ! o!rwise applicable    
resid5t limit is n less ?an #aj & !     
hospital tra9s at lea/ #cj p]c5t ( !    
full-"t equival5t resid5ts ( ! hospital 
9 prim>y c>e & g5]al surg]y 7z ( ! date 
( enactm5t ( ?is p>agraph72 &  7,,ii7   
%all cont9ue to tra9 at lea/ #cj p]c5t (
 ! full-"t equival5t resid5ts ( !       
hospital 9 prim>y c>e & g5]al surg]y = !
 #e-ye> p]iod beg9n+ on su* date4  ,9 ! 
case :]e ! ,secret>y det]m9es t a       
hospital describ$ 9 clause 7i7 no long] 
meets ! requirem5t ( subclause 7,,ii71 !
 ,secret>y may r$uce ! o!rwise          
applicable resid5t limit ( ! hospital by
 ! am\nt by :i* su* limit 0 increas$ "u 
?is subp>agraph4  7iii7 ,cl>ification   
reg>d+ eligibility = o!r additional     
resid5cy positions ,no?+ 9 ?is          
subp>agraph %all be con/ru$ z prev5t+ a 
hospital describ$ 9 clause 7i7 f apply+ 
= & receiv+ additional resid5cy         

positions "u ?is p>agraph t are n res]v$
 = di/ribution "u ?is subp>agraph4  7,c7
 ,di/ribution ( o!r positions ,=        
purposes ( det]m9+ an increase 9 !      
o!rwise applicable resid5t limit "u     
subp>agraph 7,a7 7o!r ?an su* an        
increase describ$ 9 subp>agraph 7,b771 !
 foll[+ %all apply3  7i7 ,consid]ations 
9 di/ribution ,9 det]m9+ = :i* hospitals
 su* an increase is provid$ "u          
subp>agraph 7,a71 ! ,secret>y %all take 
into acc\nt ! demon/rat$ likelihood ( ! 
hospital fill+ ! positions made         
available "u ?is p>agraph )9 ! fir/ #e  
co/ report+ p]iods beg9n+ aft] ! date ! 
increase w\ld be effective1 z det]m9$ by
 ! ,secret>y4  7ii7 ,priority = c]ta9   
hospitals ,subject to clause 7iii71 9   
det]m9+ = :i* hospitals su* an increase 
is provid$1 ! ,secret>y %all di/ribute !
 increase 9 ! foll[+ priority ord]3     
7,i7 ,fir/1 to hospitals ) approv$      
m$ical resid5cy tra9+ programs affiliat$
 ) m$ical s*ools t h at lea/ #dj p]c5t (
 graduates mat*$ 9 prim>y c>e resid5cy  

program 9 ! #e ye>s prior4  7,,ii7      
,second1 to hospitals 9 ,/ates ) 7aa7   
new m$ical s*ools t receiv$ ,c&idate    
,s*ool /atus f ! ,liaison ,committee on 
,m$ical ,education or t receiv$         
,pre-,accr$itation /atus f ! ,am]ican   
,o/eopa?ic ,association ,commission on  
,o/eopa?ic ,college ,accr$itation on or 
aft] ,janu>y #a1 #bjjj1 & t h a*iev$ or 
cont9ue to progress t[>d ,full          
,accr$itation /atus 7z su* t]m is def9$ 
by ! ,liaison ,committee on ,m$ical     
,education7 or t[>d ,accr$itation /atus 
7z su* t]m is def9$ by ! ,am]ican       
,o/eopa?ic ,association ,commission on  
,o/eopa?ic ,college ,accr$itation71 or  
7bb7 additional locations & bran*       
campuses e/abli%$ on or aft] ,janu>y #a1
 #bjjj1 by m$ical s*ools ) ,full        
,accr$itation /atus 7z su* t]m is def9$ 
by ! ,liaison ,committee on ,m$ical     
,education7 or ,accr$itation /atus 7z   
su* t]m is def9$ by ! ,am]ican          
,o/eopa?ic ,association ,commission on  
,o/eopa?ic ,college ,accr$itation74     

