,,ii #aahth ,,congress #ast ,session ,s4 #bcj ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #b1 #bjbc,mr4 ,tester 7for himself1 ,mr4 ,barrasso1 ,ms4 ,murkowski1 ,ms4 ,collins1 ,ms4 ,sinema1 ,mrs4 ,hyde-,smith1 ,mr4 ,cramer1 ,mr4 ,kelly1 ,mr4 ,heinrich1 ,mrs4 ,capito1 and ,ms4 ,cortez ,masto7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to support rural residency training funding that is equitable for all ,states1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,rural ,physician ,workforce ,production ,act of #bjbc4 #b4 ,elective rural sustainability per resident payment for residents training in rural training locations 7a7 ,in general ,section #ahhf of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7 is amended by adding at the end the following new subsection3 7u7 ,elective rural sustainability per resident payment amount for residents training in rural training locations 7#a7 ,determination of elective rural sustainability per resident payment amount 7,a7 ,in general ,the elective rural sustainability per resident payment amount determined under this subsection for an applicable hospital 7as defined in paragraph 7#g77;,a77 that makes an election under paragraph 7#b71 with respect to each full-time-equivalent resident in an approved medical residency training program that receives training in a rural training location 7as defined in paragraph 7#g77;,c771 is an amount equal to the difference between-- 7i7 the total elective rural sustainability amount determined under subparagraph 7,b7 7or1 in the case of an applicable hospital not located in a rural area1 the total elective rural sustainability amount or urban total elective rural sustainability amount1 as applicable1 determined under such subparagraph72 and 7ii7 the amount 7if any7 the applicable hospital otherwise receives for direct graduate medical education costs under subsection 7h7 or section #ahad7l71 as applicable1 with respect to each such resident4 7,b7 ,total elective rural sustainability amount 7i7 ,establishment for initial cost reporting periods 7,i7 ,in general ,subject to subclause 7,,ii71 for cost reporting periods beginning during the first year beginning on or after the date of the enactment of this subsection1 the ,secretary shall establish a total elective rural sustainability amount for time spent by each full-time-equivalent resident in an approved medical residency training program that receives training in a rural training location4 ,such amount shall be the amount that the ,secretary determines is equal to the median national direct ,,gme training costs per full-time equivalent resident for #bjae described in table #i on page #cc of the ,march #bjah ,,gao report on ,physician ,workforce 7,,gao-#ah-bdj71 updated for each subsequent year through the first year beginning on or after the date of the enactment of this subsection1 by the annual percentage increase in the consumer price index for all urban consumers 7all items2 ,united ,states city average74 7,,ii7 ,application to urban hospitals ,for cost reporting periods beginning during the first year beginning on or after the date of the enactment of this subsection1 in the case of an applicable hospital that is not located in a rural area-- 7aa7 with respect to such residents that receive training in a rural track or an integrated rural track1 the total elective rural sustainability amount per resident shall be equal to the amount established under subclause 7,i72 and 7bb7 with respect to such residents that receive training in a rural training location and who are not participating in a rural track or an integrated rural track1 the total elective rural sustainability amount per resident shall be equal to #ej percent of the amount established under subclause 7,i7 7referred to in this subsection as the urban total elective rural sustainability amount74 7ii7 ,updating for subsequent cost reporting periods ,for each subsequent cost reporting period1 the total elective rural sustainability amount under clause 7i77,i7 and clause 7i77,,ii77aa7 and the urban total elective rural sustainability amount under clause 7i77,,ii77bb71 respectively1 are equal to such amounts determined under such clause for the previous cost reporting period updated1 through the midpoint of the period1 by projecting the estimated percentage change in the consumer price index for all urban consumers 7all items2 ,united ,states city average7 during the #ab-month period ending at that midpoint1 with appropriate adjustments to reflect previous under- or over-estimations under this clause in the projected percentage change in the consumer price index for medical care services4 7,c7 ,clarification ,the total elective rural sustainability amount1 the urban total elective rural sustainability amount1 and the elective rural sustainability per resident payment amount determined under this paragraph shall not be discounted or otherwise adjusted based on the ,medicare patient load 7as defined in subsection 7h77#c77;,c77 of an applicable hospital or discharges in a diagnosis-related group4 7#b7 ,election ,for cost reporting periods beginning on or after the date that is #a year after the date of the enactment of this subsection1 an applicable hospital may elect to receive the elective rural sustainability per resident payment