CHGME-ApplicationGuidance- 06.26.24 FINAL

U.S. Department of Health and Human Services

Health Resources & Services Administration
(HRSA)
Bureau of Health Workforce
Division of Medicine and Dentistry
Children’s Hospitals Graduate Medical Education
(CHGME) Payment Program

Application Guidance
(Updated June 2024)

Department of Health and Human Services
Health Resources and Services Administration
Bureau of Health Workforce

OMB No. 0915-0247
Expiration Date: 12/31/2025

Dear Applicant:

The Children’s Hospitals Graduate Medical Education (CHGME) Payment Program
application guidance, including descriptions of all applicable forms and instructions, is
available on-line within Health Resources and Services Administration’s Electronic
Handbooks (EHBs). It is very important to thoroughly read the detailed application guidanc e
and instructions before completing the required application forms. The material contains
information related to submission of both the initial and reconciliation applications.
Your completed application must be submitted through the HRSA EHBs following the
guidance provided in the “Application Cycle and Deadlines” section of the application
guidance. Applications must be received by the stated deadlines in the CHGME Payment
Program Notice of Funding Opportunity to be considered for CHGME Payment Program
funding.
If you have questions regarding the application, please call Dr. Witzard Seide, Branch Chief
to the Graduate Medical Education Branch at 301-945-3428 or email at wseide@hrsa.gov.

Sincerely yours,
/s/ Luis Padilla, M.D.
Associate Administrator

Enclosures

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Children’s Hospitals Graduate Medical Education (CHGME)
Payment Program Application Guidance

Table of Contents
Section I: Overview of the CHGME Payment Program
Introduction
Administration

Section II: Application Cycle and Deadlines
Initial Application
Interim Payment Determination and Disbursement (Based Upon the Initial
Application)
Assessment of Resident Full-Time Equivalent Counts Reported in Initial Applications
Reconciliation Application
Final Payment Determination and Disbursement (Based Upon the Reconciliation
Application)

Section III: CHGME Payment Program Application Forms
HRSA 99: Demographic and Contact Information
HRSA 99-1: Determination of Weighted and Unweighted Resident Full-Time
Equivalent Counts
HRSA 99-2: Determination of Indirect Medical Education Data Related to the
Teaching of Residents
HRSA 99-4: Government Performance and Results Act Tables
HRSA 99-5: Application Checklist
Additional Application Supporting Documentation

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Section IV: Hospital Eligibility
Eligibility Criteria
Changes in Eligibility

Section V: Payment Methodology
Payment Methodology

Section VI: Hospital Data Needed to Complete the CHGME
Payment Program Application
Data Sources for Children’s Hospitals that File Full Medicare Cost Reports
Data Sources for Children’s Hospitals that File Low- or No-Utilization Medicare Cost
Reports
Data Sources for Children’s Hospitals that Have Not Completed Three (3) Medicare
Cost Report Periods
Data Sources for Children’s Hospitals that Have Not Completed One (1) Medicare
Cost Report Period

Section VII: Determining the Total Number of Resident Full-Time
Equivalents
Cap and Cap Year
Adjustments to a Hospital’s Cap
§422 of Medicare Modernization Act 2003
§5503 of the Affordable Care Act of 2010
Medicare GME Affiliation Agreements and Other Regulations Allowing the
Establishment or Adjustment of a Hospital Cap
Exceeding the Cap
Impact of §422 of the MMA When a Hospital Exceeds its Cap
Impact of §5503 of the MMA When a Hospital Exceeds its Cap
Eligible Residency Programs (Approved Training Programs)
Eligible Residents

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International Medical Graduates (IMGs)
Resident Full-Time Equivalent Counts
Initial Residency Period
Weighting of Resident Full-Time Equivalent Counts
Where Residents are Counted
Hospital Complex
Non-Provider/Non-Hospital Settings and Written Agreements
Partial Resident Full-Time Equivalents
Research Time
Resident Full-Time Equivalent Count Accuracy and Documentation

Section VIII: Special Instructions for Calculating Reductions and
Increases to a Hospital’s 1996 Base Year Cap as a Result of §422 of
the Medicare Modernization Act of 2003
Decrease to a Hospital’s 1996 Base Year Cap (§422 Cap Reduction)
Increase to a Hospital’s 1996 Base Year Cap (§422 Cap Increase)

Section IX: Special Instructions for Calculating Reductions and
Increases to a Hospital’s 1996 Base Year Cap as a Result of §5503
of the Affordable Care Act of 2010
Decrease to a Hospital’s 1996 Base Year Cap (§5503 Cap Reduction)
Increase to a Hospital’s 1996 Base Year Cap (§5503 Cap Increase)

Section X: Special Instructions for Calculating Increases to a Hospital’s
1996 Base Year Cap as a Result of §126, §127, and §131 of the
Consolidated Appropriations Act of 2021
Increase to a Hospital’s 1996 Base Year Cap (§126, §127, and §131 Cap Increase)

Section XI: Special Instructions for Calculating Indirect Medical
Education Payment Variables
Number of Inpatient Discharges

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Case Mix Index
Number of Available Beds
Intern/Resident to Bed Ratio

Section XII: Special Calculation Instructions for Hospitals that
Have Not Completed a Medicare Cost Reporting Period
Determining the Period of Eligibility
Calculating the Resident Full-Time Equivalent Count for an Incomplete Cost
Reporting Period
Calculating the Case Mix Index for an Incomplete Cost Reporting Period
Calculating Discharges for an Incomplete Cost Reporting Period
Calculating the Number of Available Beds for an Incomplete Cost Reporting Period
Calculating Inpatient Days for an Incomplete Cost Reporting Period
Calculating Outpatient Services for an Incomplete Cost Reporting Period

Section XIII: Special Calculation Instructions for Establishing a “CHGME
cap” for Newly Qualified Hospitals
Section XIV: CHGME Payment Program Application Form
Instructions
HRSA 99: Hospital Demographic and Contact Information
HRSA 99-1: Determination of Weighted and Unweighted Resident Full-Time
Equivalent Counts
HRSA 99-2: Determination of Indirect Medical Education Data Related to the
Teaching of Residents
HRSA 99-4: Government Performance and Results Act Tables
HRSA 99-5: Application Checklist

Section XV: References
Commonly Used Acronyms

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Section I: Overview of the CHGME Payment Program

Introduction
In 1999, Congress addressed the disparity of graduate medical education (GME) funding
between freestanding children’s teaching hospitals and other teaching hospitals by passing
the Healthcare Research and Quality Act, which established the Children’s Hospitals
Graduate Medical Education (CHGME) Payment Program. The act was signed on
December 6, 1999, and the statute authorized the program for Federal fiscal year (FY) 2000
and FY 2001. On October 17, 2000, the Children’s Health Act of 2000 amended the
Healthcare Research and Quality Act of 1999 extending the CHGME Payment Program
through FY 2005. On December 23, 2004, additional amendments under Public Law 108490 were made to Title III, Section 340E of the Public Health Service Act affecting the
CHGME Payment Program. In October 2006, the Children’s Hospital GME Support
Reauthorization Act of 2006 reauthorized the CHGME Payment Program through FY 2011.
In April 2014, the Children’s Hospital GME Support Reauthorization Act of 2013 reauthorized
the CHGME Payment Program through FY 2019 and included a provision to allow newly
qualified hospitals to apply for CHGME funding. Most recently, the CHGME Payment
Program was reauthorized by the Dr. Benjy Frances Brooks Children's Hospital GME
Support Reauthorization Act of 2018 (P.L. 115-241). The CHGME Payment Program
continues to operate through an appropriation.
CHGME funding supports the education and training of physician and dental residents and
enhances their ability to care for low-income patients. The CHGME program funds nearly
60 freestanding children’s teaching hospitals across the country that train 55 percent of the
Nation’s pediatricians and 53 percent of pediatric specialists trained in the United States 1
These are the physicians who care for America’s youngest population – its children. Almost
50 percent of the patient care that children’s teaching hospitals provide is for low-income
children, including those covered by Medicaid and those who are uninsured. In addition,
these hospitals are regional and national referral centers for very sick children, often serving
as the only source of care for many critical pediatric services. In Academic Year 2022–2023,
CHGME funded hospitals served as sponsoring institutions for 44 medical residency
programs and 267 fellowship programs 2.
The CHGME Payment Program provides a more adequate level of support for GME training
in U.S. children’s teaching hospitals that have a separate Medicare provider payment

1

U.S. Department of Health and Human Services, Health Resources and Services Administration
Fiscal Year 2025 Justification of Estimates for Appropriation Committees
2 Ibid.

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agreement. These hospitals receive relatively little funding from Medicare for GME. In 2020,
Medicare paid over $16.1 billion in funding to support GME training at around 1,319
hospitals, with an average payment of approximately $11 million per hospital. 3 4
In FY 2023, the CHGME Payment Program through the Notice of Funding Opportunity ,
HRSA-23-012, provided $363,725,699 in GME payments to 59 children's hospitals in 30
states, the District of Columbia and Puerto Rico; and $1,743,656 in Quality Bonus Systems
payments to 29 eligible children’s hospitals. Since the inception of this program in 1999, the
program has disbursed over $6.1 billion in Federal GME support to freestanding children’s
teaching hospitals.

Administration
The CHGME Payment Program is administered by the Graduate Medical Education Branch
(GMEB) of the Division of Medicine and Dentistry (DMD), Bureau of Health Workforce
(BHW), Health Resources and Services Administration (HRSA), Department of Health and
Human Services (DHHS). Questions regarding the CHGME Payment Program should be
directed to the:
Department of Health and Human Services
Health Resources and Services Administration
Bureau of Health Workforce
Division of Medicine and Dentistry
Graduate Medical Education Branch
Attn: Dr. Wizard Seide, MD
5600 Fishers Lane
Room 15N116
Rockville, Maryland 20857
Telephone: 301-945-3428
Email: wseide@hrsa.gov

3

United States Government Accountability Office (GAO). Report to Congressional Requesters.
PHYSICIAN WORKFORCE: Caps on Medicare-Funded Graduate Medical Education: An
Overview. GA0-21-391, May 2021. https://www.gao.gov/products/gao-21-391
4

Congressional Research Service (CRS). Analysis of FY2020 Medicare hospital cost report data.
https://crsreports.congress.gov/product/pdf/IF/IF10960

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Section II: Application Cycle and Deadlines
For hospitals to be considered for CHGME Payment Program funding, they must comply
with statutory eligibility requirements described herein and participate in the CHGME
Payment Program’s application cycle, which consists of specific processes for any given
fiscal year (FY). These processes are guided by the CHGME Payment Program’s statute
and are described below.

Initial Application
For children’s hospitals, meeting all statutory and eligibility requirements, to receive CHGME
Payment Program funding, they must submit a completed initial application for CHGME
Payment Program funding in accordance with the established deadlines noted in the most
current Notice of Funding Opportunity (NOFO). During the initial application process, eligible
children’s hospitals provide the CHGME Payment Program with information relevant to the
interim determination of payments.
Initial applications for CHGME Payment Program funding must include the following forms:
i.
ii.
iii.
iv.

HRSA 99: Demographic and Contact Information
HRSA 99-1: Determination of Weighted and Unweighted Resident FTE Counts
HRSA 99-2: Determination of Indirect Medical Education Data Related to the
Teaching of Residents
HRSA 99-5: Application Checklist

Applications accepted for review must be completed following the application guidance and
instructions provided herein, submitted in English, and include the above completed forms
and supporting documentation as identified in the HRSA 99-5 (Application Checklist). The
forms HRSA 99, HRSA 99-1, HRSA 99-2, and HRSA 99- 5 must be submitted electronically
through the secure HRSA Electronic Handbooks (EHBs) web-application system.
The Initial Application package includes a mandatory submission of a PROJECT
ABSTRACT. A project abstract is REQUIRED to be submitted to consider an application
complete. The project abstract should accurately describe your organization’s objectives
and goals within the context of a summary of the project. As an applicant, please seek
guidance from your organization’s Designated Institutional Official (DIO) to complete the
project abstract form. The project abstract form can be found in Grants.gov.
The CHGME Initial Application will be available through the current fiscal year CHGME
Payment Program Notice of Funding Opportunity posted on Grants.gov. Highlighting there
are multiple registrations to be completed by an applicant to be able to apply for federal
funding including registrations in SAM.gov, Grants.gov, and HRSA EHBs. The current
NOFO will have contact information of these websites. CHGME Payment Program strongly
encourages applicants to register as soon as possible as it can take up to one moth for
registration in all systems to be complete.
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Interim Payment Determination and Disbursement (Based Upon the Initial
Application)
In accordance with CHGME Payment Program statutory requirements, information provided
by participating children’s hospitals in their initial applications is used by the CHGME
Payment Program to calculate payments for all eligible children’s hospitals for interim
payments beginning of the FY (October 1st) for which children’s hospitals have applied for
CHGME Payment Program funding. CHGME Direct Medical Education (DME), and Indirect
Medical Education (IME) payments, allocated to eligible children’s hospitals, are based on
the information reported in their initial applications for CHGME Payment Program funding.
Each of the payments is determined by formula, and a hospital receives its proportion of the
total CHGME funding based on the calculation of the formula. For DME, the CHGME funding
is proportional to the number of residents the hospital trains. Furthermore, the DME payment
formula accounts for a hospital’s specific geographic variations in costs, and inflation. For
IME, the CHGME funding takes into account the severity of illness of its inpatients, the
number of available beds, as well as the number of residents the hospital trains.
DME and IME payment calculations are subject to all regulations and policies governing the
CHGME Payment Program.
On or after October 1st of the FY for which eligible children’s hospitals have applied for
CHGME Payment Program funding, the CHGME Payment Program will begin making
interim payments. CHGME Program payments to eligible children’s hospitals will be
contingent upon enactment of the FY Federal budget. Children’s hospitals will be notified, in
writing, of the Secretary’s interim payment determination. In accordance with the CHGME
Payment Program statute, payments will reflect up to a 25 percent withholding from each
interim installment (payment) for both DME and IME payments, as necessary, to ensure that
a hospital will not be overpaid on an interim basis.

Assessment of FTE Resident Counts Reported in Initial Applications
The CHGME Payment Program statute, at 42 USC 256e(e)(3), mandates that “the Secretary
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 payable
to the hospital for the current fiscal year for both direct expense and indirect expense
amounts.” Therefore, prior to the end of the FY for which children’s hospitals have applied
for CHGME Payment Program funding, the Secretary must determine (reconcile) any
changes to the number of FTE residents reported by a hospital in its initial application for
the current FY, which will impact final payments made by the CHGME Payment Program to
all eligible children’s hospitals. This determination is done by conducting a comprehensiv e
assessment of the FTE resident counts claimed by children’s hospitals in their initial
applications for CHGME Payment Program funding.

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The CHGME Payment Program has contracted with CHGME Fiscal Intermediaries (FIs) to
carry out an assessment of FTE resident counts (hereinafter the “FTE Resident Assessment
Program”) reflected in participating children’s hospitals initial applications for CHGME
Payment Program funding to determine any changes to the FTE resident counts initially
reported. An assessment of FTE resident counts reported by children’s hospitals in their
initial applications for CHGME Payment Program funding is performed regardless of the
type(s) of Medicare cost report (MCR) the hospital files (e.g., full, low- or no-utilization) for
purposes of receiving CHGME Payment Program funding. This process is designed to
assess FTE resident counts for all children’s hospitals in an equitable fashion and within
CHGME Payment Program time constraints.
The FTE Resident Assessment Program requires participating children’s hospitals to comply
with requests from the CHGME FIs, within the time constraints provided, as any changes to
FTE resident counts in one children’s hospital’s application for CHGME Payment Program
funding affects the distribution of funds among all eligible children’s hospitals. To minimize
public burden, CHGME FIs use and build upon work previously conducted by CHGME
and/or Medicare Administrative Contractors (MACs) in prior years.
At the conclusion of the FTE Resident Assessment Program, the CHGME FIs will forward
final assessment reports to the respective children’s hospitals, the MACs, and the CHGME
Payment Program explaining the results of the review. The assessment reports include
CHGME FI- generated HRSA 99-1’s, which children’s hospitals must use to complete their
reconciliation applications (see Reconciliation Application below). The assessment reports
may also include supporting documentation including, but not limited to adjustment reports,
updates to the intern and resident database, adjustments to the Centers for Medicare and
Medicaid Services (CMS) form 2552-10 Worksheet E-4 (2552-96 Worksheet E-3, Part IV),
or letters to the MAC requesting the reopening of one or more MCRs.

Reconciliation Application
During the third quarter of each FY (typically April 1st) for which payments are being made,
the CHGME Payment Program will release a reconciliation application for use by
participating children’s hospitals to report changes in the FTE resident counts reported in
their initial applications for CHGME Payment Program funding. For children’s hospitals to
continue receiving CHGME Payment Program funding, they must submit a completed
reconciliation application for CHGME Payment Program funding in accordance with
established deadlines noted below. The FTE resident counts reported by children’s hospitals
in their reconciliation applications must be for the same MCR period(s) identified in the
hospital’s initial application for the subject FY and consistent with those reported in the
CHGME FIs FTE resident final assessment report to be accepted by the CHGME Payment
Program.
The FTE resident counts from the final assessment reports are used to determine the final
amounts payable to children’s hospitals for the current FY for both DME and IME. Children’s

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hospitals whose FTE resident counts have not changed are not exempt from completing and
submitting a CHGME Payment Program reconciliation application.
Reconciliation applications for CHGME Payment Program funding must include the
following forms:
i.
ii.
iii.
iv.
v.

HRSA 99: Hospital Demographic and Contact Information
HRSA 99-1: Determination of Weighted and Unweighted Resident FTE Counts
HRSA 99-2: Determination of Indirect Medical Education Data Related to the
Teaching of Residents
HRSA 99-4: Government Performance and Results Act Tables
HRSA 99-5: Application Checklist

Applications accepted for review must be completed following the application guidance and
instructions provided herein, submitted in English and include the above completed forms
and supporting documentation as identified in the HRSA 99- 5 (Application Checklist). The
forms HRSA 99, HRSA 99-1, HRSA 99-2, HRSA 99-4 and HRSA 99-5 must be submitted
electronically through the secure EHBs web- application system.
Children’s hospitals that were not eligible to participate or did not apply for funding during
the initial application process for a given FY are not eligible to apply for and receive funding
during the reconciliation application process for the same FY. These hospitals must wait
until the next (initial) application cycle to apply for CHGME Payment Program funding.

