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 Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Rural Physician Work-
force Production Act of 2023’’. 
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SEC. 2. ELECTIVE RURAL SUSTAINABILITY PER RESIDENT 
PAYMENT 
FOR 
RESIDENTS 
TRAINING 
IN 
RURAL TRAINING LOCATIONS. 
(a) IN GENERAL.—Section 1886 of the Social Secu-
rity Act (42 U.S.C. 1395ww) is amended by adding at the 
end the following new subsection: 
‘‘(u) ELECTIVE RURAL SUSTAINABILITY PER RESI-
DENT PAYMENT AMOUNT FOR RESIDENTS TRAINING IN 
RURAL TRAINING LOCATIONS.— 
‘‘(1) DETERMINATION
OF
ELECTIVE
RURAL 
SUSTAINABILITY
PER
RESIDENT
PAYMENT 
AMOUNT.— 
‘‘(A) IN GENERAL.—The elective rural sus-
tainability per resident payment amount deter-
mined under this subsection for an applicable 
hospital (as defined in paragraph (7)(A)) that 
makes an election under paragraph (2), with re-
spect to each full-time-equivalent resident in an 
approved medical residency training program 
that receives training in a rural training loca-
tion (as defined in paragraph (7)(C)), is an 
amount equal to the difference between— 
‘‘(i) the total elective rural sustain-
ability amount determined under subpara-
graph (B) (or, in the case of an applicable 
hospital not located in a rural area, the 
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total elective rural sustainability amount or 
urban total elective rural sustainability 
amount, as applicable, determined under 
such subparagraph); and 
‘‘(ii) the amount (if any) the applica-
ble hospital otherwise receives for direct 
graduate medical education costs under 
subsection (h) or section 1814(l), as appli-
cable, with respect to each such resident. 
‘‘(B) TOTAL
ELECTIVE
RURAL
SUSTAIN-
ABILITY AMOUNT.— 
‘‘(i) ESTABLISHMENT
FOR
INITIAL 
COST REPORTING PERIODS.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), for cost reporting peri-
ods beginning during the first year be-
ginning on or after the date of the en-
actment of this subsection, the Sec-
retary shall establish a total elective 
rural sustainability amount for time 
spent by each full-time-equivalent resi-
dent in an approved medical residency 
training program that receives train-
ing in a rural training location. Such 
amount shall be the amount that the 
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Secretary determines is equal to the 
median national direct GME training 
costs per full-time-equivalent resident 
for 2015 described in table 9 on page 
33 of the March 2018 GAO report on 
Physician Workforce (GAO–18–240), 
updated for each subsequent year 
through the first year beginning on or 
after the date of the enactment of this 
subsection, by the annual percentage 
increase in the consumer price index 
for all urban consumers (all items; 
United States city average). 
‘‘(II) APPLICATION
TO
URBAN 
HOSPITALS.—For cost reporting peri-
ods beginning during the first year be-
ginning on or after the date of the en-
actment of this subsection, in the case 
of an applicable hospital that is not 
located in a rural area— 
‘‘(aa) with respect to such 
residents that receive training in 
a rural track or an integrated 
rural track, the total elective 
rural sustainability amount per 
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resident shall be equal to the 
amount established under sub-
clause (I); and 
‘‘(bb) 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 
track, the total elective rural sus-
tainability amount per resident 
shall be equal to 50 percent of 
the amount established under 
subclause (I) (referred to in this 
subsection as the ‘urban total 
elective 
rural 
sustainability 
amount’). 
‘‘(ii) UPDATING
FOR
SUBSEQUENT 
COST REPORTING PERIODS.—For each sub-
sequent cost reporting period, the total 
elective rural sustainability amount under 
clause (i)(I) and clause (i)(II)(aa) and the 
urban total elective rural sustainability 
amount under clause (i)(II)(bb), respec-
tively, are equal to such amounts deter-
mined under such clause for the previous 
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cost reporting period updated, through the 
midpoint of the period, by projecting the 
estimated percentage change in the con-
sumer price index for all urban consumers 
(all items; United States city average) dur-
ing the 12-month period ending at that 
midpoint, with appropriate adjustments to 
reflect previous under- or over-estimations 
under this clause in the projected percent-
age change in the consumer price index for 
medical care services. 
‘‘(C) CLARIFICATION.—The total elective 
rural sustainability amount, the urban total 
elective rural sustainability amount, and the 
elective rural sustainability per resident pay-
ment amount determined under this paragraph 
shall not be discounted or otherwise adjusted 
based on the Medicare patient load (as defined 
in subsection (h)(3)(C)) of an applicable hos-
pital or discharges in a diagnosis-related group. 
‘‘(2) ELECTION.—For cost reporting periods 
beginning on or after the date that is 1 year after 
the date of the enactment of this subsection, an ap-
plicable hospital may elect to receive the elective 
rural sustainability per resident payment amount for 
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each full-time-equivalent resident in an approved 
medical residency training program that receives 
training in a rural training location in accordance 
with this subsection. An applicable hospital may 
make an election under the preceding sentence re-
gardless of whether the applicable hospital is other-
wise eligible for a payment or adjustment for indi-
rect and direct graduate medical education costs 
under subsections (d)(5)(B) and (h) or section 
1814(l), as applicable, with respect to such resi-
dents. 