7,,iii7 ,?ird1 to hospitals t are       
eligible = inc5tive paym5ts "u section  
#ahhf7n7 or #aijc7t7 z ( ! date !       
hospital submits an application = su*   
increase "u subp>agraph 7,a74  7,,iv7   
,f\r?1 to all o!r hospitals4  7iii7     
,di/ribution to hospitals 9 high]       
priority gr\p prior to di/ribution 9 l[]
 priority gr\ps ,! ,secret>y may only   
di/ribute su* an increase to a l[]      
priority gr\p "u clause 7ii7 if all     
qualify+ hospitals 9 ! high] priority   
gr\p or gr\ps h receiv$ ! maximum numb] 
( increases "u su* subp>agraph t !      
hospital is eligible = "u ?is p>agraph =
 ! fiscal ye>4  7iv7 ,requirem5ts = use 
( additional positions  7,i7 ,9 g5]al   
,subject to subclause 7,,ii71 a hospital
 t receives su* an increase %all ensure1
 dur+ ! #e-ye> p]iod beg9n+ on !        
effective date ( su* increase1 t--  7aa7
 n less ?an #ej p]c5t ( ! positions     
attributable to su* increase t are us$ 9
 a giv5 ye> dur+ su* #e-ye> p]iod are   
us$ to tra9 full-"t equival5t resid5ts 9

 a %ortage specialty resid5cy program 7z
 def9$ 9 subp>agraph 7,g77v771 z det]m9$
 by ! ,secret>y at ! end ( su* #e-ye>   
p]iod2  7bb7 ! total numb] ( full-"t    
equival5t resid5ts1 exclud+ any         
additional positions attributable to su*
 increase1 is n less ?an ! av]age numb] 
( full-"t equival5t resid5ts dur+ ! #c  
mo/ rec5t co/ report+ p]iods end+ on or 
be=e ! effective date ( su* increase2 & 
7cc7 ! ratio ( full-"t equival5t        
resid5ts 9 a %ortage specialty resid5cy 
program 7z s def9$7 is n less ?an !     
av]age ratio ( full-"t equival5t        
resid5ts 9 su* a program dur+ ! #c mo/  
rec5t co/ report+ p]iods end+ on or be=e
 ! effective date ( su* increase4       
7,,ii7 ,r$i/ribution ( positions if     
hospital no long] meets c]ta9           
requirem5ts ,) respect to ea* fiscal ye>
 describ$ 9 subp>agraph 7,a71 !         
,secret>y %all det]m9e :e!r or n a      
hospital describ$ 9 subclause 7,i7 meets
 ! requirem5ts ( su* subclause4 ,9 !    
case t ! ,secret>y det]m9es t su* a     

hospital does n meet su* requirem5ts1 ! 
,secret>y %all--  7aa7 r$uce ! o!rwise  
applicable resid5t limit ( ! hospital by
 ! am\nt by :i* su* limit 0 increas$ "u 
?is p>agraph2 &  7bb7 provide = !       
di/ribution ( positions attributable to 
su* r$uction 9 accordance ) !           
requirem5ts ( ?is p>agraph4  7,d7       
,limitation ,a hospital may n receive m 
?an #ge full-"t equival5t additional    
resid5cy positions "u ?is p>agraph = any
 fiscal ye>4  7,e7 ,application ( p]    
resid5t am\nts = prim>y c>e & nonprim>y 
c>e ,) respect to additional resid5cy   
positions 9 a hospital attributable to !
 increase provid$ "u ?is p>agraph1 !    
approv$ ,,fte p] resid5t am\nts are     
deem$ to be equal to ! hospital p]      
resid5t am\nts = prim>y c>e & nonprim>y 
c>e comput$ "u p>agraph 7#b77;,d7 = t   
hospital4  7,f7 ,p]mitt+ facilities to  
apply aggregation rules ,! ,secret>y    
%all p]mit hospitals receiv+ additional 
resid5cy positions attributable to !    
increase provid$ "u ?is p>agraph to1    

beg9n+ 9 ! fif? ye> aft] ! effective    
date ( su* increase1 apply su* positions
 to ! limitation am\nt "u p>agraph      
7#d77;,f7 t may be aggregat$ pursuant to
 p>agraph 7#d77;,h7 among memb]s ( !    
same affiliat$ gr\p4  7,g7 ,def9itions  
,9 ?is p>agraph3  7i7 ,o!rwise          
applicable resid5t limit ,! t]m o!rwise 
applicable resid5t limit means1 )       
respect to a hospital1 ! limit o!rwise  
applicable "u subp>agraphs 7,f77i7 &    
7,h7 ( p>agraph 7#d7 on ! resid5t level 
= ! hospital det]m9$ )\t reg>d to ?is   
p>agraph b tak+ into acc\nt p>agraphs   
7#g77;,a71 7#g77;,b71 7#h77;,a71 &      
7#h77;,b74  7ii7 ,prim>y c>e ,! t]m     
prim>y c>e means family m$ic9e1 g5]al   
int]nal m$ic9e1 g5]al p$iatrics1        
g]iatrics1 prev5tive m$ic9e1 ob/etrics &
 gynecology1 g5]al surg]y1 & psy*iatry4 
7iii7 ,ref]5ce resid5t level ,except z  
o!rwise provid$ 9 subclause 7,,ii71 !   
t]m ref]5ce resid5t level means1 )      
respect to a hospital1 ! resid5t level =
 ! mo/ rec5t co/ report+ p]iod ( !      

