I 111th CONGRESS 1st Session H. R. 2350 IN THE HOUSE OF REPRESENTATIVES May 12, 2009 Ms. Schwartz (for herself, Mr. Abercrombie, Ms. Berkley, Mr. Berman, Mr. Bishop of New York, Mr. Blumenauer, Mr. Boswell, Mr. Brady of Pennsylvania, Mrs. Capps, Mr. Carnahan, Ms. Castor of Florida, Mrs. Christensen, Ms. Clarke, Mr. Cleaver, Mr. Cohen, Mr. Connolly of Virginia, Mr. Courtney, Mr. Crowley, Mr. Cuellar, Mr. Davis of Illinois, Ms. DeLauro, Mr. Doggett, Mr. Driehaus, Mr. Edwards of Texas, Mr. Ellison, Mr. Farr, Mr. Fattah, Ms. Giffords, Mr. Gutierrez, Mrs. Halvorson, Mr. Hare, Mr. Hastings of Florida, Mr. Higgins, Mr. Hinchey, Ms. Hirono, Mr. Holt, Mr. Israel, Ms. Jackson-Lee of Texas, Ms. Kaptur, Mr. Kennedy, Ms. Kilroy, Mr. Kind, Mr. Kucinich, Ms. Lee of California, Mr. Levin, Mr. Lewis of Georgia, Mr. Loebsack, Mr. Maffei, Ms. Matsui, Ms. McCollum, Mr. McDermott, Mr. McGovern, Ms. Moore of Wisconsin, Mr. Moran of Virginia, Mr. Patrick J. Murphy of Pennsylvania, Mr. Murtha, Mrs. Napolitano, Mr. Neal of Massachusetts, Mr. Olver, Mr. Perlmutter, Mr. Peters, Ms. Pingree of Maine, Mr. Salazar, Mr. Schrader, Mr. Scott of Virginia, Mr. Scott of Georgia, Ms. Shea-Porter, Mr. Sires, Mr. Snyder, Mr. Van Hollen, Ms. Waters, Ms. Watson, Mr. Weiner, Mr. Wilson of Ohio, Mr. Yarmuth, Mr. Meeks of New York, Ms. Linda T. Sánchez of California, Mr. Honda, Mr. Etheridge, Ms. Sutton, Mr. Holden, Mr. Kanjorski, Mr. Langevin, Mr. Larson of Connecticut, Mr. Doyle, Mr. Wexler, and Ms. DeGette) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend the Public Health Service Act and the Social Security Act to increase the number of primary care physicians and primary care providers and to improve patient access to primary care services, and for other purposes.
1.
Short title; table of contents
(a)
Short title
This Act may be cited as the Preserving Patient Access to Primary Care Act of 2009. (b)
Table of contents
The table of contents is as follows: Sec. 1. Short title; table of contents. Sec. 2. Findings. Sec. 3. Definitions. Title I—Medical education Sec. 101. Recruitment incentives. Sec. 102. Debt forgiveness, scholarships, and service obligations. Sec. 103. Deferment of loans during residency and internships. Sec. 104. Educating medical students about primary care careers. Sec. 105. Training in a family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistance, general dentistry, and pediatric dentistry. Sec. 106. Increased funding for National Health Service Corps Scholarship and Loan Repayment Programs. Title II—Medicaid Related Provisions Sec. 201. Transformation grants to support patient centered medical homes under Medicaid and CHIP. Title III—Medicare Provisions Subtitle A—Primary Care Sec. 301. Reforming payment systems under Medicare to support primary care. Sec. 302. Coverage of patient centered medical home services. Sec. 303. Medicare primary care payment equity and access provision. Sec. 304. Additional incentive payment program for primary care services furnished in health professional shortage areas. Sec. 305. Permanent extension of floor on Medicare work geographic adjustment under the Medicare physician fee schedule. Sec. 306. Permanent extension of Medicare incentive payment program for physician scarcity areas. Sec. 307. HHS study and report on the process for determining relative value under the Medicare physician fee schedule. Subtitle B—Preventive services Sec. 311. Eliminating time restriction for initial preventive physical examination. Sec. 312. Elimination of cost-sharing for preventive benefits under the Medicare program. Sec. 313. HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries. Subtitle C—Other provisions Sec. 321. HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D. Sec. 322. HHS study and report on improved patient care through increased caregiver and physician interaction. Sec. 323. Improved patient care through expanded support for limited English proficiency (LEP) services. Sec. 324. HHS study and report on use of real-time Medicare claims adjudication. Sec. 325. Ongoing assessment by MedPAC of the impact of medicare payments on primary care access and equity. Sec. 326. Distribution of additional residency positions. Sec. 327. Counting resident time in outpatient settings. Sec. 328. Rules for counting resident time for didactic and scholarly activities and other activities. Sec. 329. Preservation of resident cap positions from closed and acquired hospitals. Sec. 330. Quality improvement organization assistance for physician practices seeking to be patient centered medical home practices. Title IV—Studies Sec. 401. Study concerning the designation of primary care as a shortage profession. Sec. 402. Study concerning the education debt of medical school graduates. Sec. 403. Study on minority representation in primary care.
2.
Findings
Congress makes the following findings: (1)Approximately 21 percent of physicians who were board certified in general internal medicine during the early 1990s have left internal medicine, compared to a 5 percent departure rate for those who were certified in subspecialties of internal medicine. (2)The number of United States medical graduates going into family medicine has fallen by more than 50 percent from 1997 to 2005. (3)In 2007, only 88 percent of the available medicine residency positions were filled and only 42 percent of those were filled by United States medical school graduates. (4)In 2006, only 24 percent of third-year internal medicine resident intended to pursue careers in general internal medicine, down from 54 percent in 1998. (5)Primary care physicians and primary care providers serve as the point of first contact for most patients and are able to coordinate the care of the whole person, reducing unnecessary care and duplicative testing. (6)Primary care physicians and primary care providers practicing preventive care, including screening for illness and treating diseases, can help prevent complications that result in more costly care. (7)Patients with primary care physicians or primary care providers have lower health care expenditures and primary care is correlated with better health status, lower overall mortality, and longer life expectancy. (8)Higher proportions of primary care physicians are associated with significantly reduced utilization. (9)The United States has a higher ratio of specialists to primary care physicians than other industrialized nations and the population of the United States is growing faster than the expected rate of growth in the supply of primary care physicians. (10)The number of Americans age 65 and older, those eligible for Medicare and who use far more ambulatory care visits per person as those under age 65, is expected to double from 2000 to 2030. (11)A decrease in Federal spending to carry out programs authorized by title VII of the Public Health Service Act threatens the viability of one of the programs used to solve the problem of inadequate access to primary care. (12)The National Health Service Corps program has a proven record of supplying physicians to underserved areas, and has played an important role in expanding access for underserved populations in rural and inner city communities. (13)Individuals in many geographic areas, especially rural areas, lack adequate access to high quality preventive, primary health care, contributing to significant health disparities that impair America's public health and economic productivity. (14)About 20 percent of the population of the United States resides in primary medical care Health Professional Shortage Areas.
3.
Definitions
(a)
General definitions
In this Act: (1)
Chronic Care Coordination
The term chronic care coordination means the coordination of services that is based on the Chronic Care Model that provides on-going health care to patients with chronic diseases that may include any of the following services: (A)The development of an initial plan of care, and subsequent appropriate revisions to such plan of care. (B)The management of, and referral for, medical and other health services, including interdisciplinary care conferences and management with other providers. (C)The monitoring and management of medications. (D)Patient education and counseling services. (E)Family caregiver education and counseling services. (F)Self-management services, including health education and risk appraisal to identify behavioral risk factors through self-assessment. (G)Providing access by telephone with physicians and other appropriate health care professionals, including 24-hour availability of such professionals for emergencies. (H)Management with the principal nonprofessional caregiver in the home. (I)Managing and facilitating transitions among health care professionals and across settings of care, including the following: (i)Pursuing the treatment option elected by the individual. (ii)Including any advance directive executed by the individual in the medical file of the individual. (J)Information about, and referral to, hospice care, including patient and family caregiver education and counseling about hospice care, and facilitating transition to hospice care when elected. (K)Information about, referral to, and management with, community services. (2)
Critical shortage health facility
The term critical shortage health facility means a public or private nonprofit health facility that does not serve a health professional shortage area (as designated under section 332 of the Public Health Service Act), but that has a critical shortage of physicians (as determined by the Secretary) in a primary care field. (3)
Physician
The term physician has the meaning given such term in section 1861(r)(1) of the Social Security Act. (4)
Primary care
The term primary care means the provision of integrated, high-quality, accessible health care services by health care providers who are accountable for addressing a full range of personal health and health care needs, developing a sustained partnership with patients, practicing in the context of family and community, and working to minimize disparities across population subgroups. (5)
Primary care field
The term primary care field means any of the following fields: (A)The field of family medicine. (B)The field of general internal medicine. (C)The field of geriatric medicine. (D)The field of pediatric medicine (6)
Primary care physician
The term primary care physician means a physician who is trained in a primary care field who provides first contact, continuous, and comprehensive care to patients. (7)
Primary care provider
The term primary care provider means— (A)a nurse practitioner; or (B)a physician assistant practicing as a member of a physician-directed or nurse-practitioner-directed team; who provides first contact, continuous, and comprehensive care to patients. (8)
Principal care
The term principal care means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management, developing a sustained physician-patient partnership and practicing within the context of family and community. (9)
Secretary
The term Secretary means the Secretary of Health and Human Services. (b)
Primary Medical Care Shortage Area
(1)
In general
In this Act, the term primary medical care shortage area or PMCSA means a geographic area with a shortage of physicians (as designated by the Secretary) in a primary care field, as designated in accordance with paragraph (2). (2)
Designation
To be designated by the Secretary as a PMCSA, the Secretary must find that the geographic area involved has an established shortage of primary care physicians for the population served. The Secretary shall make such a designation with respect to an urban or rural geographic area if the following criteria are met: (A)The area is a rational area for the delivery of primary care services. (B)One of the following conditions prevails within the area: (i)The area has a population to full-time-equivalent primary care physician ratio of at least 3,500 to 1. (ii)The area has a population to full-time-equivalent primary care physician ratio of less than 3,500 to 1 and has unusually high needs for primary care services or insufficient capacity of existing primary care providers. (C)Primary care providers in contiguous geographic areas are overutilized. (c)
Medically Underserved Area
(1)
In general
In this Act, the term medically underserved area or MUA means a rational service area with a demonstrable shortage of primary health care resources relative to the needs of the entire population within the service area as determined in accordance with paragraph (2) through the use of the Index of Medical Underservice (referred to in this subsection as the IMU) with respect to data on a service area. (2)
Determinations
Under criteria to be established by the Secretary with respect to the IMU, if a service area is determined by the Secretary to have a score of 62.0 or less, such area shall be eligible to be designated as a MUA. (3)
IMU variables
In establishing criteria under paragraph (2), the Secretary shall ensure that the following variables are utilized: (A)The ratio of primary medical care physicians per 1,000 individuals in the population of the area involved. (B)The infant mortality rate in the area involved. (C)The percentage of the population involved with incomes below the poverty level. (D)The percentage of the population involved age 65 or over. The value of each of such variables for the service area involved shall be converted by the Secretary to a weighted value, according to established criteria, and added together to obtain the area's IMU score. (d)
Patient Centered Medical Home
(1)
In general
In this Act, the term patient centered medical home means a physician-directed practice (or a nurse-practitioner-directed practice in those States in which such functions are included in the scope of practice of licensed nurse practitioners) that has been certified by an organization under paragraph (3) as meeting the following standards: (A)The practice provides patients who elect to obtain care through a patient centered medical home (referred to as participating patients) with direct and ongoing access to a primary or principal care physician or nurse practitioner who accepts responsibility for providing first contact, continuous, and comprehensive care to the whole person, in collaboration with teams of other health professionals, including nurses and specialist physicians, as needed and appropriate. (B)The practice applies standards for access to care and communication with participating beneficiaries. (C)The practice has readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically. (D)The practice maintains continuous relationships with participating patients by implementing evidence-based guidelines and applying such guidelines to the identified needs of individual beneficiaries over time and with the intensity needed by such beneficiaries. (2)
Recognition of NCQA approval
Such term also includes a physician-directed (or nurse-practitioner-directed) practice that has been recognized as a medical home through the Physician Practice Connections—patient centered Medical Home (PPC–PCMH) voluntary recognition process of the National Committee for Quality Assurance. (3)
Standard Setting and Qualification Process for Medical Homes
The Secretary shall establish a process for the selection of a qualified standard setting and certification organization— (A)to establish standards, consistent with this subsection, to enable medical practices to qualify as patient centered medical homes; and (B)to provide for the review and certification of medical practices as meeting such standards. (4)
Treatment of certain practices
Nothing in this section shall be construed as preventing a nurse practitioner from leading a patient centered medical home so long as— (A)all of the requirements of this section are met; and (B)the nurse practitioner is acting consistently with State law. (e)
Application under Medicare, Medicaid, PHSA, etc
Unless otherwise provided, the provisions of the previous subsections shall apply for purposes of provisions of the Social Security Act, the Public Health Service Act, and any other Act amended by this Act.
