,,ii  #aah? ,,congress  #a/ ,session    
,s4 #bcj  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,febru>y #b1 #bjbc,mr4 
,te/] 7= himself1 ,mr4 ,b>rasso1 ,ms4   
,murk[ski1 ,ms4 ,coll9s1 ,ms4 ,s9ema1   
,mrs4 ,hyde-,smi?1 ,mr4 ,cram]1 ,mr4    
,kelly1 ,mr4 ,he9ri*1 ,mrs4 ,capito1 &  
,ms4 ,cortez ,ma/o7 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 ( #bjbc4  #b4 
,elective rural su/a9ability 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 ,elective   
rural su/a9ability p] resid5t paym5t    
am\nt = resid5ts tra9+ 9 rural tra9+    
locations  7#a7 ,det]m9ation ( elective 

rural su/a9ability p] resid5t paym5t    
am\nt  7,a7 ,9 g5]al ,! elective rural  
su/a9ability p] resid5t paym5t am\nt    
det]m9$ "u ?is subsection = an          
applicable hospital 7z def9$ 9 p>agraph 
7#g77;,a77 t makes an election "u       
p>agraph 7#b71 ) respect to ea*         
full-"t-equival5t resid5t 9 an approv$  
m$ical resid5cy tra9+ program t receives
 tra9+ 9 a rural tra9+ location 7z def9$
 9 p>agraph 7#g77;,c771 is an am\nt     
equal to ! diff]5ce betwe5-- 7i7 ! total
 elective rural su/a9ability am\nt      
det]m9$ "u subp>agraph 7,b7 7or1 9 !    
case ( an applicable hospital n locat$ 9
 a rural area1 ! total elective rural   
su/a9ability am\nt or urban total       
elective rural su/a9ability am\nt1 z    
applicable1 det]m9$ "u su* subp>agraph72
 &  7ii7 ! am\nt 7if any7 ! applicable  
hospital o!rwise receives = direct      
graduate m$ical education co/s "u       
subsection 7h7 or section #ahad7l71 z   
applicable1 ) respect to ea* su*        
resid5t4  7,b7 ,total elective rural    

su/a9ability am\nt  7i7 ,e/abli%m5t =   
initial co/ report+ p]iods  7,i7 ,9     
g5]al ,subject to subclause 7,,ii71 =   
co/ report+ p]iods beg9n+ dur+ ! fir/   
ye> beg9n+ on or aft] ! date ( !        
enactm5t ( ?is subsection1 ! ,secret>y  
%all e/abli% a total elective rural     
su/a9ability am\nt = "t sp5t by ea*     
full-"t-equival5t resid5t 9 an approv$  
m$ical resid5cy tra9+ program t receives
 tra9+ 9 a rural tra9+ location4 ,su*   
am\nt %all be ! am\nt t ! ,secret>y     
det]m9es is equal to ! m$ian national   
direct ,,gme tra9+ co/s p] full-"t      
equival5t resid5t = #bjae describ$ 9    
table #i on page #cc ( ! ,m>* #bjah     
,,gao report on ,physician ,work=ce     
7,,gao-#ah-bdj71 updat$ = ea* subsequ5t 
ye> ?r\gh ! fir/ ye> beg9n+ on or aft] !
 date ( ! enactm5t ( ?is subsection1 by 
! annual p]c5tage increase 9 ! consum]  
price index = all urban consum]s 7all   
items2 ,unit$ ,/ates city av]age74      
7,,ii7 ,application to urban hospitals  
,= co/ report+ p]iods beg9n+ dur+ ! fir/

 ye> beg9n+ on or aft] ! date ( !       
enactm5t ( ?is subsection1 9 ! case ( an
 applicable hospital t is n locat$ 9 a  
rural area-- 7aa7 ) respect to su*      
resid5ts t receive tra9+ 9 a rural track
 or an integrat$ rural track1 ! total   
elective rural su/a9ability am\nt p]    
resid5t %all be equal to ! am\nt        
e/abli%$ "u subclause 7,i72 &  7bb7 )   
respect to su* resid5ts t receive tra9+ 
9 a rural tra9+ location & :o are n     
p>ticipat+ 9 a rural track or an        
integrat$ rural track1 ! total elective 
rural su/a9ability am\nt p] resid5t %all
 be equal to #ej p]c5t ( ! am\nt        
e/abli%$ "u subclause 7,i7 7ref]r$ to 9 
?is subsection z ! urban total elective 
rural su/a9ability am\nt74  7ii7 ,updat+
 = subsequ5t co/ report+ p]iods ,= ea*  
subsequ5t co/ report+ p]iod1 ! total    
elective rural su/a9ability am\nt "u    
clause 7i77,i7 & clause 7i77,,ii77aa7 & 
! urban total elective rural            
su/a9ability am\nt "u clause            
7i77,,ii77bb71 respectively1 are equal  