hospital end+ on or be=e ! date (       
enactm5t ( ?is p>agraph1 = :i* a co/    
report has be5 settl$ 7or1 if n1        
submitt$ 7subject to audit771 z det]m9$ 
by ! ,secret>y4  7iv7 ,resid5t level ,! 
t]m resid5t level has ! mean+ giv5 su*  
t]m 9 p>agraph 7#g77;,c77i74  7v7       
,%ortage specialty resid5cy program ,!  
t]m %ortage specialty resid5cy program  
means ! foll[+3  7,i7 ,prior to report  
on %ortage specialties ,prior to ! date 
on :i* ! report is submitt$ "u section  
#aj7;a7 ( ! ,tra9+ ,tomorr['s ,doctors  
,today ,act1 any approv$ resid5cy tra9+ 
program 9 a specialty id5tifi$ 9 !      
report entitl$ ,! ,physician ,work=ce3  
,projections & ,rese>* into ,curr5t     
,issues ,affect+ ,supply & ,dem&1 issu$ 
9 ,decemb] #bjjh by ! ,heal? ,res\rces &
 ,s]vices ,adm9i/ration1 z a specialty  
^: basel9e physician requirem5ts        
projections exce$ ! project$ supply (   
total active physicians = ! p]iod (     
#bjje ?r\gh #bjbj4  7,,ii7 ,aft] report 
on %ortage specialities ,on or aft] !   

date on :i* ! report is submitt$ "u su* 
section #e1 any approv$ resid5cy tra9+  
program 9 a physician specialty id5tifi$
 9 su* report z a specialty = :i* !re is
 a %ortage4  4  7b7 ,,ime ,section      
#ahhf7;d77#e77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieww7d77#e77;,b77 is am5d$--  7#a7 9 
clause 7v71 9 ! second s5t5ce1 by /rik+ 
subsections 7h77#g7 & 7h77#h7 & ins]t+  
subsections 7h77#g71 7h77#h71 & 7h77#i72
  7#b7 by r$esignat+ clause 7x71 z add$ 
by section #eeje7;b7 ( ! ,pati5t        
,protection & ,af=dable ,c>e ,act       
7,public ,law #aaa-adh71 z clause 7xi7 &
 mov+ su* clause #d ems to ! left2 &    
7#c7 by add+ aft] clause 7xi71 z        
r$esignat$ by subp>agraph 7,a71 ! foll[+
 new clause3  7xii7 ,= dis*>ges occurr+ 
on or aft] ,july #a1 #bjad1 ins(> z an  
additional paym5t am\nt "u ?is          
subp>agraph is attributable to resid5t  
positions di/ribut$ to a hospital "u    
subsection 7h77#i71 ! indirect tea*+    
adju/m5t factor %all be comput$ 9 ! same

 mann] z provid$ "u clause 7ii7 )       
respect to su* resid5t positions4  4    
#c4 ,additional rules relat+ to         
application ( #c-ye> roll+ av]age =     
r$i/ribut$ resid5cy positions  7a7      
,elim9ation ( #c-,ye> roll+ av]age      
relat+ to r$i/ributions aft] a hospital 
closes & "u ,,ppaca r$i/ributions  7#a7 
,,dgme  7,a7 ,r$i/ribution ( resid5cy   
slots aft] a hospital closes  7i7 ,9    
g5]al ,section #ahhf7;h77#d77;,h77vi7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acieww7h77#d77;,h77vi77 is am5d$ by    
add+ at ! end ! foll[+ new subclause3   
7,,vi7 ,?ree-ye> roll+ av]age           
inapplicable ,9 apply+ subp>agraph 7,g71
 9 ! case ( additional resid5cy         
positions 9 a hospital attributable to !
 increase 9 ! o!rwise applicable resid5t
 limit provid$ "u ?is p>agraph pursuant 
to ?is clause1 ! ref]5ce to ! av]age ( !
 actual full-"t equival5t resid5t c\nts 
= ! co/ report+ p]iod & ! prec$+ two co/
 report+ p]iods %all be deem$ to be a   
ref]5ce to ! actual full-"t equival5t   