<enum>I</enum><header>Medical education</header> <section id="H232568C18CDD41F9B020A3DF1AE6EA54"><enum>101.</enum><header>Recruitment incentives</header><text display-inline="no-display-inline">Title VII of the Higher Education Act of 1965 (20 U.S.C. 1133 et seq.) is amended by adding at the end the following:</text> <quoted-block display-inline="no-display-inline" id="HCBC76BCA1DCB46AB916669B32E1066E1" style="OLC"> <part id="HC8AD3BED49134619BB0C9DE11675840D"><enum>F</enum><header>Medical education recruitment incentives</header> <section id="HF962889218014F4CBDF07FD4235560FE"><enum>786.</enum><header>Medical education recruitment incentives</header> <subsection id="HD37A3152EC2740E88C0C76BD250BD985"><enum>(a)</enum><header>In general</header><text>The Secretary is authorized to award grants or contracts to institutions of higher education that are graduate medical schools, to enable the graduate medical schools to improve primary care education and training for medical students.</text> </subsection> <subsection id="HDFB937872DBD402CBCEC752501EB5A2E"><enum>(b)</enum><header>Application</header><text>A graduate medical school that desires to receive a grant under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.</text> </subsection> <subsection id="H3AE9A7225DCC4C57967E921CCD968093"><enum>(c)</enum><header>Uses of funds</header><text>A graduate medical school that receives a grant under this section shall use such grant funds to carry out 1 or more of the following:</text> <paragraph id="H560E3993BEA6442D88F4E3DA04CA0719"><enum>(1)</enum><text>The creation of primary care mentorship programs.</text> </paragraph> <paragraph id="HC1BA55DF29FD4B5692299AB7138178B1"><enum>(2)</enum><text>Curriculum development for population-based primary care models of care, such as the patient centered medical home.</text> </paragraph> <paragraph id="H1009877B062A4085B47FF19E0D2BF08D"><enum>(3)</enum><text>Increased opportunities for ambulatory, community-based training.</text> </paragraph> <paragraph id="HC0F9CD98DE6440CB89CC324AC8EB2216"><enum>(4)</enum><text display-inline="yes-display-inline">Development of generalist curriculum to enhance care for rural and underserved populations in primary care or general surgery.</text> </paragraph></subsection> <subsection id="H6ADDB38B410B44E4AA7CD8E21656588E"><enum>(d)</enum><header>Authorization of appropriations</header><text>There is authorized to be appropriated to carry out this section $50,000,000 for each of the fiscal years 2010 through 2012.</text> </subsection></section></part><after-quoted-block>.</after-quoted-block></quoted-block> </section> <section id="H73334C371D90455A9FDD99A5CA7AC271"><enum>102.</enum><header>Debt forgiveness, scholarships, and service obligations</header> <subsection id="H2CD256B237AE4D57990FD544BE0994B8"><enum>(a)</enum><header>Purpose</header><text>It is the purpose of this section to encourage individuals to enter and continue in primary care physician careers.</text> </subsection> <subsection id="H194842F78A324457B6E7B6FB7944914B"><enum>(b)</enum><header>Amendment to the Public Health Service Act</header><text>Part D of title III of the Public Health Service Act (42 U.S.C. 254b et seq.) is amended by adding at the end the following:</text> <quoted-block display-inline="no-display-inline" id="H5AC7C841C1FF4AA7ABAAA7EE57F1C475" style="OLC"> <subpart id="HB74FE3FD1BA24B5AB7A9BA107A96D14B"><enum>XI</enum><header>Primary care medical education</header> <section id="H32AF37EC70374AA79BB39F36A3903125"><enum>340I.</enum><header>Scholarships</header> <subsection id="H26FCDFBB1BA04DB1A70DBC2A5ABE1EB9"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall award grants to critical shortage health facilities to enable such facilities to provide scholarships to individuals who agree to serve as physicians at such facilities after completing a residency in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009).</text> </subsection> <subsection id="HA39284AA11B54BEFB85FEA8D0AFD4EA8"><enum>(b)</enum><header>Scholarships</header><text>A health facility shall use amounts received under a grant under this section to enter into contracts with eligible individuals under which—</text> <paragraph id="HC18F477BF023467685D2F338BAD5994B"><enum>(1)</enum><text>the facility agrees to provide the individual with a scholarship for each school year (not to exceed 4 school years) in which the individual is enrolled as a full-time student in a school of medicine or a school of osteopathic medicine; and</text> </paragraph> <paragraph id="H61D83C3EFCEF425EA206E31F54C54ED1"><enum>(2)</enum><text>the individual agrees—</text> <subparagraph id="HAF8A91052651448581A112641746A970"><enum>(A)</enum><text>to maintain an acceptable level of academic standing;</text> </subparagraph> <subparagraph id="HC60742E60F1A4988AF29398632E08330"><enum>(B)</enum><text>to complete a residency in a primary care field; and</text> </subparagraph> <subparagraph id="HE09F3E9D70A042AE840DBF31412C862D"><enum>(C)</enum><text>after completing the residency, to serve as a primary care physician at such facility in such field for a time period equal to the greater of—</text> <clause id="H2CA2F64D92B941FBB5424EF3B1DC5E25"><enum>(i)</enum><text>one year for each school year for which the individual was provided a scholarship under this section; or</text> </clause> <clause id="HB16E902E5A60473BB7B4A46DF693D4F1"><enum>(ii)</enum><text>two years.</text> </clause></subparagraph></paragraph></subsection> <subsection id="HBB8B27CC2ABD4BD58FF10B46949A2BD8"><enum>(c)</enum><header>Amount</header> <paragraph commented="no" id="HFBA04A17855240659FA5CC2AC19310D9"><enum>(1)</enum><header>In general</header><text>The amount paid by a health facility to an individual under a scholarship under this section shall not exceed $35,000 for any school year.</text> </paragraph> <paragraph id="H158B6D9810314804AA13EE41DB1C2D1C"><enum>(2)</enum><header>Considerations</header><text>In determining the amount of a scholarship to be provided to an individual under this section, a health facility may take into consideration the individual's financial need, geographic differences, and educational costs.</text> </paragraph> <paragraph id="H657768329AD5428585CEDC883E3E736C"><enum>(3)</enum><header>Exclusion from gross income</header><text>For purposes of the Internal Revenue Code of 1986, gross income shall not include any amount received as a scholarship under this section.</text> </paragraph></subsection> <subsection id="H9C0A8FA1715542F993544D977A622144"><enum>(d)</enum><header>Application of certain provisions</header><text>The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.</text> </subsection> <subsection id="H226F888270E543C09F4D42C560DD7E38"><enum>(e)</enum><header>Definitions</header><text>In this section:</text> <paragraph id="H5D1C79ECF1F24276924C4D3BD4FE4D90"><enum>(1)</enum><header>Critical shortage health facility</header><text display-inline="yes-display-inline">The term <term>critical shortage health facility</term> means a public or private nonprofit health facility that does not serve a health professional shortage area (as designated under section 332), but has a critical shortage of physicians (as determined by the Secretary) in a primary care field.</text> </paragraph> <paragraph id="HC24626D840914C3D95221E95C696353F"><enum>(2)</enum><header>Eligible individual</header><text>The term <term>eligible individual</term> means an individual who is enrolled, or accepted for enrollment, as a full-time student in an accredited school of medicine or school of osteopathic medicine.</text> </paragraph></subsection></section> <section id="H29DCB38A808640EB8FCEE630064E78F1"><enum>340J.</enum><header>Loan repayment program</header> <subsection id="H00BA9479D48F4A7CA9FB1B4CFC4934FD"><enum>(a)</enum><header>Purpose</header><text>It is the purpose of this section to alleviate critical shortages of primary care physicians and primary care providers.</text> </subsection> <subsection id="H07FD107D1CFF4AD5A43E461E22AE19AD"><enum>(b)</enum><header>Loan repayments</header><text>The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a program of entering into contracts with eligible individuals under which—</text> <paragraph id="H800C2AF4DB3A4196B4FA508BFDF98EC1"><enum>(1)</enum><text>the individual agrees to serve—</text> <subparagraph id="H5EAECC33681F45F68AB3C2D1936FBD94"><enum>(A)</enum><text display-inline="yes-display-inline">as a primary care physician or primary care provider in a primary care field; and</text> </subparagraph> <subparagraph id="H75C6B578A8E947E2B5DA45EEB5D277FB"><enum>(B)</enum><text>in an area that is not a health professional shortage area (as designated under section 332), but has a critical shortage of primary care physicians and primary care providers (as determined by the Secretary) in such field; and</text> </subparagraph></paragraph> <paragraph id="H3AE3DC8D47F043B5983948C453C4F37B"><enum>(2)</enum><text>the Secretary agrees to pay, for each year of such service, not more than $35,000 of the principal and interest of the undergraduate or graduate educational loans of the individual.</text> </paragraph></subsection> <subsection id="H6D8E782501C940A5A2E4036B5587FA6C"><enum>(c)</enum><header>Service requirement</header><text>A contract entered into under this section shall allow the individual receiving the loan repayment to satisfy the service requirement described in subsection (a)(1) through employment in a solo or group practice, a clinic, a public or private nonprofit hospital, or any other appropriate health care entity.</text> </subsection> <subsection id="HA645DE4252B944FCB60308332C7CA390"><enum>(d)</enum><header>Application of certain provisions</header><text>The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.</text> </subsection> <subsection id="H8A74074361434E4CBBCCDB6607ABBAAA"><enum>(e)</enum><header>Definition</header><text>In this section, the term <term>eligible individual</term> means—</text> <paragraph id="HC97CAA96C6D44B08A60E980D70CA3795"><enum>(1)</enum><text>an individual with a degree in medicine or osteopathic medicine; or</text> </paragraph> <paragraph id="H69078A47758D4A78A0818113BD443B55"><enum>(2)</enum><text>a nurse practitioner.</text> </paragraph></subsection></section> <section id="H6E7DC28F37B5471CA266F9C529056E78"><enum>340K.</enum><header>Loan repayments for physicians in the fields of obstetrics and gynecology and certified nurse midwives</header> <subsection id="H2364803EC14641D8BB40AFE35E9277D4"><enum>(a)</enum><header>Purpose</header><text>It is the purpose of this section to alleviate critical shortages of physicians in the fields of obstetrics and gynecology and certified nurse midwives.</text> </subsection> <subsection id="HF297A11FC3DA4EFFBED48B5744D1A354"><enum>(b)</enum><header>Loan repayments</header><text>The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a program of entering into contracts with eligible individuals under which—</text> <paragraph id="H4492FC3B2A61495AB8C6E0456A85C8EB"><enum>(1)</enum><text>the individual agrees to serve—</text> <subparagraph id="H4D92C42DDB0A4A60A55F855745EFF3E5"><enum>(A)</enum><text>as a physician in the field of obstetrics and gynecology or as a certified nurse midwife; and</text> </subparagraph> <subparagraph id="H033BD1BF8F244DAEBB59B410FBC9C0A9"><enum>(B)</enum><text>in an area that is not a health professional shortage area (as designated under section 332), but has a critical shortage of physicians in the fields of obstetrics and gynecology or certified nurse midwives (as determined by the Secretary), respectively; and</text> </subparagraph></paragraph> <paragraph id="H74F5021C29844975BB00E4CA7CD651D"><enum>(2)</enum><text>the Secretary agrees to pay, for each year of such service, not more than $35,000 of the principal and interest of the undergraduate or graduate educational loans of the individual.</text> </paragraph></subsection> <subsection id="H81CA6EF7B2F5433BA799247407DD54BE"><enum>(c)</enum><header>Service requirement</header><text>A contract entered into under this section shall allow the individual receiving the loan repayment to satisfy the service requirement described in subsection (a)(1) through employment in a solo or group practice, a clinic, a public or private nonprofit hospital, or any other appropriate health care entity.</text> </subsection> <subsection id="H4EFFC28CC07E44AD916173669FA67F91"><enum>(d)</enum><header>Application of certain provisions</header><text>The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.</text> </subsection> <subsection id="HCE19DB85F04F48218D64B7527A20B6BD"><enum>(e)</enum><header>Definition</header><text>In this section, the term <term>eligible individual</term> means—</text> <paragraph id="HF4FDA50E2E4B461EB1180B61B02B8853"><enum>(1)</enum><text>a physician in the field of obstetrics and gynecology; or</text> </paragraph> <paragraph id="H21B986A37A43430B96E6222C2B91B68F"><enum>(2)</enum><text>a certified nurse midwife.</text> </paragraph></subsection></section> <section id="H81B8099B8B354F87938FB27AE1DA8CEC"><enum>340L.</enum><header>Reports</header><text display-inline="no-display-inline">Not later than 18 months after the date of enactment of this section, and annually thereafter, the Secretary shall submit to Congress a report that describes the programs carried out under this subpart, including statements concerning—</text> <paragraph id="H949F03B3456042C88668376551400202"><enum>(1)</enum><text>the number of enrollees, scholarships, loan repayments, and grant recipients;</text> </paragraph> <paragraph id="H2F88DA88F84F4F6FA2E413C697C691D8"><enum>(2)</enum><text>the number of graduates;</text> </paragraph> <paragraph id="HF48A5D3AA2A94DC18AAD42F485B06E92"><enum>(3)</enum><text>the amount of scholarship payments and loan repayments made;</text> </paragraph> <paragraph id="H7AC00E039BB94D8DA8FC7596574DCF51"><enum>(4)</enum><text>which educational institution the recipients attended;</text> </paragraph> <paragraph id="H20FEFB819CBE41D89C57D318073C22D9"><enum>(5)</enum><text>the number and placement location of the scholarship and loan repayment recipients at health care facilities with a critical shortage of primary care physicians;</text> </paragraph> <paragraph id="H00DD0623858745C0972CC71AB78A03C3"><enum>(6)</enum><text>the default rate and actions required;</text> </paragraph> <paragraph id="H0515D678077141C194548AF353FB528E"><enum>(7)</enum><text>the amount of outstanding default funds of both the scholarship and loan repayment programs;</text> </paragraph> <paragraph id="H37440B3982EC4A0FB1F80FB665DFE920"><enum>(8)</enum><text>to the extent that it can be determined, the reason for the default;</text> </paragraph> <paragraph id="H5533720CEBE042FFB9A44DA07821F1A9"><enum>(9)</enum><text>the demographics of the individuals participating in the scholarship and loan repayment programs;</text> </paragraph> <paragraph id="H75AF971D407845B096B803F7E7F0E987"><enum>(10)</enum><text>the justification for the allocation of funds between the scholarship and loan repayment programs; and</text> </paragraph> <paragraph id="H4892013D383346B1821D7C3CC2851511"><enum>(11)</enum><text>an evaluation of the overall costs and benefits of the programs.</text> </paragraph></section> <section id="HB7762665685E4285AC888B07113FD9DB"><enum>340M.</enum><header>Authorization of appropriations</header><text display-inline="no-display-inline">To carry out sections 340I, 340J, and 340K there are authorized to be appropriated $55,000,000 for fiscal year 2010, $90,000,000 for fiscal year 2011, and $125,000,000 for fiscal year 2012, to be used solely for scholarships and loan repayment awards for primary care physicians and primary care providers.</text> </section></subpart><after-quoted-block>.</after-quoted-block></quoted-block> </subsection></section> <section id="HE4B6D73ADD4F4D2785F5F858F464CE45"><enum>103.</enum><header>Deferment of loans during residency and internships</header> <subsection id="H439119711428464B9DF405AC99B41DFC"><enum>(a)</enum><header>Loan requirements</header><text>Section 427(a)(2)(C)(i) of the Higher Education Act of 1965 (20 U.S.C. 1077(a)(2)(C)(i)) is amended by inserting <quote>unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)</quote> after <quote>residency program</quote>.