,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #bhi  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,janu>y #ca1 #bjai,mr4 
,g>dn] 7= himself1 ,mr4 ,te/]1 & ,mrs4  
,hyde-,smi?7 introduc$ ! foll[+ bill2   
:i* 0 read twice & ref]r$ to !          
,committee on ,f9ance  ,a ,,bill  ,to   
am5d title ,,xviii ( ! ,social ,security
 ,act to support rural resid5cy tra9+   
fund+ t is equitable = all ,/ates1 & =  
o!r purposes4  #a4 ,%ort title ,?is ,act
 may be cit$ z ! ,rural ,physician      
,work=ce ,production ,act ( #bjai4  #b4 
,alt]native national p] resid5t paym5t =
 resid5ts tra9+ 9 rural tra9+ locations 
7a7 ,9 g5]al ,section #ahhf ( ! ,social 
,security ,act 7#db ,u4,s4,c4 #acieww7  
is am5d$ by add+ at ! end ! foll[+ new  
subsection3  7u7 ,alt]native national p]
 resid5t paym5t am\nt = resid5ts tra9+ 9
 rural tra9+ locations  7#a7 ,9 g5]al   
7,a7 ,e/abli%m5t ,! ,secret>y %all      
e/abli% a national p] resid5t paym5t    
7,,nprp7 am\nt = "t sp5t by resid5ts    
tra9+ 9 rural tra9+ locations 9         

accordance ) p>agraph 7#b74  7,b7       
,election ,= co/ report+ p]iods beg9n+  
on or aft] ! date t is #a ye> aft] !    
date ( enactm5t ( ?is subsection1 an    
applicable hospital 7z def9$ 9 p>agraph 
7#f77;,a771 may elect to receive !      
paym5t am\nt "u ?is subsection = ea*    
full-"t-equival5t resid5t 9 an approv$  
m$ical resid5cy tra9+ program t receives
 tra9+ 9 a rural tra9+ location 9       
accordance ) p>agraph 7#b74 ,an         
applicable hospital may make an election
 "u ! prec$+ s5t5ce reg>dless ( :e!r !  
applicable hospital is o!rwise eligible 
= a paym5t or adju/m5t = indirect &     
direct graduate m$ical education co/s "u
 subsections 7d77#e77;,b7 & 7h7 or      
section #ahad7l71 z applicable1 )       
respect to su* resid5ts4 ,if !          
applicable hospital is o!rwise eligible 
= su* a paym5t or adju/m5t1 ! national  
p] resid5t paym5t am\nt "u ?is          
subsection %all be 9 lieu ( su* paym5t  
or adju/m5t4  7,c7 ,application ,!      
provisions ( ?is subsection1 or !       

application ( su* provisions to an      
applicable hospital1 %all n result 9 or 
o!rwise effect ! foll[+3  7i7 ,!        
e/abli%m5t ( a limitation on ! numb] (  
resid5ts 9 allopa?ic or o/eopa?ic m$ic9e
 = purposes ( subsections 7d77#e77;,b7 &
 7h7 ) respect to an approv$ m$ical     
resid5cy tra9+ program ( an applicable  
hospital 7or be tak5 into acc\nt 9      
det]m9+ su* a limitation dur+ ! cap     
build+ p]iod ( an applicable hospital74 
7ii7 ,! det]m9ation (-- 7,i7 !          
additional paym5t am\nt "u subsection   
7d77#e77;,b72 or  7,,ii7                
hospital-specific approv$ ,,fte resid5t 
am\nts "u subsection 7h74  7iii7 ,!     
c\nt+ ( any resid5t ) respect to :i* !  
applicable hospital receives a national 
p] resid5t paym5t "u ?is subsection     
t[>ds ! application ( ! limitation      
describ$ 9 clause 7i7 = purposes (      
subsections 7d77#e77;,b7 & 7h74  7#b7   
,paym5t am\nt  7,a7 ,base am\nt ,!      
national p] resid5t paym5t am\nt1 )     
respect to full-"t equival5t resid5ts   

