42 U.S.C. § 256e — Program of payments to children’s hos-

Page 443 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256e 1 See References in Text note below. Pub. L. 103–43, title XX, § 2008(i)(2)(A)(ii), June 10, 1993, 107 Stat. 213; amended Pub. L. 104–299, § 4(a)(2), Oct. 11, 1996, 110 Stat. 3645.) Editorial Notes AMENDMENTS 1996—Subsec. (a)(2). Pub. L. 104–299 substituted ‘‘with assistance provided under section 254b of this title’’ for ‘‘under the programs established in sections 254b, 254c, 256, and 256a of this title.’’ Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1996 AMENDMENT Amendment by Pub. L. 104–299 effective Oct. 1, 1996, see section 5 of Pub. L. 104–299, as amended, set out as a note under section 233 of this title. § 256d. Breast and cervical cancer information (a) In general As a condition of receiving grants, cooperative agreements, or contracts under this chapter, each of the entities specified in subsection (c) shall, to the extent determined to be appro- priate by the Secretary, make available infor- mation concerning breast and cervical cancer. (b) Certain authorities In carrying out subsection (a), an entity speci- fied in subsection (c)— (1) may make the information involved available to such individuals as the entity de- termines appropriate; (2) may, as appropriate, provide information under subsection (a) on the need for self-exam- ination of the breasts and on the skills for such self-examinations; (3) shall provide information under sub- section (a) in the language and cultural con- text most appropriate to the individuals to whom the information is provided; and (4) shall refer such clients as the entities de- termine appropriate for breast and cervical cancer screening, treatment, or other appro- priate services. (c) Relevant entities The entities specified in this subsection are the following: (1) Entities receiving assistance under sec- tion 247b–7 1 of this title (relating to tuber- culosis). (2) Entities receiving assistance under sec- tion 247c of this title (relating to sexually transmitted diseases). (3) Migrant health centers receiving assist- ance under section 254b 1 of this title. (4) Community health centers receiving as- sistance under section 254c 1 of this title. (5) Entities receiving assistance under sec- tion 254b(h) of this title (relating to homeless individuals). (6) Entities receiving assistance under sec- tion 256a 1 of this title (relating to health serv- ices for residents of public housing). (7) Entities providing services with assist- ance under subchapter III–A or subchapter XVII. (8) Entities receiving assistance under sec- tion 300 of this title (relating to family plan- ning). (9) Entities receiving assistance under sub- chapter XXIV (relating to services with re- spect to acquired immune deficiency syn- drome). (10) Non-Federal entities authorized under the Indian Self-Determination Act [25 U.S.C. 5321 et seq.]. (July 1, 1944, ch. 373, title III, § 340D, as added Pub. L. 103–183, title I, § 104, Dec. 14, 1993, 107 Stat. 2230; amended Pub. L. 106–310, div. A, title XXV, § 2502(b), Oct. 17, 2000, 114 Stat. 1163; Pub. L. 107–251, title VI, § 601(a), Oct. 26, 2002, 116 Stat. 1664.) Editorial Notes REFERENCES IN TEXT Section 247b–7 of this title, referred to in subsec. (c)(1), relates to loan repayment program and not to as- sistance relating to tuberculosis. Sections 254b and 254c of this title, referred to in sub- sec. (c)(3), (4), were in the original references to sec- tions 329 and 330, meaning sections 329 and 330 of act July 1, 1944, which were omitted in the general amend- ment of subpart I (§ 254b et seq.) of this part by Pub. L. 104–299, § 2, Oct. 11, 1996, 110 Stat. 3626. Sections 2 and 3(a) of Pub. L. 104–299 enacted new sections 330 and 330A of act July 1, 1944, which are classified, respectively, to sections 254b and 254c of this title. Section 256a of this title, referred to in subsec. (c)(6), was repealed by Pub. L. 104–299, § 4(a)(3), Oct. 11, 1996, 110 Stat. 3645. The Indian Self-Determination Act, referred to in subsec. (c)(10), is title I of Pub. L. 93–638, Jan. 4, 1975, 88 Stat. 2206, which is classified principally to sub- chapter I (§ 5321 et seq.) of chapter 46 of Title 25, Indi- ans. For complete classification of this Act to the Code, see Short Title note set out under section 5301 of Title 25 and Tables. AMENDMENTS 2002—Subsec. (c)(5). Pub. L. 107–251 substituted ‘‘254b(h)’’ for ‘‘256’’. 