; and (2) in the case of a hospital in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act), 4 years after the date of the enactment of this title. (e) Study Not later than 1 year after the date of the enactment of this title, the Secretary, acting through the Director of the Agency for Healthcare Research and Quality shall complete a study of registered and practical nurse staffing requirements in clinics and other outpatient settings, and its effects on patient care in outpatient settings. The Director may contract with a qualified entity or organization to carry out such study under this subsection. The Director shall consult with registered nurses and licensed practice nurses working in outpatient settings, including professional nursing associations and labor organizations representing both registered and practice nurses working in outpatient settings regarding the design and conduct of the study. 3404. Adjustment in reimbursement (a) Medicare reimbursement The Secretary shall adjust payments made to hospitals (other than federally operated hospitals) under title XVIII of the Social Security Act in an amount equal to the net amount of additional costs incurred in providing services to Medicare beneficiaries that are attributable to compliance with requirements imposed under sections 3401 through 3403. The amount of such payment adjustments shall take into account recommendations contained in the report submitted by the Medicare Payment Advisory Commission under subsection (c). (b) Authorization of appropriation for federally operated hospitals There are authorized to be appropriated such additional sums as are required for federally operated hospitals to comply with the additional requirements established under sections 3401 through 3403. (c) Medpac report Not later than 2 years after the date of the enactment of this title, the Medicare Payment Advisory Commission (established under section 1805 of the Social Security Act) shall submit to Congress and the Secretary a report