[Congressional Record Volume 164, Number 138 (Monday, August 20, 2018)]
[Senate]
[Pages S5723-S5724]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SA 3749. Mr. GARDNER submitted an amendment intended to be proposed
to amendment SA 3695 proposed by Mr. Shelby to the bill H.R. 6157,
making appropriations for the Department of Defense for the fiscal year
ending September 30, 2019, and for other purposes; which was ordered to
lie on the table; as follows:
At the appropriate place in title V of division B, insert
the following:
Sec. _. (a) Section 1886 of the Social Security Act (42
U.S.C. 1395ww) is amended by adding at the end the following
new subsection:
``(u) Alternative National Per Resident Payment Amount for
Residents Training in Rural Training Locations.--
``(1) In general.--
``(A) Establishment.--The Secretary shall establish a
national per resident payment (NPRP) amount for time spent by
residents training in rural training locations in accordance
with paragraph (2).
``(B) Election.--For cost reporting periods beginning on or
after the date that is 1 year after the date of enactment of
this subsection, an applicable hospital (as defined in
paragraph (6)(A)), may elect to receive the payment amount
under this subsection for each full-time-equivalent resident
in an approved medical residency training program that
receives training in a rural training location in accordance
with paragraph (2). An applicable hospital may make an
election under the preceding sentence regardless of whether
the applicable hospital is otherwise eligible for a payment
or adjustment for indirect and direct graduate medical
education costs under subsections (d)(5)(B) and (h) or
section 1814(l), as applicable, with respect to such
residents. If the applicable hospital is otherwise eligible
for such a payment or adjustment, the national per resident
payment amount under this subsection shall be in lieu of such
payment or adjustment.
``(C) Application.--The provisions of this subsection, or
the application of such provisions to an applicable hospital,
shall not result in or otherwise effect the following:
``(i) The establishment of a limitation on the number of
residents in allopathic or osteopathic medicine for purposes
of subsections (d)(5)(B) and (h) with respect to an approved
medical residency training program of an applicable hospital
(or be taken into account in determining such a limitation
during the cap building period of an applicable hospital).
``(ii) The determination of--
``(I) the additional payment amount under subsection
(d)(5)(B); or
``(II) hospital-specific approved FTE resident amounts
under subsection (h).
``(iii) The counting of any resident with respect to which
the applicable hospital receives a national per resident
payment under this subsection towards the application of the
limitation described in clause (i) for purposes of
subsections (d)(5)(B) and (h).
``(2) Payment amount.--
``(A) Base amount.--The national per resident payment
amount, with respect to full-time equivalent residents
training in rural training locations, for cost reporting
periods beginning during the first year beginning on or after
the date of enactment of this subsection shall be, based on
the most recently available data with respect to cost
reporting periods beginning during a preceding year (referred
to in this subparagraph as the `base cost reporting period'),
equal to the sum of the following:
``(i) Direct gme.--The amount that, out of all of the
payment amounts (determined on a per resident basis) received
by hospitals under subsection (h) for such base cost
reporting period, is equal to the national 85th percentile of
such payment amounts.
``(ii) Indirect gme.--The amount that, out of all of the
additional payment amounts (determined on a per resident
basis) received by hospitals under subsection (d)(5)(B) for
such base cost reporting period, is equal to the national
85th percentile of such payment amounts.
``(B) Updating for subsequent cost reporting periods.--For
each subsequent cost reporting period, the national per
resident payment amount is equal to such amount determined
under this paragraph for the previous cost reporting period
updated, through the midpoint of the period, by projecting
the estimated percentage change in the consumer price index
during the 12-month period ending at that midpoint, with
appropriate adjustments to reflect previous under- or over-
estimations under this subparagraph in the projected
percentage change in the consumer price index.
``(C) Clarification.--The national per resident payment
amount shall not be discounted or otherwise adjusted based on
the Medicare patient load (as defined in subsection
(h)(3)(C)) of an applicable hospital or discharges in a
diagnosis-related group.
``(3) Allocation of payments.--In providing for payments
under this subsection, the Secretary shall provide for an
allocation of such payments between parts A and part B (and
the trust funds established under the respective parts) as
reasonably reflects the proportion of such costs associated
with the
[[Page S5724]]
provision of services under each respective part.
``(4) Eligibility for payment.--
``(A) In general.--An applicable hospital shall be eligible
for payment of the national per resident payment amount under
this subsection for time spent by a resident training in a
rural training location if the following requirements are
met:
``(i) The resident spends the equivalent of at least 8
weeks over the course of their training in a rural training
location.
``(ii) The hospital pays the salary and benefits of the
resident for the time spent training in a rural training
location.
``(B) Treatment of time spent in rural tracks.--An
applicable hospital shall be eligible for payment of the
national per resident payment amount under this subsection
for all time spent by residents in an approved medical
residency program (or separately defined track within a
program) that provides 50 percent or more of the total
residency training time in rural training locations (as
defined in paragraph (6)(C)), regardless of where the
training occurs and regardless of specialty.
``(5) Determination of full-time-equivalent residents.--The
determination of full-time-equivalent residents for purposes
of this subsection shall be made in the same manner as the
determination of full-time-equivalent residents under
subsection (h)(4).
``(6) Definitions.--In this subsection:
``(A) Applicable hospital.--The term `applicable hospital'
means a hospital or critical access hospital.
``(B) Approved medical residency training program; direct
graduate medical education costs; resident.--The terms
`approved medical residency training program', `direct
graduate medical education costs', and `resident' have the
meanings given those terms in subsection (h)(5).