2000—Subsec. (c)(1). Pub. L. 106–310 substituted ‘‘sec- tion 247b–7 of this title’’ for ‘‘section 247b–6 of this title’’. Statutory Notes and Related Subsidiaries REFERENCE TO COMMUNITY, MIGRANT, PUBLIC HOUSING, OR HOMELESS HEALTH CENTER CONSIDERED REF- ERENCE TO HEALTH CENTER Reference to community health center, migrant health center, public housing health center, or home- less health center, considered reference to health cen- ter, see section 4(c) of Pub. L. 104–299, set out as a note under section 254b of this title. SUBPART IX—SUPPORT OF GRADUATE MEDICAL EDUCATION PROGRAMS IN CHILDREN’S HOSPITALS § 256e. Program of payments to children’s hos- pitals that operate graduate medical edu- cation programs (a) Payments The Secretary shall make two payments under this section to each children’s hospital for each of fiscal years 2000 through 2005, each of fiscal years 2007 through 2011, each of fiscal years 2014 through 2018, and each of fiscal years 2019 through 2023, one for the direct expenses and the other for indirect expenses associated with oper- ating approved graduate medical residency training programs. The Secretary shall promul- Page 444 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256e gate regulations pursuant to the rulemaking re- quirements of title 5 which shall govern pay- ments made under this subpart. (b) Amount of payments (1) In general Subject to paragraphs (2) and (3), the amounts payable under this section to a chil- dren’s hospital for an approved graduate med- ical residency training program for a fiscal year are each of the following amounts: (A) Direct expense amount The amount determined under subsection (c) for direct expenses associated with oper- ating approved graduate medical residency training programs. (B) Indirect expense amount The amount determined under subsection (d) for indirect expenses associated with the treatment of more severely ill patients and the additional costs relating to teaching residents in such programs. (2) Capped amount (A) In general The total of the payments made to chil- dren’s hospitals under paragraph (1)(A) or paragraph (1)(B) in a fiscal year shall not ex- ceed the funds appropriated under paragraph (1) or (2), respectively, of subsection (f) for such payments for that fiscal year. (B) Pro rata reductions of payments for di- rect expenses If the Secretary determines that the amount of funds appropriated under sub- section (f)(1) for a fiscal year is insufficient to provide the total amount of payments otherwise due for such periods under para- graph (1)(A), the Secretary shall reduce the amounts so payable on a pro rata basis to re- flect such shortfall. (3) Annual reporting required (A) Reduction in payment for failure to re- port (i) In general The amount payable under this section to a children’s hospital for a fiscal year (beginning with fiscal year 2008 and after taking into account paragraph (2)) shall be reduced by 25 percent if the Secretary de- termines that— (I) the hospital has failed to provide the Secretary, as an addendum to the hospital’s application under this section for such fiscal year, the report required under subparagraph (B) for the previous fiscal year; or (II) such report fails to provide the in- formation required under any clause of such subparagraph. (ii) Notice and opportunity to provide miss- ing information Before imposing a reduction under clause (i) on the basis of a hospital’s fail- ure to provide information described in clause (i)(II), the Secretary shall provide notice to the hospital of such failure and the Secretary’s intention to impose such reduction and shall provide the hospital with the opportunity to provide the re- quired information within a period of 30 days beginning on the date of such notice. If the hospital provides such information within such period, no reduction shall be made under clause (i) on the basis of the previous failure to provide such informa- tion. (B) Annual report The report required under this subpara- graph for a children’s hospital for a fiscal year is a report that includes (in a form and manner specified by the Secretary) the fol- lowing information for the residency aca- demic year completed immediately prior to such fiscal year: (i) The types of resident training pro- grams that the hospital provided for resi- dents described in subparagraph (C), such as general pediatrics, internal medicine/pe- diatrics, and pediatric subspecialties, in- cluding both medical subspecialties cer- tified by the American Board of Pediatrics (such as pediatric gastroenterology) and non-medical subspecialties approved by other medical certification boards (such as pediatric surgery). (ii) The number of training positions for residents described in subparagraph (C), the number of such positions recruited to fill, and the number of such positions filled. (iii) The types of training that the hos- pital provided for residents described in subparagraph (C) related to the health care needs of different populations, such