</text> </subsection> <subsection id="H1FC0627357B04B08A594A3BC82376B48"><enum>(b)</enum><header>FFEL loans</header><text display-inline="yes-display-inline">Section 428(b)(1)(M)(i) of the Higher Education Act of 1965 (20 U.S.C. 1078(b)(1)(M)(i)) is amended by inserting <quote>unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)</quote> after <quote>residency program</quote>.</text> </subsection> <subsection id="H40FEA94DB63C430F9FD527518564590B"><enum>(c)</enum><header>Federal Direct Loans</header><text display-inline="yes-display-inline">Section 455(f)(2)(A) of the Higher Education Act of 1965 (20 U.S.C. 1087e(f)(2)(A)) is amended by inserting <quote>unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)</quote> after <quote>residency program</quote>.</text> </subsection> <subsection id="H72E2388C9E2A4C50A51BCEAD787B4886"><enum>(d)</enum><header>Federal Perkins Loans</header><text>Section 464(c)(2)(A)(i) of the Higher Education Act of 1965 (20 U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting <quote>unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)</quote> after <quote>residency program</quote>.</text> </subsection></section> <section id="HA0BBB44F7D0B457D8D3B57E8270DC2D9"><enum>104.</enum><header>Educating medical students about primary care careers</header><text display-inline="no-display-inline">Part C of title VII of the Public Health Service Act (42 U.S.C. 293k) is amended by adding at the end the following:</text> <quoted-block display-inline="no-display-inline" id="HAFF0B4C65A5645ACBBCA879F83C190F1" style="OLC"> <section id="H0DA5BF9A16934E94BD9AB3182708BBCE"><enum>749.</enum><header>Educating Medical Students about Primary Care Careers</header> <subsection id="HC2250372B1564844AB1742BA7C57AFFE"><enum>(a)</enum><header>In general</header><text>The Secretary shall award grants to eligible State and local government entities for the development of informational materials that promote careers in primary care by highlighting the advantages and rewards of primary care, and that encourage medical students, particularly students from disadvantaged backgrounds, to become primary care physicians.</text> </subsection> <subsection id="HD3354D1C36684C70B5AD5B10ED5C1623"><enum>(b)</enum><header>Announcement</header><text>The grants described in subsection (a) shall be announced through a publication in the Federal Register and through appropriate media outlets in a manner intended to reach medical education institutions, associations, physician groups, and others who communicate with medical students.</text> </subsection> <subsection id="H77C2DF8842C3481399FF97BFF8198FC7"><enum>(c)</enum><header>Eligibility</header><text>To be eligible to receive a grant under this section an entity shall—</text> <paragraph id="HF6C74FC6A65B44088E3ADACDF1F5027F"><enum>(1)</enum><text>be a State or local entity; and</text> </paragraph> <paragraph id="HEDACD18FC4B74F8F97E4FAE8BD5280C1"><enum>(2)</enum><text>submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.</text> </paragraph></subsection> <subsection id="HA515FA76EA054B3382D932FF85FA98DF"><enum>(d)</enum><header>Use of funds</header> <paragraph id="H752CFA5FCE874DE8A68E1E3F2B65F037"><enum>(1)</enum><header>In general</header><text>An entity shall use amounts received under a grant under this section to support State and local campaigns through appropriate media outlets to promote careers in primary care and to encourage individuals from disadvantaged backgrounds to enter and pursue careers in primary care.</text> </paragraph> <paragraph id="H2F5154AB10A546629CFC8E85C35FF6F8"><enum>(2)</enum><header>Specific uses</header><text>In carrying out activities under paragraph (1), an entity shall use grants funds to develop informational materials in a manner intended to reach as wide and diverse an audience of medical students as possible, in order to—</text> <subparagraph id="H8C2A1BFA40D84C53BEFE84F88C567A6E"><enum>(A)</enum><text>advertise and promote careers in primary care;</text> </subparagraph> <subparagraph id="HD9B94208A4DD4ECC84666CA52FA9224F"><enum>(B)</enum><text>promote primary care medical education programs;</text> </subparagraph> <subparagraph id="H18A2FE9038AC4D28A40260AAA97FC977"><enum>(C)</enum><text>inform the public of financial assistance regarding such education programs;</text> </subparagraph> <subparagraph id="H8BA53BEF142A4ADBBFC5E971F1BB2610"><enum>(D)</enum><text>highlight individuals in the community who are practicing primary care physicians; or</text> </subparagraph> <subparagraph id="H6EC80D1098164943B142D5DAC8FEB13F"><enum>(E)</enum><text>provide any other information to recruit individuals for careers in primary care.</text> </subparagraph></paragraph></subsection> <subsection id="H930751EBED90434983E7374AAF94886A"><enum>(e)</enum><header>Limitation</header><text>An entity shall not use amounts received under a grant under this section to advertise particular employment opportunities.</text> </subsection> <subsection id="H0CF4B6B3C484451B931A78A1AE1B4893"><enum>(f)</enum><header>Authorization of appropriations</header><text>There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2010 through 2013.</text> </subsection></section><after-quoted-block>.</after-quoted-block></quoted-block> </section> <section id="HFAF6D316F4C74AA686598B197E9E4C61"><enum>105.</enum><header>Training in a family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistance, general dentistry, and pediatric dentistry</header><text display-inline="no-display-inline">Section 747(e) of the Public Health Service Act (42 U.S.C. 293k) is amended by striking paragraph (1) and inserting the following:</text> <quoted-block display-inline="no-display-inline" id="H2F4453EBCC5F475B94BDF280D71C1E5A" style="OLC"> <paragraph id="HFE833A0387A4488390EAF49067AFA5BA"><enum>(1)</enum><header>Authorization of appropriations</header><text display-inline="yes-display-inline">For the purpose of carrying out this section, there is authorized to be appropriated $198,000,000 for each of fiscal years 2010 through 2012.</text> </paragraph><after-quoted-block>.</after-quoted-block></quoted-block> </section> <section id="H3E939D64988A4CF4AB6DD773E759BA4C"><enum>106.</enum><header>Increased funding for National Health Service Corps Scholarship and Loan Repayment Programs</header> <subsection id="H12DB2BA972B343B395F93DA2CE00F4E3"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">There is authorized to be appropriated $332,000,000 for the period of fiscal years 2010 through 2012 for the purpose of carrying out subpart III of part D of title III of the Public Health Service Act (42 U.S.C. 254l et seq.). Such authorization of appropriations is in addition to the authorization of appropriations in section 338H of such Act (42 U.S.C. 254q) and any other authorization of appropriations for such purpose.</text> </subsection> <subsection id="HBAC9D3DFCE494F69A799C6807B86905B"><enum>(b)</enum><header>Allocation</header><text display-inline="yes-display-inline">Of the amounts appropriated under subsection (a) for the period of fiscal years 2010 through 2012, the Secretary shall obligate $96,000,000 for the purpose of providing contracts for scholarships and loan repayments to individuals who—</text> <paragraph id="HB4FA200CEA594B99B88DA9283D919980"><enum>(1)</enum><text>are primary care physicians or primary care providers; and</text> </paragraph> <paragraph id="H182FC39D07394903A336326E8914C67C"><enum>(2)</enum><text display-inline="yes-display-inline">have not previously received a scholarship or loan repayment under subpart III of part D of title III of the Public Health Service Act (42 U.S.C. 254l et seq.).</text> </paragraph></subsection></section> <enum>II</enum><header>Medicaid Related Provisions</header> <section id="HABCB1B0146934E57AC436B339E9BBA79"><enum>201.</enum><header>Transformation grants to support patient centered medical homes under Medicaid and CHIP</header> <subsection id="H0A532469355D40D2A903F4DC11B827DF"><enum>(a)</enum><header>In general</header><text>Section 1903(z) of the Social Security Act (42 U.S.C. 1396b(z)) is amended—</text> <paragraph id="H1988681998AE4A339AED76AEDA3BF7BB"><enum>(1)</enum><text>in paragraph (2), by adding at the end the following new subparagraph:</text> <quoted-block display-inline="no-display-inline" id="H179BE82998564FDBB8F50365D752C360" style="OLC"> <subparagraph id="H0904C1B0633B419991C2203E0306F4FE"><enum>(G)</enum><text>Methods for improving the effectiveness and efficiency of medical assistance provided under this title and child health assistance provided under title XXI by encouraging the adoption of medical practices that satisfy the standards established by the Secretary under paragraph (2) of section 3(d) of the Preserving Patient Access to Primary Care Act of 2009 for medical practices to qualify as patient centered medical homes (as defined in paragraph (1) of such section).</text> </subparagraph><after-quoted-block>; and</after-quoted-block></quoted-block> </paragraph> <paragraph id="H919A35803FDD4571842E7576A5231B28"><enum>(2)</enum><text>in paragraph (4)—</text> <subparagraph id="H690296F069024D8EA8B6E5FC97AFAF70"><enum>(A)</enum><text>in subparagraph (A)—</text> <clause id="HC2CD8F56DA41461AAC7D9B82F2812B3F"><enum>(i)</enum><text>in clause (i), by striking <quote>and</quote> at the end;</text> </clause> <clause id="HC86615791D3B4C39A9EC8119E8B8DE7D"><enum>(ii)</enum><text>in clause (ii), by striking the period at the end and inserting <quote>; and</quote>; and</text> </clause> <clause id="H940B372F3C51409E957BEBF7A209B893"><enum>(iii)</enum><text>by inserting after clause (ii), the following new clause:</text> <quoted-block display-inline="no-display-inline" id="HB02280D8828B4E85B2220ACDFC6681F9" style="OLC"> <clause id="H3DE5724460664BE08929EDBEC51D1CB3"><enum>(iii)</enum><text>$25,000,000 for each of fiscal years 2010, 2011, and 2012.</text> </clause><after-quoted-block>; and</after-quoted-block></quoted-block> </clause></subparagraph> <subparagraph id="H3D1A9C8C84F14F7EAA0475A1750CA319"><enum>(B)</enum><text>in subparagraph (B), by striking the second and third sentences and inserting the following: <quote>Such method shall provide that 100 percent of such funds for each of fiscal years 2010, 2011, and 2012 shall be allocated among States that design programs to adopt the innovative methods described in paragraph (2)(G), with preference given to States that design programs involving multipayers (including under title XVIII and private health plans) test projects for implementation of the elements necessary to be recognized as a patient centered medical home practice under the National Committee for Quality Assurance Physicians Practice Connection—PCMH module (or any other equivalent process, as determined by the Secretary).</quote>.</text> </subparagraph></paragraph></subsection> <subsection id="H9548A8BF17F64FBD8A6739733C3D2754"><enum>(b)</enum><header>Effective date</header><text>The amendments made by this section take effect on October 1, 2010.</text> </subsection></section> <enum>III</enum><header>Medicare Provisions</header> <subtitle id="H4532C20FB5E44C0CB197E8DEA7557E36"><enum>A</enum><header>Primary Care</header> <section id="HF024232963A04190B3F12E2EFEFC5E9A"><enum>301.</enum><header>Reforming payment systems under Medicare to support primary care</header> <subsection id="H28B49BAB829B4FF7AAB5B6C32D522C60"><enum>(a)</enum><header>Increasing budget neutrality limits under the physician fee schedule To account for anticipated savings resulting from payments for certain services and the coordination of beneficiary care</header><text>Section 1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended—</text> <paragraph id="H18B74EC1826C4DB1816CB676D0E62952"><enum>(1)</enum><text>in clause (ii)(II), by striking <quote>(iv) and (v)</quote> and inserting <quote>(iv), (v), and (vii)</quote>; and</text> </paragraph> <paragraph id="H031AF17E71B24018965BE840BA463B5E"><enum>(2)</enum><text>by adding at the end the following new clause:</text> <quoted-block display-inline="no-display-inline" id="HECC8D1067B964024A7F22BB6DE4DDDAD" style="OLC"> <clause id="HFB2FDF38987442AD852E32D74DACFC7D"><enum>(vii)</enum><header>Increase in limitation to account for certain anticipated savings</header> <subclause id="HF37EFB86CFC94B3AAD2611C02FD0D944"><enum>(I)</enum><header>In general</header><text>Effective for fee schedules established beginning with 2010, the Secretary shall increase the limitation on annual adjustments under clause (ii)(II) by an amount equal to the anticipated savings under parts A, B, and D (including any savings with respect to items and services for which payment is not made under this section) which are a result of payments for designated primary care services and comprehensive care coordination services under section 1834(m) and the coverage of patient centered medical home services under section 1861(s)(2)(FF) (as determined by the Secretary).</text> </subclause> <subclause id="H1AC768276C5941B9B38C82A0AF50A79C"><enum>(II)</enum><header>Mechanism to determine application of increase</header><text>The Secretary shall establish a mechanism for determining which relative value units established under this paragraph for physicians' services shall be subject to an adjustment under clause (ii)(I) as a result of the increase under subclause (I).</text> </subclause> <subclause id="H3AEC8EE86A814A8B91F31274061FFDD1"><enum>(III)</enum><header>Additional funding as determined necessary by the secretary</header><text>In addition to any funding that may be made available as a result of an increase in the limitation on annual adjustments under subclause (I), there shall also be available to the Secretary, for purposes of making payments under this title for new services and capabilities to improve care provided to individuals under this title and to generate efficiencies under this title, such additional funds as the Secretary determines are necessary.</text> </subclause></clause><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph></subsection> <subsection id="HF64A8F5F58F84FF2B0AD2631BCA3269D"><enum>(b)</enum><header>Separate medicare payment for designated primary care services and comprehensive care coordination services</header> <paragraph id="H70C319B016414F93834D9E63BE4A4805"><enum>(1)</enum><header>In general</header><text>Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:</text> <quoted-block display-inline="no-display-inline" id="H812170F3C0694940805E393828A9458C" style="OLC"> <subsection id="HC29F7B5C7F8A4B83887C14EDF5ECEF7B"><enum>(n)</enum><header>Payment for designated primary care services and comprehensive care coordination services</header> <paragraph id="H15AC6297470D47C1A5232AC11D029DC0"><enum>(1)</enum><header>In general</header><text>The Secretary shall pay for designated primary care services and comprehensive care coordination services furnished to an individual enrolled under this part.</text> </paragraph> <paragraph id="H450709025FD948099CE3CCC5BCA62F2D"><enum>(2)</enum><header>Payment amount</header><text>The Secretary shall determine the amount of payment for designated primary care services and comprehensive care coordination services under this subsection.</text> </paragraph> <paragraph commented="no" display-inline="no-display-inline" id="H6A511B53DC88474C869F733303545C5D"><enum>(3)</enum><header display-inline="yes-display-inline">Documentation requirements</header><text display-inline="yes-display-inline">The Secretary shall propose appropriate documentation requirements to justify payments for designated primary care services and comprehensive care coordination services under this subsection.</text> </paragraph> <paragraph id="HED930930172540EFB75D2B55CB701970"><enum>(4)</enum><header>Definitions</header> <subparagraph id="HBA7C7B88B0F54579B42CF65EECDD947F"><enum>(A)</enum><header>Comprehensive care coordination services</header><text>The term <term>comprehensive care coordination services</term> means care coordination services with procedure codes established by the Secretary (as appropriate) which are furnished to an individual enrolled under this part by a primary care provider or principal care physician.