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(i) The closure of a hospital means that the hospital terminates its Medicare agreement in accordance with the provisions of page 489.52 of this chapter. (4) The net effect of adjustments (positive or negative) on the total ceiling of Medicare GME hospitals for each GME Medicare affiliation agreement may be zero. On September 29, 2020, CMS announced that the deadlines (1) for the presentation of new membership agreements for the academic year have been extended until 1 January 2021 for the presentation of changes to existing membership agreements for the previous academic year, until 30 June 2020. Previously, CMS extended these two deadlines to October 1, 2020 in response to the public health emergency cosvid-19. CMS announced the time changes in the Covid-19 Blanket Waivers Emergency Declaration, which describes formal regulatory changes under the supervision of Section 1135 of the Social Security Act. The corresponding paragraph states that „the CMS authorizes hospitals to submit new and/or amended GME Medicare affiliation agreements that apply to CMS and CMCs by January 1, 2021.” It also notes that hospitals, as under existing procedures, „should send agreements to CMS to Medicare_GME_Affiliation_Agreement@cms.hhs.gov by e-mail and indicate in the object whether the affiliation agreement is a new agreement or an amended agreement.” Separately, hospitals should also reach their MCS. 4. Adjustment to the number of FTEs of each participating hospital results from the participation of the resident (or residents) in a joint rotation agreement in each hospital participating in the Medicare GME affiliate group, for each year in which the Medicare GME affiliate agreement is in effect. This adjustment to the number of ETPs of each participating hospital is also reflected in the overall adjustment of each hospital`s ETP ceilings (in accordance with paragraph 3 of this definition); and (D) the overall adjustment of the ETP ceilings of each participating hospital for each academic year indicates that the Medicare GME emergency agreement is in effect for both the direct GME and the ME; this reflects a positive adaptation of the host hospital`s direct and indirect ETP ceilings, which is offset by a negative adjustment to the direct and indirect ETP caps of the home hospital (or hospitals) at least the same amount as the following – 1) The sum of the adjustments to the TDR ceilings of all participating hospitals under the Emergency Medicare GME agreement does not exceed the overall adjusted ETP limits of hospitals participating in the emergency group. (1) With the exception of point f) (6) of this section, it is provided: Each hospital of the Medicare GME affiliated group must provide a copy to the CMS holder or mac who cares for the hospital, the Medicare GME affiliation agreement, pursuant to Section 413.75 (b) of this section, and submit a copy to the CMS Central Office no later than July 1 of the year of residence in which the Medicare GME affiliate agreement enters into force.

During the fiscal year (FY) 2019, the Fixed Payment System (IPPS) proposed: to allow new municipal teaching hospitals to jointly use GME research and development niches with other new teaching hospitals, while, in the final rule of GJ 2019, CMS has expanded this proposal to allow new municipal teaching hospitals to share GME TDR slots with existing teaching hospitals that begin five years after meeting their ETP caps.