as children who are underserved for reasons of family income or geographic location, including rural and urban areas. (iv) The changes in residency training for residents described in subparagraph (C) which the hospital has made during such residency academic year (except that the first report submitted by the hospital under this subparagraph shall be for such changes since the first year in which the hospital received payment under this sec- tion), including— (I) changes in curricula, training expe- riences, and types of training programs, and benefits that have resulted from such changes; and (II) changes for purposes of training the residents in the measurement and improvement of the quality and safety of patient care. (v) The numbers of residents described in subparagraph (C) who completed their resi- dency training at the end of such residency academic year and care for children within the borders of the service area of the hos- pital or within the borders of the State in which the hospital is located. Such num- bers shall be disaggregated with respect to residents who completed residencies in general pediatrics or internal medicine/pe- diatrics, subspecialty residencies, and den- tal residencies. Page 445 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256e (C) Residents The residents described in this subpara- graph are those who— (i) are in full-time equivalent resident training positions in any training program sponsored by the hospital; or (ii) are in a training program sponsored by an entity other than the hospital, but who spend more than 75 percent of their training time at the hospital. (D) Report to Congress Not later than the end of fiscal year 2018, and the end of fiscal year 2022, the Sec- retary, acting through the Administrator of the Health Resources and Services Adminis- tration, shall submit a report to the Con- gress— (i) summarizing the information sub- mitted in reports to the Secretary under subparagraph (B); (ii) describing the results of the program carried out under this section; and (iii) making recommendations for im- provements to the program. (c) Amount of payment for direct graduate med- ical education (1) In general The amount determined under this sub- section for payments to a children’s hospital for direct graduate expenses relating to ap- proved graduate medical residency training programs for a fiscal year is equal to the prod- uct of— (A) the updated per resident amount for di- rect graduate medical education, as deter- mined under paragraph (2); and (B) the average number of full-time equiv- alent residents in the hospital’s graduate ap- proved medical residency training programs (as determined under section 1395ww(h)(4) of this title during the fiscal year. (2) Updated per resident amount for direct graduate medical education The updated per resident amount for direct graduate medical education for a hospital for a fiscal year is an amount determined as fol- lows: (A) Determination of hospital single per resi- dent amount The Secretary shall compute for each hos- pital operating an approved graduate med- ical education program (regardless of wheth- er or not it is a children’s hospital) a single per resident amount equal to the average (weighted by number of full-time equivalent residents) of the primary care per resident amount and the non-primary care per resi- dent amount computed under section 1395ww(h)(2) of this title for cost reporting periods ending during fiscal year 1997. (B) Determination of wage and non-wage-re- lated proportion of the single per resi- dent amount The Secretary shall estimate the average proportion of the single per resident amounts computed under subparagraph (A) that is attributable to wages and wage-re- lated costs. (C) Standardizing per resident amounts The Secretary shall establish a standard- ized per resident amount for each such hos- pital— (i) by dividing the single per resident amount computed under subparagraph (A) into a wage-related portion and a non- wage-related portion by applying the pro- portion determined under subparagraph (B); (ii) by dividing the wage-related portion by the factor applied under section 1395ww(d)(3)(E) of this title for discharges occurring during fiscal year 1999 for the hospital’s area; and (iii) by adding the non-wage-related por- tion to the amount computed under clause (ii). (D) Determination of national average The Secretary shall compute a national average per resident amount equal to the av- erage of the standardized per resident amounts computed under subparagraph (C) for such hospitals, with the amount for each hospital weighted by the average number of full-time equivalent residents at such hos- pital. (E) Application to individual