</text> </subparagraph> <subparagraph id="H892460247EC4492E9F3D89AB50A6C375"><enum>(B)</enum><header>Designated primary care services</header><text>The term <term>designated primary care service</term> means a service which the Secretary determines has a procedure code which involves a clinical interaction with an individual enrolled under this part that is inherent to care coordination, including interactions outside of a face-to-face encounter. Such term includes the following:</text> <clause id="H6B96B827906A441CAFE49E6435C09FBE"><enum>(i)</enum><text>Care plan oversight.</text> </clause> <clause id="HD26249965C9D45798E83546FF8E9E510"><enum>(ii)</enum><text>Evaluation and management provided by phone.</text> </clause> <clause id="HC4B03F26B2554027A16927F7138FF3D0"><enum>(iii)</enum><text>Evaluation and management provided using internet resources.</text> </clause> <clause id="HB6E2FB1E57B14FBE907DDB40C89357E0"><enum>(iv)</enum><text>Collection and review of physiologic data, such as from a remote monitoring device.</text> </clause> <clause id="H43F7B3A08106471C9A460AA2BAE864CB"><enum>(v)</enum><text>Education and training for patient self management.</text> </clause> <clause id="H786A82A46E6E464BB5EB885C3DD73A14"><enum>(vi)</enum><text>Anticoagulation management services.</text> </clause> <clause id="HA43C4D14A95C48498BE78B6626E062B4"><enum>(vii)</enum><text>Any other service determined appropriate by the Secretary.</text> </clause></subparagraph></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph> <paragraph id="HDB770750BF784A5599034EB7BDEDA086"><enum>(2)</enum><header>Effective date</header><text>The amendment made by this section shall apply to items and services furnished on or after January 1, 2010.</text> </paragraph></subsection></section> <section id="HE76E8F41039240238D7EA39AD400A0E1"><enum>302.</enum><header>Coverage of patient centered medical home services</header> <subsection id="H8FC296C8B99542BF8EF94E8F11CFE1EF"><enum>(a)</enum><header>In general</header><text>Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—</text> <paragraph id="HCC56722EDF144D8B91745C45539B6665"><enum>(1)</enum><text>in subparagraph (DD), by striking <quote>and</quote> at the end;</text> </paragraph> <paragraph id="HE940FDEEE4A341C8B3FD3E3CDAE36599"><enum>(2)</enum><text>in subparagraph (EE), by inserting <quote>and</quote> at the end; and</text> </paragraph> <paragraph id="H862410E001AD44658759B8AEBF3A1675"><enum>(3)</enum><text>by adding at the end the following new subparagraph:</text> <quoted-block display-inline="no-display-inline" id="HDD0C25CB37A74750A74E0B7403B7CB9B" style="OLC"> <subparagraph id="H96BF74B5530A4D5793C77B74C0711858" indent="up1"><enum>(FF)</enum><text>patient centered medical home services (as defined in subsection (hhh)(1));</text> </subparagraph><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph></subsection> <subsection id="H1235900E894044F3ACCEBACA549741C0"><enum>(b)</enum><header>Definition of patient centered medical home services</header><text>Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:</text> <quoted-block display-inline="no-display-inline" id="H5AC32121600041ADA6A21771BCCB916C" other-style="archaic" style="other"> <subsection id="HB35C8F82BDF8436A9FC69B1F335CCF45"><enum>(hhh)</enum><header>Patient centered medical home services</header> <paragraph commented="no" display-inline="yes-display-inline" id="HEF4BA69601E44D8D827D288C87DFED72"><enum>(1)</enum><text>The term <term>patient centered medical home services</term> means care coordination services furnished by a qualified patient centered medical home.</text> </paragraph> <paragraph id="H9689D7C7BCFC459CB77646775AD8BBBC" indent="up1"><enum>(2)</enum><text display-inline="yes-display-inline">The term <term>qualified patient centered medical home</term> means a patient centered medical home (as defined in section 3(d) of the Preserving Patient Access to Primary Care Act of 2009).</text> </paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection id="H178E3FC0EEB34F81985270DFD1A5CA5E"><enum>(c)</enum><header>Monthly fee for patient centered medical home services</header><text>Section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended by adding at the end the following new subsection:</text> <quoted-block display-inline="no-display-inline" id="H6D2DEAC6E1834C5AB0859C1372C69680" style="OLC"> <subsection id="H215D037352CF424ABA2673968C215A90"><enum>(p)</enum><header>Monthly fee for patient centered medical home services</header> <paragraph id="H4C88DBE661D349938C79E4ED779726CA"><enum>(1)</enum><header>Monthly fee</header> <subparagraph id="H9AA87590623E44818499162F398FFE8C"><enum>(A)</enum><header>In general</header><text>Not later than January 1, 2012, the Secretary shall establish a payment methodology for patient centered medical home services (as defined in paragraph (1) of section 1861(hhh)). Under such payment methodology, the Secretary shall pay qualified patient centered medical homes (as defined in paragraph (2) of such section) a monthly fee for each individual who elects to receive patient centered medical home services at that medical home. Such fee shall be paid on a prospective basis.</text> </subparagraph> <subparagraph id="H3C1C7A841A504750928C3039F737FC42"><enum>(B)</enum><header>Considerations</header><text>The Secretary shall take into account the results of the Medicare medical home demonstration project under section 204 of the Medicare Improvement and Extension Act of 2006 (42 U.S.C. 1395b–1 note; division B of Public Law 109–432) in establishing the payment methodology under subparagraph (A).</text> </subparagraph></paragraph> <paragraph id="HC8BF472F8EF64FE9A0A0F2A90739F648"><enum>(2)</enum><header>Amount of payment</header> <subparagraph id="H045ED4DF7FA64D1385725D0F68F92486"><enum>(A)</enum><header>Considerations</header><text>In determining the amount of such fee, subject to paragraph (3), the Secretary shall consider the following:</text> <clause id="H72122667E18A42FAA3F3EE6DD2543E52"><enum>(i)</enum><text>The clinical work and practice expenses involved in providing care coordination services consistent with the patient centered medical home model (such as providing increased access, care coordination, disease population management, and education) for which payment is not made under this section as of the date of enactment of this subsection.</text> </clause> <clause id="H748DDE2B23604AB786274AAEDD2F1758"><enum>(ii)</enum><text>Ensuring that the amount of payment is sufficient to support the acquisition, use, and maintenance of clinical information systems which—</text> <subclause id="H014C14A4863B462B94EDB1A87E57E36B"><enum>(I)</enum><text>are needed by a qualified patient centered medical home; and</text> </subclause> <subclause id="H99CB235059A04471ADA619EAE694678C"><enum>(II)</enum><text>have been shown to facilitate improved outcomes through care coordination.</text> </subclause></clause> <clause id="HE48C51DBE8294C2384F526D7842A55DB"><enum>(iii)</enum><text>The establishment of a tiered monthly care management fee that provides for a range of payment depending on how advanced the capabilities of a qualified patient centered medical home are in having the information systems needed to support care coordination.</text> </clause></subparagraph> <subparagraph id="HE5FCFE2F3D5A4327A9B18B71C9BFD4A7"><enum>(B)</enum><header>Risk-adjustment</header><text>The Secretary shall use appropriate risk-adjustment in determining the amount of the monthly fee under this paragraph.</text> </subparagraph></paragraph> <paragraph commented="no" id="H072F730D8677446FA2674D81EB1DA512"><enum>(3)</enum><header>Funding</header> <subparagraph commented="no" id="HE1C61FEF70E144F1A3621C8ACD7455F4"><enum>(A)</enum><header>In general</header><text>The Secretary shall determine the aggregate estimated savings for a calendar year as a result of the implementation of this subsection on reducing preventable hospital admissions, duplicate testing, medication errors and drug interactions, and other savings under this part and part A (including any savings with respect to items and services for which payment is not made under this section).</text> </subparagraph> <subparagraph commented="no" id="HB7FD238E9A5543CB8E4AB9C9238DD43F"><enum>(B)</enum><header>Funding</header><text>Subject to subparagraph (C), the aggregate amount available for payment of the monthly fee under this subsection during a calendar year shall be equal to the aggregate estimated savings (as determined under subparagraph (A)) for the calendar year (as determined by the Secretary).</text> </subparagraph> <subparagraph commented="no" id="H50AD850EA9A74C7D9BE95E7B04347BD8"><enum>(C)</enum><header>Additional funding</header><text>In the case where the amount of the aggregate actual savings during the preceding 3 years exceeds the amount of the aggregate estimated savings (as determined under subparagraph (A)) during such period, the aggregate amount available for payment of the monthly fee under this subsection during the calendar year (as determined under subparagraph (B)) shall be increased by the amount of such excess.</text> </subparagraph> <subparagraph commented="no" display-inline="no-display-inline" id="HB628ACFEA0A24C8D98F58A4A804E1297"><enum>(D)</enum><header display-inline="yes-display-inline">Additional funding as determined necessary by the secretary</header><text display-inline="yes-display-inline">In addition to any funding made available under subparagraphs (B) and (C), there shall also be available to the Secretary, for purposes of effectively implementing this subsection, such additional funds as the Secretary determines are necessary.</text> </subparagraph></paragraph> <paragraph id="H365868AEAC3943A6A709148C374A3A5A"><enum>(4)</enum><header>Performance-based bonus payments</header><text>The Secretary shall establish a process for paying a performance-based bonus to qualified patient centered medical homes which meet or achieve substantial improvements in performance (as specified under clinical, patient satisfaction, and efficiency benchmarks established by the Secretary). Such bonus shall be in an amount determined appropriate by the Secretary.</text> </paragraph> <paragraph commented="no" id="HF7DF92BC0D0D493BB71936858C8A502B"><enum>(5)</enum><header>No effect on payments for evaluation and management services</header><text>The monthly fee under this subsection shall have no effect on the amount of payment for evaluation and management services under this title.</text> </paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection commented="no" id="H8CD5CF9A0A6E49318F17FF7785383167"><enum>(d)</enum><header>Coinsurance</header><text>Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—</text> <paragraph commented="no" id="H01026B0663624C45B252D990D8167AC5"><enum>(1)</enum><text>by striking <quote>and</quote> before <quote>(W)</quote>; and</text> </paragraph> <paragraph commented="no" id="H42A23DE758C64966BDB4B756830A8909"><enum>(2)</enum><text>by inserting before the semicolon at the end the following: <quote>, and (X) with respect to patient centered medical home services (as defined in section 1861(hhh)(1)), the amount paid shall be (i) in the case of such services which are physicians' services, the amount determined under subparagraph (N), and (ii) in the case of all other such services, 80 percent of the lesser of the actual charge for the service or the amount determined under a fee schedule established by the Secretary for purposes of this subparagraph</quote>.</text> </paragraph></subsection> <subsection commented="no" id="H87410B2734234760B2476B12C66DC297"><enum>(e)</enum><header>Effective date</header><text>The amendments made by this section shall apply to services furnished on or after January 1, 2012.</text> </subsection></section> <section id="H534DBE4863F5406DB69D5BE788820CB6"><enum>303.</enum><header>Medicare primary care payment equity and access provision</header> <subsection id="H23B053AF1EB54862BA70261085634A51"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Section 1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended by section 302(c), is amended by adding at the end the following new subsection:</text> <quoted-block display-inline="no-display-inline" id="HF7DDAA40A4754AE3A8D6340F42F4D7A9" style="OLC"> <subsection id="H5398F90120354DA29369A8369907A982"><enum>(q)</enum><header>Primary care payment equity and access</header> <paragraph id="H619EB9F851BA4E2BBB2359B818EC0DAC"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Not later than January 1, 2010, the Secretary shall develop a methodology, in consultation with primary care physician organizations and primary care provider organizations, the Medicare Payment Advisory Commission, and other experts, to increase payments under this section for designated evaluation and management services provided by primary care physicians, primary care providers, and principal care providers through 1 or more of the following:</text> <subparagraph id="HFE0DDE477EA64388AF9D7D2F56930F9B"><enum>(A)</enum><text display-inline="yes-display-inline">A service-specific modifier to the relative value units established for such services.</text> </subparagraph> <subparagraph id="H9C075FA6733B460FAB4E67BB718983E1"><enum>(B)</enum><text display-inline="yes-display-inline">Service-specific bonus payments.</text> </subparagraph> <subparagraph id="H309BA2724022460FAC02A4340D567910"><enum>(C)</enum><text display-inline="yes-display-inline">Any other methodology determined appropriate by the Secretary.</text> </subparagraph></paragraph> <paragraph id="HB23665D1EA1C4D7F9F5554F995CDAB31"><enum>(2)</enum><header>Inclusion of proposed criteria</header><text display-inline="yes-display-inline">The methodology developed under paragraph (1) shall include proposed criteria for providers to qualify for such increased payments, including consideration of—</text> <subparagraph id="H42F72537925F4DDEA241A7F77ED0102B"><enum>(A)</enum><text display-inline="yes-display-inline">the type of service being rendered;</text> </subparagraph> <subparagraph id="H72E730FD42C34E138F595C34995C06B7"><enum>(B)</enum><text display-inline="yes-display-inline">the specialty of the provider providing the service; and</text> </subparagraph> <subparagraph id="HB7FF69BD3ACB40A3B667551689251EC6"><enum>(C)</enum><text display-inline="yes-display-inline">demonstration by the provider of voluntary participation in programs to improve quality, such as participation in the Physician Quality Reporting Initiative (as determined by the Secretary) or practice-level qualification as a patient centered medical home.</text> </subparagraph></paragraph> <paragraph id="H18F742CEC03E41CB84AD11EFB7542CC6"><enum>(3)</enum><header>Funding</header> <subparagraph id="HBBEDBE9C1F3E40338D073681B99CFC38"><enum>(A)</enum><header>Determination</header><text display-inline="yes-display-inline">The Secretary shall determine the aggregate estimated savings for a calendar year as a result of such increased payments on reducing preventable hospital admissions, duplicate testing, medication errors and drug interactions, Intensive Care Unit admissions, per capita health care expenditures, and other savings under this part and part A (including any savings with respect to items and services for which payment is not made under this section).</text> </subparagraph> <subparagraph commented="no" id="H3DD6D7C3B67A466C8C6A9CA01EE30B78"><enum>(B)</enum><header>Funding</header><text display-inline="yes-display-inline">The aggregate amount available for such increased payments during a calendar year shall be equal to the aggregate estimated savings (as determined under subparagraph (A)) for the calendar year (as determined by the Secretary).</text> </subparagraph> <subparagraph commented="no" id="H2235498903A046CDBE08F7D616A0781B"><enum>(C)</enum><header>Additional funding as determined necessary by the secretary</header><text display-inline="yes-display-inline">In addition to any funding made available under subparagraph (B), there shall also be available to the Secretary, for purposes of effectively implementing this subsection, such additional funds as the Secretary determines are necessary.</text> </subparagraph></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection id="H17F67FDFA6D748D8B163C02ED20C9FC2"><enum>(b)</enum><header>Effective date</header><text>The amendment made by this section shall apply to services furnished on or after January 1, 2010.