to su* am\nts det]m9$ "u su* clause = ! 
previ\s co/ report+ p]iod updat$1 ?r\gh 
! midpo9t ( ! p]iod1 by project+ !      
e/imat$ p]c5tage *ange 9 ! consum] price
 index = all urban consum]s 7all items2 
,unit$ ,/ates city av]age7 dur+ !       
#ab-mon? p]iod end+ at t midpo9t1 )     
appropriate adju/m5ts to reflect previ\s
 "u- or ov]-e/imations "u ?is clause 9 !
 project$ p]c5tage *ange 9 ! consum]    
price index = m$ical c>e s]vices4  7,c7 
,cl>ification ,! total elective rural   
su/a9ability am\nt1 ! urban total       
elective rural su/a9ability am\nt1 & !  
elective rural su/a9ability p] resid5t  
paym5t am\nt det]m9$ "u ?is p>agraph    
%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#b7 ,election  
,= co/ report+ p]iods beg9n+ on or aft] 
! date t is #a ye> aft] ! date ( !      
enactm5t ( ?is subsection1 an applicable
 hospital may elect to receive !        

elective rural su/a9ability p] resid5t  
paym5t am\nt = ea* full-"t-equival5t    
resid5t 9 an approv$ m$ical resid5cy    
tra9+ program t receives tra9+ 9 a rural
 tra9+ location 9 accordance ) ?is      
subsection4 ,an applicable hospital may 
make an election "u ! prec$+ s5t5ce     
reg>dless ( :e!r ! applicable hospital  
is o!rwise eligible = a paym5t or       
adju/m5t = indirect & direct graduate   
m$ical education co/s "u subsections    
7d77#e77;,b7 & 7h7 or section #ahad7l71 
z applicable1 ) respect to su* resid5ts4
  7#c7 ,application ,! provisions ( ?is 
subsection1 or ! application ( su*      
provisions to an applicable hospital--  
7,a7 %all n result 9-- 7i7 ! e/abli%m5t 
( a limitation on ! numb] ( resid5ts 9  
allopa?ic or o/eopa?ic m$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 hospital72 or  7ii7 ! c\nt+ (

 any resid5t ) respect to :i* !         
applicable hospital receives an elective
 rural su/a9ability p] resid5t paym5t   
am\nt "u ?is subsection t[>ds !         
application ( ! limitation describ$ 9   
clause 7i7 = purposes ( subsections     
7d77#e77;,b7 & 7h72 &  7,b7 %all n h any
 effect on ! det]m9ation (-- 7i7 !      
additional paym5t am\nt "u subsection   
7d77#e77;,b72 or  7ii7 hospital-specific
 approv$ ,,fte resid5t am\nts "u        
subsection 7h74  7#d7 ,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#e7 ,eligibility = paym5t  7,a7 ,9
 g5]al ,an applicable hospital %all be  
eligible = paym5t ( ! elective rural    
su/a9ability 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 or   
integrat$ rural tracks ,an applicable   
hospital %all be eligible = paym5t ( !  
elective rural su/a9ability 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 m ?an #ej
 p]c5t ( ! total resid5cy tra9+ "t 9    
rural tra9+ locations1 reg>dless ( :]e !
 tra9+ occurs & reg>dless ( specialty4  
7#f7 ,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#d71 b n tak+ into acc\nt !        
limitation "u subp>agraph 7,f7 ( su*    

subsection4  7#g7 ,def9itions ,9 ?is    
subsection3 7,a7 ,applicable hospital ,!
 t]m applicable hospital means a        
hospital1 critical access hospital1 sole
 community hospital 7z def9$ 9          
subsection 7d77#e77;,d77iii771 or rural 
em]g5cy hospital 7z def9$ 9 section     
#ahfa7kkk77#b774  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 sole community hospital 7z   

def9$ 9 subsection 7d77#e77;,d77iii77 or
 9 a location t is )9 #aj miles ( a sole
 community hospital4  7#h7 ,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 is treat$ z a           
non-provid] sett+ ( ano!r 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+ tracks  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 ( #bjbc1 #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 ( #bjbc1 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 m ?an #ej p]c5t ( ! 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           
7iv77,,ii71 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 ( elective     
rural su/a9ability p] resid5t paym5t    
am\nt ,= special rules reg>d+           
application ( ! elective rural          
su/a9ability p] resid5t paym5t am\nt "u 
subsection 7u71 see p>agraph 7#c7 ( su* 
subsection4  4  7b7 ,indirect m$ical    
education ,section #ahhf7;d77#e77;,b77v7
 ( su* ,act 7#db ,u4,s4,c4              
#acieww7d77#e77;,b77v77 is am5d$-- 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 (  
#bjbc1 #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 (  
#bjbc1 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 m  
?an #ej p]c5t ( ! 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 ( ! elective rural          
su/a9ability p] resid5t paym5t am\nt "u 
subsection 7u71 see p>agraph 7#c7 ( su* 
subsection44