resid5ts c\nt = ! co/ report+ p]iod4  4 
7ii7 ,effective date ,! am5dm5t made by 
clause 7i7 %all apply ) respect to      
hospitals ) an approv$ m$ical resid5cy  
program t closes on or aft] ,m>* #bc1   
#bjjh4  7,b7 ,di/ribution ( additional  
resid5cy slots "u ,,ppaca  7i7 ,9 g5]al 
,section #ahhf7;h77#h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieww7h77#h77 is am5d$ by add+ at !   
end ! foll[+ new subp>agraph3  7,j7     
,?ree-ye> roll+ av]age inapplicable ,9  
apply+ p>agraph 7#d77;,g71 9 ! case (   
additional resid5cy positions 9 a       
hospital attributable to ! increase 9 ! 
o!rwise applicable resid5t limit provid$
 "u ?is p>agraph1 ! ref]5ce to ! av]age 
( ! actual full-"t equival5t resid5t    
c\nts = ! co/ report+ p]iod & ! prec$+  
two co/ report+ p]iods %all be deem$ to 
be a ref]5ce to ! actual full-"t        
equival5t resid5ts c\nt = ! co/ report+ 
p]iod4  4  7ii7 ,effective date ,!      
am5dm5t made by clause 7i7 %all apply ) 
respect to co/ report+ p]iods occurr+ on

 or aft] ,july #a1 #bjaa4  7#b7 #c-ye>  
roll+ av]age & ,int]n & ,resid5t ,b$    
ratio cap inapplicable "u ,,ime  7,a7 ,9
 g5]al ,section #ahhf7;d77#e77;,b7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7d77#e77;,b771 z am5d$ by section
 #b7;b71 is fur!r am5d$--  7i7 9        
subclause 7,i7 ( clause 7xi71 z         
r$esignat$ by section #b7;b77#b71 by    
/rik+ ,! provisions & ins]t+ ,subject to
 clauses 7xiii7 & 7xiv72 &  7ii7 by add+
 at ! end ! foll[+ new clauses3  7xiii7 
,9 ! case ( additional resid5cy         
positions 9 a hospital attributable to !
 increase 9 ! o!rwise applicable resid5t
 limit provid$ "u subsection            
7h77#d77;,h77vi7 or 7h77#h71 !          
provisions ( clause 7vi77,,ii7 %all be  
appli$ be deem+ ! ref]5ce to ! av]age ( 
! actual full-"t equival5t resid5t c\nt 
= ! co/ report+ p]iod & ! prec$+ two co/
 report+ p]iods to be a ref]5ce to !    
actual full-"t equival5t resid5t c\nt = 
! co/ report+ p]iod4  7xiv7 ,9 ! case ( 
additional resid5cy positions 9 a       

hospital attributable to ! increase 9 ! 
o!rwise applicable resid5t limit provid$
 "u subsection 7h77#d77;,h77vi7 or      
7h77#h71 ! ratio ( ! hospital's full-"t 
equival5t int]ns & resid5ts to b$s %all 
be equal to ! ratio = ! hospital's      
curr5t co/ report+ p]iod4  4  7,b7      
,effective date ,! am5dm5ts made by     
subp>agraph 7,a7 %all apply--  7i7 to ! 
ext5t su* am5dm5ts relate to section    
#ahhf7;h77#d77;,h77vi7 ( ! ,social      
,security ,act1 z if includ$ 9 !        
enactm5t ( section #eejf ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act2 &    
7ii7 to ! ext5t su* am5dm5ts relate to  
section #ahhf7;h77#h7 ( ! ,social       
,security ,act1 z if includ$ 9 !        
enactm5t ( section #eejc ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act4  7b7 
,elim9ation ( #c-,ye> ,roll+ ,av]age &  
,int]n & ,resid5t ,b$ ,ratio ,cap beg9n+
 9 #bjac  7#a7 ,,dgme ,section          
#ahhf7;h77#d77;,g7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieww7h77#d77;,g77 is am5d$--  7,a7 9 

clause 7i71 by ins]t+ & be=e ,decemb]   
#ca1 #bjab1 aft] ,octob] #a1 #aiig12 &  
7,b7 by add+ at ! end ! foll[+ new      
clause3  7iv7 ,curr5t ye> c\nt us$ to   
det]m9e full-"t equival5t resid5t c\nt  
,= co/ report+ p]iods beg9n+ on or aft] 
,decemb] #ca1 #bjab1 subject to ! limit 
describ$ 9 subp>agraph 7,f71 ! total    
numb] ( full-"t equival5t resid5ts =    
det]m9+ a hospital's graduate m$ical    
education paym5t %all equal ! actual    
full-"t equival5t resid5ts c\nt = !     
hospital's co/ report+ p]iod4  4  7#b7  
,,ime ,section #ahhf7;d77#e77;,b7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7d77#e77;,b771 z am5d$ by        
subsection 7b71 is fur!r am5d$ by add+  
at ! end ! foll[+ new clauses3  7xv7 ,= 
co/ report+ p]iods beg9n+ on or aft]    
,decemb] #ca1 #bjab1 subject to ! limits
 describ$ 9 clauses 7iv7 & 7v71 ! total 
numb] ( full-"t equival5t resid5ts =    
paym5t purposes %all equal ! actual     
full-"t equival5t resid5t c\nt = !      
hospital's co/ report+ p]iod4  7xvi7 ,= 