</text> </subsection></section> <section id="H295715AA7D9E4A95BA125D287D3AA39F"><enum>304.</enum><header>Additional incentive payment program for primary care services furnished in health professional shortage areas</header> <subsection id="H0754DE046AB54955B7F9050DA1E2CF62"><enum>(a)</enum><header>In general</header><text>Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended by adding at the end the following new subsection:</text> <quoted-block display-inline="no-display-inline" id="HE52C0EAC237D4D149BB5BAB8B733BED5" style="OLC"> <subsection commented="no" display-inline="no-display-inline" id="H17AA0D69AC18470BB974FD3308AF2D7D"><enum>(x)</enum><header display-inline="yes-display-inline">Additional incentive payments for primary care services furnished in health professional shortage areas</header> <paragraph commented="no" display-inline="no-display-inline" id="H8F6DFC8F1AC7487BB3354E1C52839073"><enum>(1)</enum><header>In general</header><text>In the case of primary care services furnished on or after January 1, 2010, by a primary care physician or primary care provider in an area that is designated (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area as identified by the Secretary prior to the beginning of the year involved, in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service under this part.</text> </paragraph> <paragraph commented="no" display-inline="no-display-inline" id="H934AD0825F1047C7B114D26151842CDC"><enum>(2)</enum><header>Definitions</header><text>In this subsection:</text> <subparagraph commented="no" display-inline="no-display-inline" id="H3AD17395D1FE4D01A77245EE3552F607"><enum>(A)</enum><header>Primary care physician; primary care provider</header><text display-inline="yes-display-inline">The terms <term>primary care physician</term> and <term>primary care provider</term> have the meaning given such terms in paragraphs (6) and (7), respectively, of section 3(a) of the Preserving Patient Access to Primary Care Act of 2009.</text> </subparagraph> <subparagraph commented="no" display-inline="no-display-inline" id="H21D6DCA327754FA5BA86A056835653A0"><enum>(B)</enum><header>Primary care services</header><text>The term <term>primary care services</term> means procedure codes for services in the category of the Healthcare Common Procedure Coding System, as established by the Secretary under section 1848(c)(5) (as of December 31, 2008, and as subsequently modified by the Secretary) consisting of evaluation and management services, but limited to such procedure codes in the category of office or other outpatient services, and consisting of subcategories of such procedure codes for services for both new and established patients.</text> </subparagraph></paragraph> <paragraph id="HD1F7E5056F4C4731A3F94E71AA46A2F3"><enum>(3)</enum><header>Judicial review</header><text>There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the identification of primary care physicians, primary care providers, or primary care services under this subsection.</text> </paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection commented="no" display-inline="no-display-inline" id="H62D9C5D902C746849B3425175FD1D2F2"><enum>(b)</enum><header>Conforming amendment</header><text>Section 1834(g)(2)(B) of the Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by adding at the end the following sentence: <quote>Section 1833(x) shall not be taken into account in determining the amounts that would otherwise be paid pursuant to the preceding sentence.</quote>.</text> </subsection></section> <section id="H2D91D09C1F814CE0AA136E953DAE2255"><enum>305.</enum><header>Permanent extension of floor on Medicare work geographic adjustment under the Medicare physician fee schedule</header><text display-inline="no-display-inline">Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w–4(e)(1)(E)) is amended by striking <quote>and before January 1, 2010,</quote>.</text> </section> <section id="H76395CE272F948F39C3D7DF4528EBD50" section-type="subsequent-section"><enum>306.</enum><header>Permanent extension of Medicare incentive payment program for physician scarcity areas</header><text display-inline="no-display-inline">Section 1833(u) of the Social Security Act (42 U.S.C. 1395l(u)) is amended—</text> <paragraph id="HD1566C3D0DC7439D8B37B646B5C38972"><enum>(1)</enum><text display-inline="yes-display-inline">in paragraph (1)—</text> <subparagraph id="HAF67E0658AD74F488835276D6AF96B6A"><enum>(A)</enum><text display-inline="yes-display-inline">by inserting <quote>or on or after July 1, 2009</quote> after <quote>before July 1, 2008</quote>; and</text> </subparagraph> <subparagraph id="H8D9ED361ACD54CAAAABADB810E53E9F5"><enum>(B)</enum><text>by inserting <quote>(or, in the case of services furnished on or after July 1, 2009, 10 percent)</quote> after <quote>5 percent</quote>; and</text> </subparagraph></paragraph> <paragraph commented="no" display-inline="no-display-inline" id="HFCEDAB86F1DD4BB7B2B119BDFF8C549F"><enum>(2)</enum><text>in paragraph (4)(D), by striking <quote>before July 1, 2008</quote> and inserting <quote>before January 1, 2010</quote>.</text> </paragraph></section> <section id="H427E6DEC7F394A34AB265A52E09B159A"><enum>307.</enum><header>HHS study and report on the process for determining relative value under the Medicare physician fee schedule</header> <subsection id="H941BBE795576488596A415FAAB1320D1"><enum>(a)</enum><header>Study</header><text>The Secretary shall conduct a study on the process used by the Secretary for determining relative value under the Medicare physician fee schedule under section 1848(c) of the Social Security Act (42 U.S.C. 1395w–4(c)). Such study shall include an analysis of the following:</text> <paragraph id="HC6251D2CD6984F2F9BF0F909EA369B55"><enum>(1)</enum> <subparagraph commented="no" display-inline="yes-display-inline" id="H11E1E05699A74EA7A4A9F0443DDC0245"><enum>(A)</enum><text>Whether the existing process includes equitable representation of primary care physicians (as defined in section 3(a)(6)); and</text> </subparagraph> <subparagraph id="HF2AFBA2586BD4D4C991313D13F0EEE65" indent="up1"><enum>(B)</enum><text>any changes that may be necessary to ensure such equitable representation.</text> </subparagraph></paragraph> <paragraph id="H44A1AF7E67A543FFA2A2AA93C11064FB"><enum>(2)</enum> <subparagraph commented="no" display-inline="yes-display-inline" id="HA3A6B48C923A4BDEB5D53EA25ABB5B6C"><enum>(A)</enum><text>Whether the existing process provides the Secretary with expert and impartial input from physicians in medical specialties that provide primary care to patients with multiple chronic diseases, the fastest growing part of the Medicare population; and</text> </subparagraph> <subparagraph id="H00EC5BD8801C44949191A8F89D120A01" indent="up1"><enum>(B)</enum><text>any changes that may be necessary to ensure such input.</text> </subparagraph></paragraph> <paragraph id="H6D204C194A7C4508BED269B1A93F1DAE"><enum>(3)</enum> <subparagraph commented="no" display-inline="yes-display-inline" id="H946BC94789294993B452FE7C179A33F7"><enum>(A)</enum><text>Whether the existing process includes equitable representation of physician medical specialties in proportion to their relative contributions toward caring for Medicare beneficiaries, as determined by the percentage of Medicare billings per specialty, percentage of Medicare encounters by specialty, or such other measures of relative contributions to patient care as determined by the Secretary; and</text> </subparagraph> <subparagraph id="H6EF81AD91F044CC3AE13DEC956F57BA4" indent="up1"><enum>(B)</enum><text>any changes that may be necessary to reflect such equitable representation.</text> </subparagraph></paragraph> <paragraph id="H6B53256395DD4BEBB3B2C5E988B19160"><enum>(4)</enum> <subparagraph commented="no" display-inline="yes-display-inline" id="H1E4EDEE4FC14404BBAFEF94C5F1DE0C8"><enum>(A)</enum><text>Whether the existing process, including the application of budget neutrality rules, unfairly disadvantages primary care physicians, primary care providers, or other physicians who principally provide evaluation and management services; and</text> </subparagraph> <subparagraph id="HDB453A7227E84B35BE08DBF6F873854E" indent="up1"><enum>(B)</enum><text>any changes that may be necessary to eliminate such disadvantages.</text> </subparagraph></paragraph></subsection> <subsection id="HCBF243CCF22D47E286DB65FBDCDE80BB"><enum>(b)</enum><header>Report</header><text>Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.</text> </subsection></section></subtitle> <subtitle id="HCF249449260448E38A76C46EA3B9FF60"><enum>B</enum><header>Preventive services</header> <section id="H62220A7D6C1840809D29481F8BA0AAB1"><enum>311.</enum><header>Eliminating time restriction for initial preventive physical examination</header> <subsection id="H2C8B5C9E4CA241278D5FEBF7F01DC87B"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Section 1862(a)(1)(K) of the Social Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended by striking <quote>more than</quote> and all that follows before the comma at the end and inserting <quote>more than one time during the lifetime of the individual</quote>.</text> </subsection> <subsection id="H49BBB606CA8B4D4BB59FBA852FF6EFE4"><enum>(b)</enum><header>Effective date</header><text>The amendments made by this section shall apply to services furnished on or after January 1, 2010.</text> </subsection></section> <section id="H668B48632846413BB82F80534D4D06D8"><enum>312.</enum><header>Elimination of cost-sharing for preventive benefits under the Medicare program</header> <subsection id="HAD61FEDBF1FF4D368ECEF51D58F58A4F"><enum>(a)</enum><header>Definition of preventive services</header><text>Section 1861(ddd) of the Social Security Act (42 U.S.C. 1395w(dd)) is amended—</text> <paragraph id="H983E141FB07147379628D5ED04A8D6ED"><enum>(1)</enum><text>in the heading, by inserting <quote><header-in-text level="subsection" other-style="archaic" style="other">; preventive services</header-in-text></quote> after <quote><header-in-text level="subsection" other-style="archaic" style="other">services</header-in-text></quote>;</text> </paragraph> <paragraph id="HAC5D4112A102447DB44CD6E091CA19EF"><enum>(2)</enum><text>in paragraph (1), by striking <quote>not otherwise described in this title</quote> and inserting <quote>not described in subparagraphs (A) through (N) of paragraph (3)</quote>; and</text> </paragraph> <paragraph id="HD2EFF300CF1D4C77AC47FEA2D2ABCC5C"><enum>(3)</enum><text>by adding at the end the following new paragraph:</text> <quoted-block display-inline="no-display-inline" id="H583F143F5F924024A63D0D6CAE3381CC" style="OLC"> <paragraph id="H4C237378F7DB41BA84FF1BB59A0DE009" indent="up1"><enum>(3)</enum><text>The term <term>preventive services</term> means the following:</text> <subparagraph id="H977446EC46574D5A968426DB538E517F"><enum>(A)</enum><text display-inline="yes-display-inline">Prostate cancer screening tests (as defined in subsection (oo)).</text> </subparagraph> <subparagraph id="H33BFD416FC484FB1B807456E02725D7B"><enum>(B)</enum><text>Colorectal cancer screening tests (as defined in subsection (pp)).</text> </subparagraph> <subparagraph id="H4F14072AC1E4463E96765949FBF1D393"><enum>(C)</enum><text>Diabetes outpatient self-management training services (as defined in subsection (qq)).</text> </subparagraph> <subparagraph id="H52D339701CFC452C824457F89E86289C"><enum>(D)</enum><text>Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)).</text> </subparagraph> <subparagraph id="HAB33E28F260D4B9490746B3D6CEF8F02"><enum>(E)</enum><text>Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)).</text> </subparagraph> <subparagraph id="H58F2996C7241465FA2A0EDB403C600DF"><enum>(F)</enum><text>An initial preventive physical examination (as defined in subsection (ww)).</text> </subparagraph> <subparagraph id="HBE188C0F363045C4A0D592AB7A323C2C"><enum>(G)</enum><text>Cardiovascular screening blood tests (as defined in subsection (xx)(1)).</text> </subparagraph> <subparagraph id="H28E3D47161294340870EFE767A10E805"><enum>(H)</enum><text>Diabetes screening tests (as defined in subsection (yy)).</text> </subparagraph> <subparagraph id="H61598F56E4EB4E6AAFBE41BBA3E11162"><enum>(I)</enum><text>Ultrasound screening for abdominal aortic aneurysm for certain individuals (as described in subsection (s)(2)(AA)).</text> </subparagraph> <subparagraph id="H2BB8B161080944EAA66383CD75B32A1A"><enum>(J)</enum><text>Pneumococcal and influenza vaccine and their administration (as described in subsection (s)(10)(A)).</text> </subparagraph> <subparagraph id="H08CACBD1FA3F48E4A4F65E6AE20A9F41"><enum>(K)</enum><text>Hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)).</text> </subparagraph> <subparagraph id="HD6B82043F0D9456AB4A0CAAE7BA09BCD"><enum>(L)</enum><text>Screening mammography (as defined in subsection (jj)).</text> </subparagraph> <subparagraph id="H178B1F4C60FB4711BE68D6E99BAF4C0C"><enum>(M)</enum><text>Screening pap smear and screening pelvic exam (as described in subsection (s)(14)).</text> </subparagraph> <subparagraph id="H17E87FE324B441FDA0ADB769A6002396"><enum>(N)</enum><text>Bone mass measurement (as defined in subsection (rr)).</text> </subparagraph> <subparagraph id="H4643DF7023B3423BB02389B46A968722"><enum>(O)</enum><text>Additional preventive services (as determined under paragraph (1)).</text> </subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph></subsection> <subsection id="H959CDEA6641F4BCC89A66CAF77C1630D"><enum>(b)</enum><header>Coinsurance</header> <paragraph id="HA2E0D5D472B74DE484578E2F7924187E"><enum>(1)</enum><header>General application</header> <subparagraph id="H837B0FBD8D9046838473F033BB7B0B96"><enum>(A)</enum><header>In general</header><text>Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 302, is amended—</text> <clause id="HF48B037A752B4C0C9C45C643DF0FFDA5"><enum>(i)</enum><text>in subparagraph (T), by striking <quote>80 percent</quote> and inserting <quote>100 percent</quote>;</text> </clause> <clause id="H2C709E4779844336851A75A23FA2A03E"><enum>(ii)</enum><text>in subparagraph (W), by striking <quote>80 percent</quote> and inserting <quote>100 percent</quote>;</text> </clause> <clause id="HDE13475906364F20967850F573EE5ACA"><enum>(iii)</enum><text>by striking <quote>and</quote> before <quote>(X)</quote>; and</text> </clause> <clause commented="no" display-inline="no-display-inline" id="HDD48EFA4BEC949D59DD80D10ECE6AC03"><enum>(iv)</enum><text>by inserting before the semicolon at the end the following: <quote>, and (Y) with respect to preventive services described in subparagraphs (A) through (O) of section 1861(ddd)(3), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the fee schedule that applies to such services under this part</quote>.</text> </clause></subparagraph></paragraph> <paragraph id="H8C4AFACEFE674399B1C208C23FF3DB6D"><enum>(2)</enum><header>Elimination of coinsurance for screening sigmoidoscopies and colonoscopies</header><text>Section 1834(d) of the Social Security Act (42 U.S.C. 1395m(d)) is amended—</text> <subparagraph id="H65C299B8489E4BCBA30058A16892F14B"><enum>(A)</enum><text>in paragraph (2)—</text> <clause id="H61540651F9FF46EAB91E8D86F2EEEB8B"><enum>(i)</enum><text>in subparagraph (A), by inserting <quote>, except that payment for such tests under such section shall be 100 percent of the payment determined under such section for such tests</quote> before the period at the end; and</text> </clause> <clause id="H940D7BE4DE914CA991A100B25CCA2F14"><enum>(ii)</enum><text>in subparagraph (C)—</text> <subclause id="H49AAFE474EE8402FB5514213623A5309"><enum>(I)</enum><text>by striking clause (ii); and</text> </subclause> <subclause id="H0DB3E7A5E28E43DAA588626C52605CA8"><enum>(II)</enum><text>in clause (i)—</text> <item id="H072F080425B84B169348C3202282EB75"><enum>(aa)</enum><text>by striking <quote>(i) <header-in-text level="clause" style="OLC">In general.