Final Payment Determination and Disbursement (Based Upon the
Reconciliation Application)
The Secretary will determine any balance due, or any overpayment made to individual
hospitals following the determination of changes, if any, to the number of FTE residents
reported by children’s hospitals in their reconciliation applications because of the FTE
Resident Assessment Program. Children’s hospitals will be notified, in writing, of the
Secretary’s final reconciliation payment determination during the fourth quarter (July 1st –
September 30th) of the FY in which payments are being made.
Reconciliation payments will be made to individual hospitals on or before the end of the FY
(September 30th) in which payments are being made. The Secretary will include in the
reconciliation payments funding initially withheld in accordance with statutory requirements.
All hospitals, whether or not they report changes to their FTE resident counts during the
reconciliation process, can expect changes to their final payment determination as a result
of FTE resident count changes reported by other participating children’s hospitals. This is
due to the methodology used to determine CHGME Payment Program payments. More
detailed information is available on the CHGME Payment Program payment methodology in
Section V of this application package.

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The DME and IME payment calculations are subject to all statutes and accompanying
policies relating to the CHGME Payment Program, including the June 19, 2000, Federal
Register notice for DME, the July 20, 2001, Federal Register notice for IME, §422 of the
Medicare Modernization Act (MMA) of 2003, and sections 5503, 5504, 5505, and 5506 of
the Affordable Care Act (ACA) of 2010, Sections 126, 127 and 131 of the Consolidated
Appropriations Act (CAA) of 2021, and other pertinent legislation, if applicable.
At the end of the FY, the CHGME Payment Program may make a final payment to
distribute any remaining funds, including those funds that have been returned to the DHHS
during the FY because of overpayment or hospitals’ loss of eligibility.

Section III: Application Forms
Department of Health and Human Services
Health Resources and Services Administration

OMB No. 0915-0247
Expiration Date: 12/31/2025

Public Burden Statement
The purpose of this information collection is to obtain performance data for the
following: HRSA Grantees and cooperative agreement recipients, public health, and
applications. In addition, these data will facilitate the ability to demonstrate
alignment between BHW programs and CHGME Payment Program’s participating
children’s hospitals. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this information collection is 0915-0247
and it is valid until 12/31/2025. Public reporting burden for this collection of information is
estimated to average 3.7 hours per response, including the time for reviewing instructions,
searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to HRSA
Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville,
Maryland, 20857 or paperwork@hrsa.gov.

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Application Forms for Use by CHGME Applicant and Participating Hospitals

HRSA 99: Demographic and Contact Information.
Initial and Reconciliation Applications
This required form is used to identify the applicant hospital’s Medicare Provider Number,
Tax Identification Number, DUNS number, and the appropriate hospital liaisons for
application processing and auditing purposes. This form is the initial part of each application.

HRSA 99-1: Determination of Weighted and Un-weighted Resident FTE
Counts.
Initial Application
This required form must be completed as a component of the initial application. Information
is requested on the hospital’s number of resident FTE unweighted and weighted counts for
the current, previous, penultimate and base (1996) Medicate cost report (MCR) periods.
Reconciliation Application
This required form must be completed as a component of the reconciliation application.
Information is requested on the hospital’s number of resident FTE unweighted and weighted
counts for the current, previous, penultimate and base (1996) MCR periods.
Per section 340E(c)(1) of the Public Health Service Act, payments for direct expenses
relating to the hospital’s approved GME programs for a FY are equal to the product of (a)
an updated national per resident amount for direct GME with wage adjustment and a labor
share for each children’s hospital’s area applied to a standard wage-related portion, and (b)
the average number of FTE residents as determined under Section 1886(h)(4) of the Social
Security Act.

HRSA 99-2: Determination of IME Data Related to the Teaching of
Residents.
Initial Application
This required form must be completed as a component of the initial application. Information
is requested on the hospital’s number of inpatient days, number of inpatient discharges,
number of available beds, case-mix index (CMI) and intern/resident to bed (IRB) ratio for the
current, previous, penultimate and base (1996) MCR periods.
Reconciliation Application
This required form must be completed as a component of the reconciliation application.
Information is requested on the hospital’s number of inpatient days, number of inpatient

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discharges, number of available beds, CMI and IRB ratio for the current, previous,
penultimate and base (1996) MCR periods.
Per section 340E(d) of the PHS Act, the Secretary must determine the amounts of IME
payments by taking into account factors identified in section 340E(d)(2)(A) of the PHS Act -- variations in case mix, and the number of resident FTEs in the hospital’s approved GME
training programs for a fiscal year.

HRSA 99-4: Government Performance and Results Act (GPRA) Tables.
Reconciliation Application
This required form is for the collection of information per the GPRA of 1993, as well as §5504
of the Affordable Care Act of 2010 (ACA). It is requested before the end of the FY when the
reconciliation application cycle occurs and the HRSA 99-1 and HRSA 99-2 are resubmitted
reflecting changes, if any, to the resident FTE counts reported by the children’s hospitals in
their initial applications for CHGME Payment Program funding.

HRSA 99-5: Application Checklist.
Initial and Reconciliation Application
This required form is a checklist developed in response to numerous requests by
participating children’s hospitals to provide them with a checklist that they could use to
ensure that their application for CHGME Payment Program funding was complete before
submitting it to the CHGME Payment Program for consideration. The checklist identifies all
required forms and supporting documentation, where appropriate, that an applicant
children’s hospital must submit to the CHGME Payment Program to be considered for
funding.

Additional Application Supporting Documentation:
Application Cover Letter (Initial and Reconciliation Applications)
This optional letter includes a brief description of the application submitted and an
explanation of issues that may require attention, as well as a list of the documents included
for review by CHGME Payment Program. This letter is a document the children’s hospital
uploads as an attachment to the CHGME Payment Program application and is not a HRSA
form nor a template provided to the children’s hospitals. A copy of the form/template has not
been included in this guidance, because each letter uploaded varies depending on the
applicant children’s hospital.

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Exhibit 2: Revised GME Affiliation Agreement(s) for an Aggregate Cap
Initial and Reconciliation Applications
Revised GME Affiliation Agreement(s) for an Aggregate Cap, if available, as well as the
email confirmation receipt to CMS and proof of submission to the Medicare Administrativ e
Contractor (MAC). This agreement is a document the children’s hospital uploads as an
attachment to the CHGME Payment Program application and is not a HRSA form nor a
template provided to the children’s hospitals. A copy of the form/template has not been
included in this guidance, because each agreement uploaded varies depending on the
applicant children’s hospital.

Exhibit 3: Medicare Cost Reports
Initial and Reconciliation Applications
Updated CMS form 2552-10, Worksheet E-4 (formerly named Worksheet E-3, Part IV, and
Worksheet E-3, Part VI), if required. This worksheet is a document the children’s hospital
uploads as an attachment to the CHGME Payment Program application and is not a HRSA
form nor a template provided to the children’s hospitals. A copy of the form/template has not
been included in this guidance, because each worksheet uploaded varies depending on the
applicant children’s hospital.

Exhibit 4: CMS Letter Supporting Add-on to Cap
Initial and Reconciliation Applications
A confirmation letter from CMS, must be included if hospital claims an add-on to their 1996
cap. This letter is a copy of the letter sent to the provider by CMS informing the hospital of
an increase and/or reduction in the resident FTE cap due to Section 422 of MMA, Sections
5503 and 5506 of the ACA, Sections 126, 127 and 131 of the CAA, or other pertinent
legislation, if applicable. This letter is a document the children’s hospital uploads as an
attachment to the CHGME Payment Program application and is not a HRSA form nor a
template provided to the children’s hospitals. A copy of the form/template has not been
included in this guidance, because each letter uploaded varies depending on the applicant
children’s hospital.

CFO Form Letter
Initial and Reconciliation Applications
This required letter includes a brief description of the application resubmitted with corrections
and an explanation of changes made as well as a list of the revised documents included for
further review by CHGME Payment Program. This letter is a document the children’s hospital
uploads as an attachment to the CHGME Payment Program application and is not a HRSA
form nor a template provided to the children’s hospitals. The CFO Form Letter may be signed
by the Project Director (PD), Authorizing Official (AO), the Chief Operating Officer (CFO) or
other designated hospital official. A copy of the form/template has not been included in this
guidance, because each letter uploaded varies depending on the applicant children’s
hospital.
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Section IV: Hospital Eligibility Criteria
According to Public Law 106-310, a children’s teaching hospital must meet the following
eligibility criteria for CHGME Payment Program funding. The hospital must:
1. participate in an approved GME program;
2. have a Medicare Provider Agreement;
3. be excluded from the Medicare inpatient prospective payment system (PPS) under
section 1886(d)(1)(B)(iii) of the Social Security Act, and its accompanying
regulations(1); and
4. operate as a “freestanding” children’s teaching hospital, as defined by the CHGME
Payment Program.(2)
As per the Children’s Hospital GME Support Reauthorization Act of 2013 (Public Law 113–
98), a freestanding hospital that meets the following criteria may be eligible as a newly
qualified hospital for CHGME payments depending on the level of funding appropriated to
the program:
1. It has an approved medical residency training program as defined in section
1886(h)(5)(A) of the Social Security Act;
2. It has a Medicare provider agreement and is excluded from the Medicare inpatient
hospital prospective payment system (IPPS) pursuant to section 1886(d)(1)(B) of
the Social Security Act and its accompanying regulations;
3. Its inpatients are predominantly individuals under 18 years of age;
4. It is not otherwise qualified to receive payments under this section or section
1886(h) of the Social Security Act. For those free-standing children’s hospitals that
met the above requirements as of April 7, 2014, when the Secretary has not
previously determined an average number of FTE residents under section
1886(h)(4) of the Social Security Act, the Secretary may establish such number of
FTE residents for the purposes of calculating CHGME program payments.
(1) A

hospital with a 3300 series Medicare provider number would meet this criterion (i.e.,
55- 3300).
(2)A

children’s teaching hospital is considered “freestanding” if it does not operate under a
Medicare hospital provider number assigned to a larger health care entity that receives
Medicare GME payments.
Additional references:
 Social Security Act, Section 1886
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)

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Changes in Eligibility
A hospital remains eligible for CHGME Payment Program funding as long as it meets the
eligibility criteria listed above and trains residents as a “freestanding” children’s hospital
during the FY for which CHGME Program payments are being made.
If a hospital becomes ineligible for payments:
1. it must notify the CHGME Payment Program immediately of the change in status
and the date of the change; and
2. it will be liable for the reimbursement, with interest, of any funds received during the
period of ineligibility.
Additional references:
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)

Section V
Payment Methodology
CHGME Payment Program funding to individual children’s hospitals is based upon a number
of variables, including the rolling average of weighted and un-weighted FTE resident counts,
which are used to calculate DME and IME payments, respectively. Payment variables and
calculations are subject to all other statutes, rules and CMS regulations and accompanying
policies relating to the CHGME Payment Program statute, including the June 19, 2000
Federal Register Notice for DME (65 FR 37985), the March 1, 2001 Federal Register Notice
(66 FR 12940), the July 20, 2001 Federal Register Notice for IME (66 FR 37980), the
October 22, 2003 Federal Register Notice (68 FR 60396), §422 of the MMA of 2003, as well
as and Sections 5503, 5504, 5505, and 5506 of the ACA of 2010, and Sections 126, 127
and 131 of the CAA of 2021, and other pertinent legislation, if applicable.
The rolling average is the average of the FTE resident counts reported by the children’s
hospital for the (1):
1. most recently filed MCR (or the most recently completed MCR period); and
2. the prior 2 years.
(1) CHGME

Payment Program funding to a children’s hospital that has not completed three
(3) MCR periods will be based upon the hospital’s FTE resident count from its “most
recently filed” or “most recently completed” MCR period until three (3) MCR periods have
been completed.

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The rolling average FTE resident count includes all residents except those that qualify for
an adjustment after the averaging rules are applied in accordance with 42 CFR 413.77.
The FTE resident count for any MCR period is based upon the number of:
1. allopathic and osteopathic residents following application of the “cap”, where
applicable; and
2. dental and podiatric residents.
Effective “for portions of cost reporting periods occurring on or after July 1, 2005”, the
CHGME Payment Program will not include FTE residents counted against the §422 cap
increase in the 3-year rolling average calculation for purposes of DME and IME payments.
Additional information regarding the CHGME Payment Program’s implementation of §422
of the MMA of 2003 is included in Sections VII and VIII of this application guidance.
Effective “for portions of cost reporting periods ending on or after July 1, 2011”, the CHGME
Payment Program will include FTE residents counted against the §5503 cap increase in the
3-year rolling average calculation for purposes of DME and IME payments. Additional
information regarding the CHGME Payment Program’s implementation of §5503 of the ACA
of 2010 is included in Sections VII and VIII of this application guidance.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.77
 CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72194)
 CHGME Payment Program, Federal Register Notice, June 19, 2000 (65 FR 37985)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
 CHGME Payment Program, Federal Register Notice, October 22, 2003 (68 FR
60396)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

CHGME Payment Program Application Guidance

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Section VI: Hospital Data Needed to Complete the CHGME Payment
Program Application
Data Sources for Children’s Hospitals that File Full MCRs
To complete a CHGME Payment Program application, hospitals that file full MCRs (i.e.,
report residents to Medicare on CMS 2552-10, Worksheet E-4 (formerly named CMS
2552-96, Worksheet E-3, Part IV)) must use the data as reflected in their:
1. most recently filed MCR for the period ending on or before December 31, 1996 (the
“cap year");
2. most recently filed MCR; and the
3. prior 2 years.
In addition, hospitals who received adjustments to their cap (increases or decreases) as a
result of §422 of the MMA of 2003 must use data included in and provide a copy of their
written notification from CMS regarding these adjustments on CMS 2552-10, Worksheet E4 (formerly named CMS 2552-96, Worksheet E-3, Part VI). Additional information regarding
the CHGME Payment Program’s implementation of §422 of the MMA of 2003 is included in
Sections VII and VIII of this application guidance.
Also, hospitals who received adjustments to their cap (increases or decreases) as a result
of §5503 of the ACA of 2010 must use data included in and provide a copy of their written
notification from CMS regarding these adjustments on CMS 2552-10, Worksheet E-4
(formerly named CMS 2552-96, Worksheet E-3, Part IV). Additional information regarding
the CHGME Payment Program’s implementation of §5503 of the ACA of 2010 is included in
Sections VII and VIII of this application guidance.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.77
 CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72192)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Data Sources for Children’s Hospitals that File Low- or No-Utilization
MCRs
To complete a CHGME Payment Program application, hospitals that file low- or noutilization MCRs (i.e., do not report residents to Medicare on CMS 2552-10, Worksheet E-

CHGME Payment Program Application Guidance

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4 (formerly named CMS 2552-96, Worksheet E-3, Part IV)) must use the data as reflected
in their hospital records for the:
1. most recently completed MCR period for the period ending on or before December
31, 1996 (the “cap year”);
2. most recently completed MCR period; and the
3. completed MCR periods for the prior 2 years.
In addition, hospitals who received adjustments to their cap (increases or decreases) as a
result of §422 of the MMA of 2003 must use data included in and provide a copy of their
written notification from CMS regarding these adjustments. Additional information regarding
the CHGME Payment Program’s implementation of §422 of the MMA of 2003 is included in
Sections VII and VIII of this application guidance.
Also, hospitals who received adjustments to their cap (increases or decreases) as a result
of §5503 of the ACA of 2010 must use data included in and provide a copy of their written
notification from CMS regarding these adjustments. Additional information regarding the
CHGME Payment Program’s implementation of §5503 of the ACA of 2010 is included in
Sections VII and VIII of this application guidance.
Hospitals whose most recently completed MCR period ends less than five (5) months prior
to the stated CHGME Payment Program initial application deadline may report as their most
recently completed MCR period FTE resident counts from their most recently completed or
the previously completed MCR period.
Example:
Charlie’s Angels Children’s Center (CACC) will file a low-utilization MCR for its 06/30/23
year- end. The CHGME Payment Program application deadline for FY 2024 is August 1,
2023 (approximately 1 month after CACC’s year-end). CACC has the option of reporting as
its “most recently completed MCR period” data from its 6/30/22 or 6/30/23 year-end. Since
CACC needs time to close-out its FTE resident counts and financial records for its 6/30/23
year-end, it decides to use the FTE resident count data from its 6/30/22 cost reporting period
to complete Section 4 of HRSA-99-1. Consequently, CACC must use data from its 6/30/21
and 6/30/20 MCR periods to complete Sections 5 and 6 of the HRSA-99-1, respectively.
CACC must also use its hospital data from its 6/30/22 cost reporting period to complete all
subsequent application forms (i.e., HRSA- 99-2, HRSA-99-4, etc.). CACC cannot use the
FTE resident count data from its 6/30/23 MCR period until the next CHGME Payment
Program initial application cycle (FY 2025).
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.77
 CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72152)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

