I 

118TH CONGRESS 

1ST SESSION H. R. 834 

To amend title XVIII of the Social Security Act to support rural residency 

training funding that is equitable for all States, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 6, 2023 

Mrs. HARSHBARGER (for herself, Ms. SCHRIER, Mr. CUELLAR, and Mr. 

BACON) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to support 

rural residency training funding that is equitable for 

all States, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Rural Physician Work5 force Production Act of 2023’’. 


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1 SEC. 2. ELECTIVE RURAL SUSTAINABILITY PER RESIDENT 

2 PAYMENT FOR RESIDENTS TRAINING IN 

3 RURAL TRAINING LOCATIONS. 

4 (a) IN GENERAL.—Section 1886 of the Social Secu5 rity Act (42 U.S.C. 1395ww) is amended by adding at the 

6 end the following new subsection: 

7 ‘‘(u) ELECTIVE RURAL SUSTAINABILITY PER RESI8 DENT PAYMENT AMOUNT FOR RESIDENTS TRAINING IN

9 RURAL TRAINING LOCATIONS.— 

10 ‘‘(1) DETERMINATION OF ELECTIVE RURAL

11 SUSTAINABILITY PER RESIDENT PAYMENT

12 AMOUNT.— 

13 ‘‘(A) IN GENERAL.—The elective rural sus14 tainability per resident payment amount deter15 mined under this subsection for an applicable 

16 hospital (as defined in paragraph (7)(A)) that 

17 makes an election under paragraph (2), with re18 spect to each full-time-equivalent resident in an 

19 approved medical residency training program 

20 that receives training in a rural training loca21 tion (as defined in paragraph (7)(C)), is an 

22 amount equal to the difference between— 

23 ‘‘(i) the total elective rural sustain24 ability amount determined under subpara25 graph (B) (or, in the case of an applicable 

26 hospital not located in a rural area, the 


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1 total elective rural sustainability amount or 

2 urban total elective rural sustainability 

3 amount, as applicable, determined under 

4 such subparagraph); and 

5 ‘‘(ii) the amount (if any) the applica6 ble hospital otherwise receives for direct 

7 graduate medical education costs under 

8 subsection (h) or section 1814(l), as appli9 cable, with respect to each such resident. 

10 ‘‘(B) TOTAL ELECTIVE RURAL SUSTAIN11 ABILITY AMOUNT.— 

12 ‘‘(i) ESTABLISHMENT FOR INITIAL

13 COST REPORTING PERIODS.— 

14 ‘‘(I) IN GENERAL.—Subject to 

15 subclause (II), for cost reporting peri16 ods beginning during the first year be17 ginning on or after the date of the en18 actment of this subsection, the Sec19 retary shall establish a total elective 

20 rural sustainability amount for time 

21 spent by each full-time-equivalent resi22 dent in an approved medical residency 

23 training program that receives train24 ing in a rural training location. Such 

25 amount shall be the amount that the 


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1 Secretary determines is equal to the 

2 median national direct GME training 

3 costs per full-time-equivalent resident 

4 for 2015 described in table 9 on page 

5 33 of the March 2018 GAO report on 

6 Physician Workforce (GAO–18–240), 

7 updated for each subsequent year 

8 through the first year beginning on or 

9 after the date of the enactment of this 

10 subsection, by the annual percentage 

11 increase in the consumer price index 

12 for all urban consumers (all items; 

13 United States city average). 

14 ‘‘(II) APPLICATION TO URBAN

15 HOSPITALS.—For cost reporting peri16 ods beginning during the first year be17 ginning on or after the date of the en18 actment of this subsection, in the case 

19 of an applicable hospital that is not 

20 located in a rural area— 

21 ‘‘(aa) with respect to such 

22 residents that receive training in 

23 a rural track or an integrated 

24 rural track, the total elective 

25 rural sustainability amount per 


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1 resident shall be equal to the 

2 amount established under sub3 clause (I); and 

4 ‘‘(bb) with respect to such 

5 residents that receive training in 

6 a rural training location and who 

7 are not participating in a rural 

8 track or an integrated rural 

9 track, the total elective rural sus10 tainability amount per resident 

11 shall be equal to 50 percent of 

12 the amount established under 

13 subclause (I) (referred to in this 

14 subsection as the ‘urban total 

15 elective rural sustainability 

16 amount’). 