—</header-in-text>Notwithstanding</quote> and inserting <quote>Notwithstanding</quote>;</text> </item> <item id="HFA895193168F4EFC82B90045ED90A379"><enum>(bb)</enum><text>by redesignating subclauses (I) and (II) as clauses (i) and (ii), respectively, and moving such clauses 2 ems to the left; and</text> </item> <item id="H60526D791FDB4DE8856A4BE0218AD0F4"><enum>(cc)</enum><text>in the flush matter following clause (ii), as so redesignated, by inserting <quote>100 percent of</quote> after <quote>based on</quote>; and</text> </item></subclause></clause></subparagraph> <subparagraph id="H1C04E590761F4B548076A36E0339454E"><enum>(B)</enum><text>in paragraph (3)—</text> <clause id="HDC3F802C4B92453A9412CEB3817152C9"><enum>(i)</enum><text>in subparagraph (A), by inserting <quote>, except that payment for such tests under such section shall be 100 percent of the payment determined under such section for such tests</quote> before the period at the end; and</text> </clause> <clause id="H3B1CD60837BC493FB6E042E5CD2A7059"><enum>(ii)</enum><text>in subparagraph (C)—</text> <subclause id="H5F1DCDD0444743739300F8C5DB795022"><enum>(I)</enum><text>by striking clause (ii); and</text> </subclause> <subclause id="H868092B472874EA5A2206FB768952453"><enum>(II)</enum><text>in clause (i)—</text> <item id="H57ECA8DC7DCF4BCF8A458AFEB0C2C32D"><enum>(aa)</enum><text>by striking <quote>(i) <header-in-text level="clause" style="OLC">In general.—</header-in-text>Notwithstanding</quote> and inserting <quote>Notwithstanding</quote>; and</text> </item> <item id="HF14134D0AC354BD88845EFF37C799A19"><enum>(bb)</enum><text>by inserting <quote>100 percent of</quote> after <quote>based on</quote>.</text> </item></subclause></clause></subparagraph></paragraph> <paragraph id="H50E82A554B87435B92A23BD72439835A"><enum>(3)</enum><header>Elimination of coinsurance in outpatient hospital settings</header> <subparagraph id="H127D84019932400D92B2930AB75F5C2F"><enum>(A)</enum><header>Exclusion from OPD fee schedule</header><text>Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking <quote>and diagnostic mammography</quote> and inserting <quote>, diagnostic mammography, and preventive services (as defined in section 1861(ddd)(3))</quote>.</text> </subparagraph> <subparagraph id="H42D1A186164D4EC8A18700D66CA5868E"><enum>(B)</enum><header>Conforming amendments</header><text>Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended—</text> <clause id="HC8E8EB8A27564741872902F40645143E"><enum>(i)</enum><text>in subparagraph (F), by striking <quote>and</quote> after the semicolon at the end;</text> </clause> <clause id="H60DA56BB55F64806A64F1A4CEF471CE2"><enum>(ii)</enum><text>in subparagraph (G)(ii), by adding <quote>and</quote> at the end; and</text> </clause> <clause id="HF97737D0CB3442119CC60363C245093D"><enum>(iii)</enum><text>by adding at the end the following new subparagraph:</text> <quoted-block id="H03483B59E3754F0991BB362AC4E02D70"> <subparagraph id="H24FF482804B04DC99FC4813B3BAAA9A1"><enum>(H)</enum><text>with respect to preventive services (as defined in section 1861(ddd)(3)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(W) or (1)(X), as applicable;</text> </subparagraph><after-quoted-block>.</after-quoted-block></quoted-block> </clause></subparagraph></paragraph></subsection> <subsection id="HDE3BD3BA486240A7894D64843575C97A"><enum>(c)</enum><header>Waiver of application of deductible</header><text>The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended—</text> <paragraph id="H18F1B3DFA80D483E86CC098A2B35D5E1"><enum>(1)</enum><text>in clause (1), by striking <quote>items and services described in section 1861(s)(10)(A)</quote> and inserting <quote>preventive services (as defined in section 1861(ddd)(3))</quote>;</text> </paragraph> <paragraph id="H540D923173FD4E2CA5FBA783BEF24EA4"><enum>(2)</enum><text>by inserting <quote>and</quote> before <quote>(4)</quote>; and</text> </paragraph> <paragraph commented="no" display-inline="no-display-inline" id="H3136B89F1BD3421FBD7DFAADF5EA7AFE"><enum>(3)</enum><text>by striking <quote>, (5)</quote> and all that follows up to the period at the end.</text> </paragraph></subsection></section> <section commented="no" display-inline="no-display-inline" id="H4213D684B25444C590533721854ABBD0"><enum>313.</enum><header>HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries</header> <subsection id="H62D119C78D684062888B0DE892C101FA"><enum>(a)</enum><header>Study</header><text>The Secretary, in consultation with provider organizations and other appropriate stakeholders, shall conduct a study on—</text> <paragraph id="HE41DB14D0A084E67A2A31A7C63F1915C"><enum>(1)</enum><text>ways to assist primary care physicians and primary care providers (as defined in section 3(a)) in—</text> <subparagraph id="H8D0BFB8121F64F2D9227F7E94ED0A15A"><enum>(A)</enum><text>furnishing appropriate preventive services (as defined in section 1861(ddd)(3) of the Social Security Act, as added by section 312) to individuals enrolled under part B of title XVIII of such Act; and</text> </subparagraph> <subparagraph id="H4B5056E012754FFDB5E1831ECCA484A7"><enum>(B)</enum><text>referring such individuals for other items and services furnished by other physicians and health care providers; and</text> </subparagraph></paragraph> <paragraph id="H5BED5978131141DAB7AB7CCC3AEA586D"><enum>(2)</enum><text>the advisability and feasability of making additional payments under the Medicare program to physicians and primary care providers for—</text> <subparagraph id="HF98380AA811B4AF5B1532AC4EF7AFB1D"><enum>(A)</enum><text>the work involved in ensuring that such individuals receive appropriate preventive services furnished by other physicians and health care providers; and</text> </subparagraph> <subparagraph id="H3FD9E166EC584B24B3382E8812B5929F"><enum>(B)</enum><text>incorporating the resulting clinical information into the treatment plan for the individual.</text> </subparagraph></paragraph></subsection> <subsection id="HF80FA3BCDDF9412DA864DE7B7697E439"><enum>(b)</enum><header>Report</header><text>Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.</text> </subsection></section></subtitle> <subtitle id="H34552C0F05AE4BB493CB3AA2D48EEC5A"><enum>C</enum><header>Other provisions</header> <section commented="no" display-inline="no-display-inline" id="H5A6C0CE508E84749892181AC826C2F4C"><enum>321.</enum><header>HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D</header> <subsection id="H16F97F9508414FF0B764781C40FC536D"><enum>(a)</enum><header>Study</header><text>The Secretary, in consultation with physician organizations and other appropriate stakeholders, shall conduct a study on the development and implementation of mechanisms to facilitate increased efficiency relating to the role of physicians and primary care providers in Medicare beneficiaries obtaining needed prescription drugs under the Medicare prescription drug program under part D of title XVIII of the Social Security Act. Such study shall include an analysis of ways to—</text> <paragraph id="H819F37B4DE5B4A43BC101848F8C90B5B"><enum>(1)</enum><text>improve the accessibility of formulary information;</text> </paragraph> <paragraph id="HAF5D96141FA24ACD825BC4A74DCC8A6A"><enum>(2)</enum><text>streamline the prior authorization, exception, and appeals processes, through, at a minimum, standardizing formats and allowing electronic exchange of information; and</text> </paragraph> <paragraph id="H8288DC49EF444936A750F3403153BD17"><enum>(3)</enum><text>recognize the work of the physician and primary care provider involved in the prescribing process, especially work that may extend beyond the amount considered to be bundled into payment for evaluation and management services.</text> </paragraph></subsection> <subsection id="HEF4BE7D857CC417B84BAE5DA137A825F"><enum>(b)</enum><header>Report</header><text>Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.</text> </subsection></section> <section id="H985E16C69E4C492E9AFDD129418B4791"><enum>322.</enum><header>HHS study and report on improved patient care through increased caregiver and physician interaction</header> <subsection id="H088530002A5544B6B3D46C68F33BA1DF"><enum>(a)</enum><header>Study</header><text>The Secretary, in consultation with appropriate stakeholders, shall conduct a study on the development and implementation of mechanisms to promote and increase interaction between physicians or primary care providers and the families of Medicare beneficiaries, as well as other caregivers who support such beneficiaries, for the purpose of improving patient care under the Medicare program. Such study shall include an analysis of—</text> <paragraph id="HA14E7770C3E14FEAAC8098E893EF278E"><enum>(1)</enum><text>ways to recognize the work of physicians and primary care providers involved in discussing clinical issues with caregivers that relate to the care of the beneficiary; and</text> </paragraph> <paragraph id="HF62615E101244B6681DEEEFBF58ECD00"><enum>(2)</enum><text>regulations under the Medicare program that are barriers to interactions between caregivers and physicians or primary care providers and how such regulations should be revised to eliminate such barriers.</text> </paragraph></subsection> <subsection id="H78812DAD038143E095E04867D44DE98D"><enum>(b)</enum><header>Report</header><text>Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.</text> </subsection></section> <section id="HE507D71C5195459A8D6FF9CA6A1A9BDC"><enum>323.</enum><header>Improved patient care through expanded support for limited English proficiency (LEP) services</header> <subsection id="HBFD58E60E9044124A74BEF962AF7705F"><enum>(a)</enum><header>Additional payments for primary care physicians and primary care providers</header><text>Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section 304, is amended by adding at the end the following new subsection:</text> <quoted-block display-inline="no-display-inline" id="H4730F98F2DC642A4A5CF85FADB2EB40F" style="OLC"> <subsection id="H02BD2236C99C4DE1B7C8C1B573D84FEA"><enum>(y)</enum><header>Additional payments for providing services to individuals with limited English proficiency</header> <paragraph id="H43652975292C4997B411A30184E3F615"><enum>(1)</enum><header>In general</header><text>In the case of primary care physicians and primary care providers’ services furnished on or after January 1, 2010, to an individual with limited English proficiency by a provider, in addition to the amount of payment that would otherwise be made for such services under this part, there shall also be paid an appropriate amount (as determined by the Secretary) in order to recognize the additional time involved in furnishing the service to such individual.</text> </paragraph> <paragraph commented="no" display-inline="no-display-inline" id="H750117E8735C4AFA99B85CE395322517"><enum>(2)</enum><header display-inline="yes-display-inline">Judicial review</header><text display-inline="yes-display-inline">There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the determination of the amount of additional payment under this subsection.</text> </paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection id="H131F853D49CA4E0DB1CB5D41CA5C1561"><enum>(b)</enum><header>National clearinghouse</header><text>Not later than 180 days after the date of enactment of this Act, the Secretary shall establish a national clearinghouse to make available to the primary care physicians, primary care providers, patients, and States translated documents regarding patient care and education under the Medicare program, the Medicaid program, and the State Children's Health Insurance Program under titles XVIII, XIX, and XXI, respectively, of the Social Security Act.</text> </subsection> <subsection id="HCF9F3A3082F44B46BF0FCE096B3CCAED"><enum>(c)</enum><header>Grants To support language translation services in underserved communities</header> <paragraph id="H85841474D401406886D2CD940F37E7FE"><enum>(1)</enum><header>Authority to award grants</header><text>The Secretary shall award grants to support language translation services for primary care physicians and primary care providers in medically underserved areas (as defined in section 3(c)).</text> </paragraph> <paragraph id="HDBD07DA3E5ED416299AC70AF0E3F604A"><enum>(2)</enum><header>Authorization of appropriations</header><text>There are authorized to be appropriated to the Secretary to award grants under this subsection, such sums as are necessary for fiscal years beginning with fiscal year 2010.</text> </paragraph></subsection></section> <section id="HF125E6194C95412B84436B2FCE7C07F3"><enum>324.</enum><header>HHS study and report on use of real-time Medicare claims adjudication</header> <subsection id="H0209451CE5F94D64A5F462597DEF3388"><enum>(a)</enum><header>Study</header><text>The Secretary shall conduct a study to assess the ability of the Medicare program under title XVIII of the Social Security Act to engage in real-time claims adjudication for items and services furnished to Medicare beneficiaries.</text> </subsection> <subsection id="HE9A8923EF20D464E868B6BC2B864AE29"><enum>(b)</enum><header>Consultation</header><text>In conducting the study under subsection (a), the Secretary consult with stakeholders in the private sector, including stakeholders who are using or are testing real-time claims adjudication systems.</text> </subsection> <subsection id="HAD1C6243D1D54A2A9B3CD1648349720B"><enum>(c)</enum><header>Report</header><text>Not later than January 1, 2011, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.</text> </subsection></section> <section commented="no" id="H74D17F69F3154E74ACCDFF38E591A39E"><enum>325.</enum><header>Ongoing assessment by MedPAC of the impact of medicare payments on primary care access and equity</header><text display-inline="no-display-inline">The Medicare Payment Advisory Commission, beginning in 2010 and in each of its subsequent annual reports to Congress on Medicare physician payment policies, shall provide an assessment of the impact of changes in Medicare payment policies in improving access to and equity of payments to primary care physicians and primary care providers. Such assessment shall include an assessment of the effectiveness, once implemented, of the Medicare payment-related reforms required by this Act to support primary care as well as any other payment changes that may be required by Congress to improve access to and equity of payments to primary care physicians and primary care providers.</text> </section> <section id="HB945F83B6B2F4C57B2276B0A10433D5F"><enum>326.</enum><header>Distribution of additional residency positions</header> <subsection id="HE5DC3E0DD95D41B49CE105F9CDEFF850"><enum>(a)</enum><header>In general</header><text>Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended—</text> <paragraph id="H215A7FB464FD4A42B0CBE29CF5946275"><enum>(1)</enum><text>in paragraph (4)(F)(i), by striking <quote>paragraph (7)</quote> and inserting <quote>paragraphs (7) and (8)</quote>;</text> </paragraph> <paragraph id="H0833C473DC6343F29C8BE2C2B94E99FB"><enum>(2)</enum><text>in paragraph (4)(H)(i), by striking <quote>paragraph (7)</quote> and inserting <quote>paragraphs (7) and (8)</quote>; and</text> </paragraph> <paragraph id="H32626AF34C9F48109A8E185865130BB5"><enum>(3)</enum><text>by adding at the end the following new paragraph:</text> <quoted-block display-inline="no-display-inline" id="HEFAAF2C61ABD49E185850AFB1214662E" style="OLC"> <paragraph id="H1B3E4DB4CB6B41B4879E7EE81B0BCD7C"><enum>(8)</enum><header>Distribution of additional residency positions</header> <subparagraph id="H616ADC744FE74DE9B800746F7E91F4F7"><enum>(A)</enum><header>Additional residency positions</header> <clause id="HB1FF7FA13E444001BCA9AF913570FADA"><enum>(i)</enum><header>Reduction in limit based on unused positions</header> <subclause id="HEC17D0B84D3245FB9B5CC94396E96501"><enum>(I)</enum><header>In general</header><text>The Secretary shall reduce the otherwise applicable resident limit for a hospital that the Secretary determines had residency positions that were unused for all 5 of the most recent cost reporting periods ending prior to the date of enactment of this paragraph by an amount that is equal to the number of such unused residency positions.</text> </subclause> <subclause id="HEC862DE3EEC14CE3AD6CF19E93E2E20E"><enum>(II)</enum><header>Exception for rural hospitals and certain other hospitals</header><text>This subparagraph shall not apply to a hospital—</text> <item id="H11D55127A74847309130E98D96E3F9D2"><enum>(aa)</enum><text>located in a rural area (as defined in subsection (d)(2)(D)(ii));</text> </item> <item id="HBFFBC5D0F85D492FBA69BDC39CE383D8"><enum>(bb)</enum><text>that has participated in a voluntary reduction plan under paragraph (6); or</text> </item> <item id="H620A705EFD3842A1A2F2CE58962920ED"><enum>(cc)</enum><text>that has participated in a demonstration project approved as of October 31, 2003, under the authority of section 402 of Public Law 90–248.