tra9+ 9 rural tra9+ locations1 = co/    
report+ p]iods beg9n+ dur+ ! fir/ ye>   
beg9n+ on or aft] ! date ( enactm5t (   
?is subsection %all be1 bas$ on ! mo/   
rec5tly available data ) respect to co/ 
report+ p]iods beg9n+ dur+ a prec$+ ye> 
7ref]r$ to 9 ?is subp>agraph z ! base   
co/ report+ p]iod71 equal to ! sum ( !  
foll[+3  7i7 ,direct ,,gme ,! am\nt t1  
out ( all ( ! paym5t am\nts 7det]m9$ on 
a p] resid5t basis7 receiv$ by hospitals
 "u subsection 7h7 = su* base co/       
report+ p]iod1 is equal to ! national   
#he? p]c5tile ( su* paym5t am\nts4  7ii7
 ,indirect ,,gme ,! am\nt t1 out ( all (
 ! additional paym5t am\nts 7det]m9$ on 
a p] resid5t basis7 receiv$ by hospitals
 "u subsection 7d77#e77;,b7 = su* base  
co/ report+ p]iod1 is equal to !        
national #he? p]c5tile ( su* paym5t     
am\nts4  7,b7 ,updat+ = subsequ5t co/   
report+ p]iods ,= ea* subsequ5t co/     
report+ p]iod1 ! national p] resid5t    
paym5t am\nt is equal to su* am\nt      
det]m9$ "u ?is p>agraph = ! previ\s co/ 

report+ p]iod updat$1 ?r\gh ! midpo9t ( 
! p]iod1 by project+ ! e/imat$ p]c5tage 
*ange 9 ! consum] price index dur+ !    
#ab-mon? p]iod end+ at t midpo9t1 )     
appropriate adju/m5ts to reflect previ\s
 "u- or ov]-e/imations "u ?is           
subp>agraph 9 ! project$ p]c5tage *ange 
9 ! consum] price index4  7,c7          
,cl>ification ,! national p] resid5t    
paym5t am\nt %all n be disc\nt$ or      
o!rwise adju/$ bas$ on ! ,m$ic>e pati5t 
load 7z def9$ 9 subsection 7h77#c77;,c77
 ( an applicable hospital or dis*>ges 9 
a diagnosis-relat$ gr\p4  7#c7          
,allocation ( paym5ts ,9 provid+ =      
paym5ts "u ?is subsection1 ! ,secret>y  
%all provide = an allocation ( su*      
paym5ts betwe5 p>ts ,a & "p ,b 7& ! tru/
 funds e/abli%$ "u ! respective p>ts7 z 
reasonably reflects ! proportion ( su*  
co/s associat$ ) ! provision ( s]vices  
"u ea* respective "p4  7#d7 ,eligibility
 = paym5t  7,a7 ,9 g5]al ,an applicable 
hospital %all be eligible = paym5t ( !  
national p] resid5t paym5t am\nt "u ?is 

subsection = "t sp5t by a resid5t tra9+ 
9 a rural tra9+ location if ! foll[+    
requirem5ts are met3  7i7 ,! resid5t    
sp5ds ! equival5t ( at lea/ #h weeks ov]
 ! c\rse ( _! tra9+ 9 a rural tra9+     
location4  7ii7 ,! hospital pays ! sal>y
 & b5efits ( ! resid5t = ! "t sp5t tra9+
 9 a rural tra9+ location4  7,b7        
,treatm5t ( "t sp5t 9 rural tracks ,an  
applicable hospital %all be eligible =  
paym5t ( ! national p] resid5t paym5t   
am\nt "u ?is subsection = all "t sp5t by
 resid5ts 9 an approv$ m$ical resid5cy  
program 7or sep>ately def9$ track )9 a  
program7 t provides #ej p]c5t or m ( !  
total resid5cy tra9+ "t 9 rural tra9+   
locations 7z def9$ 9 p>agraph           
7#f77;,c771 reg>dless ( :]e ! tra9+     
occurs & reg>dless ( specialty4  7#e7   
,det]m9ation ( full-"t-equival5t        
resid5ts ,! det]m9ation (               
full-"t-equival5t resid5ts = purposes ( 
?is subsection %all be made 9 ! same    
mann] z ! det]m9ation (                 
full-"t-equival5t resid5ts "u subsection