17 ‘‘(ii) UPDATING FOR SUBSEQUENT

18 COST REPORTING PERIODS.—For each sub19 sequent cost reporting period, the total 

20 elective rural sustainability amount under 

21 clause (i)(I) and clause (i)(II)(aa) and the 

22 urban total elective rural sustainability 

23 amount under clause (i)(II)(bb), respec24 tively, are equal to such amounts deter25 mined under such clause for the previous 


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1 cost reporting period updated, through the 

2 midpoint of the period, by projecting the 

3 estimated percentage change in the con4 sumer price index for all urban consumers 

5 (all items; United States city average) dur6 ing the 12-month period ending at that 

7 midpoint, with appropriate adjustments to 

8 reflect previous under- or over-estimations 

9 under this clause in the projected percent10 age change in the consumer price index for 

11 medical care services. 

12 ‘‘(C) CLARIFICATION.—The total elective 

13 rural sustainability amount, the urban total 

14 elective rural sustainability amount, and the 

15 elective rural sustainability per resident pay16 ment amount determined under this paragraph 

17 shall not be discounted or otherwise adjusted 

18 based on the Medicare patient load (as defined 

19 in subsection (h)(3)(C)) of an applicable hos20 pital or discharges in a diagnosis-related group. 

21 ‘‘(2) ELECTION.—For cost reporting periods 

22 beginning on or after the date that is 1 year after 

23 the date of the enactment of this subsection, an ap24 plicable hospital may elect to receive the elective 

25 rural sustainability per resident payment amount for 


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1 each full-time-equivalent resident in an approved 

2 medical residency training program that receives 

3 training in a rural training location in accordance 

4 with this subsection. An applicable hospital may 

5 make an election under the preceding sentence re6 gardless of whether the applicable hospital is other7 wise eligible for a payment or adjustment for indi8 rect and direct graduate medical education costs 

9 under subsections (d)(5)(B) and (h) or section 

10 1814(l), as applicable, with respect to such resi11 dents. 

12 ‘‘(3) APPLICATION.—The provisions of this sub13 section, or the application of such provisions to an 

14 applicable hospital— 

15 ‘‘(A) shall not result in— 

16 ‘‘(i) the establishment of a limitation 

17 on the number of residents in allopathic or 

18 osteopathic medicine for purposes of sub19 sections (d)(5)(B) and (h) with respect to 

20 an approved medical residency training 

21 program of an applicable hospital (or be 

22 taken into account in determining such a 

23 limitation during the cap building period of 

24 an applicable hospital); or 


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1 ‘‘(ii) the counting of any resident with 

2 respect to which the applicable hospital re3 ceives an elective rural sustainability per 

4 resident payment amount under this sub5 section towards the application of the limi6 tation described in clause (i) for purposes 

7 of subsections (d)(5)(B) and (h); and 

8 ‘‘(B) shall not have any effect on the de9 termination of— 

10 ‘‘(i) the additional payment amount 

11 under subsection (d)(5)(B); or 

12 ‘‘(ii) hospital-specific approved FTE 

13 resident amounts under subsection (h). 

14 ‘‘(4) ALLOCATION OF PAYMENTS.—In providing 

15 for payments under this subsection, the Secretary 

16 shall provide for an allocation of such payments be17 tween parts A and part B (and the trust funds es18 tablished under the respective parts) as reasonably 

19 reflects the proportion of such costs associated with 

20 the provision of services under each respective part. 

21 ‘‘(5) ELIGIBILITY FOR PAYMENT.— 

22 ‘‘(A) IN GENERAL.—An applicable hospital 

23 shall be eligible for payment of the elective 

24 rural sustainability per resident payment 

25 amount under this subsection for time spent by 


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1 a resident training in a rural training location 

2 if the following requirements are met: 

3 ‘‘(i) The resident spends the equiva4 lent of at least 8 weeks over the course of 

5 their training in a rural training location. 

6 ‘‘(ii) The hospital pays the salary and 

7 benefits of the resident for the time spent 

8 training in a rural training location. 

9 ‘‘(B) TREATMENT OF TIME SPENT IN

10 RURAL TRACKS OR INTEGRATED RURAL

11 TRACKS.—An applicable hospital shall be eligi12 ble for payment of the elective rural sustain13 ability per resident payment amount under this 

14 subsection for all time spent by residents in an 

15 approved medical residency program (or sepa16 rately defined track within a program) that pro17 vides more than 50 percent of the total resi18 dency training time in rural training locations, 

19 regardless of where the training occurs and re20 gardless of specialty. 