</text> </item></subclause></clause> <clause id="H6BB9E8D9F93E48668B2A55610C5F7D4C"><enum>(ii)</enum><header>Number available for distribution</header><text>The number of additional residency positions available for distribution under subparagraph (B) shall be an amount that the Secretary determines would result in a 15 percent increase in the aggregate number of full-time equivalent residents in approved medical training programs (as determined based on the most recent cost reports available at the time of distribution). One-third of such number shall only be available for distribution to hospitals described in subclause (I) of subparagraph (B)(ii) under such subparagraph.</text> </clause></subparagraph> <subparagraph id="H8E38C1C73092488DB50907CFBEA90E5D"><enum>(B)</enum><header>Distribution</header> <clause id="H0EAA1D7063844C0587410FED3CDF60A6"><enum>(i)</enum><header>In general</header><text>The Secretary shall 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 on or after the date of enactment of this paragraph. The aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to the number of additional residency positions available for distribution under subparagraph (A)(ii).</text> </clause> <clause id="HC6248DA3E383446A8985C037860EA86A"><enum>(ii)</enum><header>Distribution to hospitals already operating over resident limit</header> <subclause id="H408B81C3EB774D4DAD08692EF4792A56"><enum>(I)</enum><header>In general</header><text>Subject to subclause (II), in the case of a hospital in which the reference resident level of the hospital (as defined in clause (ii)) is greater than the otherwise applicable resident limit, the increase in the otherwise applicable resident limit under this subparagraph shall be an amount equal to the product of the total number of additional residency positions available for distribution under subparagraph (A)(ii) and the quotient of—</text> <item id="H567E5FFD6C4F4FA9B222B6135FF904B1"><enum>(aa)</enum><text>the number of resident positions by which the reference resident level of the hospital exceeds the otherwise applicable resident limit for the hospital; and</text> </item> <item id="H18584EA29D3F4AA89B1D24DB12FCDC88"><enum>(bb)</enum><text>the number of resident positions by which the reference resident level of all such hospitals with respect to which an application is approved under this subparagraph exceeds the otherwise applicable resident limit for such hospitals.</text> </item></subclause> <subclause id="H955015201A39452EA16A10124E683DDF"><enum>(II)</enum><header>Requirements</header><text>A hospital described in subclause (I)—</text> <item id="H2156085F4A354C9F83D6CF147F7EDB92"><enum>(aa)</enum><text>is not eligible for an increase in the otherwise applicable resident limit under this subparagraph unless the amount by which the reference resident level of the hospital exceeds the otherwise applicable resident limit is not less than 10 and the hospital trains at least 25 percent of the full-time equivalent residents of the hospital in primary care and general surgery (as of the date of enactment of this paragraph); and</text> </item> <item id="H6EA627F0CBD646F2B1F8EA656B368D7A"><enum>(bb)</enum><text>shall continue to train at least 25 percent of the full-time equivalent residents of the hospital in primary care and general surgery for the 10-year period beginning on such date.</text> </item><continuation-text continuation-text-level="subclause">In the case where the Secretary determines that a hospital no longer meets the requirement of item (bb), the Secretary may reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this clause.</continuation-text></subclause> <subclause id="H9D2AE2BDEA05432DAF8957ED3C4DB4DA"><enum>(III)</enum><header>Clarification regarding eligibility for other additional residency positions</header><text>Nothing in this clause shall be construed as preventing a hospital described in subclause (I) from applying for additional residency positions under this paragraph that are not reserved for distribution under this clause.</text> </subclause></clause> <clause id="HDACAAF1344B847B6B13EA1BB14BD23A9"><enum>(iii)</enum><header>Reference resident level</header> <subclause id="HD82E41A02A3E4DFBB7BBF61A2158329A"><enum>(I)</enum><header>In general</header><text>Except as otherwise provided in subclause (II), the reference resident level specified in this clause for a hospital is the resident level for the most recent cost reporting period of the hospital ending on or before the date of enactment of this paragraph, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.</text> </subclause> <subclause id="H58AB0BEABF8746E5970E03EDE73CBDAA"><enum>(II)</enum><header>Use of most recent accounting period to recognize expansion of existing program or establishment of new program</header><text>If a hospital submits a timely request to increase its resident level due to an expansion of an existing residency training program or the establishment of a new residency training program that is not reflected on the most recent cost report that has been settled (or, if not, submitted (subject to audit)), after audit and subject to the discretion of the Secretary, the reference resident level for such hospital is the resident level for the cost reporting period that includes the additional residents attributable to such expansion or establishment, as determined by the Secretary.</text> </subclause></clause></subparagraph> <subparagraph id="HCA46570799FD4989970F63753409073B"><enum>(C)</enum><header>Considerations in redistribution</header><text>In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B) (other than an increase under subparagraph (B)(ii)), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2010, made available under this paragraph, as determined by the Secretary.</text> </subparagraph> <subparagraph id="HE14A544CF43444A299CDDF864C1F2166"><enum>(D)</enum><header>Priority for certain areas</header><text>In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B) (other than an increase under subparagraph (B)(ii)), the Secretary shall distribute the increase to hospitals based on the following criteria:</text> <clause id="H7D5A25ED0F2E432B9DA4C7EF57B3D50F"><enum>(i)</enum><text>The Secretary shall give preference to hospitals that submit applications for new primary care and general surgery residency positions. In the case of any increase based on such preference, a hospital shall ensure that—</text> <subclause id="H343E186FCE604B16BCDB1990C46AA75E"><enum>(I)</enum><text>the position made available as a result of such increase remains a primary care or general surgery residency position for not less than 10 years after the date on which the position is filled; and</text> </subclause> <subclause id="HC1976C306FA5481CBA070D2B87D2A364"><enum>(II)</enum><text>the total number of primary care and general surgery residency positions in the hospital (determined based on the number of such positions as of the date of such increase, including any position added as a result of such increase) is not decreased during such 10-year period.</text> </subclause><continuation-text continuation-text-level="clause">In the case where the Secretary determines that a hospital no longer meets the requirement of subclause (II), the Secretary may reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this paragraph.</continuation-text></clause> <clause id="H517853FEC05842639292D80E001A2982"><enum>(ii)</enum><text display-inline="yes-display-inline">The Secretary shall give preference to hospitals that emphasizes training in community health centers and other community-based clinical settings.</text> </clause> <clause id="H9D3F4BF3BA5B4961AC27ED87469584AC"><enum>(iii)</enum><text>The Secretary shall give preference to hospitals in States that have more medical students than residency positions available (including a greater preference for those States with smaller resident-to-medical-student ratios). In determining the number of medical students in a State for purposes of the preceding sentence, the Secretary shall include planned students at medical schools which have provisional accreditation by the Liaison Committee on Medical Education or the American Osteopathic Association.</text> </clause> <clause id="HD837A6C7A0BC446789E94B3BA07EBCD1"><enum>(iv)</enum><text>The Secretary shall give preference to hospitals in States that have low resident-to-population ratios (including a greater preference for those States with lower resident-to-population ratios).</text> </clause></subparagraph> <subparagraph id="H681B3C9DA9474C0DBAFBCD7820E5AC92"><enum>(E)</enum><header>Limitation</header> <clause id="HBF0513ADC47B458FA8E1D744FB5FD4D9"><enum>(i)</enum><header>In general</header><text>Except as provided in clause (ii), in no case may a hospital (other than a hospital described in subparagraph (B)(ii)(I), subject to the limitation under subparagraph (B)(ii)(III)) apply for more than 50 full-time equivalent additional residency positions under this paragraph.</text> </clause> <clause id="HA1D50717F08647A980722641BF7B165D"><enum>(ii)</enum><header>Increase in number of additional positions available for distribution</header><text>The Secretary shall increase the number of full-time equivalent additional residency positions a hospital may apply for under this paragraph if the Secretary determines that the number of additional residency positions available for distribution under subparagraph (A)(ii) exceeds the number of such applications approved.</text> </clause></subparagraph> <subparagraph id="H0A758DCDE5DA4F6EB2BB42D965D5A6DD"><enum>(F)</enum><header>Application of per resident amounts for primary care and nonprimary care</header><text>With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital.</text> </subparagraph> <subparagraph id="HDAD84AD0C5C9454DBD1458E83773AAD2"><enum>(G)</enum><header>Distribution</header><text>The Secretary shall distribute the increase to hospitals under this paragraph not later than 2 years after the date of enactment of this paragraph.</text> </subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph></subsection> <subsection id="H43D110EC41F94265A9EDF6FCF77F77F6"><enum>(b)</enum><header>IME</header> <paragraph id="HC080A66E944D4F308DC2C9B9755424AD"><enum>(1)</enum><header>In general</header><text>Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, is amended—</text> <subparagraph id="H421DD3DE88684702A3FEF2841C145959"><enum>(A)</enum><text>by striking <quote>subsection (h)(7)</quote> and inserting <quote>subsections (h)(7) and (h)(8)</quote>; and</text> </subparagraph> <subparagraph commented="no" display-inline="no-display-inline" id="HD1F1523CCE394B2891C402CAE9FEE584"><enum>(B)</enum><text>by striking <quote>it applies</quote> and inserting <quote>they apply</quote>.</text> </subparagraph></paragraph> <paragraph id="HC0027FC20061447FBD54E87E4BE2F567"><enum>(2)</enum><header>Conforming provision</header><text>Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following clause:</text> <quoted-block display-inline="no-display-inline" id="H10647827B9214750B92CEC624BDF064B" style="OLC"> <clause commented="no" display-inline="no-display-inline" id="H25922779FCE641ACA1FF252C0C6889E3" indent="up2"><enum>(x)</enum><text display-inline="yes-display-inline">For discharges occurring on or after the date of enactment of this clause, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(8)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions.</text> </clause><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph></subsection></section> <section id="H69A9856DEF3E4EB991CE7D169BF51E4C" section-type="subsequent-section"><enum>327.</enum><header>Counting resident time in outpatient settings</header> <subsection id="H9B5144D24D554B2A8CDCBC29CEA10DE3"><enum>(a)</enum><header>D–GME</header><text>Section 1886(h)(4)(E) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amended—</text> <paragraph id="H527036EEEA624119925440A8043DC587"><enum>(1)</enum><text>by striking <quote>under an approved medical residency training program</quote>; and</text> </paragraph> <paragraph id="H699FD58E30364A7EAE2BBE556DB94EF0"><enum>(2)</enum><text>by striking <quote>if the hospital incurs all, or substantially all, of the costs for the training program in that setting</quote> and inserting <quote>if the hospital continues to incur the costs of the stipends and fringe benefits of the resident during the time the resident spends in that setting</quote>.</text> </paragraph></subsection> <subsection id="H40483663ECA14D94BE64E1A6A2D51AF6"><enum>(b)</enum><header>IME</header><text>Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended—</text> <paragraph id="H86D9D17055A44C75908509369672C3B2"><enum>(1)</enum><text>by striking <quote>under an approved medical residency training program</quote>; and</text> </paragraph> <paragraph id="H1D9824BD23DE4F979A413ADECEC99360"><enum>(2)</enum><text>by striking <quote>if the hospital incurs all, or substantially all, of the costs for the training program in that setting</quote> and inserting <quote>if the hospital continues to incur the costs of the stipends and fringe benefits of the intern or resident during the time the intern or resident spends in that setting</quote>.</text> </paragraph></subsection> <subsection id="HDCF770B83D7442A9AF7BB77CAE4E52B0"><enum>(c)</enum><header>Effective dates; application</header> <paragraph commented="no" id="H6800093C1C9E430FAF265D38F75D0FB8"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Effective for cost reporting periods beginning on or after July 1, 2009, the Secretary of Health and Human Services shall implement the amendments made by this section in a manner so as to apply to cost reporting periods beginning on or after July 1, 2009.</text> </paragraph> <paragraph commented="no" display-inline="no-display-inline" id="H3DBF30EC67EB4C40BC53A8E538FD6B16"><enum>(2)</enum><header>Application</header><text display-inline="yes-display-inline">The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h)).</text> </paragraph></subsection></section> <section id="H1742EE883F8C46EAA56CE24AA74A685A" section-type="subsequent-section"><enum>328.</enum><header>Rules for counting resident time for didactic and scholarly activities and other activities</header> <subsection id="H02B18713DC284E46B505AD021B3D4922"><enum>(a)</enum><header>GME</header><text>Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), as amended by section 327(a), is amended—</text> <paragraph id="H2C44366DC15947B3B0DD9BE0CB99CD85"><enum>(1)</enum><text>in paragraph (4)(E)—</text> <subparagraph id="H9E21C0929DEC496EB093F8F35B0717D6"><enum>(A)</enum><text>by designating the first sentence as a clause (i) with the heading <quote><header-in-text level="clause" style="OLC">In general</header-in-text></quote> and appropriate indentation and by striking <quote>Such rules</quote> and inserting <quote>Subject to clause (ii), such rules</quote>; and</text> </subparagraph> <subparagraph id="HEF2E7B05A9F143E980CDE4B46C969E11"><enum>(B)</enum><text>by adding at the end the following new clause:</text> <quoted-block display-inline="no-display-inline" id="HB2CDACC437764585A5EF04532025D7D8" style="OLC"> <clause id="HA43CA1393DBB47DEA53F1A4E3197DB42"><enum>(ii)</enum><header>Treatment of certain nonhospital and didactic activities</header><text display-inline="yes-display-inline">Such rules shall provide that all time spent by an intern or resident in an approved medical residency training program in a nonhospital setting that is primarily engaged in furnishing patient care (as defined in paragraph (5)(K)) in non-patient care activities, such as didactic conferences and seminars, but not including research not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall be counted toward the determination of full-time equivalency.