‘‘(3) APPLICATION.—The provisions of this sub-
section, or the application of such provisions to an 
applicable hospital— 
‘‘(A) shall not result in— 
‘‘(i) the establishment of a limitation 
on the number of residents in allopathic or 
osteopathic medicine for purposes of sub-
sections (d)(5)(B) and (h) with respect to 
an approved medical residency training 
program of an applicable hospital (or be 
taken into account in determining such a 
limitation during the cap building period of 
an applicable hospital); or 
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‘‘(ii) the counting of any resident with 
respect to which the applicable hospital re-
ceives an elective rural sustainability per 
resident payment amount under this sub-
section towards the application of the limi-
tation described in clause (i) for purposes 
of subsections (d)(5)(B) and (h); and 
‘‘(B) shall not have any effect on the de-
termination of— 
‘‘(i) the additional payment amount 
under subsection (d)(5)(B); or 
‘‘(ii) hospital-specific approved FTE 
resident amounts under subsection (h). 
‘‘(4) ALLOCATION OF PAYMENTS.—In providing 
for payments under this subsection, the Secretary 
shall provide for an allocation of such payments be-
tween parts A and part B (and the trust funds es-
tablished under the respective parts) as reasonably 
reflects the proportion of such costs associated with 
the provision of services under each respective part. 
‘‘(5) ELIGIBILITY FOR PAYMENT.— 
‘‘(A) 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 
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a resident training in a rural training location 
if the following requirements are met: 
‘‘(i) The resident spends the equiva-
lent of at least 8 weeks over the course of 
their training in a rural training location. 
‘‘(ii) The hospital pays the salary and 
benefits of the resident for the time spent 
training in a rural training location. 
‘‘(B) TREATMENT
OF
TIME
SPENT
IN 
RURAL
TRACKS
OR
INTEGRATED
RURAL 
TRACKS.—An applicable hospital shall be eligi-
ble for payment of the elective rural sustain-
ability per resident payment amount under this 
subsection for all time spent by residents in an 
approved medical residency program (or sepa-
rately defined track within a program) that pro-
vides more than 50 percent of the total resi-
dency training time in rural training locations, 
regardless of where the training occurs and re-
gardless of specialty. 
‘‘(6) DETERMINATION
OF
FULL-TIME-EQUIVA-
LENT RESIDENTS.—The determination of full-time- 
equivalent residents for purposes of this subsection 
shall be made in the same manner as the determina-
tion of full-time-equivalent residents under sub-
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section (h)(4), but not taking into account the limi-
tation under subparagraph (F) of such subsection. 
‘‘(7) DEFINITIONS.—In this subsection: 
‘‘(A) APPLICABLE
HOSPITAL.—The term 
‘applicable hospital’ means a hospital, critical 
access hospital, sole community hospital (as de-
fined in subsection (d)(5)(D)(iii)), or rural 
emergency hospital (as defined in section 
1861(kkk)(2)). 
‘‘(B) 
APPROVED
MEDICAL
RESIDENCY 
TRAINING PROGRAM; DIRECT GRADUATE MED-
ICAL
EDUCATION
COSTS; 
RESIDENT.—The 
terms ‘approved medical residency training pro-
gram’, ‘direct graduate medical education 
costs’, and ‘resident’ have the meanings given 
those terms in subsection (h)(5). 
‘‘(C) RURAL
TRAINING
LOCATION.—The 
term ‘rural training location’ means a location 
in which training occurs that, based on the 
2010 census or any subsequent census adjust-
ment, meets one or more of the following cri-
teria: 
‘‘(i) The training occurs in a location 
that is a rural area (as defined in section 
1886(d)(2)(D)). 
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‘‘(ii) The training occurs in a location 
that has a rural-urban commuting area 
code equal to or greater than 4.0. 
‘‘(iii) The training occurs in a sole 
community hospital (as defined in sub-
section (d)(5)(D)(iii)) or in a location that 
is within 10 miles of a sole community hos-
pital. 
‘‘(8) BUDGET
NEUTRALITY
REQUIREMENT.— 
The Secretary shall ensure that aggregate payments 
for direct medical education costs and indirect med-
ical education costs under this title, including any 
payments under this subsection, for each year (effec-
tive beginning on or after the date that is 1 year 
after the date of enactment of this subsection) 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 subsection. 
For purposes of carrying out the budget neutrality 
requirement under the preceding sentence, the Sec-
retary may make appropriate adjustments to the 
amount of such payments for direct graduate med-
ical education costs and indirect medical education 
costs under subsections (h) and (d)(5)(B), respec-
tively.’’. 
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(b) TREATMENT OF CRITICAL ACCESS HOSPITALS 
AND SOLE COMMUNITY HOSPITALS.— 
(1) CRITICAL
ACCESS
HOSPITALS.—Section 
1814(l) of the Social Security Act (42 U.S.C. 