hospitals The Secretary shall compute for each such hospital that is a children’s hospital a per resident amount— (i) by dividing the national average per resident amount computed under subpara- graph (D) into a wage-related portion and a non-wage-related portion by applying the proportion determined under subpara- graph (B); (ii) by multiplying the wage-related por- tion by the factor applied under section 1395ww(d)(3)(E) of this title for discharges occurring during the preceding fiscal year for the hospital’s area; and (iii) by adding the non-wage-related por- tion to the amount computed under clause (ii). (F) Updating rate The Secretary shall update such per resi- dent amount for each such children’s hos- pital by the estimated percentage increase in the consumer price index for all urban consumers during the period beginning Octo- ber 1997 and ending with the midpoint of the Federal fiscal year for which payments are made. (d) Amount of payment for indirect medical edu- cation (1) In general The amount determined under this sub- section for payments to a children’s hospital for indirect expenses associated with the treatment of more severely ill patients and the additional costs associated with the teach- ing of residents for a fiscal year is equal to an amount determined appropriate by the Sec- retary. (2) Factors In determining the amount under paragraph (1), the Secretary shall— Page 446 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256e 1 See References in Text note below. (A) take into account variations in case mix among children’s hospitals and the ratio of the number of full-time equivalent resi- dents in the hospitals’ approved graduate medical residency training programs to beds (but excluding beds or bassinets assigned to healthy newborn infants); and (B) assure that the aggregate of the pay- ments for indirect expenses associated with the treatment of more severely ill patients and the additional costs related to the teaching of residents under this section in a fiscal year are equal to the amount appro- priated for such expenses for the fiscal year involved under subsection (f)(2). (e) Making of payments (1) Interim payments The Secretary shall determine, before the beginning of each fiscal year involved for which payments may be made for a hospital under this section, the amounts of the pay- ments for direct graduate medical education and indirect medical education for such fiscal year and shall (subject to paragraph (2)) make the payments of such amounts in 12 equal in- terim installments during such period. Such interim payments to each individual hospital shall be based on the number of residents re- ported in the hospital’s most recently filed Medicare cost report prior to the application date for the Federal fiscal year for which the interim payment amounts are established. In the case of a hospital that does not report resi- dents on a Medicare cost report, such interim payments shall be based on the number of resi- dents trained during the hospital’s most re- cently completed Medicare cost report filing period. (2) Withholding The Secretary shall withhold up to 25 per- cent from each interim installment for direct and indirect graduate medical education paid under paragraph (1) as necessary to ensure a hospital will not be overpaid on an interim basis. (3) Reconciliation Prior to the end of each fiscal year, the Sec- retary shall determine any changes to the number of residents reported by a hospital in the application of the hospital for the current fiscal year to determine the final amount pay- able to the hospital for the current fiscal year for both direct expense and indirect expense amounts. Based on such determination, the Secretary shall recoup any overpayments made and pay any balance due to the extent possible. The final amount so determined shall be considered a final intermediary determina- tion for the purposes of section 1395oo of this title and shall be subject to administrative and judicial review under that section in the same manner as the amount of payment under section 1395ww(d) 1 of this title is subject to re- view under such section. (f) Authorization of appropriations (1) Direct graduate medical education (A) In general There are hereby authorized to be appro- priated, out of any money in the Treasury not otherwise appropriated, for payments under subsection (b)(1)(A)— (i) for fiscal year 2000, $90,000,000; (ii) for fiscal year 2001, $95,000,000; (iii) for each of the fiscal years 2002 through 2005, such sums as may be nec- essary; (iv) for each of fiscal years 2007 through 2011, $110,000,000; (v) for each of fiscal years 2014 through 2018, $100,000,000; and (vi) for each of fiscal years 2019 through 