[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 289 Introduced in Senate (IS)]

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116th CONGRESS
  1st Session
                                 S. 289

   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 SENATE OF THE UNITED STATES

                            January 31, 2019

 Mr. Gardner (for himself, Mr. Tester, and Mrs. Hyde-Smith) introduced 
the following bill; 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 States, and for 
                            other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Rural Physician Workforce Production 
Act of 2019''.

SEC. 2. ALTERNATIVE NATIONAL PER RESIDENT PAYMENT FOR RESIDENTS 
              TRAINING IN RURAL TRAINING LOCATIONS.

    (a) In General.--Section 1886 of the Social Security Act (42 U.S.C. 
1395ww) is amended by adding at the end the following new subsection:
    ``(u) Alternative National Per Resident Payment Amount for 
Residents Training in Rural Training Locations.--
            ``(1) In general.--
                    ``(A) Establishment.--The Secretary shall establish 
                a national per resident payment (NPRP) amount for time 
                spent by residents training in rural training locations 
                in accordance with paragraph (2).
                    ``(B) Election.--For cost reporting periods 
                beginning on or after the date that is 1 year after the 
                date of enactment of this subsection, an applicable 
                hospital (as defined in paragraph (6)(A)), may elect to 
                receive the payment amount under this subsection for 
                each full-time-equivalent resident in an approved 
                medical residency training program that receives 
                training in a rural training location in accordance 
                with paragraph (2). 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 
                (d)(5)(B) and (h) or section 1814(l), as applicable, 
                with respect to such residents. If the applicable 
                hospital is otherwise eligible for such a payment or 
                adjustment, the national per resident payment amount 
                under this subsection shall be in lieu of such payment 
                or adjustment.
                    ``(C) Application.--The provisions of this 
                subsection, or the application of such provisions to an 
                applicable hospital, shall not result in or otherwise 
                effect the following:
                            ``(i) The establishment of a limitation on 
                        the number of residents in allopathic or 
                        osteopathic medicine for purposes of 
                        subsections (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).
                            ``(ii) The determination of--
                                    ``(I) the additional payment amount 
                                under subsection (d)(5)(B); or
                                    ``(II) hospital-specific approved 
                                FTE resident amounts under subsection 
                                (h).
                            ``(iii) The counting of any resident with 
                        respect to which the applicable hospital 
                        receives a national per resident payment under 
                        this subsection towards the application of the 
                        limitation described in clause (i) for purposes 
                        of subsections (d)(5)(B) and (h).
            ``(2) Payment amount.--
                    ``(A) Base amount.--The national per resident 
                payment amount, with respect to full-time equivalent 
                residents training in rural training locations, for 
                cost reporting periods beginning during the first year 
                beginning on or after the date of enactment of this 
                subsection shall be, based on the most recently 
                available data with respect to cost reporting periods 
                beginning during a preceding year (referred to in this 
                subparagraph as the `base cost reporting period'), 
                equal to the sum of the following:
                            ``(i) Direct gme.--The amount that, out of 
                        all of the payment amounts (determined on a per 
                        resident basis) received by hospitals under 
                        subsection (h) for such base cost reporting 
                        period, is equal to the national 85th 
                        percentile of such payment amounts.
                            ``(ii) Indirect gme.--The amount that, out 
                        of all of the additional payment amounts 
                        (determined on a per resident basis) received 
                        by hospitals under subsection (d)(5)(B) for 
                        such base cost reporting period, is equal to 
                        the national 85th percentile of such payment 
                        amounts.
                    ``(B) Updating for subsequent cost reporting 
                periods.--For each subsequent cost reporting period, 
                the national per resident payment amount is equal to 
                such amount determined under this paragraph for the 
                previous cost reporting period updated, through the 
                midpoint of the period, by projecting the estimated 
                percentage change in the consumer price index during 
                the 12-month period ending at that midpoint, with 
                appropriate adjustments to reflect previous under- or 
                over-estimations under this subparagraph in the 
                projected percentage change in the consumer price 
                index.
                    ``(C) Clarification.--The national per resident 
                payment amount shall not be discounted or otherwise 
                adjusted based on the Medicare patient load (as defined 
                in subsection (h)(3)(C)) of an applicable hospital or 
