S.Amdt. 2909

SA 2909. Mr. NELSON of Florida (for himself, Mr. Reid, Mr. Schumer,
Mr. Kerry, Ms. Stabenow, and Mr. Leahy) submitted an amendment intended
to be proposed to amendment SA 2786 proposed by Mr. Reid (for himself,
Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the bill H.R. 3590, to amend
the Internal Revenue Code of 1986 to modify the first-time homebuyers
credit in the case of members of the Armed Forces and certain other
Federal employees,

[[Page S12428]]

and for other purposes; which was ordered to lie on the table; as
follows:

Beginning on page 1449, strike line 1 and all that follows
through page 1458, line 5, and insert the following:

SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.

(a) In General.--Section 1886(h) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(F)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(2) in paragraph (4)(H)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)''; and
(3) by adding at the end the following new paragraph:
``(8) Distribution of additional residency positions.--
``(A) Additional residency positions.--
``(i) Reduction in limit based on unused positions.--

``(I) In general.--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.
``(II) Exception for rural hospitals and certain other
hospitals.--This subparagraph shall not apply to a hospital--

``(aa) located in a rural area (as defined in subsection
(d)(2)(D)(ii));
``(bb) that has participated in a voluntary reduction plan
under paragraph (6); or
``(cc) that has participated in a demonstration project
approved as of October 31, 2003, under the authority of
section 402 of Public Law 90-248.
``(ii) Number available for distribution.--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.
``(B) Distribution.--
``(i) In general.--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).
``(ii) Distribution to hospitals already operating over
resident limit.--

``(I) In general.--Subject to subclause (II), in the case
of a hospital in which the reference resident level of the
hospital (as specified in clause (iii)) 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--

``(aa) the number of resident positions by which the
reference resident level of the hospital exceeds the
otherwise applicable resident limit for the hospital; and
``(bb) 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.

``(II) Requirements.--A hospital described in subclause
(I)--

``(aa) 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
``(bb) 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.

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.
``(III) Clarification regarding eligibility for other
additional residency positions.--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.

``(iii) Reference resident level.--

``(I) In general.--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.
``(II) Use of most recent accounting period to recognize
expansion of existing program or establishment of new
program.--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)), 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.

``(C) Considerations in redistribution.--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.
``(D) Priority for certain areas.--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:
``(i) 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--

``(I) 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
``(II) 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.

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.
``(ii) The Secretary shall give preference to hospitals
that emphasize training in community health centers and other
community-based clinical settings.
``(iii) 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.
``(iv) 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).
``(E) Limitation.--
``(i) In general.--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.
``(ii) Increase in number of additional positions available
for distribution.--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.
``(F) Application of per resident amounts for primary care
and nonprimary care.--With respect to additional residency
positions in a hospital attributable to the increase provided
under this 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.
``(G) Distribution.--The Secretary shall distribute the
increase to hospitals under this paragraph not later than 2
years after the date of enactment of this paragraph.''.
(b) IME.--
(1) In general.--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--
(A) by striking ``subsection (h)(7)'' and inserting
``subsections (h)(7) and (h)(8)''; and
(B) by striking ``it applies'' and inserting ``they
apply''.
(2) Conforming provision.--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:
``(x) For discharges occurring on or after the date of
enactment of this clause, insofar as an additional payment
amount under this

[[Page S12429]]

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.''.
______