,i  #aadth ,,congress  #b;d ,session    
,h4 ,r4 #fjci  ,,in ,,the ,,house ,,of  
,,representatives  ,september #ae1      
#bjaf,mr4 ,hardy introduced the         
following bill2 which was referred to   
the ,committee on ,ways and ,means1 and 
in addition to the ,committee on ,energy
 and ,commerce1 for a period to be      
subsequently determined by the ,speaker1
 in each case for consideration of such 
provisions as fall within the           
jurisdiction of the committee concerned 
,a ,,bill  ,to amend title ,,xviii of   
the ,social ,security ,act to           
redistribute unused residency positions 
to hospitals in ,states with shortages  
of residents and health professionals1  
and for other purposes4  #a4 ,short     
title ,this ,act may be cited as the    
,graduate ,opportunities in ,medical    
,education ,distribution ,act of #bjaf4 
#b4 ,redistributing unused residency    
positions to hospitals in ,states with  
shortages of residents and health       
professionals  7a7 ,in general ,section 

#ahhf7;h7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acieww7h77 is amended-- 
7#a7 in paragraph 7#d77;,f77i71 by      
striking 7#g7 and 7#h7 and inserting    
7#g71 7#h71 and 7#i72  7#b7 in paragraph
 7#d77;,h77i71 by striking 7#g7 and 7#h7
 and inserting 7#g71 7#h71 and 7#i72    
7#c7 in paragraph 7#g77;,e71 by striking
 paragraph 7#h7 and inserting paragraph 
7#h7 or 7#i7 before the period at the   
end2 and  7#d7 by adding at the end the 
following new paragraph3  7#i7          
,distribution of additional residency   
positions  7,a7 ,reductions in limit    
based on unused positions  7i7 ,making  
of determinations ,not later than #ahj  
days after the date of the enactment of 
this paragraph and each four years      
thereafter1 the ,secretary shall make a 
set of reduction determinations 7as     
defined in clause 7ii774  7ii7 ,set of  
reduction determinations defined ,for   
purposes of this paragraph1 the term set
 of reduction determinations means      
determinations with respect to each     

hospital of whether1 with respect to the
 one-year period ending on the date of  
such set of reduction determinations    
7referred to in this paragraph as the   
measurement period for such set of      
reduction determinations71 the          
hospital's reference resident level 7as 
defined in subparagraph 7,f77i77 for    
such period was less than the otherwise 
applicable resident limit 7as defined in
 subparagraph 7,f77iii77 for such       
hospital and period4  7iii7 ,reduction  
based on determination ,in the case     
that1 with respect to the measurement   
period for a set of reduction           
determinations1 the ,secretary          
determines under this subparagraph that 
the reference resident level of a       
hospital for such period was less than  
the otherwise applicable resident limit 
for such hospital and period1 effective 
for portions of cost reporting periods  
occurring after the date of such set of 
reduction determinations and on or      
before the date of any subsequent set of

 reduction determinations under clause  
7i7 7referred to in this paragraph as   
the consequence period for such set of  
reduction determinations71 the otherwise
 applicable resident limit for such     
hospital shall be reduced by #fe percent
 of the difference between such         
otherwise applicable resident limit for 
the hospital and measurement period and 
such reference resident level for the   
hospital and measurement period 7or1 in 
the case that the ,secretary determines 
that1 with respect to the consequence   
period immediately preceding such       
consequence period1 the hospital was a  
hospital described in clause 7ii7 of    
subparagraph 7,b7 that did not meet the 
requirements of such clause1 by the     
number described in clause 7iv774  7iv7 
,number described ,the number described 
in this clause1 with respect to a       
hospital and consequence period         
7referred to in this clause as the      
target consequence period71 is the      
greater of--  7,i7 the number by which  

the otherwise applicable resident limit 
for such hospital would be reduced for  
the target consequence period under     
clause 7iii7 without the application of 
this clause2 and  7,,ii7 the number by  
which the otherwise applicable resident 
limit for such hospital was increased   
for the consequence period that         
immediately preceded the target         
consequence period4  7v7 ,exception     
,this subparagraph shall not apply to a 
hospital located in a rural area 7as    
defined in subsection 7d77#b77;,d77ii77 
with fewer than #bej acute care         
inpatient beds4  7vi7 ,determination    
timing ,in the case of a reduction      
determination made in a year by the     
,secretary under clause 7i7 that is not 
the first such reduction determination  
so made1 the ,secretary shall make such 
determination on a date that is not     
later than ,march #ca of such year4     
7,b7 ,distribution  7i7 ,in general     
,with respect to each set of reduction  
determinations under subparagraph       

7,a77i71 the ,secretary shall1 in       
accordance with the succeeding          
provisions of this paragraph1 increase  
the otherwise applicable resident limit 
for each qualifying hospital that       
submits an application under this       
subparagraph by such number as the      
,secretary may approve for portions of  
cost reporting periods occurring during 
the consequence period for such set of  
reduction determinations4 ,the aggregate
 number of increases in the otherwise   
applicable resident limit under this    
subparagraph for such consequence period
 shall be equal to the aggregate        
reduction in such limits attributable to
 subparagraph 7,a7 7as estimated by the 
,secretary7 for such consequence period4
  7ii7 ,requirements ,a hospital that   
receives an increase in the otherwise   
applicable resident limit under this    
subparagraph for a consequence period   
shall ensure that1 during such          
consequence period1 the positions       
resulting from the increase under this  