                discharges in a diagnosis-related group.
            ``(3) Allocation of payments.--In providing for payments 
        under this subsection, the Secretary shall provide for an 
        allocation of such payments between parts A and part B (and the 
        trust funds established under the respective parts) as 
        reasonably reflects the proportion of such costs associated 
        with the provision of services under each respective part.
            ``(4) Eligibility for payment.--
                    ``(A) In general.--An applicable hospital shall be 
                eligible for payment of the national per resident 
                payment amount under this subsection for time spent by 
                a resident training in a rural training location if the 
                following requirements are met:
                            ``(i) The resident spends the equivalent 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.--An 
                applicable hospital shall be eligible for payment of 
                the national per resident payment amount under this 
                subsection for all time spent by residents in an 
                approved medical residency program (or separately 
                defined track within a program) that provides 50 
                percent or more of the total residency training time in 
                rural training locations (as defined in paragraph 
                (6)(C)), regardless of where the training occurs and 
                regardless of specialty.
            ``(5) 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 (h)(4).
            ``(6) Definitions.--In this subsection:
                    ``(A) Applicable hospital.--The term `applicable 
                hospital' means a hospital or critical access hospital.
                    ``(B) Approved medical residency training program; 
                direct graduate medical education costs; resident.--The 
                terms `approved medical residency training program', 
                `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 adjustment, meets one or more of the following 
                criteria:
                            ``(i) The training occurs in a location 
                        that is a rural area (as defined in section 
                        1886(d)(2)(D)).
                            ``(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 location 
                        that is within 10 miles of a sole community 
                        hospital (as defined in subsection 
                        (d)(5)(D)(iii))).
            ``(7) Budget neutrality requirement.--The Secretary shall 
        ensure that aggregate payments for direct medical education 
        costs and indirect medical education costs under this title, 
        including any payments under this subsection, for each year 
        (effective 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 Secretary may 
        make appropriate adjustments to the amount of such payments for 
        direct graduate medical education costs and indirect medical 
        education costs under subsections (h) and (d)(5)(B), 
        respectively.''.
    (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 following 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 medical education costs and 
        direct graduate medical education costs for the time spent by 
        the resident in that setting under subsections (d)(5)(B) and 
        (h), respectively, of section 1886.
            ``(B) Medical education costs shall not be considered 
        reasonable costs of a critical access hospital for purposes of 
        payment under paragraph (1), to the extent that the critical 
        access 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.''.
            (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 determined under clause (i)(I) with 
respect to a sole community hospital shall not include 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 Secretary'' 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 striking 
                        ``subsection (k)'' and inserting ``subsection 
                        (k) or subsection (u)''.

SEC. 3. SUPPORTING NEW, EXPANDING, AND EXISTING RURAL TRAINING TRACK 
              RESIDENCIES.

    (a) Direct Graduate Medical Education.--Section 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 
                        inserting ``for cost reporting periods 
                        beginning on or after October 1, 1997, and 
                        before the date that is 1 year after the date 
                        of enactment of the Rural Physician Workforce 
                        Production Act of 2019, 130 percent''; and
                            (ii) 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 2019, 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 50 percent or more 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.''; and
                    (B) in subparagraph (H)--
                            (i) in clause (i), in the second sentence, 
                        by inserting the following before the period: 
                        ``, in accordance with the second sentence of 
                        clause (i) of such subparagraph''; and
                            (ii) in clause (iv), by inserting the 
                        following 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 application of 
                national per resident payment amount.--For special 
                rules regarding application of the national per 
                resident payment amount under subsection (u), see 
                paragraph (1)(C) 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 October 1, 1997, and 
        before the date that is 1 year after the date of enactment of 
        the Rural Physician Workforce Production Act of 2019, 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 2019, 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 50 percent or more 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 national per 
        resident payment amount under subsection (u), see paragraph 
        (1)(C) of such subsection.''.
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