,i  #aae? ,,congress  #a/ ,session  ,h4 
,r4 #aafg  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,febru>y #af1         
#bjag,mrs4 ,love 7= h]self1 ,mr4 ,ru%1 &
 ,mrs4 ,mc,morris ,rodg]s7 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 promote       
physician tra9+ 9 newly recogniz$ prim>y
 m$ical specialties1 & = o!r purposes4  
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,enhanc+ ,opportunities = ,m$ical     
,doctors ,act ( #bjag4  #b4 ,r$i/ribut+ 
unus$ resid5cy positions to promote !   
e/abli%m5t ( resid5cy programs = newly  
recogniz$ prim>y m$ical specialties  7a7
 ,9 g5]al ,section #ahhf7;h7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acieww7h77 is am5d$--  7#a7 9 p>agraph 

7#d77;,f77i71 by /rik+ 7#g7 & 7#h7 &    
ins]t+ 7#g71 7#h71 & 7#i72  7#b7 9      
p>agraph 7#d77;,h77i71 by /rik+ 7#g7 &  
7#h7 & ins]t+ 7#g71 7#h71 & 7#i72  7#c7 
9 p>agraph 7#g77;,e71 by /rik+ p>agraph 
7#h7 & ins]t+ p>agraph 7#h7 or 7#i7 be=e
 ! p]iod at ! end2 &  7#d7 by add+ at ! 
end ! foll[+ new p>agraph3  7#i7        
,di/ribution ( additional resid5cy      
positions  7,a7 ,r$uctions 9 limit bas$ 
on unus$ positions  7i7 ,9 g5]al ,if a  
hospital's ref]5ce resid5t level 7z     
def9$ 9 subp>agraph 7,g77i77 is less ?an
 ! o!rwise applicable resid5t limit 7z  
def9$ 9 subp>agraph 7,g77iii771         
effective = portions ( co/ report+      
p]iods occurr+ on or aft] ,july #a1     
#bjah1 ! o!rwise applicable resid5t     
limit %all be r$uc$ by #fe p]c5t ( !    
diff]5ce betwe5 su* o!rwise applicable  
resid5t limit & su* ref]5ce resid5t     
level4  7ii7 ,exception ,?is subp>agraph
 %all n apply to a hospital locat$ 9 a  
rural area 7z def9$ 9 subsection        
7d77#b77;,d77ii77 ) few] ?an #bej acute 

c>e inpati5t b$s4  7,b7 ,di/ribution    
7i7 ,9 g5]al ,! ,secret>y %all1 9       
accordance ) ! succe$+ provisions ( ?is 
p>agraph1 increase ! o!rwise applicable 
resid5t limit = ea* qualify+ hospital t 
submits an application "u ?is           
subp>agraph by su* numb] z ! ,secret>y  
may approve = portions ( co/ report+    
p]iods occurr+ on or aft] ,july #a1     
#bjah4 ,! aggregate numb] ( increases 9 
! o!rwise applicable resid5t limit "u   
?is subp>agraph %all be equal to !      
aggregate r$uction 9 su* limits         
attributable to subp>agraph 7,a7 7z     
e/imat$ by ! ,secret>y74  7ii7          
,requirem5ts ,subject to clause 7iii71 a
 hospital t receives an increase 9 !    
o!rwise applicable resid5t limit "u ?is 
subp>agraph %all ensure1 dur+ ! #c-ye>  
p]iod beg9n+ on ! date ( su* increase1 t
 ! positions result+ f ! increase "u ?is
 p>agraph w be fill$4 ,! ,secret>y may  
det]m9e :e!r a hospital has met !       
requirem5ts "u ?is clause dur+ su*      
#c-ye> p]iod 9 su* mann] & at su* "t z !