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Data Sources for Children’s Hospitals that Have Not Completed Three
(3) MCR Periods
If a hospital has completed at least one (1), but not more than two (2) MCR periods, CHGME
Payment Program funding to the children’s hospital will be based upon data from the
hospital’s “most recently filed” or “most recently completed” MCR period until three (3) MCR
periods have been completed. Hence, the hospital will not complete sections 5 and 6 of
HRSA-99-1 and its DME and IME payments will not be based upon a 3-year rolling average
FTE resident count.
Upon completion of three (3) MCR periods, the hospital will complete sections 5 and 6 of
HRSA-99-1 and will receive DME and IME payments based upon a 3-year rolling average
FTE resident count.
In addition, hospitals who received adjustments to their cap (increases or decreases) as a
result of §422 of the MMA of 2003 must use data included in and provide a copy of their
written notification from CMS regarding these adjustments. Additional information regarding
the CHGME Payment Program’s implementation of §422 of the MMA of 2003 is included in
Sections VII and VIII of this application guidance.
Also, hospitals who received adjustments to their cap (increases or decreases) as a result
of §5503 of the ACA of 2010 must use data included in and provide a copy of their written
notification from CMS regarding these adjustments. Additional information regarding the
CHGME Payment Program’s implementation of §5503 of the ACA of 2010 is included in
Sections VII and VIII of this application guidance.
Additional references:
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
 CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72152)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Data Sources for Children’s Hospitals that Have Not Completed One (1)
MCR Period
New children’s teaching hospitals (new to the CHGME Payment Program) training residents
who were originally trained in a program that received and will continue to receive funding
under the CHGME Payment Program are required to wait until they have completed a MCR
period before applying for CHGME Payment Program funding. These hospitals must also
apply the 3-year rolling average (to their FTE resident counts) in accordance with Medicare

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regulations. Over a 3-year period, the “new children’s teaching hospital” will gradually
increase its number of FTE residents that can be claimed in the CHGME Payment Program
as the children’s hospital that originally trained those FTE residents gradually decreases its
FTE resident count for determining payments from the CHGME Payment Program.
New children’s teaching hospitals (new to the CHGME Payment Program) training residents
previously trained at a hospital that never received (or is no longer receiving) funding under
the CHGME Payment Program are eligible for CHGME Payment Program funding without
having completed a MCR period. In addition, a hospital that becomes newly eligible for the
CHGME Payment Program by starting its own “new medical residency training program”
according to Medicare regulation 42 CFR 413.79(e)(1) will also be eligible for CHGME
Payment Program funding without having completed a MCR period.
Hospitals that are eligible to receive CHGME Payment Program funding without having
completed a MCR period must follow the guidance provided in Section X of this application
guidance which provides special calculation instructions for hospitals that have not
completed a MCR report.
Additional references:
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Section VII: Determining the Total Number of Resident Full-Time
Equivalents
Cap and Cap Year
Section 1886(d)(5)(B)(v) of the Social Security Act established “caps” on the number of
allopathic and osteopathic residents that a hospital operating an approved GME program
may count when requesting payment for DME and IME costs. A hospital’s “cap” (hereinafter
the “1996 Base Year Cap”) is currently defined as the “number of un-weighted FTE residents
enrolled in a hospital’s allopathic and osteopathic residency programs during the most recent
cost reporting period ending on or before December 31, 1996 (the “cap year”).” The cap (i.e.,
limit) on the number of allopathic and osteopathic residents is effective for all cost reporting
periods beginning on or after October 1, 1997. Dental and podiatric residents are exempt
from the cap but are included in the FTE resident counts for all relevant years to calculate
the 3-year rolling average.
The “cap year” is defined as a hospital’s most recent cost reporting period ending on or
before December 31, 1996.

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Example:
CACC had 75 FTE residents enrolled in its allopathic programs, 25 FTE residents enrolled
in its osteopathic programs and 7 FTE residents enrolled in its dental and podiatric programs
for its 6/30/96 MCR period (its most recent MCR period ending on or before December 31,
1996). Hence, CACC’s cap for Medicare and CHGME Payment Program purposes is 100
(75+25=100). Note: Dental residents do not count towards the cap amount.
Hospitals that are eligible to receive CHGME funds as “newly qualified hospitals” under the
Children’s Hospital GME Support Reauthorization Act of 2013, and that do not already have
a CMS cap established and are not able to apply for a CMS cap as a new residency training
program, will have a “CHGME cap” established using the number of FTE residents trained
during the most recent Medicare cost report period completed on or before April 7, 2014,
the date of enactment of the Children’s Hospital GME Support Reauthorization Act of 2013,
as verified by the CHGME auditors during the FTE Resident Assessment Program.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.79
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA-99-1 and HRSA-99-2

Adjustments to a Hospital’s Cap
As noted above, Section 1886(d)(5)(B)(v) of the Social Security Act established caps on the
number of allopathic and osteopathic residents that a hospital operating an approved GME
program may count when requesting payment for DME and IME costs. While Medicare and
the CHGME Payment Program only make DME and IME payments for the number of
allopathic and osteopathic FTE residents up to a hospital’s “1996 Base Year Cap”, some
hospitals have trained allopathic and osteopathic residents in excess of their 1996 Base
Year Cap. There are also a number of hospitals that have reduced their resident positions
to a level below their 1996 Base Year Cap.
Subsequent legislative actions and related Federal Register notices addressing these issues
allow a hospital’s cap to be permanently changed (increased or decreased) by CMS or
temporarily adjusted at the request of the hospital and approved by CMS. These provisions
are detailed below.

§422 of the Medicare Modernization Act of 2003
In December 2003, the President signed the MMA of 2003 (also known as the Medicare
Prescription Drug and Improvement Act of 2003), Public Law 108-173. Section 422 of the
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23

MMA added Section 1886(h)(7) to the Social Security Act (SSA). This provision reduced the
1996 Base Year Cap for certain hospitals and redistributed those positions to other hospitals
that applied for and received an increase to their 1996 Base Year Cap under §422.
Hereinafter, any decreases to a hospital’s 1996 Base Year Cap as a result of §422 will be
referred to as the “§422 Cap Reduction” and any increases to the 1996 Base Year Cap as
a result of §422 will be referred to as the “§422 Cap Increase.” Authority for implementing
§422 of the MMA was delegated to CMS. Determinations made and implemented by CMS
in response to §422 are final and not subject to appeal, and binding on the CHGME Payment
Program.
Under the CHGME Payment Program statute, by incorporation of the SSA provisions, HRSA
must implement the counting law and rules of Medicare, which include those related to the
implementation of §422 of the MMA. Additional information regarding the CHGME Payment
Program’s implementation of §422 of the MMA can be found in Section VIII of this application
guidance.

§5503 of the Affordable Care Act of 2010
In March 2010, the President signed the ACA of 2010 (also known as the Affordable Care
Act of 2010), Public Law 111-148. Section 5503 of the ACA added Section 1886(h)(8)(F) to
the SSA. This provision reduced the 1996 Base Year Cap for certain hospitals and
redistributed those positions to other hospitals that applied for and received an increase to
their 1996 Base Year Cap under §5503.
Hereinafter, any decreases to a hospital’s 1996 Base Year Cap as a result of
§5503 will be referred to as the “§5503 Cap Reduction” and any increases to the 1996 Base
Year Cap as a result of §5503 will be referred to as the “§5503 Cap Increase.” Authority for
implementing §5503 of the ACA was delegated to CMS. Determinations made and
implemented by CMS in response to §5503 are final and not subject to appeal, and binding
on the CHGME Payment Program.
Under the CHGME Payment Program statute, by incorporation of the SSA provisions, HRSA
must implement the counting law and rules of Medicare, which include those related to the
implementation of §5503 of the ACA. Additional information regarding the CHGME Payment
Program’s implementation of §5503 of the ACA can be found in Section VIII of this
application guidance.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.79(c)(2)

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Medicare GME Affiliation Agreements and Other Regulations Allowing
the Establishment or Adjustment of a Hospital Cap
Hospitals that meet criteria as currently eligible hospitals (Section IV) that were not in
existence for the most recent cost reporting period ending on or before December 31, 1996,
do not have a “1996 Base Year Cap” and are, therefore, “capped” to an FTE resident count
of zero “0”. Hence, eligible hospitals must obtain (or adjust) their 1996 Base Year Cap (or
lack thereof) in order to receive CHGME Payment Program funding.
To provide an adjustment to a cap, the CHGME Payment Program will allow hospitals to
add FTE residents to their “1996 Base Year Cap” based on the following Medicare and
CHGME Payment Program regulations:
1. the formation of a new medical residency program as described in 42 CFR
413.79(e)(1); or
2. the redistribution of FTE resident positions from a closed hospital as described in
§5506 of the ACA (75 FR 72212, November 24, 2010), with the following
exceptions:
i.
In the first cost reporting period in which the hospital takes displaced residents
and the hospital closure occurs, the applying hospital would receive a
temporary cap adjustment, and the displaced FTE residents would be exempt
from the 3-year rolling average and the Intern/Resident to Bed (IRB) ratio cap.
ii.
In the cost reporting period following the one in which the hospital closure
occurred, the applying hospital’s permanent cap increase would take effect,
and the displaced FTE residents would no longer be exempt from the 3-year
rolling average and the IRB ratio cap.
3. the execution of a Medicare GME Affiliation Agreement for an aggregate cap, as set
forth in 42 CFR 413.79(f) and 63 FR 26338 as published in the Federal Register on
May 12, 1998, with the following exceptions:
i.
A “new children's teaching hospital” participating in the CHGME Payment
Program for the first year must establish an effective date of the agreement for
purposes of the CHGME Payment Program. For the first year, unless otherwise
specified, the Department will use as the effective date of the Medicare GME
Affiliation Agreement for an aggregate cap the date that the hospital becomes
eligible for CHGME Payment Program funding. This effective date will only
apply to the CHGME Payment Program. A hospital must also have an effective
date of July 1st for the Medicare Program. Subsequent to the first year of the
Medicare GME Affiliation Agreement, the effective date must comply with the
above- cited Federal Register final rule, which specifies an effective date of
July 1st for all affiliation agreements.
The CHGME Payment Program allows this exception because hospitals must meet eligibility
criteria and have their caps determined prior to the CHGME Payment Program application
deadline. If the CHGME Payment Program application deadline occurs before July 1st, some
hospitals would have a cap of zero and thus be excluded from receiving funds. By deviating

CHGME Payment Program Application Guidance

25

from the prescribed Medicare final rule, the CHGME Payment Program will not place some
hospitals in this position.
Unlike the Medicare Program, for the first year that a hospital is eligible to participate in the
CHGME Payment Program, the CHGME Payment Program will not prorate the cap based
on the effective date of the cap.
Instead, the full value of the cap as determined by the Medicare GME Affiliation Agreement
will be used. For purposes of the CHGME Payment Program and its application forms, a
hospital that is now starting to train residents previously trained at a hospital that never
received or is no longer receiving funds from the CHGME Payment Program will be allowed
to use the cap agreed upon in the Medicare GME Affiliation Agreement until the full value of
the cap is reflected in the MCR. Afterwards, the hospital will use the FTE resident count and
cap from its filed MCR as indicated in Section VI of this application guidance.
Example:
CACC opened as a freestanding children’s hospital on January 1, 2023, and would like to
apply for FY 2024 CHGME Payment Program funding. The CHGME Payment Program
FY2024 application deadline is August 1, 2023. Since CACC did not train residents in 1996
and does not qualify as an NQH, it has a cap of zero, but was able to arrange a Medicare
GME Affiliation Agreement for an aggregate cap with Shirley Temple Medical Center in
which CACC’s current residents had previously trained.
CACC did the following in order to apply for CHGME Payment Program funding:
1. Established a cap by forming a Medicare GME Affiliation Agreement with Shirley
Temple Medical Center for an aggregate cap.
2. The agreement had an effective date of January 1, 2023 (for CHGME Payment
Program purposes only) and an effective date of July 1, 2023, and expiration date of
June 30, 2024, for and in accordance with Medicare rules and regulations.
3. CACC and Shirley Temple Medical Center filed the agreement with their MACs (the
hospitals have different MACs) before June 30, 2023 (in accordance with Medicare
rules and regulations) and provided a signed copy of the CHGME Payment
Program following acceptance by the FIs.
Hospitals that report residents to Medicare and are part of an affiliated group may elect to
apply the FTE resident limit on an aggregate basis under Medicare rules and regulations. If
the combined FTE resident counts for the individual members of the group exceed the
aggregate limit, each hospital’s FTE resident cap will be adjusted per the agreement
between the members of the affiliated group. These adjustments must be reflected in the
filed MCR in order to be considered for the CHGME Payment Program.
Hospitals that receive an increase to their 1996 Base Year Cap from CMS under §422 of
the MMA of 2003 and participate in a Medicare GME Affiliation Agreement under 42 CFR
413.79(f) on or after July 1, 2005, may only affiliate for the purpose of adjusting their (original)
1996 Base Year Cap. The additional slots that a hospital receives under

CHGME Payment Program Application Guidance

26

§422 may not be aggregated and applied (through Medicare GME Affiliation Agreements)
to the cap of any other hospitals.
The additional slots that a hospital receives under §5503 may not be aggregated and applied
(through Medicare GME Affiliation Agreements) to the cap of any other hospitals for the 5year probationary period. Hospitals that receive an increase to their 1996 Base Year Cap
from CMS under §5503 of the ACA of 2010 and participate in a Medicare GME Affiliation
Agreement under 42 CFR 413.79(f) for cost reporting periods ending on or after July 1, 2011,
may only affiliate for the purpose of adjusting their (original) 1996 Base Year Cap.
After the 5-year probationary period, hospitals that receive an increase to their 1996 Base
Year Cap from CMS under §5503 of the ACA and participate in a Medicare GME Affiliation
Agreement under 42 CFR 413.79(f) for cost reporting periods ending on or after July 1, 2011,
may affiliate for the purpose of adjusting their (original) 1996 Base Year Cap and their §5503
Cap Increase. The additional slots that a hospital receives under §5503 may be aggregated
and applied (through Medicare GME Affiliation Agreements) to the cap of any other hospitals
following the 5-year probationary period beginning July 1, 2016.
Hospitals should refer to 42 CFR 413.79(f) for additional information on adjustments to the
cap.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.79(f)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72195)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Exceeding the Cap
For DME payment calculations if a hospital’s un-weighted FTE resident count for allopathic
and osteopathic residents exceeds its FTE limit (“cap”), the weighted count is reduced by
the ratio of the FTE resident limit to the actual un-weighted FTE resident count for the
subject cost reporting period. Additional information regarding the CHGME Payment
Program’s implementation of §422 of the MMA of 2003 and §5503 of the ACA of 2010 is
provided below.
Example:
CACC, per its Medicare GME Affiliation Agreement, has a cap of 100. For its 6/30/23
MCR, CACC reported an un-weighted FTE resident count of 150 and a weighted count of
105 for its allopathic and osteopathic programs.

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For DME payment purposes, CACC would determine its weighted allopathic and
osteopathic FTE resident count by taking its cap divided by its total un-weighted FTE
resident count and multiplying that product by the total weighted FTE resident for allopathic
and osteopathic residents [(100/150) x 105 = 70.00]. The weighted count of any dental and
podiatric residents trained during this MCR period would be added to the 70.00 as dental
and podiatric residents are exempt from (i.e., not subject to) the cap.
For IME payment calculations if a hospital’s un-weighted FTE resident count for allopathic
and osteopathic residents exceeds its FTE limit (“cap”), the hospital must report the lesser
of the un-weighted FTE resident count or the cap for the subject cost reporting period.
Additional information regarding the CHGME Payment Program’s implementation of §422
of the MMA of 2003 and §5503 of the ACA of 2010 is provided below.
Example:
CACC, per its Medicare GME Affiliation Agreement, has a cap of 100. For its 6/30/23
MCR, CACC reported an un-weighted FTE resident count of 150 and a weighted count of
105 for its allopathic and osteopathic programs.
For IME payment purposes, CACC would report 100.00 [the lesser of the un-weighted
allopathic and osteopathic FTE resident count (150) or the cap (100)]. The un-weighted
count of any dental and podiatric residents trained during this MCR period would be added
to the 100.00 as dental and podiatric residents are exempt from (i.e., not subject to) the
cap.

Impact of §422 of the MMA When a Hospital Exceeds Its Cap
Section 422 of the MMA will affect the determination of DME and IME payments for each
of the children’s hospitals participating in the CHGME Payment Program. The CHGME
Payment Program will begin accounting for the redistribution of the 1996 caps under §422
of the MMA in determining DME and IME payments starting with “portions of a hospital’s
cost reporting periods occurring on or after July 1, 2005.”
Children’s hospitals whose cap has been reduced under §422 of the MMA will report and
be paid based on the §422 Cap Reduction effective “for portions of cost reporting periods
occurring on or after July 1, 2005.” The 1996 Base Year Cap will be used for MCR periods
prior to the effective date. Children’s hospitals will be asked to submit a copy of the letter
they received from CMS informing them of the reduction in their cap that includes the
actual reduction. The full effect of the reduction for a given hospital will take about 3 years
following implementation of §422 when all three MCR periods reflected in the hospital’s
application for CHGME Payment Program funding are affected by the §422 Cap
Reduction.
For children’s hospitals who received an increase to their 1996 Base Year Cap under
§422 of the MMA, the CHGME Payment Program will not include FTE residents counted
against the §422 Cap Increase in the 3-year rolling average calculation for purposes of

CHGME Payment Program Application Guidance

28

DME and IME payments effective for portions of cost reporting periods and discharges
occurring on or after July 1, 2005. In addition, effective for discharges occurring on or after
July 1, 2005, the CHGME Payment Program will not apply the intern/resident to bed (IRB)
ratio cap to the residents claimed against a hospital’s §422 Cap Increase. However,
residents claimed against the 1996 Base Year Cap will be subject to the 3-year rolling
average and will be subject to the IRB ratio cap.