1395f(l)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(6) For cost reporting periods beginning on or after 
the date that is 1 year after the date of enactment of this 
paragraph, the following shall apply: 
‘‘(A) 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 med-
ical education costs and direct graduate medical edu-
cation costs for the time spent by the resident in 
that setting under subsections (d)(5)(B) and (h), re-
spectively, of section 1886. 
‘‘(B) Direct medical education costs shall not be 
considered reasonable costs of a critical access hos-
pital for purposes of payment under paragraph (1), 
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 (d)(5)(B), subsection (h), or 
subsection (u) of section 1886.’’. 
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(2) SOLE
COMMUNITY
HOSPITALS.—Section 
1886(d)(5)(D) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(D)) is amended by adding at the end 
the following new clause: 
‘‘(vi) For cost reporting periods beginning on or after 
the date that is 1 year after the date of enactment of this 
paragraph, the hospital-specific payment amount deter-
mined under clause (i)(I) with respect to a sole community 
hospital shall not include direct medical education costs, 
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 (u).’’. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 1886 of the Social Security Act (42 
U.S.C. 1395ww) is amended— 
(A) in subsection (d)(5)(B), in the matter 
preceding clause (i), by striking ‘‘The Sec-
retary’’ and inserting ‘‘Subject to subsection 
(u), the Secretary’’; and 
(B) in subsection (h)— 
(i) in paragraph (1), by inserting 
‘‘subject 
to 
subsection 
(u)’’ 
after 
‘‘1861(v),’’; and 
(ii) in paragraph (3), in the flush 
matter following subparagraph (B), by 
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striking ‘‘subsection (k)’’ and inserting 
‘‘subsection (k) or subsection (u)’’. 
SEC. 3. SUPPORTING NEW, EXPANDING, AND EXISTING 
RURAL TRAINING TRACKS. 
(a) DIRECT GRADUATE MEDICAL EDUCATION.—Sec-
tion 1886(h) of the Social Security Act (42 U.S.C. 
1395ww(h)) is amended— 
(1) in paragraph (4)— 
(A) in subparagraph (F)(i)— 
(i) by striking ‘‘130 percent’’ and in-
serting ‘‘for cost reporting periods begin-
ning on or after October 1, 1997, and be-
fore the date that is 1 year after the date 
of enactment of the Rural Physician Work-
force Production Act of 2023, 130 per-
cent’’; and 
(ii) by adding at the end the fol-
lowing: ‘‘For cost reporting periods begin-
ning on or after the date that is 1 year 
after the date of enactment of the Rural 
Physician Workforce Production Act of 
2023, such rules shall provide that any 
full-time-equivalent resident in an ap-
proved medical residency program (or sep-
arately defined track within a program) 
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that provides more than 50 percent of the 
total residency training time in rural train-
ing locations (as defined in subsection 
(u)(6)(C)), regardless of where the training 
occurs and regardless of specialty, shall 
not be taken into account for purposes of 
applying the limitation under this subpara-
graph.’’; and 
(B) in subparagraph (H)— 
(i) in clause (i), in the second sen-
tence, by inserting the following before the 
period: ‘‘, in accordance with the second 
sentence of clause (i) of such subpara-
graph’’; and 
(ii) in clause (iv), by inserting the fol-
lowing before the period: ‘‘, in accordance 
with the second sentence of clause (i) of 
such subparagraph’’; and 
(2) in paragraph (5), by adding at the end the 
following new subparagraph: 
‘‘(L) SPECIAL RULES REGARDING APPLICA-
TION OF ELECTIVE RURAL SUSTAINABILITY PER 
RESIDENT
PAYMENT
AMOUNT.—For special 
rules regarding application of the elective rural 
sustainability per resident payment amount 
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under subsection (u), see paragraph (3) of such 
subsection.’’. 
(b) 
INDIRECT
MEDICAL
EDUCATION.—Section 
1886(d)(5)(B)(v) is amended— 
(1) by striking ‘‘130 percent’’ and inserting 
‘‘for cost reporting periods beginning on or after Oc-
tober 1, 1997, and before the date that is 1 year 
after the date of enactment of the Rural Physician 
Workforce Production Act of 2023, 130 percent’’; 
and 
(2) by adding at the end the following: ‘‘For 
cost reporting periods beginning on or after the date 
that is 1 year after the date of enactment of the 
Rural Physician Workforce Production Act of 2023, 
such rules shall provide that any full-time-equivalent 
resident in an approved medical residency program 
(or separately defined track within a program) that 
provides more than 50 percent of the total residency 
training time in rural training locations (as defined 
in subsection (u)(6)(C)), regardless of where the 
training occurs and regardless of specialty, shall not 
be taken into account for purposes of applying the 
limitation under this subparagraph. For special rules 
regarding application of the elective rural sustain-
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ability per resident payment amount under sub-
section (u), see paragraph (3) of such subsection.’’. 
Æ 
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