 ,secret>y det]m9es appropriate1 includ+
 at ! end ( su* #c-ye> p]iod4  7iii7    
,r$i/ribution ( positions if hospital no
 long] meets c]ta9 requirem5ts ,9 ! case
 :]e ! ,secret>y det]m9es t a hospital  
describ$ 9 clause 7ii7 does n meet !    
requirem5ts ( su* clause1 ! ,secret>y   
%all--  7,i7 r$uce ! o!rwise applicable 
resid5t limit ( ! hospital by ! am\nt by
 :i* su* limit 0 increas$ "u ?is        
p>agraph2 &  7,,ii7 provide = !         
di/ribution ( positions attributable to 
su* r$uction 9 accordance ) !           
requirem5ts ( ?is p>agraph4  7,c7       
,capacity consid]ations 9 r$i/ribution  
,9 det]m9+ = :i* hospitals ! increase 9 
! o!rwise applicable resid5t limit is   
provid$ "u subp>agraph 7,b71 ! ,secret>y
 %all take into acc\nt ! demon/ration   
likelihood ( ! hospital fill+ !         
positions made available "u ?is p>agraph
 )9 ! fir/ #c co/ report+ p]iods beg9n+ 
on or aft] ,july #a1 #bjah1 z det]m9$ by
 ! ,secret>y4  7,d7 ,priority 9         
r$i/ribution ,subject to subp>agraphs   

7,c7 & 7,e71 ! ,secret>y %all det]m9e   
:i* qualify+ hospitals receive increases
 "u subp>agraph 7,b7 9 ! o!rwise        
applicable resid5t limits = su*         
hospitals 9 a mann] t di/ributes !      
positions made available to hospitals "u
 ?is p>agraph 9 accordance ) ! foll[+3  
7i7 ,! ,secret>y %all make su* positions
 available to hospitals ) applicable    
resid5cy tra9+ programs4  7ii7 ,9 ! case
 t ! application ( clause 7i7 does n    
result 9 ! di/ribution ( all positions  
made available "u ?is p>agraph1 !       
,secret>y %all make any positions t     
rema9 undi/ribut$ aft] ! application (  
su* clause available to hospitals t are 
locat$ 9--  7,i7 a ,/ate ) a            
resid5t-to-population ratio 9 ! l[e/    
qu>tile 7z det]m9$ by ! ,secret>y72     
7,,ii7 a ,/ate1 a t]ritory ( ! ,unit$   
,/ates1 or ! ,di/rict ( ,columbia t is  
among ! top #aj ,/ates1 t]ritories1 or  
,di/ricts 9 t]ms ( ! ratio ( ! total    
population ( ! ,/ate1 t]ritory1 or      
,di/rict liv+ 9 an area designat$ 7"u   