Impact of §5503 of the ACA When a Hospital Exceeds Its Cap
Section 5503 of the ACA will affect the determination of DME and IME payments for each
of the children’s hospitals participating in the CHGME Payment Program. The CHGME
Payment Program will begin accounting for the redistribution of the 1996 caps under
§5503 of the ACA in determining DME and IME payments starting with “portions of a
hospital’s cost reporting periods ending on or after July 1, 2011.”
Children’s hospitals whose cap has been reduced under §5503 of the ACA will report and
be paid based on the §5503 Cap Reduction effective “for portions of cost reporting periods
ending on or after July 1, 2011.” The 1996 Base Year Cap and §422 of the MMA (if
applicable) will be used for MCR periods prior to the effective date. Children’s hospitals will
be asked to submit a copy of the letter they received from CMS informing them of the
reduction in their cap that includes the actual reduction. The full effect of the reduction for a
given hospital will immediately take effect following implementation of
§5503 when the current MCR period reflected in the hospital’s application for CHGME
Payment Program funding is affected by the §5503 Cap Reduction.
For children’s hospitals who received an increase to their 1996 Base Year Cap under
§5503 of the ACA, the CHGME Payment Program will include FTE residents counted
against the §5503 Cap Increase in the 3-year rolling average calculation for purposes of
DME and IME payments effective for portions of cost reporting periods ending on or after
July 1, 2011.
In addition, effective for portions of cost reporting periods ending on or after July 1, 2011,
the CHGME Payment Program will apply the intern/resident to bed (IRB) ratio cap to the
residents claimed against a hospital’s §5503 Cap Increase.
Additional references:

 CMS, Federal Register Notice, November 24, 2010 (75 FR 72194)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
In FY 2026, HRSA plans to issue a Federal Register Notice regarding updates to the direct
graduate medical education (DGME) methodology. Additional information regarding any
change in DGME methodology would also be made available on the CHGME Payment
Program website. If any changes to DGME methodology are made, HRSA plans to

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address this methodology in a future Technical Assistance (TA) Webinar should timing
allow.

Eligible Residency Programs (Approved Training Programs)
Residents may be included in a hospital’s FTE resident count for CHGME Payment Program
purposes if the residency program (in which the resident is enrolled) meets one of the
following criteria:
•

The program must be approved by one of the following accrediting bodies:
o Accreditation Council for Graduate Medical Education (ACGME);
o Committee on Hospitals of the Bureau of Professional Education of the
American Osteopathic Association;
o Commission on Dental Accreditation of the American Dental Association; or
o Council of Podiatric Medicine Education of the American Podiatric Medical
Association.

•

The program may count towards certification of the participant in a specialty or
subspecialty listed in the current edition of the Directory of Graduate Medical
Education Programs (published by the American Medical Association) or the Annual
Report and Reference Handbook (published by the American Board of Medical
Specialties).

•

The program is approved by the ACGME as a fellowship program in geriatric
medicine; or

•

The program would be accredited except for the accrediting agency’s reliance upon
an accreditation standard that requires an entity to perform an induced abortion or
require, provide, or refer for training in the performance of induced abortions, or make
arrangements for such training, regardless of whether the standard provides
exceptions or exemptions.

Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.75(b)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

ACGME-I (International)
The ACGME-I (International) program is NOT included as a program to be counted in a
hospital’s reported resident or fellow count for funding and reporting for the CHGME
Payment Program purposes. An approved graduate medical education (GME) program for
the CHGME Payment Program means one of the following: Per 42 CFR 415.152 “Approved
graduate medical education (GME) program” is (1) a residency program approved by the
Accreditation Council for Graduate Medical Education, by the American Osteopathic

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Association, by the Commission on Dental Accreditation of the American Dental Association,
or by the Council on Podiatric Medical Education of the American Podiatric Medical
Association; and (2) a program otherwise recognized as an “approved medical residency
program” under § 413.75(b) of this chapter, that restates an approved medical residency
program is approved by one of the national organizations listed in § 415.152 of this chapter.
§ 413.75 Direct GME payments: General requirements.
(b) Definitions. For purposes of this section and §§ 413.76 through 413.83, the following
definitions apply: Approved medical residency program means a program that meets one
of the following criteria: (1) Is approved by one of the national organizations listed in §
415.152 of this chapter.
§ 415.152 Definitions.
As used in this subpart— Approved graduate medical education (GME) program means
one of the following: 42 CFR 415.152 “Approved graduate medical education (GME)
program” (1) A residency program approved by the Accreditation Council for Graduate
Medical Education, by the American Osteopathic Association, by the Commission on
Dental Accreditation of the American Dental Association, or by the Council on Podiatric
Medical Education of the American Podiatric Medical Association. (2) A program
otherwise recognized as an “approved medical residency program” under § 413.75(b) of
this chapter.

Eligible Residents
In order to be counted in CHGME payment calculations, a resident must be:
in an approved residency training program (see Eligible Residency Program above);
and either
•
•

a graduate of an accredited medical school in the U.S. or Canada; or
have passed the United States Medical Licensing Examination (USMLE) Parts I & II
(international or foreign medical graduates)

Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.75(b)
 CMS, 42 CFR 413.80
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

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International Medical Graduates (IMGs)
An IMG [(formerly known as a foreign medical graduate (FMG)] is a resident who is not a
graduate of a medical, osteopathy, dental, or podiatry school, respectively, accredited or
approved as meeting the standards necessary for accreditation by the:
1.
2.
3.
4.

Liaison Committee on Medical Education of the American Medical Association;
American Osteopathic Association;
Commission on Dental Accreditation; or the
Council on Podiatric Medical Education.

In order for an IMG to be included in a hospital’s FTE resident count, s/he must have
passed Parts I and II of the USMLE and be enrolled in an eligible residency program.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.75(b)
 CMS, 42 CFR 413.80
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Resident Full-Time Equivalent Counts
The FTE resident counts are based on the number of residents training at the hospital
complex and certain non-hospital/non-provider settings/sites throughout the hospital’s fiscal
year. Residents are counted as FTEs based on the total time necessary to fill a full-time
residency slot for the year.
For purposes of clarification, is measured in terms of time worked during a residency training
year. It is not a measure of the number of individual residents who are working.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.78
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Initial Residency Period
Residents are divided into two categories, those in their:
1. initial residency period (IRP);
i.
Effective July 1, 1995, an IRP is defined as the minimum number of years
required for board eligibility.
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ii.

For osteopathic, dentistry, and podiatric programs, the IRP is the minimum
number of years of formal training necessary to satisfy the requirements of the
approving body for those programs.
iii.
Prior to July 1, 1995, an IRP is defined as the minimum number of years
required for board eligibility in a specialty or subspecialty plus 1 year (not to
exceed 5 years with some exceptions).
2. and those beyond their IRP.
Example:
The IRP for pediatrics is 3 years. Therefore, the initial residency period for all pediatric
subspecialties (e.g., pediatric cardiology) is 3 years.
The IRP for general surgery is 5 years. Therefore, the initial residency period of all surgical
subspecialties (e.g., pediatric surgery) is 5 years even if the training program requires a
longer period of training.
A Pediatric Surgery (subspecialty) resident (or fellow) who previously completed a 5-year
general surgery residency program and is now in his first year of subspecialty training (in
Pediatric Surgery) is beyond his IRP. His IRP was 5 years (general surgery).
Exceptions apply to the IRP for residents enrolled in preventive medicine, geriatric medicine,
transitional year and combined residency programs. Refer to 42 CFR 413.79(a) for
additional information on the IRP and exceptions.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.79(a)
Applicable to the following application forms: HRSA-99-1

Weighting of FTE Resident Counts
The CHGME Payment Program, like Medicare, assigns a 0.5 (or ½) weighting factor to
residents who are beyond their IRP. Hence a resident who is beyond his or her initial
residency period is factored by 0.5 regardless of the number of years or length of the training
program in which s/he is currently enrolled.
Example:
John Doe completed a 3-year pediatric residency program on June 30, 2022, at CACC.
Following completion of his residency program, John continued his training in a pediatric
cardiology fellowship program also at CACC. During the first year of his fellowship program
(July 1, 2022, to June 30, 2023), John spent 40% of the academic year at CACC and 60%
of the academic year rotating to other teaching hospitals.

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CACC’s MCR period is the same as the academic year (July 1 to June 30). Hence, CACC
would report John as 0.20 for the MCR period ending June 30, 2023 [(40/100) x 0.5 = .20].
CACC must weight John’s FTE resident count because the IRP for pediatrics is 3 years and
John is in his 4th year of training (3 years of residency training and 1 year of fellowship
training).
For CHGME Payment Program purposes, the weighting of FTE resident counts is also
applicable to the increase in FTE residents based on §422 of the MMA and §5503 of the
ACA et al.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.79(b)
Applicable to the following application forms: HRSA-99-1

Where Residents Are Counted
The time a resident spends anywhere within the hospital complex (see “Hospital Complex”
below) may be included in the FTE resident count for CHGME Payment Program purposes.
In addition, the time spent by residents in certain non-hospital/non- provider settings/sites is
counted if the criteria identified below (under “Non- Provider/Non-Hospital Settings and
Written Agreements”) are met.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.78
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Hospital Complex
The time a resident spends anywhere within the hospital complex (as defined in 42 CFR
413.65) may be included in the FTE resident count for CHGME Payment Program purposes.
The CMS final rule implementing the per resident amount (PRA) methodology for payment
of the direct GME costs of approved GME activities defines a hospital complex as “hospitals
and hospital-based providers and sub providers” (54 FR 40286, September 29, 1989). The
term “hospital” is defined in section 1861(e) of the Social Security Act as, in part, an
institution which is primarily engaged in providing, by or under the supervision of physicians,
diagnostic and therapeutic services to inpatients.

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The term “provider of services” is defined in section 1861(u) of the Social Security Act as a
hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health
agency, hospice program, or, for purposes of section 1814(g) and section 1835(c), a fund.
The term “sub provider” is defined in the Provider Reimbursement Manual (PRM) Part II,
section 2405(b) as “a portion of a general hospital which has been issued a sub provider
identification number because it offers a clearly different type of service from the remainder
of the hospital, such as long-term psychiatric.”
The CHGME Payment Program, however, does not differentiate between PPS and non-PPS
locations within a hospital complex.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.65
 CMS, 42 CFR 413.78(a)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Non-Provider/Non-Hospital Settings and Written Agreements
The time a resident spends in a non-provider (or non-hospital) setting such as a physician’s
office or a freestanding community health center in connection with an approved program
may be included in the FTE resident count if the criteria in Federal regulation 42 CFR 413.78
(75 FR 72141, November 24, 2010) and §5504 of the ACA are met. For CHGME Payment
Program purposes, 42 CFR 413.78 and §5504 of the ACA applies to both DME and IME
funding received under the CHGME Payment Program.
Written agreements covering residents’ time spent in non-provider/non-hospital settings
shall cover a period of 1 year and must commence on the start of the cost reporting period
and must be between the hospital and the non-hospital setting, not between the related
School of Medicine (SOM), School of Podiatric Medicine (SOPM), or School of Dentistry
(SOD). Refer to 42 CFR413.78 and §5504 of the ACA for additional information on written
agreements.
Additional references and application forms:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.78
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72134)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72141)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

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Partial Resident Full-Time Equivalents
A partial FTE resident is a resident who does not spend all time that is part of the approved
training program in the hospital complex or qualified non-hospital setting. A resident will
count as a partial FTE resident based on the proportion of allowable time worked at the
children’s hospital and qualified non-hospital (provider) settings compared to the total time
necessary to fill a full-time residency slot. Instances where a resident would be counted as
a partial FTE resident include, if the resident:

1. is part-time;
2. rotates to other hospitals as part of the approved training program sponsored by
the children’s hospital;
3. is in a program sponsored by another hospital and spends one or more rotations
at the children's hospital;
4. is on leave;
5. joins or leaves a program mid-year; or
6. passes the USMLE mid-year.
Hospitals should consult with their FIs regarding additional exceptions.
The sum of partial FTE resident counts at all institutions where an individual resident works
as part of his/her approved residency program may not exceed 1.0 FTE. Also, time spent
by residents moonlighting may not be counted.
Example:
During the course of the year, a full-time resident in orthopedic surgery spends 90 days at
the children’s hospital and 275 days at the hospital sponsoring the residency program. The
resident would count as a 0.25 FTE at the children’s hospital [90/365 = 0.2465 (rounded to
0.25)].
A part-time third year resident in pediatrics works 4 days week. The normal workweek for a
full time third year pediatric residents is 6 days per week. The resident would count as 0.67
FTE [4/6
= .6666 (rounded to 0.67)]
During the course of the year, a full-time resident (who is also a foreign medical graduate)
is enrolled in his second year of a 3-year family practice residency program at CACC. The
resident spends the entire academic year (2022-2023) at CACC and does not rotate to any
other sites. The resident took and passed Part I of the USMLE in September 2022. On May
1, 2023, the resident sat for Part II of the USMLE and is awaiting the examination results. In
June 2023 the resident learns that he passed Part II of the USMLE. Since CACC’s year-end
is June 30, CACC may count and include the resident in their FTE resident counts (as a
partial FTE) for the period May 1, 2023 (the date he took the examination) to June 30, 2023

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(CACC’s year end). The resident would count as 0.17 FTE [61 days (31 days in May + 30
days in June)/ 365 days = 0.1671 (rounded to 0.17)].
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.78(b)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Research Time
Research may be included in a hospital’s FTE resident count if the research is part of the
residency program, and the resident carries out the research in:
1. the children’s hospital complex (clinical or bench research); or
2. in a non-provider setting where the research involves patient care and the
compensation for both the residents, the faculty and other teaching costs are paid
by the children’s hospital (requirements listed at 42 CFR 413.78 and §5505 of the
ACA must be met. (See 66 FR 39896, Aug. 1, 2001, and 75 FR 72144, Nov. 24,
2010).
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.75
 CMS, 42 CFR 413.78
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72144)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA 99-2, and HRSA 99-4

FTE Resident Count Accuracy and Documentation
Children’s hospitals are responsible for the accuracy of the FTE resident counts submitted
to HRSA and are subject to audit. More specifically, the Secretary, by statute, must
determine any changes to the number of residents reported by a hospital in the initial
application of the hospital for the current FY for both direct and indirect expense amounts.
This mandate is accomplished through the FTE Resident Assessment Program carried out
by the CHGME Payment Program (see “Application Cycle and Deadlines”). Children’s
hospitals are not required to submit with their completed initial applications for CHGME
Payment Program funding documentation in support of the FTE resident data reported in
their applications.
However, at the time children’s hospitals certify their applications, the hospital should
possess documentation in accordance with 413.75(d) and other applicable Medicare recordkeeping regulations. Hospitals that do not report FTE resident counts to Medicare are not
exempt from this policy.
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Additional references:
 CMS, 42 CFR 413.20
 CMS, 42 CFR 413.24
 CMS, 42 CFR 413.75(d)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA 99-2, and HRSA 99-4

Section VIII: Special Instructions for Calculating Reductions and
Increases to a Hospital’s 1996 Base Year Cap as a Result of §422 of the
Medicare Modernization Act of 2003
Hospitals that received an increase or reduction to their 1996 Base Year Cap as a result of
§422 of the MMA must use the following methodology for calculating and claiming FTE
resident counts against their caps.

Decrease to a Hospital’s 1996 Base Year Cap (§422 Cap Reduction)
Children’s hospitals who received a decrease to their 1996 Base Year Cap as a result of
§422 of the MMA will report and be paid based on the §422 Cap Reduction effective “for
portions of cost reporting periods occurring on or after July 1, 2005.” The 1996 Base Year
Cap will be used for MCR periods prior to the effective date. Children’s hospitals will be
asked to submit a copy of the letter they received from CMS informing them of the reduction
in their cap that includes the actual reduction amount. The full effect of the reduction for a
given hospital will take about 3 years following the implementation of §422 when all three
MCR periods reflected in the hospital’s application for CHGME Payment Program funding
are subject to the §422 Cap Reduction.
Example:
CACC had 75 FTE residents enrolled in its allopathic programs, 25 FTE residents enrolled
in its osteopathic programs and 7 FTE residents enrolled in its dental and podiatric programs
for its 6/30/96 MCR period (its most recent MCR period ending on or before December 31,
1996).
Hence, CACC’s 1996 Base Year Cap for Medicare and CHGME Payment Program
purposes is 100 (75+25=100). However, in December 2004 CACC received a letter from
CMS indicating that their 1996 Base Year Cap would be reduced by 7.50 FTE residents
under §422 of the MMA. CACC’s new, revised cap is now 92.50 (1996 Base Year Cap §422 Cap Reduction). Any dental and podiatric residents trained during this MCR period
would not be included in the 1996 Base Year Cap or the “new, revised” cap as dental and
podiatric residents are exempt from (i.e., not subject to) the cap.
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Increase to a Hospital’s 1996 Base Year Cap (§422 Cap Increase)
Children’s hospitals who received an increase to their 1996 Base Year Cap as a result of
§422 of the MMA will report and be paid based on the §422 Cap Increase effective “for
portions of cost reporting periods occurring on or after July 1, 2005.” The 1996 Base Year
Cap will be used for MCR periods prior to the effective date. Children’s hospitals will be
asked to submit a copy of the letter they received from CMS informing them of the
adjustment to their cap that includes the actual increase amount. It is important to note that
a §422 Cap Increase is not automatically added to a hospital’s 1996 Base Year Cap. A
hospital’s ability to utilize their §422 Cap Increase is contingent upon whether the hospital is
training (unweighted and/or weighted FTE residents) above or below their total adjusted cap
(including the 1996 Base Year Cap and the §5503 Cap (if applicable)).
Examples are provided below.
CACC had 75 FTE residents enrolled in its allopathic programs, 25 FTE residents enrolled
in its osteopathic programs and 7 FTE residents enrolled in its dental and podiatric programs
for its 6/30/96 MCR period (its most recent MCR period ending on or before December 31,
1996).
Hence, CACC’s 1996 Base Year Cap for Medicare and CHGME Payment Program
purposes is 100 (75+25=100). However, in December 2004 CACC received a letter from
CMS indicating that their 1996 Base Year Cap would be increased by 20 FTE residents
under §422 of the MMA. CACC now has a 1996 Base Year Cap of 100 and a §422 Cap
Increase of 20.
Examples (for Hospitals Training “Above” Their 1996 Base Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed 110 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and §422 Cap Increase of 20, CACC would claim 100 FTE residents
against its 1996 Base Year Cap and the remaining 10 FTE residents would be claimed
against its §422 Cap Increase. Any dental and podiatric residents trained during this MCR
period would be added to the total (un)weighted allopathic and osteopathic FTE residents
following application of the caps as dental and podiatric residents are exempt from (i.e., not
subject to) the cap.
Example #2: During CACC’s most recent MCR period, CACC claimed 140 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and §422 Cap Increase of 20, CACC would claim 100 FTE residents
against its 1996 Base Year Cap and the remaining 40 FTE residents would be claimed
against its §422 Cap Increase. As CACC’s number of FTE residents claimed exceeds both
its 1996 Base Year Cap and its §422 Cap Increase, the DME and IME payment calculation
methodology described in Section VII of this application guidance (“Exceeding the Cap”)
would be followed. Any dental and podiatric residents trained during this MCR period would

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be added to the total (un)weighted allopathic and osteopathic FTE residents following
application of the caps as dental and podiatric residents are exempt from (i.e., not subjec t
to) the cap.
Examples (for Hospitals Training “Below” Their 1996 Base Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed 95 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and a §422 Cap Increase of 20, CACC would claim 95 FTE residents
against its 1996 Base Year Cap and zero “0” residents against its §422 Cap Increase. Any
dental and podiatric residents trained during this MCR period would be added to the total
(un)weighted allopathic and osteopathic FTE residents following application of the caps as
dental and podiatric residents are exempt from (i.e., not subject to) the cap.
Example #2: During CACC’s most recent MCR period, CACC claimed 105 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. In August 2011 CACC
received a letter from CMS indicating that their 1996 Base Year Cap would be increased by
10 FTE residents under §5503 of the ACA. Based on CACC’s 1996 Base Year Cap of 100,
a §5503 Cap Increase of 10, and a §422 Cap Increase of 20, CACC would claim 100 FTE
residents against its 1996 Base Year Cap, five “5” FTE resident against its §5503 Cap
Increase and zero “0” residents against its §422 Cap Increase. Any dental and podiatric
residents trained during this MCR period would be added to the total (un)weighted allopathic
and osteopathic FTE residents following application of the caps as dental and podiatric
residents are exempt from (i.e., not subject to) the cap.
Additional references:
 Social Security Act, Section 1886(h)(7)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72193)
 CMS, 42 CFR 413.79(b)
Applicable to the following application forms: HRSA-99-1

Section IX: Special Instructions for Calculating Reductions and
Increases to a Hospital’s 1996 Base Year Cap as a Result of §5503 of the
Affordable Care Act of 2010
Hospitals that received an increase or reduction to their 1996 Base Year Cap as a result of
§5503 of the ACA must use the following methodology for calculating and claiming FTE
resident counts against their caps. It is important to note that 75% of the §5503 Cap Increase
must be used to train residents in primary care (defined in 42 CFR 413.75(b)) as an approved
program in family medicine, general internal medicine, general pediatrics, preventive
medicine, geriatric medicine, or osteopathic general practice) and general surgery

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programs. Additional information regarding §5503 Cap Increase and its FTE resident
requirements is specified in §1886(h)(8)(B)(ii) of the SSA.