co/ report+ p]iods beg9n+ on or aft]    
,decemb] #ca1 #bjab1 ! ratio ( !        
hospital's full-"t equival5t int]ns &   
resid5ts to b$s %all be equal to ! ratio
 = ! hospital's co/ report+ p]iod4  4   
#d4 ,rules = det]m9+ full-"t equival5t  
resid5ts  7a7 ,,dgme ,section           
#ahhf7;h77#d7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acieww7h77#d77 is      
am5d$--  7#a7 9 subp>agraph 7,e71 by    
/rik+ ,subject to subp>agraphs 7,j7 &   
7,k71 su* rules & ins]t+ ,subject to    
subp>agraphs 7,j71 7,k71 & 7,l71 su*    
rules2  7#b7 9 subp>agraph 7,j71 by     
/rik+ ,su* rules & ins]t+ ,subject to   
subp>agraph 7,l71 su* rules  7#c7 9     
subp>agraph 7,k71 by /rik+ ,9 det]m9+ & 
ins]t+ ,subject to subp>agraph 7,l71 9  
det]m9+2 &  7#d7 by add+ at ! end !     
foll[+ new subp>agraph3  7,l7 ,treatm5t 
( "t sp5t 9 approv$ m$ical resid5cy     
tra9+ program ) respect to c]ta9        
hospitals ,= purposes ( co/ report+     
p]iods beg9n+ on or aft] ,july #a1      
#bjad1 9 det]m9+ ! numb] ( full-"t      

equival5t resid5ts ( ! hospital =       
purposes ( ?is p>agraph1 all ! "t sp5t  
by an int]n or resid5t 9 an approv$     
m$ical resid5cy tra9+ program1 reg>dless
 ( sett+1 %all be c\nt$ t[>d !          
det]m9ation ( full-"t equival5cy1 &     
subp>agraphs 7,j7 & 7,k7 %all n apply1  
if ! hospital--  7i7 is recogniz$ z a   
subsection 7d7 hospital2  7ii7 is       
recogniz$ z a subsection 7d7 ,pu]to     
,rico hospital2  7iii7 is reimburs$ "u a
 reimbursem5t sy/em au?oriz$ "u section 
#ahad7;b77#c72 or  7iv7 is a            
provid]-bas$ hospital outpati5t         
dep>tm5t4  4  7b7 ,,ime ,! second clause
 7x7 ( section #ahhf7;d77#e77;,b7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7d77#e77;,b77 is am5d$--  7#a7 9 
subclause 7,,ii71 by /rik+ ,9 det]m9+ & 
ins]t+ ,subject to subclause 7x77,,iv71 
9 det]m9+2  7#b7 9 subclause 7,,iii71 by
 /rik+ ,9 det]m9+ & ins]t+ ,subject to  
subclause 7x77,,iv71 9 det]m9+2 &  7#c7 
by add+ at ! end ! foll[+ new subclause3
  7,,iv7 ,! provisions ( subp>agraph    

7,l7 ( subsection 7h77#d7 %all apply "u 
?is subp>agraph 9 ! same mann] z !y     
apply "u su* subsection4  4  #e4        
,treatm5t ( hospitals ) rotat+ resid5ts 
,section #ahhf7;h77#b77;,f7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acieww7h77#b77;,f77 is am5d$ by add+ at
 ! end ! foll[+ s5t5ce3 ,9 apply+ ?is   
subp>agraph = co/ report+ p]iods beg9n+ 
on or aft] ,july #a1 #bjac1 ! ,secret>y 
%all n treat a co/ report+ p]iod = :i* a
 hospital tra9s resid5ts p>ticipat+ 9 a 
program ( ano!r hospital z a p]iod = :i*
 ! hospital has an approv$ m$ical       
resid5cy tra9+ program44  #f4           
,aggregation rules relat+ to apply+     
limitation on numb] ( resid5ts  7a7     
,requir$ rules ,to p]mit memb]s ( same  
affiliat$ gr\p ,to elect ,to apply      
limitation on aggregate level ,section  
#ahhf7;h77#d77;,h77ii7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieww7h77#d77;,h77ii77 is am5d$ by    
/rik+ may & ins]t+ %all4  7b7 ,election 
= new facilities ,su* section is fur!r  