2023, $105,000,000. (B) Carryover of excess The amounts appropriated under subpara- graph (A) for fiscal year 2000 shall remain available for obligation through the end of fiscal year 2001. (2) Indirect medical education There are hereby authorized to be appro- priated, out of any money in the Treasury not otherwise appropriated, for payments under subsection (b)(1)(B)— (A) for fiscal year 2000, $190,000,000; (B) for fiscal year 2001, $190,000,000; (C) for each of the fiscal years 2002 through 2005, such sums as may be necessary; (D) for each of fiscal years 2007 through 2011, $220,000,000; (E) for each of fiscal years 2014 through 2018, $200,000,000; and (F) for each of fiscal years 2019 through 2023, $220,000,000. (g) Definitions In this section: (1) Approved graduate medical residency train- ing program The term ‘‘approved graduate medical resi- dency training program’’ has the meaning given the term ‘‘approved medical residency training program’’ in section 1395ww(h)(5)(A) of this title. (2) Children’s hospital The term ‘‘children’s hospital’’ means a hos- pital with a Medicare payment agreement and which is excluded from the Medicare inpatient prospective payment system pursuant to sec- tion 1395ww(d)(1)(B)(iii) of this title and its ac- companying regulations. (3) Direct graduate medical education costs The term ‘‘direct graduate medical edu- cation costs’’ has the meaning given such term in section 1395ww(h)(5)(C) of this title. (h) Additional provisions (1) In general The Secretary is authorized to make avail- able up to 25 percent of the total amounts in excess of $245,000,000 appropriated under para- graphs (1) and (2) of subsection (f), but not to exceed $7,000,000, for payments to hospitals Page 447 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256e qualified as described in paragraph (2), for the direct and indirect expenses associated with operating approved graduate medical resi- dency training programs, as described in sub- section (a). (2) Qualified hospitals (A) In general To qualify to receive payments under paragraph (1), a hospital shall be a free- standing hospital— (i) with a Medicare payment agreement and that is excluded from the Medicare in- patient hospital prospective payment sys- tem pursuant to section 1395ww(d)(1)(B) of this title and its accompanying regula- tions; (ii) whose inpatients are predominantly individuals under 18 years of age; (iii) that has an approved medical resi- dency training program as defined in sec- tion 1395ww(h)(5)(A) of this title; and (iv) that is not otherwise qualified to re- ceive payments under this section or sec- tion 1395ww(h) of this title. (B) Establishment of residency cap In the case of a freestanding children’s hospital that, on April 7, 2014, meets the re- quirements of subparagraph (A) but for which the Secretary has not determined an average number of full-time equivalent resi- dents under section 1395ww(h)(4) of this title, the Secretary may establish such number of full-time equivalent residents for the pur- poses of calculating payments under this subsection. (3) Payments Payments to hospitals made under this sub- section shall be made in the same manner as payments are made to children’s hospitals, as described in subsections (b) through (e). (4) Payment amounts The direct and indirect payment amounts under this subsection shall be determined using per resident amounts that are no greater than the per resident amounts used for deter- mining direct and indirect payment amounts under subsection (a). (5) Reporting A hospital receiving payments under this subsection shall be subject to the reporting re- quirements under subsection (b)(3). (6) Remaining funds (A) In general If the payments to qualified hospitals under paragraph (1) for a fiscal year are less than the total amount made available under such paragraph for that fiscal year, any re- maining amounts for such fiscal year may be made available to all hospitals participating in the program under this subsection or sub- section (a). (B) Quality bonus system For purposes of distributing the remaining amounts described in subparagraph (A), the Secretary may establish a quality bonus sys- tem, whereby the Secretary distributes bonus payments to hospitals participating in the program under this subsection or sub- section (a) that meet standards specified by the Secretary, which may include a focus on quality measurement and improvement, interpersonal and communications skills, delivering patient-centered care, and prac- ticing in integrated health systems, includ- ing training in community-based settings. In developing such standards, the Secretary shall collaborate with relevant stakeholders, including program accrediting bodies, certi- fying