Decrease to a Hospital’s 1996 Base Year Cap (§5503 Cap Reduction)
Children’s hospitals who received a decrease to their 1996 Base Year Cap as a result of
§5503 of the ACA will report and be paid based on the §5503 Cap Reduction effective “for
portions of cost reporting periods ending on or after July 1, 2011.” The 1996 Base Year Cap
and the §422 Cap Reduction (if applicable) will be used for MCR periods prior to the effective
date.
Children’s hospitals will be asked to submit a copy of the letter they received from CMS
informing them of the reduction in their cap that includes the actual reduction amount. The
full effect of the reduction for a given hospital will immediately take effect following
implementation of §5503 when the current MCR period reflected in the hospital’s application
for CHGME Payment Program funding is affected by the §5503 Cap Reduction.
Example:
CACC had 75 FTE residents enrolled in its allopathic programs, 25 FTE residents enrolled
in its osteopathic programs and 7 FTE residents enrolled in its dental and podiatric programs
for its 6/30/96 MCR period (its most recent MCR period ending on or before December 31,
1996).
Hence, CACC’s 1996 Base Year Cap for Medicare and CHGME Payment Program
purposes is 100 (75+25=100). However, in August 2011 CACC received a letter from CMS
indicating that their 1996 Base Year Cap would be reduced by 7.50 FTE residents under
§5503 of the ACA. CACC’s new, revised cap is now 92.50 (1996 Base Year Cap - §5503
Cap Reduction). Any dental and podiatric residents trained during this MCR period would
not be included in the 1996 Base Year Cap or the “new, revised” cap as dental and podiatric
residents are exempt from (i.e., not subject to) the cap.

Increase to a Hospital’s 1996 Base Year Cap (§5503 Cap Increase)
Children’s hospitals who received an increase to their 1996 Base Year Cap as a result of
§5503 of the MMA will report and be paid based on the §5503 Cap Increase effective “for
portions of cost reporting periods ending on or after July 1, 2011.” The 1996 Base Year Cap
and the §422 Cap Increase (if applicable) will be used for MCR periods prior to the effective
date. Children’s hospitals will be asked to submit a copy of the letter they received from CMS
informing them of the adjustment to their cap that includes the actual increase amount. It is
important to note that a §5503 Cap Increase is not automatically added to a hospital’s 1996
Base Year Cap. A hospital’s ability to utilize their §5503 Cap Increase is contingent upon
whether the hospital is training above or below their 1996 Base Year Cap.

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Examples are provided below.
CACC had 75 FTE residents enrolled in its allopathic programs, 25 FTE residents enrolled
in its osteopathic programs and 7 FTE residents enrolled in its dental and podiatric programs
for its 6/30/96 MCR period (its most recent MCR period ending on or before December 31,
1996).
Hence, CACC’s 1996 Base Year Cap for Medicare and CHGME Payment Program
purposes is 100 (75+25=100). However, in August 2011 CACC received a letter from CMS
indicating that their 1996 Base Year Cap would be increased by 20 FTE residents under
§5503 of the ACA. CACC now has a 1996 Base Year Cap of 100 and a §5503 Cap Increase
of 20.
Examples (for Hospitals Training “Above” Their 1996 Base Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed 110 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and §5503 Cap Increase of 20, CACC would claim 100 FTE residents
against its 1996 Base Year Cap and the remaining 10 FTE residents would be claimed
against its §5503 Cap Increase. Please note 75% (in this case 7.5) of the FTE residents
claimed against the §5503 Cap Increase would need to be residents training in primary care
and general surgery programs. Any dental and podiatric residents trained during this MCR
period would be added to the total (un)weighted allopathic and osteopathic FTE residents
following application of the caps as dental and podiatric residents are exempt from (i.e., not
subject to) the cap. Example #2: During CACC’s most recent MCR period, CACC claimed
140 allopathic and osteopathic FTE residents and 7 dental and podiatric FTE residents.
Based on CACC’s 1996 Base Year Cap of 100 and §5503 Cap Increase of 20, CACC would
claim 100 FTE residents against its 1996 Base Year Cap, and the remaining 40 FTE
residents would be claimed against its §5503 Cap Increase. As CACC’s number of FTE
residents claimed exceeds both its 1996 Base Year Cap and its §5503 Cap Increase, the
DME and IME payment calculation methodology described in Section VII of this application
guidance (“Exceeding the Cap”) would be followed. Please note 75% (in this case 15) of the
FTE residents claimed against the §5503 Cap Increase would need to be residents training
in primary care and general surgery programs. Any dental and podiatric residents trained
during this MCR period would be added to the total (un)weighted allopathic and osteopathic
FTE residents following application of the caps as dental and podiatric residents are exempt
from (i.e., not subject to) the cap.
Examples (for Hospitals Training “Below” Their 1996 Base Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed 95 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and a §5503 Cap Increase of 20, CACC would claim 95 FTE residents
against its 1996 Base Year Cap and zero “0” residents against its §5503 Cap Increase. Any
dental and podiatric residents trained during this MCR period would be added to the total

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(un)weighted allopathic and osteopathic FTE residents following application of the caps as
dental and podiatric residents are exempt from (i.e., not subject to) the cap.
Additional references:
 Social Security Act, Section 1886(h)(8)(F)
 CMS, Federal Register Notice, November 24, 2010 (75 FR 72147)
 CMS, 42 CFR 413.79(b)
Applicable to the following application forms: HRSA-99-1

Section X: Special Instructions for Calculating Increases to a Hospital’s
1996 Base Year Cap as a Result of §126, §127, and §131 of the
Consolidated Appropriations Act (CAA) of 2021
Hospitals that received an increase to their 1996 Base Year Cap as a result of §126, §127,
and/or §131 of the CAA, must use the following methodology for calculating and claiming
FTE resident counts against their caps. Section 126 of the CAA makes available an
additional 1,000 FTE resident cap slots phased in at a rate of no more than 200 slots per
year beginning in fiscal year 2023. Section 127 of the CAA specifies that in the case of a
hospital not located in a rural area that established or establishes a medical residency
training program (or rural track) in a rural area, the hospital, and each such hospital located
in a rural area that participates in such a training, is allowed to receive an adjustment to its
FTE resident limit. Section 131 of the provides an opportunity for hospitals that meet certain
criteria and that have very small FTE resident caps to replace those caps if the Secretary
determines the hospital begins training residents in a new program beginning on or after
enactment (December 27, 2020) and before 5 years after enactment (December 26, 2025).
Additional information regarding §126, §127, and §131 of the CAA and its FTE resident
requirements is specified in §1886(h)(4)(H) of the SSA.

Increase to a Hospital’s 1996 Base Year Cap (§126, §127, and §131 Cap
Increase)
Children’s hospitals who received an increase to their 1996 Base Year Cap as a result of
§126, §127, and/or §131 of the CAA will be asked to submit a copy of the letter they received
from CMS informing them of the adjustment to their cap that includes the actual increase
amount.
It is important to note that a §126, §127, and §131 Cap Increase is not automatically
added to a hospital’s 1996 Base Year Cap. A hospital’s ability to utilize their §126,
§127, and/or §131 of the CAA Cap Increase is contingent upon whether the hospital
is training above or below their 1996 Base Year Cap, and subject to the annual FTE
assessment audit.

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Examples are provided below.
CACC had 75 FTE residents enrolled in its allopathic programs, 25 FTE residents enrolled
in its osteopathic programs and 7 FTE residents enrolled in its dental and podiatric programs
for its 6/30/96 MCR period (its most recent MCR period ending on or before December 31,
1996).
Hence, CACC’s 1996 Base Year Cap for Medicare and CHGME Payment Program
purposes is 100 (75+25=100). However, in January 2023 CACC received a letter from CMS
indicating that their 1996 Base Year Cap would be increased by 2 FTE residents under §126,
§127, and/or §131 of the CAA. CACC now has a 1996 Base Year Cap of 100 and a §126,
§127, and §131 Cap Increase of 2.
Examples (for Hospitals Training “Above” Their 1996 Base Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed 110 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and §126, §127, and/or §131 Cap Increase of 2, CACC would claim
100 FTE residents against its 1996 Base Year Cap and the remaining 10 FTE residents
would be claimed against its §126, §127, and/or §131 Cap Increase of 2. Any dental and
podiatric residents trained during this MCR period would be added to the total (un)weighted
allopathic and osteopathic FTE residents following application of the caps as dental and
podiatric residents are exempt from (i.e., not subject to) the cap. Example #2: During
CACC’s most recent MCR period, CACC claimed 140 allopathic and osteopathic FTE
residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996 Base Year Cap
of 100 and §126, §127, and/or §131 Cap Increase of 2, CACC would claim 100 FTE
residents against its 1996 Base Year Cap, and the remaining 40 FTE residents would be
claimed against its §126, §127, and/or §131 Cap Increase. As CACC’s number of FTE
residents claimed exceeds both its 1996 Base Year Cap and its §126, §127, and/or §131
Cap Increase, the DME and IME payment calculation methodology described in Section VII
of this application guidance (“Exceeding the Cap”) would be followed. Any dental and
podiatric residents trained during this MCR period would be added to the total (un)weighted
allopathic and osteopathic FTE residents following application of the caps as dental and
podiatric residents are exempt from (i.e., not subject to) the cap.
Examples (for Hospitals Training “Below” Their 1996 Base Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed 95 allopathic and
osteopathic FTE residents and 7 dental and podiatric FTE residents. Based on CACC’s 1996
Base Year Cap of 100 and a §126, §127, and/or §131 Cap Increase of 2, CACC would claim
95 FTE residents against its 1996 Base Year Cap and zero “0” residents against its §126,
§127, and/or §131 Cap Increase. Any dental and podiatric residents trained during this MCR
period would be added to the total (un)weighted allopathic and osteopathic FTE residents
following application of the caps as dental and podiatric residents are exempt from (i.e., not
subject to) the cap.

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Additional references:
 Social Security Act, Section 1886(h)(4)(H)
 CMS, Federal Register Notice, December 27, 2021 (86 FR 73416)
 CMS, 42 CFR 413.79(b)
Applicable to the following application forms: HRSA-99-1

Section XI: Special Instructions for Calculating Indirect Medical
Education Payment Variables
Hospitals applying for IME payments should follow the instructions provided below when
calculating inpatient discharges, case mix index, available beds, and the intern/resident to
bed ratio. Additional information and “calculation” instructions are provided in Section X of
this application guidance for hospitals that are eligible to begin receiving CHGME Payment
Program funding without having completed a MCR period.

Number of Inpatient Discharges
The number of inpatient discharges is a measure of a hospital’s inpatient care. This measure
is defined as the sum of all daily inpatient discharges for the hospital’s most recently filed
(or most recently completed) MCR period from all parts of the hospital complex including
healthy newborns from the healthy newborn nursery. Public Law 108-490 does not exclude
inpatient discharges associated with healthy newborns inpatient stays in the “well baby”
nursery.
Additional references:
 Social Security Act, Section 1886
 Public Law 108-490, December 23, 2004
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37986)
Applicable to the following application forms: HRSA-99-2

Case Mix Index (CMI)
The CMI is the sum of the diagnosis-related group (DRG) weights for all inpatient discharges
excluding healthy newborns from the most recently filed (or most recently completed) MCR
period divided by the number of inpatient discharges for the same period. All hospitals
applying for IME payments must submit a CMI on all inpatient discharges using the
appropriate CMS DRG version, excluding healthy newborns. This value must be reported to
four decimal points. The CMS DRG version to be used for CHGME Payment Program

CHGME Payment Program Application Guidance

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purposes is published by CMS. The principles in determining the version of the CMS
grouper is delineated is the July 20, 2001 CHGME Payment Program Federal Register
Notice.
Additional references:
 Social Security Act, Section 1886
 Public Law 108-490, December 23, 2004
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-2

Number of Available Beds
An available bed is defined as an adult or pediatric bed, including beds or bassinets available
for lodging inpatients including beds in intensive care units, coronary care units, neonatal
intensive care units, short stay units, and other special care inpatient hospital units. Beds in
the following location are excluded: healthy newborn nursery, labor rooms, post-anesthesia
or post-operative recovery rooms, outpatient areas, emergency rooms, ancillary
departments, nurses’ and other staff residence, and other areas as are regularly maintained
and utilized for purposes other than lodging inpatients. To be considered an available bed,
a bed must be permanently maintained for lodging inpatients. It must be available for use
and housed in patient rooms or wards (i.e., not in corridors or temporary beds). CMS in its
August 11, 2004, final inpatient PPS Federal Register Notice, revised its regulations at 42
CFR 412.105(b) and 412.106(a)(1)(ii) to specify that bed days in a unit that was occupied to
inpatient care for at least 1 day during the preceding 3 months are included in the available
bed day count for a month. In addition, bed days for any beds within a unit that would
otherwise be considered occupied should be excluded from the available bed day count for
the current month if the bed has remained unavailable (could not be made available for
patient occupancy within 24 hours) for 30 consecutive days, or if the bed is used to provide
outpatient observation services or swing bed skilled nursing care. This clarified policy is
effective for discharges occurring on or after October 1, 2004.
The available bed count for the current or prior MCR period is the sum of all available beds
per day in the cost reporting period, excluding beds and bassinets in the healthy newborn
nursery, divided by the number of days in that period.
Additional references:
 Social Security Act, Section 1886
 Public Law 108-490, December 23, 2004
 CMS, 42CFR412.105(b)
 CMS, 42 CFR 412.106(a)(1)(ii)
 CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)

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 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR
12940CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR
37980, 37986)
Applicable to the following application forms: HRSA-99-2

Intern/Resident to Bed (IRB) Ratio
The IRB ratio for the most recently filed (or most recently completed) MCR period is equal
to the 3-year un-weighted rolling average divided by the number of available beds for the
same period. The IRB ratio for the previous MCR period is equal to the un- weighted FTE
resident count for the previous MCR period divided by the number of available beds for the
same period. To comply as closely as possible with Medicare rules and regulations, the
Department applies a cap on the IRB ratio pursuant to regulations at 42 CFR 412.105(a)(1),
whereby the ratio from the most recently filed (or most recently completed) MCR period may
not exceed the ratio for the hospital's prior cost reporting period as defined above. Hospitals
that meet the criteria for an exception or adjustment to their 1996 Base Year Cap (e.g.,
through a Medicare GME Affiliation Agreement) should refer to the CMS August 1, 2001,
Federal Register Notice which provides additional information and guidance in determining
the IRB ratio subject to these exceptions.
Effective for portions of cost reporting periods and discharges occurring on or after July 1,
2005, the CHGME Payment Program will not include FTE residents counted against the
§422 cap in the 3-year rolling average calculation and the CHGME Payment Program will
not apply an IRB ratio cap to the FTE residents counted against a hospital’s §422 Cap
Increase for purposes of determining IME payments. A §422 IRB calculation will be
implemented as guided by CMS rules and regulations. Effective for portions of cost reporting
periods ending on or after July 1, 2011, the CHGME Payment Program will include FTE
residents counted against the §5503 cap in the 3-year rolling average calculation, and the
CHGME Payment Program will apply an IRB ratio cap to the FTE residents counted against
a hospital’s §5503 Cap Increase for purposes of determining IME payments.
Additional references:
 Social Security Act, Section 1886
 CMS, 42 CFR 413.77
 CMS, Federal Register Notice, August 1, 2001 (66 FR 39878)
 CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
 CHGME Payment Program, Federal Register Notice, June 19, 2000 (65 FR 37985)
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
 CHGME Payment Program, Federal Register Notice, October 22, 2003 (68 FR
60396)
Applicable to the following application forms: HRSA-99-2

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Section XII: Special Calculation Instructions for Hospitals that Have Not
Completed a Medicare Cost Reporting Period
Hospitals eligible to begin receiving CHGME Payment Program funding without having
completed a MCR period, must use the following methodology to convert a partial MCR
period to a full one. To calculate the variables that follow below, the participating children’s
hospitals must first determine the number of days in which the hospital has been eligible to
receive CHGME Payment Program funding (its period of eligibility for CHGME Payment
Program funding).