amount for each full-time-equivalent resident in an approved medical residency training program that receives training in a rural training location in accordance with this subsection4 ,an applicable hospital may make an election under the preceding sentence regardless of whether the applicable hospital is otherwise eligible for a payment or adjustment for indirect and direct graduate medical education costs under subsections 7d77#e77;,b7 and 7h7 or section #ahad7l71 as applicable1 with respect to such residents4 7#c7 ,application ,the provisions of this subsection1 or the application of such provisions to an applicable hospital-- 7,a7 shall not result in-- 7i7 the establishment of a limitation on the number of residents in allopathic or osteopathic medicine for purposes of subsections 7d77#e77;,b7 and 7h7 with respect to an approved medical residency training program of an applicable hospital 7or be taken into account in determining such a limitation during the cap building period of an applicable hospital72 or 7ii7 the counting of any resident with respect to which the applicable hospital receives an elective rural sustainability per resident payment amount under this subsection towards the application of the limitation described in clause 7i7 for purposes of subsections 7d77#e77;,b7 and 7h72 and 7,b7 shall not have any effect on the determination of-- 7i7 the additional payment amount under subsection 7d77#e77;,b72 or 7ii7 hospital-specific approved ,,fte resident amounts under subsection 7h74 7#d7 ,allocation of payments ,in providing for payments under this subsection1 the ,secretary shall provide for an allocation of such payments between parts ,a and part ,b 7and the trust funds established under the respective parts7 as reasonably reflects the proportion of such costs associated with the provision of services under each respective part4 7#e7 ,eligibility for payment 7,a7 ,in general ,an applicable hospital shall be eligible for payment of the elective rural sustainability per resident payment amount under this subsection for time spent by a resident training in a rural training location if the following requirements are met3 7i7 ,the resident spends the equivalent of at least #h weeks over the course of their training in a rural training location4 7ii7 ,the hospital pays the salary and benefits of the resident for the time spent training in a rural training location4 7,b7 ,treatment of time spent in rural tracks or integrated rural tracks ,an applicable hospital shall be eligible for payment of the elective rural sustainability per resident payment amount under this subsection for all time spent by residents in an approved medical residency program 7or separately defined track within a program7 that provides more than #ej percent of the total residency training time in rural training locations1 regardless of where the training occurs and regardless of specialty4 7#f7 ,determination of full-time-equivalent residents ,the determination of full-time-equivalent residents for purposes of this subsection shall be made in the same manner as the determination of full-time-equivalent residents under subsection 7h77#d71 but not taking into account the limitation under subparagraph 7,f7 of such subsection4 7#g7 ,definitions ,in this subsection3 7,a7 ,applicable hospital ,the term applicable hospital means a hospital1 critical access hospital1 sole community hospital 7as defined in subsection 7d77#e77;,d77iii771 or rural emergency hospital 7as defined in section #ahfa7kkk77#b774 7,b7 ,approved medical residency training program2 direct graduate medical education costs2 resident ,the terms approved medical residency training program1 direct graduate medical education costs1 and resident have the meanings given those terms in subsection 7h77#e74 7,c7 ,rural training location ,the term rural training location means a location in which training occurs that1 based on the #bjaj census or any subsequent census adjustment1 meets one or more of the following criteria3 7i7 ,the training occurs in a location that is a rural area 7as defined in section #ahhf7;d77#b77;,d774 7ii7 ,the training occurs in a location that has a rural-urban commuting area code equal to or greater than #d4j4 7iii7 ,the training occurs in a sole community hospital 7as defined in subsection 7d77#e77;,d77iii77 or in a location that is within #aj miles of a sole community hospital4 7#h7 ,budget neutrality requirement ,the ,secretary shall ensure that aggregate payments for direct medical education costs and indirect medical education costs under this title1 including any payments under this subsection1 for each year 7effective beginning on or after the date that is #a year after the date of enactment of this subsection7 are not greater than the aggregate payments for such costs that would have been made under this title for the year without the application of this subsection4 ,for purposes of carrying out the budget neutrality requirement under the preceding sentence1 the ,secretary may make appropriate adjustments to the amount of such payments for direct graduate medical education costs and indirect medical education costs under subsections 7h7 and 7d77#e77;,b71 respectively4 4 7b7 ,treatment of critical access hospitals and sole community hospitals 7#a7 ,critical access hospitals ,section #ahad7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7l77 is amended by adding at the end the following new paragraph3 7#f7 ,for cost reporting periods beginning on or after the date that is #a year after the date of enactment of this paragraph1 the following shall apply3 7,a7 ,a critical access hospital may elect to be treated as a hospital or as a non-provider setting for purposes of counting resident time for indirect medical education costs and direct graduate medical education costs for the time spent by the resident in that setting under subsections 7d77#e77;,b7 and 7h71 respectively1 of section #ahhf4 7,b7 ,medical education costs shall not be considered reasonable costs of a critical access hospital for purposes of payment under paragraph 7#a71 to the extent that the critical access hospital is treated as a non-provider setting of another hospital or another hospital receives payment for such costs for the time spent by the resident in that setting pursuant to subsection 7d77#e77;,b71 subsection 7h71 or subsection 7u7 of section #ahhf4 4 7#b7 ,sole community hospitals ,section #ahhf7;d77#e77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,d77 is amended by adding at the end the following new clause3 7vi7 ,for cost reporting periods beginning on or after the date that is #a year after the date of enactment of this paragraph1 the hospital-specific payment amount determined under clause 7i77,i7 with respect to a sole community hospital shall not include medical education costs1 to the extent that the sole community hospital receives payment for such costs for the time spent by the resident in that setting pursuant to subsection 7u74 4 7c7 ,conforming amendments 7#a7 ,section #ahhf of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7 is amended-- 7,a7 in subsection 7d77#e77;,b71 in the matter preceding clause 7i71 by striking ,the ,secretary and inserting ,subject to subsection 7u71 the ,secretary2 and 7,b7 in subsection 7h7-- 7i7 in paragraph 7#a71 by inserting subject to subsection 7u7 after #ahfa7v712 and 7ii7 in paragraph 7#c71 in the flush matter following subparagraph 7,b71 by striking subsection 7k7 and inserting subsection 7k7 or subsection 7u74 #c4 ,supporting new1 expanding1 and existing rural training tracks 7a7 ,direct graduate medical education ,section #ahhf7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77 is amended-- 7#a7 in paragraph 7#d7-- 7,a7 in subparagraph 7,f77i7-- 7i7 by striking #acj percent and inserting for cost reporting periods beginning on or after ,october #a1 #aiig1 and before the date that is #a year after the date of enactment of the ,rural ,physician ,workforce ,production ,act of #bjbc1 #acj percent2 and 7ii7 by adding at the end the following3 ,for cost reporting periods beginning on or after the date that is #a year after the date of enactment of the ,rural ,physician ,workforce ,production ,act of #bjbc1 such rules shall provide that any full-time-equivalent resident in an approved medical residency program 7or separately defined track within a program7 that provides more than #ej percent of the total residency training time in rural training locations 7as defined in subsection 7u77#f77;,c771 regardless of where the training occurs and regardless of specialty1 shall not be taken into account for purposes of applying the limitation under this subparagraph42 and 7,b7 in subparagraph 7,h7-- 7i7 in clause 7i71 in the second sentence1 by inserting the following before the period3 1 in accordance with the second sentence of clause 7i7 of such subparagraph2 and 7ii7 in clause 7iv77,,ii71 by inserting the following before the period3 1 in accordance with the second sentence of clause 7i7 of such subparagraph2 and 7#b7 in paragraph 7#e71 by adding at the end the following new subparagraph3 7,l7 ,special rules regarding application of elective rural sustainability per resident payment amount ,for special rules regarding application of the elective rural sustainability per resident payment amount under subsection 7u71 see paragraph 7#c7 of such subsection4 4 7b7 ,indirect medical education ,section #ahhf7;d77#e77;,b77v7 of such ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77v77 is amended-- 7#a7 by striking #acj percent and inserting for cost reporting periods beginning on or after ,october #a1 #aiig1 and before the date that is #a year after the date of enactment of the ,rural ,physician ,workforce ,production ,act of #bjbc1 #acj percent2 and 7#b7 by adding at the end the following3 ,for cost reporting periods beginning on or after the date that is #a year after the date of enactment of the ,rural ,physician ,workforce ,production ,act of #bjbc1 such rules shall provide that any full-time-equivalent resident in an approved medical residency program 7or separately defined track within a program7 that provides more than #ej percent of the total residency training time in rural training locations 7as defined in subsection 7u77#f77;,c771 regardless of where the training occurs and regardless of specialty1 shall not be taken into account for purposes of applying the limitation under this subparagraph4 ,for special rules regarding application of the elective rural sustainability per resident payment amount under subsection 7u71 see paragraph 7#c7 of such subsection44