boards, training programs, health care organizations, health care purchasers, and patient and consumer groups. (July 1, 1944, ch. 373, title III, § 340E, as added Pub. L. 106–129, § 4, Dec. 6, 1999, 113 Stat. 1671; amended Pub. L. 106–310, div. A, title XX, § 2001, Oct. 17, 2000, 114 Stat. 1155; Pub. L. 108–490, § 1(a), Dec. 23, 2004, 118 Stat. 3972; Pub. L. 109–307, § 2, Oct. 6, 2006, 120 Stat. 1721; Pub. L. 113–98, §§ 2, 3, Apr. 7, 2014, 128 Stat. 1140; Pub. L. 115–241, § 2, Sept. 18, 2018, 132 Stat. 2892.) Editorial Notes REFERENCES IN TEXT Section 1395ww(d) of this title, referred to in subsec. (e)(3), was in the original ‘‘section 1186(d) of such Act’’ and was translated as reading ‘‘section 1886(d) of such Act’’, meaning section 1886(d) of the Social Security Act, to reflect the probable intent of Congress, because the Social Security Act does not contain a section 1186 and section 1395ww(d) of this title relates to review of inpatient hospital service payments. AMENDMENTS 2018—Subsec. (a). Pub. L. 115–241, § 2(1), substituted ‘‘each of fiscal years 2014 through 2018, and each of fis- cal years 2019 through 2023,’’ for ‘‘and each of fiscal years 2014 through 2018,’’. Subsec. (b)(3)(D). Pub. L. 115–241, § 2(2), inserted ‘‘and the end of fiscal year 2022,’’ after ‘‘fiscal year 2018,’’ in introductory provisions. Subsec. (f)(1)(A)(vi). Pub. L. 115–241, § 2(3)(A), added cl. (vi). Subsec. (f)(2)(F). Pub. L. 115–241, § 2(3)(B), added sub- par. (F). 2014—Subsec. (a). Pub. L. 113–98, § 2(a)(1), substituted ‘‘through 2005, each of fiscal years 2007 through 2011, and each of fiscal years 2014 through 2018’’ for ‘‘through 2005 and each of fiscal years 2007 through 2011’’. Subsec. (b)(3)(D). Pub. L. 113–98, § 2(b), substituted ‘‘Not later than the end of fiscal year 2018’’ for ‘‘Not later than the end of fiscal year 2011’’ in introductory provisions. Subsec. (f)(1)(A)(v). Pub. L. 113–98, § 2(a)(2)(A), added cl. (v). Subsec. (f)(2)(E). Pub. L. 113–98, § 2(a)(2)(B), added sub- par. (E). Subsec. (h). Pub. L. 113–98, § 3, added subsec. (h). 2006—Subsec. (a). Pub. L. 109–307, § 2(a)(1), inserted ‘‘and each of fiscal years 2007 through 2011’’ after ‘‘for each of fiscal years 2000 through 2005’’. Subsec. (b)(1). Pub. L. 109–307, § 2(b)(1), substituted ‘‘paragraphs (2) and (3)’’ for ‘‘paragraph (2)’’ in intro- ductory provisions. Subsec. (b)(3). Pub. L. 109–307, § 2(b)(2), added par. (3). Subsec. (c)(2)(E)(ii). Pub. L. 109–307, § 2(c)(1), sub- stituted ‘‘applied under section 1395ww(d)(3)(E) of this title for discharges occurring during the preceding fis- cal year’’ for ‘‘described in subparagraph (C)(ii)’’. Subsec. (e)(1). Pub. L. 109–307, § 2(a)(2), substituted ‘‘12’’ for ‘‘26’’. Subsec. (e)(2). Pub. L. 109–307, § 2(c)(2), struck out first sentence which read as follows: ‘‘The Secretary shall Page 448 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 256f withhold up to 25 percent from each interim install- ment for direct and indirect graduate medical edu- cation paid under paragraph (1).’’ Subsec. (e)(3). Pub. L. 109–307, § 2(c)(3), substituted ‘‘made and pay’’ for ‘‘made to pay’’. Subsec. (f)(1)(A)(iv). Pub. L. 109–307, § 2(a)(3), added cl. (iv). Subsec. (f)(2). Pub. L. 109–307, § 2(a)(4)(A), substituted ‘‘subsection (b)(1)(B)’’ for ‘‘subsection (b)(1)(A)’’ in in- troductory provisions. Subsec. (f)(2)(D). Pub. L. 109–307, § 2(a)(4)(B)–(D), added subpar. (D). 2004—Subsec. (d)(1). Pub. L. 108–490, § 1(a)(1), sub- stituted ‘‘costs associated with’’ for ‘‘costs related to’’. Subsec. (d)(2)(A). Pub. L. 108–490, § 1(a)(2), inserted ‘‘ratio of the’’ after ‘‘hospitals and the’’ and ‘‘to beds (but excluding beds or bassinets assigned to healthy newborn infants)’’ before semicolon. 2000—Subsec. (a). Pub. L. 106–310, § 2001(a), substituted ‘‘2000 through 2005’’ for ‘‘2000 and 2001’’ and inserted at end ‘‘The Secretary shall promulgate regulations pur- suant to the rulemaking requirements of title 5 which shall govern payments made under this subpart.’’ Subsec. (c)(2)(F). Pub. L. 106–310, § 2001(b), substituted ‘‘Federal fiscal year for which payments are made’’ for ‘‘hospital’s cost reporting period that begins during fis- cal year 2000’’. Subsec. (e)(1). Pub. L. 106–310, § 2001(c), inserted at end ‘‘Such interim payments to each individual hospital shall be based on the number of residents reported in the hospital’s most recently filed Medicare cost report prior to the application date for the Federal fiscal year for which the interim payment amounts are estab- lished. In the case of a hospital that does not report residents on a Medicare cost report, such interim pay- ments shall be based on the number of residents trained during the hospital’s most recently completed Medi- care cost report filing period.’’ Subsec. (e)(2). Pub. L. 106–310, § 2001(d), inserted ‘‘and indirect’’ after ‘‘interim installment for direct’’ and in- serted at end ‘‘The Secretary shall withhold up to 25 percent from each interim installment for direct and indirect graduate medical education paid under para- graph (1) as necessary to ensure a hospital will not be overpaid on an interim basis.’’ Subsec. (e)(3). Pub. L. 106–310, § 2001(e), reenacted heading without change and amended text generally. Prior to amendment, text read as follows: ‘‘At the end of each fiscal year for which payments may be made under this section, the hospital shall submit to the Sec- retary such information as the Secretary determines to be necessary to determine the percent (if any) of the total amount withheld under paragraph (2) that is due under this section for the hospital for the fiscal year. Based on such determination, the Secretary shall re- coup any overpayments made, or pay any balance due. The amount so determined shall be considered a final intermediary determination for purposes of applying section 1395oo of this title and shall be subject to re- view under that section in the same manner as the amount of payment under section 1395ww(d) of this title is subject to review under such section.’’ Subsec. (f)(1)(A)(iii). Pub. L. 106–310, § 2001(f)(1), added cl. (iii). Subsec. (f)(2)(C). Pub. L. 106–310, § 2001(f)(2), added sub- par. (C). Subsec. (g)(2). Pub. L. 106–310, § 2001(g), substituted ‘‘with a Medicare payment agreement and which is ex- cluded from the Medicare inpatient prospective pay- ment system pursuant to section 1395ww(d)(1)(B)(iii) of this title and its accompanying regulations’’ for ‘‘de- scribed in section 1395ww(d)(1)(B)(iii) of this title’’. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2004 AMENDMENT Pub. L. 108–490, § 1(b), Dec. 23, 2004, 118 Stat. 3972, pro- vided that: ‘‘The amendments made by subsection (a) [amending this section] shall apply to payments for pe- riods beginning with fiscal year 2005.’’ SUBPART X—PRIMARY DENTAL PROGRAMS § 256f. Designated dental health professional shortage area In this subpart, the term ‘‘designated dental health professional shortage area’’ means an area, population group, or facility that is des- ignated by the Secretary as a dental health pro- fessional shortage area under section 254e of this title or designated by the applicable State as having a dental health professional shortage. (July 1, 1944, ch. 373, title III, § 340F, as added Pub. L. 107–251, title IV, § 403, Oct. 26, 2002, 116 Stat. 1660.) § 256g. Grants for innovative programs (a) Grant program authorized The Secretary, acting through the Adminis- trator of the Health Resources and Services Ad- ministration, is authorized to award grants to States for the purpose of helping States develop and implement innovative programs to address the dental workforce needs of designated dental health professional shortage areas in a manner that is appropriate to the States’ individual needs. (b) State activities A State receiving a grant under subsection (a) may use funds received under the grant for— (1) loan forgiveness and repayment programs for dentists who— (A) agree to practice in designated dental health professional shortage areas; (B) are dental school graduates who agree to serve as public health dentists for the Federal, State, or local government; and (C) agree to— (i) provide services to patients regardless of such patients’ ability to pay; and (ii) use a sliding payment scale for pa- tients who are unable to pay the total cost of services; (2) dental recruitment and retention efforts; (3) grants and low-interest or no-interest loans to help dentists who participate in the medicaid program under title XIX of the So- cial Security Act (42 U.S.C. 1396 et seq.) to es- tablish or expand practices in designated den- tal health professional shortage areas by equipping dental offices or sharing in the over- head costs of such practices; (4) the establishment or expansion of dental residency programs in coordination with ac- credited dental training institutions in States without dental schools; (5) programs developed in consultation with State and local dental societies to expand or establish oral health services and facilities in designated dental health professional shortage areas, including services and facilities for chil- dren with special needs, such as— (A) the expansion or establishment of a community-based dental facility, free-stand- ing dental clinic, consolidated health center dental facility, school-linked dental facility, or United States dental school-based facil- ity; (B) the establishment of a mobile or port- able dental clinic;