Determining the Period of Eligibility
For the initial application process, the period of eligibility is equal to the number of days from
the date the hospital became eligible to participate in the CHGME Payment Program to the
CHGME Payment Program initial application deadline date. The start date for hospitals that
are training residents from an existent program is the effective date of the affiliation
agreement for the aggregate cap, established for purposes of the CHGME Payment
Program. For new hospitals starting a new residency program, the start date is the date on
which the hospital first trains residents.
For the reconciliation application process, the hospital will report the actual FTE resident
count from the most recently filed (or most recently completed) MCR. If the hospital has not
filed (or completed) an MCR period by the CHGME Payment Program reconciliation
application deadline, the period of eligibility is equal to the number of days from the
beginning of the FY for which payments are being made (October 1) to the CHGME Payment
Program reconciliation application deadline date.
Example:
CACC became a freestanding children’s hospital when it received its own Medicare provider
number (55-3300) on January 1, 2023. CACC has a June 30th MCR year-end. On July 1,
2023, CACC began training residents previously trained at a hospital that has never received
funding from the CHGME Payment Program. The FY 2024 CHGME Payment Program
application deadline is August 1, 2023. CACC’s period of eligibility for the initial application
is July 1, 2023, to July 30, 2023. Hence, the FTE resident counts, and all other data reported
in CACC’s CHGME Payment Program initial application will be based on this period (7/1/23
through 7/30/23). CACC will follow the instructions provided herein to calculate its FTE
resident counts, CMI, etc. for an incomplete cost reporting period. CACC’s CHGME Payment
Program funding will not be based upon a rolling-average until three (3) MCR periods have
been completed.
The reconciliation application deadline is May 1, 2024. CACC will not complete its first MCR
period until June 30, 2024. Consequently, CACC’s period of eligibility for the reconciliation
application will be October 1, 2023, through May 1, 2024.

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The following methodology should be used to convert relevant data from a partial MCR
period to a full MCR period.

Calculating the FTE Resident Count for an Incomplete Cost Reporting
Period
To convert the FTE resident count from a partial MCR period to a full MCR period:
Determine the hospital’s period of eligibility.
1. Count the actual (“raw”) number of un-weighted allopathic and osteopathic FTE
residents during the hospital’s period of eligibility.
2. Divide the un-weighted resident FTE count for allopathic and osteopathic residents
(number 2 above) by the number of days in during the hospital’s period of eligibility
(number 1 above). This number is the average number of un- weighted FTE
residents per day.
3. Multiply the average number of un-weighted FTE residents (number 3 above) by the
number of days that your hospital will be training residents during the FY in which
payments are being made. This number is the estimated number of un-weighted
allopathic and osteopathic FTE residents trained per year.
4. Use the same methodology (steps 1-4 above) to determine the weighted FTE
resident count of allopathic and osteopathic residents. The example below includes
the calculation of the weighted FTE resident count.
5. Use the same methodology (steps 1-4 above) to determine the un-weighted and
weighted FTE resident count for dental and podiatric residents.
The concept of converting a partial MCR period into a full MCR period is consistent with
Medicare regulations. Since the CHGME Payment Program is paying hospitals for training
residents during the FY for which payments are being made, the Program will convert a
partial training period to reflect the amount of time the hospital will training residents during
the FY for which payments are being made. Although this methodology delineates the
method by which partial year residents are counted, it is important to note that all counts are
subjected to the cap set by the affiliation agreement.
Example:
CACC received its unique Medicare provider number (in the 3300 series) classifying it as a
children’s hospital on January 1, 2023. CACC did not begin training residents until Shirley
Temple Medical Center transferred its pediatric residents to CACC on July 1, 2023, at which
time it met all CHGME Payment Program hospital eligibility criteria. CACC has an affiliation
agreement with Shirley Temple Medical Center giving it an aggregate cap of 100 FTE
residents. Based upon its eligibility, CACC will apply for FY 2024 CHGME Payment Program
funding.
1. The number of days in which CACC was eligible to participate in the CHGME
Payment Program is 30 days (the number of days from July 1, 2023, to July 30,
2023). CACC chose to use July 30 as its “end date” to allow time for completing and

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validating its CHGME Payment Program application and to ensure that the
application was postmarked by the CHGME Payment Program application deadline.
CACC was not eligible to receive CHGME Payment Program funding prior to July 1,
2023, because it was not training residents.
2. From July 1st to July 30th CACC trained a total of 10 un-weighted FTE residents
and 8.5 weighted FTE residents. This FTE resident count reflects the actual “raw”
number of FTE residents that CACC trained during July. [e.g., The normal
workweek for a pediatric resident is 6 days. During the week of July 1 through July 7
CACC had one full-time resident in his IRP that worked 6/6 days (6/6 = 1 FTE) and
one part-time FTE in her IRP that worked 4/6 days (4/6 = 0.67 FTE). Hence, the
actual “raw” number of weighted and un-weighted residents that CACC trained
during the first week of July is 1.67 (1 + .67 = 1.67).]
3. The average un-weighted FTE resident count per day is 0.3333 (10 FTE
residents/30 days = 0.3333) and the average weighted FTE resident count per day
is 0.2833 (8.5 FTE residents/30 days = 0.2833).
4. Since CACC will be eligible for the CHGME Payment Program and training
residents every day of FY 2004 for which it is applying for CHGME Payment
Program funding (October 1, 2023 to September 30, 2024), CACC will report an
“estimated annualized” un-weighted FTE resident count of 121.65 [365 x 0.3333 =
121.65 (rounded from 121.6545)] and an “estimated annualized” weighted FTE
count of 103.40 [365 x 0.2833= 103.40 (rounded from 103.4045]. Since CACC's unweighted FTE resident count is more than its FTE cap (of 100), CACC will have to
reduce its FTE resident count using the methodology described under “Exceeding
the Cap”.
Additional references:
 CMS, 42 CFR 413.77
 CHGME Payment Program, Federal Register Notice, March 1, 2001 (66 FR 12940)
Applicable to the following application forms: HRSA-99-1, HRSA-99-2, and HRSA-99-4

Calculating the Case Mix Index (CMI) for an Incomplete Cost Reporting
Period
Hospitals that have not completed a MCR period will report a CMI to the CHGME Payment
Program based upon the discharges during the hospital’s period of eligibility.
Example:
CACC received its unique Medicare provider (3300 series) number on January 1, 2023.
CACC did not begin training residents until Shirley Temple Medical Center transferred its
pediatric residents to CACC on July 1, 2023, at which time it met all CHGME Payment
Program hospital eligibility criteria. The number of days in which CACC was eligible to
participate in the CHGME Payment Program is 30 days (the number of days from July 1,
2023, to July 30, 2023). CACC chose to use July 30 as its “end date” to allow time for
completing and validating its CHGME Payment Program application and to ensure that the
application was postmarked by the CHGME Payment Program application deadline. CACC

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was not eligible to receive CHGME Payment Program funding prior to July 1, 2023, because
it was not training residents. Hence, CACC’s CMI will be based upon all discharges from
July 1 to July 30 using the CMS DRG-version specified by the CHGME Payment Program.
Additional references:
 CMS, 42 CFR 413.77
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA 99-2

Calculating Discharges for an Incomplete Cost Reporting Period
Hospitals that have not completed a MCR period will report discharge data to the CHGME
Payment Program based upon discharges during the hospital’s period of eligibility using
the following methodology:
1. Calculate the number of discharges during the hospital’s period of eligibility. This
number represents the total number of discharges during the hospital’s period of
eligibility.
2. Divide the total number of discharges by the number of days in during the hospital’s
period of eligibility. This represents the average number of discharges per day.
3. Multiply the average number of discharges per day by the number of days in which
the hospital is eligible to receive CHGME Payment Program funding during the FY
for which it is applying for funding.
Example:
The number of days in which CACC was eligible to participate in the CHGME Payment
Program is 30 days (the number of days from July 1, 2023, to July 30, 2023). CACC chose
to use July 30 as its “end date” to allow time for completing and validating its CHGME
Payment Program application and to ensure that the application was postmarked by the
CHGME Payment Program application deadline. CACC was not eligible to receive CHGME
Payment Program funding prior to July 1, 2023, because it was not training residents.
1. CACC had 752 discharges from July 1 to July 30.
2. CACC’s average number of discharges per day is 25.07 (752 discharges/30 days =
25.0666).
3. Since CACC will be caring for patients as a freestanding children’s teaching hospital
during the entire FY 2004 (October 1, 2023 – September 30, 2024) for which it is
applying for CHGME Payment Program funding, CACC will report 9,150 discharges
on HRSA-99-2 [365 days x 25.07 discharges per day = 9,150.55 discharges (whole
numbers only)].

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Additional references:
 CMS, 42 CFR 413.77(e)(2)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA 99-2

Calculating the Number of Available Beds for an Incomplete Cost
Reporting Period
Hospitals that have not completed a MCR period will calculate their bed count by summing
the total available bed count during the hospital’s period of eligibility.
Example:
The number of days in which CACC was eligible to participate in the CHGME Payment
Program is 30 days (the number of days from July 1, 2023, to July 30, 2023). CACC chose
to use July 30 as its “end date” to allow time for completing and validating its CHGME
Payment Program application and to ensure that the application was postmarked by the
CHGME Payment Program application deadline. CACC was not eligible to receive CHGME
Payment Program funding prior to July 1, 2023, because it was not training residents.
During the period July 1 to July 30, 2023, CACC had 2,730 beds available to house pediatric
inpatients and 910 bassinets available for healthy newborn babies. Therefore, the bed count
is 91 beds per day (2,730 beds/30 days=91) as healthy newborn babies should be excluded
from the reported available bed count.
Additional references:
 CMS, 42 CFR 413.77(e)(2)
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA 99-2

Calculating Inpatient Days for an Incomplete Cost Reporting Period
Hospitals that have not completed a MCR period will calculate their inpatient days during
the hospital’s period of eligibility using the following methodology:
1. Sum the daily midnight census during the hospital’s period of eligibility.
2. Divide that sum by the number of days in that period, resulting in the average midnight
census.
3. Multiply the average midnight census with the number of days that the hospital is
eligible for the CHGME Payment Program during the FY in which payments are to be
made.

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Example:
The number of days in which CACC was eligible to participate in the CHGME Payment
Program is 30 days (the number of days from July 1, 2023, to July 30, 2023). CACC chose
to use July 30 as its “end date” to allow time for completing and validating its CHGME
Payment Program application and to ensure that the application was postmarked by the
CHGME Payment Program application deadline. CACC was not eligible to receive CHGME
Payment Program funding prior to July 1, 2023, because it was not training residents.
From July 1 to July 30, the CACC had a total of 1,911 inpatient days, resulting in an average
of 63.70 inpatients per day (1,911 inpatient days/30 days). Their inpatient day total for the
FY would be 365 days x 64 inpatients per day = 23,360 inpatient days (must also use whole
numbers).
Additional references:
 CMS, 42 CFR 413.77
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)
Applicable to the following application forms: HRSA 99-2

Calculating Outpatient Services for an Incomplete Cost Reporting
Period
Hospitals will not complete this section until a MCR period has been completed.
Additional references:
 CHGME Payment Program, Federal Register Notice, July 20, 2001 (66 FR 37980)

Section XIII: Special Calculation Instructions for Establishing a CHGME
cap for Newly Qualified Hospitals
Hospitals that are newly qualified to receive CHGME funds as “newly qualified hospitals”
under the Children’s Hospital GME Support Reauthorization Act of 2013, and that do not
already have a CMS cap established and are not able to apply for a CMS cap as a new
residency training program, will have a “CHGME cap” established. The “CHGME cap” will
be established using the number of FTE residents trained during the most recent Medicare
cost reporting period completed on or before April 7, 2014, the date of enactment of the
Children’s Hospital GME Support Reauthorization Act of 2013, as verified by the CHGME
auditors during the FTE resident Assessment Program. The “CHGME cap” will be entered
in Sections 4, 5, and 6 of the HRSA 99-1, on lines 4.06, 5.06, and 6.06 respectively.

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Section XIV: CHGME Payment Program Application Form Instructions

HRSA 99: Hospital Demographic and Contact Information
The HRSA 99 must be completed in its entirety. All sections of this form must be
completed unless otherwise specified. Specific line item instructions are provided below.

Section
1

2

3

4

5

6

Instructions
Provide the official name, physical address, tax identification number, county
where the hospital is physically located, Medicare provider number, UEI
number, and website of the applicant children’s hospital. Information
regarding UEI numbers can be obtained at 1-800-234-3867 or
www.sam.gov.
Provide the complete name, title, mailing address, telephone number and
email address of the person to be notified if the application is funded. All
future correspondence will be mailed to this individual only (e.g., notice of
award letters).
Provide the complete name, title, mailing address, telephone number, and
email address of the person authorized to submit the application for the
applicant hospital.
Provide the complete name, title, mailing address, telephone number, and
email address of the hospital’s Director of Graduate Medical Education. If the
hospital does not have a Director of GME, the individual who has oversight
responsibility for residents participating in GME programs at the hospital should
be identified.
Provide the complete name, title, mailing address, telephone number and email
address of the person who can provide documentation in support of the
information reported in the CHGME Payment Program application for funding.
Like all Federal programs, information submitted is subject to audit. All FTE
resident Assessment inquiries and related communications will be
directed to this individual..
Provide the complete name, title, mailing address, telephone number, and
email address of the person who prepared and/or completed this application
package for the applicant hospital. This individual will be the person
contacted if there are questions or issues related to the information submitted
in the CHGME Payment Program application for funding.

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HRSA 99-1: Determination of Weighted and Unweighted Resident FTE
Counts
All values entered on HRSA 99-1 must be taken to the hundredth place [two decimal points
(e.g., 38.00 or 12.43)] and the standard rounding rules applied [if the number is .5 or greater
then round up to the next number (e.g., 38.189 would be rounded to 38.19)].

Instructions for the Initial Application Cycle
The Section and Line Number that the instruct-ions apply to are identified in this area
in the following table.
Hospitals that filed a full MCR for the subject cost reporting period must follow the
instructions provided in this (left) column for each section. Where specified, hospitals must
report the data as stated in the hospital’s CMS 2552-10, Worksheet E-4 (formerly named
CMS 2552-96 Worksheets E-3, Part IV and E-3, Part VI) from the subject cost reporting
period. Deviation from what is stated on Worksheets E-3, Part IV and E-3, Part VI must be
supported and attested to by the FI prior to submission of this application in order to be
accepted by the CHGME Payment Program. In some instances, the instructions are the
same for all hospitals irrespective of the type of MCR the hospital filed for the subject cost
reporting period. In those cases, only one set (i.e., one column) of instructions is provided.
Hospitals that filed a Low or No-Utilization MCR for the subject recent cost reporting
period must follow the instructions provided in this (right) column for each section. In some
instances, the instructions are the same for all hospitals irrespective of the type of MCR the
hospital filed for the subject cost reporting period. In those cases, only one set (i.e., one
column) of instructions is provided.
Hospitals that have not completed at least three (3) MCR periods must follow the
instructions provided in italics, where provided below.
Section 1: DETERMINATION OF RESIDENT FTE CAP FOR THE HOSPITAL’S MOST
RECENT COST
REPORTING PERIOD ENDING ON OR BEFORE DECEMBER 31, 1996
Hospitals that did not train residents during the most recent cost reporting period
ending on or before December 31, 1996, should enter “N/A” on lines 1.01 through 1.03.
1.01: Enter the inclusive dates of the subject cost reporting period. The following
format must be used: (From:) mm/dd/yyyy (To:) mm/dd/yyyy.

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1.02: Enter the status of the subject MCR using the codes below:
S

Settled.

S/R/P

This status refers to cost reports that have been settled [a notice of
program reimbursement (NPR) issued] by the MAC.
Settled/Reopened/Preliminary FI.
This status refers to cost reports that have been settled (an NPR
issued by the MAC), then re-opened by the MAC and any changes
(to the resident FTE counts during the reopening) have been
assessed by the CHGME FI (or MAC).

S/R/RS

Settled/Reopened/Resettled.
This status refers to cost reports that have been settled (an NPR
issued by the MAC), re-opened by the MAC, and then re-settled by
the MAC.

L

Low-utilization MCR.
This status refers to resident FTE counts submitted by the hospital
in their initial application that have not been assessed by the
CHGME FI.

N

No-utilization MCR.
This status refers to resident FTE counts submitted by the hospital
in their initial application that have not been assessed by the
CHGME FI.

C

Complete.
This status refers to resident FTE counts that have been assessed
by the CHGME FI and reported to the hospital and the CHGME
Payment Program in the CHGME FI’s final assessment report.

R

Re-issue.
This status refers to resident FTE counts reported in a CHGME FI’s
final assessment report that have been re-assessed based on a
request from the children’s hospital or the CHGME FI and the
results of the reassessment reported to the hospital and the
CHGME Payment Program in the CHGME FI’s final re-assessment
report.

1.03: Enter the un-weighted resident FTE count for allopathic and osteopathic programs for
the most recent cost reporting period ending on or before December 31, 1996. Worksheet
E-4 (formerly named Worksheet E-3, Part IV) Line 3.01 on the hospital’s MCR beginning on
or after October 1, 1997.)

