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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