21 ‘‘(6) DETERMINATION OF FULL-TIME-EQUIVA22 LENT RESIDENTS.—The determination of full-time23 equivalent residents for purposes of this subsection 

24 shall be made in the same manner as the determina25 tion of full-time-equivalent residents under subVerDate Sep 11 2014 06:36 Mar 02, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H834.IH H834

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1 section (h)(4), but not taking into account the limi2 tation under subparagraph (F) of such subsection. 

3 ‘‘(7) DEFINITIONS.—In this subsection: 

4 ‘‘(A) APPLICABLE HOSPITAL.—The term 

5 ‘applicable hospital’ means a hospital, critical 

6 access hospital, sole community hospital (as de7 fined in subsection (d)(5)(D)(iii)), or rural 

8 emergency hospital (as defined in section 

9 1861(kkk)(2)). 

10 ‘‘(B) APPROVED MEDICAL RESIDENCY

11 TRAINING PROGRAM; DIRECT GRADUATE MED12 ICAL EDUCATION COSTS; RESIDENT.—The 

13 terms ‘approved medical residency training pro14 gram’, ‘direct graduate medical education 

15 costs’, and ‘resident’ have the meanings given 

16 those terms in subsection (h)(5). 

17 ‘‘(C) RURAL TRAINING LOCATION.—The 

18 term ‘rural training location’ means a location 

19 in which training occurs that, based on the 

20 2010 census or any subsequent census adjust21 ment, meets one or more of the following cri22 teria: 

23 ‘‘(i) The training occurs in a location 

24 that is a rural area (as defined in section 

25 1886(d)(2)(D)). 


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1 ‘‘(ii) The training occurs in a location 

2 that has a rural-urban commuting area 

3 code equal to or greater than 4.0. 

4 ‘‘(iii) The training occurs in a sole 

5 community hospital (as defined in sub6 section (d)(5)(D)(iii)) or in a location that 

7 is within 10 miles of a sole community hos8 pital. 

9 ‘‘(8) BUDGET NEUTRALITY REQUIREMENT.— 

10 The Secretary shall ensure that aggregate payments 

11 for direct medical education costs and indirect med12 ical education costs under this title, including any 

13 payments under this subsection, for each year (effec14 tive beginning on or after the date that is 1 year 

15 after the date of enactment of this subsection) are 

16 not greater than the aggregate payments for such 

17 costs that would have been made under this title for 

18 the year without the application of this subsection. 

19 For purposes of carrying out the budget neutrality 

20 requirement under the preceding sentence, the Sec21 retary may make appropriate adjustments to the 

22 amount of such payments for direct graduate med23 ical education costs and indirect medical education 

24 costs under subsections (h) and (d)(5)(B), respec25 tively.’’. 


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1 (b) TREATMENT OF CRITICAL ACCESS HOSPITALS

2 AND SOLE COMMUNITY HOSPITALS.— 

3 (1) CRITICAL ACCESS HOSPITALS.—Section 

4 1814(l) of the Social Security Act (42 U.S.C. 

5 1395f(l)) is amended by adding at the end the fol6 lowing new paragraph: 

7 ‘‘(6) For cost reporting periods beginning on or after 

8 the date that is 1 year after the date of enactment of this 

9 paragraph, the following shall apply: 

10 ‘‘(A) A critical access hospital may elect to be 

11 treated as a hospital or as a non-provider setting for 

12 purposes of counting resident time for indirect med13 ical education costs and direct graduate medical edu14 cation costs for the time spent by the resident in 

15 that setting under subsections (d)(5)(B) and (h), re16 spectively, of section 1886. 

17 ‘‘(B) Direct medical education costs shall not be 

18 considered reasonable costs of a critical access hos19 pital for purposes of payment under paragraph (1), 

20 to the extent that the critical access hospital is 

21 treated as a non-provider setting of another hospital 

22 or another hospital receives payment for such costs 

23 for the time spent by the resident in that setting 

24 pursuant to subsection (d)(5)(B), subsection (h), or 

25 subsection (u) of section 1886.’’. 


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1 (2) SOLE COMMUNITY HOSPITALS.—Section 

2 1886(d)(5)(D) of the Social Security Act (42 U.S.C. 

3 1395ww(d)(5)(D)) is amended by adding at the end 

4 the following new clause: 

5 ‘‘(vi) For cost reporting periods beginning on or after 

6 the date that is 1 year after the date of enactment of this 

7 paragraph, the hospital-specific payment amount deter8 mined under clause (i)(I) with respect to a sole community 

9 hospital shall not include direct medical education costs, 

10 to the extent that the sole community hospital receives 

11 payment for such costs for the time spent by the resident 

12 in that setting pursuant to subsection (u).’’. 