am5d$ by add+ at ! end ! foll[+ new     
s5t5ce3 ,su* rules %all provide t all   
facilities e/abli%$ on or aft] ,janu>y  
#a1 #bjjj1 ^: resid5t limits are adju/$ 
accord+ to ?is subp>agraph on or aft]   
,janu>y #a1 #aiig1 may elect to apply ! 
limitation "u subp>agraph 7,f7 on an    
aggregate basis aft] a p]iod specifi$ by
 ! ,secret>y b t %all n exce$ #e ye>s f 
! date ( su* adju/m5t44  #g4 ,p]iod (   
bo>d eligibility = resid5ts :o *ange    
programs ,section #ahhf7;h77#e77;,g7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acieww7h77#e77;,g77 is am5d$--  7#a7 9 
clause 7i71 by /rik+ 7iv71 & 7v7 &      
ins]t+ 7iv71 7v71 & 7vi72 &  7#b7 by    
add+ at ! end ! foll[+ new clause3  7vi7
 ,9 ! case ( a resid5t :o *anges        
resid5cy specialties1 ! p]iod ( bo>d    
eligibility & ! initial resid5cy p]iod  
%all be equal to ! m9imum numb] ( ye>s (
 =mal tra9+ requir$ to satisfy !        
requirem5ts = ! initial bo>d eligibility
 ( ! program into :i* ! resid5t         
transf]s4  4  #h4 ,m$ic>e indirect      

m$ical education p]=mance adju/m5t      
,section #ahhf ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acieww7 is am5d$-- 
7#a7 9 subsection 7d77#e77;,b71 9 !     
matt] prec$+ clause 7i71 by ins]t+      
subject to subsection 7t7 & be=e except 
z foll[s2 &  7#b7 by add+ at ! end !    
foll[+ new subsection3  7t7 ,indirect   
m$ical education p]=mance adju/m5ts     
7#a7 ,9 g5]al ,subject to ! succe$+     
provisions ( ?is subsection1 ! ,secret>y
 %all e/abli% & implem5t proc$ures "u   
:i* ! am\nt ( paym5ts t a hospital 7z   
def9$ 9 p>agraph 7#aa77 w\ld o!rwise    
receive = indirect m$ical education co/s
 "u subsection 7d77#e77;,b7 = dis*>ges  
occurr+ dur+ a fiscal ye> is adju/$ bas$
 on ! report+ ( measures & ! p]=mance ( 
! hospital on measures ( pati5t c>e     
priorities specifi$ by ! ,secret>y4     
7#b7 ,adju/m5ts to beg9 9 fiscal ye>    
#bjah ,! adju/m5ts %all apply to paym5ts
 = dis*>ges occurr+--  7,a7 ) respect to
 ! adju/m5ts = report+ "u p>agraph      
7#h77;,a71 dur+ fiscal ye> #bjah2 &     

7,b7 ) respect to ! adju/m5ts = p]=mance
 "u p>agraph 7#h77;,b71 on or aft]      
,octob] #a1 #bjah4  7#c7 ,measures ,!   
measures ( pati5t c>e priorities        
specifi$ by ! ,secret>y "u ?is          
subsection %all include ! ext5t ( tra9+ 
provid$ 9--  7,a7 ! deliv]y ( s]vices   
categoriz$ z evaluation & managem5t     
codes by ! ,c5t]s = ,m$ic>e  ,m$icaid   
,s]vices2  7,b7 a v>iety ( sett+s &     
sy/ems2  7,c7 ! coord9ation ( pati5t c>e
 across sett+s2  7,d7 ! relevant co/ &  
value ( v>i\s diagno/ic & treatm5t      
options2  7,e7 int]pr(essional &        
multidiscipl9>y c>e teams2  7,f7 me?ods 
= id5tify+ sy/em errors & implem5t+     
sy/em solutions2 &  7,g7 ! use ( heal?  
in=mation te*nology4  7#d7 ,measure     
developm5t process  7,a7 ,9 g5]al ,!    
measures ( pati5t c>e specifi$ by !     
,secret>y "u ?is subsection--  7i7      
%all--  7,i7 be measures t h be5 adopt$ 
or endors$ by an accr$it+ organization  
7su* z ! ,accr$itation ,c\ncil =        
,graduate ,m$ical ,education or ,am]ican

 ,o/eopa?ic ,association72 &  7,,ii7 be 
measures t ! ,secret>y id5tifies z hav+ 
us$ a cons5sus-bas$ process = develop+  
su* measures2 &  7ii7 may include       
measures t h be5 submitt$ by tea*+      
hospitals & m$ical s*ools4  7,b7        
,propos$ set ( initial measures ,n lat] 
?an ,july #a1 #bjae1 ! ,secret>y %all   
publi% 9 ! ,f$]al ,regi/] a propos$     
initial set ( measures = use "u ?is     
subsection4 ,! ,secret>y %all provide = 
a p]iod ( public comm5t on su* measures4
  7,c7 ,f9al set ( initial measures ,n  
lat] ?an ,janu>y #a1 #bjaf1 ! ,secret>y 
%all publi% 9 ! ,f$]al ,regi/] ! set (  
initial measures to be specifi$ by !    
,secret>y = use "u ?is subsection4  7,d7
 ,update ( measures ,! ,secret>y may1   
?r\gh notice & comm5t rulemak+1         
p]iodically update ! measures specifi$  
"u ?is subsection pursuant to !         
requirem5ts "u subp>agraph 7,a74  7#e7  
,p]=mance /&>ds ,! ,secret>y %all       
e/abli% p]=mance /&>ds ) respect to     
measures specifi$ by ! ,secret>y "u ?is 