 7h77#d74  7#f7 ,def9itions ,9 ?is      
subsection3 7,a7 ,applicable hospital ,!
 t]m applicable hospital means a        
hospital or critical access hospital4   
7,b7 ,approv$ m$ical resid5cy tra9+     
program2 direct graduate m$ical         
education co/s2 resid5t ,! t]ms approv$ 
m$ical resid5cy tra9+ program1 direct   
graduate m$ical education co/s1 &       
resid5t h ! mean+s giv5 ^? t]ms 9       
subsection 7h77#e74  7,c7 ,rural tra9+  
location ,! t]m rural tra9+ location    
means a location 9 :i* tra9+ occurs t1  
bas$ on ! #bjaj c5sus or any subsequ5t  
c5sus adju/m5t1 meets "o or m ( ! foll[+
 crit]ia3  7i7 ,! tra9+ occurs 9 a      
location t is a rural area 7z def9$ 9   
section #ahhf7;d77#b77;,d774  7ii7 ,!   
tra9+ occurs 9 a location t has a       
rural-urban commut+ area code equal to  
or great] ?an #d4j4  7iii7 ,! tra9+     
occurs 9 a location t is )9 #aj miles ( 
a sole community hospital 7z def9$ 9    
subsection 7d77#e77;,d77iii7774  7#g7   
,budget neutrality requirem5t ,!        

,secret>y %all ensure t aggregate       
paym5ts = direct m$ical education co/s &
 indirect m$ical education co/s "u ?is  
title1 includ+ any paym5ts "u ?is       
subsection1 = ea* ye> 7effective beg9n+ 
on or aft] ! date t is #a ye> aft] !    
date ( enactm5t ( ?is subsection7 are n 
great] ?an ! aggregate paym5ts = su*    
co/s t w\ld h be5 made "u ?is title = ! 
ye> )\t ! application ( ?is subsection4 
,= purposes ( c>ry+ out ! budget        
neutrality requirem5t "u ! prec$+       
s5t5ce1 ! ,secret>y may make appropriate
 adju/m5ts to ! am\nt ( su* paym5ts =   
direct graduate m$ical education co/s & 
indirect m$ical education co/s "u       
subsections 7h7 & 7d77#e77;,b71         
respectively4  4  7b7 ,treatm5t (       
critical access hospitals & sole        
community hospitals  7#a7 ,critical     
access hospitals ,section #ahad7l7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acie;f7l77 is am5d$ by add+ at ! end ! 
foll[+ new p>agraph3  7#f7 ,= co/       
report+ p]iods beg9n+ on or aft] ! date 

t is #a ye> aft] ! date ( enactm5t ( ?is
 p>agraph1 ! foll[+ %all apply3  7,a7 ,a
 critical access hospital may elect to  
be treat$ z a hospital or z a           
non-provid] sett+ = purposes ( c\nt+    
resid5t "t = indirect m$ical education  
co/s & direct graduate m$ical education 
co/s = ! "t sp5t by ! resid5t 9 t sett+ 
"u subsections 7d77#e77;,b7 & 7h71      
respectively1 ( section #ahhf4  7,b7    
,m$ical education co/s %all n be        
consid]$ reasonable co/s ( a critical   
access hospital = purposes ( paym5t "u  
p>agraph 7#a71 to ! ext5t t ! critical  
access hospital or ano!r hospital       
receives paym5t = su* co/s = ! "t sp5t  
by ! resid5t 9 t sett+ pursuant to      
subsection 7d77#e77;,b71 subsection 7h71
 or subsection 7u7 ( section #ahhf4  4  
7#b7 ,sole community hospitals ,section 
#ahhf7;d77#e77;,d7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieww7d77#e77;,d77 is am5d$ by add+ at
 ! end ! foll[+ new clause3  7vi7 ,= co/
 report+ p]iods beg9n+ on or aft] ! date

 t is #a ye> aft] ! date ( enactm5t (   
?is p>agraph1 ! hospital-specific paym5t
 am\nt det]m9$ "u clause 7i77,i7 )      
respect to a sole community hospital    
%all n include m$ical education co/s1 to
 ! ext5t t ! sole community hospital    
receives paym5t = su* co/s = ! "t sp5t  
by ! resid5t 9 t sett+ pursuant to      
subsection 7u74  4  7c7 ,con=m+ am5dm5ts
  7#a7 ,section #ahhf ( ! ,social       
,security ,act 7#db ,u4,s4,c4 #acieww7  
is am5d$-- 7,a7 9 subsection            
7d77#e77;,b71 9 ! matt] prec$+ clause   
7i71 by /rik+ ,! ,secret>y & ins]t+     
,subject to subsection 7u71 ! ,secret>y2
 &  7,b7 9 subsection 7h7-- 7i7 9       
p>agraph 7#a71 by ins]t+ subject to     
subsection 7u7 aft] #ahfa7v712 &  7ii7 9
 p>agraph 7#c71 9 ! flu% matt] foll[+   
subp>agraph 7,b71 by /rik+ subsection   
7k7 & ins]t+ subsection 7k7 or          
subsection 7u74  #c4 ,support+ new1     
exp&+1 & exi/+ rural tra9+ track        
resid5cies  7a7 ,direct graduate m$ical 
education ,section #ahhf7;h7 ( ! ,social