``(C) Rural training location.--The term `rural training
location' means a location in which training occurs that,
based on the 2010 census or any subsequent census adjustment,
meets one or more of the following criteria:
``(i) The training occurs in a location that is a rural
area (as defined in section 1886(d)(2)(D)).
``(ii) The training occurs in a location that has a rural-
urban commuting area code equal to or greater than 4.0.
``(iii) The training occurs in a location that is within 10
miles of a sole community hospital (as defined in subsection
(d)(5)(D)(iii))).
``(7) Budget neutrality requirement.--The Secretary shall
ensure that aggregate payments for direct medical education
costs and indirect medical education costs under this title,
including any payments under this subsection, for each year
(effective beginning on or after the date that is 1 year
after the date of enactment of this subsection) are not
greater than the aggregate payments for such costs that would
have been made under this title for the year without the
application of this subsection. For purposes of carrying out
the budget neutrality requirement under the preceding
sentence, the Secretary may make appropriate adjustments to
the amount of such payments for direct graduate medical
education costs and indirect medical education costs under
subsections (h) and (d)(5)(B), respectively.''.
(b)(1) Section 1814(l) of the Social Security Act (42
U.S.C. 1395f(l)) is amended by adding at the end the
following new paragraph:
``(6) For cost reporting periods beginning on or after the
date that is 1 year after the date of enactment of this
paragraph, the following shall apply:
``(A) A critical access hospital may elect to be treated as
a hospital or as a non-provider setting for purposes of
counting resident time for indirect medical education costs
and direct graduate medical education costs for the time
spent by the resident in that setting under subsections
(d)(5)(B) and (h), respectively, of section 1886.
``(B) Medical education costs shall not be considered
reasonable costs of a critical access hospital for purposes
of payment under paragraph (1), to the extent that the
critical access hospital or another hospital receives payment
for such costs for the time spent by the resident in that
setting pursuant to subsection (d)(5)(B), subsection (h), or
subsection (u) of section 1886.''.
(2) Section 1886(d)(5)(D) of the Social Security Act (42
U.S.C. 1395ww(d)(5)(D)) is amended by adding at the end the
following new clause:
``(vi) For cost reporting periods beginning on or after the
date that is 1 year after the date of enactment of this
paragraph, the hospital-specific payment amount determined
under clause (i)(I) with respect to a sole community hospital
shall not include medical education costs, to the extent that
the sole community hospital receives payment for such costs
for the time spent by the resident in that setting pursuant
to subsection (u).''.
(c) Section 1886 of the Social Security Act (42 U.S.C.
1395ww) is amended--
(1) in subsection (d)(5)(B), in the matter preceding clause
(i), by striking ``The Secretary'' and inserting ``Subject to
subsection (u), the Secretary''; and
(2) in subsection (h)--
(A) in paragraph (1), by inserting ``subject to subsection
(u)'' after ``1861(v),''; and
(B) in paragraph (3), in the flush matter at the end, by
striking ``subsection (k)'' and inserting ``subsection (k) or
subsection (u)''.
Sec. _. (a) Section 1886(h) of the Social Security Act (42
U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)--
(A) in subparagraph (F)(i)--
(i) by striking ``130 percent'' and inserting ``for cost
reporting periods beginning on or after October 1, 1997, and
before the date that is 1 year after the date of enactment of
the Department of Defense and Labor, Health and Human
Services, and Education Appropriations Act, 2019, 130
percent''; and
(ii) by adding at the end the following: ``For cost
reporting periods beginning on or after the date that is 1
year after the date of enactment of the Department of Defense
and Labor, Health and Human Services, and Education
Appropriations Act, 2019, such rules shall provide that any
full-time-equivalent resident in an approved medical
residency program (or separately defined track within a
program) that provides 50 percent or more of the total
residency training time in rural training locations (as
defined in subsection (u)(6)(C)), regardless of where the
training occurs and regardless of specialty, shall not be
taken into account for purposes of applying the limitation
under this subparagraph.''; and
(iii) in subparagraph (H)--
(I) in clause (i), in the second sentence, by inserting the
following before the period: ``, in accordance with the
second sentence of clause (i) of such subparagraph''; and
(II) in clause (iv), by inserting the following before the
period: ``, in accordance with the second sentence of clause
(i) of such subparagraph''; and
(iv) in paragraph (5), by adding at the end the following
new subparagraph:
``(L) Special rules regarding application of national per
resident payment amount.--For special rules regarding
application of the national per resident payment amount under
subsection (u), see paragraph (1)(C) of such subsection.''.
(b) Section 1886(d)(5)(B)(v) is amended--
(1) by striking ``130 percent'' and inserting ``for cost
reporting periods beginning on or after October 1, 1997, and
before the date that is 1 year after the date of enactment of
the Department of Defense and Labor, Health and Human
Services, and Education Appropriations Act, 2019, 130
percent''; and
(2) by adding at the end the following: ``For cost
reporting periods beginning on or after the date that is 1
year after the date of enactment of the Department of Defense
and Labor, Health and Human Services, and Education
Appropriations Act, 2019, such rules shall provide that any
full-time-equivalent resident in an approved medical
residency program (or separately defined track within a
program) that provides 50 percent or more of the total
residency training time in rural training locations (as
defined in subsection (u)(6)(C)), regardless of where the
training occurs and regardless of specialty, shall not be
taken into account for purposes of applying the limitation
under this subparagraph. For special rules regarding
application of the national per resident payment amount under
subsection (u), see paragraph (1)(C) of such subsection.''.
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