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Hospitals must complete Sections 4 through 6 of Form HRSA-99-1 prior to completing
Sections 2 and 3.
Section 2: AVERAGE UNWEIGHTED RESIDENT FTE COUNT
2.01: Enter the amount from line 4.19 of the 1996 Cap Year column.
2.02: Enter the amount from line 5.19 of the 1996 Cap Year column. Hospitals that have
not completed three (3) MCR periods should enter “N/A”.
2.03: Enter the amount from line 6.19 of the 1996 Cap Year column. Hospitals that have
not completed three (3) MCR periods should enter “N/A”.
2.04: Enter the sum of lines 2.01, 2.02 and 2.03 from above divided by 3. Hospitals that
have not completed three (3) MCR periods should enter the amount from line 2.01 above.
2.05: Enter the un-weighted number of resident FTEs in the initial years of all programs that
meet the rolling average exception criteria in 42 CFR 413.79(d).
2.06: Enter the sum of lines 2.04 and 2.05 from above.
2.07: Enter the amount from line 4.19 of the §422 of the MMA column.
2.08: Enter the sum of lines 2.06 and 2.07 from above.

Section 3: AVERAGE WEIGHTED RESIDENT FTE COUNT
3.01: Enter the amount from line 4.20 of the 1996 Cap Year column.
3.02: Enter the amount from line 5.20 of the 1996 Cap Year column. Hospitals that have
not completed three (3) MCR periods should enter “N/A”.
3.03: Enter the amount from line 6.20 of the 1996 Cap Year column. Hospitals that have
not completed three (3) MCR periods should enter “N/A”.
3.04: Hospitals that have not completed three (3) MCR periods should enter the amount
from line 3.01 above.
Hospitals that have completed three (3) MCR periods should enter the sum of lines 3.01,
3.02 and 3.03 from above divided by 3. Enter the sum of lines 3.15 and 3.21 from CMS
2552-10, Worksheet E-4 (formerly named CMS 2552-96 Worksheet E-3, Part IV) from your
most recently filed MCR which is equivalent to the sum of lines 3.01, 3.02 and 3.03 from
above divided by 3. If the sum of lines 3.01 through 3.03 divided by 3 does not equal the
sum of lines 3.15 and 3.21 from CMS 2552-10, Worksheet E-4 (formerly named CMS 255296) on your most recently filed MCR, please contact your regional manager immediately.

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3.05: Hospitals that have not completed three (3) MCR periods should enter the weighted
number of resident FTEs in the initial years of all programs that meet the rolling average
exception criteria in 42 CFR 413.79(d).
Hospitals that have completed three (3) MCR periods should enter the weighted number of
resident FTEs in the initial years of all programs that meet the rolling average exception
criteria in 42 CFR 413.79(d).
3.06: Hospitals that have not completed three (3) MCR should enter the sum of lines 3.04
and 3.05 from above. This is the weighted resident FTE count.
Hospitals that have completed three (3) MCR periods should enter the sum of lines 3.04 and
3.05 from above.
3.07: Enter the amount from line 4.20 of the §422 of the MMA column.
3.08: Enter the sum of lines 3.06 and 3.07 from above.

Section 4: DETERMINATION OF RESIDENT FTE COUNT FOR THE HOSPITAL’S MOST
RECENTLY COMPLETED COST REPORTING PERIOD
Hospitals that have not completed a MCR period must use the methodology described in
the application guidance section titled “Special Calculation Instructions for Hospitals that
Have Not Completed a Medicare Cost Reporting Period” to determine their weighted and
un-weighted resident FTE counts based upon an incomplete cost reporting period.
4.01: Enter the inclusive dates of the subject cost reporting period. The following format
must be used: (From:) mm/dd/yyyy (To:) mm/dd/yyyy.
Hospitals that have not completed a full MCR period must enter the date in which the hospital
became eligible to participate (i.e., date that the hospital obtained a Medicare provider
number and began training residents) and the CHGME Payment Program application
deadline. This is the hospital’s period of eligibility.
4.02: Enter the status of the subject MCR using the codes below:

AF

As Filed.
This status refers to cost reports that have been submitted by the
children’s hospital to the MAC but have not yet been reviewed by the
CHGME FI (or MAC).

AM

Amended.
This status refers to cost reports that have been amended and
submitted by the children’s hospital to the MAC but have not yet been
reviewed by the CHGME FI (or MAC).

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P

Preliminary.
This status refers to resident FTE counts that have been assessed by
the CHGME FI (or MAC where the cost report has not yet been
settled (notice of program reimbursement has not been issued).

S

Settled.
This status refers to cost reports that have been settled [an NPR
issued] by the MAC.

S/R/P

Settled/Reopened/Preliminary FI.
This status refers to cost reports that have been settled (an NPR
issued by the Medicare FI), then re-opened by the Medicare FI and
any changes (to the resident FTE counts during the reopening) have
been assessed by the CHGME FI (or MAC).

S/R/RS

Settled/Reopened/Resettled.
This status refers to cost reports that have been settled (an NPR
issued by the MAC), re-opened by the MAC, and then re-settled by
the MAC.

L

Low-utilization MCR.
This status refers to resident FTE counts submitted by the hospital in
their initial application that have not been assessed by the CHGME
FI.

N

No-utilization MCR.
This status refers to resident FTE counts submitted by the hospital in
their initial application that have not been assessed by the CHGME
FI.

C

Complete.
This status refers to resident FTE counts that have been assessed by
the CHGME FI and reported to the hospital and the CHGME Payment
Program in the CHGME FI’s final assessment report.

R

Re-issue.
This status refers to resident FTE counts reported in a CHGME FI’s
final assessment report that have been re-assessed based on a
request from the children’s hospital or the CHGME FI and the results
of the reassessment reported to the hospital and the CHGME
Payment Program in the CHGME FI’s final re-assessment report.

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4.03: Enter the un-weighted resident FTE count for allopathic and osteopathic programs for
the most recent cost reporting period ending on or before December 31, 1996, which is
equivalent to Line 3.01 Line 3.01 from CMS 2552-96 Worksheet E-3, Part IV or to Line 1.0
from CMS 2552-10 Worksheet E-4 from the subject cost reporting period. For hospitals
whose MCR did not contain an entry on line 3.01, enter “0”. If Line 3.01 from Worksheet E3, Part IV does not equal line 1.03 from above, line 3.01 from CMS 2552-96 Worksheet E3, part IV or to Line 1.0 from CMS 2552-10 Worksheet E-4 must be supported and attested
to by the FI prior to submission of this application in order to be accepted by the CHGME
Payment Program.
4.04: Enter the un-weighted resident FTE count for allopathic and osteopathic programs
which meet the criteria for an add-on to the cap for new programs in accordance with 42
CFR 413.79(e) [which is equivalent to Line 3.02 from CMS 2552-96 Worksheet E-3, Part IV
or to Line 2 from CMS 2552-10 Worksheet E-4 from the subject MCR]
4.04a: Enter the reduction for the un-weighted resident FTE count for allopathic or
osteopathic programs due to §422 of the MMA [which is equivalent to Line 2.0 from CMS
2552-96 Worksheet E-3, Part VI or to Line 3.0 from CMS 2552-10 Worksheet E-4 from the
subject cost reporting period].
4.04b: Enter the reduction for the un-weighted resident FTE count for allopathic or
osteopathic programs due to §5503 of the ACA in accordance with 42 CFR 413.79(m) [which
is equivalent to Line 3.01 from CMS 2552-10 Worksheet E-4 from the subject cost reporting
period].
4.05: Enter the adjustment (increase or decrease) for the un-weighted resident FTE count
for allopathic or osteopathic programs for affiliated programs in accordance with 42 CFR
413.75(b), 413.79(c)(2)(iv), and 63 FR 26336 of May 12, 1998 [which is equivalent to Line
3.03 from CMS 2552-96 Worksheet E-3, Part IV or to Line 4.0 from CMS 2552-10 Worksheet
E-4 from the subject cost reporting period], and/or 413.75(b) and 87 FR 49075 (August 10,
2022) [which is equivalent to Line 3.02 from CMS 2552-96 Worksheet E-3, Part IV or to Line
4.0 from CMS 2552-10 Worksheet E-4 from the subject cost reporting period].
4.05a: Enter the addition for un-weighted FTE resident count for allopathic and osteopathic
programs in accordance with §5503 of the ACA [which is equivalent to Line 4.01 from CMS
2552-10 Worksheet E-4 from the subject cost reporting period], and/or § 126, § 127, and/or
§ 131 of the CAA [which is equivalent to Line 1.01, 2.26, 4.21 from CMS 2552-10 Worksheet
E-4 from the subject cost reporting period].
4.05b: Enter the addition for un-weighted FTE resident count for allopathic and osteopathic
programs in accordance with §5506 of the ACA [which is equivalent to Line 4.02 from CMS
2552-10 Worksheet E-4 from the subject cost reporting period].
4.06 - 1996 cap year column: Enter the sum of lines 4.03 through 4.05b from above. This
is the FTE adjusted cap. If the hospital’s 1996 Base Year Cap is reduced under 42 CFR
413.79(c)(3) due to unused resident slots, effective for cost reporting periods ending on or
after July 1, 2005, enter Line 3.04 from CMS 2552-96 Worksheet E-3, Part IV from the

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subject MCR which is equivalent to the sum of Line 3.03 from CMS 2552-96 Worksheet E3, Part IV and Line 4 from Worksheet E-3, Part VI from the subject MCR. cost reporting
period. Line 5 from CMS 2552-10 Worksheet E-4 is equivalent to the sum of Line 3.03 from
CMS 2552-10 Worksheet E-4 and Line 4.0 from Worksheet E-4 from the subject cost
reporting period.
If the hospital was not required to file CMS 2552-96 Worksheets E-3, Part IV or E-3, Part VI
following the 1996 Base Year Cap reduction under 42 CFR 413.79(c)(3) for the subject cost
reporting period contact your regional manager.
For “newly qualified” hospitals which will have a CHGME “cap” established by the Secretary
according to Public Law 113-98, enter the number of FTEs trained during the most recent
Medicare Cost Report period completed on or before April 7, 2014.
4.06 - §422 of the MMA column: Enter the number of un-weighted allopathic and
osteopathic GME FTE resident cap slots the hospital received under 42 CFR 413.79(c)(4)
[which is equivalent to Line 5 (or 5.01 for cost reporting periods that overlap July 1, 2005)
from CMS 2552-96 Worksheet E-3, Part VI or Line 20.0 from CMS 2552-10 Worksheet E-4
from the subject cost reporting period. If the hospital received GME FTE resident cap slots
under 42 CFR 413.79(c)(4) but was not required to file CMS 2552-96 Worksheets E-3, Part
VI or to file CMS 2552-10 Worksheets E-4 for the subject cost reporting period contact your
regional manager. If the hospital did not receive GME FTE resident cap slots under 42 CFR
413.79(c) enter “zero” on Lines 4.06 through 4.13, 4.19 and 4.20 of this columns.
4.07 - 1996 cap year column: Enter the un-weighted resident FTE count for allopathic or
osteopathic programs for the current year from your records, other than those in the initial
years of the program that meet the criteria for an exception to the rolling average rules (42
CFR 413.79(d) and/or (e)). This is equivalent to Line 3.05 from CMS 2552-96 Worksheet
E-3, Part IV or enter line 6.0 from CMS 2552-10 Worksheet E-4 from the subject cost
reporting period.
4.07 - §422 of the MMA column: Enter the sum of Lines 4.07 minus 4.08 from the 1996
Cap Year Column.
4.08 - 1996 cap year column: Enter the lesser of lines 4.06 or 4.07 from above (lesser of
lines 5.06 or 5.07 for Section 5 and lines 6.06 or 6.07 for Section 6). Enter line 3.06 from
CMS 2552-96 Worksheet E-3, Part IV or enter line 7.0 from CMS 2552-10 Worksheet E-4
from the subject cost reporting period.
4.08 - §422 of the MMA column: enter the lesser of Lines 4.06 or 4.07 from above.
4.09 - 1996 cap year column: Enter the un-weighted FTE resident count for allopathic and
osteopathic residents in their initial residency period.
4.09 - §422 of the MMA column: Enter the un-weighted FTE resident count for allopathic
and osteopathic residents in their initial residency period.
4.10 - 1996 cap year column: Enter the hospital’s un-weighted FTE resident count for
allopathic and osteopathic residents beyond their initial residency period. The sum of lines

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4.09 and 4.10 should equal line 4.07 from above (the sum of lines 5.09 and 5.10 should
equal line 5.07 for Section 5 and the sum of lines 6.09 and 6.10 should equal line 6.07 for
Section 6).
4.10 - §422 of the MMA column: Enter the hospital’s un-weighted FTE resident count for
allopathic and osteopathic residents beyond their initial residency period. The sum of lines
4.09 and 4.10 should equal line 4.07 from above.
4.11 - 1996 cap year column: Multiply line 4.10 from above (line 5.10 for Section 5 and
line 6.10 for Section 6) by 0.5 and enter the product. This is the weighted FTE resident
count for allopathic and osteopathic residents beyond their initial residency period.
4.11 - §422 of the MMA column: Multiply line 4.10 from above by 0.5 and enter the product.
This is the weighted FTE resident count for allopathic and osteopathic residents beyond their
initial residency period.
4.12 - 1996 cap year column: Enter the sum of lines 4.09 and 4.11 from above (sum of
lines 5.09 and 5.11 for Section 5 and lines 6.09 and 6.11 for Section 6). This is the total
weighted resident FTE count for allopathic and osteopathic programs.
Enter line 3.09 from CMS 2552-96 Worksheet E-3, Part IV or enter line 8.0 from CMS 255210 Worksheet E-4. This should equal the sum of lines 4.09 and 4.11 from above.
4.12 - §422 of the MMA column: Enter the sum of lines 4.09 and 4.11 from above.
4.13 - 1996 cap year column: For Section 4: If line 4.07 is less than or equal to line 4.06
enter the amount from line 4.12 above. If line 4.07 is greater than line 4.06, multiply line
4.12 by (line 4.06 divided by line 4.07) and enter the product.
Enter line 3.10 from CMS 2552-96 Worksheet E-3, Part IV or enter line 9.0 from CMS 255210 Worksheet E-4.
For Section 5: If line 5.07 is less than or equal to line 5.06 enter the amount from line 5.12
above. If line 5.07 is greater than line 5.06, multiply line 5.12 by (line 5.06 divided by line
5.07) and enter the product.For Section 6: If line 6.07 is less than or equal to line 6.06 enter
the amount from line 6.12 above. If line 6.07 is greater than line 6.06, multiply line 6.12 by
(line 6.06 divided by line 6.07) and enter the product.4.13 - §422 of the MMA column: If
line 4.07 is less than or equal to line 4.06, enter the amount from line 4.12 above. If line
4.07 is greater than line 4.06, multiply line 4.12 by (line 4.06 divided by line 4.07) and enter
the product.
4.14: Enter the un-weighted resident FTE count for dental and podiatric programs.
4.15: Enter the un-weighted resident FTE count for dental and podiatric residents in their
initial residency period.
4.16: Enter the un-weighted resident FTE count for dental and podiatric residents beyond
their initial residency period.
4.17: Multiply line 4.16 from above (line 5.16 for Section 5 and line 6.16 for Section 6) by
0.5 and enter the product.
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4.18: 1996 cap year column: Enter the sum of lines 4.15 and 4.17 from above (the sum of
lines 5.15 and 5.17 for Section 5 and lines 6.15 and 6.17 for Section 6). This is the total
weighted resident FTE count for dental and podiatric programs.
Enter line 3.11 from CMS 2552-96 Worksheet E-3, Part IV or enter line 10.0 from CMS 255210 Worksheet E-4. This should equal the sum of lines 4.15 and 4.17. For hospitals who’s
MCR did not contain an entry on line 3.11 on Worksheet E-3, Part IV enter the sum of lines
4.15 and 4.17 from above (the sum of lines 5.15 and 5.17 for Section 5 and lines 6.15 and
6.17 for Section 6).
4.19 - 1996 cap year column: Enter the sum of lines 4.08, 4.15 and 4.16 from above (the
sum of lines 5.08, 5.15 and 5.16 for Section 5 and the sum of lines 6.08, 6.15 and 6.16 for
Section 6). This is the hospital’s total un-weighted FTE resident count.
4.19 - §422 of the MMA column: Enter line 4.08 from above.
4.20 - 1996 cap year column: Enter the sum of lines 4.13 and 4.18 from above (sum of
lines 5.13 and 5.18 for Section 5 and the sum of lines 6.13 and 6.18 for Section 6). This is
the hospital’s total weighted FTE resident count.
Enter the sum of lines 3.10 and 3.11 from CMS 2552-96 Worksheet E-3, Part IV or enter
line 11.0 from CMS 2552-10 Worksheet E-4. This should equal the sum of lines 4.13 and
4.18 (sum of lines 5.13 and 5.18 for Section 5 and the sum of lines 6.13 and 6.18 for Section
6).
4.20 - §422 of the MMA column: Enter line 4.13 from above.

Section 5: DETERMINATION OF RESIDENT FTE COUNT FOR THE HOSPITAL’S
PRIOR COST REPORTING PERIOD
The direct GME FTE resident cap slots hospitals received under 42 CFR 413.79(c)(4) are
not subject to the 3-year rolling average; therefore, Section 5 does not include a §422 of the
MMA column and related guidance is not applicable this section.
Hospitals that have not completed three (3) MCR periods should enter “N/A” on lines
5.01 through 5.20.

Section 6: DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL’S
PENULTIMATE COST REPORTING PERIOD
The direct GME FTE resident cap slots hospitals received under 42 CFR 413.79(c)(4) are
not subject to the 3-year rolling average; therefore, Section 6 does not include a §422 of the
MMA column and related guidance is not applicable this section.
Hospitals that have not completed three (3) MCR periods should enter “N/A” on lines 6.01
through 6.20.

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Instructions for the Reconciliation Application Cycle
All children’s hospitals, regardless of their filing status, will use the resident FTE counts as
reported by their CHGME FI in his/her final Resident FTE Assessment Report to complete
their reconciliation application which includes an updated and revised, as needed, HRSA
99-1. For additional information regarding the Resident FTE Assessment Program see
Section II.

