1.Short title; table of
contents
(a)This Act may be cited
as the Preserving Patient Access to
Primary Care Act of 2009
.
(b)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 assistant
education, 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.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 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.
(a)In this Act:
(1)Chronic Care
CoordinationThe 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 facilityThe 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)The
term physician has the meaning given such term in section 1861(r)(1) of the
Social Security Act.
(4)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)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)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)The term primary care provider
means—
(A)a nurse
practitioner; or
(B)a physician assistant practicing as a
member of a physician-directed team;
who provides
first contact, continuous, and comprehensive care to patients.(8)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)The
term Secretary means the Secretary of Health and Human
Services.
(b)Primary Medical
Care Shortage Area
(1)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)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 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)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)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 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 a primary care
provider 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 approvalSuch 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 HomesThe 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 practicesNothing 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, etcUnless 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 primary care
provider (as defined in section 3(a)(7) of the
<short-title>Preserving Patient Access to Primary Care Act
of 2009</short-title>).</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 assistant education, 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 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>