 ,security ,act 7#db ,u4,s4,c4          
#acieww7h77 is am5d$--  7#a7 9 p>agraph 
7#d7-- 7,a7 9 subp>agraph 7,f77i7--  7i7
 by /rik+ #acj p]c5t & ins]t+ = co/     
report+ p]iods beg9n+ on or aft] ,octob]
 #a1 #aiig1 & be=e ! date t is #a ye>   
aft] ! date ( enactm5t ( ! ,rural       
,physician ,work=ce ,production ,act (  
#bjai1 #acj p]c5t2 &  7ii7 by add+ at ! 
end ! foll[+3 ,= co/ report+ p]iods     
beg9n+ on or aft] ! date t is #a ye>    
aft] ! date ( enactm5t ( ! ,rural       
,physician ,work=ce ,production ,act (  
#bjai1 su* rules %all provide t any     
full-"t-equival5t resid5t 9 an approv$  
m$ical resid5cy program 7or sep>ately   
def9$ track )9 a program7 t provides #ej
 p]c5t or m ( ! total resid5cy tra9+ "t 
9 rural tra9+ locations 7z def9$ 9      
subsection 7u77#f77;,c771 reg>dless (   
:]e ! tra9+ occurs & reg>dless (        
specialty1 %all n be tak5 into acc\nt = 
purposes ( apply+ ! limitation "u ?is   
subp>agraph42 &  7,b7 9 subp>agraph     
7,h7-- 7i7 9 clause 7i71 9 ! second     

s5t5ce1 by ins]t+ ! foll[+ be=e ! p]iod3
 1 9 accordance ) ! second s5t5ce (     
clause 7i7 ( su* subp>agraph2 &  7ii7 9 
clause 7iv71 by ins]t+ ! foll[+ be=e !  
p]iod3 1 9 accordance ) ! second s5t5ce 
( clause 7i7 ( su* subp>agraph2 &  7#b7 
9 p>agraph 7#e71 by add+ at ! end !     
foll[+ new subp>agraph3  7,l7 ,special  
rules reg>d+ application ( national p]  
resid5t paym5t am\nt ,= special rules   
reg>d+ application ( ! national p]      
resid5t paym5t am\nt "u subsection 7u71 
see p>agraph 7#a77;,c7 ( su* subsection4
  4  7b7 ,indirect m$ical education     
,section #ahhf7;d77#e77;,b77v7 is       
am5d$-- 7#a7 by /rik+ #acj p]c5t &      
ins]t+ = co/ report+ p]iods beg9n+ on or
 aft] ,octob] #a1 #aiig1 & be=e ! date t
 is #a ye> aft] ! date ( enactm5t ( !   
,rural ,physician ,work=ce ,production  
,act ( #bjai1 #acj p]c5t2 &  7#b7 by    
add+ at ! end ! foll[+3 ,= co/ report+  
p]iods beg9n+ on or aft] ! date t is #a 
ye> aft] ! date ( enactm5t ( ! ,rural   
,physician ,work=ce ,production ,act (  

#bjai1 su* rules %all provide t any     
full-"t-equival5t resid5t 9 an approv$  
m$ical resid5cy program 7or sep>ately   
def9$ track )9 a program7 t provides #ej
 p]c5t or m ( ! total resid5cy tra9+ "t 
9 rural tra9+ locations 7z def9$ 9      
subsection 7u77#f77;,c771 reg>dless (   
:]e ! tra9+ occurs & reg>dless (        
specialty1 %all n be tak5 into acc\nt = 
purposes ( apply+ ! limitation "u ?is   
subp>agraph4 ,= special rules reg>d+    
application ( ! national p] resid5t     
paym5t am\nt "u subsection 7u71 see     
p>agraph 7#a77;,c7 ( su* subsection44