HRSA 99-2: Determination of Indirect Medical Education Data Related to
the Teaching of Residents
Inpatient Data for the Current Medicare Cost Report (MCR) Period
The “current” MCR period is defined as the hospital’s most recently filed MCR for hospitals
that file full MCRs (report residents to Medicare on CMS 2552-10, Worksheet E-4 (formerly
named CMS 2552-96, Worksheet E-3, Part IV)) or the most recently completed MCR period
for hospitals that file low or no-utilization MCRs.
Hospitals that have not completed a full MCR period must use the methodology
described in the application guidance section titled “Special Calculation Instructions for
Hospitals that Have Not Completed a Medicare Cost Reporting Period” to complete the
below.
1.01: Inclusive dates of the current MCR period. Enter the inclusive dates of the MCR period
reported on line 4.01 of HRSA 99-1.
1.02: Number of Inpatient Days. The sum of the entire midnight census counts including
nursery days for the MCR period reported on line 1.01 above. [Value must be taken to
two decimal points (i.e., 38.00 or 12.43).]
1.03: Number of Inpatient Discharges. The sum of all inpatient discharges including healthy
newborns for the MCR period reported on line 1.01 above. [Value must be taken to two
decimal points (i.e., 38.00 or 12.43).]
1.04: Case Mix Index (CMI). The CMI is the sum of the diagnosis-related group (DRG)
weights for all discharges during the MCR period identified on line 1.01 above divided by the
number of discharges. The CMI represents the average DRG relative weight for the hospital.
All hospitals must submit a CMI on all patient discharges using the appropriate CMS DRG
version, excluding healthy newborns. [Value must be taken to 4 decimal points (i.e.,
1.2105).]

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The CMI is utilized in the IME formula to determine IME payments. Hospitals that do not
submit a CMI are not eligible for IME payments. These hospitals are required to initial the
appropriate box on line 1.04 of HRSA 99-2 acknowledging their ineligibility for IME
payments.
Intern/Resident-to-Bed (IRB) Ratio
To comply as closely as possible with Medicare rules and regulations, the Department
applies a cap on the IRB ratio, similar to the cap applied by the Medicare program pursuant
to regulations at 42 CFR 412.105(a)(1), whereby the ratio may not exceed the ratio for the
hospital's most recent prior cost reporting period. For those hospitals whose IRB ratio
changes, there will be a 1-year delay in the implementation of the revised IRB. Starting in
FY 2002 the CHGME Payment Program will implement a cap on the IRB ratio. The IRB cap
may not exceed the ratio for the hospital’s previous cost reporting period.
Calculate the IRB Ratio for the Current MCR Period
The “current” MCR period is defined as the hospital’s most recently filed MCR for hospitals
that file full MCRs (report residents to Medicare on CMS 2552-10, Worksheet E-4 (formerly
named CMS 2552-96, Worksheet E-3, Part IV)) or the most recently completed MCR period
for hospitals that file low or no-utilization MCRs.
Hospitals that meet the criteria for an exception or adjustment to the cap should refer to the
Centers for Medicare and Medicaid Services August 1, 2001, Federal Register Notice (66
FR 39878) which provides additional information and guidance in calculating the IRB ratio.
1.05: Enter the 3-year adjusted un-weighted FTE rolling average for the current MCR period.
The 3-year un-weighted FTE rolling average for the current MCR period is equal to line 2.06
of HRSA 99-1. Enter the data reported on line 2.06 of HRSA 99-1. [Value must be taken
to two decimal points (i.e., 38.00 or 12.43).]
1.06: Enter the bed count for the current MCR period. The bed count for the current MCR
period is the sum of all available beds per day in the cost reporting period, excluding beds
and bassinets in the healthy newborn nursery, divided by the number of days in that period.
If a children’s hospital has not completed a Medicare cost report period prior to submission
of an application to the CHGME Payment Program , it would base the bed count on the sum
of all available beds per day, excluding beds and bassinets in the healthy newborn nursery,
in the period from the day it became eligible for the CHGME program until the CHGME
application deadline, divided by the number of days in that period. A bed is any bed that is
permanently maintained for lodging inpatients. The bed count number is utilized in the IME
formula to determine IME payments. [Value must be taken to two decimal points (i.e.,
38.00 or 12.43).]
1.07: Enter the IRB ratio for the current MCR period. The IRB ratio is equal to the 3-year
un-weighted rolling average (line 1.05 above) divided by the bed count (line 1.06 above).
[Value must be taken to six decimal points (i.e., 34.567800).]

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Calculate the IRB Ratio for the Previous MCR Period
The “previous” MCR period refers to the annual cost reporting period that ended 1 year prior
to the cost reporting period identified on line 1.01 above. The previous MCR period should
equal line 5.01 of HRSA 99-1
Hospitals that were not required to complete section 5 of HRSA 99-1 should contact their
regional manager for additional information and guidance for lines 1.08 through 1.11 below.
Hospitals that meet the criteria for an exception or adjustment to the cap should refer to the
Centers for Medicare and Medicaid Services August 1, 2001, Federal Register Notice (66
FR 39878) which provides additional information and guidance in calculating the IRB ratio.
1.08: Inclusive dates of the previous MCR period. Enter the inclusive dates of the MCR
period reported on line 5.01 of HRSA 99-1.
1.09: Unweighted FTE count for the previous MCR period. Enter the un-weighted FTE count
for the previous MCR period which is equal to line 5.19 of HRSA 99-1. [Value must be
taken to two decimal points (i.e., 38.00 or 12.43).]
1.10: Bed count for the previous MCR period. Calculate the available bed count for the
previous MCR period. The bed count for the previous MCR period is the sum of all available
beds per day in the cost reporting period, excluding beds and bassinets in the healthy
newborn nursery, divided by the number of days in that period. [Value must be taken to
two decimal points (i.e., 38.00 or 12.43).]
1.11: IRB ratio for the previous MCR period. Calculate the IRB ratio for the previous MCR
period. The IRB ratio is equal to the un-weighted FTE count for the previous MCR period
(line 1.09 above) divided by the bed count (line 1.10 above). [Value must be taken to six
decimal points (i.e., 34.567890 or 12.540000).]
IRB Cap
1.12: IRB Cap. Enter the lesser of 1.07 or 1.11. [Value must be taken to six decimal
points (i.e., 34.567890.] Hospitals that have not completed three (3) MCR periods should
enter the amount from line 1.07 above.
§422 of the MMA IRB Ratio for the Current MCR Period
1.13: §422 of the MMA un-weighted resident FTE count for the current MCR period. The
un-weighted resident FTE count for the current MCR period is equal to line 4.19 of the §422
of the MMA column of the HRSA 99-1. Enter the data reported on line 4.19 from the §422
of the MMA column of HRSA 99-1. [Value must be taken to two decimal points (i.e.,
38.00 or 12.43).]

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1.14: Bed count for the current MCR period. Enter the available bed count for the current
MCR period. This should be consistent with the data reported in line 1.06 above. [Value
must be taken to two decimal points (i.e., 38.00 or 12.43).]
1.15: §422 of the MMA IRB ratio for the current MCR period. Calculate the §422 of the MMA
IRB ratio for the current MCR period. The §422 of the MMA IRB ratio is equal to the increase
in the un-weighted FTE count (line 1.13 above) divided by the bed count (line 1.14 above).
[Value must be taken to six decimal points (i.e., 34.567890 or 12.540000).]
Outpatient Data
1.16: Number of Ambulatory Surgery Visits. Total number of scheduled outpatient
ambulatory surgical visit provided to patients who do not remain in the hospital overnight.
The surgery may be performed in operating suites also used for inpatient surgery specifically
designed surgical suites for outpatient surgery, or procedure rooms within an outpatient care
facility.
1.17: Number of Radiology Visits. Total number of diagnostic radiology visits provided to
patients in the outpatient setting such as computed tomographic scanner (CT scan),
magnetic resonance imaging (MRI), position emission tomography (PET), Single photon
emission computerized tomography (SPECT), and ultrasound. (Do not include inpatient
testing)
1.18: Number of Urgent Care Visits. Total number of urgent care visits that provide care
and treatment for problems that are not life threatening but require attention over the short
term.
1.19: Number of Emergency Department Visits. Total number of emergency room visits for
patients whose condition requires immediate care.
1.20: Number of Clinic Visits. Total number of clinic visits to each specialized medical unit
responsible for the diagnosis and treatment of patients on an outpatient, non-emergency
basis. Visits to the satellite clinics and primary group practices should be included if revenue
is received by the hospital.

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HRSA 99-4: Government Performance and Results Act Tables

Hospitals must report data from the cost reporting period reflected on line 4.01 of
HRSA 99-1

Table 1. Number of FTE Residents Supported by the Children’s Hospitals in Approved
Residency Training Programs
Note: Applicants requesting funding must submit the required data in the following format.
This data is for residents rotating through both the inpatient and outpatient settings of the
hospital. Resident FTE counts reported below should be un-weighted and line 1.04 (below)
should be consistent with the un-weighted resident FTE counts reflected in Form HRSA 991 Section 4.
Line
1.01

1.02

1.03

1.04

1.05

Instructions
Sponsored* by the Children’s Hospital and Rotating at the Children’s Hospital.
Provide the number of FTE residents (family medicine, general internal medicine, general
pediatrics, preventive medicine, geriatric medicine, osteopathic general practice, general
surgery, subspecialty pediatric & fellows, and all other non-pediatric) training in your
hospital and sponsored by your hospital during the cost reporting period.
Sponsored by the Children’s Hospital and Rotating at Non-provider Sites. Provide
the number of FTE residents in family medicine, general internal medicine, general
pediatrics, preventive medicine, geriatric medicine, osteopathic general practice, general
surgery, subspecialty pediatric & fellows, and all other non-pediatric sponsored by your
hospital but are rotating to non-provider sites during the cost reporting period.
Sponsored by Other Hospitals and Rotating at the Children’s Hospital. Provide the
number of FTE residents (family medicine, general internal medicine, general pediatrics,
preventive medicine, geriatric medicine, osteopathic general practice,
general surgery, subspecialty pediatric & fellows, and all other non-pediatric sponsored by
another hospital but are rotating to your hospital during the cost reporting period.
Total Number of FTE Residents. Provide the total number of FTE Residents from the
sum of Lines 1.01 through 1.03
(above)
Sponsored by the Children’s Hospital and Rotating at Other Hospitals. Provide the
number of FTE residents in family medicine, general internal medicine, general pediatrics,
preventive medicine, geriatric medicine, osteopathic general practice,
general surgery, subspecialty pediatric & fellows, and all other non-pediatric sponsored by
your hospital but are rotating to other hospitals during the cost reporting period.

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Definitions
Sponsoring Institution

Family Medicine Resident
General Internal Medicine
Resident
General Pediatric Resident
Preventive Medicine
Resident
Geriatric Medicine Resident

*CHGME Payment Program defines a sponsoring institution as an
institution, which assumes the ultimate responsibility for a graduate
medical education program.
According to the Accreditation Council for Graduate Medical Education
(ACGME), the following are the institutional requirements for a
Sponsoring Institution: 1) A residency program must operate under the
authority and control of a sponsoring institution. 2) There must be a written
statement of institutional commitment to GME that is supported by the
governing authority, the administration, and the teaching staff. 3)
Sponsoring institutions must be in substantial compliance with the
Institutional Requirements and must ensure that their ACGME-accredited
programs are in substantial compliance with the Program Requirements
and the applicable Institutional Requirements. 4) An institution’s failure to
comply substantially with the Institutional Requirements may jeopardize
the accreditation of all of its sponsored residency programs.
Residents training in their initial residency period of a family medicine
residency program
Residents training in their initial residency period of a general
internal medicine residency program
Residents training in their initial residency period of a general
pediatric residency program
Residents training in their initial residency period of a preventive
medicine residency program

Residents training in their initial residency period of a geriatric
medicine residency program
Osteopathic General Practice Residents training in their initial residency period of an osteopathic
general practice residency program
Resident

General Surgery Resident
Subspecialty Pediatric
Resident
All Other Non-Pediatric
Resident

Residents training in their initial residency period of a general
surgery residency program
Residents training beyond their initial residency period (i.e., fellows)
Residents training in their initial residency period not specifically in
family medicine, general internal medicine, general pediatrics,
preventive medicine, geriatric medicine, osteopathic general
practice, general surgery (i.e., radiology, pathology, endocrinology,
dental)

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Table 2. Hospital's Total and Operating Margins
Total Margins
Hospitals Filing Low or No-Utilization Medicare Cost Reports
Total margin is defined as the net income from all sources [(net patient revenue + all other
income) - [(total operating expenses + other expenses)] divided by total hospital revenues
(net patient revenues + total other income) multiplied by 100
Hospitals Filing Full Medicare Cost Reports
To calculate the total margin, take Worksheet G-3 Line 31 and divide it by Line 3 + Line 25.
Operating Margins
Hospitals Filing Low or No-Utilization Medicare Cost Reports
The operating margin is defined as the net income from service to patients (net patient
revenues – total operating expenses) divided by net patient revenues (total patient revenues
– contractual allowances) multiplied by 100
Hospitals Filing Full Medicare Cost Reports
To calculate the operating margin, take the number from Worksheet G-3 line 3, subtract the
number from worksheet A Column 3 line 118, divide by the number from worksheet G-3,
line 3 and multiply it by 100.

Table 3. Hospital’s Allowable Operating Expenses
Margin Types
Total Allowable Operating Expenses
Hospitals Filing Low or No-Utilization Medicare Cost Reports
Contact the hospital’s fiscal intermediary to clarify what Medicare accepts as allowable
operating expenses, if mechanism is not already identified in the hospital’s financial
statements.
Hospitals Filing Full Medicare Cost Reports
The total allowable operating expenses can be identified on the hospital’s Medicare cost
report - Worksheet G-2 Part II Line 29.

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Table 4. Hospital’s Revenue and Expenses Attributed to Patient Care
Inpatient

Outpatient

Hospital’s gross revenue attributed to
Medicaid and SCHIP (Medicaid refers to any
funding provided by Title XIX including that from
Medicaid HMOs and DSH payments. SCHIPState Children’s Health Insurance Program refers
to funding provided under Title XXI).

Hospital’s gross revenue attributed to
Medicaid and SCHIP (Medicaid refers to any
funding provided by Title XIX including that from
Medicaid HMOs and DSH payments. SCHIPState Children’s Health Insurance Program refers
to funding provided under Title XXI).

Revenue received by the hospital from the
Medicaid and SCHIP programs for inpatient care.
Report as dollar amounts rather than
percentages
Hospital’s gross revenue attributed to Medicare

Revenue received by the hospital from the
Medicaid and SCHIP programs for outpatient
care. Report as dollar amounts rather than
percentages
Hospital’s gross revenue attributed to Medicare

Revenue received by the hospital from the Medicare
for inpatient care. Report as dollar amounts rather
than percentages

Revenue received by the hospital from the Medicare
for outpatient care. Report as dollar amounts rather
than percentages

Hospital’s gross revenue attributed to self-pay Hospital’s gross revenue attributed to self-pay
Revenue received by the hospital directly
from patients for inpatient care. Report as dollar
amounts rather than percentages

Revenue received by the hospital directly from
patients for outpatient care. Report as dollar
amounts rather than percentages

Hospital ‘s gross revenue attributed to other
sources

Hospital ‘s gross revenue attributed to other
sources

Revenue received by the hospital from other
sources for inpatient care not listed above. Report
as dollar amounts rather than percentages

Revenue received by the hospital from other sources
for outpatient care not listed above. Report as dollar
amounts rather than percentages

Hospital’s total gross revenue attributed to
patient care

Hospital’s total gross revenue attributed to
patient care

Total gross revenue received by the hospital for
inpatient care (sum of inpatient columns 1-4).
Report as dollar amounts rather than percentages.

Total gross revenue received by the hospital for
outpatient care (sum of outpatient columns 1-4).
Report as dollar amounts rather than percentages.

Hospital’s total expenses attributed to
uncompensated care

Hospital’s total expenses attributed to
uncompensated care

Total expenses that the hospital attributes to
uncompensated inpatient care. Report as dollar
amounts rather than percentages.

Total expenses that the hospital attributes to
uncompensated outpatient care. Report as dollar
amounts rather than percentages.

Hospital’s total expenses attributed to charity
care

Hospital’s total expenses attributed to charity
care

Total expenses that the hospital attributes to charity Total expenses that the hospital attributes to charity
care in the inpatient setting. Report as dollar
care in the outpatient setting. Report as dollar
amounts rather than percentages.
amounts rather than percentages.

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HRSA 99-5: Application Checklist

The application checklist must be completed following the instructions provided on the
checklist itself. All required forms and supporting documentation should be included in
the application package submitted in the HRSA Electronic Handbooks to the CHGME
Payment Program in the order that the forms and supporting documentation are listed on
the checklist.

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Section XV: References
Commonly Used Acronyms
ACGME

ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION

AF

AS FILED

CH

CHILDREN'S HOSPITAL

CHGME

CHILDREN'S HOSPITALS GRADUATE MEDICAL EDUCATION
Payment Program PAYMENT PROGRAM
CMI

CASE MIX INDEX

CMS

CENTERS FOR MEDICARE AND MEDICAID SERVICES

D(G)ME

DIRECT (GRADUATE) MEDICAL EDUCATION

EHBs

ELECTRONIC HANDBOOKS

FEL

FELLOW

FI

FISCAL INTERMEDIARY

FY

FEDERAL FISCAL YEAR

FRN

FEDERAL REGISTER NOTICE

FTE

FULL-TIME EQUIVALENT

GME

GRADUATE MEDICAL EDUCATION

GPRA

GOVERNMENT PERFORMANCE AND RESULTS ACT OF 1993

HRSA

HEALTH RESOURCES AND SERVICES ADMINISTRATION

IME

INDIRECT MEDICAL EDUCATION

IRB

INTERN RESIDENT BED COUNT

IRP

INITIAL RESIDENCY PERIOD

MAC

MEDICARE ADMINISTRATIVE CONTRACTOR

MCR

MEDICARE COST REPORT

NBME

NATIONAL BOARD OF MEDICAL EXAMINERS

PGY1

POST-GRADUATE YEAR (1, 2,….)

PPS

PROSPECTIVE PAYMENT SYSTEM

RES (R)

RESIDENT (1,2,…)

USMLE

UNITED STATES MEDICAL LICENSING EXAMINATION

WI

WAGE INDEX

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