su* section #ccb7;a77#a77;,a77 z a heal?
 pr(essional %ortage area 7z ( ! date ( 
enactm5t ( ?is p>agraph71 to ! total    
population ( ! ,/ate1 t]ritory1 or      
,di/rict 7z det]m9$ by ! ,secret>y bas$ 
on ! mo/ rec5t available population data
 publi%$ by ! ,bureau ( ! ,c5sus72 or   
7,,iii7 a rural area 7z def9$ 9         
subsection 7d77#b77;,d77ii774  7iii7 ,9 
! case t ! application ( clauses 7i7 &  
7ii7 does n result 9 ! di/ribution ( all
 positions made available "u ?is        
p>agraph1 ! ,secret>y %all make any     
positions t rema9 undi/ribut$ aft] !    
application ( su* clauses available to  
hospitals t e/abli% a m$ical resid5cy   
program t is sponsor$ by1 or affiliat$  
)1 a m$ical s*ool t 0 fir/ accr$it$ dur+
 ! co/ report+ p]iod prior to ! co/     
report+ p]iod ) respect to :i* su*      
application applies4  7,e7 ,limitation  
,a hospital may n receive m ?an #ge     
full-"t equival5t additional resid5cy   
positions "u ?is p>agraph4  7,f7        
,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,g7  
,def9itions ,9 ?is p>agraph3 7i7        
,ref]5ce resid5t level ,! t]m ref]5ce   
resid5t level means1 ) respect to a     
hospital1 ! highe/ resid5t level = any (
 ! #c mo/ rec5t co/ report+ p]iods 7end+
 be=e ! date ( ! enactm5t ( ?is         
p>agraph7 ( ! hospital = :i* a co/      
report has be5 settl$ 7or1 if n1        
submitt$ 7subject to audit771 z det]m9$ 
by ! ,secret>y4  7ii7 ,resid5t level ,! 
t]m resid5t level has ! mean+ giv5 su*  
t]m 9 p>agraph 7#g77;,c77i74  7iii7     
,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>agraph 7#g77;,a74  7iv7 ,applicable  
resid5cy tra9+ program  7,i7 ,9 g5]al ,!
 t]m applicable resid5cy tra9+ program  
means a m$ical resid5cy tra9+ program t 
is = ! applicable prim>y specialty t1 z 
( ! date ( ! enactm5t ( ?is p>agraph1 is
 ! applicable prim>y specialty t has mo/
 rec5tly be5 designat$ z a prim>y       
specialty by ! ,am]ican ,bo>d ( ,m$ical 
,specialties4  7,,ii7 ,applicable prim>y
 specialty ,! t]m applicable prim>y     
specialty means a prim>y specialty a    
resid5t ( :i* is n1 z ( ! date ( !      
enactm5t ( ?is p>agraph1 c\nt$ z an     
,,fte resid5t = purposes ( ?is          
subsection4 ,= purposes ( ! prec$+      
s5t5ce1 ! t]m prim>y specialty does n   
include a subspecialty4  7,h7           
,affiliation ,! provisions ( ?is        
p>agraph %all be appli$ to hospitals :i*
 are memb]s ( ! same affiliat$ gr\p 7z  
def9$ by ! ,secret>y "u p>agraph        
7#d77;,h77ii77 & ! ref]5ce resid5t level

 = ea* su* hospital %all be ! ref]5ce   
resid5t level ) respect to ! co/ report+
 p]iod t results 9 ! smalle/ diff]5ce   
betwe5 ! ref]5ce resid5t level & !      
o!rwise applicable resid5t limit4  4    
7b7 ,,ime  7#a7 ,9 g5]al ,section       
#ahhf7;d77#e77;,b77v7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,b77v771 9 ! second     
s5t5ce1 is am5d$ by /rik+ subsections   
7h77#g7 & 7h77#h7 & ins]t+ subsections  
7h77#g71 7h77#h71 & 7h77#i74  7#b7      
,con=m+ am5dm5t ,section                
#ahhf7;d77#e77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieww7d77#e77;,b77 is am5d$ by add+ at
 ! end ! foll[+ clause3  7xii7 ,=       
dis*>ges occurr+ on or aft] ,july #a1   
#bjah1 ins(> z an additional paym5t     
am\nt "u ?is subp>agraph is attributable
 to resid5t positions di/ribut$ to a    
hospital "u subsection 7h77#i77;,b71 !  
indirect tea*+ adju/m5t factor %all be  
comput$ 9 ! same mann] z provid$ "u     
clause 7ii7 ) respect to su* resid5t    

positions4  4  7c7 ,con=m+ am5dm5t      
,section #dbb7;b77#b7 ( ! ,m$ic>e       
,prescription ,drug1 ,improvem5t1 &     
,mod]nization ,act ( #bjjc 7,public ,law
 #ajh-agc71 z am5d$ by section #eejc ( !
 ,pati5t ,protection & ,af=dable ,c>e   
,act 7,public ,law #aaa-adh71 is am5d$  
by /rik+ p>agraphs 7#g7 & 7#h7 & ins]t+ 
p>agraphs 7#g71 7#h71 & 7#i744