subsection = a p]=mance p]iod = a fiscal
 ye> 7z e/abli%$ "u p>agraph 7#f774     
7#f7 ,p]=mance p]iod ,! ,secret>y %all  
e/abli% ! p]=mance p]iod = a fiscal ye>4
 ,su* p]=mance p]iod %all beg9 & end    
prior to ! beg9n+ ( su* fiscal ye>4     
7#g7 ,report+ ( measures ,! proc$ures   
e/abli%$ & implem5t$ "u p>agraph 7#a7   
%all include a process "u :i* hospitals 
%all submit data on ! measures specifi$ 
by ! ,secret>y "u ?is subsection to !   
,secret>y 9 a =m & mann]1 & at a "t1    
specifi$ by ! ,secret>y = purposes ( ?is
 subsection4  7#h7 ,adju/m5ts  7,a7     
,report+ = fiscal ye> #bjah ,= fiscal   
ye> #bjah1 9 ! case ( a hospital t does 
n submit1 to ! ,secret>y 9 accordance ) 
?is subsection1 data requir$ to be      
submitt$ "u p>agraph 7#g7 = a p]iod     
7det]m9$ appropriate by ! ,secret>y7 =  
su* fiscal ye>1 ! total am\nt t !       
hospital w\ld o!rwise receive "u        
subsection 7d77#e77;,b7 = dis*>ges 9 su*
 fiscal ye> %all be r$uc$ by #j4e p]c5t4
  7,b7 ,p]=mance = fiscal ye> #bjai &   

subsequ5t fiscal ye>s  7i7 ,9 g5]al     
,subject to clause 7ii71 bas$ on !      
p]=mance ( ea* hospital ) respect to    
compliance ) ! measures = a p]=mance    
p]iod = a fiscal ye> 7beg9n+ ) fiscal   
ye> #bjai71 ! ,secret>y %all det]m9e !  
am\nt ( any adju/m5t "u ?is subp>agraph 
to paym5ts to ! hospital "u subsection  
7d77#e77;,b7 = dis*>ges 9 su* fiscal    
ye>4 ,su* adju/m5t may n exce$ an am\nt 
equal to #b p]c5t ( ! total am\nt t !   
hospital w\ld o!rwise receive "u su*    
subsection = dis*>ges 9 su* fiscal ye>4 
7ii7 ,budget neutral ,9 mak+ adju/m5ts  
"u ?is subp>agraph1 ! ,secret>y %all    
ensure t ! total am\nt ( paym5ts made to
 all hospitals "u subsection            
7d77#e77;,b7 = dis*>ges 9 a fiscal ye>  
is equal to ! total am\nt ( paym5ts t   
w\ld h be5 made to su* hospitals "u su* 
subsection = dis*>ges 9 su* fiscal ye>  
if ?is subsection _h n be5 enact$4  7#i7
 ,no effect 9 subsequ5t fiscal ye>s ,any
 adju/m5t "u subp>agraph 7,a7 or 7,b7 ( 
p>agraph 7#h7 %all apply only ) respect 

to ! fiscal ye> involv$1 & ! ,secret>y  
%all n take into acc\nt any su* adju/m5t
 9 mak+ paym5ts to a hospital "u ?is    
section 9 a subsequ5t fiscal ye>4  7#aj7
 ,evaluation ( submission ( p]=mance    
measures ,n lat] ?an ,janu>y #a1 #bjah1 
! ,secret>y %all submit to ,congress a  
report on ! implem5tation ( ?is         
subsection1 includ+--  7,a7 ! measure   
developm5t proc$ures1 includ+ any b>ri]s
 to measure developm5t2  7,b7 !         
compliance ) report+ on ! p]=mance      
measures1 includ+ any b>ri]s to su*     
compliance2 &  7,c7 recomm5dations to   
address any b>ri]s describ$ 9           
subp>agraph 7,a7 or 7,b74  7#aa7        
,def9ition ( hospital ,9 ?is subsection1
 ! t]m hospital means a hospital t      
receives paym5ts "u subsection          
7d77#e77;,b74  4  #i4 ,increas+ graduate
 m$ical education transp>5cy  7a7 ,9    
g5]al ,n lat] ?an #b ye>s aft] ! date ( 
! enactm5t ( ?is ,act1 & annually       
!reaft]1 ! ,secret>y ( ,heal? & ,human  
,s]vices %all submit to ,congress & !   