</text> </clause><after-quoted-block>;</after-quoted-block></quoted-block> </subparagraph></paragraph> <paragraph id="H78AA594EC55A48E49E3BBEF1ABDF9F41"><enum>(2)</enum><text>in paragraph (4), by adding at the end the following new subparagraph:</text> <quoted-block display-inline="no-display-inline" id="H51D5B20F21A841B5AEDC2289431D21B7" style="OLC"> <subparagraph id="H784B3107D9AC4CE3819C6F70BBDED350"><enum>(I)</enum><text display-inline="yes-display-inline">In determining the hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program on vacation, sick leave, or other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the normal duration of the program shall be counted toward the determination of full-time equivalency.</text> </subparagraph><after-quoted-block>; and</after-quoted-block></quoted-block> </paragraph> <paragraph id="H06E33DD581E24E9CB364E27E3A6F2A32"><enum>(3)</enum><text>in paragraph (5), by adding at the end the following new subparagraph:</text> <quoted-block display-inline="no-display-inline" id="HDD22358841A044D3B5FAAC12FF7EC937" style="OLC"> <subparagraph id="HCD2644F41BD244CF81B94FB0C9C4B3C3"><enum>(M)</enum><header>Nonhospital setting that is primarily engaged in furnishing patient care</header><text display-inline="yes-display-inline">The term <term>nonhospital setting that is primarily engaged in furnishing patient care</term> means a nonhospital setting in which the primary activity is the care and treatment of patients, as defined by the Secretary.</text> </subparagraph><after-quoted-block>.</after-quoted-block></quoted-block> </paragraph></subsection> <subsection id="HCC29B97814CE4CB9970E592F2F74F24F"><enum>(b)</enum><header>IME determinations</header><text display-inline="yes-display-inline">Section 1886(d)(5)(B) of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by section 326(b), is amended by adding at the end the following new clause:</text> <quoted-block display-inline="no-display-inline" id="HBA2B23C89A9A47C4852416D56727A928" style="OLC"> <clause id="HAE22DB95CF82484A8CF110D07BEB911B" indent="up2"><enum>(xi)</enum> <subclause commented="no" display-inline="yes-display-inline" id="H251D533EE4F943C6939EA45F740146C7"><enum>(I)</enum><text display-inline="yes-display-inline">The provisions of subparagraph (I) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.</text> </subclause> <subclause id="HD1A29EF9D11C48A8ACDCEB992C502B5C" indent="up1"><enum>(II)</enum><text display-inline="yes-display-inline">In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary, that occurs in the hospital shall be counted toward the determination of full-time equivalency if the hospital—</text> <item id="HACDC787A6AB14430A60B15C738931446"><enum>(aa)</enum><text>is recognized as a subsection (d) hospital;</text> </item> <item id="H6BD0CEAE185A407E9442B99DD931C5DD"><enum>(bb)</enum><text display-inline="yes-display-inline">is recognized as a subsection (d) Puerto Rico hospital;</text> </item> <item id="H754BDBA2BD46434F84C326D251D1CB01"><enum>(cc)</enum><text>is reimbursed under a reimbursement system authorized under section 1814(b)(3); or</text> </item> <item id="H0EB1EDC1C2A444B889259B112FEA95A6"><enum>(dd)</enum><text>is a provider-based hospital outpatient department.</text> </item></subclause> <subclause id="HCCD082EE87B845C0AE665AA2738C588E" indent="up1"><enum>(III)</enum><text display-inline="yes-display-inline">In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in research activities that are not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall not be counted toward the determination of full-time equivalency.</text> </subclause></clause><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection id="H79C6726A41EB4C01A2EDCCE5F0649E6F"><enum>(c)</enum><header>Effective dates; application</header> <paragraph id="H21CEB76BCA76473F9B9665B95BDC8900"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Except as otherwise provided, the Secretary of Health and Human Services shall implement the amendments made by this section in a manner so as to apply to cost reporting periods beginning on or after January 1, 1983.</text> </paragraph> <paragraph id="H4C1087DF3DA54C8285011488FEED51CA"><enum>(2)</enum><header>Direct GME</header><text>Section 1886(h)(4)(E)(ii) of the Social Security Act, as added by subsection (a)(1)(B), shall apply to cost reporting periods beginning on or after July 1, 2009.</text> </paragraph> <paragraph id="HB127F3618502464F80931197D85A6CB9"><enum>(3)</enum><header>IME</header><text display-inline="yes-display-inline">Section 1886(d)(5)(B)(xi)(III) of the Social Security Act, as added by subsection (b), shall apply to cost reporting periods beginning on or after October 1, 2001. Such section, as so added, shall not give rise to any inference on how the law in effect prior to such date should be interpreted.</text> </paragraph> <paragraph commented="no" display-inline="no-display-inline" id="H85D09B76E84F4B758562D5939BB0BED5"><enum>(4)</enum><header>Application</header><text display-inline="yes-display-inline">The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act or for direct graduate medical education costs under section 1886(h) of such Act.</text> </paragraph></subsection></section> <section id="H688EE155A6664D3D82C1CEB9AAE1B39F"><enum>329.</enum><header>Preservation of resident cap positions from closed and acquired hospitals</header> <subsection id="HEC3FBF3D6E0C4ABD80C3DB291965DF2D"><enum>(a)</enum><header>GME</header><text display-inline="yes-display-inline">Section 1886(h)(4)(H) of the Social Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end the following new clauses:</text> <quoted-block display-inline="no-display-inline" id="H38DE5D21D93C4F0D9910AC1F027937FD" style="OLC"> <clause id="H960E900C89074D55822B891775C8E25D"><enum>(vi)</enum><header>Redistribution of residency slots after a hospital closes</header> <subclause id="H092EFD17AEA64815867917D43840380C"><enum>(I)</enum><header>In general</header><text>Subject to the succeeding provisions of this clause, the Secretary shall, by regulation, establish a process under which, in the case where a hospital with an approved medical residency program closes on or after the date of enactment of the Balanced Budget Act of 1997, the Secretary shall increase the otherwise applicable resident limit under this paragraph for other hospitals in accordance with this clause.</text> </subclause> <subclause id="H8E6D14ADED034459B68AD014DE4A02FE"><enum>(II)</enum><header>Priority for hospitals in certain areas</header><text>Subject to the succeeding provisions of this clause, in determining for which hospitals the increase in the otherwise applicable resident limit is provided under such process, the Secretary shall distribute the increase to hospitals located in the following priority order (with preference given within each category to hospitals that are members of the same affiliated group (as defined by the Secretary under clause (ii)) as the closed hospital):</text> <item id="H8F29CE8F729D42A6AE67BD4108EF768A"><enum>(aa)</enum><text>First, to hospitals located in the same core-based statistical area as, or a core-based statistical area contiguous to, the hospital that closed.</text> </item> <item id="H46DD2C00B44F440E83CE2B59F2662448"><enum>(bb)</enum><text>Second, to hospitals located in the same State as the hospital that closed.</text> </item> <item id="HB969B4E6E0FF423BA7D4D1AA6DB42041"><enum>(cc)</enum><text>Third, to hospitals located in the same region of the country as the hospital that closed.</text> </item> <item id="H32378BB4E3394A5E8289276F17D81F23"><enum>(dd)</enum><text>Fourth, to all other hospitals.</text> </item></subclause> <subclause id="H55D11DC4471F4EA986DD37C47DFCA668"><enum>(III)</enum><header>Requirement hospital likely to fill position within certain time period</header><text>The Secretary may only increase the otherwise applicable resident limit of a hospital under such process if the Secretary determines the hospital has demonstrated a likelihood of filling the positions made available under this clause within 3 years.</text> </subclause> <subclause id="HE4A79530DF48494F8A4A9D8393891574"><enum>(IV)</enum><header>Limitation</header><text>The aggregate number of increases in the otherwise applicable resident limits for hospitals under this clause shall be equal to the number of resident positions in the approved medical residency programs that closed on or after the date described in subclause (I).</text> </subclause></clause> <clause id="HF40ED57BB582424CAED3ABC650A4FC2C"><enum>(vii)</enum><header>Special rule for acquired hospitals</header> <subclause id="H83813D34DEAB49C88863E6B7D772B4AD"><enum>(I)</enum><header>In general</header><text>In the case of a hospital that is acquired (through any mechanism) by another entity with the approval of a bankruptcy court, during a period determined by the Secretary (but not less than 3 years), the applicable resident limit of the acquired hospital shall, except as provided in subclause (II), be the applicable resident limit of the hospital that was acquired (as of the date immediately before the acquisition), without regard to whether the acquiring entity accepts assignment of the Medicare provider agreement of the hospital that was acquired, so long as the acquiring entity continues to operate the hospital that was acquired and to furnish services, medical residency programs, and volume of patients similar to the services, medical residency programs, and volume of patients of the hospital that was acquired (as determined by the Secretary) during such period.</text> </subclause> <subclause id="H74F22B74465642348245745F4765D0CC"><enum>(II)</enum><header>Limitation</header><text>Subclause (I) shall only apply in the case where an acquiring entity waives the right as a new provider under the program under this title to have the otherwise applicable resident limit of the acquired hospital re-established or increased.</text> </subclause></clause><after-quoted-block>.</after-quoted-block></quoted-block> </subsection> <subsection id="H2AA0887A21B4481CABD883D8B2362CF2"><enum>(b)</enum><header>IME</header><text>Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended by section 326(b), is amended by striking <quote>subsections (h)(7) and (h)(8)</quote> and inserting <quote>subsections (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and (h)(8)</quote>.</text> </subsection> <subsection id="H85FB28E8D5C2479996AB8BE978E0690D"><enum>(c)</enum><header>Application</header><text display-inline="yes-display-inline">The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h)).</text> </subsection> <subsection commented="no" id="HC6CBDAC09E084062A06A912459F08C16"><enum>(d)</enum><header>No affect on temporary FTE cap adjustments</header><text>The amendments made by this section shall not affect any temporary adjustment to a hospital's FTE cap under section 413.79(h) of title 42, Code of Federal Regulations (as in effect on the date of enactment of this Act).</text> </subsection></section> <section id="H9E2363455AB145E5B93A4F85324778F3"><enum>330.</enum><header>Quality improvement organization assistance for physician practices seeking to be patient centered medical home practices</header><text display-inline="no-display-inline">Not later than 90 days after the date of enactment of this Act, the Secretary of Health and Human Services shall revise the 9th Statement of Work under the Quality Improvement Program under part B of title XI of the Social Security Act to include a requirement that, in order to be an eligible Quality Improvement Organization (in this section referred to as a <quote>QIO</quote>) for the 9th Statement of Work contract cycle, a QIO shall provide assistance, including technical assistance, to physicians under the Medicare program under title XVIII of the Social Security Act that seek to acquire the elements necessary to be recognized as a patient centered medical home practice under the National Committee for Quality Assurance's Physician Practice Connections—PCMH module (or any successor module issued by such Committee).</text> </section></subtitle> <enum>IV</enum><header>Studies</header> <section id="H0CD4A523C8FF4E7188B279DB81D2FBC6"><enum>401.</enum><header>Study concerning the designation of primary care as a shortage profession</header> <subsection id="HE5F5F082520344428DBCB5F752274F18"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Not later than June 30, 2010, the Secretary of Labor shall conduct a study and submit to the Committee on Education and Labor of the House of Representatives and the Committee on Health, Education, Labor, and Pensions a report that contains—</text> <paragraph id="H1EAB5FF0BC4E47E5AFA96F179FB47B0F"><enum>(1)</enum><text display-inline="yes-display-inline">a description of the criteria for the designation of primary care physicians as professions in shortage as defined by the Secretary under section 212(a)(5)(A) of the Immigration and Nationality Act;</text> </paragraph> <paragraph id="HF4D1ADBC596242A68E5585DFEAC2553C"><enum>(2)</enum><text display-inline="yes-display-inline">the findings of the Secretary on whether primary care physician professions will, on the date on which the report is submitted, or within the 5-year period beginning on such date, satisfy the criteria referred to in paragraph (1); and</text> </paragraph> <paragraph id="H6FFA7CCE2B3C45D0829DE72DC14B17F9"><enum>(3)</enum><text display-inline="yes-display-inline">if the Secretary finds that such professions will not satisfy such criteria, recommendations for modifications to such criteria to enable primary care physicians to be so designated as a profession in shortage.</text> </paragraph></subsection> <subsection id="HD510DA3C971D43B8921E4A063A87774F"><enum>(b)</enum><header>Requirements</header><text display-inline="yes-display-inline">In conducting the study under subsection (a), the Secretary of Labor shall consider workforce data from the Health Resources and Services Administration, the Council on Graduate Medical Education, the Association of American Medical Colleges, and input from physician membership organizations that represent primary care physicians.</text> </subsection></section> <section id="H5185E45F1B7F48EEB2105EC41B6852AC"><enum>402.</enum><header>Study concerning the education debt of medical school graduates</header> <subsection id="H6EDA4F1D214747BBB09873A2F21D9389"><enum>(a)</enum><header>Study</header><text>The Comptroller General of the United States shall conduct a study to evaluate the higher education-related indebtedness of medical school graduates in the United States at the time of graduation from medical school, and the impact of such indebtedness on specialty choice, including the impact on the field of primary care.</text> </subsection> <subsection id="HC1229795E302450492A5041EBC54D554"><enum>(b)</enum><header>Report</header> <paragraph id="H1B070F46FB944CAC9830C66FE96445B0"><enum>(1)</enum><header>Submission and dissemination of report</header><text>Not later than 1 year after the date of enactment of this Act, the Comptroller General shall submit a report on the study required by subsection (a) to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Education and Labor of the House of Representatives, and shall make such report widely available to the public.</text> </paragraph> <paragraph id="HDDAA4D794F1848499EC07896A6F4D857"><enum>(2)</enum><header>Additional reports</header><text>The Comptroller General may periodically prepare and release as necessary additional reports on the topic described in subsection (a).</text> </paragraph></subsection></section> <section id="HF2C2B42557B143C29DC3CAE695B7A63C"><enum>403.</enum><header>Study on minority representation in primary care</header> <subsection id="HCB719093642642FFB8035CE83171CD10"><enum>(a)</enum><header>Study</header><text>The Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, shall conduct a study of minority representation in training, and in practice, in primary care specialties.</text> </subsection> <subsection id="HB788A271189144BB894D9CF5DF904064"><enum>(b)</enum><header>Report</header><text>Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, shall submit to the appropriate committees of Congress a report concerning the study conducted under subsection (a), including recommendations for achieving a primary care workforce that is more representative of the population of the United States.</text> </subsection></section>