paragraph will be filled4 ,the          
,secretary may determine whether a      
hospital has met the requirements under 
this clause during such consequence     
period in such manner and at such time  
as the ,secretary determines            
appropriate1 including at the end of    
such period4  7,c7 ,capacity            
considerations in redistribution ,in    
determining which hospitals are to      
receive increases in their otherwise    
applicable resident limits under        
subparagraph 7,b7 for a consequence     
period for a set of reduction           
determinations1 the ,secretary shall    
take into account the demonstrated      
likelihood of each such hospital filling
 the positions made available under this
 paragraph within such consequence      
period1 as determined by the ,secretary4
  7,d7 ,priority in redistribution      
,subject to subparagraph 7,c71 the      
,secretary shall select1 with respect to
 a set of reduction determinations under
 subparagraph 7,a77i71 the qualifying   

hospitals that will receive increases   
under subparagraph 7,b7 in the otherwise
 applicable resident limits for such    
hospitals for the consequence period for
 such set of reduction determinations4  
,the ,secretary shall make such         
selection in a manner that distributes  
the positions made available to         
hospitals for such consequence period   
under this paragraph in accordance with 
the following3  7i7 ,the ,secretary     
shall1 with respect to such positions   
that are so made available for such     
consequence period1 make--  7,i7 #gj    
percent of such positions available to  
hospitals located in low                
resident-to-population ,states 7as      
defined in subparagraph 7,f77iv772 and  
7,,ii7 #cj percent of such positions    
available to hospitals located in high  
,,hpsa-to-population ,states 7as defined
 in subparagraph 7,f77v774  7ii7 ,the   
,secretary shall1 in accordance with    
clause 7i71 make such positions         
available for such consequence period in

 a manner that prioritizes the          
distribution of such positions to       
hospitals that are anticipated to fill  
such positions with individuals from    
residence programs located in the ,state
 in which such hospitals are located4   
7,e7 ,application of per resident       
amounts for primary care and nonprimary 
care ,with respect to additional        
residency positions in a hospital       
attributable to the increase provided   
under this paragraph1 the approved ,,fte
 per resident amounts are deemed to be  
equal to the hospital per resident      
amounts for primary care and nonprimary 
care computed under paragraph 7#b77;,d7 
for that hospital4  7,f7 ,definitions   
,in this paragraph3 7i7 ,reference      
resident level ,the term reference      
resident level means1 with respect to a 
hospital and measurement period1 the    
resident level for the cost reporting   
periods of the hospital occurring during
 such measurement period and for which a
 cost report has been settled 7or1 if   

not1 submitted 7subject to audit771 as  
determined by the ,secretary4  7ii7     
,resident level ,the term resident level
 has the meaning given such term in     
paragraph 7#g77;,c77i74  7iii7          
,otherwise applicable resident limit    
,the term otherwise applicable resident 
limit means1 with respect to a hospital 
and period1 the limit otherwise         
applicable under subparagraphs 7,f77i7  
and 7,h7 of paragraph 7#d7 on the       
resident level of the hospital for such 
period1 determined without regard to    
this paragraph but taking into account  
paragraph 7#g77;,a74  7iv7 ,low         
resident-to-population ,states  7,i7 ,in
 general ,the term low                  
resident-to-population ,state means a   
,state that has a smaller applicable    
number than do at least #ge percent of  
all ,states4  7,,ii7 ,applicable number 
,for purposes of subclause 7,i71 the    
term applicable number means1 with      
respect to a ,state1 the number that    
results from dividing the number of     

residents in the ,state by the number of
 individuals residing in the ,state4    
7v7 ,high ,,hpsa-to-population ,states  
7,i7 ,in general ,the term high         
,,hpsa-to-population ,state means a     
,state that has a larger applicable     
number than do at least #ij percent of  
all ,states4  7,,ii7 ,applicable number 
,for purposes of subclause 7,i71 the    
term applicable number means1 with      
respect to a ,state1 the number that    
results from dividing the number of     
areas in the ,state designated by the   
,health ,resources  ,services           
,administration of the ,department of   
,health and ,human ,services as ,health 
,professional ,shortage ,areas by the   
number of individuals residing in the   
,state4  7,g7 ,affiliation ,the         
provisions of this paragraph shall be   
applied to hospitals which are members  
of the same affiliated group 7as defined
 by the ,secretary under paragraph      
7#d77;,h77ii774  4  7b7 ,,ime  7#a7 ,in 
general ,section #ahhf7;d77#e77;,b77v7  

of the ,social ,security ,act 7#db      
,u4,s4,c4 #acieww7d77#e77;,b77v771 in   
the second sentence1 is amended by      
striking subsections 7h77#g7 and 7h77#h7
 and inserting subsections 7h77#g71     
7h77#h71 and 7h77#i74  7#b7 ,conforming 
amendment ,section #ahhf7;d77#e77;,b7 of
 the ,social ,security ,act 7#db        
,u4,s4,c4 #acieww7d77#e77;,b77 is       
amended by adding at the end the        
following clause3  7xii7 ,for discharges
 occurring on or after the date that is 
#ahj days after the date of the         
enactment of this clause1 insofar as an 
additional payment amount under this    
subparagraph is attributable to resident
 positions distributed to a hospital    
under subsection 7h77#i77;,b71 the      
indirect teaching adjustment factor     
shall be computed in the same manner as 
provided under clause 7ii7 with respect 
to such resident positions4  4  7c7     
,conforming amendment ,section          
#dbb7;b77#b7 of the ,medicare           
,prescription ,drug1 ,improvement1 and  

,modernization ,act of #bjjc 7,public   
,law #ajh-agc71 as amended by section   
#eejc of the ,patient ,protection and   
,affordable ,care ,act 7,public ,law    
#aaa-adh71 is amended by striking       
paragraphs 7#g7 and 7#h7 and inserting  
paragraphs 7#g71 7#h71 and 7#i744