13 (c) CONFORMING AMENDMENTS.— 

14 (1) Section 1886 of the Social Security Act (42 

15 U.S.C. 1395ww) is amended— 

16 (A) in subsection (d)(5)(B), in the matter 

17 preceding clause (i), by striking ‘‘The Sec18 retary’’ and inserting ‘‘Subject to subsection 

19 (u), the Secretary’’; and 

20 (B) in subsection (h)— 

21 (i) in paragraph (1), by inserting 

22 ‘‘subject to subsection (u)’’ after 

23 ‘‘1861(v),’’; and 

24 (ii) in paragraph (3), in the flush 

25 matter following subparagraph (B), by 


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1 striking ‘‘subsection (k)’’ and inserting 

2 ‘‘subsection (k) or subsection (u)’’. 

3 SEC. 3. SUPPORTING NEW, EXPANDING, AND EXISTING 

4 RURAL TRAINING TRACKS. 

5 (a) DIRECT GRADUATE MEDICAL EDUCATION.—Sec6 tion 1886(h) of the Social Security Act (42 U.S.C. 

7 1395ww(h)) is amended— 

8 (1) in paragraph (4)— 

9 (A) in subparagraph (F)(i)— 

10 (i) by striking ‘‘130 percent’’ and in11 serting ‘‘for cost reporting periods begin12 ning on or after October 1, 1997, and be13 fore the date that is 1 year after the date 

14 of enactment of the Rural Physician Work15 force Production Act of 2023, 130 per16 cent’’; and 

17 (ii) by adding at the end the fol18 lowing: ‘‘For cost reporting periods begin19 ning on or after the date that is 1 year 

20 after the date of enactment of the Rural 

21 Physician Workforce Production Act of 

22 2023, such rules shall provide that any 

23 full-time-equivalent resident in an ap24 proved medical residency program (or sep25 arately defined track within a program) 


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1 that provides more than 50 percent of the 

2 total residency training time in rural train3 ing locations (as defined in subsection 

4 (u)(6)(C)), regardless of where the training 

5 occurs and regardless of specialty, shall 

6 not be taken into account for purposes of 

7 applying the limitation under this subpara8 graph.’’; and 

9 (B) in subparagraph (H)— 

10 (i) in clause (i), in the second sen11 tence, by inserting the following before the 

12 period: ‘‘, in accordance with the second 

13 sentence of clause (i) of such subpara14 graph’’; and 

15 (ii) in clause (iv), by inserting the fol16 lowing before the period: ‘‘, in accordance 

17 with the second sentence of clause (i) of 

18 such subparagraph’’; and 

19 (2) in paragraph (5), by adding at the end the 

20 following new subparagraph: 

21 ‘‘(L) SPECIAL RULES REGARDING APPLICA22 TION OF ELECTIVE RURAL SUSTAINABILITY PER

23 RESIDENT PAYMENT AMOUNT.—For special 

24 rules regarding application of the elective rural 

25 sustainability per resident payment amount 


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1 under subsection (u), see paragraph (3) of such 

2 subsection.’’. 

3 (b) INDIRECT MEDICAL EDUCATION.—Section 

4 1886(d)(5)(B)(v) is amended— 

5 (1) by striking ‘‘130 percent’’ and inserting 

6 ‘‘for cost reporting periods beginning on or after Oc7 tober 1, 1997, and before the date that is 1 year 

8 after the date of enactment of the Rural Physician 

9 Workforce Production Act of 2023, 130 percent’’; 

10 and 

11 (2) by adding at the end the following: ‘‘For 

12 cost reporting periods beginning on or after the date 

13 that is 1 year after the date of enactment of the 

14 Rural Physician Workforce Production Act of 2023, 

15 such rules shall provide that any full-time-equivalent 

16 resident in an approved medical residency program 

17 (or separately defined track within a program) that 

18 provides more than 50 percent of the total residency 

19 training time in rural training locations (as defined 

20 in subsection (u)(6)(C)), regardless of where the 

21 training occurs and regardless of specialty, shall not 

22 be taken into account for purposes of applying the 

23 limitation under this subparagraph. For special rules 

24 regarding application of the elective rural sustainVerDate Sep 11 2014 06:36 Mar 02, 2023 Jkt 039200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\H834.IH H834

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1 ability per resident payment amount under sub2 section (u), see paragraph (3) of such subsection.’’. 

Æ 


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