,national ,heal? ,c>e ,work=ce          
,commission a report on ! graduate      
m$ical education paym5ts t hospitals    
receive "u ! ,m$ic>e program4 ,! report 
%all include ! foll[+ in=mation )       
respect to ea* hospital t receives su*  
paym5ts3  7#a7 ,! direct graduate m$ical
 education paym5ts made to ! hospital "u
 section #ahhf7;h7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acieww7h774  7#b7 
,! total co/s ( direct graduate m$ical  
education to ! hospital z report$ on !  
annual ,m$ic>e ,co/ ,reports4  7#c7 ,!  
indirect m$ical education paym5ts made  
to ! hospital "u section                
#ahhf7;d77#e77;,b7 ( su* ,act 7#db      
,u4,s4,c4 #acieww7d77#a77;,b774  7#d7 ,!
 numb] ( full-"t-equival5t resid5ts     
c\nt$ = purposes ( mak+ ! paym5ts       
describ$ 9 p>agraph 7#a74  7#e7 ,! numb]
 ( full-"t-equival5t resid5ts c\nt$ =   
purposes ( mak+ ! paym5ts describ$ 9    
p>agraph 7#c74  7#f7 ,! numb] (         
full-"t-equival5t resid5ts1 if any1 t   
are n c\nt$ = purposes ( mak+ paym5ts   

describ$ 9 p>agraph 7#a74  7#g7 ,! numb]
 ( full-"t-equival5t resid5ts1 if any1 t
 are n c\nt$ = purposes ( mak+ paym5ts  
describ$ 9 p>agraph 7#c74  7#h7 ,!      
factors contribut+ to ! high] co/s (    
pati5t c>e provid$ by ! hospital1       
includ+--  7,a7 ! co/s ( trauma1 burn1  
o!r /&by s]vices2  7,b7 translation     
s]vices = disabl$ or non-,engli% speak+ 
pati5ts2  7,c7 ! co/ ( uncomp5sat$ c>e2 
7,d7 f9ancial losses ) respect to       
,m$icaid pati5ts2 &  7,e7 uncomp5sat$   
co/s ( cl9ical rese>*4  #aj4 ,,gao      
/udies & reports  7a7 ,on physician     
work=ce  7#a7 ,/udy ,! ,comptroll]      
,g5]al ( ! ,unit$ ,/ates %all conduct a 
/udy on ! physician work=ce4 ,su* /udy  
%all include ! id5tification ( physician
 specialties = :i* !re is a %ortage1 z  
def9$ by ! ,comptroll] ,g5]al4  7#b7    
,report ,n lat] ?an ,janu>y #a1 #bjae1 !
 ,comptroll] ,g5]al %all submit to      
,congress a report on ! /udy conduct$ "u
 subsection 7a71 toge!r ) recomm5dations
 = su* legislation & adm9i/rative action

 z ! ,comptroll] ,g5]al det]m9es        
appropriate4  7b7 ,on /rategies =       
increas+ div]sity  7#a7 ,/udy ,!        
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct a /udy on /rategies =      
increas+ ! div]sity ( ! heal?           
pr(essional work=ce4 ,su* /udy %all     
include an analysis ( /rategies =       
increas+ ! numb] ( heal? pr(essionals f 
rural1 l[] income1 & "u-repres5t$       
m9ority communities1 includ+ :i*        
/rategies are mo/ effective = a*iev+ su*
 goal4  7#b7 ,report ,n lat] ?an #b ye>s
 aft] ! date ( enactm5t ( ?is ,act1 !   
,comptroll] ,g5]al %all submit to       
,congress a report on ! /udy conduct$ "u
 subsection 7a71 toge!r ) recomm5dations
 = su* legislation & adm9i/rative action
 z ! ,comptroll] ,g5]al det]m9es        
appropriate4  7c7 ,on protect+ old]     
adults  7#a7 ,/udy ,! ,comptroll] ,g5]al
 ( ! ,unit$ ,/ates %all conduct a /udy t
 addresses ! compet5cy ( ! physician    
work=ce to c>e = old] adults ^u !       
completion ( su* work=ce's resid5cy     

tra9+4  7#b7 ,report ,n lat] ?an #b ye>s
 aft] ! date ( ! enactm5t ( ?is ,act1 ! 
,comptroll] ,g5]al %all submit to       
,congress a report on su* /udy1 includ+ 
su* recomm5dations = legislation &      
adm9i/rative action z ! ,comptroll]     
,g5]al det]m9es appropriate bas$ on su* 
/udy4