Form CMS-10790 Appendix A Proposed Collection Applicant Information for

APPENDIX A
Proposed Collection Applicant Information for Graduate Medical Education (GME) Section 126

1. Provide information identifying the applicant hospital to include:
• Hospital Name
• CMS Certification Number (CCN)
• Mailing Address
• Core-Based Statistical Area (CBSA)
• Servicing Medicare Administrative Contractor (MAC)
2. Provide primary and secondary contact information for the applicant hospital to include:
• Name
• Organization
• Occupational/Job Title
• Phone Number
• Email Address
• Mailing Address
3. Provide the name of the residency program for which the hospital is applying.
4. Indicate whether the residency program for which the hospital is applying is a psychiatry
program or subspecialty of psychiatry.
5. Provide the Accreditation Council for Graduate Medical Education (ACGME)
accreditation number for the residency program for which the hospital is applying.
6. If the residency program does not have an ACGME accreditation number, please explain
why.
7. Indicate the number of full-time equivalent (FTE) positions the hospital is requesting (up
to 5.0 FTEs each for direct graduate medical education (DGME) and indirect medical
education (IME)). Note: The maximum amount that can be requested is equal to the
length of the program for which a hospital is applying, with up to 1.0 FTE being awarded
per program year, not to exceed a program length of 5 years or 5.0 FTEs. For example, a
hospital applying to train residents in a program in which the length of the program is 3
years may request up to 3.0 FTEs.
8. The applicant hospital must provide documentation to demonstrate the likelihood of
filling requested slots under section 126 within the first five training years beginning after
July 1, 2023. Select the demonstrated likelihood criteria (DCL) that best describes this
Note: The application questions in this appendix are based on CMS’s final policy to implement the
provisions of Section 126 of the Consolidated Appropriations Act, 2021 (Public Law 116-93) as presented
in the FY 2022 IPPS final rule with comment period (CMS-1752-FC3; December 17, 2021). Although this
collection is processing independently of a rulemaking schedule, these collection questions are subject
to change/revision when the final policies are adopted after consideration of public comments in future
iterations of the FY 2022 IPPS final rule. The application questions for this collection will be updated, as
necessary, as soon as possible after the rule is finalized.

APPENDIX A
Proposed Collection Applicant Information for Graduate Medical Education (GME) Section 126

application. Options include, DLC 1 (establishing a new residency program) or DLC 2
(expanding an existing residency program).
9. Include information to support the DLC selection.
Under Demonstrated Likelihood Criterion 1, the hospital is required to select at least one
of the following as part of its application:
•

•

Application for accreditation of the new residency program has been submitted to the
ACGME or application for approval of the new residency program has been
submitted to the American Board of Medical Specialties (ABMS) by the application
deadline.
The hospital has received written correspondence from the ACGME (or ABMS)
acknowledging receipt of the application for the new residency program, or other
types of communication concerning the new program accreditation or approval
process (such as notification of site visit) by the application deadline.

Under Demonstrated Likelihood Criterion 2, the hospital would be required to select at
least one of the following as part of its application:
•
•
•

The hospital has received approval by the application deadline from an appropriate
accrediting body (the ACGME or ABMS) to expand the number of FTE residents in
the program.
The hospital has submitted a request the application deadline for a permanent
complement increase of the existing residency program.
The hospital currently has unfilled positions in its residency program that have
previously been approved by the ACGME, and is now seeking to fill those positions.

9. Indicate the eligibility category or categories met by the hospital. The hospital would be
required to select from one or more of the following categories:
•
•
•

The hospital is located in a rural area (as defined in section 1886(d)(2)(D) of the
Social Security Act) or is treated as being located in a rural area pursuant to section
1886(d)(8)(E) of the Social Security Act.
The hospital is currently training over its DGME and/or IME cap. The reference
resident level of the hospital (as specified in section 1886(h)(9)(F)(iii) of the Social
Security Act) is greater than the otherwise applicable resident limit.
The hospital is located in a State with a new medical school (as specified in section
1886(h)(9)(B)(ii)(III)(aa) of the Act), or with additional locations and branch

Note: The application questions in this appendix are based on CMS’s final policy to implement the
provisions of Section 126 of the Consolidated Appropriations Act, 2021 (Public Law 116-93) as presented
in the FY 2022 IPPS final rule with comment period (CMS-1752-FC3; December 17, 2021). Although this
collection is processing independently of a rulemaking schedule, these collection questions are subject
to change/revision when the final policies are adopted after consideration of public comments in future
iterations of the FY 2022 IPPS final rule. The application questions for this collection will be updated, as
necessary, as soon as possible after the rule is finalized.

APPENDIX A
Proposed Collection Applicant Information for Graduate Medical Education (GME) Section 126

•

campuses established by medical schools (as specified in section
1886(h)(9)(B)(ii)(III)(bb) of the Act) on or after January 1, 2000. Those states and
territories are Alabama, Arizona, Arkansas, California, Colorado, Connecticut,
Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana,
Massachusetts, Michigan, Mississippi, Missouri, Nevada, New Jersey, New Mexico,
New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Puerto Rico, South
Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and
Wisconsin.
The hospital is serving an area designated as a health professional shortage area
(HPSA) under section 332(a)(1)(A) of the Public Health Service Act (PHSA), as
determined by the Secretary. A hospital is qualified under Category Four if it
participates in training residents in a program where the residents rotate for at least 50
percent of their training time to scheduled training sites physically located in a
geographic HPSA.

10. Using the find shortage areas by address tool, https://data.hrsa.gov/tools/shortagearea/byaddress, enter the address of a training location (included on the hospital’s rotation
schedule or similar documentation). Using the results of the address entered, identify and
choose either a geographic or population HPSA to include in the hospital’s application.
Note: In order for the hospital to prioritized for distribution of additional residency
positions, the location chosen must participate in training residents in a program where at
least 50 percent (5 percent if an Indian and Tribal facility is included) of the training time
occurs in the HPSA.
11. Indicate which training time prioritization criteria is met.
Under Population HPSA, the hospital would be required to select one of the following as
part of its application:
•

•

In the population HPSA the hospital is requesting that CMS use for prioritization of its
application, at least 50 percent of the program’s training time based on resident rotation
schedules (or similar documentation) occurs at training sites that treat the designated
underserved population of the HPSA and are physically located in the HPSA.
In the population HPSA the hospital is requesting that CMS use for prioritization of its
application, at least 5 percent of the program’s training time based on resident rotation
schedules (or similar documentation) occurs at training sites that treat the designated
underserved population of the HPSA and are physically located in the HPSA, and the
program’s training time at those sites plus the program’s training time at Indian or Tribal
facilities located outside of that HPSA is at least 50 percent of the program’s training
time.

Note: The application questions in this appendix are based on CMS’s final policy to implement the
provisions of Section 126 of the Consolidated Appropriations Act, 2021 (Public Law 116-93) as presented
in the FY 2022 IPPS final rule with comment period (CMS-1752-FC3; December 17, 2021). Although this
collection is processing independently of a rulemaking schedule, these collection questions are subject
to change/revision when the final policies are adopted after consideration of public comments in future
iterations of the FY 2022 IPPS final rule. The application questions for this collection will be updated, as
necessary, as soon as possible after the rule is finalized.

APPENDIX A
Proposed Collection Applicant Information for Graduate Medical Education (GME) Section 126

•

The hospital does not meet either of the two criteria above.
Under Geographic HPSA, the hospital would be required to select one of the following as
part of its application:

•

•

•

In the geographic HPSA the hospital is requesting that CMS use for prioritization of its
application, at least 50 percent of the program’s training time based on resident rotation
schedules (or similar documentation) occurs at training sites that treat the population of
the HPSA and are physically located in the HPSA.
In the geographic HPSA the hospital is requesting that CMS use for prioritization of its
application, at least 5 percent of the program’s training time based on resident rotation
schedules (or similar documentation) occurs at training sites that treat the population of
the HPSA and are physically located in the HPSA, and the program’s training time at
those sites plus the program’s training time at Indian or Tribal facilities located outside of
the HPSA is at least 50 percent of the program’s training time..
The hospital does not meet either of the two criteria above.

12. In the application, include the HPSA ID and HPSA discipline (primary care or mental
health) (and type if population HPSA) as depicted in the find shortage areas by address
tool.
13. Include Worksheets E, Part A and E-4 of the most recent as-filed cost report (CMS-255210).
14. Download an attestation form that consists of attestation statements as finalized in the FY
2022 IPPS final rule with comment period (CMS-1752-FC3). Ensure the attestation form
is signed and dated by an officer or administrator of the hospital who signs the hospital’s
Medicare cost report.
15. Upload the signed and dated (digital or scanned) copy of the attestation form.
16. Review a summary of the details included in the application and submit the application.

Note: The application questions in this appendix are based on CMS’s final policy to implement the
provisions of Section 126 of the Consolidated Appropriations Act, 2021 (Public Law 116-93) as presented
in the FY 2022 IPPS final rule with comment period (CMS-1752-FC3; December 17, 2021). Although this
collection is processing independently of a rulemaking schedule, these collection questions are subject
to change/revision when the final policies are adopted after consideration of public comments in future
iterations of the FY 2022 IPPS final rule. The application questions for this collection will be updated, as
necessary, as soon as possible after the rule is finalized.